Integrated Co-Occurring Integrated Co-Occurring Treatment (ICT) Treatment (ICT) ©©

A Developing Practice for Youth with Co-A Developing Practice for Youth with Co-Occurring Conditions and Juvenile Occurring Conditions and Juvenile

Justice InvolvementJustice Involvement

The Center for Innovative The Center for Innovative PracticesPractices

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What is Integrated What is Integrated Treatment?Treatment?

Mental Health and Substance Abuse Mental Health and Substance Abuse Services are integratedServices are integrated

One provider teamOne provider team

One assessmentOne assessment

One treatment planOne treatment plan

One youthOne youth

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Why Integrated Care?Why Integrated Care?

Unrecognized mental health disorders reduce Unrecognized mental health disorders reduce engagement, retention and completion engagement, retention and completion

Untreated co-morbid disorders persist after Untreated co-morbid disorders persist after recovery: ADHD, Mood Disordersrecovery: ADHD, Mood Disorders

After recovery from SUD, depression in youth is After recovery from SUD, depression in youth is much more likely to persist compared to adults.much more likely to persist compared to adults.

(Turner)(Turner)

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Co-occurring Disorders with Co-occurring Disorders with Juvenile Justice Involved YouthJuvenile Justice Involved Youth

63% of juvenile detainees assessed with a 63% of juvenile detainees assessed with a substance abuse disorder were also co-morbid for substance abuse disorder were also co-morbid for at least one mental health diagnosis (Cleveland at least one mental health diagnosis (Cleveland SAMHSA SCY project, Hussey, D., Drinkard, A., SAMHSA SCY project, Hussey, D., Drinkard, A., Murphy, M., & Ols, K., March, 2005).  Murphy, M., & Ols, K., March, 2005). 

60% of youth with a substance abuse diagnosis 60% of youth with a substance abuse diagnosis had a co-morbid psychiatric diagnosis of which had a co-morbid psychiatric diagnosis of which conduct disorder and oppositional defiant conduct disorder and oppositional defiant disorder were the most common co-morbid disorder were the most common co-morbid diagnoses (Armstrong and Costello 2002)diagnoses (Armstrong and Costello 2002)

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OJJDP Multi-State Prevalence OJJDP Multi-State Prevalence StudyStudy (Skowrya & Cocozza, (Skowrya & Cocozza,

2006)2006) 70.4% of justice-involved youth meet criteria for a 70.4% of justice-involved youth meet criteria for a

diagnosable mental disorderdiagnosable mental disorder

27% of justice-involved youth have serious mental 27% of justice-involved youth have serious mental disordersdisorders

55.2% met criteria for at least two diagnoses55.2% met criteria for at least two diagnoses

90.3% of youth with Conduct Disorder also met criteria for 90.3% of youth with Conduct Disorder also met criteria for at least one other disorderat least one other disorder

37.5% of youth in the sample had both a mental 37.5% of youth in the sample had both a mental health disorder and a substance use disorderhealth disorder and a substance use disorder

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MH Needs of Youth in JJ SystemMH Needs of Youth in JJ SystemNIMH Study (Teplin et al., NIMH Study (Teplin et al.,

2002)2002) 66% of boys and 75% of girls in Cook County 66% of boys and 75% of girls in Cook County Juvenile Detention had at least 1 psychiatric Juvenile Detention had at least 1 psychiatric disorderdisorder

50% abused or addicted to drugs50% abused or addicted to drugs

When Conduct Disorder removed, 60% of males When Conduct Disorder removed, 60% of males and 66% of females met Dx criteria one or more and 66% of females met Dx criteria one or more MH or SA disordersMH or SA disorders

Rates of dysthymia or depression: 17.2% for Rates of dysthymia or depression: 17.2% for males; 26.3% for femalesmales; 26.3% for females

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Treating one disorder in Treating one disorder in isolation is not sufficient isolation is not sufficient

Substance abuse treatmentSubstance abuse treatment helps to helps to reduce the frequency of use and the reduce the frequency of use and the number of abuse/dependence symptoms number of abuse/dependence symptoms but has only but has only indirect impactindirect impact on emotional on emotional and behavioral problemsand behavioral problems (M. Dennis, 2004)(M. Dennis, 2004)

Psychiatric treatment alonePsychiatric treatment alone for youth with for youth with mood disorders and co-occurring SUD mood disorders and co-occurring SUD does notdoes not significantly reduce substance significantly reduce substance useuse (Geller et al., 1998) (Geller et al., 1998)

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Integrated Co-occurring Treatment Integrated Co-occurring Treatment

(H. Cleminshaw and R. Shepler; P. Kanary)(H. Cleminshaw and R. Shepler; P. Kanary)

