Crime, Violence and Managing Client and Public Safety

1
Crime, Violence and Managing Client and Public
Safety

• Michael L. Dennis, Ph.D.,
• Chestnut Health Systems, Bloomington, IL
• Part of the continuing education workshop,
  Advancing the Field of Adolescent Substance
  Abuse Treatment, Hamden, CT, April 22, 2005.
  Sponsored by the Department of Children and
  Families Substance Abuse Division. The content of
  this presentations are based on treatment
  research funded by the Center for Substance Abuse
  Treatment (CSAT), Substance Abuse and Mental
  Health Services Administration (SAMHSA) under
  contract 270-2003-00006 using data provided by
  the CYT and AMT grantees (TI11320, TI11324,
  TI11317, TI11321, TI11323, TI11874, TI11424,
  TI11894, TI11871, TI11433, TI11423, TI11432,
  TI11422, TI11892, TI11888). The meta analysis of
  juvenile offender intervention data was adapted
  from an earlier presentation by Mark Lipsey with
  his permission. The opinions are those of the
  author and do not reflect official positions of
  the consortium or government. Available on line
  at www.chestnut.org/LI/Posters or by contacting
  Joan Unsicker at 720 West Chestnut, Bloomington,
  IL 61701, phone [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org

2
Goals of this Presentation

• To summarize the need for measuring substance
  use, crime and violence and its correlates
• To examine the utility of the GAINs Substance
  Problem for assessing the risk of relapse and
  recidivism
• To summarize the results of meta analyses of
  effective programs for juvenile offenders by
  Lipsey and colleagues

3
Adolescent Present with a Broad Range of Past
Year Illegal Activity and Violence
100
95
93
93
86
85
90
82
81
81
80
78
74
80
71
69
68
65
70
60
50
40
30
20
10
0
OP/IOP (n560)
LTR (n390)
STR (n594)
Any illegal activity
Property crimes
Interpersonal crimes
Drug related crimes
Acts of physical violence
Source Adolescent Treatment Model (ATM) data
4
Substance Abuse Treatment (particularly
residential) Reduces Illegal Activity
60
STR\t,s,ts
LTR\t,ts
50
OP\s
40
Intake
3
6
9
12
Months from Intake
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
5
Background

• Substance use and crime are inter-related.
• Self-report method is valid and useful for
  predicting treatment placement, relapse and
  recidivism.
• Typically, substance use measures have been used
  to predict placement and relapse, while
  criminological measures have been used to predict
  recidivism.
• This is one of the first adolescent studies to
  look at the ability of substance use and
  criminological measures combined to predict
  placement, relapse, and recidivism in the same
  population or study.

6
Location of CYT/ATM Treatment Sites

• Adolescent Treatment
• Model (ATM) Sites
• Chestnut Health Systems, Bloomington, IL
• Dynamite Youth, New York, NY
• Four Corners Regional Adolescent Center/
  University of Oklahoma Shiprock, NM
• Friends Institute/Epoch Counseling, Catonsville,
  MD
• Mountain Manor, Baltimore, MD
• Public Health Institute/Thunder Road, Oakland, CA
• Rand Corp./Phoenix Academy/Group Homes, Santa
  Monica, CA
• University. of Arizona/IMPACT, Phoenix, AZ
• University of Arizona/La Cañada/7-Challenges/Drug
  Court, Tucson, Az
• University of Miami/MDFT/The Village, Miami, FL

• Cannabis Youth Treatment (CYT) Sites
• Chestnut Health Systems, Madison County, IL
• Childrens Hospital of Phil., Philadelphia, PA
• Operation PAR, St. Petersburg, FL
• Univ. of Conn. Health Center, Farmington, CT

Sponsored by Center for Substance Abuse
Treatment (CSAT), Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services
7
Evaluation

• Target Population Adolescents entering
  substance abuse treatment.
• Inclusion Criteria 12 to 22 year old adolescents
  who present for substance abuse treatment and
  received at least 2 outpatient sessions or 1 week
  of residential treatment.
• Data Sources Self-report measures of diagnosis
  and outcome collected with the Global Appraisal
  of Individual Needs (GAIN).
• Participants 2007 adolescents recruited from 14
  sites around the U.S. and interviewed at 3, 6, 9
  and 12 months later (98 completed 1 plus
  interview 92 completed 12 month interview).

