Treatment for Youth with Traumatic Stress and Substance Abuse Problems

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1 Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems Oe patiet whom I talked to said that she had to lie to be able to get adequate treatmet for both disorders. She was told whe she wet to a PTSD treatmet program that she could t have substace abuse or she would t be able to get treatmet she had to be clea first. 1 Lisa M. Najavits, PhD Assistat Professor of Psychology Harvard Medical School I a ideal world, careful assessmet of traumatic stress ad substace abuse problems ad their effects would be a itegral part of the services provided by all agecies ad idividuals workig with adolescets. Each troubled adolescet would receive a idividualized treatmet pla that took ito cosideratio the liks betwee traumatic stress ad substace abuse, ad treatmet services for each disorder would be itegrated ad coordiated. I reality, although much progress has bee made i the treatmet of both substace abuse ad traumatic stress, these fields have grow idepedetly of each other. As a result, despite the clear lik betwee these two cliical areas, very few attempts have bee made to itegrate the services provided by each group, ad each has developed differet assessmet protocols ad treatmet approaches. Trauma ad Substace Abuse: Myths ad Facts Few treatmet providers are proficiet i the multiple areas of eed amog youth with co-occurrig disorders. Substace abuse providers, for example, may ot have the tools ecessary to idetify the impact of trauma exposure, ad may ot have experiece or traiig i usig trauma-iformed itervetios. Trauma treatmet specialists ad metal health providers i geeral may overlook sigs of icreasig substace abuse. They may ot have a deep uderstadig of the process of addictio, or may ot be familiar with effective strategies to stregthe Myth: Available evidece-based assessmet tools for trauma or substace abuse are too log ad complicated to be implemeted i real cliical practice settigs. Fact: May of the older evidece-based assessmet istrumets do have a reputatio for beig log ad complicated, as well as expesive. However, over the past decade the assessmet field has produced may more assessmet tools that are accessible ad cliicia-friedly i terms of both degree of complexity ad legth. The Natioal Child Traumatic Stress Network

2 youths abilities to reduce use or abstai from substaces, ad therefore fail to target these problems as a cetral part of the itervetio. Screeig ad Assessmet of Trauma ad Substace Abuse The sigs ad symptoms of trauma ad substace abuse ca at times be hard to spot, especially amidst the turbulet lives of teeagers today. May of the sigs of both trauma ad substace abuse are similar to problem behaviors that are part of the atural developmetal course of adolescece. For this reaso, it may be hard to recogize these problems early. What is evidet about this group of teeagers is that they ofte experiece a great deal of distress ad eed cosiderable help. Proper assessmet of trauma ad substace abuse is critical i order to provide adequate care. Therefore, all service providers who have regular cotact with adolescets should icorporate screeig ad assessmet istrumets that address trauma ad substace use ito their geeral itake process. Clarissa s Story* Clarissa was oly five years old whe her stepfather started sexually abusig her. She lived i a rural tow where everyoe kew everyoe else. Clarissa s eighbors ad classmates oticed that she always kept to herself ad was usually o edge. She was very scared that her stepfather would hurt her or her mother if she told ayoe about the thigs he did to her whe they were aloe. It was t util Clarissa tured 11 that a school guidace couselor foud out what she was goig through. The Departmet of Social Services was otified, ad Clarissa was removed from her parets home. She wet through several foster placemets before settlig i with a aut ad ucle who lived i a big city i a crowded apartmet with may other relatives. Clarissa started to get ito fights with her cousis ad would ofte refuse to participate i activities with her relatives. Whe she was reprimaded for her failig grades, Clarissa told her aut that she wished she did t exist. Her teachers oticed that Clarissa had trouble maagig her emotios, ofte exhibitig deep sadess, irritability, agitatio, ad/or itese ager. The social worker assiged to the case told her caregivers that he was cocered that Clarissa displayed a lack of regard for her ow safety ad well-beig, as she was gettig ivolved i several risky activities. She was itroduced to marijuaa at school whe she was 13 ad quickly progressed to alcohol use, ad later to OxyCoti. Whe she tured 15, Clarissa told her frieds that she felt worthless ad uimportat. Oe of the ways she respoded to coflict ad tesios i the home was by goig ito her room ad makig superficial cuts o her arms with a razor blade. Her teachers wodered why she wore log sleeves all the time. Clarissa tried to stay away from home as much as possible, spedig a lot of her time with peers i usafe eighborhoods. O her way back from a party with frieds late oe ight, Clarissa was attacked by a group of tees o the trai, but oe of her frieds tried to help her because they were high at the time. She felt betrayed by her frieds, whom she felt had t stood up for her. Clarissa was already failig i school, had lost trust i her frieds ad family, ad did ot feel that she had ayoe to go to. She started cosiderig the possibility of edig her life. * Clarissa is a composite based o real teeage cliets strugglig with traumatic stress ad substace abuse. 2 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

