A Model Curriculum for Substance Abuse Education in Child and Adolescent Psychiatry Training Programs JAMES A.HALIKAS,M .D .

Abstract. Child psychiatry training recognizes substance abuse as a problem requiring an educ ational effort to provide fellows with adequ ate clinical skills to manage these patients. The components of a substance abuse education al module which may be integrated into existing child psychiatry fellowships are presented , with a discussion of practical problems raised by the expansion of child psychiatry into this neglected area. J . Am. Acad. Chi/dAdolesc. Psychiatry , 1990,29,5:817-820. Key Words: model, child, substance abuse, curriculum.

Within the field of child and adolescent psychiatry, little attention has been devoted to the substance abuse aspects of adolescents seeking psychiatric assistance . Rather , substance use has been seen in the context of one of several possible acting out behaviors prompted by underlying psychopathology. However, the impact of substance abuse as a complication of any primary mental health problem faced by a child or adolescent is often significant and may be the cause of symptomatology mimicking other diagnoses, such as depression (Morrison and Smith, 1987). Stefanis and Kokkevi (1987) , in a study of 11,058 young Greek adolescents , found a progressive increase of depres sive mood levels proceeding from nonusers to substance users , suggesting a link between depressive mood and substance dependence. The interaction of early onset substance abuse and psychiatric problem s, and the causal relationship between them , remain to be elucidated at a research as well as clinical level. Practicing child psychiatrists are therefore faced with complex diagno stic and treatment questions for which they may be unprepared. There is a consensus among researchers that the cause of substance abuse in children and adolescents is unknown (Newcomb et aI., 1986; Bailey , 1989). There appear , however , to be a number of risk factors that predispose adolescents to abuse substances: family history (Schuckit, 1983), personality traits such as low self-esteem, anxiety , and lack of control (Carroll , 1981; Kandel et aI. , 1978; Kandel , 1981) and environmental and social factors (Kellam et al. , 1982) resulting from parental (Kandel, 1974; Hartocollis, 1982) and peer drug use (Semlitz and Gold, 1986). The unique aspects of substance abuse in children and adolescents require assessment and management which differ from the adult model. In adults, one measure of dependence is continued use of a substance despite adverse consequences. "Adverse consequences" to the adolescent are more likely

AcceptedApri/20,1990 . Dr . Halika s is Professor of Psychiatry, Director ofResiden cy Training, Director ofChemical Dependency Treatm ent , University ofMinne-

sota . Reprint requests to Dr.Halikas , Department ofPsychiatry, University ofMinnesota, Box 393 Mayo Mem orial Bui/ding, 420 Delaware Street S. E., Minneapolis , MN 55455. 0890-8567/90/2905-0817/0$2.00/0 © 1990 by the American Academy of Child and Adolescent Psychiatry.

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to occur in school, family life , and relation ships with peers than in adult areas such as the workplace. There is clearly a need for training in substance abuse issues specific to the concerns and development of adolescents. There has been some progres s towards a clinical assessment scale specific to adolescent drug use . Halikas et al. (1984) developed a scale that translated DSM-III symptoms into three life areas of concern to adolescents: psychosocial problems, biomedical problems, and school problems. In a study of 1,185 adolescents , those who qualified for a diagnosis of alcohol abuse and those who did not were successfully identified (Halikas et al. , 1984). Because of their brief time course of use, adolescents do not typically display physiological withdrawal symptoms . Thus , it is difficult to objectively discriminate between substance abuse and substance dependence. Of substance abusing adolescents, only 6% to 10% meet criteria for dependence (Wheeler and Malmquist, 1987) , The drug abusing adolescent population is heterogenous, requiring multidimensional treatment measures. Adolescents presenting for treatment are likely to have multiple problems, including depression, conduct disorder, past legal problems, and family difficulties (Hoffman et aI. , 1987). Furthermore, insight into substance abuse is confounded in the treatment of adolescents who often do not recognize the consequences of their actions and are still in the process of shaping their values and individuality. At this immature stage , an adolescent may have coping behaviors which would differ significantly from his adult behaviors (Blum, 1987) . In the short run , group therapy treatments appear to be effecti ve, as adolescents are responsive to the support and confrontation of peers (Wheeler and Malmquist, 1987). Much clinical experience has been obtained in the last decade in the treatment of substance abuse problems in adolescents , whether they are considered as primary illnesses separate from any psychopathology, or as concomitant problems requiring additional attention. Considering the high incidence of current substance use among children and adolescents seeking mental health services, it is appropriate that child psychiatrists be knowledgeable and comfortable in the management of these youngsters. This report presents a model substance abuse educational curriculum outline and summarizes relevant issues to be considered in initiating new educational programming attempts .

