1. Working with Youth with Co-Occurring Disorders Sharon Hunt, TA Partnership Interim Substance Abuse Resource Specialist Rachel Freed, Research Associate for the TA Partnership Rebecca Spotts, Research Assistant for the TA Partnership Cathy Ciano, Executive Director, Parent Support Network of Rhode Island Nick Vaske, youth presenter from Families First & Foremost

2. Overview Sharon R. Hunt 202-403-6914 shunt@air.org

4. Prevalence & Chronicity Co-occurring mental disorders are common and serious (prevalence rates 20% - 80%, depending on sample pool). Research indicates the onset of the mental disorder often precedes the addictive disorder. (Temporal order) The likelihood of adolescent substance use and dependence is strongly associated with younger age of onset, severity of emotional and behavioral problems, true across age and gender. Initially use is voluntary, thus the earlier the intervention the greater the impact on offsetting what later becomes a chronic, relapsing disease in which brain chemistry is altered.

6. Most Common Presenting Problems Verbal/physical Aggressiveness Academic Difficulties Impulsivity Hyperactivity Depressed Mood Poor Social Skills

7. Substance Use History at Intake by Age Category* Have you ever used: * Substance use information was based on self reports from youth 11 years or older. Substances 11 to 14 Years Old: Number of children varied from 2,440 to 2,452. 15 to 18 Years Old: Number of children varied from 1,571 to 1,575.

8. Multiple Co-occurring Problems Are the Norm and Increase with Level of Care Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) studies

9. Multiple Co-occurring Problems By Lifetime Dependence Diagnosis Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) studies

10. Adolescents in Treatment Substance Use Disorders 40 – 90% Report Victimization 20 – 25% Report Victimization in last 90 days, or current concern regarding reoccurrence Source: Dennis, Stevens & Chaffin, in press

11. *Because children may have more than one diagnosis, the diagnosis variable may add to more than 100%. ** V Code refers to Relational Problems, Problems Related to Abuse or Neglect, and additional conditions that may be a focus of clinical attention. Clinical Diagnosis on any Axis at Intake by Comorbidity Status* No Comorbidity: n = 4,855. Comorbidity w/o Substance Use: n = 4,633. Comorbidity w/ Substance Use: n = 697. Percent Clinical Diagnoses

12. Treatment Prognosis Prognosis is worse for youth with co- occurring disorders for many reasons: motivation; academic, family, and behavior problems; and limited coping and social skills. May lag in important adolescent development tasks – individuation, moral development and conceptualization of future family, vocational and educational goals.

13. Cumulative Recovery Pattern at 30 months: (The majority vacillate in and out of recovery) Source: Dennis et al, in press; forthcoming, CYT, PETSA 37% Sustained Problems 5% Sustained Recovery 19% Intermittent, currently in recovery 39% Intermittent, currently not in recovery

14. Adapting Treatment for Adolescents Examples need to be altered to relevant substances, situations, and triggers Consequences have to be altered to things of concern to adolescents Most adolescents do not recognize their substance use as a problem and are being mandated to treatment All materials need to be converted from abstract to concrete concepts Comorbid problems (mental, trauma, legal) are the norm and often predate substance use Treatment has to take into account the multiple systems (family, school, welfare, criminal justice) Less control of life and recovery environment Less aftercare and social support Complicated staffing needs

15. MENTAL HEALTH INTERVENTIONS FOR CO-OCCURING DISORDERS EVIDENCE-BASED INTERVENTIONS COGNITIVE BEHAVIOR- THERAPY(CBT) INTEGRATED COGNITIVE- BEHAVIOR THERAPY FOR TRAUMATIC STRESS SYMPTOMS AND SUBSTANCE ABUSE MULTI-SYSTEMIC THERAPY MOTIVATIONAL ENHANCEMENT THERAPY WITH CBT EFFECTIVE INTERVENTIONS SUPPORTIVE THERAPY SYSTEMIC FAMILY THERAPY INTENSIVE CASE MANAGEMENT COMMUNITY REINFORCEMENT NETWORK THERAPY METHADONE NALTREXONE

16. Racial/Ethnic Disparities in Drug Prevalence among Youth Rebecca Spotts rspotts@air.org rspotts@air.orgrspotts@air.org 202-403-5847

17. Racial/Ethnic Disparities in Drug Prevalence among Youth Prevalence The role of culture Equal access to treatment

18. Prevalence by Race/Ethnicity Evidence shows a significantly greater prevalence of substance abuse among Hispanics and Caucasian youth than African American youth at every grade level (National Institutes for Health) American Indian/Alaska Native youth had the highest rate of illicit drug use among youth age 12-17 at 19.6%, compared to 10.9% for Caucasian youth and 10.7% for African American youth (1999 National Household Survey on Drug Abuse)

