Effectiveness of intensive day treatment for dually diagnosed African-American and Latino adolescents

Dually Diagnosed African-American and Latino adolescents

DUALLY-DIAGNOSED African-American AND LATINO ADOLESCENTS: THE EFFECTIVENESS OF AN INTENSIVE DAY TREATMENT MODEL FOR AN AT-RISK COMMUNITY

Abuse of substances on the part of adolescents has grown to be a national concern in the United States and has sparked many studies in this area in the last decade. Great challenges are presented for the clinician and the substance abuse treatment system in developing and applying appropriate and effective treatment for these adolescents. Studies have shown that of the adolescents who have substance abuse disorders, many of them also have mental health illness a combination of which is termed 'dual diagnoses or co-occurring disorders. The combination of these two disorders often have devastating impacts on the adolescent, their family and this in the areas of their social, emotional, educational, and economic aspects of life.

The problem is that most of the previous research in this area focuses on the White middle class adolescent individual while the minority and traditionally underserved populations which includes ethnic and racial minorities and those of low socioeconomic status are those most at risk. This vulnerable sector of the population represents a great need in terms of treatment and that treatment must be culturally competent if it is to be effective. The characteristics of the African-American and Latino youth are different from the characteristics of the majority race youth and it is necessary to calculate these factors into any treatment programs design. Needed as well are evaluations of dual-diagnosis treatment programs for determination what treatment modalities, philosophies and approaches are effective and efficient in the provision of treatment to African-American and Latino youth.

This study utilizes a 'culturally competent, multi-systems theory-based treatment program. The purpose of this study is the determination of the effectiveness of intensive treatment for dual-diagnosis of mental illness and substance use disorder in treating African-American and Latino youth. This study uses a culturally competent, multi-systems theory-based treatment program. Furthermore, this study seeks to aid in the development of a profile that can help clinicians predict treatment outcomes for individuals seeking treatment. The profile can assist clinicians in appropriately assessing patients for the level of care and treatment needed. Research has shown that age of first substance use, family history of substance abuse, prior treatment experience, and legal status are associated with treatment outcomes. This study will determine if these factors are associated with treatment outcomes for this urban population of African-American and Latino youth. '

This study examines data from the Revelation Program, a program developed through Shields for Families, Inc. This program integrates substance abuse models and mental health treatment combined with a systemic approach that includes family, school, and community. The Revelation program was created to provide treatment that would be culturally competent and appropriate for the African-American and Latino populations who are of low socioeconomic status and who may be mono-lingual. The mission of the Revelation Program is to provide mental health services and substance abuse counseling to youth ages 13-21 that have a past or present history of drug abuse and mental illness. The aim of the program is to assist youth in sustaining a drug-free lifestyle and to equip them with skills to become independent, productive, and successful citizens. The sample will include male and female African-American and Latino youth ages 13-21. The youth will have demonstrated substance abuse and psychiatric symptoms. The youth reside in Service Planning Area 6, the South Los Angeles communities inclusive of Watts, South Central, Compton, and Crenshaw. According to population estimates, this area has the largest percentage of people of color in the county, with a breakdown in ethnicity as follows:

Latino - 59%

African-American - 35%

Caucasian - 35%

Other - 3%

This area also has the highest rates of unemployment and overcrowded housing units in Los Angeles County. The median income for this area is approximately $15,000. The youth are referred to the program through the Department of Probation, Department of Children and Family Services, Family Preservation Services, Juvenile Court, Los Angeles Unified School District, Compton Unified School District, or through other means (i.e., self, parent/family, and another Shields' program). For this study, archival data from 150 youth admitted to this intensive outpatient day treatment program from 2003-2005 will be analyzed. The study will involve a review and analysis of records collected over the past 2 years. A variety of variables that describe the patient, patient's family, and patient's environment will be examined to determine which are predictive of successful vs. non-favorable treatment outcomes. Upon intake, the individual therapist conducts a structured clinical interview with the patient and patient's parents. The therapist also completes the Adolescent Psychological Assessment. The case manager completes the Los Angeles County Participant Reporting System Registration (LACPR) and a psychosocial assessment of the patient. Upon discharge both therapist and case manager complete discharge summaries, which include program involvement, program completion, attainment of treatment goals, substance usage, psychiatric symptoms, and functioning within the family, school, and community. The case manager also completes a discharge LACPR.

Dually-Diagnosed African-American and Latino Adolescents: The Effectiveness of an Intensive Day Treatment Model for an At-Risk Community

Literature Review

I. Prevalence of Youth Diagnosed with Co-Occurring Disorders review of the literature reveals that the Youth population between the ages of 8-17 is stated to be a group with "prevalence of serious emotional disturbances referring to the range of all diagnosable emotional, behavioral, and mental disorder when the disorders disrupt daily functioning in home, school, or community." (Mental Health Offenders in the Custody of the Oregon Youth Authority April 2002) The focus was on two initial goals: 1) to determine the prevalence of diagnosed mental illness in the Youth Authority's population - both in correctional facilities and under community supervision; and 2) to identify gaps in services for youth suffering from diagnosed mental disorders and substance dependency/abuse