8
Intensity of Juvenile Justice System Involvement
Row
Low
Hi
Severity
0
10
20
30
40
50
60
70
80
90
100
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
9
Intensity by Level of Care
Row
Total
Step Down OP
Outpatient/IOP
Long Term Residential
Short Term Residential
0
10
20
30
40
50
60
70
80
90
100
Detention 14 days (n433)
Probation/ Parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
10
Demographic Characteristics
Row
Source CYT ATM Data
11
Demographics by Intensity
Col
100
90
80
70
60
50
40
30
20
10
0
Female
Caucasian
African
Hispanic
Native
Other
American
American
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
12
Demographics by Intensity (continued)
Col
Detention 14 days (n433)
Probation/ Parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
13
Substance Use Characteristics
Row
Source CYT ATM Data
14
Substance Use Disorder Diagnosis by Intensity
Col
Detention 14 days (n433)
Probation/ Parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data a\
Self report for past year
15
External Diagnoses by Intensity
Col
Detention 14 days (n433)
Probation/ Parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
16
Internal Diagnoses/Problems by Intensity
Col
Detention 14 days (n433)
Probation/ Parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data \b n1838
because some sites did not ask trauma questions
17
Pattern of Co-occurring Disorders by Intensity
Col
Detention 14 days (n433)
Probation/ Parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
18
Legal Characteristics
Row
Source CYT ATM Data
19
Crime/Other Problems by Intensity
Focus of JJ Detention
Col
Stress Can lead to higher rates of health problems
Also higher incidents of Running away
100
90
80
70
60
50
40
30
20
10
0
Detention 14 days (n433)
Probation/ Parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
20
Substance Problem Scale (SPS)

• The SPS (alpha.88) is a count of 16 past year
  symptoms based
• on
• three common screening questions (S9c-e),
• two questions related to substance induced
  psychological or health disorders (S9f-g),
• lay versions of the DSM-IV/ICD-9 criteria for
  substance abuse (S9h-m),
• Lay versions of the DSM-IV/ICD-9 criteria for
  substance dependence (S9n-u).
• The latter also forms the Substance Dependence
  Subscale (SDS
• alpha.82). The SPS symptom count severity is
  triaged as Low
• (0 past year symptoms), Moderate (1 to 9
  symptoms) or High (10
• to 16 symptoms) severity.

21

• S9. When was the last time that . . . (code 1 if
  past year, 0 if before or never)
• c. you tried to hide that you were using
  alcohol or drugs?
• d. your parents, family, partner, co-workers,
  classmates or friends complained about your
  alcohol or drug use?
• e. you used alcohol or drugs weekly?
• f. your alcohol or drug use caused you to feel
  depressed, nervous, suspicious, uninterested in
  things, reduced your sexual desire or caused
  other psychological problems?
• g. your alcohol or drug use caused you to have
  numbness, tingling, shakes, blackouts, hepatitis,
  TB, sexually transmitted disease or any other
  health problems?
• h. you kept using alcohol or drugs even though
  you knew it was keeping you from meeting your
  responsibilities at work, school, or home?
• j. you used alcohol or drugs where it made the
  situation unsafe or dangerous for you, such as
  when you were driving a car, using a machine, or
  where you might have been forced into sex or
  hurt?
• k. your alcohol or drug use caused you to have
  repeated problems with the law?
• m. you kept using alcohol or drugs even after
  you knew it could get you into fights or other
  kinds of legal trouble?

