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Drug and Alcohol Services for Adolescents
  <= /span>
=
&#= 13;
Presented by
Howard Dounn
Phoenix House. Lake View Terrace
There = have been a number of responses from local, state and federal levels to address these issues and build a host of new service delivery options.

Goal := Share provider insight since 1978 – where we are and where we need to go = as a field
Grossl= y underfunded LAO report
Recove= ry Model vs Treatment Model
Self H= elp Model vs Treatment Model – tried to integrate these two very dichotomous approaches
We hav= e existed in a silo to a large extent and marginalized ourself

DADP S= et vision ,mission and goals for reducing SA Ensure a network of services ; license providers ensure quality Set standards&n= bsp; Secure administer fiscal system&n= bsp; Data system

Provid= er Mission     &nb= sp; Recapture and save lives
       pro= vider services

Common= Goals   BUILD AND SUSTAIN CAPACITY=      WORKFORCE  AND PROGRAMS/FACILTIES


Increa= ses in juvenile crime and adolescent substance abuse increased significantly in = the early 90’s  the Center= for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Health Services Administration (SAMSHA) funded a wide variety of demonstration projects.  Monograph: strategies for Integrating Substance Abuse Treatment= and the Juvenile Justice System A Practice Guide”

While = many projects are guided by strong evaluative components wherever possible, as well as emerging process grounded data and practice wisdom.


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SUD Impedes Development in <= /span><= span style=3D'font-size:91%;text-shadow:auto;color:#5C71AC'>Adolescent Subst= ance Abusers
•
•Coping skills
•Social/interpersonal skills
•Communication skills&#= 13;
•Identity, values consolidation
•Affect identification/regulation
•Self-efficacy and external locus control
•Pro-social network &am= p; role models
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Prevalence
ØDrug abuse/dependence: 3-9% = 3;
ØAlcohol abuse/dependence: 5-8%&= #13;
ØHigher prevalence SUD reported = if in juvenile justice system
ØHigher SUD (60-80%) if psychiat= ric disorder
ØOnly 1 in 10 with SUD receive treatment, of those that do, only 25% receive enough
<= span style=3D'font-family:Tahoma;font-size:88%;visibility:hidden'>•
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Methamphetamine Use
•<= /span>methamphetamine use and abuse (= MA) is increasing
•
•1997 -  annual use estim= ated at 2.3% amongst 12th graders – in 2003 risen t= o 13%
•
•treatment admissions for MA in CA have doubled = since 1992-2002,  total admissions have only increased 17%
•
•cognitive impairment, auditory hallucinations, psychological dysfunction, and suicidal impulses
•
•chronic methamphetamine use can permanently <= span style=3D'font-family:Tahoma;font-size:81%'>alter brain & cognitive functioning (exposure & amount)
•
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Characteristics of Youth Seeking Treatment for MA in Los Angele= s
•More whites and Latinos using methamphetamine than= other groups •Fastest growth in rates of MA among older adolesce= nt females compared with males •Alcohol and marijuana initiation patterns tended to occur earlier in MA = ;•Teens are coming from drug saturated environments = with exposure to parental substance abuse & associations with drug using peers
•
• &= nbsp; Rawson,Gonzles, Obert,McCann, Brethen  2005
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J= uvenile Offenders
Ø   
Ø = 44% meet clinical DSM-IV criter= ia for substance     =
Øabuse or dependence (v.7.4%)
Ø
Ø27.8% meet criteria for addiction (v. 3.4%)
Ø
Ø3.6% receive substance abuse treatment <= /div>
Ø
Ø80% suffer from learning disabilities
Ø
Ø75% have mental health disorder
–
•“ Criminal Neglect: Substance Abuse, Juvenile Justice & the Children Left Behind”   www.casacolumbia.org
    