HALIKAS

Existing Models In a 1987-1988 survey, an identifiable substance abuse educational component was found in 26 child and adolescent residency programs. For most, this consisted of a series of lectures, with or without a formal curriculum. Eleven offered a clinical experience only as an elective. Where an obligatory clinical experience exists, the three existing models are the one week immersion model, the part-time model, and the full-time model. The immersion model was a 1- to 5-day block clinical experience at an adolescent drug treatment program. Such an experience is best managed after a basic body of information has been communicated by readings and lectures. Such an experience is limited by the inability to manage cases directly. Such visitors are observers who sit in on group sessions and participate in clinical interviews that are, at best, consultative, rather than central to the care of the patient. The part-time model suggests a regular block of time on a weekly basis, ranging from 2 hours to 1 day for several weeks or several months. In some adolescent substance abuse treatment programs, the treatment format may be quite specific and structured, so as to allow for a particularly significant therapeutic event to be captured on a regular basis. If, for example, residents spend Monday afternoon and Friday afternoon at a treatment program over a period of 2 to 3 months, they are likely to see the evolution of particular patients and be able to monitor their progress fairly carefully, especially if those time segments encompass group therapy sessions that review weekend activities and progress during the week. Anything briefer than a half-day segment probably offers little more than a series of educational seminars given by members of the on-site treatment team. The full-time block rotation, as currently available, includes rotation of 1 to 3 months as a member of a treatment team in an adolescent substance abuse treatment program or an adolescent dual diagnosis unit. Such a rotation provides the opportunity for a total immersion in what is currently the standard of treatment in the field, but limits the exposure of the resident to diverse treatment philosophies and treatment approaches. The educational advantage of being the directly responsible physician, of course, cannot be overstated. The practicability of such a rotation on an obligatory rather than elective basis is in doubt.

TABLE

Dependency Module

Seminar series (with readings) Alcohol/drug information base Child/adolescent Sociology/epidemiology/community/resource fact base Symptomatology/assessment/diagnosis Dual diagnosis Treatment models Aftercare/integration with larger treatment goals.

are presented, or a psychosocial model in which topics in substance abuse within the framework of various theoretical perspectives on normal and abnormal development are presented. Each child program and each group of educators should design such a series to their own specifications. Table 2 presents the second component. This is a block rotation on an adolescent chemical dependency inpatient service. It is based on the premise that either a significant part-time experience of at least half-time, or a full-time clinical experience, is necessary to learn about all aspects of patient management in a substance abuse treatment context and to follow at least a few patients from beginning to end of treatment. A 1- to 2-month minimum educational experience is recommended. Within that time frame, the child resident has the opportunity to work up patients as their primary therapist and physician, interview others as a consultant diagnostician and contributing member of a therapeutic team, and observe all patients being treated in the context of an ongoing treatment program. The resident will participate in the group therapy experience, learn to do individual counseling, and participate in family therapy activities. Watching the evolution of patients from admission to discharge provides a significant and memorable learning experience with substance abuse patients, just as with all other psychiatric patients. In addition, the full-time block rotation allows the child resident to identify important issues in the field and important limitations in the current state of our treatment knowledge.