The study states findings of a rate of incidence of psychiatric disorders to be in actuality higher in the correctional facilities than the perilous Chicago study stated. Of the 1070 youth in the facilities there were 62% that had received a diagnosis of at least one mental health disorder and of those 57% were taking psychotropic medication prescribed to them in the individualized treatment program. Stated as the four most common psychiatric diagnoses for these youth were those of:

1) depressive disorder;

2) attention-deficit disorder;

3) post-traumatic disorder; and 4) oppositional defiant disorder. (Ibid)

Furthermore these offenders would have to learn to function in a life-long coping with their illness which may prove difficult due to the inability to easily acquire social skills and maintain healthy relationships. The prognosis for treatment and education in those with developmental disorders such as Aspergers (8% of the population at facilities) in combination creates a complex interplay between management of medication, accountability whether individual or group, personal accountability. Learning disabilities often accompany these other problems making reading and written expression difficult for these youth. The report relates that those with both substance abuse and mental health disorders comprise approximately 27% of the total of all correctional facility population. These youth acknowledge personal abuse. One-third reported sexual abuse and one -- half had reported abuse of the emotional or physical nature.. These reports were not in relation to victimization of domestic violence, seeing parents arrested, or family verbal or physical violence. Family members psychiatric history is called to be 'significant[ly] matched when they are compared to the mental health conditions of the youth in addition to the fact that 34% of the offenders were from families characterized by physical violence.

The findings state that: "While there are distinctive differences between correctional facility offenders and those under community supervision, certain similarities separate both groups from the general adolescent population. The Youth Authority's 2002 survey found that youth in its correctional facilities had a prevalence rate of a mental health condition more than three times that of the general adolescent population as reported by the Center for Mental Health Services. Furthermore, the Youth Authority's survey found that youth on parole/probation had a rate of diagnosed mental health condition more than double the general population. Similarities between both correctional facility and community supervised offenders include identical reporting of the most common mental disorders in order of prevalence: depressive disorders, attention-deficit disorder, post-traumatic stress disorder, and oppositional defiant disorder. Community supervised offenders have lower percentages in all four mental health conditions with the exception of post-traumatic stress disorder (15% for each group)." (Ibid)

The work entitled "Bridging the Gap: What We Know and Don't Know About Dual Diagnosis" states that dual diagnosis is:."..a descriptor used by clinicians and insurance companies to categorize person with severe, co-occurring mental illness and substance use disorders." (1998) Current addiction theory holds that addition is a 'chronic brain disorder with intrinsic behavioral and social-context components, similar to other forms of mental illness." (1998) Addiction, much like other diseases requires care of a long-term nature with the goal being one of reasonable treatment instead of cure. (1998; paraphrased) Young people that have been dually diagnosed are divided into two distinct groups by Mather et al. (1999) which are:

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

Alcohol

Juvenile Mental

SED

Child and Justice

Health

Welfare Drug

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:

Assessment

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)

Involvement in self-help groups such as AA and NA (Bukstein, 1998)

Additionally stated in the report is that while studies have been done in this area they have."..failed to demonstrate the superiority of any one treatment approach over another, and instead have shown only that some treatment is better than no treatment. (Buckstein, 1998; as cited by The National Institute on Drug Abuse, nd) The work of Walton (2001) cites cultural specific considerations and states findings that minority and female individuals have fewer financial resources, have fewer positive social supports and that females present symptoms of great distress psychological (i.e. low self-esteem, depression, sexual abuse, physical abuse) and that African-Americans are at a higher relapse risk due to the social situations faced after treatment.

Also supporting treatment that is 'culturally competent is the work entitled: "Racial/Ethnic Differences in Social Vulnerability Among Women with Co-Occurring Mental Health and Substance Disorders: Implications for Treatment Services" written by Amara, et al. (2006) which states that "Little attention has been given to racial/ethnic differences in studies of co-occurring disorders among women. In this article, we present findings from analyses conducted on the influence of racial/ethnic differences on the demographic and clinical profiles of 2,534 women in the Substance Abuse and Mental Health Services Administration-sponsored Women, Co-Occurring Disorders and Violence Study. Black and Hispanic women demonstrated more disadvantaged economic and social life conditions than White women. After controlling for socioeconomic differences, Hispanic women experienced more criminal justice involvement than others did, and both Black and Hispanic women were more likely to be exposed to community violence although they did not demonstrate more severe clinical symptoms than White women. In the design and delivery of services racial/ethnic differences should be considered, and research questions regarding underlying explanatory factors raised." (Amaro, 2005)

The work of Daniel L. Howard (2003) entitled: "Are the Treatment Goals of Culturally Competent Outpatient Substance Abuse Treatment Units Congruent with their Client Profile? published in the Journal of Substance Abuse Treatment 24 (2003) 103-113 is an examination of whether treatment goals in organizations of outpatient substance abuse treatment units that claim the provision of culturally competent care and specifically for African-Americans are varied. Analysis shows that: "A congruency exists among culturally competent OSAT units between the client profile, which is more distressful than for non-culturally competent units, and the orientation of treatment goals, which are more holistic, that is, treating the total individual, rather than the addiction only." (Howard, 2003)

Blane (1993) states that recent advances in the epidemiology of alcohol and ethnicity over the past ten years stress the "intra-ethnic variation, factors influence drinking behavior, and building conceptual models." While there has been progress noted the focus remains on the ethnicity and race as a variable of a demographic nature with studies of ethnic hypotheses being few. Gordon (1994) in the work entitled: "Managing Multiculturalism In Substance Abuse Services" states that the shift in philosophy combined with the demographics change occurring in the U.S. are reflective of a growth in population requiring cultural competency in the substance abuse field. Consideration has to be place don understanding how different cultural and ethnic communities view or define health and illness and specifically in the definition applied to substance abuse This work notes the difficulties inherent in development of a "culture-specific and multicultural framework in the field of substance abuse which focuses on an educational model is that multi-cultural that takes the role of leadership in the field.

