Effective Use of Revised Child COD Supplemental Forms:

MH 552, MH 553, MH 554

Your Trainers

Joy Chudzynski, Psy.D.UCLA Integrated Substance Abuse Programs

Thomas E. Freese, Ph.D.UCLA Integrated Substance Abuse Programs

Introduction:What we will cover

• Review of substance use in children and adolescents

• Review screening and assessment in developing appropriate interventions for those who are using or are at-risk for using alcohol / drugs.

• Review Revised Forms MH 552, 553, 554• Practice New Forms• Wrap-Up, Q & A

Substance Use Patterns of Children and Adolescents

Prevalence .…• In 2012, 60% of Students age 12-17 report that

drugs are used, kept or sold on their school grounds.1

• 52% say there is a place on or near school grounds where students go to drink, smoke, or use drugs during school. 1

• Before the age 13, 21% of high school students reported that they tried alcohol; 8% reported that they tried marijuana before the age of 13. 2

1 National Center on Addiction and Substance Use, 2012 2 Centers for Disease Control and Prevention, 2012

Children & Adolescents with Substance Use Disorders...

• Are largely undiagnosed;• Are distributed across diverse health and social

service systems; • Are more likely to be involved in the juvenile

justice system;• Have higher rates of child abuse (neglect,

physical and sexual abuse);• Have high co-morbidity with psychiatric

conditions.

More than half of new illicit drug users begin with marijuana

National Survey on Drug Use and Health (NSDUH), 2010

Drug use is highest among those in their late teens and twenties

National Survey on Drug Use and Health (NSDUH), 2010

National Survey Data: Substance Abuse/Dependence among Youth (12-17)

National Survey on Drug Use and Health, 2002–2011

Adolescents Receiving Substance Abuse Tx. in County Programs,

Los Angeles (N=1,591)

67%

33%

GenderMaleFemale

67%

12%6% 15%

Race/Ethnicity

LatinoCaucasianAfrican-AfricanOther

FY 07/1/11-06/30/12

Adolescents Receiving Substance Abuse Tx. in County Programs,

Los Angeles (N=1,591)

92%

8%

Age13-17 y/o18-24 y/o

71%

11% 10%5%

2%1%

DOC

Marijuana

Alcohol

Meth

Other

Heroin

Crack/Coke

FY 07/1/11-06/30/12

Total Open Children and TAY in 457 DMH Directly Operated/Contracted Programs

(July, 2012 – Dec, 2012)              

39,27158%

28,79942%

ChildTAY

N = 68,070

Children and TAY Clients with Dual Codes Completed

(July, 2012 – Dec, 2012)

MH Only SU <Dx SUD/Dual Dx0%

10%

20%

30%

40%

50%

60%

70%

80%73%

8%

19%

37%

15%

48%

Child (n=3,255) TAY (n=12,094)

COD in Children and Adolescents

Facts About Adolescent COD

• In 2011, 2.0 million youth (8.2% of the population aged 12-17) reported at least one major depressive episode (MDE) in the past year.

• Among 12-17 year olds who had past year MDE, 36% had used illicit drugs during the same period.

SOURCE: 2011 National Survey on Drug Use and Health, SAMHSA.

Substance Use among Youth*, by MDE in Past Year (2011)

SOURCE: 2011 National Survey on Drug Use and Health, SAMHSA.

COD 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;

• About 30% of incarcerated youth with substance use disorders 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

Trauma among Adolescents Presenting for Treatment for SUD

• 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

Substance Use among those with Developmental Disabilities (DD)

• Prevalence of use among those with DD may be twice as high

• Exposure and experimentation among those with a DD may be delayed, but problems arise sooner after initial use

• Social, academic, economic, and mental health issues may cause stresses that contribute to use.

• Parents/teachers/providers often “protect” such individuals from information or education, and delay identifying and addressing experimentation, use, abuse.

Westermeyer et al., 1996; National AIA Resource Center , 2005

Conceptualizing COD in Children and Adolescents

Screening and Assessing Children and Adolescents

for Substance Use Risk

What is the Difference between…What’s Going On in These Pictures?

Screening

• Conducted with large numbersof people to identify the potentialthat a problem exists

• Screening is intended to be broad scale and produce false positives

• Screening leads to more in-depth assessment and intervention for people identified with a potential problem

Assessment

• Assessment is individualized andspecific.

• Assessment is designed to identify particular needs and rule-out false positives

• Assessment leads to more individualized intervention for those identified with a problem

What can be determined through the screening and assessment process?

• The interplay between the substance use and the mental health problem, and the degree to which substance use affects mental health functioning

• The frequency, duration and quantity of use and resulting diagnosis (i.e., substance abuse or dependence)

• Use of Screening (MH554), Parent (MH552), and Supplemental COD Assessment (MH 553) forms ensures that the topic will be raised and those who need additional assessment and intervention are appropriately identified.

• This will better inform the Treatment Plan and help identify substance use interventions that support Mental Health Goals.

Rationale for Revising COD Child Forms

• Health Reform = new expectations / requirements for the delivery of more integrated and evidence-based care, and better documentation of service.

• Substance use/abuse cannot be the principal mental health diagnosis of a DMH consumer, yet many are severely impacted by substance use which compounds mental health symptoms.

• There have been system-wide challenges aligning substance use issues and mental health diagnoses when screening and assessing COD among Child and Adolescent consumers.

• DMH designed new forms (with the help of UCLA and others) to help clinician engage, and gather appropriate information to assist in development of COD interventions that will improve mental health functioning.

• Implementation of IBHIS allowed for revisions and streamlining.

