SAMHSA logo Report to Congress - Nov 2002








Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 4 - Evidence-Based practices for Co-Occurring Disorders - Interventions for Children and Adolescents with Co-Occurring Disorders




Interventions for Children and Adolescents with Co-Occurring Disorders

As noted elsewhere in this report, growing evidence suggests that co-occurring substance abuse disorders and mental disorders affect adolescents. In studies of adolescents receiving mental health services, about half had a co-occurring substance abuse disorder (Greenbaum, 1996). The study found that depression and conduct disorders were the most frequent mental disorders diagnosed in the presence of a co-occurring substance abuse disorder.

Available data indicates that adolescents who have a substance abuse disorder have an increased risk of experiencing other mental disorders (Beitchman, 2001). In fact, Wise (2001) points out that the majority of adolescents with substance abuse disorders have a current anxiety, mood or disruptive disorder. Conduct disorders and mood disorders are the two disorders most consistently reported (Wise, 2001).

In addition to recognizing the relationship between substance abuse disorders and other mental disorders, it is important to note which substances are most likely to be abused by adolescents: alcohol, marijuana, and cocaine. While adolescents use other substances of abuse, the demand for treatment may not be keyed to these other substances. Nevertheless, all substances of abuse should be taken into consideration when addressing the needs of adolescents who present for treatment of either a substance abuse or mental disorder.

Co-occurring disorders among children and adolescents present special challenges and opportunities, not the least of which is engaging in the processes of treatment and recovery. The experience of many youth and their families has been difficult at best, and potentially damaging. Their dilemma is described in the report from a SAMHSA-sponsored work group of the Federation of Families for Children's Mental Health and Key for Networking, Inc. titled, Blamed and Ashamed (Federation of Families, 2000). The report notes, "Youth and family members were severely blamed and shamed by providers and systems when what they needed was nonjudgmental recognition of their struggle to find caring help and support." Adolescents with severe emotional or behavioral disorders and substance use problems require careful and thorough assessment, individual treatment plans, and increased supervision in order to prevent risk behaviors and to increase the possibility of discharge placement into the community rather than to another institution (Weiner, et al., 2001). During input meetings, SAMHSA constituents identified the need to better address the care of children and adolescents with co-occurring disorders at the system, program, and research level (SAMHSA, 2002f).

Barriers to Treatment

Children and adolescents with co-occurring substance abuse disorders and mental disorders, and their families face special challenges to treatment. In part, the challenges arise because more knowledge is needed about the prevalence (rates) of co-occurring substance abuse disorders and mental disorders among children and adolescents. Developmentally appropriate assessment standards to help in that effort need to be standardized.

Other factors arise as well. The knowledge base about what services work best to help adolescents with either substance abuse or mental disorders is robust. However, far less is known about what practices are most effective to meet the needs of adolescents with co-occurring substance abuse disorders and mental disorders (CSAT, 1993). For that reason, both substance abuse and mental health services programs designed for adults may not be appropriate for children or adolescents. Certain program elements, such as confrontation, may alienate children or teens. Experts in the field acknowledge the need to differentiate between the needs of adolescents and adults in treatment and engagement approaches, ensuring that developmental issues are addressed for children and adolescents of all ages.

Identifying and securing relevant services for children with co-occurring substance abuse disorders and mental disorders is complicated by the broad web of agencies with which families must contend - schools, juvenile justice system, health care system, substance abuse and mental health services systems, child welfare system, among others. The ability to negotiate these myriad systems also can be frustrated by the stigma that still accompanies mental and substance abuse disorders. Families choose not to have their child "labeled," or may be concerned about community response. All of these factors combine to suggest that integrated services are especially beneficial for children with co-occurring disorders and their families.

Moreover, too often, children and adolescents receive whatever services are supported by public or private funding, such as health insurance, regardless of their primary need. Thus, adolescents with co-occurring disorders may be hospitalized because payers favor that, though there is little evidence to show its greater efficacy when compared to outpatient or community-based services (Petrila et al., 1996).

Effective Interventions

While children and adolescents with co-occurring substance abuse disorders and mental disorders are not simply small adults, some of the treatment issues are similar. As with adults, co-occurring disorders in children and adolescents vary in level of severity; as with adults, assessment is on ongoing process. Youth should be able to move back and forth across the level of care continuum based on their progress and changes in the environment. In addition, the therapeutic alliance between the child or adolescent and the therapist is a critical component, even in family therapy models (CSAT, 1999a).