The authors Kreps and Kunimoto (1994) in the work entitled: "Effective Communication in Multicultural Health Care Settings" states that individuals as well as groups construct their identity that is made of a combination of cultures that are based in nationality, ethnicity, age, religion, socio-economic class, sexual orientation, political affiliation, health conditions and interests." (paraphrased) The study states specifically that "based on heritage and life experiences we each develop our own idiosyncratic multicultural identity." (p. 3) The authors believe that communication that is improved across the different cultures has the capacity to increase the effectiveness of delivery of the health care because the participants of health care are educated concerning the cultural assumptions as well as the cultural expectations and are able to gain a new perspective in the process of treating medical and psychological problems that are complex.

The work of Amodeo and Jones (1997) entitled: "Viewing Alcohol and other Drug Use Cross Culturally: A Cultural Framework for Clinical Practice" presents a conceptual framework for use in the investigation of cross cultural alcohol and other drug issues inclusive of the factors of:

1) Attitudes;

2) Values and 3) Behaviors.

Inclusive as well are elements of cultural views relating to alcohol and other drug use as well as life problems and seeking help, relapse and recovery. The authors state findings that acculturation, subgroup identity and migration are variables that are critically important within this framework which may be utilized to view one culture or for comparison of several cultures as well as understanding community messages in relation to the AOD use and accompanying stigma and shame within a culture.

The study of Carter, Liu and Cross (1994) entitled: "Enhancing Ethnic Sensitivity; Implications for Alcoholism Counselors" states that ethnic sensitivity is a "common measure of practice effectiveness" and this is evidenced in the recent growth of workshops and conferences related to diversity issues and ethnic sensitive treatment practices among those who counsel patients who are alcoholics. Emphasized is the "similarities between traditional African-American, Asian-American, and American Indian culture-specific alcoholism strategies for working with ethnic minorities of color." Ethnicity has been shown to affect the patterns of alcohol use as well as having an effect on the perceptions and problem-solving methods of individuals. Stated is that: "The sustaining environment of traditional African-American, Asian-American and American Indian and other ethnic minorities of color is less likely to be congruent with their nurturing environment than is true of the dominant culture." (Carter, Liu and Cross, 1994) The findings of the study state that: "Commonalities exist with the nurturing system of traditional African-Americans." (Ibid)

The study of Finn (1994) entitled: "Addressing the Needs of Cultural Minorities in Drug Treatment" emphasizes and assists with understanding the importance of cultural consideration in the treatment of substance abusers of the minority ethnic groups. Cultural responsiveness is stated to be important in the areas of:

Recognizing multiple aspects of the client's identity;

2) Overcoming cultural barriers to recovery or to participation in the counseling process, 3) In addressing a source of stress that may contribute to substance abuse."

The study recongnizes four techniques for being 'culturally responsive' which includes:

1) "Individualizing the counseling process;

2) Avoiding assumptions

3) Acting to build trust; and 4) Identifying cultural issues that affect client recovery."

According to Finn's research effective response to the cultural characteristics of the client should be a provision of the counselor in relation to the values of the family through a "one-person family or bicultural counseling and responding to different types of communication (directive vs. nondirective, expressive vs. detached, hiding vs. disclosing, and physician reserve vs. demonstrative)" (Finn, 1994) Use of alcohol and other drugs (AOD) has been shown to increase the risk of the adolescent in experiencing problems in many different aspects of their life. Nationally there are three surveys that give estimates of the prevalence and incidence of AOD use in the youth population. Those surveys are:

1) The National Survey on Dug Use and Health (NSDUJ);

2) Monitoring the Future (MTF) and 3) The Youth Risk Behavior Survey (YRBS). (Adolescent Substance Abuse Needs and Services Planning Final Report (Finn, 2004) p.11

Multi-systemic Therapy

Multisystemic Therapy (MST) is focused on the goal of addressing serious antisocial behavior in individuals (children and adolescents) who abuse substances. Therapy targets the behavior within the environments of the family, school, neighborhood and community (NIDA, 1999) so that treatment takes place in the everyday settings of the child. MST has been shown by research to significantly reduce the use of drugs by adolescents both during the treatment therapy and ongoing for six months and more after treatment. However, this type of therapy has not been yet tested specific to individuals who have received a dual diagnosis. In fact, the results from the National Survey on Drug Use and Health (NSDUH) gives indication that youth between ages 12 and 17 report a 17.6% rate of current use of alcohol (within the past 30 days) 10.7 of youth report binge drinking in the past 30 days (five or more drinks on the same occasion at least one time in the past 30 days) Heavy alcohol use was reported by 2% of youth. As for illicit dug use 11.6% reported current drug use with 8.2% reporting marijuana use and another 5.7% reporting other than marijuana illicit drug use including cocaine, methamphetamines and inhalants. This work states that: "...there is limited information regarding the prevalence of substance use among special populations of adolescents, including those being served in the various public sectors such as juvenile justice, child welfare, mental health and continuation schools." (NIDA, 1999)

