TREATMENT OF YOUTH WITH

CO-OCCURRING DISORDERS

FINANCING EFFECTIVE, COMMUNITY-BASED

BEHAVIORAL HEALTHCARE SERVICES AND

SUPPORTS FOR YOUTH DIVERTED FROM THE

JUVENILE JUSTICE SYSTEM

RICK SHEPLER, PH.D., PCC-S

June 28, 2016

Co-Occurring Disorders in Youth:Definition

The presence of one or more substance use disorders

(SUD) & one or more mental health disorders (MHD)

Interact differently from person to person but at least

one disorder of each type (MHD-SUD) can be

diagnosed independent of the other (SAMHSA Report to

Congress, 2002)

The severity of the co-occurring disorders are such

that the youth experiences decreased functioning in

multiple life domains

2

Special Focus: Juvenile Justice

Any contact with the Juvenile Justice system:

70%+ at least one MH Disorder

Externalizing disorders most prominent

Followed by: Mood, Anxiety and PTSD

50%+ substance use

Trauma and victimization in 62 to 80% of youth (Higher rates in females)

60%+ Co-Occurring Disorders

Youth with co-occurring disorders had more juvenile court charges (misdemeanors, felonies, and adjudicated delinquencies), than youth without co-occurring disorders (Kretschmar & Butcher, BHJJ)

Sources: Cocozza 2006; Kretschmar and Butcher, BHJJ, Teplin 2013; Hussey 2007; Turner 2004

Youth with Co-Occurring Disorders have

Multiple and Complex Concerns4

• 5+ problems are the norm

• Numerous systems involvedMultiple

• Trauma and victimization in 62 –80%Complex

• Chronic relapsing disorder

• Multiple treatment attempts over time

Persistent

5

Influence, Interaction, and Manifestation of

Multiple Occurring Conditions

Family

Substance Use

Disorder

Mental Health

Disorder

Risk & Resiliency

Factors

Developmental

Factors

Salient

Behavior/

Symptom

Trauma Factors

Contexts (Home,

School, Peers,

Community, etc.)

Safety Concerns

Youth

Realistic Outcomes and Expectations

Think trajectory of wellness not cure

Think abstinence-orientation (Mee-Lee)

Chronic relapsing disorder, requiring multiple treatment

attempts over time (White and Dennis)

Completion rates low/High rate of treatment drop-out.

About half of adolescents treated report no use after treatment

Measure what you do: risk reduction across life domains

Track multiple outcomes

Conversation with key stakeholders about realistic outcome

expectations (increased functioning; decreased level of care

needs; etc.)

3 Types of Treatment for

Co-Occurring Disorders7

Sequential Parallel Integrated

Necessity of Multiple Interventions to Counter

Multiple Risks (Sameroff, Gutman, and Peck, 2003)

“Interventions need to be as complex as the multiplicity of

risk factors and contexts (388) .”

“Most interventions in single domains have not produced

major reductions in problem behaviors (364) .”

“Most youth experience multiple risks in multiple social

contexts (388).”

Interventions need to address all the social contexts in

which the risks occur

Target factors that promote resiliency and healthy development – not just risk factors and illness (Hobfoll)

Categories of Effective

Substance Use Practices

NIDA has identified four categories of effective practices for

Adolescents (SAMHSA, 2013)

1. Behavioral and Cognitive Treatments

2. Family Based Treatments

3. Recovery Support Services

4. Addiction Medications

9

Behavior and Cognitive Treatments

Adolescent Community Reinforcement Approach

Contingency Management

Cognitive Behavior Therapy

Motivational Enhancement Therapy

10

Family-Based Treatment

Brief Strategic Family Therapy

Family Behavior Therapy

Family Support Network

Functional Family Therapy-CM

Mulitdimensional Family Therapy (MDFT)

Multisystemic Therapy-SU

Family-based interventions are highly effective – even superior

to individual and group formats (especially with ‘higher-end

need’ youth)

11

Recovery Support Services

Intended to reinforce gains made in treatment and improve

quality of life

Assertive Continuing Care

Mutual Help Groups

Peer Recovery Support Services

Recovery High Schools

High Fidelity Wraparound (HFWA)

12

Recovery Support Process

In addition to the recovery supports listed by NIDA, High Fidelity Wraparound (HFWA) is a planning process that matches up well to the unique needs of youth with COD.