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Self
Family
 <= b>Adolescent Substance Abuse Treatment
3D"Venn
=
Education
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Phoenix Academies
Modified Therapeutic Communities =
SAMSHA’s National Registry of Evidence-based Programs
Office of Juvenile Justice Delinquency Prevention Model Program Drug Strategies 
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P= hoenix Academies
ØResidential substance abuse treatment model utilizing modified Therapeutic Community Methodology
ØBased on th= e view that substance abuse is the manifestation of underlying emotional and developmental disorder
ØView the community as the method of incremental social learning
ØOn-site accredited high schools in partnership with local education jurisdiction
Ø
The= se patterns suggest the need for a more comprehensive approach to treatment that incl= udes assessment and intergrated treatment of a wide range of disorders includi= ng victimization, anger and poor coping skills as well as tailored to the developmental; age and gender issues for our children.


The= Therapeutic Community – modified for adolescents –Linkages – primary with education.  Changes in = last few years- health; mental health; social services –Independent Livi= ng; probation; AOD.

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A= dolescent Therapeutic C= ommunity
<= span style=3D'font-size:88%'>ØDuration of stay (9 to 12 months)
ØEmphasis on education, social development & = recreation ØLess confrontational than adult TC – focused on growth and development needs of adolescence <= /span>
<= span style=3D'font-size:88%'>ØMore supervision & evaluation by staff members=
ØAssessment of emotional, psychological & = learning disorders
<= span style=3D'font-size:88%'>ØUse of psychotropic medications, as appropriate
Elemen= ts of the Therapeutic Community Model (DeLeon, 1= 997)
Partic= ipant roles
Member= ship feedback
Member= s as role models
Collec= tive formats for guiding individual change
Shared= norms and values
Struct= ure and systems
Open c= ommunication
Positi= ve relationships with peers and staff
Shared lexicon/terminology
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Adolescent Therapeutic C= ommunity
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.97%;font-fami= ly: Wingdings'>ØExpanded role of family members
ØBehavior  shaping based on introspection & self- determination &= amp; regulation ØExpression of appropriate age independence & autonomy supported  ØCompletion of phase objectives with two to three months of orientation; three to six months of primary treatment; and two to <= span style=3D'position:absolute;top:78.0%;left:9.73%;width:87.82%;height:6.0%'>= three months of re-entry; twelve months of live-out (continuing care)=
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Activities That Promote Change
•Five primary, distinct, yet overlappi= ng categories of activity:
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Behavior Management/Shaping
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Emotional= / Psychological
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Intellect= ual and Spiritual
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Vocationa= l / Survival Skills
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Biomedical Management
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Therapeutic Community:  Behavior Shaping Element
•Application of Behavior Modification Theory
–Rewards for positive behavior. . .Negative consequences.  Three to One ratio. . .
–Graduated rewards =
•Artful application of Dissonance Theory can increase outcome of interventions
–Pre-decision conflict (dissonance)= =3D post decision commitment to the choice =
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A Hierarchy of Behavior Shaping = Tools
3D"Text
Incre= ase in Severity
3D"Text
•Decrease in Frequency
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quoted-printable Content-Type: text/html; charset="us-ascii" Slide 1
Therapeutic Community:
= Emotional/Psychological Element
•<= /span>Encounter Group: Deals with the here and now.  Behavior shaping
•<= /span>Static Group:&nbs= p; Consistent group of peers and leader; meets over a long period of time throughout treatment experience
•<= /span>Probes and Marathons:  Psychodrama etc., <= span style=3D'position:absolute;top:55.75%;left:9.73%;width:94.0%;height:6.0%'>= Special groups (ACA, Abuse) periodic and as needed.
•<= /span>One-to-One Counseling:  Intimacy/Shame/Guilt/Complex Emotions
•<= /span>Family Counseling:  Systems Treatment, Couples Counseling
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Therapeutic Community:  Intellectual/Ethical
•<= /span>Formal Learning:&= nbsp; School, GED, emphasis on social competencies, basic skills.