TABLE

Components of a Substance Abuse Educational Module Which May Be Feasible There are three components to a potentially practical substance abuse educational experience for child psychiatry residents that can be incorporated sequentially or simultaneously into an existing curriculum. The first component is a seminar series consisting of 6 to 12 sessions which would include readings and which would be ideally placed in the first half of the first year of the fellowship. Table 1 presents examples of one organizational matrix for such a seminar series. It is based on the traditional medical model of basic information, description, diagnosis, treatment, and aftercare. Another approach might be developmental and chronological, where, within each life segment, various aspects of substance abuse 818

1. First Components ofa Theoretical Chemical

2. Second Component ofa Theoretical Chemical Dependency Module

Block rotation on an adolescent chemical dependency inpatient service Part-time or full-time Performing workups Doing differential diagnosis Participating in group process Following evolution of patients Identifying issues Antipsychiatric bias Procrustean bed of chemical dependency treatment Limitations of traditional psychiatric model Working with chemical dependency Impaired families Community-school--court interface

l.Am.Acad. Child Adolesc.Psychiatry, 29:5, September 1990

CHILD PSYCHIATRY SUBSTANCE ABUSE CURRICULUM TABLE

3. Third Component ofa Theoretical Chemical Dependency Module Ongoing experience

A chemical dependency consult liaison service to staff all child/adolescent cases having chemical dependency component with child resident and staff Contact with child/adolescent emergency service seeing child/adolescent drug alcohol emergency patients Case presentations to larger division, integrating chemical dependency child/adolescent cases into mainstream of child psychiatry care Ongoing long-term case management with significant chemical dependency component and focused dual supervision

The resident will learn to work with the substance abuse treatment team in the most democratic team setting that he or she is likely to encounter. The trainee will learn to work with significantly impaired, multiproblem families and will interface with school and court settings. The resident will learn the limitations of traditional psychiatric therapeutic models and, simultaneously, learn of the limitations and antipsychiatric bias ofthe substance abuse treatment model. Thus, a full-time rotation provides both an effective learning experience to extend the trainee's knowledge base and an important social learning experience for dealing with allied health professionals in a significant therapeutic modality. The third component of a realistic substance abuse treatment module is possibly the least obvious and yet probably the most important learning experience available for the child resident. This module is that of ongoing experiences during the entire residentship. It provides for a concurrent focus on substance abuse issues that occur during the course of management of other psychiatric patients. Table 3 summarizes the components of this module. A functioning substance abuse treatment service can provide most of these experiences, which are of a tutorial and modeling basis. Often, however, substance abuse divisions limit themselves to adults and senior adolescents without providing services for children and young adolescents. This is an educational as well as a clinical limitation. The ongoing experiences of importance to a child resident in the field of substance abuse include the availability of consultation for all of their patients no matter what the age and what the service. This stimulates the residents to assess all patients comprehensively and recognize the interplay of substance use with other psychopathology. These consultations should provide a staffing component with follOW-Up that involves the child resident and possibly the child service staff psychiatrist as well, so that collaboration and consultation becomes a routine professional behavior. The child resident should have the opportunity to see child and adolescent substance abuse emergencies in an emergency room context. This may occur as part of the block rotation in a substance abuse treatment program. It may occur by taking home call and coming into the emergency room if called upon by the adult psychiatry junior resident taking in-house call. Here, the child resident is consultant and teacher as well as student. The backup of an addiction medicine faculty group for such cases is essential. A third component of the ongoing J.Am.Acad. Child Adolesc, Psychiatry, 29:5, September 1990

