dual diagnosis– understanding the unique challenges facing children suffering from co-occurring...
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Dual Diagnosis– Understanding the Unique Challenges Facing Children
Suffering from Co-occurring Behavioral Health and Addiction Disorders
Randolph D. Muck, M.Ed.
Advocates for Youth and Family Behavioral Health
Treatment, LLC
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We know the parents are really the problem!
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Ea
rly In
terven
tio
n
and
Pr
even
tio
n
are Imp
ortan
t b
ecau
se . . . .
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Lin
k B
etw
een
P
ercep
tio
n
and
U
se
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Examples of Treating Adolescents with Co-occurring Disorders
• An integrated approach to treating issues
Integrated Co-Occurring Treatment Model (ICT)-Ohio Dept. of MH, State and Center for Innovative Practices, child Guidance and Family Solutions
• Gender and Cultural Competence Voices, Stephanie Covington
• Continuing CareAssertive Continuing Care, Susan Godley,
et al
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7
Multiple Clinical Problems are the NORM!
20%
41%
80%
48%
33%
63%
11%
24%
14%
34%
27%0% 10
%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Alcohol
Cannabis
Other drug disorder
Depression
Anxiety
Trauma
ADHD
CD
Suicide
Victimization
Violence/ illegal activity
Source: CSAT 2009 Summary Analytic Data Set (n=20,826)
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Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars
The Cost of Substance Abuse Treatment is Trivial Relative to the Costs Treatment Reduces
$407$1,132$1,249$1,384$1,517$2,486$4,277
$10,228$14,818
$0 $10,
000
$20,
000
$30,
000
$40,
000
$50,
000
$60,
000
$70,
000
Screening & Brief Inter.(1-2 days)Outpatient (18 weeks)
In-prison Therap. Com. (28 weeks) Intensive Outpatient (12 weeks)
Adolescent Outpatient (12 weeks)Treatment Drug Court (46 weeks)
Methadone Maintenance (87 weeks)Residential (13 weeks)
Therapeutic Community (33 weeks)
$22,000 / year to incarcerate an adult
$30,000/ child-year in foster care
$70,000/year to keep a child in detention
• $750 per night in Medical Detox• $1,115 per night in hospital • $13,000 per week in intensive care for premature baby• $27,000 per robbery• $67,000 per assault
SBIRT models popular due to ease of implementation and low cost
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Investing in Substance Abuse Treatment Results in a Positive Return on Investment (ROI)
• Substance abuse treatment has an ROI of between $1.28 to $7.26 per dollar invested.
• Consequently, for every treatment dollar cut in the proposed budget, the actual costs to taxpayers will increase between $1.28 and $7.26.
• How will this happen? Individuals needing substance abuse treatment will not disappear but instead interface with much more expensive systems such as emergency rooms and prisons.
• Bottom line = The proposed $55 million dollar cut will cost Illinois taxpayers between $70 and $400 million within the next 1 to 2 years.
Source: Bhati et al., (2008); Ettner et al., (2006)
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Similarity of Clinical Outcomes : Cannabis Youth Treatment (CYT)
Source: Dennis et al., 2004
200
220
240
260
280
300
Tota
l day
s ab
stin
ent.
over
12
mon
ths
0%
10%
20%
30%
40%
50%
Per
cen
t in
Rec
ove
ry.
at M
onth
12
Total Days Abstinent* 269 256 260 251 265 257
Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19
MET/ CBT5 (n=102)
MET/ CBT12
FSN (n=102)
MET/ CBT5 (n=99)
ACRA (n=100)
MDFT (n=99)
Trial 1 Trial 2
* n.s.d., effect size f=0.06** n.s.d., effect size f=0.12
* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16
Not significantly different by condition.
