The ASALA Citar Teatrane Csr for Introduction to the Levels of Service ‘Similar to earlier editions, The ASAM Criteria describes treatment as a continuum marked by four broad levels of service and an early inter- vention level. Since the First Edition of the crite- ria (1991), Roman numerals have been used to en peers Bee | roe Peay Ea Eatyotenentin Outpatient Sevices Intensive Outpatient Series Parl Hosptlzaton Series Cinkaly Managed Low intensity Rsidental ences "tn il ofa not designated for Abolescent populations Cnc Managed Meum intensy Resdental Series Metical Monitored High ntensty Inpatient Services Medical Maraged neni np ent Serves cas not species here lor adolescent populetes though infomation may be ound in ssson fea srces sve, Suowance Seated and Co Occuring Condions> Identify each level of care. But in the 21* century, when technology allows for immediate electronic dissemination of Information worldwide, Roman. numerals are especially limiting. Thus, with this Eatyinenenion| Outpatient Series Inte Outpatient Serdces Paral Hospaltion Seevces ‘lnc Managed ow nny Residertial Series Cincy Managed Populaon pectic Hh nen Reiser Sees inal Managed High Intensity esiderbal Series Meal Montored ite sive lnpatent Senices eda Managed inter sive apa Series pli reamert Progam (evel) edition, regular Arabic numerals will be used to describe all levels of care (Levels 0.5 through 4). easiest and education oa india vo de ot meet agree fsb seus dsorer esthan 9 hour ef serviclne (ade than bourne adlecens freer or tween eshancenenttepiedstaages ‘exer hors serve ad 6 noe bare alent tat mah ensoaliasabty 20 mor house! sevcvee or muti menses notequng 28-hour are ‘Whow sracre wih aati tne peso Shows ical sence 2Wheurcace wihied ours tsar imide ner ange: esi terse ie and rep tenet tas with ogo coher nian male use ‘ul aoe miu a henpexiccommuniy haste with tne ounseoto sie ‘ulema eign ger and prepare ‘or ouptrt anton le sleme and se ful ave rile arene comunity ‘hour musing ae wth physio abit festa problems in Dimensions 1,213. ‘ghousdy oun aby ‘shou nusing cae and daly phypican care ferseve, usable protlensinDimensos 1, 2013. Counseling alable tw engage pater, invement Dai eal ines wel op got edition ad cousin zaiblta mata ralidimensionasaiylorhse with sere pid we deericon The ASBIN Esserdials of Addiction Madicrse, aM Edd Laces. Boing Keine timeby Ieells By emnery Placement Criteria and Strategies for ] 7 PU Cera aa eee tut 1 | s) Matching Daas ary Ithough the fields of adolescent treatment in general and adolescent treatment out- comes research in particular are still in their early suages, recent progress has been consid- erable. Over the past 25 years, much has been leamed about the effectiveness and limitations of current adolescent treatment methods and programs, Reviews of the published lterature have shown favorable outcomes up to 1 year alter treatment and beyond, across various modalities and levels of care. Lite is known about the differential effectiveness of vatious treatment strategies, intensities, and treatment program components DEVELOPMENTAL CONSIDERATIONS IN ADOLESCENT PLACEMENT (One ofthe most important advances in the field of adolescent treatment is the articulation of approaches that are developmentally specific to the adolescent population. These respond to the principle that adolescents must be approached diferently from adults because of diferences in thei levels of emotional, cogaitive, physical social, and moral development. Substance use can prevent a young person from completing the maturational asks of adolescence, which involve formation of personal relationships, acquis! tion of social skills, psychologic development, ‘identity formation,” individuation, education, employment, and family role responsibilities. ‘Adolescent treatment thus often requires habili- tative rather than rehabilitative approaches, emphasizing the acquisition of new capacities rather than the restoration of lost ones. ‘Among adolescents, there may be special populations to take into consideration. Younger adolescents havea very narrow view ofthe worl, 594, with little capacity to think of future implica tions of present actions. Some adolescents may adopt a pseudomature ("street-wise") posture, despite their overall immaturity. Adolescents who live in a chaotic family system may have difficulties with normative expectations of behavioral contingency. Adolescents who have various cognitive difficulties may be delayed or impaired in acquiring abstract thinking, In general, for a given degree of severity or functional impairment, adolescents require greater intensity of treatment than do adults ‘This is reflected in clinical practice by a