Multisystemic Therapy (MST) is defined by the Consortium on Children, Families and the Law to be: "an intensive family- and community-based treatment that addresses the multiple determinants of serious antisocial behavior in juvenile offenders." (nd) MST is stated to be a "pragmatic, goal-oriented treatment program that targets factors in a youth's social network that contribute to his or her antisocial behavior. MST interventions are stated to "typically aim to: improve caregiver discipline practices; enhance family relations; decrease a youth's association with deviant peers; increase a youth's association with pro-social peers, improve a youth's school or vocational performance; engage youth in positive recreational outlets; and develop a natural support network of extended family, neighbors, and friends to help caregivers achieve and maintain such changes." (Ibid, nd)

MST therapy has been shown to "reduce drug use in juvenile offenders compared with control groups" (Consortium, nd) and has "increased mainstream school attendance for substance-abusing delinquents and youths with serious emotional disturbances in comparison with control groups." (Consortium, nd) In identification of factors that are possibly linked to the problems of youth the youth and their interaction with family, peers, school, neighborhood and community are considered. In a study funded by the National Institute on Drug Abuse, which took place in Charleston, South Carolina which evaluated the use of Multisystemic Therapy with juvenile offenders who were substance abusers as compared to the usual community services it was found that MST reduced self-reported use of drugs by 46%. (Consortium, nd) MST is stated to be effective because it:

focuses on addressing the known causes of delinquency, builds on strengths in the youth and those in his social setting and reducing risk factors, delivers services in the youth's natural environment rather than in an institutional or out-of-home placement, and ensures that therapists who provide services strictly adhere to the MST program. (Consortium, nd)

Multisystemic Therapy (MST) is focused on the goal of addressing serious antisocial behavior in individuals (children and adolescents) who abuse substances. Therapy targets the behavior within the environments of the family, school, neighborhood and community (NIDA, 1999) so that treatment takes place in the everyday settings of the child. MST has been shown by research to significantly reduce the use of drugs by adolescents both during the treatment therapy and ongoing for six months and more after treatment. However, this type of therapy has not been yet tested specific to individuals who have received a dual diagnosis.

Multisystemic therapy has been shown to be effective for use in a population of delinquents in the work of Henggeler, Rodick, Borduin, Hanson, Watson & Urey (1986) when compared to a diversion services program with post-treatment with stated findings of improved family relations, decreased behavior problems, and decreased association with deviant peers.. Henggeler, Bordium, Melton, Mann, Smith, Hall, Cone & Fucci (1991) in a study of a population of serious juvenile offenders using MST compared to the treatment method of individual counseling and the usual community services showed findings that at a three-year follow-up alcohol and marijuana use had decreased as well as had drug-related arrests.

In a separate study Henggeler, Pickrel, & Brondino (1999) of a population of substance abusing and dependent delinquents state findings that multisystemic therapy when compared to community services at a one year follow-up found that drug use had decreased by 50%. Treatment adherence in this study was stated to be linked with decreased use of drugs. The incremental cost of MST was nearly offset by between-groups differences in out-of-home-placement. Other findings include increased attendance in regular school settings and decreased violent crime as well as increased marijuana abstinence. The study of Schoenwald, Ward, Henggeler, Pickerel Patel repeat the same findings with this study as well as do Brown, Henggeler, Pickrel & Patel (1996) and Henggeler, Clingempeel, Brondino & Pickrel (2002) (Multisystemic Therapy has been integrated with the Community Reinforcement Approach and reported in the work of Budney & Higgins, 1998) in which substance abuse orders among youth were addressed. The CRA approach is inclusive of tracking the use of substance through screening urine and providing rewards for clean urine. Included as well is functional analyses geared toward identifying triggers for use of illicit drugs or alcohol and self-management plans for addressing triggers of substance use and finally includes drug avoidance skills. The integration of these two models addresses the social context and the substance use issues in treatment. Multisystemic Therapy has also been integrated with the Continuum of Care model toward addressing needs of adolescents with serious mental illnesses while at the same time addressing substance use problems. The service includes home-based service delivery with intensive outpatient and crisis interventions as well as family resource specialists who partner with parents. Included as well is therapeutic foster care, respite services and access to residential and hospital access and integration of psychopharmacological treatment that is evidence-based.

The work entitled: "Co-Occurring Mental Health and Substance Abuse Disorders" by author Paige Ouimette, Ph.D. relates that Randall and colleagues through use of data in a randomized trial that evaluated Multisystemic Therapy made an examination of 16-month outcomes for 18 adolescent's individuals with substance use disorders. Finding state that 28 of these adolescents were externalizing the disorder while 26% had an internalizing disorder and 15% had both types of disorders. The externalizing/internalizing distinction is believed by Randall and colleagues to have a possible critical implication clinically. The externalizing disorders may point to a behavioral problem such as substance abuse where as the internalizing disorder may suggest a self-medicating on the part of the client.