3 Numerous tools are available for the assessmet of traumatic stress ad of substace abuse. Table 1 provides iformatio about some well-validated assessmet resources. A more comprehesive list of trauma assessmet ad screeig tools ca be foud at The Natioal Ceter for Child Traumatic Stress Network s olie Measures Review database (www.nctsn.org/measures). To optimize assessmet accuracy ad esure appropriate treatmet, providers should try to icorporate iformatio from multiple sources. Such a multi-faceted approach will help providers geerate a treatmet pla that is based o complete evaluatio of the sigs ad symptoms of trauma ad substace abuse, as well as the degree of fuctioal impairmet caused by these problems. Treatig Youth with Substace Abuse ad Traumatic Stress There is a dearth of research evaluatig itegrated treatmet approaches for youth with substace abuse ad traumatic stress problems. However, a review of the adolescet substace abuse treatmet literature suggests that traumatized youth do ot do well i treatmet focusig oly o substace use. 7 9 Adolescets who have experieced trauma ad adversity ofte tur to alcohol ad drug use i order to cope with paiful emotios. Youth with both substace abuse ad trauma exposure show more severe ad diverse cliical problems tha do youth who have bee afflicted with oly oe of these types of problems. Whe these problems are treated separately, youth are more likely to relapse ad revert to previous maladaptive copig strategies. Although the research o itegrated treatmet approaches for this populatio is limited, there are guidelies that providers ca follow to better serve this populatio. Give the Trauma ad Substace Abuse: Myths ad Facts Myth: Maualized itervetios are too rigid ad simplistic to address the complex eeds of adolescets sufferig from traumatic stress ad substace abuse problems. Fact: Most of today s evidece-based itervetios are maual-guided rather tha maualized. This distictio reflects a movemet away from scripted, iflexible sessio cotet ad structure ad toward a therapeutic model with flexible sessio cotet ad structure. multiple ad complex eeds of youth with co-occurrig traumatic stress ad substace abuse problems, several ivestigators have proposed the followig recommedatios: Iclude assessmets of substace abuse problems ad traumatic stress as part of routie screeig ad assessmet procedures Provide youth ad families with more itese treatmet optios to address the magitude of difficulties ofte experieced by this populatio The Natioal Child Traumatic Stress Network

4 Table 1. Validated Assessmet Istrumets for Traumatic Stress ad Substace Abuse Disorders Resource Brief Descriptio Source Adquest 2 This self-report measure allows adolescets to idetify various issues Adolescet Itake Questioaire 2 of cocer, which the therapist ca the use to egage adolescets i discussio o a variety of topics icludig health, sexuality, safety, substace abuse ad frieds. Peake, K., Epstei, I., ad Medeiros, D. (2005). Cliical ad research uses of a adolescet metal health itake questioaire: What kids eed to talk about. Bighamto, NY: The Haworth Press, Ic. CANS-TEA Child ad Adolescet Needs ad Stregths-Trauma Exposure ad Adaptatio Versio This cliicia-report istrumet assesses a variety of domais icludig trauma history, traumatic stress symptoms, emotioal ad behavioral regulatio (e.g., axiety, depressio, self-harm, substace abuse), evirometal stability, caregiver fuctioig, attachmet, child stregths ad child fuctioig. For iformatio o the guidelies for use ad developmet cotact Cassadra Kisiel: (312) GAIN The GAIN is a series of cliicia-admiistered biopsychosocial assessmets Global Appraisal of Idividual Needs 3 desiged to provide iformatio useful for screeigs, diagosis, treatmet plaig, ad moitorig progress. Domais measured o the GAIN-Iitial (GAIN-I) iclude substace use, physical health, risk behaviors, metal health, eviromet, legal ad vocatioal. Several scales are derived from the GAIN-I, icludig substace problem, traumatic stress, ad victimizatio idices. Deis, M., White, M., Titus, J., ad Usicker, J. (2006). Global Appraisal of Idividual Needs (GAIN): Admiistratio guide for the GAIN ad related measures (Versio 5.4.0). Bloomigto, IL: Chestut Health Systems. Retrieved April 17, 2008, from GAIN_I/GAIN-I_v_5-4/Idex.html. TSCC Trauma Symptom Checklist for Childre 4 The Trauma Symptom Checklist for Childre is a self-ratig measure used to evaluate both acute ad chroic posttraumatic stress symptoms. Joh Briere, Ph.D. Psychological Assessmet Services aspx?productid=tscc UCLA PTSD RI for DSM-IV Uiversity of Califoria Los Ageles Posttraumatic Stress Disorder Reactio Idex 5 This scale is used to scree for exposure to traumatic evets ad DSM-IV PTSD symptoms. Three versios exist: a self-report for school-age childre, a self-report for adolescets, ad a paret report. A abbreviated versio of the UCLA PTSD RI is also available. This ie-item measure provides a quick scree for PTSD symptoms. UCLA Trauma Psychiatry Service 300 UCLA Medical Plaza, Ste 2232 Los Ageles, CA Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue

5 Resource Brief Descriptio Source Screeig ad Assessig Adolescets for Substace Use Disorders: Treatmet Improvemet Protocol (TIP) Series 31 6 This guide provides iformatio regardig screeig ad assessmet of adolescets with substace use disorders icludig descriptios of specific assessmet istrumets. Substace Abuse ad Metal Health Services Admiistratio. (1999). TIP 31: Screeig ad assessig adolescets for substace use disorders. Rockville, MD U.S. Dept. of Health ad Huma Services. Retrieved April 18, 2008 from bv.fcgi?rid=hstat5.chapter POSIT Problem Orieted Screeig Istrumet for Teeagers This scale was desiged to idetify potetial problems i eed of further assessmet, ad potetial treatmet or service eeds, i 10 areas icludig substace abuse, metal health, physical health, family relatios, peer relatios, educatioal status, vocatioal status, social skills, recreatio, ad aggressive behavior/deliquecy. Natioal Istitute o Drug Abuse (NIDA), Natioal Istitutes of Health Elizabeth Rahdert, Ph.D., 6001 Executive Blvd, Bethesda, MD, CPSS Child Posttraumatic Stress Disorder Symptom Scale The CPSS was adapted from the adult Posttraumatic Diagostic Scale (PTDS). The CPSS is a self-report measure that assesses the frequecy of all DSM-IV-defied PTSD symptoms ad was also desiged to assess PTSD diagosis. The measure yields a total Symptom Severity score as well as a daily fuctioig ad impairmet score. To obtai the CPSS, cotact: Eda Foa, Ph.D. Ceter for the Treatmet ad Study of Axiety Uiversity of Pe. School of Medicie Departmet of Psychiatry 3535 Market Street, Sixth Floor Philadelphia, PA CRAFFT The CRAFFT is a six-item measure that assesses adolescet substace use. The measure assesses reasos for drikig or other substace use, risky behavior associated with substace use, peer ad family behavior surroudig substace use, as well as whether the adolescet has ever bee i trouble as a result of his or her substace use. The CRAFFT questios were developed by The Ceter for Adolescet Substace Use Research (CeASAR). To get permissio to make copies of the CRAFFT test, The Natioal Child Traumatic Stress Network 5

6 Emphasize maagemet ad reductio of both substace use ad PTSD symptoms early i the recovery process Start relapse prevetio efforts targetig both substace ad trauma-related cues early i treatmet (e.g., problem solvig, drug refusal, ad safety skills ad desesitizatio to trauma remiders) Establish a therapeutic relatioship that is cosistet, trustig, ad collaborative Focus o stress maagemet skills such as relaxatio ad positive self-talk Help cliets develop emotioal regulatio skills such as the idetificatio, expressio, ad modulatio of egative affect Icorporate cogitive restructurig techiques such as recogizig, challegig, ad correctig egative cogitios Provide social skills traiig ad cosider referral to adolescet self-help groups as eeded Provide psychoeducatio for both youth ad their families about trauma ad substace abuse problems, ad ecourage paretal ivolvemet i treatmet with the goal of icreasig paretig skills, commuicatio, ad coflict resolutio Make use of school-based treatmet programs to reach at-risk youth For some adolescets, effective treatmet may also require radom urie drug screes to moitor abstiece from drugs or alcohol, ad adjuct psychopharmacologic treatmet to relieve acute symptoms of drug withdrawal or traumatic stress. Cosiderig Culture ad Cotext It is importat to remember that adolescets with co-occurrig traumatic stress ad substace abuse ca belog to ay umber of cultural commuities. Cultural backgroud goes beyod ethicity ad race, ad ca iclude idetities associated with disability, socioecoomic status, sexual orietatio, homelessess, immigratio/refugee status, spiritual or religious groups, foster care, ad others. Providig services that are culturally competet lays the foudatio for establishig a safe, respectful eviromet that tells adolescets ad families that they are respected ad valued. Culturally competet service providers are specially traied i ad are aware ad respectful of the values, beliefs, traditios, customs, ad paretig styles of the youths ad families they serve. Key characteristics of culturally competet care iclude: 14,15 6 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

7 Uderstadig ad respect for diverse worldviews The presece of staff who reflect the cultural diversity of the commuity served Use of iterpreter services or, preferably, biligual providers for cliets with limited Eglish proficiecy Ogoig cultural competecy educatio ad traiig for staff Use of liguistically ad culturally appropriate educatioal materials A physical eviromet that reflects the diversity of commuities served, icludig artwork, accessibility, ad materials Culturally relevat assessmets Workig withi the family s defied structure (e.g., the family may iclude elders or other relatives) Uderstadig ad respect for the social mores related to iteractios by geder ad age Whatever the cultural or social backgroud of the adolescet, it is importat to adopt a stregth-based approach that capitalizes o idividual, family, ad cotextual factors that ca serve to promote healthy copig ad adjustmet. These factors ca iclude a family s religious or spiritual beliefs, exteded families ad available social support etworks, positive role models i the commuity, opportuities for participatio i positive recreatioal, artistic, or academic activities, ad adolescets built-i capacity to grow ad flourish i the midst of adversity. Special Treatmet Cosideratios Whe Workig with Homeless Youth Give the high rates of trauma exposure ad substace use amog homeless youth 16,17, it is particularly importat to be aware of treatmet cosideratios specific to this populatio. 18 The lives of homeless youth are ofte characterized by high levels of persoal ad evirometal istability, icludig ucertaity about basic eeds such as havig access to a meal or a place to sleep. Eve the most elemetal therapeutic processes, such as egagig youth i treatmet, ad attemptig to develop a trustig relatioship betwee the adolescet ad service providers, ca be quite challegig. I additio, it might also be difficult to safely coduct more ivolved therapeutic strategies such as exposure-based treatmet, particularly whe access to evirometal supports ad the possibility of regular attedace is limited. For this reaso, it is importat to prioritize homeless youths immediate ad primary eeds, ad to provide access to complemetary services that address additioal psychosocial eeds. Brief itervetios employig motivatioal iterviewig 19 as well as skill-based cogitive-behavioral approaches appear to be best suited for this populatio. These approaches are described i the sectios that follow. The Natioal Child Traumatic Stress Network 7