greater tendency to place adolescents in more intensive levels of cae. The mixed features of both adolescence and adulthood for young adults or transition age youth require a special approach. Some provid- ers have begun to develop specialized program- ‘ming for this group and its unique clinical needs. Eventually, the separation of a third category (adolescent, adult, and transition age youth) of developmental programming may become standard. The tensions inherent in their tran- sition often require a balancing act, especially between emerging independence and persistent dependence. For example, issues of confiden- ality versus open sharing of information with parenis/caregivers are common. Other common issues include financial support, shared liv- ing environments with parents, and extension of standard insurance coverage under parental policies until age 26 with the Affordable Care Act. These tensions and the dynamic interplay between youth and parents are dramatized in the caricatured quotes: “I'm old enough to take care of myself...” versus “You may think you're all grown up, but as long as you're living under my roof...”CHAPTER 105 « PLACEMENT CRITERIA AND STRATEGIES FOR ADOLESCENT TREATMENT MATCHING 595 ‘THE ASAM CRITERIA ‘The American Society of Addiction Medicine’ (ASAMS) ASAM Criteria 3rd ed. is a clinical guide that has been widely adopted to assist in ‘matching patients to appropriate treatment set- tings. In contrast to previous editions that had separate sections for adolescents and adults, this edition has an integrated approach that emphasizes common features and then calls special attention to those features that dilfer for adolescents. The criteria rest on the concept of enhancing the use of multidimensional assess- ‘ments in placement decisions by organizing the assessment of the substance-using adolescent {nto six dimensions and specifying appropriate placements according to gradations of problem severity within each dimension, Assessment-Based Treatment Matching and Clinical Appropriateness The ASAM criteria use decision rules to guide placement in specified levels of care, which exist along a continuum, These also attempt to standardize some of the program specifica- tions for each level of care. The principal goal of the ASAM criteria is to facilitate the process of matching patients in need of treatment for substance use disorders (SUDs) with appropri: ate treatment services and settings to maximize the accessibility effectiveness, and efficiency of the treatment experience. The reality of limited availablity ofservicesis, ofcourse, a major prob- Jem, panicularly in the treatment of adolescents. The ASAM Criteria outline a full range of treatment services appropriate to the needs of all druginvolved adolescents, whether they are privately insured, publicly insured, under- insured, or uninsured. Although they may not have access to it, many marginalized or home- Jess adolescents and those in the juvenile justice system may need an even broader continuum of services than do those with greater resources. In general, adolescents with fewer supports, less eiliency, and lower levels of baseline function- jng may need a higher intensity of services and Tonger lengths of service at all levels of care than do those with the benefits conferred by eco- ‘nomic advantage. Placement and Treatment Considerations by Assessment Dimension 1: Intoxication and Withdrawal Potential Severe physiologic withdrawal and the need for its management are seen less frequently in ado- lescents than in adults, given typical patterns of use and duration of exposure. Therefore, the pro- vision of detoxification as « stand-alone service is less common and less needed with adolescents versus adults. Services to manage the withdrawal in a setting separate from other treatment ser- vices for adolescents with SUD are also clinically undesirable because of the developmental issues involved inthe care of adolescents. This phase of treatment frequently requires an initial intensity to establish treatment engagement that will lead to the next steps of recovery. Dimension 2: Biomedical Conditions and Complications ‘Although the medical sequelae of addiction gen- erally are not as common or as severe in ado- lescents as in adults, these sequelae certainly reed to be considered in treatynent placement decisions. Some of the acute and subacute medi- cal complications of substance use include rau matic injuries associated with any substance intoxication, respiratory depression and death caused by opioid overdose, acute alcohol pol- soning, hypoxia and cardiac arshythrala from inhalants (‘sudden snifing death syndrome"), complications of injection drug use