19. Estimated Lifetime Prevalence of Selected Drugs by Race/Ethnicity for Students in Grade 12 (%): 2000. *Source: U.S. Department of Health and Human Services National Institutes of Health report Drug Use Among Racial/Ethnic Minorities

20. Dr. Gayle Porter, TA Partnership

22. What puts youth at risk for drug abuse? The role of culture “The cultures from which people hail affect all aspects of mental health and illness, including the types of stresses that they confront, whether they seek help, what type of help they seek…and what types of coping styles and social supports they possess.” (U.S. Department of Health and Human Services, 2001) (U.S. Department of Health and Human Services, 2001)

23. Sources of Risk for Substance Abuse (www.safeyouth.org) Three sources –Individual child factors - biology, behavior and personality Youth with emotional and psychological problems are at greater risk for substance use and abuse (www.safeyouth.org ) www.safeyouth.org –Family factors Do not perceive a strong parental disapproval for drug use –Environmental factors Youth do not perceive appropriate risk involved with substance abuse

24. Increased Risk: Environmental Factors (www.safeyouth.org) Community disorganization Lack of community bonding Community attitudes toward favorable drug use Inadequate services and opportunities for youth Pro-drug messages in the media

25. Disparities for Children of Diverse Racial and Ethnic Groups African American and Hispanic/Latino youth identified/referred at same rates as general population, but less likely to receive mental health or meds (Kelleher, 2000) Minority children tend to receive mental health services through juvenile justice and child welfare systems more often that through schools or mental health settings (Allegria, 2000) African American and Hispanic/Latino children have the highest rates of unmet need (Strum, 2000)

26. How do youth get access to substance abuse treatment? Primary referral source by Racial and Ethnic Group in 1998-99 Funded SOC communities (Guilford, 2004 ORC Macro) American Indian/Alaska Native Caregiver/Self (44.7%) African American Juvenile Justice (24.9%) White Non-Hispanic Education (20.1%) Hispanic/Latino Juvenile Justice (28.4%) Asian Juvenile Justice (28.2%) Native Hawaiian Child Welfare (22.2%) Multi-Race Mental Health (32.5%) Other Mental Health (22.4%)

27. Access to Services and Treatment –SOC communities must develop a culturally competent strategy to reach out to at-risk youth in their area to combat substance abuse before it begins. www.preventioncurriculum.com/ handbook/Chapter5FullText.pdf

28. Nick Vaske Families First & Foremost 402-441-3803 (Number for Families First & Foremost) nvaske@neb.rr.com

29. Ecstasy and Club Drugs Rachel Freed 202-403-5389 rfreed@air.org

30. “I remember the feeling I had the first time I did Ecstasy: complete and utter bliss. I could feel the pulse of the universe; I let every breath, touch and molecule move my soul. It was as if I had unlocked some sort of secret world; it was as if I'd found heaven. And I have to admit, I wondered how anything that made you feel so good could possibly be bad.” –Lynn Smith

31. What Are Club Drugs? Drug Street Name GHB G, liquid ecstasy, Grievous Bodily Harm, gib, soap, scoop, nitro Rohypnol Mexican valium, circles, roofies, la rocha, roche, rophies, R2, rope, forget-me pill Ketamine K, special K, super K, vitamin K, kit-kat, keets, super acid, jet, cat valiums MDMA Ecstasy, X, M, E, XTC, rolls, beans, Clarity, Adam, lover's speed, hug drug The most widely used club drugs are GHB, Rohypnol, Ketamine, and MDMA

32. What Are Club Drugs? GBH –GHB is usually abused either for its intoxicating/sedating/euphoria-inducing properties, or for its growth hormone-releasing effects –Overdose may result in seizures, coma, and death –May also produce withdrawal effects, including insomnia, anxiety, tremors, and sweating Ketamine –Large doses cause reactions similar to those associated with use of PCP, such as dream-like states and altered perceptions or hallucinations. –At higher doses, can cause delirium, amnesia, impaired motor function, high blood pressure, depression, and potentially fatal respiratory problems Rohypnol –Produces sensations of floating outside the body, visual hallucinations, and a dream-like state –When mixed with alcohol, it can incapacitate victims and prevent them from resisting sexual assault –Often produces anterograde amnesia –May be lethal when mixed with alcohol and/or other depressants.

