Improving Outcomes for Court-Involved Youth with Co-occurring Disorders October 24, 2014

Improving Outcomes for Court-Involved Youth with Co-occurring Disorders

October 24, 2014

Moderator:

Joseph J. Cocozza, Ph.D.Director, National Center for Mental Health and Juvenile Justice

Coordinator:

Tom Templeton, M.S.Ed.Project Assistant II, National Center for Mental Health and Juvenile Justice

The recording of this webinar, along with the PowerPoint slides, will be available at ncmhjj.com

If you experience technical issues during the webinar, please use the chat feature to ask for help

The format of today’s webinar will include three presentations

A follow-up Ask the Expert series will be held to allow sufficient time for questions and discussion

An eBlast with registration information for the Ask the Expert sessions is forthcoming to all webinar participants

FYI…

Wednesday, November 12, 2014 2:00 PM EDT – 3:30 PM EDT

Robert Kinscherff, Ph.D., J.D.

Friday, December 5, 2014 2:00 PM EDT – 3:30 PM EDT Holly Hills, Ph.D.

Wednesday, December 17, 2014 2:00 PM EDT – 3:30 PM EDT

Richard Shepler, Ph.D., PCC-S

Ask the Experts Schedule

Improving Outcomes for Court-Involved Youth with Co-occurring Disorders

October 24, 2014

Sponsored by the

National Center for Mental Health and Juvenile Justice

and the

National Council of Juvenile and Family Court Judges

This webinar is designed to identify the need for addressing court-involved youth with

co-occurring disorders suggest new directions for improving policies and programs describe effective treatment models that address the needs

of youth with co-occurring disorders offer examples of model programs that have demonstrated

success

Objectives

Many youth involved in the juvenile justice system simultaneously experience both mental health and substance use disorders, also known as co-occurring disorders

Research shows that these youth present multiple, complex issues, and demonstrate poor treatment outcomes

Their presence creates unique challenges for juvenile drug treatment courts

Changes in policy, practice, and treatment are necessary to successfully address the needs of youth with co-occurring disorders

Why Focus on Youth with Co-occurring Disorders?

Developing Effective Policies for Addressing the Needs of Court-Involved Youth with Co-occurring Disorders

Robert Kinscherff, Ph.D., J.D. and Joseph J. Cocozza, Ph.D.

Providing Effective Treatment for Youth with Co-occurring Disorders

Patrick Kanary, E.Ed., Richard Shepler, Ph.D., PCC-S, and Michael Fox, M.A., PCC

New Directions to Address Co-occurring Mental DisordersHolly Hills, Ph.D., and Karli J. Keator, M.P.H.

Advancing Juvenile Drug Treatment Courts (Briefs available at ncmhjj.com)

Robert Kinscherff, Ph.D., J.D.Senior Associate at the National Center for Mental Health and Juvenile Justice; Associate Vice President for Community Engagement at the Massachusetts School of Professional Psychology

Richard Shepler, Ph.D., PCC-SSenior Research Associate at the Begun Center for Violence Prevention Research and Education, the Jack, Joseph, and Morton Mandel School of Applied Sciences, Case Western Reserve University

Holly Hills, Ph.D. Associate Professor in the Department of Mental Health Law and Policy at the Louis de la Parte Florida Mental Health Institute in the College of Behavioral and Community Sciences at the University of South Florida

Presenters

Developing Effective Policies for Addressing the Needs of Youth with Co-occurring

Disorders

Robert Kinscherff, Ph.D., J.D.

Increasing Awareness of COD

Recognition that policy and program changes are needed to address court-involved youth with co-occurring mental and substance use disorders

Develop the local capacity for integrated care to effectively treat these youth

Key Decisions in Building COD Capacity

Establishing Eligibility and Exclusion CriteriaScreening and AssessmentYouth and Family Involvement Integrated Treatment ServicesViolations, Sanctions, and RewardsGraduation Expectations

Adapting Policy for Youth with COD

Eligibility Criteria

Criteria broadly excluding youth with MHD should be changed to permit inclusion of youth with MHD

Avoid using criteria exclusively based upon specific diagnosis and focus instead upon degree of functional impairment arising from the MHD and the SUD

Adapting Policy for Youth with COD

Screening and Assessment

Screening of all potentially eligible youth for both MHD and SUD using consistent protocols and empirically validated tools for screening

Refer youth screened “positive” for individualized assessments:• Administered by clinicians trained in COD assessment

methods• Attentive to trauma-informed assessment• Geared toward case-specific plans, “treatment

“matching”• Focused upon effective, integrated treatment

Adapting Policy for Youth with COD

Youth and Family Involvement Better outcomes with higher level of family engagement

Consider requiring family participation in screening, assessment, and treatment by at least one “family” member (not necessarily a parent)