such as hhepatiis C, cellulitis and endocarditis, STDs, gastritis caused by alcohol use, and exacerba- Uion of reactive airway disease caused by smok- {ng marijuana, Another notable area of medical complication in adolescents is the exacerbation of chronic illness (such as diabetes, asthma, ot sickle cell disease) that results from impaired self-care and poor compliance with indicated ‘medial treatments ‘The special needs and medical vulnerabilities of pregnant substance-using teenagers require particular care in selecting treatment services. Overall, the need for contraception and other medical prevention and treatment services related to sexual behaviors in drug-involved adolescents cannot be overemphasized. —— oc eemmameel |596 SECTION 13 « CHILDREN AND ADOLESCENTS. Dimension 3: Emotional, Behavioral, and Cognitive Conditions and Complications Drug-involved adolescents typically demon- strate a very high degree of co-occurring psy- cchopathology, which frequently does not remit with abstinence. Many experts estimate that rates of psychiatric comorbidity, or dual diag- nosis, are higher in adolescents than in adults Many issues should be taken into consideration 1. Previously diagnosed psychiatric tllnesses High rates of depressive disorders, typically characterized by irritability, moodiness, averreactvity, anxiety, rather than sadess 3. Subsyndromal symptoms such as mood Unbility or anger issues 4. The nonspecific features of smmature or impaired executive functioning including ‘impulsiveness, explosiveness, por alfective sel-regulation, or poor strategic planning 5. Cognitive functioning and problems such 4s borderline intellectual functioning, fetal alcohol effects, assorted attentional deficits, or learning disorders 6. Complications of substance use (such as ‘natijuana-induced amnestic disorder) Behavioral issues 8. Adolescent learning in normal adolescent development as well as in those with the delayed development and immaturity that often accompanies drug use and co-occur- ring psychiatric disorders Dimension 4: Readiness to Change Placement decisions based on dimension 4 will fnclude consideration of whether the adoles- cent (and related systems, such as the family) is in the “precontemplation,” “contemplation,” “preparation,” or “action” stage of change. Motivational interviewing and other motiva- tional enhancement techniques have formed the basis ofa variety of intervention models at vari- ous levels of care, including early intervention and outpatient treatment. Dimension 5: Relapse, Continued Use, or Continued Problem Potential Dimension 5 entails an estimation of the Likelihood of resumption or continuation of substance use. Four subdomains have been pro- posed as issues to take into consideration: (1) historical pattern of use (including amount, frequency, chronicity, and treatment response), (2) pharmacologic response to the ellecs from particular substances (including positive rein- forcement such as pleasure with use and crav- ings and negative reinforcement such as relief from withdrawal or other negative experiences), (3) response to external stimuli (including reac tivity to environmental wiggers and acute or chronic stress) and (4) cognitive and behavioral vulnerability and resiliency factors (including traits of impulsivity passivity, locus of control, and overall coping capacities). Response to past treatment also may be a way of using indi- vidualized treatment effectiveness as a guide to placement. Dimension 6: Recovery/Living Environment Dimension 6 aims to assess the ability of the adolescents home environment to support or impede treatment and recovery. For adoles- cents, the most important features of the recov- ery environment generally involve family and peers There is an acute shortage of availability of services that provide recovery environment suppor for youth. These structured, protective living environments are frequently vital to sup- port ongoing treatment that might be integrated into the living environment itself or more com morly coordinated with programming offsite. Frequently, these environments serve the func- tion of a supervised context where adolescents can sustain and rehearse therapeutic gains initi- ated at a more intensive level of care. This need for step down, lower-intensity residential sup- port is perhaps even more vital in the contin- tuum of care for youth than for adults because of their lack of independence and reliance on the support or partial support of caregiving adults. For younger adolescents, these programs would typically be Level 3.1 (see below for descrip- tion of that level of care), often group homes or similar programs, For young adults, these pro- grams