1) Those with serious mental illnesses such as schizophrenia, bi-polar disorder with major depression and who use alcohol and drugs to self-mediate to cope with the symptoms; and 2) Those with borderline personality and anti-social personality disorders including anxiety disorder that is complicated by use of alcohol and illicit drugs. (Mather et al. 1999)
Presenting further difficulty is the establishment of problems with alcohol and illicit drug use for adolescents entering service programs outside of the AOD system. (National Survey on Drug Use and Health, 2005) In an analysis of data taken form a sample group of youth in five San Diego county sectors of AOD treatment, mental health, juvenile justice, child welfare and public school-based services for severely emotionally disturbed [SED] youth gives indication that "there are relatively high rates of substance use disorders among adolescents in these systems, as determined in diagnostic interview with DSM-IV criteria." (National Survey on Drug Use and Health, 2005) The following chart illustrates the 'special population substance use disorders'
Special Population Substance Use Disorders
Child and Justice
Substance Use Disorders - Lifetime
Substance Use Disorders - Past Year
Source: National Survey on Drug Use and Health (2005)
Stated as 'core youth-specific training areas' for caseworkers and counselors are the area of:
Family Dynamics, including cross cultural ones
Adolescent psychological development, including gender and sexuality, personal and group identity and life skills
Adolescent substance use patterns and AOD-related concerns
Physiological and developmental effects of alcohol and other psychoactive drugs on adolescents
Common mental health diagnoses and interventions with youth
Common adolescent health issues, emergency procedures, suicide risks, victimization, reproductive rights, infectious diseases and medication
Staff-client relationship and boundary setting with youth
Treatment client confidentiality, minors informed consent issues, child welfare regulations and safety and abuse issues; and Cross systems service referral and follow up procedures for youth (National Survey on Drug Use & Health, 2005)
The article entitled; "Adolescent Substance Abuse Needs and Services Planning Report" (2005) states the following 'Principles' for Development of a Model System: "The model should broaden access with implementation of the "no wrong door principle" (2005) Public information strategies and community awareness should be developed to:
Reduce barriers to access and reduce stigma which is inclusive of making treatment accessible, appropriate and acceptable;
needs-driven treatment design should be developed;
model system should place AOD treatment for youth squarely within the framework of health and public health;
model system should include a framework for the delivery of AOD services over a more extended period of time and should work with youth to manage the common occurrence of relapse;
The model system should include referral networks and on-site services linked to schools and other settings that routinely see youth and their families, such as after-school programs, neighborhood centers and locations near transportation hub;
The system should be structured to deliver treatment to youth in the least restrictive setting that ensures their physical and emotional safety.
The system Should create intensive levels of care that would allow youth in treatment to remain safely with their families and in their communities;
The model AOD treatment system should have a central position in the larger world of comprehensive health, education and social services for youth." (Adolescent Substance Abuse Needs and Services Planning, 2005)
In the same report and in the section entitled: "Model Development: Treatment Design Issues' stated is that the creation of a model system holds the requisites of AOD treatment being redesigned in a manner that will bring about improvement in treatment effectiveness in the treatment of youth. Required will be a treatment approach that "will respond to and enhance client's age appropriate development. These approaches will foster increased client engagement, retention and attainment of treatment goals. Improving treatment in these ways will require instituting standards of program excellence that draw on evidence-based practices, and initiating performance monitoring based on those standards. Workforce development also will be a crucial element of this initiative.
The stated 'Nine Key Principles for Improving Treatment Effectiveness' are:
Principle 1 - Treatment of each client should match his/her assessed needs, and treatment should match the complexity and severity of the assessed problems
Principle 2 -Services should be planned and delivered to address all domains of the youth's life.
Principle 3 - The treatment model must be developmentally specific to adolescence
Principle 4 - The involvement of the youth's parents, family members and adult caregivers must be central to the AOD treatment model.18
Principle 5 - A "therapeutic alliance" must be built between the youth and the program staff based on mutual trust and partnership.
