October 2003
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In this issue
-- SAVVY........
-- SKILLS........
-- SOUL.........
-- SHAMELESS SELLING.....
-- STUMP the SHRINK...
-- Until next time......

WELCOME!

A TIPS & TOPICS reader recently asked about information on adolescent treatment. I realized that many of you are working with youth and adolescents, and we have not addressed your needs specifically thus far. So for everyone who works with adolescents, or has ever been an adolescent, this edition is for you.

SAVVY........
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The reader wrote:
"It is difficult to sort out addiction from abuse with adolescents. My sense is we have more addicts than in previous years".

These two sentences echo what many in the behavioral health field experience. They raise a variety of assessment and treatment issues. I suspect the reader was not asking about the fine points of distinction between the diagnostic criteria of Substance Abuse versus Substance Dependence (See the Substance Use Disorders section of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders -DSM-IV.)

Rather, I took the comment to raise this question: when is an adolescent just being an adolescent and experimenting with alcohol and other drugs? How do you tell if s/he is now addicted, needing definitive addiction treatment versus education and risk counseling?

Tips:

• In assessing adolescents, developmental issues are paramount. But over- emphasizing developmental issues can hold the danger of minimizing a young person's alcohol or other drug use, and dismissing problems as youthful indiscretion and experimentation. Conversely, forgetting developmental issues can hold a danger of seeing adolescent addiction everywhere - every time we hear of an Ecstasy death at a rave party, or read about five drunk teens in a car wreck.
  
  
  
• Because children and adolescents are not independent and rely heavily on adult support, they often have food, clothing, shelter and money in their pocket regardless of what their drinking or drugging may be doing to their educational, legal and social life. In other words, when an adolescent says: "I don't see what the problem is"; or "You're making a big deal about nothing", their statements may be quite genuine. They may not be experiencing any tangible difficulties their using causes. In contrast, an adult whose marriage, job, finances and mortgage are on the line because of their drinking and drugging can not so easily ignore the consequences of their use.
  
  One obvious clinical implication is this: it is critical to involve the family and significant others in both assessment and treatment. Parental attitudes and behavior about substance use; limit setting and disciplinary style; and the family history of addiction all influence the diagnostic and treatment process. For example, a parent whose father was alcohol-dependent and physically abusive may have determined to be a teetotaler. He may overreact to his son's experimentation with alcohol and see addiction where it does not exist. Or parents who repeatedly threaten consequences but do not set consistent, predictable limits, may prolong recognition of their teenager's out-of- control substance dependence.
  
  

• Two free resources available from the National Clearinghouse for Alcohol/Drug Information, Rockville, MD: (800) 729-6686) are:
  
  >> "Screening and Assessing Adolescents for Substance Use Disorders" Treatment Improvement Protocol (TIP) Series No. 31. Revision Consensus Panel Chair Ken C. Winters, Ph.D. Center for Substance Abuse Treatment DHHS Publication No. (SMA) 99-3344, 1999.
  
  >> "Treatment of Adolescents With Substance Use Disorders" Treatment Improvement Protocol (TIP) Series No. 32. Revision Consensus Panel Chair Ken C. Winters, Ph.D. Center for Substance Abuse Treatment DHHS Publication No. (SMA) 99-3345, 1999.

SKILLS........
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

So how do you decide if the adolescent substance use is just "normal" developmental experimentation, or problem use? Is the speeding or drinking-driving violation simple youthful omnipotent risk-taking, or substance- dependent dangerous behavior? Besides the help you can get from active involvement of parents and significant others, here are a few other tips.

Tips:

• A biopsychosocial perspective can help. If several areas of the adolescent's functioning are being affected, it may be addiction.
  
  > Bio: Is the adolescent's substance use beginning to affect his or her physical health like oversleeping; increased or decreased appetite and weight; poor personal hygiene and self-care?
  > Psych: Are their frequent emotional outbursts and mood changes of a different quality from the teen's usual temperament and emotional style? Are there frequent displays of hostile, defensive arguments; or the reverse - isolated, withdrawn depression or irritability?
  > Social: Has there been a persistent attachment ,or clear change in friends, to the 'drug crowd?' Are school grades persistently deteriorating? Are there ongoing incidents of appearing drunk or high at school? Missing money at home?

• One or two of these signs may well just be a developmental issue.
  For example, a teen may not bathe or eat well to distinguish himself from the good little boy who always washed behind his ears or ate his vegetables. Or rather than mature reflection, she may express frustration or self-doubt in emotional outbursts or irritability. Grades may be poor because the peer group is not invested in studying. The teen's priority of socializing now is much more interesting than delayed gratification. The long-term view (of how the poor grades will affect college choices in two years' time) melts at tonight's party.
  