experience is the integration of substance abuse patients into the clinical material seen in child case conferences and case presentations throughout the residentship. Thus, the presence of a separate training module in substance abuse should not either preclude the discussion of substance abuse issues in youngsters with multiple psychopathology, nor should it preclude the presentation of such youngsters at larger case conferences. Indeed, having available expertise should stimulate recognition and interest within the larger child division. A fourth component is the provision of long-term case management of patients with a significant substance abuse component and the provision of focused dual supervision. Beyond recognition of the presence of substance abuse issues as a significant component in many youngsters' life problems, a willingness to simultaneously treat all aspects is needed. The primary treater-in this case the child psychiatry resident-must be the final pathway for treatment, but the resident can receive supervision simultaneously from experts in child psychiatry and in substance abuse or, ideally, from a child psychiatrist who has a special interest and experience in substance abuse. Such dual supervision would help the resident understand and appreciate the nature of the substance abuse and its relationship to the other psychopathology in treatment. In this instance, as well, having the availability of dual supervision will stimulate identification of dually disabled adolescents and alert staff as well as residents to the need for simultaneous treatment. Practical Issues Several interlocking issues pose challenges to the development of such a substance abuse curriculum. Child residencies have only 2 years in which to train child psychiatrists. The time within current residentships is filled. Something must be bumped in order to find time to teach substance abuse. What should get compressed or eliminated? In all aspects of medical education having the specialist available often determines how much time is spent teaching the topic. Thus, finding time for substance abuse education in the curriculum may be contingent on finding someone on the clinical or full-time faculty with an interest in teaching the subject and with some influence on the child psychiatry curriculum. External pressure such as heightened awareness, dramatic cases on the service, pressure from the trainees, pressure from concerned families, etc., also may have some role in moving programs towards development of such a curriculum. The content of the curriculum must be designed by the faculty responsible for its presentation. Materials are available that can be used for a starting point. Societies such as AMERSA (the Association of Medical Education and Research in Substance Abuse) and ASAM (the American Society of Addiction Medicine) both have developed model curricula for substance abuse, in general, and have considered particular child and adolescent aspects. The American Psychiatric Association reviewed curricula in use in adult programs and has materials available that would be of assistance. The National Institute on Drug Abuse has developed curriculum materials that can be used to provide an overview ofthe field as well. 819

HALIKAS

Some substance abuse education occurs in adult residency training. This is neither focused on children and adolescents nor presented generally by experts in child and adolescent psychiatry. Such an important component of dealing with children and adolescents cannot be given over to the adult overview. A comprehensive review of the field of child psychiatry substance abuse diagnosis and treatment is now available (Halikas, 1990). Additionally, a recent Pediatric Clinics ofNorth America (1987 , Vol. 34), provides excellent material, and a comprehensive review of the literature has been published (Bailey, 1989). Funding support for stipends and for programmatic aspects needs to be addressed. Stipends can usually be negotiated with local specialty treatment programs if the decision is made to rotate residents through these programs. Some services for that stipend must be negotiated. Should a division of child psychiatry decide to focus treatment efforts on the dually disabled adolescent or on a substance abuse treatment program in-house, the funding for programmatic staffbeyond the resident and the staff physician needs to be developed. This is a large project. In practical terms, rotation through affiliated programs is the most likely course, at least in the short term. Such a rotation through affiliate programs will highlight political issues and sensitive field issues. The substance abuse treatment field in general has been hostile to psychiatry because of its perception that psychiatry fails to identify substance abuse as a unique group of illnesses. Psychiatry is also perceived as a "Johnnie come lately," jumping in now when there seems to be sufficient funding for the care ofthese individuals. In addition, the psychiatrist in the field of substance abuse is least likely to personally be a recovering physician. As such, he or she is often perceived as not having sufficient zeal for the Alcoholics Anonymous 12 Step recovery philosophy. Also, psychiatry is perceived as being soft on issues of total abstinence versus sporadic relapse. Still another issue identifies addiction medicine as a separate field with a rather large new funding base which psychiatry seeks to exploit. Another issue dividing the field is the perception that psychiatrists are likely to prescribe psychotropic medications for these chemically dependent individuals, thereby violating tenets of total abstinence of all mood altering substances. From the perspective of psychiatry, the substance abuse field fails to recognize the relevance of comorbidity and the need for prudent use of nonaddicting psychotropics such as antidepressants, neuroleptics, lithium, and carbamazepine. These and other issues trouble the relationship. Thus, covert hostil-

