working with youth with co-occurring disorders sharon hunt, ta partnership interim substance abuse...
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Working with Youth with Co-Occurring Disorders
Sharon Hunt, TA Partnership Interim Substance Abuse Resource Specialist
Rachel Freed, Research Associate for the TA Partnership
Rebecca Spotts, Research Assistant for the TA Partnership
Cathy Ciano, Executive Director, Parent Support Network of Rhode Island
Nick Vaske, youth presenter from Families First & Foremost
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 younger age of onset, severity of emotional and behavioral problems, true across age and gender.
Initially use is voluntary, thus the earlier the intervention the greater the impact on offsetting what later becomes a chronic, relapsing disease in which brain chemistry is altered.
Most Common Presenting Problems
• Verbal/physical Aggressiveness• Academic Difficulties• Impulsivity• Hyperactivity• Depressed Mood• Poor Social Skills
Substance Use History at Intake by Age Category*
Have you ever used:
* Substance use information was based on self reports from youth 11 years or older.
1.7%
3.9%
6.0%
11.4%
6.5%
12.5%
8.8%
12.1%
13.1%
18.4%
14.4%
64.0%
71.9%
72.8%
0.2%
1.1%
1.2%
2.1%
1.7%
3.2%
1.8%
6.8%
2.7%
4.3%
5.1%
27.2%
35.8%
45.9%
0% 20% 40% 60% 80% 100%
Quaaludes (e.g. quads)
Heroin, Smack
Barbituates (e.g. downers)
Narcotics (e.g. morphine)
Crack or Rock in a Hard Chunk Form
Amphetamines
Tranquilizers (e.g. Valium)
Inhalants (e.g. spray cans)
Cocaine in a Powder Form
LSD, Acid, PCP or Other Psychedelics
Non-prescription or Over-the-counter Drugs
Marijuana, Grass, Pot, or Hashish
Alcohol
Cigarettes
Percent
11 to 14 Years Old
15 to 18 Years Old
Su
bs
tan
ce
s
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.
Multiple Co-occurring Problems Are the Norm and Increase with Level of Care
Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) studies
44
2125
21
70
47 43
7880
65
88
56
3635
68
445252
0
20
40
60
80
100
ConductDisorder
ADHD MajorDepressiveDisorder
GeneralizedAnxietyDisorder
TraumaticStress
Disorder
Any Co-OccuringDisorder
Outpatient Long Term Residential Short Term Residential
Multiple Co-occurring Problems By Lifetime Dependence Diagnosis
Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) studies
0%
20%
40%
60%
80%
100%
Abuse 49% 33% 14% 19% 18% 64%
Dependence 79% 64% 47% 51% 43% 89%
Conduct Disorder
ADHDMajor
Depressive Disorder
Generalized Anxiety Disorder
Traumatic Stress
Disorder
Any Co-Occuring Disorder
Adolescents in TreatmentSubstance Use Disorders
40 – 90% Report Victimization
20 – 25% Report Victimization in last 90 days, or current concern regarding reoccurrence
Source: Dennis, Stevens & Chaffin, in press
*Because children may have more than one diagnosis, the diagnosis variable may add to more than 100%.** V Code refers to Relational Problems, Problems Related to Abuse or Neglect, and additional conditions that may be a focus of clinical attention.
Clinical Diagnosis on any Axis at Intake by Comorbidity Status*
No Comorbidity: n = 4,855.Comorbidity w/o Substance Use: n = 4,633.Comorbidity w/ Substance Use: n = 697.
Percent
Cli
nic
al
Dia
gn
os
es
Treatment Prognosis
Prognosis is worse for youth with co-occurring disorders for many reasons: motivation; academic, family, and behavior problems; and limited coping and social skills.
May lag in important adolescent development tasks – individuation, moral development and conceptualization of future family, vocational and educational goals.