However, key differences must be borne in mind. For example, far less is known about the staging of co-occurring disorders in young people - and whether the course of one of the disorders may affect that of the other disorder (Meyer, 1986, in CSAT, 1999a). In addition, unlike treatment for adults, treatment for youth must be appropriate to the individual's developmental stage. Thus, the treatment of a 13-year-old should not be identical to that of an 18-year-old.

While programs for young people with co-occurring disorders vary in setting, length, and intensity, research has found that the most effective interventions are comprehensive -integrating legal, health, recreational, and educational services- and include common elements such as group therapy, family involvement, and the recognition that recovery is a process (Johnson et al., 1995; CSAT, 1991). Involvement of youth in their treatment is key. A study based on in-depth interviews with 150 youth with co-occurring disorders recommended that providers engage youth in designing and evaluating treatments (Federation of Families, 2000).

Interventions by front-line professionals-including family physicians, school psychologists, child welfare workers, and others-can identify problems early and prevent or forestall the need for more intensive and expensive treatment. These professionals need to be suitably trained to assess and treat, or refer for treatment, children and adolescents with co-occurring substance abuse disorders and mental disorders (Federation of Families, 2000). These providers also should become part of the comprehensive service team that participates in or is kept well informed of a diagnosis, treatment, and aftercare provided by others.

SAMHSA's three-year Cannabis Youth Treatment (CYT) program, exemplifies the above (began in October 1997). Compared with adolescents who do not use marijuana, marijuana users were four times more likely to report symptoms related to conduct or attention deficit disorders or to have dropped out of school, been in a fight, or been engaged in illegal activity (the latter not limited to drug possession or use). Adolescent participants were assigned to one of five manualized treatment conditions: Motivational Enhancement Therapy and Cognitive Behavioral Therapy (MET/CBT) for five sessions; MET/CBT for twelve sessions; Family Support Network (including MET/CBT) for twelve sessions; Adolescent Community Reinforcement Approach; and Multidimensional Family Therapy. Findings show that all five treatments are effective.

Scant work has been done to identify ways in which programs serving either youth with substance abuse disorders or children and adolescents with mental disorders can best be adapted to serve youth with co-occurring mental and addictive disorders. Nonetheless, a number of programs and interventions designed specifically for children and youth with co-occurring disorders appear promising.

Case Management

Case management coordinates care for children and their families. As with adults, case management services for children and adolescents include a broad array of activities, ranging from brokered services to the direct provision of clinical care. Because the care needed by children and adolescents with serious emotional disturbances and co-occurring substance abuse disorders spans a broad range of service systems, case management services are of particular relevance and value for this population (U.S. DHHS, 1999b). One such model of services, called Children and Youth Intensive Case Management that provides service coordination, as well as assessment, planning, linkage, and advocacy, has been evaluated for use with children with co-occurring disorders. Initial findings are promising and support the use of intensive case management approaches with children and adolescents who have co-occurring disorders (Evans et al., 1992, in U.S. DHHS, 1999b).

Family Therapy

Family engagement is a critical element in the prevention and treatment of co-occurring disorders among children and adolescents. Family therapy has evolved from a concern that parents were the cause of their children's disorders to a recognition that parents represent one of the two most important influences on adolescents. Contemporary family therapy approaches, often termed multi-systemic or multidimensional therapy, work with adolescents, parents, parent-adolescent combinations, and whole families and include attention to the youth's environment, including peers, schools, and neighborhoods.

Families, peers, schools, and communities are the source of both multiple risk and protective factors, as highlighted in the "Prevention" chapter of this report. Including them in treatment is designed to reduce the risk factors these individuals and systems confer and increase the protective factors they offer. For example, a counselor may discourage association with deviant peers or encourage family members to join church or civic groups (CSAT, 1999a).

Family members should educate themselves and others and be encouraged to attend, as many already do, relevant 12-step or other support programs such as Alcoholics Anonymous, Al-Anon, and Narcotics Anonymous (Federation of Families, 2001; Sciacca and Hatfield, 1995). Basic tenets of the 12-step approach may conflict with adolescent development but can be adapted to younger clients without sacrificing pivotal elements (Petrila et al., 1996).