Multisystemic Therapy (MST) is believed by Henggeler, Schoenwald, Borduin, Rowland, & Cunningham (2002) to present an intervention for dually diagnosed youth that is promising and it is related that the U.S. Surgeon General "cited MST as an evidence-based treatment for adolescent substance abuse (1999). The MST model is one that is a family- and community-based intervention based on the social-ecological and family systems theories of behavior viewing the family and community system as inherently interrelated. It is the basis of this theory that by making integral changes in the greater social contest of the youth that pro-social behavior is encouraged and antisocial behavior may be reduced. The caregiver is seen as being 'key' in the outcome therefore the caregiver is taught the correct handling of the child's problematic behaviors. MST is called a "pragmatic intervention" (Ouimette, nd).

Ouimette relates that Henggeler, Schoenwald, Borduin et al. (2002) have conducted seven randomized controlled trials and one quasi-experimental trial...[which is inclusive of] "...several populations; inner-city delinquent, violent chronic juvenile offenders, juvenile offenders with substance use disorder, youths with psychiatric emergencies, maltreating families and juvenile sex offenders." (Ibid) The findings of the study claim that MST has been shown to improve relations among family members, school attendance has increased the mental health problems of youth have decreased and the use of substances and the rate of arrests has been shown to decrease with MST. Furthermore, MST shows a higher completion of treatment rates and accompanying long-term rates of out-of-home placements decreasing. High satisfaction of the consumer and cost savings are also cited. (Ouimette, nd) MST has shown 'modest results' in randomized controlled trials in youth who are dually diagnosed with mental illness and substance abuse disorder and resulting are two new models of care which have been developed by Henggeler and colleagues.

The first model adapts and integrates MST and CRA or Community Reinforcement Approach (Budney & Higgins, 1998) The NIDA and NIAAA conducted randomized trials to examine whether the outcomes are enhanced with use of MST to the CRA. In the scope of this integrated model MST service delivery systems encompass home-based services, intensive outpatient, crisis intervention, family resource specialists/parent partners, therapeutic foster care, respite services, access to residential and hospital beds and integration of evidence-based psychopharmacological treatment." (Ouimette, nd) This continuum of care is a 3-5-month treatment

The work of Bender, Springer and Kim (2006) entitled: "Treatment Effectiveness with Dually Diagnosed Adolescents: A Systematic Review" published in the Journal of Brief Treatment and Crisis Intervention relates the fact that there are many challenges presented in treating adolescents who have been dually diagnosed which include the specifically stated reasons of "complex treatment needs, poor treatment engagement and retention, and a lack of sustainable treatment outcomes." (2006) Family Behavior therapy and individual cognitive problem-solving therapy are shown to be effective treatment options in dually diagnosed adolescents. Roberts and Yeager (2004) hold that evidence-based practice is defined as the counselors "conscientious, explicit and judicious utilization of the best available and scientifically validated assessment, intervention and treatment protocols as well as critical thinking in making clinical decisions. Corcoran and Vandiver (2004) aptly point out that evidence-based practice is a process of using a variety of databases to locate the most useful sources of information -- "systematic reviews, practice guidelines, and expert consensus guidelines -- "applied to a particularly challenging client. They also note that implementing evidence-based information and guidelines in practice settings "will likely strengthen a treatment plan, and in turn, will increase the likelihood of client change and goal attainment,... enhancing treatment effectiveness"(p. 17). In recent years, the implementation of best practices and evidence-based treatments with children and youths has grown." (Roberts & Yeager, 2004)

In fact there are several evidence-based studies that state findings that both individual and group cognitive behavioral treatment is effective in treating youths specifically that multisystemic therapy has been "effective with youths with conduct disorders and management of behavior through positive reinforcement points systems." (Okamoto & Lecroy, 2004)

The University of Alabama has received a grant in the Strengthening Communities - Youth program for the development of a "multifaceted strategy for treating substance abuse among adolescents living in inner city neighborhoods in the Mobile, Alabama Metropolitan Statistical Area (MSA) Due to increased, pronounced and concentrated poverty among minorities in inner city neighborhoods substance abuse and violence have become even more of a problem that previously. The residents will become linked in working with others in the area for policy change to provide them a voice in development of policies. The work states that even an exemplary drug treatment program cannot succeed in these areas without a strong community forum. Primary goals are stated to be the creation of a treatment coalition for substance abuse including resident groups, substance abuse treatment centers place din these communities, and providing support to residents in their development of the community supports necessary to succeed. (Treatment Improvement Exchange, nd)

In the magazine the "Counselor: the Magazine for Addiction Professionals" (2006) stated by the author Fred Dyer Ph.D. CADC is that it is his belief that in order for a practice to "qualify as evidence-based it must be manualized for reproduction and dissemination; have performance and/or adherence measures; be associated with desired outcome, be feasible for given setting/population; and be ecologically valid." (2006) Dyer points out that Catalano et al. (1992) provided the following in an overview of risk factors associated with substance abuse by adolescents:

laws and norms favorable toward behavior availability of drugs extreme economic deprivation -- ¢ neighborhood disorganization physiological factors family alcohol and drug behavior and attitudes poor and inconsistent family management practices family conflict low bonding to family early and persistent problem behaviors academic failure low degree of commitment to school peer rejection in elementary grades association with drug-using peers alienation and rebelliousness attitudes favorable to drug use (Dyer, 2006)