HFWA is designed to facilitate ongoing planning and monitoring of the unique ongoing mental health and recovery support needs of youth with complex needs.

For youth with COD these supports might include both formal and informal supports including: recovery mentors, positive activities, positive peers, positive adults and connections, family recovery environment and supports, positive school connections, etc.

13

Substance use programs that impact mental health

Multi-dimensional

Family Therapy

SU EBP Psychotherapy around problem

behaviors

Addresses problem

behaviors in context of

family and eco-systemic

context

Seven Challenges SU

Promising

Practice

Skill building for substance use

behaviors that also benefits

MH behaviors (e.g., problem

solving ; stress reduction etc.);

underlying trauma that affects

SU is addressed

Curriculum based, skill

building focused.

Typically implemented in

group setting

Adolescent

Community

Reinforcement

Approach (ACRA)

SU-EBP Emphasizes development of

prosocial replacement activities

and behaviors

Skill training in problem-

solving, communication, and

prosocial skills

Implemented in

outpatient, intensive

outpatient, and

residential treatment

settings.

Mental health programs that impact substance use

behaviors

EBP Treatment Tx Focus Treatment Modality Level of MH and SU

integration

Multi-systemic

Therapy (MST)

Externalizing

Behavior EBP

Family therapy (office

based or home based)

Contingency management

for SUD

Does not address

internalizing disorders or

how they impact

externalizing behaviors

(and vice versa)

Functional Family

Therapy (FFT)

Externalizing

Behavior EBP

Parent skills training

Extensive safety planning

Contingency management

for SUD

Does not address

internalizing disorders or

how they impact

externalizing behaviors

(and vice versa)

Intentional Integration vs.

Combined Treatment

Important to differentiate between intentional integrated treatment and combined treatment

Combined treatment: EBP’s designed for one area of focus (SU; MH; or JJ) are combined together with a secondary focus into one treatment.

Intentional integrated treatment addresses the interaction patterns and mutual effects of MH on SU and SU on MH

Formulate integrated conceptualization of the interaction between SU and MH behaviors in context of the youth’s family, culture, peers, school, and greater community

Treatment programs specifically designed to treat

youth with co-occurring MH and SU

Program Level of

Evidence

EBP’s incorporated Level of integration

FIT (Family

Integrated

Transitions)

Target: youth being

transitioned from

incarceration

Promising for

Co-occurring

MST with elements of

DBT, MI, Relapse

Prevention

Component-based; one

clinician provides all

services

ICT (Integrated Co-

Occurring Treatment)

Youth diagnosed with

SU (Abuse and

Dependency) and

MH (internalizing

and externalizing

disorders)

Promising for

co-occurring

Comprehensive

evidence-informed

treatments based on

need

One clinician provides all

the services;

Comprehensive contextual

integration that addresses

the reciprocal interaction

of mental health,

substance use, trauma,

development, and

contextual factors

Syst

em

of

Care

Pri

nci

ple

sHome-Based Service Delivery

Modality

Multidimensional and Integrated

Assessment and Conceptualization

Comprehensive and Integrated

Treatment Array Matched to

Needs and Strengths

Systemic Engagement and Change

ICT Model Components

18

Resilie

ncy

-Orie

nte

d D

eve

lopm

enta

l

Persp

ective

Copyright 2006, 2009

Center for Innovative Practices

Contextual Assessment

School

Family

Peers Community

Informal Supports

+

+

+

+

-

- -

-

Work

+

-

+

-Youth

+ = Protective Factors

- = Risk Factors

Integrated and Comprehensive

Treatment Matched to Need20

Recovery &Resiliency

Eco-systemic Functioning

Basic Skills and Coping

Basic Needs, Safety, and Stabilization

Youth and Family Need Hierarchy (Shepler, 1991, 1999)

