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What a Difference 5 Minutescan make in the Lives of

Children and Adults: Screening for the Co-Occurring Disorders of Mental Health and

Substance Abuse

The 2007 ZarrowMental Health Symposium

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PresentersMary E. Dillon, MSW, Ed.D

OU OK-COSIG Associate Evaluator, Tulsa.

Andrew L. Cherry, DSW, ACSWOklahoma Endowed Professor of Mental Health

University of Oklahoma, School of Social Work, Tulsa.OU OK-COSIG Project Evaluator

L. D. Barney, ICAADC, MSW Student,University of Oklahoma, Norman Campus.

OK-COSIG Program Specialist, ODMHSAS, OKC

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Failing People with a Co-occurring Disorder

►The evidence from the field is that people with the co-occurring disorders of Mental Health, Trauma related Mental Health Issues and Substance Abuse are NOT benefiting from traditional mental health and substance abuse treatment.

►The evidence that current options are ineffective comes in the form of multiple treatment failures, years of lost productivity, and higher levels of involvement in the justice system.

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Rate of Incidence: Adults

►The need for better treatment options for people with a co-occurring disorder received critical support when the 2002 National Survey on Drug Use and Health in the United States reported that over 22% of adults with a serious mental illness and those who abuse alcohol or other drugs have a co-occurring problem of mental health and substance abuse.

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Rate of Incidence: Children

►A substantial number of children and adolescents also experience substance abuse disorders, mental disorders, or co-occurring disorders. A study of mental health service use among youth reveals that nearly 43% of youth who receive mental health services in the United States have been diagnosed with a co-occurring disorder (CMHS, 2001).

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Understanding Co-Occurring Disorders

►The time between the onset of a mental disorder The time between the onset of a mental disorder and a subsequent substance abuse disorder and a subsequent substance abuse disorder represents an important “window of represents an important “window of opportunity” in which a co-occurring disorder opportunity” in which a co-occurring disorder may be prevented (Ziedonis, 1995). It suggests may be prevented (Ziedonis, 1995). It suggests not only the value of early diagnosis and not only the value of early diagnosis and treatment of mental disorders in youth, but also treatment of mental disorders in youth, but also the critical role for alcohol and drug testing as an the critical role for alcohol and drug testing as an important tool for prevention, early important tool for prevention, early identification and intervention.identification and intervention.

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The Window of Opportunity

►More than 40% of youth, ages 11 to 17, who had More than 40% of youth, ages 11 to 17, who had either a substance use diagnosis or moderate to either a substance use diagnosis or moderate to severe functional impairment as a result of severe functional impairment as a result of substance use, reported problems that included substance use, reported problems that included involvement with the police, missing school or involvement with the police, missing school or work, changing friends to those who drink or use work, changing friends to those who drink or use drugs, getting into arguments with family and drugs, getting into arguments with family and friends, and getting in trouble in school friends, and getting in trouble in school (Manteuffel et al., 2002).(Manteuffel et al., 2002).

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Missing the Window

►When an adolescent is “acting out”, most parents When an adolescent is “acting out”, most parents hope that it is a drug related behavior, rather than hope that it is a drug related behavior, rather than a mental health disorder. However, we as a mental health disorder. However, we as clinicians need to screen the adolescent for a co-clinicians need to screen the adolescent for a co-occurring disorder, and if indicated, help parents occurring disorder, and if indicated, help parents explore both issues. If we don’t we are missing a explore both issues. If we don’t we are missing a “window of opportunity” and it may be another 8 “window of opportunity” and it may be another 8 to 10 years before the adolescent is diagnosed to 10 years before the adolescent is diagnosed with a co-occurring disorder. with a co-occurring disorder.

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Missing the Window

►When an adolescent is “acting out”, most parents When an adolescent is “acting out”, most parents hope that it is a drug related behavior, rather than hope that it is a drug related behavior, rather than a mental health disorder. However, we as a mental health disorder. However, we as clinicians need to screen the adolescent for a co-clinicians need to screen the adolescent for a co-occurring disorder, and if indicated, help parents occurring disorder, and if indicated, help parents explore both issues. If we don’t we are missing a explore both issues. If we don’t we are missing a “window of opportunity” and it may be another 8 “window of opportunity” and it may be another 8 to 10 years before the adolescent is diagnosed to 10 years before the adolescent is diagnosed with a co-occurring disorderwith a co-occurring disorder. .