But better than the average for OP in ATM (200 days of
abstinence)
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Moderate to large differences in Cost-Effectiveness by Condition
Source: Dennis et al., 2004
$0
$4
$8
$12
$16
$20
Cos
t pe
r da
y of
abs
tinen
ce o
ver
12 m
onth
s
$0
$4,000
$8,000
$12,000
$16,000
$20,000
Cos
t pe
r pe
rson
in r
eco
very
at
mon
th 1
2
CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38
CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775
MET/ CBT5
MET/ CBT12
FSN MET/ CBT5
ACRA MDFT
* p<.05 effect size f=0.48** p<.05, effect size f=0.72
Trial 1 Trial 2
* p<.05 effect size f=0.22 ** p<.05, effect size f=0.78
MET/CBT5 and 12 did better
than FSN
ACRA did better than MET/CBT5, and both did
better than MDFT
Suggest the need to consider cost-effectiveness of treatment approaches
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Average% Use Levels of CareTEDS-A 2009
Detox Residential IOP OP
Natl 3.7 15.6 15.6 65.1
State X 0.0 2.0 1.0 98.8
State Y 0.0 98.0 0 2.0
Standardized screening/assessment, appropriate level of care, continuum of system → better outcomes, fewer readmissions, cost savings
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13
Substance Use Careers Last for Decades
Cu
mu
lati
ve S
urv
ival
Years from first use to 1+ years abstinence
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median of 27 years from first use to 1+ years abstinence
Source: Dennis et al., 2005
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14
Substance Use Careers are Shorter with Sooner Treatment
Cu
mu
lati
ve S
urv
ival
20+
0-9*
10-19*
Year to 1st TxGroups
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
* p<.05 (different
from 20+)
Source: Dennis et al., 2005
Years from first use to 1+ years abstinence
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15
Substance Use Careers are Longer the Younger the Age
of First Use
Cu
mu
lati
ve S
urv
ival
Years from first use to 1+ years abstinence
under 15*
21+
15-20*
Age of 1st UseGroups
* p<.05 (different from 21+)
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Source: Dennis et al., 2005
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Interventions Associated With No or Minimal Change in Substance Use or
Symptoms• Passive referrals• Educational units alone• Probation services as usual• Unstandardized outpatient services as usual
Interventions associated with deterioration Treatment of adolescents with/in adult units
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Do you know what happens in group treatment?
Which EBP is this?
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53% Have Unfavorable Discharges
Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .
0% 20% 40% 60% 80% 100%
Outpatient(37,048 discharges)
IOP(10,292 discharges)
Detox(3,185 discharges)
STR(5,152 discharges)
LTR(5,476 discharges)
Total(61,153 discharges)
Completed Transferred ASA/ Drop out AD/Terminated
Despite being widely recommended, only 10% step down after intensive treatment
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12 to 17 18 to 25 26 or older0%
5%
10%
15%
20%
25%
7.4%
20.1%
7.0%
0.4% 1.1% 0.6%
Abuse or Dependence in past yearTreatment in past year
Substance Use Disorders are Common, US Treatment Participation Rates Are Low
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded
Few Get Treatment: 1 in 20 adolescents, 1 in 18 young adults, 1 in 11 adults
Much of the private funding is limited to 30 days or less and authorized day by day or week by week
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Potential AOD Screening & Intervention Sites
Adolescents (age 12-17)
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
0%
20%
40%
60%
80%
100%1% 0% 1%
4%
12%
29%
30%
93%
1% 1% 3% 5%
13%
35% 41
%
97%
1% 4%
9% 8% 12%
41%
42%
95%
10%
8%
15%
11% 23
%
49%
46%
95%
No use in past year Less than weekly use Weekly Use Abuse or dependence
% A
ny
Con
tact
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Early Adolescent Treatment Work
Source: Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003)
Worth Street Narcotic Clinic in NY – 743 youth
Federal Narcotic Farms in Lexington, KY & Fort Worth, TX 22-440/yr
Riverside Hospital in NYC – 250 youth
Teen Addiction Hospital Wards in several cities
Drug Abuse Reporting Program (DARP)- 5,405 youth (587 followed)
Treatment Outcome Prospective Study (TOPS)- 1042 youth (256 followed)
Services Research Outcome Study (SROS) - 156 youth
1910
1920
1930
1940
1950
1960
1970
1980
1990
1996
National Treatment Improvement Evaluation Study (NTIES) - 236 youth
Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A) - 3,382 youth (1,785 followed)
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The Current Renaissance of Adolescent Treatment Research
* Published and publicly available
Feature 1930-1997 1997-2012
Tx Studies* 17 Over 300
Random/Quasi 9 44
Tx Manuals* 0 30+
QA/Adherence Rare Common
Std Assessment* Rare Common
Participation Rates Under 50% Over 80%
Follow-up Rates 40-50% 85-95%
Methods Descriptive/Simple More Advanced
Economic Some Cost Cost, CEA, BCA
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23
Programs often LACK Evidenced Based Assessment to Identify and Practices to
Treat:
• Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment
• Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidal thoughts)
• Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime)
• HIV risk behaviors (needle use, sexual risk, victimization)
• Child maltreatment (physical, sexual, emotional)• Recovery environment and peer risk
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Assessment for ALL disorders
is needed because. . .• Having one disorder increases the risk of
developing another disorder;• The presence of a second disorder makes
treatment of the first more complicated;• Treating one disorder does NOT lead to
effective management of the other(s);• Treatment outcomes are poorer when co-
occurring disorders are present.
