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Treating Adolescents with Co-Occurring Traumatic Stress and


Treating Adolescents with Co-Occurring Traumatic Stress and Substance Abuse Problems: Part One Lucy Zammarelli, M.A., N.C.A.C. II, Willamette Family, Inc., Eugene, Oregon – PowerPoint PPT presentation

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Title: Treating Adolescents with Co-Occurring Traumatic Stress and

Treating Adolescents with Co-Occurring Traumatic
Stress and Substance Abuse Problems Part One
Lucy Zammarelli, M.A., N.C.A.C. II, Willamette
Family, Inc., Eugene, Oregon Co-Chair of the
Adolescent Trauma and Substance Abuse Committee,
National Child Traumatic Stress
Network Virginia Summer Institute for Addiction
Studies Williamsburg, VA June 19, 2008
This presentation is a result of collaboration
between the members of the Adolescent Trauma and
Substance Abuse Committee, part of the National
Child Traumatic Stress Network. Many Thanks to
La Familia and especially to
Liza Suárez, Ph.D. Boston University, Boston,
MA University of Illinois at Chicago, Chicago,
IL and
Luis Flores, M.A.LPC, LCDC, RPT-S Serving
Children and Adolescents in Need, Inc. Laredo, TX
Who Are We?
  • A little about me
  • Socio-metric Group Introductions
  • A little about each of you
  • Your name and why you are here
  • Where you work and your position,
  • Your interest in adolescents,
  • One thing you are hoping to get from todays

Time to set up some appointments!
  • Find your Calendar Page Handout.
  • You need to schedule yourself for some
    appointments today!
  • Please mix around the room and fill out your
    appointment sheets by exchanging names with
    someone you dont know for each empty time space.
  • You will meet with them later in the day, so be
    sure you each block out the same times!

Presentation Outline
  • Morning Surveying the Environment
  • Description of General Issues/Your Issues
  • Scope of the Problems/Your Problems List
  • Challenges for System Change/Your Challenges
  • Afternoon Using/Adapting Tools for Success
  • Assessment Measures
  • Toolkit for Change
  • Effective Treatment Interventions

National Child Traumatic Stress
  • Collaboration of academic and community-based
    service centers aiming to raise the standard of
    care and increase access to services for
    traumatized children in the US.
  • 2001 Congressional mandate to address childhood
    trauma in the U.S.
  • Funded by the Center for Mental Health Services,
    Substance Abuse and Mental Health Services
    Administration (SAMHSA)

National Child Traumatic Stress Network (NCTSN)
  • Established the NCTSN structure
  • 1. A National Center to collect data and direct
    the Network (UCLA and Duke Cooperative)
  • 2. Education and Service Sites
  • Disseminate Evidence Based Practices
  • 3. Community Treatment Sites
  • Collect data and implement evidence based

NCTSN Mission
  • To raise the standard of care and improve access
    to services for traumatized children, their
    families, and communities throughout the United
  • Integrate mental health care and trauma treatment
    for children and youth
  • Integrate substance abuse treatment and trauma
    treatment for youth

First Steps to Common Understanding
  • Consistent perspectives (what lens do we look
  • Victims vs violators
  • Strengths vs problems
  • Diagnoses vs impressions
  • Common language (what words do we use in our
  • Co-morbidity vs co-occurring disorders
  • Dysregulation vs deviant behavior
  • Trauma/mental health/substance treatment terms

Understanding the General Issues Related to
Traumatic Stress in Adolescents
Defining Trauma
  • Trauma is a physical and/or emotional condition
    caused by environmental factors that result in
    physical and/or mental injuries affecting health.
  • Misidentified or misdiagnosed trauma-related
    symptoms interfere in seeking help, hamper
    engagement in treatment, lead to early drop-out
    and make relapse more likely
  • (Finkelstein, 2004)

Types of traumatic events
  • Physical, sexual, and emotional abuse
  • Interpersonal violence and victimization
  • Community violence
  • Natural disasters/terrorism
  • Traumatic loss and grief
  • Medical trauma
  • Chronic and Complex trauma
  • Other events processed as trauma (witnessed)

The bodys acute response to trauma
  • Mental response
  • In times of danger, the usual mental mechanisms
    that help us make everyday decisions are
    temporarily shut down. This response enables us
    to make more primitive responses and take quick
    action rather than to think carefully about the
    situation at hand. SURVIVAL MODE!