Dyer (2006) relates that there have been few studies to date that make an examination of the effectiveness of treatment in relation to substance abuse by adolescents which becomes problematic in discerning the patterns of consistency in outcomes of the various approaches in treatment. Multisystemic Treatment (MST) is stated to have had "exceptionally high rates of treatment engagement of substance abusing juvenile offenders (Henggeler, Pickrel, Brondino, & Crouch, 1996), and has produced favorable short-term (Henggeler, Pickrel & Brondino, 1999) and long-term (Henggeler, Clingempeel, et al., 2002) reductions in drug use. Multidimensional Family Therapy (MDFT): MDFT (Liddle et al., 2001), cited by NIDA, has been the subject of considerable supported research. MDFT devotes substantive resources to building an alliance with each youth (e.g., about 40% of sessions are with adolescents alone) and reestablishing emotional connections between the adolescent and his or her caregivers (Liddle, 1999). This approach focuses more on family affective processes and less on behavioral conceptualizations of problems and their solutions. Nevertheless, the roles of extra familiar systems in maintaining problems are addressed through a case management process."

Dyer relates that there is a great challenge presented with co-occurring disorders and as well that is a growth in the literature that supports that of the youth that are referred to treatment for substance abuse, a co-occurring mental health disorder is involved with the majority of these youth. The National Mental Health Association released a report in December 2005 showing that approximately fifty percent of all adolescents receiving mental health treatment have a co-occurring substance abuse disorder and of those adolescents receiving inpatient substance abuse treatment, 75 to 80% have a mental health disorder. The report entitled "Youth with Co-Occurring Mental Health and Substance Abuse Disorders in the Juvenile Justice System' states the following findings:

Nearly two-thirds of incarcerated youth with substance use disorders have at least one other mental health disorder.

A number of studies have shown an association between conduct disorder, ADHD, and substance abuse. For example, as many as 50% of substance abusing juvenile offenders have ADHD.

Youth who have co-occurring conduct problems, ADHD, and substance use disorders have higher than normal rates of anxiety and depressive disorders; and the presence of ADHD in particular, worsens the prognosis of both the substance use disorder and the conduct disorder, increasing the likelihood of them persisting into adulthood.

Among incarcerated youth with substance use disorders, nearly one-third have a mood or anxiety disorder.

Delinquents with substance abuse and behavioral disorders, such as conduct disorder and ADHD, engage in higher rates of crime and exhibit more alcohol and illicit drug use than do youth with mood disorders; and are at higher risk for out-of-home placement and other poor outcomes.

Many incarcerated youth are exposed to higher levels of traumatic violence, which may result in symptoms of post-traumatic stress as well as increased rates of substance use. (National Mental Association as cited by Dyer, 2005)

The work entitled "Family-based Therapies for Adolescent Alcohol and Drug Use; Research Contributions and Future Research Needs" written by Howard a Liddle reports a study with the objective of characterizing the developmental status of the family-based adolescent treatment for substance abuse through identification of and discussion of the advances in both research and clinical research. Research advances are inclusive of findings "that engagement and retention rates for family-based treatments are superior to standard treatment engagement/retention methods." Further reported is that when family-based treatment are compared in clinical trials to other treatments "the family-based treatments produced superior and stable outcomes with significant decreases on target symptoms of alcohol and drug use, and related problems such as delinquency, school and family problems, and affiliation with substance abusing peers. Further stated is that."..improvements in family interaction patterns coincide with decreases in core target alcohol and drug misuse symptoms." (Liddle, 2004)

Riggs (2000) states that: "A growing research and clinical consensus indicates that treatment for adolescents is most effective when it attends to the patients' many psychosocial problems and mental health needs in addition to their drug abuse. There is also evidence that an increasing number of community-based treatment programs are successfully implementing integrated treatment services. (Drug Strategies, 2002; National Institute on Drug Abuse, 1999)" (Riggs, 2003)

Riggs points out the fact that regardless of the advances made in this area of treatment there is still a failure to integration of treatment of psychosocial treatment with the treatment for substance and drug abuse. Riggs states the claim that "clinical and systemic barriers" contribute to this failure to integrate these programs. Further attributed for reasons in this failure are child and adolescent psychiatrists that have training in this area being in a shortage and the fact that insurance companies fail to provide coverage in this area.(Rotheram-Borus and Duan, 2003; as cited by Riggs, 2003) Riggs affirms the previous research reviewed that family-based intervention and multisystemic family therapy have been successful in assisting with the necessary changes and in addressing the problems that are presented in adolescents with mental illness and substance abuse disorder. Riggs (2003) also affirms that Community Reinforcement Therapy with the combination of principles and techniques found in behavior, cognitive-behavioral, motivational and family therapy all use incentives at time for outcomes of treatment being enhanced. Riggs relates that a study conducted recently that "systematically evaluated community-based adolescent substance treatment programs" throughout the U.S. One hundred forty-four programs were examined revealing "striking overlap with the commonly shared components of the research developed modalities." Components that are shared are inclusive of:

Comprehensive, systematic evaluation to identify problems and treatment needs in multiple domains, including psychiatric comorbidity;

Use of empathic, supportive, and motivation-enhancing techniques to improve alliance, engagement, and retention;

Use of behavioral techniques informed by urine toxicology results to promote and shape desired, pro-social behaviors and discontinuation of drug use and other problem behaviors;

Use of cognitive-behavioral and skills-building techniques delivered in an individual or group format to enhance adolescents' self-efficacy, problem-solving, decision-making, communication, anger management, mood regulation, coping, and relapse prevention skills. These techniques are often used to help adolescents anticipate and avoid high-risk situations and identify triggers for drug use, decrease association with drug-using peers, and encourage involvement in enjoyable, pro-social activities incompatible with drug use;

Involvement of the family in an adolescent's treatment, emphasizing enhancement of parental monitoring and behavioral management skills and use of restructuring interventions to correct dysfunctional patterns of interaction, relationships, and behaviors to improve overall family functioning;

Emphasis on relapse prevention and the need for continuing care, including development of specific plans to manage relapse;

Focus on adequate training and ongoing staff development activities for counselors and program specialists;

Emphasis on providing developmentally appropriate interventions, often including specialized program components such as gender-specific or culture-specific programming;

Focus on evaluating treatment outcomes; and Emphasis on the importance of integrating the assessment and treatment of co-morbid psychiatric disorders with substance abuse treatment. (Riggs, 2003)

Riggs states that "given the high prevalence of co-morbid psychiatric disorders and their adverse impact on substance treatment engagement and retention, treatment programs" should attempt to develop the ability of screening early on for co-morbid disorders.

In terms of development and design of treatment Riggs suggests a step-by-step approach in which treatment is modified "as appropriate to the details of each case and with consideration of the available family, clinical, psychiatric, and program resources, such as clinical staff and training and community resources." (2003) The first step, according to Riggs (2003) is a case conference that includes all counselors, line staff, education specialists, consulting psychiatrist and the program mental health specialist, family therapist and representatives of all involved outside agencies (i.e. social workers, case manager, and probation officer). Step two, according to Riggs (2003) is engaging the adolescent through a strong treatment "alliance and collaboratively developed goals to stabilize substance abuse and begin to address co-morbid disorders as well as other problems." Riggs suggests the use of motivation-enhancing techniques along with other individual and group therapies that are empirically supported. According to the work of Riggs (2003) step 3 of this process is consideration of medications. During this stage that adolescent will likely continue use of drugs or alcohol because the youth is not yet engaged in abstinence treatment programs. Management principles stated for use within this step of the process include those as follows:

When medication is indicated, consider medications with good safety profiles, low abuse liability, and once-per-day dosing, if possible;

Use a single medication if at all possible;

Provide the patient and family with information about the potential for adverse interactions of medications with substances of abuse and the need for abstinence or reduced substance use to ensure safety and efficacy;

Establish mechanisms to closely monitor medication compliance (initially weekly), adverse effects, target symptom response, and ongoing substance use (using both self-report and urine drug screening);

Monitor compliance with regular substance abuse treatment (generally, individual and/or family counseling at least weekly) and regular urine drug screening (if not the primary substance treatment provider); and Monitor patient treatment motivation and target symptom response and behavior changes and psychosocial functioning throughout treatment

Riggs (2003) states Step 4 to be the step within the process in which the individual is assessed for improvement and if no improvement is fond the level of care of frequency of treatment is advanced. Step 5 is the point within the process sin which the counselor discusses prevention strategies and continuing care needs with the patient. Riggs concludes by stating that "controlled efficacy trials, coupled with the results of systematic treatment program evaluation, clearly indicate that treatment for adolescent SUD is effective in reducing drug use and improving associated behavioral, familial and psychosocial outcomes." (2003) Evidence supports comprehensive integration of treatment in addressing the substance abuse problem and the psychosocial problems that exist.

Issues to consider when treating adolescents are the family issues such as the background of the youth's family, the genetic and environmental characteristics and whether or not the parents of the youth have substance abuse problems themselves. Genetic characteristics are believed to advance the risk of co-occurring disorders among youth. Other factors to consider are the social and community factors. Issues both in the school and the environment of the youth are know to advance the risk factor of substance abuse. Examples are influence of peers, availability of illicit drugs in the environment of the youth as well as failing in their academic achievements. Emotional and mental Disorders also increase the risks associated with illicit drug use and abuse. Once the adolescent who have either or both mental or emotional disorders begins substance or alcohol use the problems associated with mental and emotional problems will worsen. Multisystemic treatment shows great promise because it utilizes interventions that target various aspects of the life of the adolescent. Further evidence for the need of integrated programs for treating dually diagnosed adolescents is a study conducted in the state of Maryland which reveals that of the 15 juvenile facilities in that state 53% of the youth met the criteria for diagnosis of a mental illness and two-thirds of those had either multiple mental illnesses or substance use diagnosis. A separate study in South Carolina states findings that 86% of 185 youth between the ages of 13-17 were diagnosed as having either a mental illness or substance use disorder. Another study conducted in Canada states findings that of all youth incarcerated at two secure juvenile facilities 63% had two or more mental illnesses. (Ulzer & Hamilton, 1998) A study conducted in Georgia at the Regional Youth Detention Centers states findings that 61% of the youth had mental disorders which included substance abuse disorders with 44% of those having two or more diagnoses. (Marstella et al. 1997) In analysis of these studies Kendziora and Osher came to the conclusion that 50% to 75% of youth in juvenile justice facilities either have a form of mental illness or substance abuse disorder, or the two combined.