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Barriers to Treatment

►Children and adolescents with co-occurring Children and adolescents with co-occurring substance abuse disorders and mental disorders, substance abuse disorders and mental disorders, and their families face special challenges to and their families face special challenges to treatment. In part, the challenges arise because treatment. In part, the challenges arise because more knowledge is needed about the prevalence more knowledge is needed about the prevalence (rates) of co-occurring substance abuse disorders (rates) of co-occurring substance abuse disorders and mental disorders among children and and mental disorders among children and adolescents. We also need developmentally adolescents. We also need developmentally appropriate assessment standards to help in the appropriate assessment standards to help in the screening and diagnostic process.screening and diagnostic process.

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Effective Interventions

►While children and adolescents with co-While children and adolescents with co-occurring substance abuse and mental health occurring substance abuse and mental health disorders are not simply “small adults”, some of disorders are not simply “small adults”, some of the treatment issues are similar. As with adults, the treatment issues are similar. As with adults, co-occurring disorders in children and co-occurring disorders in children and adolescents vary in level of severity; as with adolescents vary in level of severity; as with adults, assessment is an ongoing process. Youth adults, assessment is an ongoing process. Youth should be able to move back and forth across the should be able to move back and forth across the level of care continuum based on their progress level of care continuum based on their progress and changes in environment.and changes in environment.

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A Major Barrier

►One of the major barriers to identifying people with a co-existing disorder has been the cost involved in assessment.

►This process has typically required two assessments. One assessment focused on mental health disorders.

►The second focused on substance abuse disorders.

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Eliminating Some of the Burden

►To eliminate part of this burden, a rapid-response screen was developed. The AC-OK Screen for Co-Occurring Disorders (Mental Health, Trauma Related Mental Health Issues & Substance Abuse) is intended to help determine if the person requesting help needs to be clinically assessed for a co-existing mental health and substance abuse problem.

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The Reliability and ValidityThe Reliability and Validity of the AC-OK Screen of the AC-OK Screen

for Co-Occurring Disorders for Co-Occurring Disorders (Mental Health, Trauma Related (Mental Health, Trauma Related

Mental Health Issues & Mental Health Issues & Substance Abuse)Substance Abuse)

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AC-OK Screen forAC-OK Screen forCo-Occurring DisordersCo-Occurring Disorders

►The findings that support the reliability and The findings that support the reliability and validity of this screen are based on the responses validity of this screen are based on the responses of 3,608 people who were screened between of 3,608 people who were screened between February and November of 2006. The February and November of 2006. The participants were seeking treatment from one of participants were seeking treatment from one of four mental health centers, one of three four mental health centers, one of three substance abuse treatment providers, or one of substance abuse treatment providers, or one of two programs that treat people with a co-co-two programs that treat people with a co-co-occurring disorder.occurring disorder.

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The Psychometric Properties of the ScreenThe Psychometric Properties of the Screen

► The process used to determine the psychometric The process used to determine the psychometric properties of this screen was first to verify that the properties of this screen was first to verify that the questions in each of the subscales (mental health and questions in each of the subscales (mental health and substance abuse items) were conceptually related and substance abuse items) were conceptually related and if they could be reduced in number. if they could be reduced in number.

► The Factor Analysis Extraction procedure helped The Factor Analysis Extraction procedure helped answer these questions. The Varimax rotated two answer these questions. The Varimax rotated two factor solution indicates that there are two clearly factor solution indicates that there are two clearly separate conceptual dimensions and the number of separate conceptual dimensions and the number of items in the two scales could items in the two scales could notnot be reduced. The be reduced. The factor solution also accounted for 57.25% of the factor solution also accounted for 57.25% of the variance among those being screened.variance among those being screened.

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Screen ReliabilityScreen Reliability

►Second, Cronbach Alpha coefficients were used Second, Cronbach Alpha coefficients were used as a statistical measure of the internal as a statistical measure of the internal consistency of each of the two subscales. consistency of each of the two subscales.

►The Cronbach Alpha for the Mental Health The Cronbach Alpha for the Mental Health screen was very good (α = .79). screen was very good (α = .79).

►The Cronbach Alpha for the Substance Abuse The Cronbach Alpha for the Substance Abuse Screen was excellent (α = .89).Screen was excellent (α = .89).

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Screen Sensitivity & SpecificityScreen Sensitivity & Specificity

►Sensitivity and specificity were examined Sensitivity and specificity were examined against the Client Assessment Record (CAR) against the Client Assessment Record (CAR) assessment, the Addiction Severity Index (ASI) assessment, the Addiction Severity Index (ASI) assessments, and the Axis I primary and assessments, and the Axis I primary and secondary diagnosessecondary diagnoses (see Tables 1 & 2). In this (see Tables 1 & 2). In this population, the AC/OK Screen (which takes five population, the AC/OK Screen (which takes five minutes to administer) agreed with the minutes to administer) agreed with the CAR_substance abuse scale in 90.5% of cases CAR_substance abuse scale in 90.5% of cases that the individual needed to be fully assessed that the individual needed to be fully assessed for a co-occurring disorder.for a co-occurring disorder.