Physical sensations
The bodys acute response to trauma
  • Fight, flight, or freeze response The bodys
    reaction to perceived threat or danger.
  • Fight fighting off an attacker
  • Flight running away from danger
  • Freeze going dead such as during rape
  • Dissociation out of body experiences
  • Adrenalin and cortisol are released to give the
    body a burst of energy and strength

Trauma Reminders Linger
  • The bodys alarm reaction can be triggered by
    situations that remind us of the trauma, even if
    we are no longer in a truly dangerous or
    threatening situation.
  • These trauma reminders, or triggers might include
    situations that have something in common with the
    traumatic event, but they could also include
    thoughts or memories about what happened.
  • Even when we are no longer in danger, our bodys
    alarm response could become activated as if we
    were experiencing the trauma all over again.

Post Traumatic Stress Disorder
  • Re-Experiencing the traumatic event through
    intrusive thoughts or dreams of the event, or
    intense psychological distress when exposed to
    reminders of the event
  • Avoidance of thoughts, feelings, images, or
    locations that remind the adolescent of or are
    associated with the traumatic event
  • Increased arousal such as hyper-vigilance,
    irritability, exaggerated startle response, and
    sleeping difficulties

Additional problems associated with trauma
  • Anxiety and mood problems
  • Negative perceptions about oneself and others
  • Avoidance activities, such as dissociation,
    tension reduction activities (binging/purging,
    self mutilation)
  • Somatic Complaints
  • Interpersonal difficulties
  • Substance abuse

Trauma in 2 Dimensions
Adolescent Development
  • How do child development issues relate to trauma?
  • What is normal development and what is
    unusual development?
  • What areas of a teens life may be affected?

Impacts of Trauma on Teens
  • On arousal
  • On cognition and memory
  • On emotions
  • On identity and sense of self
  • On relationships
  • On dating and sexual development
  • On goals and achievements

Adolescent Brain Development
  • Myth that brain development stops at early
    childhood has been discredited
  • Patterns of brain development extend into early
    adult years, age 24-25 at least
  • Teenage brain has the potential to grow and heal
    through effective treatment techniques, family
    support, and a cessation of stressors

Understanding Substance Abuse Problems in
Substance Abuse Is Often Hidden
  • The earlier the onset age of drinking, the
    greater the risk for lifetime alcohol abuse or
    dependence (DeWit, Adlaf, Offord, Ogborne,
  • Trauma and substance abuse often co-occur.
  • Mental health diagnoses may follow prolonged
    untreated trauma and substance use.

Definition of Addiction
  • Addiction is a chronic, episodic, progressive
    disease of the brain and body characterized by
    periods of substance use followed by periods of
    abstinence. It may involve physical and/or
    psychological dependence on continued use, with
    negative impacts over a variety of areas of life.
    Recovery from the condition is possible, but it
    requires ongoing care and lifestyle change.
  • --National Institute of Drug Abuse

Abuse and Dependence
  • Substance Abuse
  • Use of drugs in a manner that is illegal or
    harmful to the individual and causes significant
    adverse consequences such as accidents or
    injuries, blackouts, legal problems, and risky
    sexual behavior.
  • Substance Dependence
  • Continued substance abuse despite significant
    substance-related problems
  • Usually includes tolerance (requiring higher
    doses to achieve the same effect) and withdrawal
    (symptoms experienced when use of the drug is

Substance Use
  • There is no one-size fits all
    approachsubstance using families tend to be
    unique, and it usually takes longer to make
    change in these families.
  • Most common substances
  • Alcohol
  • Prescription medications (often misused)
  • Marijuana
  • Other illegal drugs
  • And dont forget to ask about tobacco and
    gamblingoften these are co-addictions!

  • A hallmark of Substance Use Disorders in
    adolescents is impairment in psychosocial
    academic functioning (Martin Winters, 1998)
  • Can include family conflict or dysfunction
  • Interpersonal conflict
  • Academic Failure

Triggers and Cravings
  • A trigger is a stimulus which has been
    repeatedly associated with the preparation for,
    anticipation of or the use of drugs and/or
  • These stimuli include people, things, places,
    times of day, and emotional states.
  • Substance use craving refers to the very strong
    desire for a psychoactive substance or for the
    intoxicating effects of that substance.
  • Cravings include thoughts (about the urge to
    use), physical symptoms (heart palpitations) and
    behaviors (pacing)

Are Teens Really Addicted?
  • Some are, but many who use substances do not meet
    the NIDA definition for addiction.
  • The majority of teens who use substances quit
    their use with no formal treatment, either before
    adulthood or in early adulthood.
  • Evidence Based Practices for adults often do not
    work well with teens!
  • But neither do many traditional interventions!

