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Research Proposal Paper # 3 Revised January 28, 2004 Methods of Research & Discipline Inquiry Course # 1005 Aliya Fonseca, MA 10631 Caminito Brandon San Diego, CA 92131 (858) 536 - 8370 Denise Scatena, Ph. D Saybrook Graduate School & Research 450 Pacific St. 3 rd Fl San Francisco, CA 94133 ABSTRACT The proposal is to identify adolescents with mental health and alcohol and drug issues. The study will build on growing research, which suggests adolescents whom abuse or are dependent on alcohol or drugs are oftentimes coping with a mental illness. If the early detection of a co-existing disorder is discovered this will allow for a comprehensive behavioral treatment approach that will address both disorders concurrently.
A randomized experiment will compare a dually diagnosed group of adolescents receiving mental health counseling along with treatment for alcohol and drug abuse compared to a dually diagnosed group that only receives alcohol and drug treatment. LITERATURE REVIEW The foundation of the study rests upon the lack of research done in the field of alcohol / drug and mental health regarding dual diagnosis in adolescents. Little research has addressed the problem of dual disorders within the adolescent population. Dr. Minkoff (2001) of the Medical University of South Carolina found that 90 % of substance abuse inpatients also had a comorbid psychiatric disorder. Additionally the study expanded into the community and discovered that 30 percent of adolescents at outpatient clinics had comorbid disorders.
The proposed study will obtain participants that are dually diagnosed and who are not being treated for both disorders. In a lecture by Dr. Minkoff was stated, the most significant developments in the area of co-occurring disorders have to do with the recognition of the high prevalence of comorbidity and the realization for the need to design interventions for people with co-occurring disorders throughout the entire service system (Minkoff, 2001). Secondly, Minkoff's interview addressed the need to support: evidence-based and derived practice guidelines have been developed; these generally indicate that people who receive proper treatment will get better. This underscores the need to provide integrated treatment interventions where the individual has a primary treatment relationship in which interventions for the substance use disorder and interventions for the mental health disorder are brought together and coordinated in a person-centered, coherent whole appropriate to the level of the persons impairment and incapacity to meet these problems on his / her own (Minkoff, 2001) In treating individuals with comorbid disorders many studies support Minkoff's evidence-based approach. Mental health providers divide the services in which treatment providers offer to dually diagnosed clients in such a manner that any normal level functioning adolescent would have difficulty making sense of the treatment system, let alone an adolescent who might abuse or is dependent on alcohol or drugs and has a mental illness.
This highlights a key concern regarding the delivery of services in that the more we treat people differently, the more likely we are to precipitate poor clinical outcomes (K. Minkoff, 2001) Thirdly, Miller who developed motivational interviewing techniques has a systematic approach which combines clinical interviewing with discovering the clients readiness for change. Some of the critiques of Millers system are that it fails to address comorbid disorders and solely focuses on the clients readiness to reduce or stop the use of alcohol or drugs. This clinical interview excludes a clients coping skills to manage and address a mental illness. During the past two decades disturbing health trends among the nations adolescents have emerged that pose serious threats to their future health and welfare. The Centers for Disease Control and Prevention identifies six major risk factors that contribute to the decline in adolescents health: a) behaviors that result in unintentional and intentional injuries; b) tobacco use; c) alcohol and other drug use; d) dietary patterns that contribute to disease; e) insufficient physical activity; and f) sexual behaviors that result in HIV infection, other STDs, and unintended pregnancy.
More to the point, research has shown that these risk factors not only result in poor adolescent health, but also inhibit education and negatively impact several other social outcomes. The Centers for Disease Control reports that the identification of mental illness and substance use are major risk factors to adolescent health thus require a comprehensive treatment approach. Lastly, the CDC reports that health-related consequences specific to substance use include, but are not limited to, increases in health care costs, crime, social welfare, motor vehicle crashes, and premature death. Substance Abuse A number of diagnostic issues are related to substance abuse. With any alcohol / drug disorder one must always specify if it is with or without physiological dependence.
This helps to clarify if the client is dependent or simply abusing the alcohol or drug. Some of the key definitions that help define the difference are substance dependence which is a maladaptive patter of substance use, leading to clinically significant impairment or distress, as manifested by 3 or more of the following: Another key term is substance abuse which is a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following: early full remission- at least 1 month, but less than 12 months substance use early partial remission at least 1 month, but less than 12 months, one or more criteria for dependence or abuse have been met or sustained full remission none of the criteria for dependence or abuse have been met at any time during a period of 12 months. Even more substance withdrawal is the development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged. The alcohol disorders have many similarities except for alcohol intoxication which is the recent ingestion of alcohol. Dual Diagnosis The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders. Recently, with the fields of mental health, psychiatry, and addiction medicine, the term has been commonly used to describe the coexistence of a mental health disorder and alcohol and drug problems.