could also be Level 3.1. But there is also 4 need for less intensive Recovery Housing pro- ‘grams, with more supervision than typical adult style self-organized sober housing (e.g., Oxford Houses), or adult style Recovery House board- ‘ng houses that have minimal supervision, but pethaps with less intensity than the typical 3.1 or halfway house CHAPTER Placems Conside The adol 2R are si and end documen Level Early int explore a cor risk fa: stages of, the adole ful conse: use escal dence. Le 2 variety medical juvenile the influ interventi preventio Populatio Level 0.5 ing paren adolescen problems. ate for ad: of an SUC Level 1:( Ouipatien quently us level of ce ity of ill a "step-do has made of care, fe tial progrs tient creat therapeut! own hom fors ean b Level 2: b Partial Hi Tatensive 2.1) gener programm grams.” Av school hov‘eatment response), to the effects from ding positive rein- with use and crave nent such as reli sative experiences), uli (including reac- ‘gers and acute or itive and behavioral factors (including y, locus of control, ies). Response to way of using indi- ness as a guide 19 ing Environment the ability of the tent to support or wery. For adoles. tures of the recov- volve family and € of availability of very environment setured, prosectve tently vital to sup- ght be integrated tself or more com- gramming offsite 1ts serve the func where adolescents spentic gains inii- of care. This need ¥ residential sup- ital in the contin- adults because of ad reliance on the caregiving aduli, « programs would slow for descrip- nn group homes or adults, these pro: But there is also very Housing pro- than pica dul sing (eg, Oxford xy House board- \ supervision, but an the typical 3.1 (CHAPTER 105 » PLACEMENT CRITERIA AND STRATEGIES FOR ADOLESCENT TREATME Placement and Treatment Considerations by Levels of Care ‘The adolescent levels of care in the ASAM PPC- 2R are similar to the levels of care described fand endorsed in other expert consensus documents, Level 0.5 Early Intervention Early intervention services are designed to explore and addzess the adolescents problems or rsi factors that appear tobe related to early stages of substance use. Their goal is to help the adolescent recognize the potentially harm- ful consequences of substance use, before such nse escalates into substance abuse or depen- dence. Level 0.5 services may be delivered in a variety of settings, including primary care medical clinics, schools, social service and juvenile justice agencies, and driving under the influence intervention programs. Early intervention services are intended to combine prevention and treatment services for youth. Populations that warrant special attention at Level 0.5 are the children of substance-abus- ing parents, siblings of substance abusers, and adolescents with other emotional or behavioral problems. Early intervention is not appropri- ate for adolescents who qualify for a diagnosis of an SUD. Level 1: Outpatient Treatment ‘Outpatient treatment is by far the most fre ‘quently used level of care. Itis often the initial level of care for an adolescent with low sever: ity of iliness. Level I also may be employed as 1 “step-down” program for the adolescent who has made progress at a more intensive level of care, for example, aftercare from a residen- {ial program. One of the advantages of outpa- tient treatment is the possibilty of achieving therapeutic goals in the context of the patients ‘own home environment, where new behav- fors can be practiced and solidified in rea-ife circumstances Level 2: Intensive Outpatient Treatment Partial Hospitalization Intensive outpatient programs (IOPs—Level 2.1) generally offer at least 6 hours of structured programming per week, for example, “day pro- grams.” Adolescent 10Ps generally meet after school hours. Partial hospitalization (Level 2 often have direct access to ot close =: relationships with psychiatric and me: vices. Partial hospitalization may occur <: school hours, and many programs. espes longer term, have access to educational serv {or their adolescent patients. Level 3: Residential Treatment Although earlier editions of the ASAM crite ria treated all adolescent residential treatment as one broad undifferentiated level of care, the PPC-2R divides Level Ill into three sublevels. + Level 3.1; Clinically managed low-intensity residential treatment: Programs typically pro- vided in halfway houses and group homes. offering several hours a week of low-intensity treatment sessions for adolescents who requite a longer-ierm structured safe environ- ‘ment to learn recovery skills, relapse preven- tion, and improved social functioning + Level 3.5: Clinically managed medium- intensity