8 Itegrated Treatmet Approaches for Adolescets Although there is strog evidece to support the eed for itegrated treatmet models, there are few treatmet models available that address both trauma ad substace abuse problems amog adolescets. Some of these models are highlighted below: Seekig Safety Seekig Safety 20,21 is a maualized treatmet for co-occurrig substace abuse disorder ad PTSD i adults developed by Lisa Najavits, PhD at Harvard Medical School/McLea Hospital. The focus of Seekig Safety is to elimiate or reduce risky or dagerous behaviors, situatios, or symptoms, icludig substace abuse, dagerous relatioships, severe psychological symptoms, ad self-harm behaviors. The treatmet model posits a meaigful coectio betwee past trauma ad curret self-abusig behaviors, ad it utilizes 25 topics or modules divided amog cogitive, behavioral, ad iterpersoal themes that ca be selected based o the idividual s eed. 20 Applyig Seekig Safety to a adolescet populatio ivolves mior modificatios of the origial maual to suit the developmetal level of adolescets. Modificatios iclude offerig the iformatio verbally if a adolescet refuses to read the hadouts, usig hypothetical third-perso examples to discuss situatios, limited paretal ivolvemet with the adolescet s permissio, ad discussig details of the trauma oly if the adolescet chooses to do so. 21 I radomized cliical trials, Seekig Safety has show sigificat improvemets over treatmet as usual i both icarcerated 22 ad commuity 23 adult females. Whe implemeted with adolescet girls, Seekig Safety showed greater improvemets tha did treatmet as usual i substace abuse domais, PTSD cogitios, ad levels of deviat behavior, as well as aorexia ad somatizatio ratigs. 21 Risk Reductio through Family Therapy (RRFT) RRFT is a itervetio developed to reduce the risk of substace abuse ad other highrisk behaviors, revictimizatio, ad trauma-related psychopathology i adolescets who have bee sexually assaulted. RRFT itegrates several existig empirically supported treatmets, such as Trauma Focused-Cogitive Behavioral Therapy, Multisystemic Therapy, ad other risk reductio programs for revictimizatio ad risky sexual behaviors. Adolescets participatig i this treatmet may be heterogeeous with regard to symptom expressio; thus a cliical pathways approach is take i the RRFT maual. The maual cosists of six primary compoets: Psychoeducatio, Copig, Substace Abuse, PTSD, Sexual Educatio ad Decisio Makig, ad Sexual Revictimizatio ad Risk Reductio. A pilot trial of RRFT is curretly uderway Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

9 Trauma Systems Therapy for Substace Abuse i Adolescece TST-SA 25 applies Trauma Systems Therapy (TST) 26 to the problem of adolescet traumatic stress ad substace abuse, utilizig existig promisig practices for treatig adolescet substace abuse, traumatic stress, ad emotioal regulatio problems. The applicatio of TST to adolescet substace abuse icludes several modificatios to the existig itervetio. Motivatioal iterviewig strategies are icluded to egage youth i treatmet ad to establish a commitmet to chage. Additioally, parets ad tees are provided with psychoeducatio about substace abuse ad its iteractio with symptoms of traumatic stress. This approach icorporates a strog emphasis o behavior maagemet strategies for parets to utilize i order to icrease moitorig ad appropriate limit settig, particularly aroud drug use ad high-risk behaviors. The model also icorporates substace abuse treatmet strategies such as paret-tee commuicatio skills, recogizig ad plaig for substace abuse cues or trigger situatios, cogitive ad iterpersoal problemsolvig techiques, ad other relapse-prevetio techiques. Careful attetio is give to the coectio betwee substace abuse ad the egative emotios associated with the experiece of trauma. I additio, youth lear skills to maage emotios, behavior, ad substace abuse cravigs. A ope trial of TST-SA is curretly uderway. Trauma-Focused Itervetios for Adolescets Several successful treatmet programs have bee developed or adapted from adult models to help adolescets process traumatic memories ad maage distressig feeligs, thoughts, ad behaviors. These empirically supported mauals are described i detail below. Trauma-Focused Cogitive Behavioral Therapy (TF-CBT) TF-CBT is a short-term idividual treatmet that ivolves sessios with the youth ad parets as well as paret-oly sessios. TF-CBT is for youth aged 4 to 18 who have sigificat behavioral or emotioal problems related to traumatic life evets, eve if they do ot meet the full diagostic criteria for PTSD. 27 Utilizig weekly cliic-based, idividual treatmet, TF- CBT helps youth process traumatic memories ad maage distressig feeligs, thoughts, ad behaviors. TF-CBT also uses joit paret ad youth sessios to provide paretig ad family commuicatio skills traiig. Compared to a odirective supportive therapy, sexually abused youth aged 8 to 15 treated with TF-CBT demostrated sigificatly greater improvemet o levels of axiety, depressio, ad dissociatio at six-moth follow up. Youth treated with TF-CBT also showed a sigificat improvemet i PTSD symptoms ad dissociatio at 12-moth follow-up. 28 Olie traiig for TF-CBT is curretly available at The Natioal Child Traumatic Stress Network 9

