1. Integrated Co-Occurring Treatment (ICT) © A Developing Practice for Youth with Co- Occurring Conditions and Juvenile Justice Involvement The Center for Innovative Practices

2. 2 What is Integrated Treatment? Mental Health and Substance Abuse Services are integrated Mental Health and Substance Abuse Services are integrated One provider team One provider team One assessment One assessment One treatment plan One treatment plan One youth One youth

3. 3 Why Integrated Care? Unrecognized mental health disorders reduce engagement, retention and completion Unrecognized mental health disorders reduce engagement, retention and completion Untreated co-morbid disorders persist after recovery: ADHD, Mood Disorders Untreated co-morbid disorders persist after recovery: ADHD, Mood Disorders After recovery from SUD, depression in youth is much more likely to persist compared to adults. After recovery from SUD, depression in youth is much more likely to persist compared to adults. (Turner) (Turner)

4. 4 Co-occurring Disorders with Juvenile Justice Involved Youth 63% of juvenile detainees assessed with a substance abuse disorder were also co-morbid for at least one mental health diagnosis (Cleveland SAMHSA SCY project, Hussey, D., Drinkard, A., Murphy, M., & Ols, K., March, 2005). 63% of juvenile detainees assessed with a substance abuse disorder were also co-morbid for at least one mental health diagnosis (Cleveland SAMHSA SCY project, Hussey, D., Drinkard, A., Murphy, M., & Ols, K., March, 2005). 60% of youth with a substance abuse diagnosis had a co-morbid psychiatric diagnosis of which conduct disorder and oppositional defiant disorder were the most common co-morbid diagnoses (Armstrong and Costello 2002) 60% of youth with a substance abuse diagnosis had a co-morbid psychiatric diagnosis of which conduct disorder and oppositional defiant disorder were the most common co-morbid diagnoses (Armstrong and Costello 2002)

5. 5 OJJDP Multi-State Prevalence Study (Skowrya & Cocozza, 2006) 70.4% of justice-involved youth meet criteria for a diagnosable mental disorder 70.4% of justice-involved youth meet criteria for a diagnosable mental disorder 27% of justice-involved youth have serious mental disorders 27% of justice-involved youth have serious mental disorders 55.2% met criteria for at least two diagnoses 55.2% met criteria for at least two diagnoses 90.3% of youth with Conduct Disorder also met criteria for at least one other disorder 90.3% of youth with Conduct Disorder also met criteria for at least one other disorder 37.5% of youth in the sample had both a mental health disorder and a substance use disorder 37.5% of youth in the sample had both a mental health disorder and a substance use disorder

6. 6 MH Needs of Youth in JJ System NIMH Study (Teplin et al., 2002) 66% of boys and 75% of girls in Cook County Juvenile Detention had at least 1 psychiatric disorder 66% of boys and 75% of girls in Cook County Juvenile Detention had at least 1 psychiatric disorder 50% abused or addicted to drugs 50% abused or addicted to drugs When Conduct Disorder removed, 60% of males and 66% of females met Dx criteria one or more MH or SA disorders When Conduct Disorder removed, 60% of males and 66% of females met Dx criteria one or more MH or SA disorders Rates of dysthymia or depression: 17.2% for males; 26.3% for females Rates of dysthymia or depression: 17.2% for males; 26.3% for females

7. 7 Treating one disorder in isolation is not sufficient Substance abuse treatment helps to reduce the frequency of use and the number of abuse/dependence symptoms but has only indirect impact on emotional and behavioral problems (M. Dennis, 2004) Substance abuse treatment helps to reduce the frequency of use and the number of abuse/dependence symptoms but has only indirect impact on emotional and behavioral problems (M. Dennis, 2004) Psychiatric treatment alone for youth with mood disorders and co-occurring SUD does not significantly reduce substance use (Geller et al., 1998) Psychiatric treatment alone for youth with mood disorders and co-occurring SUD does not significantly reduce substance use (Geller et al., 1998)