residential treatment: These pro- grams are designed to provide relatively extended subacute treatments with the goal of achieving fandamental personal change for the adolescent who has significant social ‘and psychologic problems or highly unstable home environments, Such programs ate char- acterized by their reliance on the treatment community a5 a therapeutic agent of change. + Level 3.7: Medically monitored high-intensity residentiaVAnpatient treatment. This level is appropriate for adolescents whose problems are so severe that they require medically monitored residential treatment but do not need the full resources of an acute care hospital or medically managed inpatient treat- rent program (Level 4). Medically monitored services are provided under the supervision of physicians who are specialists in addiction medicine. Services typically provided include medical detoxification, titration of « psycho- pharmacologic regimen, and high-intensity behavior modification. Level 4: Medically Managed Intensive Inpatient (Hospital) Treatment Delivered in an acute care inpatient setting in ‘which the full resources ofa general or psychiat- ric hospital are available, Level # treatment tends598 SECTION 13 + CHILOREN AND ADOLESCENTS to be brief, generally consisting of emergency or crisis interventions aimed at stabilization in preparation for transfer to a less intensive level of care for ongoing treatment. Linkages Between Levels of Care Issues regarding continuity of care, continuing care, and longitudinal follow-up are. critical, ‘especially for adolescents because they are so dynamic in their developmental changes and needs, The ASAM Criteria emphasize the con- cept of treatment as a dynamic, longitudinal process rather than a discrete episode of care or particular program enrollment, However. cur- tent treatment delivery systems do not generally support the necessary continuum of care. Long- term relationships with youth and families, with the expectation of accommodating dropping in and dropping out, with changing needs over time, should be standard, While the fantasy notion that patients should be expected to be “fixed! alter a discrete episode of care (e.g. esi- ential rehab) is both common and absurd in all ages, itis even more common for youth, who ate t00 often assumed to have “learned their les- son...” or ‘grown out of it.” The need for factl- itation of continuity between linked episodes of care at different levels of care based on need is vital—role induction, coordination, communi- ‘ation, warm hand-off, assertive outreach, and overlapping level of care. KEY POINTS 1. Developmentally specific and youth- friendly approaches to adolescent treatment are critical to success in the treatment of adolescent SUDs. 2. Theadolescent section of the ASAM Criteria provides a guide to assessment, treatment, placement, and treatment matching strate- ies for youth, 3. The assessment and treatment of co- ‘occurring psychiatric disorders is critical 10 ‘success in the treatment of adolescent SUDs, 4. Continuity of care, linkages between levels of care, longitudinal treatment, and moni. toring are all essential in the treatment of adolescent SUDs. 5. Promotion of family engagement, moni- toring, and supervision has high yield in the treatment of adolescent and young adult SUDs and needs to be balanced skillfully with considerations of patient confidentiality REVIEW QUESTIONS 1 2 Which of the following statements about adolescent treatment is true? AL Adolescent treatment usually requires rehabilitative rather than habilitative approaches, emphasizing the restora- tion of lost capacities, rather than the acquisition of new capacities, B. Adolescent substance use in the form of normative experimentation is frequent and often misdiagnosed as substance use disorder. There is a shortage of treat- ment capacity for adolescents because the demand created by referrals from the health care system outstrips supply C. Historically, adolescent treatment has often consisted of adult-style compo- nents without sufficient developmen- tal adaptation, attention to adolescent learning styles, or focus on youth- friendly feavures, Which of the following are important fac- tors in assessing co-occurring mental health problems (dimension 3) in youth? A. High rates of depressive disorders, typically characterized by irrtabil moodiness, overreactivity, and anxiety, rather than sadness 1B, Subsyndromal symptoms such as mood lability or anger issues C. The nonspecific features of immature or impaired executive functioning including impulsiveness, explosive: ness, poor affective self-regulation, or oor strategic planning D. Cognitive functioning and problems suchas