•<= /span>Seminars:  Great thinkers, great ideas and concepts.
–<= /span>Philosophy – The question of life:
•Where do we come from?  Why are we here?
•What gives life meaning?  What are our moral = responsibilities?=   Who are our heroes?
•<= /span>Books:  Available and openly referred to and discussed
•<= /span>Society:  Norms – Rules – Etiquette - Manners <= /div>
•
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Therapeutic Community = Vocational Survival Skills
•The Con= text for Lessons are the result of the Social Learning Environment
•= 3;
•<= /span>Work is the primary way we participate in communit= y, in society.
•<= /span>Work as a teaching and learning tool.  Value beyond end product.
•<= /span>All tasks have meaning.  They are reality based, necessary, created by need and the environmental <= /span>situation:  Kitchen, meal prep, housekeeping
•All Tasks include a challenge to learn something.&= #13;
–Example: how = can work teach compassion?
•
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Therapeutic Community
<= b> Vocational Survival Skills
<= span style=3D'font-size:88%'>•Move from the simple to the complex.
•Emphasis on attitude as a prerequisite for = = acquiring skill = •Reward (hierarchical movement) is dependent on task completion with caring and effort <= /span>relevant to individual capacity – “Pri= de and Quality” •Through tasks we explore and develop pro-<= span style=3D'font-size:88%'>social behaviors, values, attitudes and ethics.= 3;
•
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E= motional Cartography
•Integration of 12 week structured exploration of emotions
•Precedes encounter gro= up work
•Preliminary measuremen= t of resident response to emotional competence training includes:
–Decrease in emotional confusion
–Decrease in impulsivit= y, inability to focus, etc
–Increase in retention&= #13;
•<= /span>
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Family & Outpatient Services
3D"Venn
Family Services
Mental Health
 Services
Outpatient Substance Abuse Services
Therapeutic
 Community
Pass Proposals
Visitors List
Multi-Family Groups = ;
Stipends
Functional Family Thera= py
Mentoring
Parent Council
Satisfaction Surveys= 3;
12-Step Groups
Individual Therapy =
Family Therapy
Medication Management
Random UAs <= /div>
Physical Exam
Early Engagement
Parent Ed
Rec Days
SFP Groups <= /div>
Seeking Safety
ART Groups
Group Therapy
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Tasks of the Family Program
<= span style=3D'visibility:hidden'>•
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Decrea= se guilt
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Increa= se autonomy
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Identi= fy what didn’t work
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Learn = new skills that might help
•Support= each other in the struggle to grow
•
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<= b>Elements of Family Programs
•<= /span>Family Systems Counseling
–Define family roles= 3;
–Identify problem areas
–Realign family members= in supportive functional relationships
•<= /span>Parent Education
–Current, useful information:  Substance use, = signs and symptoms, common drugs of abuse
–Intervention via: dida= ctic information, practice opportunities
–
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<= b>Elements of Family Programs
&#= 8226;Family Association:
&= #8211;Self-help peer support
&= #8211;Skills practice
&= #8211;Support to the program
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Enhancing Resilience & the “Normal”
• If we want to help vulnerable youngsters….focus on protectiv= e processes that change trajectories from risk to adaptation.
• Rutter et al 2000; Werner 1993
•
–<= /span>incremental growth & development 
–<= /span>explore the impact of adversities
–<= /span> decr= ease negative chain reactions
–<= /span> incr= ease self esteem and self efficacy
–<= /span>open up opportunities – expose to new ideas&= #13;
–<= /span>connect & use existing community resources = ;
–= 3;
–Both with adoles= cents and their guardians.
–= 3;
–
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Co-occurring Disorders Are <= /span>Common In Y= outh with SUD
<= span style=3D'font-family:Tahoma;font-size:113%'>Ø anxiety disorders
<= span style=3D'font-family:Tahoma'>Ø  post traumatic stress disorder
<= span style=3D'font-family:Tahoma'>Ø  depressive disorders
Ø  attention deficit & hyperactivity disorders <= /div>
<= span style=3D'font-family:Tahoma'>Ø  attachment disorders
<= span style=3D'font-family:Tahoma'>Ø  eating disorders
<= span style=3D'font-family:Tahoma'>Ø  sexual and physical abuse
• <= /span>
50 and= 75% of incarcerated adolescents are estimated to have diagnosable mental health disorders – Juvenile Justice administration