22

• Substance Dependence Scale (SDS alpha82) based
  on DSM-IV/ICD-9
• S9. When was the last time that (code 1 if past
  year, 0 if prior to past year or never)
• n. you needed more alcohol or drugs to get the
  same high or found that the same amount did not
  get you as high as it used to?
• p. you had withdrawal problems from alcohol or
  drugs like shaking hands, throwing up, having
  trouble sitting still or sleeping, or that you
  used any alcohol or drugs to stop being sick or
  avoid withdrawal problems?
• q. you used alcohol or drugs in larger amounts,
  more often or for a longer time than you meant
  to?
• r. you were unable to cut down or stop using
  alcohol or drugs?
• s. you spent a lot of time either getting
  alcohol or drugs, using alcohol or drugs, or
  feeling the effects of alcohol or drugs (high,
  sick)?
• t. your use of alcohol or drugs caused you to
  give up, reduce or have problems at important
  activities at work, school, home or social
  events?
• u. you kept using alcohol or drugs even after
  you knew it was causing or adding to medical,
  psychological or emotional problems you were
  having?

23
Crime and Violence Scale (CVS)

• The CVS (alpha.90) is a count of 29 past year
  symptoms from two subscales
• The General Conflict Tactic Subscale (GCTS
  alpha .88) - based on the National Family
  Violence Survey and work by Murray Strauss.
• The General Crime Subscale (GCS alpha .86) -
  based on the National Household Survey on Drug
  Abuse lay terms for the Uniform Crime Report
  categories.
• CVS symptom count severity is triaged as
• Low (0 to 2 past year symptoms),
• Moderate (3 to 6 symptoms), or
• High (7 to 29 symptoms) severity.

24

• The General Conflict Tactic Subscale (GCTS
  alpha.88) based on the
• National Family Violence Survey and work by
  Murray Strauss.
• E8. During the past 12 months, have you had a
  disagreement in which
• you did the following things?
• a. Discussed it calmly and settled the
  disagreement?
• b. Left the room or area rather than argue?
• c. Insulted, swore or cursed at someone?
• d. Threatened to hit or throw something at
  another person
• e. Actually threw something at someone?
• g. Slapped another person?
• h. Kicked, bit, or hit someone?
• j. Hit or tried to hit anyone with something
  (an object)?
• k. Beat up someone?
• m. Threatened anyone with a knife or gun?
• n. Actually used a knife or gun on another
  person?

25

• General Crime Subscale (GCS alpha.86) based on
  the National Household Survey
• on Drug Abuse lay terms for the Uniform Crime
  Report categories.
• L3. During the past 12 months have you ..
• a. purposely damaged or destroyed property
  that did not belong to you?
• b. passed bad checks, forged (or altered) a
  prescription or took money from an employer?
• c. taken something from a store without paying
  for it?
• d. other than from a store, taken money or
  property that didnt belong to you?
• e. broken into a house or building to steal
  something or just to look around?
• f. taken a car that didnt belong to you?
• g. used a weapon, force, or strong-arm methods
  to get money or things from a person?
• h. hit someone or got into a physical fight?
• j. hurt someone badly enough they needed
  bandages or a doctor?
• k. used a knife or gun or some other thing
  (like a club) to get something from a person?
• m. made someone have sex with you by force when
  they did not want to have sex?
• n. been involved in the death or murder of
  another person (including accidents)?
• p. intentionally set a building, car or other
  property on fire?
• q. driven a vehicle while under the influence of
  alcohol or illegal drugs?
• r. sold, distributed or helped to make illegal
  drugs?