Establish Positive

Connections & Functional

Success through Relational

Supports and Strategic

Accommodations

Engagement;

Readiness to

Change

Copyright 2014

Center for Innovative

Practices

Solidify Structure,

Supervision, &

Monitoring

Build Protective Factors:

Pro-Social Recovery

Environments, Asset

Building; Supports

ICT Comparison Study

All Youth Considered Together

Substance use variables (GRAD; Drug Screens)

Mental health variables: (Ohio Scales; GRAD)

Family/Parenting (GRAD)

Pro-Social Activities (GRAD)

Educational Functioning (GRAD)

ICT Did Better than TAU

Substance Use Variables (GRAD; Drug Screens)

Mental Health Problem Severity: (GRAD only)

Pro-Social Activities (GRAD)

Pro-Social Peers (GRAD-Parent Rating)

Family/Parenting (GRAD-Youth Rating)

Human Resource Challenges

Finding and attracting professionals who have co-occurring skill sets is challenging

Most staff come with skills and perspectives specific to one area (mental health or substance use)

We have a shortage of professionals trained in substance abuse assessment and treatment.

Community-based and co-occurring skill sets are typically not covered in pre-service graduate programs.

Burden falls on community agencies and clinical supervisors to train staff with the least amount of experience to work with the most at-risk populations

Example of Funding Sustainability for Integrated Co-Occurring Treatment

ProgramLocation Initial Funding Sources Ongoing Funding Sources

Summit County, Ohio

(2001 to present)

Federal Juvenile Justice Grants: Byrne;

JAIBG 2001-2004;

Behavioral Health Juvenile Justice (BHJJ) state

funding;

Medicaid and Insurance;

Local Court funding (RECLAIM- state ODYS

funding);

MHRS Board

Cuyahoga County, Ohio

(2006 - present)

SAMHSA System of Care (2006-2008) &

CSAT funding: 2006-2007;

Medicaid and insurance;

State BHJJ; ADAMH Board Funding

Kalamazoo County, Michigan

(2006 - present)

SAMHSA System of Care: 2006- 2009 Medicaid and insurance

McHenry County, Illinois

(2008 -present)

SAMHSA System of Care: 2008-2012 Medicaid and insurance

Franklin County, Ohio

(2011 to present)

Federal Bureau of Justice Affairs (BJA)

Re-Entry Implementation Grant: 2011-

2012

BHJJ (State)

Medicaid and insurance

ADAMH Board funding

Montana (Helena, Missoula,

Billings) 2013 - present

State Adolescent Treatment Enhancement

& Dissemination Grant (SAT-ED) 2013-

current

Medicaid and insurance

Lorain County, Ohio (2014-

present)

BHJJ

Medicaid

Mental Health Board

BHJJ

Medicaid

Mental Health Board

Lessons Learned

Intensive clinical supports are needed to help manage risk and safety (active safety planning and monitoring, and 24-hour on-call availability)

Engagement and motivation to change is slower

Optimal effects are more likely to be achieved using interventions that impact youth behaviors, family systems, peer relationships, and school functioning together

Ongoing treatment and supports may be needed

For integration to be effective- needs to occur at the policy, funding, and treatment levels

Collaboration with key system partners is essential (especially Courts & Schools)

Education of referral sources about prevalence of youth with co-occurring disorders and need for integrated treatment

Take Home Points

We are already serving these youth

How do we this more intentionally and integrated?