borderline intellectual function- ing, fetal alcohol effects, assorted atten- tional deficits, or learning disorders E, Complications of substance use (uch as marijuana-induced amnestic disorder) F Behavioral issues such as disruptive behavior and peer aggression G. Allof the above CHAPTER 105 3. Which « tures of: A Whi tive: cent is be inpa B Tran tial dent WE ont requ and corr CONFID! Summary by Based on "P Margaret 8 Confidentis health care ‘underlying includean i in particule the develo and the ins‘scent and young 5 to be balanced ‘ations of patient statements about WW usually requires than habilitative ‘izing the restora- ss, rather than the rpacities, 2 use in the form of tation is frequent sed as substance a shortage of treat- folescents because by referrals from ‘outstrips supply ent treatment has dult-style compo- “ent developmen- tion to adolescent focus on youth- ate important fac- ring mental health in youth? ressive disorders, ed by irritability, tivity, and anxiety, ‘oms such as mood. ures of immature ive functioning ness, explosive: self-regulation, or "8 1g and problems ellectual function- 2ts, assorted atten- ‘ning disorders substance use induced amnestic ich as disruptive zression CHAPTER 105 « PLACEMENT CRITERIA AND STRATEGIES FOR ADOLESCENT TREA’ 3 Which of the following characterize fea- tures of adolescent levels of care? ‘A. While there is evidence for safe and effec- tive ambulatory detoxification for adult, ‘most withdrawal management fr adoles cents that requires medical intervention is best accomplished at the residential {patient level of care (Level 3.70). B. Transitional lowerintensity residen- tial settings (Level 3.1) are frequently needed following higher-intensityresi- dentiaVinpatient treatment for youth to provide continued recovery envi- ronment support for ongoing outpa- tient treatment, These settings often require more supervision, structure and higher levels of staffing than do the corresponding levels of care for adults, C. Longitudinal ‘treatment and linkages between levels of care are less smpor- tant for adolescents than for adults. Discrete episodes of cere are usually ssulfcient for most adolescents because they have high levels of tnsight and are developmentally resilient, often “grow- {ng out of" their problems. D. A,Byand C E. AandB E Band 4. The following statements about family snvolvement in treatment are true, except for: ‘A. Adolescents and young adults may some- times object inappropriately to the dis- ‘losure of information to their families ‘that might be clinically helpful to them. ENTNETCONG 599 B, Families may sometimes imappropri ately demand information about their adolescents or young adult’ treat ina way that is overintrusive. C. Out of respect for confidentiality ané emerging autonomy, it is importert that an adolescent or young adults family never be Involved in treatment ANSWERS Lc 2G 3. E 4c SUGGESTED READINGS Fishman M. Placement ereria and staegies for adoles: eat treatment matching, In Ries Ry Fein D, eds Principles of addiction medicine, 51h Philadelphia, PA Lippincott Wiliams & Wilkins 2014 Sample S, Kaden R. Motivational Enhancement Therapy tnd. Cognitive Behavior Therapy for Adolescent Cannabis. Users. Cannabis youth eatment series. Volare I. Substance Abuse Mental Healih Services ‘Administration (SAMHSA). Accessible at htp//¥oew. hestoat.org/Ut Fishman M. Placement ertra end treatment planing for ‘dolescens with substance use disorders. In: KaminerY ‘Winters K, eds. Clic manual of adlecent substance bus treament. Chapter 5. Washington, DC. American Pyehiatrc Publishing, 2010:213-192 ran M. Winsaley E, Curran E, etal Treatment of ‘picid dependence in adolescents and young aduls wih entended release naliexone: preliminary case Series and feasiiliy. Addiction 2010;105169-1676. [NIDA for teen bup-neens drugabuse gov Pastnetship for Drog-Pree Kids—Where Faris ind “Anowers, hipuinwcdrughee org CONFIDENTIALITY IN DEALING WITH ADOLESCENTS Summary by Margaret R. Moon, MD, MPH Based on “Principles of Addiction Medicine” Chapter by Alain Joffe, MD, MPH, and Margaret R. Moon, MD, MPH Confidentiality is an essential component of hhealth care for adolescents. Key principles underlying the approach to confidentiality include an intrinsic dury to respectautonomy— in particular to respect, protect, and promote the developing autonomy of adolescents— and the instrumental value of establishing an environment for care that encourages access and disclosure. While autonomy—in terms of decision: making capacity—cannot be presumed for adolescents, there is evidence that, by age 14 to 15, most children make decisions about health care issues in a manner similar to adults. contd