  But if there is a "pattern of biopsychosocial" warning signs that cut across all life areas plus a steady deterioration of function, then the red flags are up for DSM Substance Abuse or Substance Dependence.

• Advocate for a period of abstinence or cutting back on use of substances if the your family work and history assessment still leaves you unclear about the "normal development or addiction problem" diagnostic challenge. If your client has trouble cutting back or stopping, this signals a high likelihood of a substance use disorder.
  
  Firstly of course, you will need to engage the adolescent in a discussion of such an abstinence or reduced-use trial. It is unlikely to reveal much helpful data if the teen agrees under the duress of court or jail, but has no intention of being honest about the diagnostic trial. One strategy that can work if done sincerely is this: join with the adolescent in a formal treatment contract that you will help him get people off his back. As part of the plan to prove to them (the court or parents) that he has no substance use problem (which is what he declares) the teen agrees to a period of abstinence or measurable reduction of use.
  

SOUL.........
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Many of you who were once adolescents will remember what it was like to not know what you want in life. And it wasn't just about the big things- what kind of career to pursue, what you wanted in choosing a girlfriend, boyfriend or life partner. It was even about such life and death issues of what to wear at the prom, whether to play volleyball or soccer or both? Not knowing what you want is not an affliction of adolescence alone. It rears its ugly head at all of life's developmental milestones and "passages".

Do I want a fulltime job right now - to get on the career treadmill having just graduated from college? Or do I want to travel the world before I settle down? Where would I want to live and settle down anyway? Should I marry first or concentrate on my career? What about having kids? Should I change careers to get satisfaction more than the financial security that has kept me in this job way longer than my heart wanted? Should I retire? Move to somewhere warm? Would I want to be a "vegetable" on a respirator, or would I want my family to pull the plug? And the questions go on!

I just received a shipment of books brand new and hot off the presses. It's called "Maintain Balance in an Unsteady World" with a variety of chapters written by speakers of the National Speakers Association. I enjoy writing these monthly TIPS & TOPICS and it is personally gratifying, especially when I hear how it has positively impacted many readers. And I also enjoyed writing one of the chapters in this newly released book. My chapter is called: "What Do You Want? - The Not-so-Simple Question".

Knowing what you want can go a long way towards decreased stress, worry, and diversionary waste of time, energy and resources. Asking and answering "What Do You Want?" is good for treatment contracting with clients and patients; but is also good for clarifying goals at every stage of life. It promotes conscious, mindful, living at choice rather than reactive, defensive victim- thinking.

Now, let me add another "S" just to this month's TIPS & TOPICS list of S's. The new "S" is: Shameless Selling.

SHAMELESS SELLING.....
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I want my Tips & Topics readers to be among the first to hear about and have the book with my chapter in it. I'm excited that the book is out. I hope you find the chapter useful. I want you to buy it - and maybe even read my chapter! In the good tradition of the TV infomercials, here is the deal (no Ginzu kitchen knives I'm afraid!).

At my website, click on the "New" announcement link on the bottom of the homepage. You will be taken to more information on a special introductory offer for "Maintain Balance in an Unsteady World" with my chapter "What Do You Want?"

But this offer expires on October 31. So take a look soon. That's the end of my Shameless Selling segment.

Click here to read about "What Do You Want? The Not-So-Simple Question"

STUMP the SHRINK...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Here's a recent question where I got stumped!

Question- Issue

"In Dimension 4-Level I a client has to agree to services but be ambivalent about recovery , resistant to acknowledging problem areas or be more interested in avoiding negative consequences than in recovery efforts. We happen to have many adolescents who agree to treatment and want to be clean for internal reasons without being ambivalent or resistant. Currently there is no official place for them in the criteria. This is a problem! The old ASAM Level I was more inclusive - with or without admission of a problem, monitoring and motivating strategies are needed to identify treatment issues.

Also, our program manager would like to know if there is an ASAM requirement of treatment reviews (every two or three months, for example) when no change in level is indicated. Currently, we are required by OHP, etc. for their recipients. What about self-pay clients?

Thank you very much and thank you also for your illuminating newsletter."