It is possible to build and sustain co-occurring

treatment programming

Co-occurring skill sets are teachable and many are

in your tool kit already and can be translated to

use with SU

Resources

Briefs:

Providing Effective Treatment for Youth with Co-Occurring Disorders

http://www.ncmhjj.com/wp-content/uploads/2013/10/Treatment-Brief-FINAL-web1.pdf

Prevalence of Youth Drug Use, Mental Health and Co-Occurring Disorder -http://www.scribd.com/doc/246378645/Case-Western-Brief-1

Screening and Assessment for Substance Use, Mental Health and Co-Occurring Disorders in Adolescents - http://www.scribd.com/doc/246378890/Case-Western-Brief-2

Overview of Evidence-Based Promising Treatment Practices for Youth With Substance Use and Co-Occurring Disorders - http://www.scribd.com/doc/254697414/Case-Western-Brief-3

Implementing Treatments for Youth with Co-Occurring Mental Health and Substance Use Disorders: Opportunities and Challenges - http://www.scribd.com/doc/253213432/Case-Western-Brief-5

Expected Outcomes in Substance Use Disorder Treatment for Youth -http://www.scribd.com/doc/254014789/Case-Western-Brief-4#scribd

Websites:

National Center for Juvenile Justice and Mental Health: http://www.ncmhjj.com

Chestnut Health Systems: http://www.chestnut.org/

Center for Innovative Practices: http://begun.case.edu/cip/practices/integratedtreatment

References

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United

States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-

4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/data/

Chan, Y., Dennis, M., & Funk, R.. (2008). Prevalence and comorbidity of major internalizing and

externalizing problems among adolescents and adults presenting to substance abuse treatment.

Journal of Substance Abuse Treatment (34), p. 19).

Cocozza, J.J., & Shufelt, J.L. (June 2006). Youth with Mental Health Disorders in the Juvenile Justice

System: Results from a Multi-State Prevalence Study. National Center for Mental Health and Juvenile

Justice.

Dennis, M. L., Godley S. H., Diamond, G., Tims, F.M., Babor, T., Donaldson, J., … Funk, R. (2004). The

Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance

Abuse Treatment, 27, 197- 213.

Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R., Passetti, L. L., & Petry, N. M. (2013)

Johnston, L. D., O’Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenberg, J. E. (2016).

Monitoring the Future national survey results on drug use,1975-2015: Overview, key findings on

adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan.

Joint CMCS and SAMHSA Informational Bulletin (2015). Coverage of Behavioral Health Services for

Youth with Substance Use Disorders.

References

Kretschmar, J. & Butcher, F (2016). Behavioral Health and Juvenile Justice, Ohio DYS Grant.

Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National

Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication

No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, p. 6

Substance Abuse and Mental Health Services Administration. (2013). What does the research tell us

about good and modern treatment and recovery services for youth with substance use disorders?

Report of the SAMHSA Technical Expert Panel. Rockville, MD: Center for Substance Abuse Treatment,

Substance Abuse and Mental Health Services Administration.

Teplin, L.A, Abram, K.M., Washburn, J.J., Welty, L.J., Hershfield, J.A., & Dulcan, M.K. (February 2013).

The Northwest Juvenile Project: Overview. Juvenile Justice Bulletin. U.S. Department of Justice. Office

of Juvenile Justice and Delinquency Prevention.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. (2015). Guide

for Policy Makers: Prevention, Early Intervention and Treatment of Risky Substance Use and Addiction.

New York. Author.

Turner, W.C, Muck, R.D, Muck, R.J., Stephens, R.L., & Sukumar B. (2004). Co-Occurring Disorders in the

Adolescent Mental Health and Substance Abuse Treatment Systems. Journal of Psychoactive Drugs,

36(4): 455-462.

Contact Information

Rick Shepler, Ph.D., PCC-S, Director

Center for Innovative Practices at the Begun Center for

Violence Prevention, at MSASS, Case Western Reserve

University

Richard.shepler@case.edu