ICT Model DefinitionICT Model Definition ICT is an integrated treatment ICT is an integrated treatment

approach embedded in an intensive approach embedded in an intensive home-based model of service home-based model of service delivery, that serves youth with the delivery, that serves youth with the co-occurring conditions of substance co-occurring conditions of substance abuse and serious emotional abuse and serious emotional disability disability

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Key Components of ICTKey Components of ICT System of care service philosophySystem of care service philosophy Home-based service delivery model Home-based service delivery model Integrated Contextual Treatment (MH and SA)Integrated Contextual Treatment (MH and SA) Comprehensive service array matched to needComprehensive service array matched to need Focus on risk and protective factor (resilience)Focus on risk and protective factor (resilience)

Resulting in an integrated approach that identifies Resulting in an integrated approach that identifies the strengths and needs of the youth and family, the strengths and needs of the youth and family, in context of the culture, community, and various in context of the culture, community, and various systems’ mandates.systems’ mandates.

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ICT Target PopulationICT Target Population

Adolescents who have a diagnosable Adolescents who have a diagnosable substance use/abuse disorder AND a substance use/abuse disorder AND a mental health disorder (excluding sole mental health disorder (excluding sole diagnosis of conduct disorder). The diagnosis of conduct disorder). The severity of the disorders are such that severity of the disorders are such that the youth experiences serious the youth experiences serious impairment in major life domains, impairment in major life domains, particularly increased risk for particularly increased risk for involvement in the juvenile justice involvement in the juvenile justice system and/or out of home placement.system and/or out of home placement.

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Home-Based ServiceHome-Based ServiceDelivery ModelDelivery Model

Location of Service:Location of Service: Home & Home & CommunityCommunity

Intensive: Intensive: 2-5 sessions/wk2-5 sessions/wk Crisis ResponseCrisis Response 24/724/7 Small caseloads: Small caseloads: 3-6 families3-6 families Flexible:Flexible: Convenient to Convenient to

familyfamily Treatment Duration:Treatment Duration: 12-24 weeks12-24 weeks

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Objectives of ICTObjectives of ICT To provide clinicians with a process and framework for To provide clinicians with a process and framework for

organizing information in order to assess, conceptualize, organizing information in order to assess, conceptualize, and intervene in a coordinated and integrated fashion. and intervene in a coordinated and integrated fashion.

To assist clinicians with positive engagement and retention To assist clinicians with positive engagement and retention of youth and families, as well as, better recognition of of youth and families, as well as, better recognition of family culture and contexts.family culture and contexts.

To aid clinicians, program leaders, and relevant To aid clinicians, program leaders, and relevant stakeholders in creating a service with realistic stakeholders in creating a service with realistic expectations for the types of interactions and relationships expectations for the types of interactions and relationships necessary to reach mutual outcomes.necessary to reach mutual outcomes.

To improve treatment outcomes.To improve treatment outcomes.

To decrease clinician frustration, burnout, fatigue when To decrease clinician frustration, burnout, fatigue when dealing with a challenging population.dealing with a challenging population.

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Target OutcomesTarget OutcomesFAMILYFAMILY Create and maintain a Create and maintain a

family recovery family recovery environment environment

Reestablish hierarchy and Reestablish hierarchy and boundariesboundaries

Decrease family conflictsDecrease family conflicts Rebuild bonds and Rebuild bonds and

relationshipsrelationships Increase positive family Increase positive family

communication communication Increase supervision and Increase supervision and

monitoringmonitoring Collaborative Problem Collaborative Problem

Solving (Greene & Ablon)Solving (Greene & Ablon)

YOUTHYOUTH Living at home or in a Living at home or in a

permanent home settingpermanent home setting Attending and achieving at Attending and achieving at

school/workschool/work Reduced involvement in Reduced involvement in

the JJ systemthe JJ system Reduced use of substancesReduced use of substances Participating in positive Participating in positive

family, peer, and family, peer, and community lifecommunity life

Accessing resources and Accessing resources and natural supports as needed natural supports as needed to maintain gainsto maintain gains

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ICT YouthICT Youth Usual Services Usual Services Comparison Comparison

GroupGroup

Size of Size of Difference in Difference in commitment commitment

and/or and/or recidivism rates recidivism rates

56 youth 56 youth 25% recidivism rate25% recidivism rate

29 Youth 29 Youth 72% commitment 72% commitment raterate

Chi Square (1, 29): Chi Square (1, 29): 17.74 17.74

Level of Level of significance: .001significance: .001

Results of ICT Study (2001-2002)Results of ICT Study (2001-2002)