Principle 6 - Follow-up services should be part of treatment planning and discharge planning in order to maintain treatment gains in the months and years following treatment.
Principle 7 - The program must provide interventions that are acknowledged as appropriate and effective for gender and cultural identity issues.
Principle 8 - Program staff must have expertise in adolescent development and its relationships to family dynamics and AOD abuse. Staff also should have knowledge of the symptoms and appropriate treatment referrals for co-occurring disorders in youth. Standards for training and proficiency, as well as clinical supervision, must be established
Principle 9 - Ongoing program evaluation should provide the basis for continuous treatment improvement and the effective targeting of resources. (Adolescent Substance Abuse Needs and Services Planning, 2005)
It is related that: "Most individuals who have co-occurring mental health and substance use problems are not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment."(Adolescent Substance Abuse Needs and Services Planning, 2005) Stated in relation to incorporation of multiple assessment domains is that each youth should receive an assessment that is thorough include the following research indicated domains for assessment and treatment history;
Parenting and household situation, immediate and extended family profile and history, economic status, family relationships and communication;
Educational status and history, any learning issues;
Mental health: any symptoms, types and severities of any disorders, medication and treatment history;
Physical health: any significant medical history;
Peer relationships, relationships with significant adults, community profile;
Personal skills and aptitudes;
Any faith, spiritual or cultural affiliations or identities;
Sexual activity and history, and gender identity and orientation;
Illegal or injurious activity involvement, patterns and consequences; and Abuse or victimization history, stressful life events and trauma. (Adolescent Substance Abuse Needs and Services Planning, 2005)
Settings suggested for youth AOD treatment are those which are non-restrictive and community based. Co-locations for after-school and other youth centers is suggested for consideration. When required to be in a restrictive environment there should be minimization of punishment and correction and safety and privacy should be emphasized. The treatment location should be youth friendly as well as developmentally appropriate and should have separate spaces for male and females "to ensure they receive, safe, equitable and gender-specific treatment." The linguistically and culturally sensitive factors should be incorporated for engagement of family members of youth in the under-served grouping. Lastly the settings should be developed that are best suited for the youth that have special service needs or issues with access (gay, lesbian, bisexual, transgender identities, runaway and street youth and those with serious emotional disorders or who are severely addicted or are alcoholics)
Interventions Identified as Effective
Identified as interventions that have been effective thus far are inclusive of the following interventions which are termed those of Family-Based Interventions: Structural-Strategic Family Therapy, Parent Management Training (PMT), Multisystemic Therapy (MST), Multidimensional Family Therapy (MDFT) Motivational Enhancement Therapy (MET): A cli0ent-centered approach used as a stand-alone, a brief intervention or integrated with other intervention modalities; helpful in addressing ambivalence or resistance and strengthening motivation for change.
Cognitive-Behavioral Therapy (CBT): Based on learning theory, often utilizes motivation-enhancing techniques, may include a functional analysis on attitudes, thinking/coping strategies, problem solving and communication skills;
Behavioral Therapy Approaches: Based on operant behavioral principles giving or withholding rewards or utilizing sanctions to modify or extinguish unwanted behaviors; and Community Reinforcement Therapy: Combines principles and techniques derived from behavioral, cognitive-behavioral, motivational and family therapy, often using incentives to enhance treatment outcomes.
Found to be effective in treating youth who are AOD affected are the use of empathy and techniques that provide both support and motivation. Secondly the behavioral and cognitive behavioral approaches have been found to be effective. Third is comprehensive assessment and targeted interventions in a range of domains related to substance abuse. Fourth is interventions that are in the form of individualized therapy. Last, the inclusion of family in treatment has shown to be effective in terms of outcomes. (Ibid)
In the work entitled: "Innovative Approaches for providing Services to Homeless People with Concurrent Disorders" the authors Kraus and Serge (2005) who prepared the research for the National Research Council of British Columbia relate the fact that U.S. studies have findings that approximately 40 to 60% of individuals that are diagnosed with…