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Adolescents with SUD. . .(Meyers et al)
• 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;
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In practice we need a Continuum of Measurement (Common Measures)
• Screening to Identify Who Needs to be “Assessed” (5-10 min)– Focus on brevity, simplicity for administration & scoring– Needs to be adequate for triage and referral– GAIN Short Screener for SUD, MH & Crime– ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD– SCL, HSCL, BSI, CANS for Mental Health– LSI, MAYSI, YLS for Crime
• Quick Assessment for Targeted Referral (20-30 min)– Assessment of who needs a feedback, brief intervention or referral
for more specialized assessment or treatment– Needs to be adequate for brief intervention– GAIN Quick – ADI, ASI, SASSI, T-ASI, MINI
• Comprehensive Biopsychosocial (1-2 hours) – Used to identify common problems and how they are interrelated– Needs to be adequate for diagnosis, treatment planning and
placement of common problems– GAIN Initial (Clinical Core and Full)– CASI, A-CASI, MATE
• Specialized Assessment (additional time per area)– Additional assessment by a specialist (e.g., psychiatrist, MD,
nurse, spec ed) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan
– CIDI, DISC, KSADS, PDI, SCAN
Screener Q
uick Com
prehensive S
pecial
Mo
re E
xtensive
/ Lon
ge
r/ Expe
nsive
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The New Age of Adolescent Services
Pooled Data now <30 ,000• Treatment of adolescents with adult models
and/or mixed with adults does not work and is actually associated with drop out and increased use
• Need to modify models to be more developmentally appropriate for youth
• Need to assess and treat a wider range of problems including victimization, co-occurring mental health needs, and education needs
• Need to modify materials to be more concrete and use examples relevant to youth
• Don’t stop asking questions!
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28
Victimization and Level of Care Interact to Predict Outcomes
Source: Funk, et al., 2003
0
5
10
15
20
25
30
35
40
Intake 6 Months Intake 6 Months
Mar
ijua
na U
se (
Day
s of
90)
OP -High OP - Low/Mod Resid-High Resid - Low/Mod.
CHS Outpatient CHS Residential Traumatized groups have higher severity
High trauma group does not respond to OP
Both groups respond to residential treatment
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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 behavior– Co-occurring disorders
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30
46%
71%
15%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Low (0) Moderate (1-3) High (4-15)
None
One
Two
Three
Four
Five to Twelve
The Number of Major Clinical Problems
is highly related to Victimization
Source: CSAT 2009 Summary Analytic Data Set (n=21,784)
Significantly more likely to
have 5+ problems
(OR=13.9)
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They had the audacity to hi-jack Christmas
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Tanner-Smith, E.E., Wilson, S.J, & Lipsey, M.W. ( ).
The comparative effectiveness of outpatient treatment for adolescent
substance abuse: A meta-analysis. Journal of
Substance Abuse Treatment , in press.
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Interventions that Typically do Better than Practice in Reducing Recidivism
(29% vs. 40%)• Aggression Replacement Training• Brief Strategic Family Therapy• Reasoning & Rehabilitation• Moral Reconation Therapy• Thinking for a Change• Interpersonal Social Problem Solving• Multisystemic Therapy• Functional Family Therapy• Multidimensional Family Therapy• Adolescent Community Reinforcement Approach• MET/CBT combinations and Other manualized CBT
Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004
NOTE: There is generally little or no differences in mean effect size between these brand names
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34
Implementation is Essential (Reduction in Recidivism)
The effect of a well implemented weak program is as big as a strong program implemented poorly
The best is to have a strong program implemented well
Thus one should optimally pick the strongest intervention that one can implement well
Source: Adapted from Lipsey, 1997, 2005
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% Change: Abstinence at 6-months post-initial
assessment
*MET/ *ACRA/ **TARGET **SEE
CBT 5 ACC YOUTH YOUTH
60.6 69.3 12.6 21.1
* GAIN Mandated
** GAIN Optional
Source: SAIS System (GPRA)
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36 Site Type IV Replication MET/CBT5
AK
AL
ARAZ
CA CO
CT
DC
DE
FL
GA
HI
IA
ID
IL IN
KS KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PARI
SC
SD
TN
TX
UTVA
VTWA
WI
WV
WY
CYT: 4 Sites
EAT: 36 Sites
Source: Dennis, Ives, & Muck, 2008
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Replication and Site Effects
• Treatment can vary by implementation within site/clinic
• We want to compare the range of implementation in practice with the clinical trials
• In order to compare sites, we will at both the central tendency (median) and distribution using a Tukey Box Plot like the one shown here.
