Addressing Co-occurring Disorders: Correcting Deficiencies

In the past, professionals treating adolescents have lacked standardized care approaches and clinical guidelines addressing treatment of youths diagnosed with co-occurring mental health and substance abuse disorders. Recently the field has received a boost in this area as national attention to adolescent care initiatives has intensified.


Denise Hall

An ongoing theme in adolescent treatment seen throughout the nation is a lack of systematic screening and assessment of clients for substance use disorders and co-occurring mental health disorders. Leaders in the adolescent substance abuse field have noted that identification and treatment of co-occurring disorders need more attention and research.1

A review of 144 highly regarded substance abuse programs for adolescents revealed some disturbing deficiencies in standardized care.2 Nine key treatment elements, drawn from current literature and a consensus panel of experts, were examined: assessment and treatment matching; a comprehensive, integrated approach; family involvement in treatment; a developmentally appropriate program; engaging and retaining adolescents in treatment; qualified staff; gender and cultural competence; continuing care; and treatment outcomes. Particularly distressing was a low rate of assessment and treatment matching. In data based on program self-report, only 45% of the 144 programs reported using a standardized assessment for substance use disorders, and only 10% reported using standardized clinical interviews or instruments for both substance use and mental health assessment.

According to SAMHSA, only one state as of late 2004 (Colorado) had formally adopted best-practice guidelines for adolescent substance abuse treatment.3 Only five states' licensure requirements for substance abuse counselors call for any knowledge of youth addiction, childhood development, or family systems.

Of the six states that have separate certification requirements for adolescent substance abuse treatment facilities, four do not designate required staffing levels; none addresses the issue of parental notification; only one addresses use of discipline/restraint; only three require staff background checks; and only three require any specialized staff training.A major contributor to these weaknesses in the adolescent substance abuse treatment system is that most states do not have a single locus of responsibility for ensuring an accessible, effective treatment system for youths and their families.

Turner and colleagues state that “there are no well-researched and documented treatment protocols that adequately address both [substance use disorders] and mental health issues in adolescents.”1 We see widespread concern over adolescent treatment providers' competency in assessing and treating co-occurring disorders in an integrated fashion. Adolescent treatment provider qualifications need to specify distinct abilities for work with youths.

Federal response

This past August, SAMHSA Administrator Charles G. Curie announced more than $19 million in grant awards to 15 states and the District of Columbia over three years to build capacity to provide effective and affordable substance abuse treatment for youths and their families. Under the effort, each state would create a staff position dedicated to ensuring that resources available for substance abuse treatment are being used in the most efficient manner.

“Responsibility for adolescent treatment is often located in a number of state agencies and is frequently not in the office that oversees substance abuse treatment services. As a result, too many young people who need treatment do not receive help,” Curie said in a statement this past summer. “These grants will help put a system in place that brings together multiple agencies, including mental health, education, health, child welfare, and juvenile justice services, in order to coordinate funding and treatment resources and better serve young people and their families.” Grants were awarded in Arizona, Connecticut, the District of Columbia, Florida, Georgia, Illinois, Kentucky, Massachusetts, North Carolina, Ohio, South Carolina, Tennessee, Vermont, Virginia, Washington, and Wisconsin.

The SAMHSA adolescent coordination grants specify these areas among the goals of the grantee states:

• Develop/improve state standards for licensure/certification/credentialing of adolescent substance abuse treatment counselors.

• Import tools, coordinate training, and support providers in the adoption ofscreening and assessment protocols that crosswalk to DSM-IV/ICD-10 criteria for mental health and substance abuse/dependence diagnoses and to the American Society of Addiction Medicine's (ASAM) Patient Placement Criteria.

Encouraging involvement

We are on our way. At the grantee meeting in November, Center for Substance Abuse Treatment (CSAT) Project Officer Randy Muck stressed the significance of these grants and the effort needed to make the program successful. If your state received an adolescent coordination grant, contact state officials and get involved. There is enough work here for everyone. If your state did not receive a grant, start the conversation and speak to adolescent treatment concerns.

If I see a heart specialist, I want to know that he/she is competent and using science to help guide treatment decisions. Why should our field settle for anything less?

References

1. Turner WC, Muck RD, Muck RJ, et al. Co-occurring disorders in the adolescent mental health and substance abuse treatment systems. J Psychoactive Drugs 2004; 36:455-62.
2. Brannigan R, Schackman BR, Falco M, et al. The quality of highly regarded adolescent substance abuse treatment programs: Results of an in-depth national survey. Arch Pediatr Adolesc Med 2004; 158:904-9.
3. SAMHSA. Notice of funding availability: State Adolescent Substance Abuse Treatment Coordination. November 2004.