10 Cogitive-Behavioral Itervetio for Trauma i Schools (CBITS) CBITS is a itervetio program for youth exposed to traumatic evets, which ca be delivered o school campuses by school-based cliicias. It was developed i collaboratio with the Los Ageles Uified School District for studets ad their families. CBITS utilizes idividual ad group sessios to teach youth relaxatio techiques ad social problemsolvig skills, as well as how to challege upsettig thoughts ad process traumatic memories. CBITS also icludes a paret ad teacher psychoeducatio compoet. I a radomized cotrolled trial comparig this itervetio with a three-moth wait-list coditio, those receivig CBITS reported lower PTSD, depressio, ad psychological dysfuctio symptom scores after three moths. 29 Structured Psychotherapy for Adolescets Respodig to Chroic Stress (SPARCS) SPARCS is a group itervetio specifically desiged to address the eeds of chroically traumatized adolescets who may still be livig with ogoig stress, are curretly experiecig stress, ad are experiecig problems i areas of fuctioig such as impulsivity, affect regulatio, self-perceptio, dissociatio, relatios with others, somatizatio, ad struggles with their ow purpose ad meaig i life. The 16-sessio program ca be provided i a variety of settigs, icludig school, outpatiet, ad residetial, ad icorporates compoets of three existig itervetios. These compoets iclude midfuless, iterpersoal, ad emotio regulatio skills derived from Dialectical Behavior Therapy for Adolescets 30, problem-solvig skills from Trauma Adaptive Recovery Group Educatio ad Therapy (TARGET) 31, ad social support ehacemet ad skills for plaig for the future from the School Based Trauma/Grief Group Psychotherapy. 32 Trauma Systems Therapy (TST) Developed at the Ceter for Medical ad Refugee Trauma at Bosto Medical Ceter 33, TST ackowledges the complexity of the social eviromet that surrouds a idividual, ad the ways i which disruptios i oe area of the social ecology may create problems i aother. The social ecological model of huma behavior i which the cotexts of family, school, peer group, eighborhood, ad culture all iteract with a idividual s developmet 34 is applied to youth exposed to traumatic stress, who ofte live i eviromets characterized by child maltreatmet, paretal illess ad substace abuse, ad domestic violece. TST itervetios are desiged to work i two dimesios: strategies that operate through ad withi the social eviromet to promote chage, ad strategies that ehace the idividual s capacity to self-regulate their emotios. The TST model ivolves choosig a series of itervetios that correspod to the fit betwee the traumatized youth s ow emotioal regulatio capacities ad the ability of the youth s social eviromet ad system-of-care to help him or her maage emotios or to protect him or her from threat. TST begis with a assessmet of both the youth s 10 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

11 level of emotioal regulatio ad the degree of evirometal stability i the youth s world. Prelimiary data from a ope trial of TST demostrate a sigificat reductio of trauma symptoms ad icreased emotioal regulatio skills amog youth, as well as a more stable social eviromet, after three moths of treatmet. 33 A cotrolled trial of TST is curretly i progress. Substace Abuse Itervetios for Adolescets Several successful treatmet programs have bee developed or adapted from adult models i order to focus o the uique cogitive chages, developmetal trasitios, ad peer ad family issues that typically occur durig adolescece. Treatmets for adolescets icorporate these developmetal cosideratios i differet ways. Described below are the curret approaches utilized withi various types of itervetios, as well as empirically supported treatmet mauals available for substace-abusig adolescets i a outpatiet settig. Brief Itervetios Itervetios that are of shorter duratio ad less extesive tha more traditioal substace abuse treatmets ca be appealig to cosumers, service providers, ad maaged care providers. These treatmets have the overarchig goal of addressig ad ehacig the motivatio to chage problem behaviors, as well as providig skills to meet these goals. Geerally, brief itervetios cotai betwee oe ad five sessios ad ca be delivered virtually aywhere by a variety of professioals. Two of the most widely used brief itervetio approaches iclude cogitive-behavioral therapy ad motivatioal iterviewig. Cogitive-Behavioral Therapy (CBT) Cogitive-behavioral models, based o social learig theory, coceptualize substace use ad related problems as leared behaviors that are iitiated ad maitaied i the cotext of evirometal factors. This treatmet approach icorporates the priciple that uwated behavior ca be chaged by clear demostratio of the desired behavior, ad cosistet reward of icremetal steps toward achievig it. CBT may icorporate emotioal exposure to iteral cues i order to ioculate idividuals agaist future relapse. Therapeutic activities iclude completig specific assigmets, rehearsig desired behaviors, experiecig imagied ad real exposures to emotios ad situatios to ehace emotioal tolerace, ad recordig ad reviewig progress. Praise ad privileges are give for meetig assiged goals. This model ca be implemeted via idividual sessios as well as withi a group treatmet approach. Accordig to research studies, idividual ad group CBT ca help adolescets become drug free ad icrease their ability to remai drug free after treatmet eds. The Natioal Child Traumatic Stress Network 11