33. What is Ecstasy? The Facts An illegal psychoactive drug Produces effects similar to hallucinogens and stimulants –energizing effect –distortions in time and sensory perceptions –feelings of peace and happiness and empathy for others –suppresses the desire to eat, drink, or sleep Popular at raves and other all-night party scenes

34. Myths and inaccurate information about the effects and long- term consequences of Ecstasy are widespread among its users...

35. Physical Effects In low doses... faintness dehydration muscle tension involuntary teeth clenching nausea blurred vision chills or sweating hypertension increases in heart rate, blood pressure, and temperature In high doses... liver, kidney, and heart failure strokes seizures

36. Psychological Effects anxiety panic attacks confusion disorientation depression delusions mood swings lapses in memory Research on animals suggests that Ecstasy use can cause long-term damage to the parts of the brain that use serotonin (NIDA, 2005).

37. There is no control over the pill ingredients The ingredients are difficult to obtain, so manufacturers often substitute ingredients –ephedrine –dextromethorphan –caffeine Other, more dangerous drugs are sometimes sold as ecstasy. Other Risks – ketamine – cocaine – methamphetamine

38. Mental Health and Ecstasy Strong correlation between Ecstasy use and depression 2 possible reasons: –Some users may be more vulnerable to the adverse effects of Ecstasy –Users may have pre-existing mental health problems for which they self-medicate by using ecstasy Some ex-users experience a mental health impairment that persists for years after they stop using this drug. Verheyden SL, Maidment R, & Curran HV (2003) Quitting ecstasy: an investigation of why people stop taking the drug and their subsequent mental health. J Psychopharmacol., 17(4), 371-378.

39. Mental Health and Ecstasy (cont.) Lieb R, Schuetz CG, Pfister H, von Sydow K, Wittchen H "Mental disorders in ecstasy users: a prospective-longitudinal investigation." Drug Alcohol Depend 2002; 68: 195-207 A study by Lieb and colleagues (2002) followed the same 2,500 14-24 year olds for four years, tracking changes in drug use and mental health:

40. Mental Health and Ecstasy (cont.) The same study found that although most Ecstasy users had some form of mental illness during the study, in the vast majority of cases, the problem emerged before they began using Ecstasy. Lieb R, Schuetz CG, Pfister H, von Sydow K, Wittchen H "Mental disorders in ecstasy users: a prospective-longitudinal investigation." Drug Alcohol Depend 2002; 68: 195-207

41. Why is it Important to Get the Facts Out? Almost half of all parents in America (48%) do not know the effects of Ecstasy 79% of parents do not know what is in Ecstasy Ecstasy is the least likely drug to be discussed when parents discuss specific drugs with their child. Partnership for a Drug Free America (2003). 2003 Partnership Attitude Tracking Study. Retrieved July 2005 from http://demo.pdfav3.somethingdigital.com/Files/Full_Report_PATS_2003

42. Why is it Important to Get the Facts Out? 3% of parents of teens think their teen has tried Ecstasy 11% of teens report trying Ecstasy 13% of parents of teens believe that Ecstasy would be “very easy” for their teen to get. 22% of teens say Ecstasy is very easy for them to get. 5% of parents of teens believe their teen has friends who have tried Ecstasy. 34% say they have close friends who use Ecstasy. Partnership for a Drug Free America (2003). 2003 Partnership Attitude Tracking Study. Retrieved July 2005 from http://demo.pdfav3.somethingdigital.com/Files/Full_Report_PATS_2003

43. Treatment Options There are currently no evidence-based treatments designed specifically for Ecstasy abuse. The most effective treatments for drug abuse and addiction in general are cognitive behavioral interventions. Substance abuse recovery support groups can also be effective in combination with behavioral interventions to support long-term, drug-free recovery. In addition, antidepressant medications might be helpful in treating the symptoms of depression and anxiety seen in Ecstasy users.

44. “I hear people say Ecstasy is a harmless, happy drug. There's nothing happy about the way that "harmless" drug chipped away at my life. Ecstasy took my strength, my motivation, my dreams, my friends, my apartment, my money and most of all, my sanity. I worry about my future and my health every day.” –Lynn Smith

45. Internet Resources http://www.clubdrugs.org/ http://www.drugabuse.com/ http://www.drugabuse.gov/drugpages/ clubdrugs.html http://www.drugdigest.org/ http://www.drugid.org/ http://www.erowid.org/ http://www.streetdrugs.org/

46. Cathy Ciano Executive Director Parent Support Network of Rhode Island 401-467-6855 CathyCiano@aol.com