Co-= Occurring psychiatric problems are common among adolescents who regularly use substances
Term c= o-occurring is used because it is difficult to ascertiain which comes first – the substance use or the psychiatric problem --- particularly,  among those entering substance a= buse treatment

Adoles= cents may be trying toself-medicate underlying psychiatric problems or may be using dr= ugs to cope (inappropriately)  w= ith high levels of environmental, personal, an traumatic stress.

Common= for psychiatric symptoms (hallucinations;&nb= sp; depression; anxiety etc )to follow sustained substance use or to emerge once use is stopped.



32% me= et dx criteria for post traumatic stress disorder
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DSM–IV Disorders
=
White = =3D 40%
Hispan= ic =3D 42%
Black = =3D 14%
Other = =3D4%  increase in Asian Pacific Island= ers and Native Americans

Varies= from county to county   higher # bl= acks in LA
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Co-Occurring Capability and = Program  Practices
ØSA/MH screening and assessment
ØIntegr= ated treatment planning and service
ØFull s= ervice partnerships through age 25
ØYouth development and leadership models
ØMulti-= dimensional & multi-disciplinary team
ØRelapse prevention model of recovery
ØCultur= ally sensitive
Ø
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Integrated Treatment of SUD and = Comorbidity<= /div>
<= span class=3DBB style=3D'position:absolute;left:-3.76%'>•Comorb= idity is rule not exception
<= span class=3DBB style=3D'position:absolute;left:-3.64%'>•Predic= tive of poorer treatment outcomes
<= span class=3DBB style=3D'position:absolute;left:-3.76%'>•Most t= eens not treated concurrently
<= span class=3DBB style=3D'position:absolute;left:-3.32%'>•Treati= ng one disorder doesn’t treat the other
•Resear= ch and clinical consensus supports integrated treatment
<= span style=3D'visibility:hidden'>•
•
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Barriers to Integrated Treatment
•Funding ag= encies have not implemented integrated treatment – funding stream & licensing barriers
•C= ritical shortage clinicians w/ experience & training
•E= xclusion from efficacy trials
&= #8211;little known about interactions drugs/ medications
&= #8211;adolescents first referred to SA treatment
= 211;treatment of psychiatric disorder contingent on Successful SUD treatment &= amp; stable abstinence prior to pharmacotherapy for comorbidity &#= 13;
•Separate f= unding streams dis-incentive integrated & coordinated care
•
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Early Peer-Supported Relapse Prevention & Continuing Ca= re
•=
–<= /span>Strong Transition Phase of Treatment with incre= ased independence and autonomy (Re-Entry Phase) =
–<= /span>Emphasize relapse & how to handle it not fa= ilure
–<= /span>Develop detailed plan for relapses and intensification of treatment until re-stabilized
–<= /span>Family education and involvement – positi= ve adult mentors
–<= /span>Involve in pro-social activity, incompatible wi= th drug use whi= le in treatment
–<= /span>Establish coordinated continuing care plan for = all problem dom= ains which is initiated during active treatment phase
–<= /span>Involve in positively reinforcing; incompatible= drug use; positive peers&= #13;
–<= /span>Maintain contact and establish mechanism for ea= rly treatment re-entry when lapses occur
–
•
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Barriers to Treatment for T= roubled Youth
<= span style=3D'visibility:hidden'>Ø
<= span style=3D'mso-special-format:bullet;position:absolute;left:-9.7%;font-famil= y: Wingdings'>Øclient
&= Oslash;
<= span style=3D'mso-special-format:bullet;position:absolute;left:-9.7%;font-famil= y: Wingdings'>Øfamily
<= span style=3D'visibility:hidden'>Ø
<= span style=3D'mso-special-format:bullet;position:absolute;left:-9.7%;font-famil= y: Wingdings'>Øcommunity
<= span style=3D'visibility:hidden'>Ø
<= span style=3D'mso-special-format:bullet;position:absolute;left:-9.7%;font-famil= y: Wingdings'>Øorganizations
<= span style=3D'visibility:hidden'>Ø
<= span style=3D'mso-special-format:bullet;position:absolute;left:-9.7%;font-famil= y: Wingdings'>Øprogram
<= span style=3D'visibility:hidden'>Ø
<= span style=3D'mso-special-format:bullet;position:absolute;left:-9.7%;top:.26em; font-family:Wingdings'>Øsystems
There = have been a number of responses from local, state and federal levels to address these issues and build a host of new service delivery options.