12 Motivatioal Iterviewig (MI) This treatmet approach ivolves usig specific iterviewig ad discussio techiques to ehace the idividual s motivatio to chage their problematic behavior. MI pertais to both a style of relatig to the cliet as well as to the therapeutic techiques that facilitate the process. Its mai teets iclude: 1) takig a empathetic, ojudgmetal stace while listeig reflectively, 2) developig discrepacy, rollig with the cliet s resistace, ad avoidig argumetatio, ad 3) supportig self-efficacy for chage. Motivatioal iterviewig has bee foud to sigificatly reduce drikig ad drivig i tees with iitial low motivatio to chage. Motivatioal Ehacemet Therapy ad Cogitive Behavioral Therapy for Caabis Users The Caabis Youth Treatmet Collaborative developed a empirically tested five-sessio treatmet maual that combies the motivatioal iterviewig treatmet approach ad cogitive behavioral therapy. The treatmet cosists of two iitial idividual sessios desiged to icrease the adolescet s motivatio to deal with their drug use, followed by three group CBT sessios desiged to help adolescets develop skills useful for stoppig or reducig marijuaa use. This brief therapy has bee prove effective i reducig marijuaa use i adolescets. There is also a optio for therapists to utilize a additioal sevesessio CBT compoet to provide additioal skills traiig. The complete mauals for both the brief five-sessio treatmet as well as the exteded treatmet with 12 CBT sessios are available at: Family-Based Therapies Family-based treatmet is the most thoroughly studied treatmet modality for adolescet substace use. Cosiderable research uderscores the ifluetial role played by family relatioships ad family eviromets i the developmet of adolescet alcohol ad drug problems. The more thoroughly researched family approaches are outlied below. Multidimesioal Family Therapy (MDFT) This is a outpatiet family-based drug abuse treatmet for teeagers. MDFT views adolescet drug use i terms of a etwork of iflueces (made up of idividual, family, peer, ad commuity) ad utilizes this etwork to reduce uwated behavior ad icrease desirable behavior i differet settigs. Treatmet icludes idividual ad family sessios held i the cliic, i the home, or with family members at family court, school, or other commuity locatios. Multidimesioal Family Therapy for Adolescet Caabis Users This maual-based treatmet itegrates family therapy ad substace-abuse treatmet ad has bee prove effective with a caabis-usig adolescet populatio. The treatmet 12 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

13 focuses o the adolescet ad the parets, as well as o patters of family iteractio, both withi the family ad with other systems such as schools, courts, ad other support etworks. The maual is available at: Brief Strategic Family Therapy (BSFT) This itervetio is used to treat adolescet drug use that occurs with other problem behaviors such as coduct problems, oppositioal behavior, deliquecy, associatig with atisocial peers, aggressive ad violet behavior, impaired family fuctioig, ad risky sexual behavior. BSFT is a family systems approach based o the premise that the drug-usig adolescet is displayig problem behaviors that are idicative of what is goig o withi the family system. BSFT holds the priciple that patters of iteractio i the family ifluece the behavior of the adolescet. The role of the BFST couselor is to pla itervetios that carefully target ad provide practical ways to chage the patters of iteractio (e.g., failig to establish rules ad cosequeces) that are directly liked to the adolescet s drug use. Brief Strategic Family Therapy for Adolescet Drug Abuse The Natioal Istitute of Drug Abuse has made a olie versio of the BSFT maual available at: Multisystemic Therapy (MST) This treatmet approach targets multiple systems that cotribute to the developmet of deliquet behavior i adolescets, icludig family, peers, school, ad the eighborhood. MST is tailored to each idividual s eeds ad may iclude idividual, family or marital therapy, peer group couselig, ad case maagemet. Services are provided withi the adolescet s atural eviromet, such as the home or school, which facilitates both the applicatio to ad the maiteace of treatmet gais i the real world. MST also helps adolescets ad their families develop social support etworks through such meas as makig coectios with exteded family or religious commuities. MST has bee show to sigificatly reduce adolescet drug use durig treatmet ad for at least six moths after treatmet. More iformatio regardig the MST approach is available olie at: mstservices.com/text/treatmet.html. Commuity-Based Itervetios Commuity-based itervetios provide metal health services withi the ormal eviromet of a idividual or populatio. Service sites may iclude the home, school, or other eighborhood settigs, which icreases access to care for uderserved populatios, particularly for idividuals who do ot have the resources to travel to specialty cliics. Because teeagers are iflueced by may aspects of their eviromet (such as family, The Natioal Child Traumatic Stress Network 13

14 peers, teachers, cultural orms), commuity itervetios ofte take place across a umber of settigs to maximize the social ecological validity of the itervetio ad to support practice of skills leared i treatmet. Commuity itervetios may target specific idividuals who have already begu to display high-risk behaviors such as drug ad alcohol abuse, deliquet behavior, ad usafe sexual behaviors or they may target select groups who may be at greater risk for egagig i these behaviors such as athletes who are at greater risk for steroid use ad teeagers who live i a commuity with a lot of gag violece. I may commuity itervetios, a social support compoet for adolescets ad their parets is importat ad may decrease the likelihood of relapse. Three itervetios for adolescets displayig high-risk behaviors, which iclude a commuity-based compoet, are described below: Adolescet Commuity Reiforcemet Approach (ACRA) This treatmet approach recogizes the powerful role the eviromet plays i ecouragig or discouragig drug use. It attempts to rearrage evirometal cotigecies to make substace use a less rewardig behavior. ACRA bleds a operat model with a social systems approach to teach tees ew ways of hadlig life s problems without drugs or alcohol. It focuses o the iterpersoal iteractio betwee idividuals ad those i their commuities. ACRA teaches adolescets whe ad where to implemet the techiques leared i treatmet as well as how to build o positive reiforcemets ad use existig commuity resources that will support positive chage. ACRA also guides adolescets i developig a positive support system. The Adolescet Commuity Reiforcemet Approach for Adolescet Caabis Users This 14-sessio treatmet model cosists of 10 idividual sessios with the youth, two sessios with oe or two caregivers, ad two sessios with both the youth ad caregiver(s). This treatmet uses fuctioal aalyses to idetify triggers for drug use as well as other prosocial activities that compete with drug use, skills traiig i a variety of areas icludig relapse prevetio, ad the Happiess scale to moitor progress. The maual is available olie at: Studet Assistace Program (SAP) This substace abuse itervetio is a school-based program for idetifyig, assessig, ad treatig studets with alcohol ad/or substace abuse problems. There are more tha 1,500 studet assistace programs i the coutry; however, these programs vary widely. For example, some SAPs refer all idetified alcohol ad drug users to cliics for treatmet, while other programs brig traied cliicias to the school to provide itervetio o-site. The most effective school-based substace abuse itervetios are empirically guided ad maualized, ad focus o providig psychoeducatio ad skills traiig to adolescets. I 14 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