Family-Friendly practices including• Scheduling when working parents can attend• Assisting with transportation, child care• Being sensitive to cultural issues• Recognizing family members who support recovery• Recruiting parents with “lived experience” as supports• Inviting parents with “lived experience” as JDC team members• Inviting former youth participants (graduates) as JDC team

members

Adapting Policy for Youth with COD

Integrated Treatment Services Better outcomes with integrated EBP treatment Avoid settling for what is available if inadequate “Something is better than nothing” = FALSE

Work with community-based clinical services providers to develop capacity for evidence-based integrated COD treatment• Bring insurers and other funders into the

conversation• Consider incentivizing a provider with sole referrals• Access technical support and consultation• Avoid “parallel” or “serial” treatment approaches

Adapting Policy for Youth with COD

Violations, Sanctions and Rewards Just as SUD recovery is characterized by relapse

along the way to recovery, MHD may have a waxing and waning course of symptoms despite participation in treatment (especially in early phases of treatment).

Violations and sanctions should focus on treatment engagement, not solely fluctuations of symptoms

Violations, sanctions, rewards should consider:• Treatment attendance and participation• Degree of progress in SUD recovery• Indications of functioning at home, school,

community

Adapting Policy for Youth with COD

Graduation Expectations Ordinarily hold youth with COD to same criteria as those

with just MHD or SUD

Consider whether failure to achieve some expectations (e.g., school attendance) reflects functional impact of active mental disorder beyond the ready control of the youth

Focus upon ultimate markers of success in COD which include• Active participation in integrated treatment• Evidence of SUD recovery over time• Improved functional capacities, reduce impairment• Reduced re-arrest and violations of JDC expectations

Adapting Policy for Youth with COD

Emerging Models for Court-Involved Youth with COD

Are promising but still developing

Require key modifications in JDC policies

Should provide access to integrated COD treatment

Providing Effective Treatment for Youth with Co-occurring Disorders

Richard Shepler, Ph.D.,PCC-S

3 Types of Treatment for Co-Occurring Disorders

Sequential: traditional belief that symptoms of one disorder (SU/MH) can’t be resolved until the symptoms of the other disorder are addressed

Parallel: both services provided at same time by different professionals in different systems or agencies, with different treatment plans

Integrated: mental health and substance use treatment is provided by one provider with one assessment and one treatment plan

Youth with co-occurring disorders are best served through an integrated screening, assessment, and treatment planning process that addresses both mental and substance use disorders, each in the context of the other

Treatment of Youth with Co-occurring Disorders: What We Have Learned

• Look for treatment programs that offer both substance use and mental health approaches delivered in home and community environments:

• Integrated Co-Occurring Treatment (ICT); • Family Integrated Transitions (FIT), • Multidimensional Family Therapy (MDFT), • Functional Family Therapy-CMT (FFT-CMT), • Multisystemic Therapy-SU (MST-SU).

• Optimal effects require interventions that impact youth symptom patterns (behaviors, cognitions, emotions), trauma, risk and safety issues, family systems and recovery environments, peer relationships, school and community functioning, and positive development.

Influence, Interaction, and Manifestation of Multiple Occurring Conditions

Family

Substance Use Disorder

Mental Health Disorder

Risk & Resiliency Factors

DevelopmentalFactors

Salient Behavior/Symptom

Trauma Factors

Contexts (Home, School, Peers,

Community, etc.)

Safety Concerns

Youth

Integrated Co-Occurring Treatment

Integrated Co-Occurring Treatment (ICT) is a promising practice that utilizes an integrated treatment approach, embedded in an intensive home-based service delivery model, to provide both mental health and substance abuse treatment services to youth with co-occurring disorders of substance use and serious emotional disability and their families. Services are provided in the home, school and community where the youth lives, with the goal of safely maintaining the youth in the least restrictive, most normative environment.

Main Purpose: Placement prevention Reunification Stabilization and safety

ICT Core Assumptions

1. Youth with COD present with multiple and complex symptom patterns and behaviors, which adversely affect their functioning in developmentally important life domains. 2. COD presentation in youth is affected by brain development; and conversely, brain development is impacted by substance use. 3. Traumatic stress experiences contribute to impaired emotional and behavioral functioning and to the adoption of risk behaviors, which in turn may lead to further exposure to victimization, violence, and trauma experiences. 4. Safety concerns and risk behaviors are elevated and need to be intensively managed and monitored.

ICT Core Assumptions (cont.)

5. Contextual factors (peers, family, school, neighborhood, and the risk and protective factors associated with them) play a mediating role in youth behaviors, use patterns, and recovery trajectory. 6. The stressors associated with co-occurring disorders negatively strain family emotional, interpersonal, and material resources. 7. Treatment engagement and readiness to change are more difficult to attain and sustain.