The equivalent phrase dual disorder also denotes the coexistence of two independent (but invariably interactive) disorders. The combinations of alcohol and drug problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more sever than the other. Indeed, the severity of both disorders may change over time.
Levels of disability and impairment in functioning may vary. Thus, there is no single combination of dual disorders; in fact, there is great variability among them. INTRODUCTION Identifying minority adolescents with a dual disorder has treatment and fiscal implications. If adolescents are screened for then treated for mental illness along with alcohol and drug abuse it would affect the way treatment is delivered and alter the funding for treatment providers in order to allow for a mental health provider. Establishing an accurate diagnosis for patients in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric disorders and psychiatric symptoms caused by Alcohol and Other Drugs (Aod's).
To do so, clinicians must obtain a thorough history of AOD use and psychiatric symptoms and disorders. There are several possible relationships between AOD use and psychiatric symptoms and disorders. Aod's may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process. The symptoms of a coexisting psychiatric disorder may be misinterpreted as poor or incomplete recovery from AOD addiction. Psychiatric disorders may interfere with patients ability and motivation to participate in addiction treatment, as well as their compliance with treatment guidelines. The methods of treating psychological disorders vary greatly.
Psychological disorders can range from mild symptoms to severe disorders and the treatments can range from hospitalization to outpatient care. Psychological disorder is one of the most elusive psychological aspects about our human functioning. Therefore we have a great deal to learn about psychological disorders and how, why, and what are the outcomes for many people who suffer with psychological disorders. The focus of this pilot study will compare the treatment outcomes of substance abuse and the other a dual treatment modality addressing both substance abuse and other psychological illnesses. Psychological disorder has been classified as a social problem. It impairs or reduces the functioning of a human.
The degree to which impairment has occurred is something assessed using the Global Assessment Scale (American Psychological Association, 2001), which records degree of deviance for levels of functioning that are appropriate and considered normal by our social standards. The Global Assessment Scale is used to categorize others based upon their ability to appropriately and socially address daily activities such as work and school. In the case of a dual diagnosis, even if both disorders have mild symptoms, when they coexist the symptoms may exacerbate one another and no longer be considered to be mild with regard to impairment and may be more likely moderate or even severe. This is one of many problems when treating co-existing disorders in adolescents.
Oftentimes it is difficult to determine which mental illness has a greater effect on the client. This is of a great concern if medications are prescribed: to what effect will the medication have on the other illness, and what about the withdrawal symptoms of a dependent or abuse? Another concern is that of the hormonal changes naturally occurring within adolescents. This can complicate the diagnosis process thereby impeding the appropriate clinical treatment for the client. Also, there is a great debate as to what kind of treatment a client who abuses alcohol and drugs should receive. There is often disagreement between mental health clinicians and substance counselors regarding the type of services dually diagnosed clients should receive.
This debate often polarizes the treatment system. The mental health counselor might suggest that the psychological disorder should take precedence since it probably exists before the alcohol and drug abuse. On the other hand, the alcohol and drug counselor might suggest that stopping all alcohol or drug use is the answer and that also includes no doctor prescribed medications. Thereby, any attempt for a client to seek treatment for both disorders concurrently rarely exists and not because the different counselors do not think the other style is not valuable; rather they simply cannot work out of the same office. And so it is, the client is left with a decision to choose either one narrow treatment approach or the other. PURPOSE OF THE STUDY The purpose of this research is to investigate a proposal that dual treatment approaches may be more effective than one used alone in the clinical treatment of clients who are dually diagnosed, especially adolescents.
By not denying either disorder we can employ a humanistic treatment approach and address both disorders concurrently. Delaying the treatment of one psychological disorder only prolongs and may exacerbate the symptoms of that disorder. Therefore, what are the differences in treatment outcomes of dual diagnosis patients who receive substance abuse treatment alone compared to dual treatment modality addressing both substance abuse and other psychological disorders? Two treatment groups will be comprised of adolescents that are dually diagnosed with a mental illness and a alcohol or drug disorder. One treatment group would receive mental health and alcohol / drug treatment while the other group would only receive alcohol / drug treatment. The research design is a randomized experiment that will examine a dual diagnosis group receiving both psychodynamic cognitive behavioral intervention and treatment for substance abuse compared to a dually diagnosed group that only receives alcohol and drug treatment.
The aims of the evaluation are to investigate effective treatment approaches for co-existing disorders within the adolescent alcohol and drug population. Also to determine treatment options for those who are participating with the case management and other drug treatment and support interventions provided within the research study. Thirdly to measure immediate and long-term treatment outcomes achieved by clients who have received mental health and alcohol and drug services. Lastly to gain a greater understanding of the relationship between co-existing disorders and the adolescent populations ability to make changes cope without the use of alcohol or drugs.