15 additio, effective programs eforce school-wide policies regardig alcohol ad drug use. Prelimiary aalyses of certai programs suggest that adolescets who participate i SAPs ca show reduced substace use. The Residetial Studet Assistace Program (RASP) RASP is a residetial substace abuse prevetio program for high-risk adolescets, modeled after the Westchester Studet Assistace Model. More iformatio is available at: or Psychiatric Care ad Psychotropic Medicatio The commoalities betwee posttraumatic stress disorder ad substace use disorders suggest that pharmacotherapies targetig a specific eurotrasmitter or euroedocrie system might be particularly beeficial. 35 A importat goal of pharmacotherapies for this populatio is to decrease PTSD symptoms so that the adolescet does ot utilize substaces of abuse i order to distace himself/herself from the traumatic evet. Some atidepressats have bee show to improve the itrusive ad depressive symptoms of PTSD. Furthermore, stadard pharmacotherapeutic treatmets for substace abuse disorders may be useful for idividuals with co-occurrig PTSD. Itegratio of pharmacotherapy ad psychotherapy may be beeficial i order to maximize treatmet outcomes i this populatio. For More Iformatio o Treatmet Optios for Substace Abuse, see Substace Abuse ad Metal Health Services Admiistratio (SAMHSA) Model Programs Society for Adolescet Substace Abuse Treatmet Effectiveess (SASATE) The Natioal Istitute of Drug Abuse (NIDA) The Natioal Istitute o Alcohol Abuse ad Alcoholism (NIAAA) The Natioal Child Traumatic Stress Network 15

16 Refereces 1. Cavalcade Productios. (1998). A video series o substace abuse treatmet: Trauma ad substace abuse. Nevada City, CA: Cavalcade Productios, Ic. Retrieved April 12, 2008, from 2. Peake, K., Epstei, I., ad Medeiros, D. (2005). Cliical ad research uses of a adolescet metal health itake questioaire: What kids eed to talk about. Bighamto, NY: The Haworth Press, Ic. 3. Deis, M., White, M., Titus, J., ad Usicker, J. (2006). Global Appraisal of Idividual Needs (GAIN): Admiistratio guide for the GAIN ad related measures (Versio 5.4.0). Bloomigto, IL: Chestut Health Systems. Retrieved April 17, 2008, from I/GAIN-I_v_5-4/Idex.html. 4. Briere, J., Johso, K., Bissada, A., Damo, L., Crouch, J., Gil, E., et al. (2001). The Trauma Symptom Checklist for Youg Childre (TSCYC): Reliability ad associatio with abuse exposure i a multi-site study. Child Abuse Negl, 25(8), Steiberg, A. M., Brymer, M. J., Decker, K. B., ad Pyoos, R. S. (2004). The Uiversity of Califoria at Los Ageles Post-traumatic Stress Disorder Reactio Idex. Curr Psychiatry Rep, 6(2), Substace Abuse ad Metal Health Services Admiistratio. (1999). TIP 31: Screeig ad assessig adolescets for substace use disorders. Rockville, MD U.S. Dept. of Health ad Huma Services. Retrieved April 18, 2008 from bv.fcgi?rid=hstat5.chapter Fuk, R. R., McDermeit, M., Godley, S. H., ad Adams, L. (2003). Maltreatmet issues by level of adolescet substace abuse treatmet: The extet of the problem at itake ad relatioship to early outcomes. Child Maltreat, 8(1), Titus, J. C., Deis, M. L., White, W. L., Scott, C. K., ad Fuk, R. R. (2003). Geder differeces i victimizatio severity ad outcomes amog adolescets treated for substace abuse. Child Maltreat, 8(1), Grella, C. E., ad Joshi, V. (2003). Treatmet processes ad outcomes amog adolescets with a history of abuse who are i drug treatmet. Child Maltreat, 8(1), Back, S., Dasky, B. S., Coffey, S. F., Saladi, M. E., Soe, S., ad Brady, K. T. (2000). Cocaie depedece with ad without post-traumatic stress disorder: A compariso of substace use, trauma history ad psychiatric comorbidity. Am J Addict, 9(1), Giacoia, R. M., Reiherz, H. Z., Paradis, A. D., ad Stashwick, C. K. (2003). Comorbidity of substace use disorders ad posttraumatic stress disorder i adolescets. I Oimette, P., ad Brow, P. J. (Eds.), Trauma ad substace abuse: Causes, cosequeces, ad treatmet of comorbid disorders (pp ). Washigto, DC: America Psychological Associatio. 12. Oimette, P., & Brow, P. J. (Eds.). (2003). Trauma ad substace abuse: Causes, cosequeces, ad treatmet of comorbid disorders. Washigto, DC: America Psychological Associatio. 16 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