Cumulative Recovery Pattern at 30 months:(The majority vacillate in and out of recovery)
Source: Dennis et al, in press; forthcoming, CYT, PETSA
37% Sustained Problems
5% Sustained Recovery
19% Intermittent, currently in
recovery
39% Intermittent, currently not in
recovery
Adapting Treatment for Adolescents
Examples need to be altered to relevant substances, situations, and triggers
Consequences have to be altered to things of concern to adolescents
Most adolescents do not recognize their substance use as a problem and are being mandated to treatment
All materials need to be converted from abstract to concrete concepts
Comorbid problems (mental, trauma, legal) are the norm and often predate substance use
Treatment has to take into account the multiple systems (family, school, welfare, criminal justice)
Less control of life and recovery environment
Less aftercare and social support
Complicated staffing needs
MENTAL HEALTH INTERVENTIONS FOR CO-OCCURING DISORDERS
EVIDENCE-BASED INTERVENTIONS
COGNITIVE BEHAVIOR-THERAPY(CBT)
INTEGRATED COGNITIVE-BEHAVIOR THERAPY FOR TRAUMATIC STRESS SYMPTOMS AND SUBSTANCE ABUSE
MULTI-SYSTEMIC THERAPY
MOTIVATIONAL ENHANCEMENT THERAPY WITH CBT
EFFECTIVE INTERVENTIONS SUPPORTIVE THERAPY SYSTEMIC FAMILY THERAPY INTENSIVE CASE
MANAGEMENT COMMUNITY
REINFORCEMENT NETWORK THERAPY METHADONE NALTREXONE
Racial/Ethnic Disparities in Racial/Ethnic Disparities in Drug Prevalence among Drug Prevalence among
YouthYouth
Rebecca SpottsRebecca Spotts
202-403-5847202-403-5847
Racial/Ethnic Disparities in Drug Racial/Ethnic Disparities in Drug Prevalence among YouthPrevalence among Youth
PrevalencePrevalence
The role of cultureThe role of culture
Equal access to treatmentEqual access to treatment
Prevalence by Race/EthnicityPrevalence by Race/Ethnicity
Evidence shows a significantly greater Evidence shows a significantly greater prevalence of substance abuse among prevalence of substance abuse among Hispanics and Caucasian youth than African Hispanics and Caucasian youth than African American youth at every grade levelAmerican youth at every grade level (National Institutes for (National Institutes for
Health)Health)
American Indian/Alaska Native youth had the American Indian/Alaska Native youth had the highest rate of illicit drug use among youth age highest rate of illicit drug use among youth age 12-17 at 19.6%, compared to 10.9% for 12-17 at 19.6%, compared to 10.9% for Caucasian youth and 10.7% for African Caucasian youth and 10.7% for African American youthAmerican youth(1999 National Household Survey on Drug Abuse)(1999 National Household Survey on Drug Abuse)
Estimated Lifetime Prevalence of Selected Drugs by Estimated Lifetime Prevalence of Selected Drugs by Race/Ethnicity for Students in Grade 12 (%): 2000.Race/Ethnicity for Students in Grade 12 (%): 2000.
*Source: U.S. Department of Health and Human Services National Institutes of Health report *Source: U.S. Department of Health and Human Services National Institutes of Health report Drug Use Among Drug Use Among Racial/Ethnic MinoritiesRacial/Ethnic Minorities
0
10
20
30
40
50
60
70
80
90
Marijuana Cigarettes Alcohol Stimulant
White Non-Hispanic African-American
Hispanic/Latino American American Indian/Alaska Native
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
No Comorbidity Comorbidity withSubstance Use
Comorbidity withoutSubstance Use
Comorbidity by Race - Female
CAUCASIAN - 1233
AFRICAN AMERICAN - 585
HISPANIC - 39
AMERICAN INDIAN - 105
ASIAN/PACIFIC ISLANDER- 17
Dr. Gayle Porter, TA PartnershipDr. Gayle Porter, TA Partnership
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
No Comorbidity Comorbidity withSubstance Use
Comorbidity withoutSubstance Use
Comorbidity by Race - Male
CAUCASIAN - 2765
AFRICAN AMERICAN -1288HISPANIC - 129
AMERICAN INDIAN - 167
ASIAN/PACIFIC ISLANDER- 46
Dr. Gayle Porter, TA PartnershipDr. Gayle Porter, TA Partnership
What puts youth at risk for drug What puts youth at risk for drug abuse? The role of cultureabuse? The role of culture
““The cultures from which The cultures from which people hail affect all aspects of people hail affect all aspects of mental health and illness, mental health and illness, including the types of stresses including the types of stresses that they confront, whether they that they confront, whether they seek help, what type of help seek help, what type of help they seek…and what types of they seek…and what types of coping styles and social coping styles and social supports they possess.” supports they possess.”