Multisystemic Therapy

Multisystemic Therapy (MST), a family and community-based intervention for youth with substance abuse disorders and histories of violence, has been cited by SAMHSA, the National Institute on Drug Abuse, and the U.S. Surgeon General (CSAT, 2001) as an evidence-based model. An extensive body of clinical research shows MST's effectiveness at improving family relations, decreasing adolescent substance use, and reducing long-term rates of re-arrest and out-of-home placements. Initial results are promising for youth receiving MST instead of psychiatric hospitalization (Henggeler et al., 1998, in U.S. DHHS, 1999b).

Therapeutic Communities

The therapeutic community model - an intensive, comprehensive adult treatment model - has been modified successfully to treat adolescents with substance abuse disorders. Adolescents entering TCs often have both substance abuse disorders and a behavior problem (e.g., truancy, poor school performance) or diagnosable mental disorder (e.g., ADHD, conduct disorder) (Jainchill, 1997, in CSAT, 1999a). A majority of youth in TCs have been referred by the juvenile justice, family court, or child welfare systems.

In contrast to TCs for adults, those for adolescents are characterized by shorter stays, less confrontational treatment interventions, greater staff supervision and evaluation, treatment that is staged across the behavioral, emotional and developmental dimensions, attention to potential learning disabilities and mental disorders (e.g., ADHD), greater focus on education than on work and preparation for employment, and, critically, family involvement (CSAT, 1999a).

TCs often also provide comprehensive family services programs: family assessments, family counseling and therapy, parent support groups, and family education programs. The ability to integrate families into the TC program for adolescents can be challenging, especially for those TCs serving youth from rural areas. In some cases, the TC itself may provide a surrogate extended family for its residents (CSAT, 1999a).

Relatively few studies have assessed effectiveness of long-term residential treatment for youth. The extant literature suggests that positive outcomes - such as reductions in substance use - occur when a full treatment course is completed (CSAT, 1999a). The need for further research, particularly regarding treatment duration and duration of positive treatment outcomes following program completion, would benefit the field.

The Comprehensive Community Mental Health Services for Children and Their Families Program

The Comprehensive Community Mental Health Services for Children and Their Families Program, administered by SAMHSA's Center for Mental Health Services, was implemented in 1993. It provides grants to States, Territories, American Indian and Alaska Native tribes, and communities in response to the broad range of disparate service needs for children with serious emotional disturbance (including those with co-occurring substance abuse disorders) and their families. The concept of a system of care, the premise on which the program is built, is based on a set of values and principles first articulated over 15 years ago by Stroul and Friedman (1986). The program consists of a comprehensive and individualized range of mental health and other services, including treatment and supports, which are organized into a coordinated network to meet the needs of children with serious emotional disturbance and their families.

Based on the program's national evaluation, children with co-occurring serious emotional disturbance and substance abuse represent 17 percent of program participants of all ages, but they constitute almost 50 percent of the adolescent participants (Santiago, 2000; CMHS, 1999b). These children with co-occurring disorders face greater challenges, yet they made greater improvements in functioning in the home, school, and community after 1 year than did those without these disorders (CMHS, 1999b). They experienced a 29-point decrease in their overall level of functional impairment as measured by the Child and Adolescent Functional Assessment Scale (CAFAS). Children without a co-occurring disorder experienced a 12-point decrease in their overall levels of impairment (CMHS, 1999b). The CAFAS assesses levels of functional impairment (severe, moderate, mild and minimal) in the areas of role performance in the school, work, home, and community; moods and emotions; behavior toward others; self-harmful behavior; substance use; and thinking.

Circles of Care

The Circles of Care grant program was initiated by CMHS in 1998 to assist federally recognized tribes and urban Indian programs. The program helped these groups to plan, design, and assess systems of care for Native youth with co-occurring substance abuse disorders and mental disorders.

Of the 16 communities that received funding, all addressed the issue of co-occurring disorders. Eight of the programs operate inpatient facilities, eight are funded by CSAT as part of its substance abuse treatment initiatives, and two have received support from the Robert Wood Johnson Healthy Nation substance abuse prevention grants. The grants have been used to improve access to funding for critical programs and to improve cultural understanding among mainstream providers for the Tribal members and organizations.