8. 8 Integrated Co-occurring Treatment (H. Cleminshaw and R. Shepler; P. Kanary) ICT Model Definition ICT Model Definition ICT is an integrated treatment approach embedded in an intensive home-based model of service delivery, that serves youth with the co-occurring conditions of substance abuse and serious emotional disability ICT is an integrated treatment approach embedded in an intensive home-based model of service delivery, that serves youth with the co-occurring conditions of substance abuse and serious emotional disability

9. 9 Key Components of ICT System of care service philosophy System of care service philosophy Home-based service delivery model Home-based service delivery model Integrated Contextual Treatment (MH and SA) Integrated Contextual Treatment (MH and SA) Comprehensive service array matched to need Comprehensive service array matched to need Focus on risk and protective factor (resilience) Focus on risk and protective factor (resilience) Resulting in an integrated approach that identifies the strengths and needs of the youth and family, in context of the culture, community, and various systems’ mandates.

10. 10 ICT Target Population Adolescents who have a diagnosable substance use/abuse disorder AND a mental health disorder (excluding sole diagnosis of conduct disorder). The severity of the disorders are such that the youth experiences serious impairment in major life domains, particularly increased risk for involvement in the juvenile justice system and/or out of home placement. Adolescents who have a diagnosable substance use/abuse disorder AND a mental health disorder (excluding sole diagnosis of conduct disorder). The severity of the disorders are such that the youth experiences serious impairment in major life domains, particularly increased risk for involvement in the juvenile justice system and/or out of home placement.

11. 11 Home-Based Service Delivery Model Location of Service:Home & Community Location of Service:Home & Community Intensive: 2-5 sessions/wk Intensive: 2-5 sessions/wk Crisis Response24/7 Crisis Response24/7 Small caseloads: 3-6 families Small caseloads: 3-6 families Flexible:Convenient to family Flexible:Convenient to family Treatment Duration:12-24 weeks Treatment Duration:12-24 weeks

12. 12 Objectives of ICT To provide clinicians with a process and framework for organizing information in order to assess, conceptualize, and intervene in a coordinated and integrated fashion. To provide clinicians with a process and framework for organizing information in order to assess, conceptualize, and intervene in a coordinated and integrated fashion. To assist clinicians with positive engagement and retention of youth and families, as well as, better recognition of family culture and contexts. To assist clinicians with positive engagement and retention of youth and families, as well as, better recognition of family culture and contexts. To aid clinicians, program leaders, and relevant stakeholders in creating a service with realistic expectations for the types of interactions and relationships necessary to reach mutual outcomes. To aid clinicians, program leaders, and relevant stakeholders in creating a service with realistic expectations for the types of interactions and relationships necessary to reach mutual outcomes. To improve treatment outcomes. To improve treatment outcomes. To decrease clinician frustration, burnout, fatigue when dealing with a challenging population. To decrease clinician frustration, burnout, fatigue when dealing with a challenging population.

13. 13 Target Outcomes FAMILY Create and maintain a family recovery environment Create and maintain a family recovery environment Reestablish hierarchy and boundaries Reestablish hierarchy and boundaries Decrease family conflicts Decrease family conflicts Rebuild bonds and relationships Rebuild bonds and relationships Increase positive family communication Increase positive family communication Increase supervision and monitoring Increase supervision and monitoring Collaborative Problem Solving (Greene & Ablon) Collaborative Problem Solving (Greene & Ablon) YOUTH Living at home or in a permanent home setting Living at home or in a permanent home setting Attending and achieving at school/work Attending and achieving at school/work Reduced involvement in the JJ system Reduced involvement in the JJ system Reduced use of substances Reduced use of substances Participating in positive family, peer, and community life Participating in positive family, peer, and community life Accessing resources and natural supports as needed to maintain gains Accessing resources and natural supports as needed to maintain gains