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Ohio Scales Gain Scores (2005 – October 2006)Ohio Scales Gain Scores (2005 – October 2006)General Clinical Population General Clinical Population

(Statewide)(Statewide) ICT ParticipantsICT Participants

30 days30 days 180 days180 days GainGain 30 days30 days 180 days180 days GainGain

Problem Severity AdultProblem Severity Adult 28.6028.60 22.7422.74 5.865.86 31.2831.28 19.3819.38 11.9011.90

Problem Severity ChildProblem Severity Child 23.9323.93 18.8518.85 5.085.08 30.3330.33 19.4819.48 10.8510.85

Hopefulness AdultHopefulness Adult 12.2912.29 10.6010.60 1.691.69 13.5213.52 10.8810.88 2.642.64

Hopefulness ChildHopefulness Child 10.6010.60 9.449.44 1.161.16 13.0913.09 10.1810.18 2.912.91

Satisfaction AdultSatisfaction Adult 8.878.87 6.426.42 2.452.45 10.2510.25 7.257.25 3.003.00

Satisfaction ChildSatisfaction Child 10.6010.60 8.538.53 2.072.07 10.1310.13 8.058.05 2.082.08

Functioning AdultFunctioning Adult 44.9844.98 48.6548.65 3.673.67 36.2036.20 44.7144.71 8.518.51

Functioning ChildFunctioning Child 55.7555.75 59.3459.34 3.593.59 49.4249.42 58.7658.76 9.349.34

Total = 27 youth; 3 Total = 27 youth; 3 ODYS ODYS CommitmentsCommitments

For "Functioning", the higher the score the better - for all others, the For "Functioning", the higher the score the better - for all others, the lower the score the better lower the score the better

Clinical cutoffs= 20 for problem severity and 51 for parent rating Clinical cutoffs= 20 for problem severity and 51 for parent rating functioning and 60 for youth rated functioningfunctioning and 60 for youth rated functioning

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Clinical and PolicyClinical and Policy Integrated documentation Integrated documentation Complexity of conceptualizationComplexity of conceptualization Finding and retaining staffFinding and retaining staff Need a county wide consistent assessment/screening Need a county wide consistent assessment/screening

process for youth with co-occurring disordersprocess for youth with co-occurring disorders Comprehensive understanding of populationComprehensive understanding of population Differing clinical perspectives between MH and SADiffering clinical perspectives between MH and SA Clinical capacity and certification/licensure to treat Clinical capacity and certification/licensure to treat

both disordersboth disorders Ethical and safety issues related to delivering Ethical and safety issues related to delivering

services in the home and communityservices in the home and community Complexity of putting it all togetherComplexity of putting it all together

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SystemicSystemic Aligning policy outcomes across public Aligning policy outcomes across public

entities, providers, and fundersentities, providers, and funders Setting Co-Occurring as a priority Setting Co-Occurring as a priority

treatment populationtreatment population Creating an infrastructure that supports Creating an infrastructure that supports

integrated treatmentintegrated treatment Creating funding streams that support Creating funding streams that support

integrated treatmentintegrated treatment Identifying cross systems shared outcomesIdentifying cross systems shared outcomes Resources to support research and Resources to support research and

evaluationevaluation

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FinancialFinancial

Need diverse and flexible funding to Need diverse and flexible funding to maximize effectiveness of the modelmaximize effectiveness of the model

Medicaid: 1) complicated documentation Medicaid: 1) complicated documentation and choices: MH vs. SA; 2) clinical impacts and choices: MH vs. SA; 2) clinical impacts of using Medicaid. E.g., not being able to of using Medicaid. E.g., not being able to directly address parent and family issues directly address parent and family issues and basic needsand basic needs

Fee for service not an effective or efficient Fee for service not an effective or efficient billing procedure for ICTbilling procedure for ICT

Funding innovative practices with Funding innovative practices with traditional funding streamstraditional funding streams

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ImplementationImplementation

Qualified practitioners and providersQualified practitioners and providers Initial training and ongoing coachingInitial training and ongoing coaching Organizational infrastructure to Organizational infrastructure to

support the modelsupport the model High level of collaboration among High level of collaboration among

MH, SA, JJ referrals sources and MH, SA, JJ referrals sources and partnerspartners

2020

More Information on ICTMore Information on ICT

Richard Shepler, Ph.D.Richard Shepler, Ph.D.ricks@starkmhb.orgricks@starkmhb.org

Eric BaltrinicEric Baltrinicebaltrinic@yahoo.comebaltrinic@yahoo.com

Patrick KanaryPatrick Kanarypatrick@cipohio.orgpatrick@cipohio.org

CIP: 330-455-3811CIP: 330-455-3811