COD Child Screening (MH 554) Revisions

MH 554 RevisionsCOD Substance Abuse Screener

• Must be interviewer-administered to all children 11 and older (clinical judgment if <11)

• # of Screener Questions Streamlined: 15 Qs 10 Qs• Less formal language (styled after CRAFFT and other EB

screeners for adolescent SU)• Several Qs removed about specific consequences• 2 Qs added about general consequences and family

member substance use• Qs (e.g., tolerance, loss of control) that support Diagnosis

moved to Child Assessment to be completed by AMHD/Clinical staff

• Any YES leads to Administration of the COD Assessment Form (MH 553)

Risk Factors for Children Age 11 and Under

• Parental/caregiver substance abuse• Substance use endemic in

school/neighborhood• School performance slipping (grades,

detention)• Shift in friends• Moodiness• Unexplained burns/sores/injuries• What else?

COD Child Parent / Caregiver Questionnaire

(MH 552) Revisions

MH 552 Revisions(COD Parent/Caregiver Screener)

• Must be interviewer-administered for all children 11 and older (clinical judgment if <11); explore family and consumer risk.

• # of Screener Questions Streamlined: 16 Qs 8 Qs• Less formal language (styled after CRAFFT and

other EB screeners for adolescent SU)• Some Qs retained or collapsed• Some Qs about specific use behaviors removed • Any YES; use clinical judgment regarding

administration of COD Assessment Form (MH 553)

COD Child Assessment (MH 553) Revisions

MH 553 Revisions(Supplemental COD Assessment)

• AUDIT C (EB Alcohol screener) – 3 Questions Added• Drug categories added and specified to reflect current

adolescent drug use trends• Quantity and frequency of use combined, Route of

Administration added• Positives/Negatives of use delineated to help support impact

of SU on MH functioning improved documentation of MH as Primary with SU exacerbating MH symptoms.

• Qs (e.g., tolerance, loss of control) that support Diagnosis moved to Child Assessment to be completed by AMHD/Clinical staff

• Administer if any YES on 554, use clinical judgment if YES on 552

Practice with the Revised Forms

• Form pairs.• One person will play the clinician and the

other will play “Marco.”• Practice using the Revised Child Screener

(MH554) and COD Assessment Forms (MH553).– Experience with new forms?– Thoughts / Feedback?

Practice: “Marco”

• 15-year old freshman in high school, has been referred to DMH by school following a series of physical fights on campus, one with a teacher.

• Threatened suicide on two occasions in the past 2 years, both following a brief reunion with his father who is in jail on gang-related crimes.

• Spends free time with older cousin who attended his high school until recently when he was kicked out for getting caught with marijuana and pills in his backpack.

• Continues to get mostly C’s and B’s in school.• Reports feeling “bummed out” about life, isolated, angry at his

mother and her new boyfriend who recently moved into the house with his mom and Marco’s younger brother.

1. PrecontemplationDefinition:

Not yet considering change or is unwilling or unable to change.

Primary Task:Raising Awareness—Connect

SU and MH Sxs 2. ContemplationDefinition:

Sees the possibility of change but is ambivalent and uncertain.

Primary Task:Resolving ambivalence/

Helping to choose change

3. DeterminationDefinition:

Committed to changing.Still considering what to do.

Primary Task:Help identify appropriate strategies to improve MH/

reduce SU4. ActionDefinition:

Taking steps toward change but hasn’t stabilized in the process.

Primary Task:Help implement change strategies

to decrease MH Sxs and SU

5. MaintenanceDefinition:

Has achieved the goals and is working to maintain change.

Primary Task:Develop new skills to maintain

improvements in MH and SU

6. RecurrenceDefinition:

Experienced a recurrence of the symptoms.

Primary Task:Cope with consequences , relate to

MH functioning as precursorand outcome Stages of Change:

Primary Tasks in Linking MH and SU

Stages of Change: Intervention Matching Guide

• Offer factual information about MH-SU connection

• Explore the events that brought them to treatment—Impact of SU/MH

• Explore results of previous efforts to improve MH. What was the role of SU?

• Explore pros and cons of improving MH and decreasing SU

• Explore the person’s sense of self-efficacy to reduce MH symptoms

• Explore expectations about change—What is the role of SU on MH Sxs?

• Summarize self-motivational statements for change in MH and SU

• Continue exploration of pros and cons of improving MH and decreasing SU

• Offer menu of options for addressing MH Sxs and SU

• Help identify pros and cons of various change options

• Identify and lower barriers to change• Help enlist social/peer support • Encourage person to publicly

announce plans to change

• Support a realistic view of change through small steps

• Identify high-risk situations for SU and impact of use on MH functioning

• Develop coping strategies• Assist in finding new reinforcers of

positive change including feeling better• Help access family/social/peer support

• Help identify and try positive behaviors and drug-free activities to maintain goals.

• Maintain supportive contact and highlight progress in maintaining improved functioning--What was the role of SU?

• Set new short and long term goals for MH and SU

• Frame recurrence as a learning opportunity—What was the impact on MH?

• Explore possible psychological, behavioral and social antecedents

• Help to develop alternative coping strategies for strong emotions

• Encourage person to stay in the process and maintain support

1. Pre-contemplation

2.Contemplation

3.Determination

4.Action

5.Maintenance

6.Recurrence

Practice with the Revised Forms

• Working in pairs, determine what stage of change Marco is in.

• Identify one MH goal appropriate for Marco

• Identify one or more SU interventions that would help move Marco toward this MH goal.

Thank you!!

joychud@ucla.edu

www.uclaisap.orgwww.psattc.org

http://sbirt.samhsa.gov/about.htmhttp://www.motivationalinterview.org

http://www.niaaa.nih.gov/http://www.drugabuse.gov/