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Definition: Sensitivity and Definition: Sensitivity and SpecificitySpecificity

►Sensitivity, the fraction of those with Sensitivity, the fraction of those with the mental health or substance abuse the mental health or substance abuse disorders correctly identified by the disorders correctly identified by the screening tool (Blume, 2002).screening tool (Blume, 2002).

►Specificity, the fraction of those Specificity, the fraction of those without a mental health or substance without a mental health or substance abuse disorder correctly identified by abuse disorder correctly identified by the screening tool (Blume, 2002).the screening tool (Blume, 2002).

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Validity of the ScreenValidity of the Screen

►The AC/OK Screen agreement with the ASI The AC/OK Screen agreement with the ASI psychiatric scale was even more impressive. psychiatric scale was even more impressive. The AC/OK Screen agreed with the ASI The AC/OK Screen agreed with the ASI psychiatric scale in 96% of the cases that the psychiatric scale in 96% of the cases that the individual needed a full assessment for a co-individual needed a full assessment for a co-occurring disorder. Finally, the AC/OK Screen occurring disorder. Finally, the AC/OK Screen (which takes five minutes to administer) agreed (which takes five minutes to administer) agreed with the DSM-IV diagnosis of a co-occurring with the DSM-IV diagnosis of a co-occurring disorder in 91% of the cases.disorder in 91% of the cases.

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The Percentage of People Identified by The Percentage of People Identified by the AC-OK Screenthe AC-OK Screen

►The AC/OK Screen identified approximately The AC/OK Screen identified approximately 72% of all people applying for treatment as 72% of all people applying for treatment as needing a full assessment to determine if the needing a full assessment to determine if the person has a co-occurring disorder. This is person has a co-occurring disorder. This is estimated to be as much as twice the number of estimated to be as much as twice the number of people who will be diagnosed with a co-people who will be diagnosed with a co-occurring disorder after a full clinical occurring disorder after a full clinical assessment for both a mental health and assessment for both a mental health and substance abuse problem. substance abuse problem.

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5 Minutes Can Make a Difference5 Minutes Can Make a Difference►What difference can 5 minutes make to a person who What difference can 5 minutes make to a person who

is seeking help for a co-existing disorder? is seeking help for a co-existing disorder? Determining that a person has a co-existing disorder Determining that a person has a co-existing disorder when he or she first asks for help can save an average when he or she first asks for help can save an average of four and a half years of that person’s life. of four and a half years of that person’s life.

► In this data there is over a four year (4.4 yrs) In this data there is over a four year (4.4 yrs) difference in the average age of people in this study difference in the average age of people in this study seeking treatment in a substance abuse treatment seeking treatment in a substance abuse treatment program (32.87 yrs) and those seeking help from a program (32.87 yrs) and those seeking help from a program providing treatment for a co-existing program providing treatment for a co-existing disorder (37.31 yrs). disorder (37.31 yrs).

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DisadvantagDisadvantageses►People with a co-occurring disorder are also People with a co-occurring disorder are also

slightly more likely to be involved in the slightly more likely to be involved in the criminal justice system. More people with a co-criminal justice system. More people with a co-occurring disorder tend to enter treatment occurring disorder tend to enter treatment struggling with suicidal ideations. They tend to struggling with suicidal ideations. They tend to have more problems with substance abuse than have more problems with substance abuse than others entering treatment for addiction.others entering treatment for addiction.

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Strengths on Which to Build aStrengths on Which to Build aLong Term RecoveryLong Term Recovery

►Yet, people with a co-occurring disorder are Yet, people with a co-occurring disorder are likely to have fewer problems with psychoses likely to have fewer problems with psychoses and anxiety disorders. They usually have a and anxiety disorders. They usually have a higher level of education. And, they tend to be higher level of education. And, they tend to be more committed to treatment (based on the more committed to treatment (based on the percentage of voluntary admissions, and the high percentage of voluntary admissions, and the high number who complete treatment) (See: number who complete treatment) (See: http://faculty-staff.ou.edu/C/Andrew.L.Cherry-1.http://faculty-staff.ou.edu/C/Andrew.L.Cherry-1.Jr/AC-CODScreenPg.htmJr/AC-CODScreenPg.htm

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