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ity may be found at seemingly cooperative affiliate programs. These are issues which need to be worked through on a local basis and which need to be shared with the residents as part of their own education for ultimate practice. All of these difficulties present a challenge to the child psychiatry division that seeks to incorporate a substance abuse curriculum into its current residentships and presents an exciting opportunity to expand the education of the beginning child psychiatrist. References Bailey, G. W. (1989), Current perspectives on substance abuse in youth, l.Am.Acad. Child Psychiatry, 28:151-162. Blum, R. W. (1987), Adolescent substance abuse: diagnostic and treatmentissues. Pediatr. Clin.NorthAm. 34:523-535. Carroll, J. K. (1981), Perspectives on marijuana use and abuse and recommendation for preventing abuse. Am. l. Drug Alcohol Abuse, 8:259-282. Halikas, J. A. (1990), Substance abuse in child and adolescents, Chapter 13, In: Psychiatric Disorders in Children and Adolescents, eds. B. D. Garfinkel, G. A. Carlson&E. B. Weller. Philadelphia: W. B. Saunders Company,pp.210-235. - - Lyttle, M. D., Morse, C. L. & Hoffman, R. G. (1984), Proposed criteria for the diagnosis of alcohol abuse in adolescents. Compr. Psychiatry, 25:581-585. Hartocollis, P. C. (1982), Personality characteristics in adolescent problem drinkers. J, Am. Acad. Child Psychiatry, 21:348-353. Hoffman, N. G., Sonis, W. A. & Halikas, J. A. (1987), Issues in the evaluation of chemical dependency treatment programs for adolescents. Pediatr. Clin .NorthAm., 34:449-460. Kandel, D. B. (1974), Inter- and intragenerational influences in adolescent marijuana use. lournalo/SocialIssues,30:107-135. - - (1981), Frequent marijuana use: correlates, possible effects, and reasons/or using and quitting. Paper presented at American Counsel on Marijuana Conference, "Treating the Marijuana Dependent Person," Bethesda, MD. --Kessler, R. C. & Margulies, R. Z. (1978), Antecedents ofadolescent initiation into stages of drug use: a developmental analysis. In: Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues, ed. D. B. Kandel. Washington, DC: HemisphereJohn Wiley. Kellam, S. G., Brown, C. H. &Fleming,J. P. (l982),Eariyantecedents ofteenager substance use: implications for prevention research. SubstanceAbuse, 4:1-11. Morrison, M. A. & Smith, Q. T. (1987), Psychiatric issues of adolescent chemical dependence. Pediatr. Clin. NorthAm., 34:461-480. Newcomb, M.D., Maddahian, E. & Bentler, P. M. (1986), Risk factors for drug use among adolescents. Am. J, Public Health, 76:525-531. Schuckit, M. A. (1983), Alcoholic men with no alcoholic first-degree relatives. Am.l. Psychiatry, 140:439-443. Semlitz, L. & Gold, M. S. (1986), Adolescent drug abuse. Psychiatr. Clin.NorthAm., 9:455-473. Stefanis, C. N. & Kokkevi, A. (1987), Depression and drug use. Psychopathology, 19:124-131. Wheeler, K. & Malmquist, J. (1987), Treatment approaches in adolescent chemical dependency. Pediatr. Clin. NorthAm., 34:437-448.

l.Am.Acad. Child Adolesc. Psychiatry, 29:5, September 1990

A model curriculum for substance abuse education in child and adolescent psychiatry training programs.

Child psychiatry training recognizes substance abuse as a problem requiring an educational effort to provide fellows with adequate clinical skills to ...
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