Time for our first appointment!
  • Check your Calendar Page and find your first
    appointment partner.
  • Move around (switch chairs) so that you may meet
    with them for the next 8-10 minutes.
  • Discuss the questions on the following slide.
  • At the end of this time, we will take a morning

What are your experiences working with this
  • Direct services with youth in schools or clinics?
  • Administrative challenges in service systems?
  • Corrections contact with youth? Family work?
  • Recreational supervision, or employment training,
    or health care?

Morning Break
  • 10-15 minutes

The connection between trauma and substance abuse
NCTSN Core Data Set Findings Summary
  • Youth with co-occurring substance abuse problems
    and trauma exposure were more likely to meet
    clinical severity criteria using the UCLA PTSD-RI
    and the TSCC, compared to youth with trauma only.
  • Co-occurring youth had higher Total and
    Externalizing CBCL scores.
  • The percentage of adolescents with problems
    according to the clinician-rated Indicators of
    Severity scale was significantly greater among
    co-occurring youth across most domains.
  • A higher proportion of co-occurring youth had
    been engaged with several service systems,
    including probation, child welfare, day
    treatment, case management, in home services,
    school counselor, and self help.

Rates of traumatic stress and substance abuse
problems among adolescents
  • High prevalence in adolescents
  • Lifetime substance abuse rates (10-32)
  • Younger ages of onset and initiation
  • Adolescents are at risk for interpersonal
    violence and victimization
  • 25 of children and adolescents will experience a
    traumatic event by age 16
  • Rates of SUD-PTSD comorbidity- 3.6 - 47

Prevalence of trauma and substance abuse in youth
  • Traumatic stress and substance abuse problems
    frequently co-occur among adolescents
  • Epidemiological studies show the overall rates of
    co-occurrence of PTSD and substance abuse can
    range from 13.5 to 29.7 1
  • However, the co-occurrence is even greater in
    treatment settings, with rates highest among
  • Lifetime prevalence rates of trauma exposure
    71-80 2, 3.
  • Lifetime prevalence rates of PTSD 24.3 -45.3 2
  • Current prevalence rates of PTSD 14- 40.0 2,

1. Kilpatrick, Ruggiero, Acierno, Saunders,
Resnick, Best (2003) , 2. Deykin Buke (1997),
3. Funk, McDermeit, Godley, Adams (2003), 4.
Diamond, Panichelli-Mindel, Shera, Dennis, Tims,
Ungemack, (2006).
Traumatic stress and substance abuse
  • Adolescents who have experienced a traumatic
    event may turn to substances in efforts to cope
    with their distress, as a way to numb their
  • Substance using youth engage in risky activities
    that can also lead to experiencing traumatic
    events, and they may be less able to cope

Which came first?
Does it matter?
Why are the risks greater for adolescents?
  • Disruption of normal brain development - not
    fully developed until age 24-25
  • Hippocampus (learning and memory)
  • Prefrontal cortex (critical thinking, planning,
    impulse control, and emotional regulation )
  • Interference with many physiological processes
    that can destabilize mood (depression,
    aggression, violence, and suicide).
  • Decision-making abilities are not fully developed

Common patterns observed in populations with
trauma and substance abuse problems
Conditioned Stimulus
Conditioned Emotional Response
Conditioned Avoidant Response
Response Cost
Emotional Dysregulation
Numbing Substance use
Negative Affect Hyperarousal
Trauma Reminder
Substance use trigger
Craving (Anxiety, Irritability)
Withdrawal Symptoms
Substance use
Pathways to the link between SUD and PTSD in
(Giaconia, Reinherz, Paradis, 2003)
  • High risk behaviors - those with SUDs are more
    likely to experience traumas that result from
    risky behavior
  • Susceptibility - those with SUDs may have less
    ability to cope with traumatic events
  • Self medication - develop problems with SUDs to
    manage PTSD or other negative emotional states

The role of stress
  • Initiation of use
  • Continuation of use
  • Relapse

  • Inability to meet major role obligations
  • Leading to reduced functioning in one or more
    areas of life
  • Risk taking behavior
  • Increase in the likelihood of legal problems due
    to possession
  • Exposure to hazardous situations