Criteria
Median
Middle 50%
“Range”
-2.00
-1.50
-1.00
-0.50
0.00
0.50
1.00
1.50
2.00
2.50
3.00
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Range of Effect Sizes (d) for Change in Days of Abstinence (intake to 12 months) by Site
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
4 CYT Sites (f=0.39)(median within site d=0.29)
36 EAT Sites (f=0.21)(median within site d=0.49)
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
Coh
en’s
d
Source: Dennis, Ives, & Muck, 2008
EAT Programs did Better than
CYT on average
75% above CYT median
6 programs completely above CYT
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39
Change in Abstinence by level of Quality Assurance: Adolescent Community Reinforcement Approach (A-CRA)
4%
24%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Training Only Training, Coaching,Certification, Monitoring
% P
oint
Cha
nge
in A
bsti
nenc
e
Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)
Effects associated with Coaching, Certification
and Monitoring (OR=7.6)
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Drugs seem so sweet when you meet them – hey her clip is pink, she doesn’t want to hurt anyone
Like falling in love for the fist time
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41
Crime/Violence and Substance Problems Interact to Predict Violent Crime or Arrest
Low
Mod.
High
LowMod
.High
Source: CYT & ATM Data
12 m
onth
rec
idiv
ism
To
vio
lent
cri
me
or a
rres
t
Substance Problem
Scale
Crime and Violence
Scale
0%
20%
40%
60%
80%
100%
Crime/ Violence predicted
violent recidivism
(Intake) Substance Problem Severity did
not predict violent recidivism
Knowing both was the best predictor
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Overlap with Crime and Violence (cont.)
• Crime levels peak between ages of 15-20 (periods of increased stimulation and low impulse control in the brain)
• Adolescent crime is still the main predictor of adult crime
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Treating Teens:
A Guide to Adolescent Drug Programs
http://drugstrategies.com/treatingteens.html
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Co-occurring Mental Health Symptoms
A Comparison of Nine Treatment Approaches • Seven Challenges
• Chestnut Health Systems
• Adolescent Community Reinforcement Approach
• Multi-Systemic Therapy
• Multi-Dimensional Family Therapy
• Motivational Enhancement Therapy-Cognitive Behavioral Therapy 5 sessions
• Family Support Network
44
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Change (post-pre) Effect Size for Emotional Problems by Type of
Treatment-0
.54
-0.4
3
-0.4
5 -0.3
9
-0.3
7
-0.3
7
-0.3
4 -0.2
9
-0.2
9
-0.1
8
-0.2
8
-0.1
9
-0.3
2
-0.1
9
-0.1
5
-0.2
1 -0.1
3 -0.0
8
-0.0
8
-0.0
9
-0.1
4
-0.2
2
-0.0
4
-0.1
3
-0.1
2 -0.0
8
-0.1
6
-0.80
-0.60
-0.40
-0.20
0.00
0.20
SevenChallenges
(n=114)
CHSTreatment(n=192)
A-CRA-CYT/AAFT
(n=2144) MST(n=85)
MDFT(n=258)
METCBT-CYT/EAT(n=5262)
METCBT-Other
(n=878) FSN
(n=369)
A-CRA-Other
(n=276)
Cha
nge
Eff
ect S
ize
d ((
mea
n fo
llow
-up
- m
ean
inta
ke)/
std
dev
. int
ake)
Emotional Problem Scale Days of traumatic memories Days of victimization
Four best on mental health outcomes include 7 challenges,
CHS, A-CRA, & MST
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Workforce Implications
• All programs reduced mental health / trauma problems with 4 doing particularly well: Seven Challenges, CHS, A-CRA, & MST
• A-CRA with a mix of BA/MA did as well as MST which targets MA level therapists and family therapists that are often in short supply
• Seven Challenges, with a mix of para-professional (non-degreed), BA/MA therapists did as well as A-CRA and MST
• While it is not the most effective, the shortest & least expensive (MET/CBT5) still has positive effects
46
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Farm Party Anyone?
Ever evolvingCyclical nature of use
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Wh
at the Brai
n Science Presente
d W
ill N
ot D
o
Make you an expert in the
science of the brain (or return to your brain everything you have forgott
en since undergraduate school).Assist you in obtaining funding for PET/M
RI/fMRI
or other technologies to screen all of your youth.Provide all of the inform
ation about the adolescent brain that is useful to know
. Sett
le the argument:
addiction is/is not a diseaseN
o quiz will follow
the presentation.