(U.S. Department of Health and Human (U.S. Department of Health and Human Services, 2001)Services, 2001)
Sources of Risk for Substance Sources of Risk for Substance AbuseAbuse
(www.safeyouth.org)(www.safeyouth.org)
Three sourcesThree sources– Individual child factors - biology, behavior and Individual child factors - biology, behavior and
personalitypersonalityYouth with emotional and psychological problems are at Youth with emotional and psychological problems are at greater risk for substance use and abuse greater risk for substance use and abuse ((www.safeyouth.org))
– Family factorsFamily factorsDo not perceive a strong parental disapproval for drug useDo not perceive a strong parental disapproval for drug use
– Environmental factorsEnvironmental factorsYouth do not perceive appropriate risk involved with Youth do not perceive appropriate risk involved with substance abusesubstance abuse
Increased Risk: Environmental FactorsIncreased Risk: Environmental Factors(www.safeyouth.org)(www.safeyouth.org)
Community disorganizationCommunity disorganization
Lack of community bondingLack of community bonding
Community attitudes toward favorable Community attitudes toward favorable drug usedrug use
Inadequate services and opportunities for Inadequate services and opportunities for youthyouth
Pro-drug messages in the mediaPro-drug messages in the media
Disparities for Children of Diverse Racial Disparities for Children of Diverse Racial and Ethnic Groupsand Ethnic Groups
African American and Hispanic/Latino youth African American and Hispanic/Latino youth identified/referred at same rates as general identified/referred at same rates as general population, but less likely to receive mental population, but less likely to receive mental health or meds health or meds (Kelleher, 2000)(Kelleher, 2000)
Minority children tend to receive mental health Minority children tend to receive mental health services through juvenile justice and child services through juvenile justice and child welfare systems more often that through schools welfare systems more often that through schools or mental health settings or mental health settings (Allegria, 2000)(Allegria, 2000)
African American and Hispanic/Latino children African American and Hispanic/Latino children have the highest rates of unmet need have the highest rates of unmet need (Strum, 2000)(Strum, 2000)
How do youth get access to How do youth get access to substance abuse treatment?substance abuse treatment?
Primary referral source by Racial and Ethnic Group in Primary referral source by Racial and Ethnic Group in 1998-99 Funded SOC communities 1998-99 Funded SOC communities (Guilford, 2004 ORC Macro)(Guilford, 2004 ORC Macro)
American Indian/Alaska American Indian/Alaska NativeNative
Caregiver/Self (44.7%)Caregiver/Self (44.7%)
African AmericanAfrican American Juvenile Justice (24.9%)Juvenile Justice (24.9%)
White Non-HispanicWhite Non-Hispanic Education (20.1%)Education (20.1%)
Hispanic/LatinoHispanic/Latino Juvenile Justice (28.4%)Juvenile Justice (28.4%)
AsianAsian Juvenile Justice (28.2%)Juvenile Justice (28.2%)
Native HawaiianNative Hawaiian Child Welfare (22.2%)Child Welfare (22.2%)
Multi-RaceMulti-Race Mental Health (32.5%)Mental Health (32.5%)
OtherOther Mental Health (22.4%)Mental Health (22.4%)
Access to Services and TreatmentAccess to Services and Treatment
– SOC communities must SOC communities must develop a culturally develop a culturally competent strategy to reach competent strategy to reach out to at-risk youth in their out to at-risk youth in their area to combat substance area to combat substance abuse before it begins.abuse before it begins.
www.preventioncurriculum.com/handbook/Chapter5FullText.pdf
Nick VaskeNick VaskeFamilies First & Families First &
ForemostForemost
402-441-3803 (Number 402-441-3803 (Number for Families First & for Families First &
Foremost)Foremost)[email protected]
“I remember the feeling I had the first time I did Ecstasy: complete and utter bliss. I could feel the pulse of the universe; I let every breath, touch and molecule move my soul. It was as
if I had unlocked some sort of secret world; it was as if I'd found heaven. And I have to admit, I wondered how anything
that made you feel so good could possibly be bad.”
–Lynn Smith
What Are Club Drugs?
DrugDrug Street NameStreet Name
GHBGHB G, liquid ecstasy, Grievous Bodily Harm, gib, soap, scoop, nitro
RohypnolRohypnol Mexican valium, circles, roofies, la rocha, roche, rophies, R2, rope, forget-me pill
KetamineKetamine K, special K, super K, vitamin K, kit-kat, keets, super acid, jet, cat valiums
MDMA MDMA Ecstasy, X, M, E, XTC, rolls, beans, Clarity, Adam, lover's speed, hug drug
The most widely used club drugs are GHB, Rohypnol, Ketamine, and MDMA
What Are Club Drugs?GBH
– GHB is usually abused either for its intoxicating/sedating/euphoria-inducing properties, or for its growth hormone-releasing effects
– Overdose may result in seizures, coma, and death– May also produce withdrawal effects, including insomnia, anxiety, tremors,
and sweating
Ketamine– Large doses cause reactions similar to those associated with use of PCP,
such as dream-like states and altered perceptions or hallucinations. – At higher doses, can cause delirium, amnesia, impaired motor function, high
blood pressure, depression, and potentially fatal respiratory problems
Rohypnol– Produces sensations of floating outside the body, visual hallucinations, and a
dream-like state– When mixed with alcohol, it can incapacitate victims and prevent them from
resisting sexual assault– Often produces anterograde amnesia– May be lethal when mixed with alcohol and/or other depressants.