Impact of SUD and PTSD on psychosocial functioning
  • Psychological, physical and social functioning
  • Less life satisfaction, greater anxiety, more
    health complaints, less social competence (Cark
    Kirisci, 1996 )
  • Poorer self esteem, more interpersonal problems,
    lower grades (Reinherz, et al., 1993)
  • Role functioning
  • Poorer academic achievement and more school
    adjustment difficulties (Cark Kirisci, 1996 )
  • Poor school performance and course failure
    (Reinherz, et al., 1993)

Impact of comorbid SUD-PTSD on psychosocial
  • Combination of deficits (Giaconia, et al.,
  • Externalizing problems (delinquent aggressive
  • Internalizing problems (anxiety, withdrawn
    behavior), perception of poor health, somatic
  • Poor school performance (course failures,
    expulsions, suspensions, absences), criminal
    arrests, serious suicidal behavior

The Cycle of Trauma and Substance Abuse
Without strong coping skills, adolescents may
make attempts to avoid/mask distress with
Substance use puts adolescents at higher risk for
trauma exposure.
Coping Skills
Substance Abuse
Traumatic stress can cause severe emotional
distress, and autonomic arousal.
  • Use of substances may cause a host of physical,
    mental, legal and/or social problems for
    adolescents while failing to provide any
    long-term relief from their trauma-related
    emotional distress.

Traumatic Stress
Kids with traumatic stress and substance abuse
often encounter chaotic environments that lead to
further distress
Adapted from Suárez, 2005
Needs/Barriers of youth with traumatic stress
and substance abuse
  • Emotional and behavioral dysregulation
  • Coping deficits
  • Family strain
  • Environmental stress
  • Academic difficulties
  • Health problems
  • Involvement with multiple service systems
    (juvenile justice, social services, mental
    health, substance abuse, special education)

Shared risk factors for youth substance use and
trauma (child abuse neglect, victimization)
Known Protective Factors
  • Individual
  • Positive coping strategies (good decision-making
    skills, assertiveness, and cognitive mastery)
  • Effective mechanisms in managing temptations
  • Family
  • Strong sense of attachment to parents.
  • Parental attitudes about substance use
  • School
  • Bonding with school
  • Having a strong commitment to doing well
  • Peer
  • Not associating with substance-using peers,
    having positive friends
  • Community
  • Availability of needed services, quality
    educational and recreational opportunities

Family Matters Substance Abuse and The American
  • Half of all children (35.6 million) in the U.S.
    live in a household where a parent or other adult
    uses tobacco, drinks heavily or uses illicit
  • 12.7 of children under age 18 (9.2 million) live
    with a parent or other adult using illicit drugs.
  • 23.8 of children under age 18 (17 million) live
    with a parent or other adult who is a binge or
    heavy drinker.
  • --National Center on Addiction and Substance
    Abuse at Columbia University (CASA) White Paper,
    March 2005

  • Helping people in recovery understand the range
    of possible connections between trauma and
    substance abuse is a key process in integrated
  • (Finkelstein,, 2004)

Treating Traumatized, Substance Using Youth
  • Our Current System

Substance Abuse and Mental Health Fields
  • Systems have traditionally developed
    independently from one another
  • Systems are evolving and making innovations, and
    system integration for youth with co-occurring
    disorders is slowly developing
  • Separate funding streams
  • Different reimbursement rates
  • Unidimensional view of needs
  • Problem-focused vs. youth/family focused

Service Fragmentation How did it happen?
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Addressing Trauma and Substance Abuse Needs
  • No Care
  • Access to one Type of Care
  • Sequential Care
  • Parallel Care
  • Coordinated Care
  • Integrated Care
  • The Higher the Severity the greater the need to
    integrate care

  • it is the constellation of coordinated
    interventions generally several evidence-based
    interventions used in combination to meet
    individual client needs, and delivered by the
    same clinicians working in one setting that
    constitutes the evidence-based practice known as
    integrated treatment for co-occurring disorders.
  • (Report to congress on the prevention and
    treatment of co-occurring substance abuse
    disorders and mental disorders, 2002, Pg57)

Challenges/Barriers for SA and Public MH fields
  • Not enough resources of even one type of service
  • Not all communities have a continuum of care (Not
    having anything to integrate)
  • Systems that may not have reimbursement systems
    that foster the use of evidence-based practices