Increa= ses in juvenile crime and adolescent substance abuse increased significantly in = the early 90’s  the Center= for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Health Services Administration (SAMSHA) funded a wide variety of demonstration projects.  Monograph: strategies for Integrating Substance Abuse Treatment= and the Juvenile Justice System A Practice Guide”

While = many projects are guided by strong evaluative components wherever possible, as well as emerging process grounded data and practice wisdom.

Great = strides, efforts occurring there are many barriers –

On all= levels,  the client; the family; the comm= unity; the organizations that offer services; the systems responsible for overall design and funding framework ( not mutually exclusive)

Cli= ent: Juvenile Offenders with Substance Abuse problems may exhibit behaviors that aliena= te treatment providers.

Fam= ily: Families may be overwhelmed by other life problems; may lack the knowledge or skil= ls ; and they may not support the goals or methods of treatment.

Com= munity: Communities may not understand or support programs v punishment; may oppo= se siting of facilities; believe treatment is ineffective; lack resources for social support or aftercare

Org= anizational: lack capacity to operate sustained comprehensive programs; expertise; fai= lure to form linkages

Pro= gram: based on social science theories; adaptable; over-regulated with outdated regualti= ons; assessments;tailored to meet needs of child by age, gender, devlopmental status etc; linkages; aftercare; inadequately trained staff and focus on deficits rather than strengths.

Sys= tems Level: lack capacity to assess needs ; lack linkages; separate treatment and prevention; schools exclude or stigmatize young people involved in the justice system; no continuity in health care; inadequate resources

Overal= l adolescent services in California remain under funded, fragmented missions and goals, out-dated infrastructure.

Guidin= g principles for thinking about desirable practices:

v<= /font>    Importance= of reshaping our view and our communities’ views of offender youth int= o a strength based and salvageable perspective.
v<= /font>    Importance= of providing holistic, effective, culturally relevant and gender specific substance abusing youthful offenders
v<= /font>    Importance= of working together across systems  to achieve successful and lasting outcomes 9juvenile justice, substance abuse treatment, education, health, mental health, social servi= ces, adult AOD for parents, faith and community based organizations)






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Fragmented and conflicting mission and goals  between referral, funding and oversight agencies<= /b>
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file:///C:/60940E55/DounnFeb15_files/slide0059.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Slide 1
Early Engagement
–<= /span>Motivational interviewing
–<= /span>Slower presentation of information
–<= /span>Involve parents/guardians early
•<= /span>Focus on opportunity to correct educational deficits
–<= /span>Build ties to program through big brother/sister&#= 13;
–<= /span>Early intensive case management – weekly con= tacts with family members & probation from beginning=
–<= /span>Stay in contact with family and probation officers= if drop out occurs (encourage return to treatment) &#= 13;
–<= /span>Parent orientation and education
–<= /span>Assessment-assessment-assessment
–= 3;
–= 3;
•
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Phoenix House
Fashion Awards
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