Juvenile facility representation of minority children is noted in the review of the work entitled: "Working Together for the Best Outcomes for Youth with Serious Emotional Disorders" published by the American Institutes for Research. Minority youth are less likely to be referred to residential care communities than are white children and are furthermore 'over-represented and receive tougher treatment than white youth at every decision point in the juvenile justice system." (Burrell, 2003) Minority youth, especially black males are likely to be branded as emotionally disturbed due to the fact that most majority race members do not understand the culture or behavior of minority males. This is also true of counseling staff working with minority youths who are mentally ill and have a substance use disorder. Ellison et al. (2000) notes in the findings of research conducted that African-American males tend to display express through exaggerations of excitement that the behavior is often believed to be inappropriate or aggressive.

The family and community are included in this treatment with one aspect of this treatment being its home-based service delivery wherein the counselor comes into the home of the adolescent. This treatment option has as its' focus the strengths of the adolescent and teaching the adolescent's family what they can do in the event the problem arises in the future. The integrated treatment systems have common ingredients through combining elements found in both mental health and addiction treatment into program that is comprehensive. This model is stated to be "currently accepted as having the most potential benefit for clients with co-occurring disorders." (Co-Occurring Disorders: Implementing Evidence-Based Practices. 2003) Culturally relevant services are lacking in most U.S. States and as well a great disparity exists in the service provision to different ethnic and culture groups. While some states have claimed they are homogenous and don't have issues with cultural competence other states divides the different aspects by socioeconomic and educational levels adapting the program by adjusting for these differences alone. The first step made in the U.S. states in addressing the problem is to place a staff member in charge of cultural competence for the provision of education, technical assistance, policies, and implementation. Specific examples are stated to be:

State training, education, social marketing on cultural competence issues;

Annual conference that addresses issue

All community mental health center must have training on cultural competence

Cultural competence coordinator is engaged in EBP implementation planning

Another challenge is how to implement best practices in rural areas of the country due to lacks in resources such as funding, workforce and infrastructure capacity. Stated challenges are those of:

1) Assertive Community Treatment - Specifically stated is the need of funding for which to take care of expenses associated with beginning this treatment provision.

2) Supported Employment

3) Family Psycho-education

4) Integrated Dual Disorder Treatment - Coordination and Collaboration of two systems

5) Medication Management

6) Multisystemic Treatment

7) Wraparound

In the family-based treatment approach the techniques are "based on four family therapy models which are:

1) Structural;

2) Strategic;

3) Functional; and 4) Behavioral.

These are used either alone of in combination of the effective parts of various models. The family is viewed as "a collection of subsystems" and with each having their own role. When the boundaries and roles are not clear or not appropriate problems then arise within the subsystem of the family. The Therapeutic Community Treatment approach is described as a treatment program that is long-term and used in cases with the adolescents who have the most severe problems with substance abuse. The treatment takes place in a highly structured environment assist in the adolescent in the development of personal and social behaviors as well as attitudes and beliefs that are more appropriate.

Summary of Literature Review

After having reviewed the foregoing literature it is clear that the development and design of a program for treatment of dual-diagnosis of mental illness and substance abuse disorder must necessarily place consideration upon the population that will be treated, or specifically the cultural factors that impact the effectiveness of treatment. In the case of treatment programs fro minority youths this literature reviewed has demonstrated that the entire environment of the adolescent must be taken into consideration which encompasses the adolescents school, home, neighborhood, and community. The research has further shown that the multi-systemic therapy design shows the most promise in treatment of dual-diagnosed adolescents and that this model integrated with the Community Reinforcement Approach and the Family-Based Intervention method of treatment has been successful in treating the dually-diagnosed adolescent. Dynamics of the family offer up many clues as to the mental illness and substance use disorder of the adolescent specifically in terms of triggers for substance use and substance relapse. In a model that works in collaboration with family, school, community and the individual receiving treatment the likelihood of a plan being developed for a successful outcome for the adolescent is much higher due to the reinforcing nature of the interactions that are orchestrated as the counselor engages each of these separate parts into the coordination of a treatment plan for the adolescent. It is somewhat ironic to note that emotional and mental disorders increase the change that an adolescent will use substances and at the same time the use of substances increases the chance that adolescents will develop mental or emotional disorders.

The most important finding of the research of this literature review is that community- and family-based reinforcement treatment options are those with the best outcome possibilities. The community and family informs the counselor of the cultural factors and elements that are presented while the counselor assists in designing an individualized treatment plan that addresses the specific needs of the adolescent for whom treatment is being provisioned. It will prove critically important in the development of these models for treatment that the lines of communication remain open between all collaborating parties in the family, community and the counselors associated with treatment of the adolescent. It is necessary that treatment is in the least restrictive environment according to the findings in the review of literature. Furthermore it is critically important the youth feel safe and that their information is confidential. Training and education will need to be provisioned for counselors in relation to cultural competency