14. 14 ICT Youth Usual Services Comparison Group Size of Difference in commitment and/or recidivism rates 56 youth 56 youth 25% recidivism rate 25% recidivism rate 29 Youth 29 Youth 72% commitment rate 72% commitment rate Chi Square (1, 29): 17.74 Level of significance:.001 Results of ICT Study (2001-2002)

15. 15 Ohio Scales Gain Scores (2005 – October 2006) General Clinical Population (Statewide) ICT Participants 30 days 180 days Gain 30 days 180 days Gain Problem Severity Adult 28.6022.745.8631.2819.3811.90 Problem Severity Child 23.9318.855.0830.3319.4810.85 Hopefulness Adult 12.2910.601.6913.5210.882.64 Hopefulness Child 10.609.441.1613.0910.182.91 Satisfaction Adult 8.876.422.4510.257.253.00 Satisfaction Child 10.608.532.0710.138.052.08 Functioning Adult 44.9848.653.6736.2044.718.51 Functioning Child 55.7559.343.5949.4258.769.34 Total = 27 youth; 3 ODYS Commitments For "Functioning", the higher the score the better - for all others, the lower the score the better For "Functioning", the higher the score the better - for all others, the lower the score the better Clinical cutoffs= 20 for problem severity and 51 for parent rating functioning and 60 for youth rated functioning Clinical cutoffs= 20 for problem severity and 51 for parent rating functioning and 60 for youth rated functioning

16. 16 Clinical and Policy Integrated documentation Integrated documentation Complexity of conceptualization Complexity of conceptualization Finding and retaining staff Finding and retaining staff Need a county wide consistent assessment/screening process for youth with co-occurring disorders Need a county wide consistent assessment/screening process for youth with co-occurring disorders Comprehensive understanding of population Comprehensive understanding of population Differing clinical perspectives between MH and SA Differing clinical perspectives between MH and SA Clinical capacity and certification/licensure to treat both disorders Clinical capacity and certification/licensure to treat both disorders Ethical and safety issues related to delivering services in the home and community Ethical and safety issues related to delivering services in the home and community Complexity of putting it all together Complexity of putting it all together

17. 17 Systemic Aligning policy outcomes across public entities, providers, and funders Aligning policy outcomes across public entities, providers, and funders Setting Co-Occurring as a priority treatment population Setting Co-Occurring as a priority treatment population Creating an infrastructure that supports integrated treatment Creating an infrastructure that supports integrated treatment Creating funding streams that support integrated treatment Creating funding streams that support integrated treatment Identifying cross systems shared outcomes Identifying cross systems shared outcomes Resources to support research and evaluation Resources to support research and evaluation

18. 18 Financial Need diverse and flexible funding to maximize effectiveness of the model Need diverse and flexible funding to maximize effectiveness of the model Medicaid: 1) complicated documentation and choices: MH vs. SA; 2) clinical impacts of using Medicaid. E.g., not being able to directly address parent and family issues and basic needs Medicaid: 1) complicated documentation and choices: MH vs. SA; 2) clinical impacts of using Medicaid. E.g., not being able to directly address parent and family issues and basic needs Fee for service not an effective or efficient billing procedure for ICT Fee for service not an effective or efficient billing procedure for ICT Funding innovative practices with traditional funding streams Funding innovative practices with traditional funding streams

19. 19 Implementation Qualified practitioners and providers Qualified practitioners and providers Initial training and ongoing coaching Initial training and ongoing coaching Organizational infrastructure to support the model Organizational infrastructure to support the model High level of collaboration among MH, SA, JJ referrals sources and partners High level of collaboration among MH, SA, JJ referrals sources and partners

20. 20 More Information on ICT Richard Shepler, Ph.D. ricks@starkmhb.org Eric Baltrinic ebaltrinic@yahoo.com Patrick Kanary patrick@cipohio.org CIP: 330-455-3811