17 13. Cohe, J. A., Maario, A. P., Zhitova, A. C., ad Capoe, M. E. (2003). Treatig child abuserelated posttraumatic stress ad comorbid substace abuse i adolescets. Child Abuse Negl, 27(12), Aderso, L. M., Scrimshaw, S. C., Fullilove, M. T., Fieldig, J. E., ad Normad, J. (2003). Culturally competet healthcare systems. A systematic review. Am J Prev Med, 24(3 Suppl), Cross, T., Bazro, B., Deis, K., ad Isaacs, M. (1999). Toward a culturally competet system of care. Washigto, DC: Georgetow Uiversity Child Developmet Ceter. 16. Gwadz, M. V., Nish, D., Leoard, N. R., ad Strauss, S. M. (2007). Geder differeces i traumatic evets ad rates of post-traumatic stress disorder amog homeless youth. J Adolesc, 30(1), Johso, K. D., Whitbeck, L. B., ad Hoyt, D. R. (2005). Substace abuse disorders amog homeless ad ruaway adolescets. Joural of Drug Issues, 35(4), Thompso, S. J., McMaus, H., ad Voss, T. (2006). Posttraumatic Stress Disorder ad substace abuse amog youth who are homeless: Treatmet issues ad implicatios. Brief Treatmet ad Crisis Itervetio 6(3), Baer, J. S., Peterso, P. L., ad Wells, E. A. (2004). Ratioale ad desig of a brief substace use itervetio for homeless adolescets. Addictio Research ad Theory, 12(4), Najavits, L. (2001). Seekig Safety: A treatmet maual for PTSD ad substace abuse. New York, NY: The Guilford Press. 21. Najavits, L. M., Gallop, R.J., ad Weiss, R. D. (2006). Seekig safety therapy for adolescet girls with PTSD ad substace use disorder: A radomized cotrolled trial. J Behav Health Serv Res, 33(4), Zlotick, C., Najavits, L. M., Rohseow, D. J., ad Johso, D. M. (2003). A cogitive-behavioral treatmet for icarcerated wome with substace abuse disorder ad posttraumatic stress disorder: Fidigs from a pilot study. J Subst Abuse Treat, 25(2), Hie, D. A., Cohe, L. R., Miele, G. M., Litt, L. C., ad Capstick, C. (2004). Promisig treatmets for wome with comorbid PTSD ad substace use disorders. Am J Psychiatry, 161(8), Daielso, C. (2006). Risk Reductio Through Family Therapy treatmet maual. Charlesto, SC: Natioal Crime Victims Research & Treatmet Ceter. 25. Suarez, L., Saxe, G., Ehrereich, J., ad Barlow, D. (2006). Trauma Systems Therapy for Substace Abuse i Adolescece (Upublished). Bosto, MA: Ceter for Axiety ad Related Disorders, Bosto Uiversity. 26. Saxe, G., Ellis, B., ad Kaplow, J. (2006). Collaborative treatmet of traumatized childre ad tees: The trauma systems therapy approach, 1st ed. New York, NY: The Guilford Press. The Natioal Child Traumatic Stress Network 17

18 27. Cohe, J., Maario, A., Berlier, L., ad Debliger, E. (2000). Trauma-focused cogitive behavioral therapy for childre ad adolescets: A empirical update. Joural of Iterpersoal Violece, 15, Cohe, J. A., Maario, A. P., ad Kudse, K. (2005). Treatig sexually abused childre: 1 year follow-up of a radomized cotrolled trial. Child Abuse Negl, 29(2), Stei, B. D., Jaycox, L. H., Kataoka, S. H., Wog, M., Tu, W., Elliott, M. N., et al. (2003). A metal health itervetio for schoolchildre exposed to violece: A radomized cotrolled trial. JAMA, 290(5), Wager, E., Rathus, J., ad Miller, A. (2006). Midfuless skills i dialectical behavior therapy. I Baer, R. (Ed.), Midfuless-based treatmet approaches: Cliicia s guide to evidece base ad applicatios. Burligto, MA: Elsevier, Ic. 31. Ford, J. D., ad Russo, E. (2006). Trauma-focused, preset-cetered, emotioal self-regulatio approach to itegrated treatmet for posttraumatic stress ad addictio: Trauma Adaptive Recovery Group Educatio ad Therapy (TARGET). Am J Psychother, 60(4), Laye, C., Pyoos, R., Saltzma, W., Arslaagic, B., Savjak, N., ad Popovic, T. (2001). Trauma/ grief focused group psychotherapy: School based postwar itervetio with traumatized Bosia adolescets. Group Dyamics: Theory, Research, ad Practice, 5, Saxe, G., Ellis, H., Fogler, J., Hase, S., ad Sorki, B. (2005). Comprehesive care for traumatized childre: A ope trial examies treatmet usig Trauma Systems Therapy. Psychiatric Aals, 35(5), Brofebreer, U. (1979). Cotexts of child rearig: Problems ad prospects. America Psychologist, 34, Brady, K., Back, S., ad Coffey, S. (2004). Substace abuse ad posttraumatic stress disorder. Curret Directios i Psychological Sciece, 13, This project was fuded by the Substace Abuse ad Metal Health Services Admiistratio (SAMHSA), U.S. Departmet of Health ad Huma Services (HHS). The views, policies, ad opiios expressed are those of the authors ad do ot ecessarily reflect those of SAMHSA or HHS. 18 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

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