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Intensive Home-Based Service Delivery Modality

Multidimensional and Integrated Assessment and

Conceptualization

Comprehensive and Integrated Treatment Array Matched to

Needs and Strengths

Cross-System Collaboration and Service Coordination

ICT Model ComponentsResiliency-O

riented Developm

ental Perspective

• Crisis intervention and stabilization• Individually-focused cognitive, emotional, and behavioral

treatments • Skill building and psycho-education• Motivational interviewing• Family-focused, systemic interventions• Cross-system coordination and supports• Asset and support building activities (e.g. linkage to

recovery mentor)

ICT Core Services

Target Outcomes

Increase functioning in major life contexts so that the youth is:• Living at home or in a permanent home setting• Attending and achieving at school/work• Reduced involvement in the JJ system• Reduced use/no use of substances• Participating in positive family, peer, and community life• Improved family recovery environment• Accessing resources and natural supports as needed to

maintain gains and prevent recidivism

Realistic Outcomes and Expectations

• Think trajectory of wellness not cure• Youth living with mental health and substance use disorders

often have ongoing treatment and/or support needs• Substance use is a chronic relapsing disorder (Dennis)

Completion rates low High rate of treatment drop-out Relapse common

• Measure what you do: risk reduction across life domains Track multiple outcomes

• Conversation with key stakeholders about realistic outcome expectations (increased functioning; decreased level of care needs; etc.)

New Directions to Effectively Address Co-occurring Mental Disorders

Holly Hills, Ph.D.

Program Modifications to Address Co-Occurring Disorders

• Evaluate the available service continuum and build relationships to fill needs

• Consider altering program policies and criteria

• Modify the content of screening and assessment tools

Examples of Program Modifications

• Summit County, OH: Crossroads Program

• Ouachita Parish, LA: 4th Judicial District Juvenile Drug Treatment Court

Summit County, OH: Crossroads Program

• 70 youth annually, aged 12-17, post adjudication

• Can get records expunged if they successfully complete

• 4 phases of contact, from weekly to monthly meetings, over a year’s time

Summit County, OH: Crossroads Program

• Youth receive services in their home • 3-5 hours of contact with their counselor per week • Probation Officers are trained in Motivational

Interviewing and Cognitive Behavioral Therapy• POs meet with youth under their supervision 2-3x

per week

Summit County, OH: Crossroads Program

• Sanctions: electronic monitoring, suspension of driver’s license, changes in curfew

• Incentives: Field trips, movie / sports tickets, gift cards

Ouachita Parish, LA: 4th Judicial District

• Youth, age 10-17 get a clinical eligibility screening to determine program course

• Youth with CODs participate for approximately 9 months

• Utilize structured screening and assessment measures

Ouachita Parish, LA: 4th Judicial District

• 2 contacts with Case Manager weekly• 2 contacts with Probation Officer weekly • Evolving to 2x month over program term

Ouachita Parish, LA: 4th Judicial District

• Two Program “Tracks”

• Track 2 has four phases with an additional aftercare phase

Ouachita Parish, LA: 4th Judicial District Juvenile Drug Treatment Court

Program Elements

• Cannabis Youth Treatment (CYT) and Solution Focused Brief Therapy (SFBT)

• Collaboration between the Court and the University of Louisiana, Monroe

• Family member / Guardian must complete a ‘Family Action Plan’

Ouachita Parish, LA: 4th Judicial District Juvenile Drug Treatment Court

Program Elements

• Incentives = gift cards, sports tickets, decreased time spent in a Phase

• Sanctions = writing assignments, increased frequency in court

• Graduation requires 8 weeks with no positive drug screens, and compliance with interventions

Conclusion

• Recognition of significant numbers of youth with CODs may require• Modification of mission • Review / expansion of Screening and Assessment

Measures • Adoption of Evidence-based Practices • Expanding Access to Psychopharmacology • Review of Outcome Measures

The recording of this webinar, along with the PowerPoint slides, will be available at ncmhjj.com

A follow-up Ask the Expert series will be held to allow sufficient time for questions and discussion

An eBlast with registration information for the Ask the Expert sessions is forthcoming to all webinar participants

Reminder…

Wednesday, November 12, 2014 2:00 PM EDT – 3:30 PM EDT

Robert Kinscherff, Ph.D., J.D.

Friday, December 5, 2014 2:00 PM EDT – 3:30 PM EDT Holly Hills, Ph.D.

Wednesday, December 17, 2014 2:00 PM EDT – 3:30 PM EDT

Richard Shepler, Ph.D., PCC-S

Ask the Experts Schedule

Contacts

Robert Kinscherff: [email protected]

Richard Shepler: [email protected]

Holly Hills: [email protected]

Tom Templeton: [email protected]