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Continuing Care
• The continuation of services in a seamless flow is imperative for successful client outcomes
• All too often, they fall through the cracks in the system
= 14 days
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Do adolescents attend 12 step meetings after residential
discharge?
85%
42%
4.5
00%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Attended One or More Meetings Median No. Meetings Attended0
1
2
3
4
5
6
7
8
9
10
Adults Adolescents
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Assertive Continuing Care
• The Assertive Continuing Care Protocol (ACC) is a continuing care intervention specifically designed for adolescents following a period of residential treatment.
• ACC is delivered primarily through home visits. • ACC case managers are assertive in their attempts
to engage participants.• Case managers deliver the Adolescent Community
Reinforcement Approach (ACRA) procedures
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Early (0-3 mon.) Abstinence Then Improves Sustained (4-9 mon.)
Abstinence
Source: Godley et al 2002, 2007
19% 22% 22%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*)
Early(0-3 mon.) Relapse
69%
59%
73%
Early (0-3 mon.) Abstainer * p<.05
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Self-Management and Recovery Training: (SMART) Recovery
• Origins in Rational Emotive Therapy• Portable, applicable in real world, online
groups• Group Modality
– Led by trained facilitators– Open enrollment– Uses common elements of CBT– Considered easy to learn and use– http://www.smartrecovery.org/intro/
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Technological Approaches CONTINUING CARE/Ongoing
Supportive Services– University of Arizona – pod casting, texting, geo-
fencing• 90 – 95% Engagement, Utilization, Satisfaction
– Recovery Services for Adolescents and their Families (RSAF) CSAT Research Project (Cell phone, Texting, Web Site, CRAFT for Parent Groups)
– Dick Dillon , St. Louis – Second Life• Continuing Care Participation Increased from
40% to 90% over 6 months
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Normal Adolescent Development
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Normal Adolescent Development
Based on the stage of their brain development, adolescents are more likely to:• act on impulse• misread or misinterpret social cues and
emotions• get into accidents of all kinds• get involved in fights• engage in dangerous or risky behavior
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Normal Adolescent Development
Adolescents are less likely to:• think before they act• pause to consider the potential consequences
of their actions• modify their dangerous or inappropriate
behaviors
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Normal Adolescent Development
• Movement Towards Independence• Struggle with sense of identity • Feeling awkward or strange about one's self
and one's body • Focus on self, alternating between high
expectations and poor self-esteem • Interests and clothing style influenced by peer
group • Moodiness
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Normal Adolescent DevelopmentMovement Towards Independence, Cont. • Improved ability to use speech to express
one's self• Realization that parents are not perfect;
identification of their faults • Less overt affection shown to parents, with
occasional rudeness • Complaints that parents interfere with
independence • Tendency to return to childish behavior,
particularly when stressed
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Normal Adolescent Development
• Future Interests and Cognitive Changes
• Mostly interested in present, with limited thoughts of the future
• Intellectual interests expand and gain in importance
• Greater ability to do work (physical, mental, emotional)
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Normal Adolescent Development• Sexuality• Display shyness, blushing, and modesty • Girls develop physically sooner than boys • Increased interest in sex • Movement toward heterosexuality with fears
of homosexuality • Concerns regarding physical and sexual
attractiveness to others • Frequently changing relationships • Worries about being normal
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Normal Adolescent Development
• Morals, Values, and Self-Direction• Rule and limit testing • Capacity for abstract thought • Development of ideals and selection of role
models • More consistent evidence of conscience • Experimentation with sex and drugs
(cigarettes, alcohol, and marijuana)
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Time for a BreakDo I Want a Cookie or Cocaine?
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How Does the Brain Communicate?
• Neuron to Neuron• Neurotransmitters - The Brain's Chemical
Messenger • Receptors - The Brain's Chemical Receivers• Transporters - The Brain's Chemical Recyclers
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Everyone who has watched futurama knows slugs will feed on your brain
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How did this happen? She was so good to me! The colors are pretty.
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Right lateral and top views of the dynamic sequence of maturation over the cortical surface
Gogtay N et al. PNAS 2004;101:8174-8179
©2004 by National Academy of Sciences
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Brain Activity on PET Scan After Cocaine Use
Be VERY Careful with interpretation of data/ imaging studies!
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Summary• Know what treatment services are provided
(EBP?, Appropriate for identified problems?, Implemented with fidelity?)
• Understand brain science and addiction• Ensure EBPs used that can be done well given
limitations (staff experience/training, cost, belief in approach)
• Push for appropriate services and demand outcome data and ongoing
CLINICAL SUPERVISION • DO NOT Ignore Continuing
Care/Supportive Services! =