Sally Louise Smith L.C.S.W.
Linn County Alcohol and Drug

Response

Hi Sally Louise:

On Dimension 4-Level I:
I am on the road and don't have my ASAM PPC-2R with me, so can't quote chapter and verse. But are you reading all the Dimension 4, Level I criteria? The criteria about ambivalence etc. were additions to what was already there in Level I to allow OP to be used to do motivational enhancement work. But the old criteria were not removed, so the person who is indeed ready to change for internal reasons is still covered by the Dimension 4 criteria in Level I.

Check again and if you can't see those "healthier" type criteria, let me know. Or if they are worded unclearly, let me know page and number and I will check them when I get home. Be sure you are reading the actual Dimension 4 criteria in the ASAM PPC-2R book, not the much-abbreviated summary crosswalk, which is not the whole detail on the criteria, though in general it gives a bird's eye view of the criteria.

On treatment reviews:
The ASAM PPC does not prescribe any set time periods for treatment reviews. That is up to the type of program, level of care, local standards etc. In general, I recommend that a rule of thumb (not official ASAM PPC policy) is every six sessions. So if it were Level II.5, then that would be a treatment plan review every week. If Level II.1, it would be about every two weeks. If in Level I, it would be every six weeks, if the person were coming once a week; or every three weeks if they were coming twice a week.

If they were stable and being seen once a month, then it would be every six months in Level I, as not much would change much at that low level of monitoring. When it comes to residential and intensive IP, the frequency depends on the severity. In level IV, where someone is quite unstable, the progress is usually reviewed every 8 hour shift. In residential levels, if someone were unstable, but not acute care, it might be every day until more stable, but I would think not less frequently than once a week.

If residential is being used as a long-term supportive living environment as in Level III.1, then treatment plan review might be perhaps once a month. The principle is to review the treatment plan at an interval that is relevant to how unstable a person is and the rate of their progress and change with the strategies being used in the treatment plan. If there is a lot of instability and more rapid change e.g., in acute withdrawal, or suicidal behavior, them more frequent review is needed. If stable and and not much intensity of service is required, then the interval of time is longer as the client's severity and level of function is not fluctuating as much and therefore does not need to be reviewed as often.

Second Reponse from Sally

"David,
Thanks so much for getting back to us. The long form of the criteria does not offer any real difference than the short one for Dimension 4 Level I. We did not know the old criteria were not removed. Thank you, too, for the treatment review response.
Sally"

Further response from DML

Sally:
I checked again ASAM PPC-2 and ASAM PPC-2R when I returned home and I see the problem you raised. You wrote: "We happen to have many adolescents who agree to treatment and want to be clean for internal reasons without being ambivalent or resistant. Currently there is no official place for them in the criteria. This is a problem!"

I was not as directly involved in the Adolescent Workgroup. In the Adult Criteria we added to the "healthier" criteria, but did not change the situation of the person who was wanting to change etc. So there isn't the same issue in the Adult Criteria.

But as I re-read the Adolescent Criteria, I agree that the fully internally-motivated, ready-to-change adolescent is not covered in Dimension 4 now as in ASAM PPC-2. I think I know why the Adolescent Workgroup modified Dimension 4, in Level I. I believe the thinking might have been that adolescents are so often brought into treatment, that ambivalence is a very common presentation. If there was no ambivalence, then the adolescent would not need any motivational enhancement or monitoring services and could go to self/help mutual help services themselves without the need for professional treatment.

But you are right, the adolescent who from day 1 or outpatient visit #1 is fully resolved that s/he has an addiction and/or mental health problem and is ready to do whatever it takes for recovery is not covered by Dimension 4, Level I adolescent criteria. These are admission criteria, and I think the workgroup felt that all adolescents enter with some readiness to change issues. It could be that in the course of treatment, the adolescent is fully ready on Dimension 4, but not able to cope with cravings or peer refusal skills on Dimension 5 which then warrants Level I or more intense treatment. That situation is covered in the Continuing Service Criteria.

Anyway, there is a problem as written, as you correctly point out. But it is a problem only if you have adolescents who, at admission into treatment right from the beginning, have no ambivalence about having a problem; and are indeed ready to change and do whatever it takes for recovery. These patients would not be covered by Dimension 4, Level I and I will put that on the list of concerns from the field.

Thanks for your feedback and correction.
David

Until next time......
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
That's it for this month. I would love to hear any Success Stories on implementing any of the TIPS and TOPICS. Send an e-mail and tell us how much identifying data you are comfortable sharing here. Talk to you next month.
David.

Contact Information
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
email: info@dmlmd.com
voice: 530-753-4300
web: http://www.dmlmd.com
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~