What is Ecstasy?The Facts
• An illegal psychoactive drug • Produces effects similar to hallucinogens and
stimulants – energizing effect – distortions in time and sensory perceptions – feelings of peace and happiness and empathy
for others – suppresses the desire to eat, drink, or sleep
• Popular at raves and other all-night party scenes
Myths and inaccurate information about the effects and long-term consequences of Ecstasy are widespread among its users . . .
Physical Effects
In low doses . . .• faintness• dehydration• muscle tension• involuntary teeth clenching• nausea• blurred vision• chills or sweating• hypertension• increases in heart rate, blood
pressure, and temperature
In high doses . . .• liver, kidney, and
heart failure• strokes • seizures
Psychological Effects
• anxiety• panic attacks• confusion• disorientation
• depression • delusions • mood swings • lapses in memory
Research on animals suggests that Ecstasy use can cause long-term damage to the parts of the
brain that use serotonin (NIDA, 2005).
There is no control over the pill ingredients
• The ingredients are difficult to obtain, so manufacturers
often substitute ingredients
– ephedrine
– dextromethorphan
– caffeine
• Other, more dangerous drugs are sometimes sold as
ecstasy.
Other Risks
– ketamine
– cocaine
– methamphetamine
Mental Health and Ecstasy • Strong correlation between Ecstasy use and
depression• 2 possible reasons:
– Some users may be more vulnerable to the adverse effects of Ecstasy
– Users may have pre-existing mental health problems for which they self-medicate by using ecstasy
• Some ex-users experience a mental health impairment that persists for years after they stop using this drug. Verheyden SL, Maidment R, & Curran HV (2003) Quitting ecstasy: an investigation of why people stop taking the drug and their subsequent mental health. J Psychopharmacol., 17(4), 371-378.
Mental Health and Ecstasy (cont.)
Lieb R, Schuetz CG, Pfister H, von Sydow K, Wittchen H "Mental disorders in ecstasy users: a prospective-longitudinal investigation." Drug Alcohol Depend 2002; 68: 195-207
A study by Lieb and colleagues (2002) followed the same 2,500 14-24 year olds for four years, tracking changes in drug use and mental health:
Mental Health and Ecstasy (cont.)
The same study found that although most Ecstasy users had some form of mental illness during the study, in the vast majority of cases, the problem emerged before they began using Ecstasy.
Lieb R, Schuetz CG, Pfister H, von Sydow K, Wittchen H "Mental disorders in ecstasy users: a prospective-longitudinal investigation." Drug Alcohol Depend 2002; 68: 195-207
Why is it Important to Get the Why is it Important to Get the Facts Out?Facts Out?
• Almost half of all parents in America (48%) do not know the effects of Ecstasy
• 79% of parents do not know what is in Ecstasy
• Ecstasy is the least likely drug to be discussed when parents discuss specific drugs with their child.
Partnership for a Drug Free America (2003). 2003 Partnership Attitude Tracking Study. Retrieved July 2005 from http://demo.pdfav3.somethingdigital.com/Files/Full_Report_PATS_2003
Why is it Important to Get the Facts Out?
• 3% of parents of teens think their teen has tried Ecstasy
• 11% of teens report trying Ecstasy
• 13% of parents of teens believe that Ecstasy would be “very easy” for their teen to get.
• 22% of teens say Ecstasy is very easy for them to get.
• 5% of parents of teens believe their teen has friends who have tried Ecstasy.
• 34% say they have close friends who use Ecstasy.
Partnership for a Drug Free America (2003). 2003 Partnership Attitude Tracking Study. Retrieved July 2005 from http://demo.pdfav3.somethingdigital.com/Files/Full_Report_PATS_2003
Treatment Options
• There are currently no evidence-based treatments designed specifically for Ecstasy abuse.
• The most effective treatments for drug abuse and addiction in general are cognitive behavioral interventions.
• Substance abuse recovery support groups can also be effective in combination with behavioral interventions to support long-term, drug-free recovery.
• In addition, antidepressant medications might be helpful in treating the symptoms of depression and anxiety seen in Ecstasy users.
“I hear people say Ecstasy is a harmless, happy drug. There's nothing happy about the way that "harmless" drug chipped away at my life. Ecstasy took my strength, my motivation, my dreams, my friends, my apartment, my money and most of all, my sanity. I worry about my future and my health every day.”
–Lynn Smith
Internet Resources
• http://www.clubdrugs.org/
• http://www.drugabuse.com/
• http://www.drugabuse.gov/drugpages/clubdrugs.html
• http://www.drugdigest.org/
• http://www.drugid.org/
• http://www.erowid.org/
• http://www.streetdrugs.org/
Cathy CianoCathy CianoExecutive DirectorExecutive Director
Parent Support Parent Support Network of Rhode Network of Rhode
IslandIsland