Challenges/Barriers SA and Public MH Field
  • Difficulty retaining staff, training staff
  • Specialty areas do not attract many people
  • Not a great deal of stability in programs or
  • Lack of qualifications to use more sophisticated
    clinical and therapeutic skills (can they address
    trauma? Substance abuse? )

  • What can SA and MH staff realistically do?
  • The process of becoming trauma-informed takes
    time and effort
  • Lack of incentives for programs to become more
    trauma or substance abuse informed
  • Clinicians in each field may know about SA/TS but
    cant do much to address both problems
    unidimensional view due to system issues

  • Assessment When information is collected (if
    collected) programs do not do much with
  • Substance abuse and community mental health
    services often do not address issues of trauma
  • Behaviors/needs are not usually seen from a
    trauma perspective.
  • Mental Health programs may emphasize a medical

  • Waiting lists
  • Passive referrals (create no change)
  • Parallel care is not a possibility sometimes
  • Ratios of population to Mental Health
    Professionals or medication prescribers
  • Private Providers are not usually trauma informed

Time for Your Second Meeting!
  • Find your second appointment!
  • Working together, you can each make a list of
    the challenges and barriers you perceive in your
    current work system.
  • Also, brainstorm some ways to decrease those
    difficulties, and make a second list of
    suggestions you could try at work.

Ready to Share?
  • Any volunteers who want to share their challenges
    and the ways they might approach them?
  • Any audience feedback?
  • What sorts of technical assistance might be
    needed to help this situation?
  • What is one thing that can be done immediately to
    create change?

  • Understanding the complexity of needs TS/SA youth
  • Integrated care in one single trauma and
    substance abuse-informed system, preferably by
    one provider or one clinical team
  • Seamless access to a wide array of services
    including psychiatric care

  • Ability to guide implementation of
    evidenced-based practices tailored to the unique
    needs youth and families
  • Intensive Case Management to coordinate care
    across multiple systems
  • Closely Coordinated Care in Substance Abuse and
    Trauma informed systems

  • Cross Training In mental health and substance
  • Screening and Assessment tools that identify
    needs in both areas
  • Focus on Fidelity
  • Access Available Resources
  • Make a decision to become trauma-informed

  • Dissemination of Evidence-based practices
  • Fostering a consistent movement towards use of
    evidence-based practices and trauma information
  • Ability of providers to organize multiple
    services across multiple systems.

  • Becoming Trauma-Informed
  • Trauma as a defining and organizing experience
  • Create an open and collaborative relationship
    between providers and youth/families, placing
    priority of their safety, choice and control
  • Integrate understanding of trauma and substance
    abuse throughout the program in order that staff
    recognize the multiple and complex interactions
  • Ensure physical and emotional safety
  • Becoming aware of trauma EBTs and trauma
  • Address comprehensive needs

  • Give staff the ability to address trauma even if
    only addressing safety, psycho-education
    stress-management, etc.
  • Develop Partnerships
  • Integrate available services
  • Increase communication between providers
  • Develop local solutions

Progress in the SA Field
  • Developmentally appropriate treatment approaches
    and materials
  • Manual-guided treatment interventions
  • Improved assessment tools and procedures that
    include screening for mental health disorders
  • States are now requiring the use of substance
    abuse evidence-based treatment approaches
  • Movement towards addressing co-occurring disorders

The Substance Use Treatment System
  • American Society of Addiction Medicine
  • ASAM is an EBP that has helped standardize
    substance abuse treatment across the nation
  • Standards used at assessment to determine the
    type of treatment referral
  • Also used during treatment for goal planning and
    completion, and discharge information

Treating Co-Occurring Disorders
  • This is the term used by the substance use system
    to refer to mental health, trauma, or psychiatric
    diagnoses that occur together with substance use.
  • These disorders take longer to treat and present
    additional challenges to either the mental health
    or substance use treatment systems.

  • Despite progress in our fields, our systems are
    not always conducive to integration!

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Your Mission Should You Choose to Accept
Working with practical tools in your setting
The NCTSN Adolescent Substance Abuse and Trauma
Toolkit will be disseminated after lunch.
Contact Information
  • Lucy Zammarelli, MA
  • Director of Adolescent and Mental Health Services
  • Willamette Family, Inc.
  • 687 Cheshire Ave.
  • Eugene, OR 97402
  • 541-343-2993