Methods The method employed is to identify and monitor the treatment provided to participants whom have symptoms of a dual disorder the methodology is based on an action research approach. An approach of self-reflective cycles of planning, acting, observing and reflecting on the research will occur. Regular meetings will be held with primary case managers to discuss processes and progress within the assessments. A journal of discussion will be recorded and key themes emerging requiring broader consideration and action beyond the individual agency level will be tabled for discussion with other local adolescent alcohol and drug treatment providers. PARTICIPANTS The participants will be minority adolescents ages 13 - 17 years old.
All participants are mandated by the courts to seek treatment. All participants in the research study are volunteers. The number of subjects screened will depend upon the length of the study. The study will include various ethnic and racial minority groups. Both male and female subjects will be assessed. The research study will use materials that the San Diego County classifies as mental health forms such as a family history sheet.
The assessment tool used in the study is the Practical Adolescent Dual Diagnosis Inventory (PADDI), and each participant will receive a clinical interview with a qualified staff. The research study participants will complete the Practical Adolescent Dual Diagnosis Inventory (PADDI) within 2 months of entering the program. The family history sheet will be completed by the parents of the adolescent before participant is admitted to the program. The clinical interview will take place within 3 months of the participants enrollment into the program. At exist / case closure participant will receive an exit interview.
The research studys outcome indicators will fall into the following domains: reduced substance abuse indicators Reduces high risk behavior indicators Improved physical health indicators Improved social functioning indicators Improved emotional and psychological well-being indicators Data Analysis Reduced substance abuse indicators as evidence by number of DUI arrests, number of arrests for AOD incidents, number of hospitalizations, disciplinary actions related to AOD. The reduction in high risk behaviors are evidence by arrests for teen violence, gang activity, school disciplinary actions related to bullying and fighting. Improved physical health indicators are evidence by increase in weight, energy levels, reduced risk of developing depressions, reduced levels of anxiety, increased appetite. Improved social functioning indicators are evidence by reduced average daily absenteeism rate, average daily truancy rate, reduced tendency to isolate, increased family communication. Improved emotional and psychological well-being indicators are evidence by reduced distress and worry, reduced negative emotional aspects, improved social environments, and reduced cognitive distortions. ETHICAL ISSUES Ethical dimensions pertaining to this study have been fully considered.
As it relates to issues of confidentiality: the confidentiality of all data collected will be guaranteed and these issues will be discussed with participants prior to the interview, the use of non identifiable codes will be used on all forms and only coded information will be given to evaluators, hard copy data collected will be transferred and stored on the computer and in a locked filing system in the researchers office (Aliya Fonseca). This information will only be able to be accessed by the research team. Responsibility for the security of confidential data will rest with the principle researcher Aliya Fonseca. Lastly, data will be held for sufficient time to allow reference.
It is recommended that the minimum period of retention is at least 5 years from the date of publication. As for informed consent: the provision of information pertaining to the study will be given to the client in both a verbal and written format. At this time the participant will be informed that their participation is entirely voluntary. Additionally written informed consent will be obtained from each participant prior to their participation in the study. Other issues that will address confidentiality are: publication of findings will only include non-identifying information, case managers will adhere to their agency policies and guidelines related to work practices and duty of care. Furthermore, interviews will be conducted in a safe and appropriate location agreed to between the interviewer and participant.
Interviews will not take place if clients appear intoxicated and / or unable to answer questions in a coherent manner. The dissemination of our research findings of this study will be firstly disseminated to case managers, workers and participants of the study. Findings will also be disseminated more broadly to San Diego County adolescent alcohol and drug treatment providers. It is anticipated that the information obtained from the study will inform policy direction and future planning and work undertaken by service systems working with adolescents experiencing co-existing symptoms in recovery treatment facilities.
References Bukstein O, Kaminer Y. (1994) The nosology of adolescent substance abuse. Am J Addict. 3 - 13 D eMilio L. (1989) Psychiatric syndromes in adolescent substance abusers. Am J Psychiatry. 146: 1212 - 1214 McLellan T, Demo R. (1993) Screening and Assessment of Alcohol and Other Drug-Abusing Adolescents. Rockville, MD: US Dept of Health and Human Services Treatment improvement protocol (TIP) series.
Substance Abuse and Mental Health Services Administration, Center for Substances Abuse Treatment. DHHS Publication No. (SMA) 93 - 2009 Miller WR, Rollnick S. (1991) Motivational Intervening: Preparing People to Change Addictive Behavior. New York, NY: Guilford Press Miller NS, Fine J. (1993) Current epidemiology of comorbidity of psychiatric and addictive disorders. Psychiatry Clin North Am. 16: 1 - 10 Stowell RJ, Est roff TW. (1992) Psychiatric disorders in substance abusing adolescent inpatients: a pilot study. J Am Acad Child Adolesc Psychiatry. 31: 1036 - 1040
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Research essay sample on Substance Abuse Psychological Disorders