26
Distribution of SPS by CVS Risk Groups
40
Percent of Total (n2007)
20
Crime and Violence Scale
Substance Problem Scale
0
High
High
Mod.
Mod.
Low
Low
Source CYT ATM Data
27
Validation of the SPS and CVS subgroups

• Endorsement of each items and subscales increased
  with the shift from low to moderate to high.
• For the Substance Problem Scale (SPS) severity
  subgroups
• Shifting from low to moderate was associated with
  sharp increases in the screener questions (c-e),
  continued use in spite of getting into fights or
  legal problems (m), and time spent on
  getting/using/recovering from substance use (s).
• Shifting from moderate to high was associated
  with more of the above and greater increases in
  the substance dependence and substance induced
  disorder symptoms.
• For Crime/Violence Scale (CVS) severity
  subgroups
• Shifting from low to moderate was associated with
  increased oral violence, property crime, and drug
  related crime.
• Shifting from moderate to high was associated
  with even more of these things, as well as more
  physical violence and interpersonal (aka violent)
  crimes.
• Next we looked at their predictive validity
  separately and together

28
Probability of Being Placed in Residential
Treatment at Intake
100
80
Crime/ Violence did not predict residential
placement
Probability of Residential Placement
60
40
20
Crime and Violence Scale
Substance Problem Scale
0
High
High
Mod.
Mod.
Low
Low
Source CYT ATM Data
29
Probability of Using at Month 12
100
(Intake) Crime/ Violence did not predict relapse
80
Probability of Using at Month 12
60
40
20
Crime and Violence Scale
Substance Problem Scale
0
High
High
Mod.
Mod.
Low
Low
Source CYT ATM Data
30
Subsequent Violence, Victimization, and Illegal
Activity (by self and others) is one of the Major
Environmental Predictors of Relapse
Baseline
Family
.32
.77
.18
Conflict
Recovery
Environment
-.54
-.13
Risk
.17
.58
.74
Family
.22
.32
-.09
Substance-
Cohesion
Substance
.43
Related
Use
.32
Problems
.82
.19
.11
Social
.19
-.08
.22
Social
Support
Baseline
Baseline
Risk
Model Fit CFI.97 to .99 RMSEA.04 to .06
.21
Baseline
Source Godley et al (2005)
31
Crime/Violence and Substance Problems Interact
to Predict Recidivism
Probability of 12 month recidivism
100
80
60
40
20
Crime and Violence Scale
Substance Problem Scale
0
High
High
Mod.
Mod.
Low
Low
Source CYT ATM Data
32
Discussion of SPS and CVS

• The GAINs SPS and CVS scales appears to be face
  valid, internally consistent and to have good
  construct validity.
• While placement in residential treatment focuses
  on substance use severity, CVS helps to predict
  relapse. This suggests the need to consider
  crime and violence more closely in placement
  decisions.
• Conversely, SPS helps to predict recidivism.
  This suggests the potential benefits of screening
  for substance use problems in juvenile justice
  settings.
• The next step is to combine these variables with
  other factors in a multivariate model.
• We also need to replicate these findings,
  preferably with a sample not presenting for
  treatment and with urine and record checks.

33
The Effectiveness of Programs for Juvenile
Offenders

• 
  N of
• Offender Sample Studies
• Preadjudication (prevention) 178
• Probation 216
• Institutionalized 90
• Aftercare 25
• Total 509

Source Adapted from Lipsey, 1997, 2005
34
Most Programs are actually a mix of components

• Average of 5.6 components distinguishable in
  program descriptions from research reports

Intensive supervision Prison visit Restitution Com
munity service Wilderness/Boot camp Tutoring Indiv
idual counseling Group counseling Family
counseling Parent counseling Recreation/sports Int
erpersonal skills
Anger management Mentoring Cognitive
behavioral Behavior modification Employment
training Vocational counseling Life
skills Provider training Casework Drug/alcohol
therapy Multimodal/individual Mediation
Source Adapted from Lipsey, 1997, 2005
35
Most programs have small effectsbut those
effects are not negligible

• The median effect size (.09) represents a
  reduction of the recidivism rate from .50 to .46
• Above that median, most of the programs reduce
  recidivism by 10 or more
• The nothing works claim that rehabilitative
  programs for juvenile offenders are ineffective
  is false

Source Adapted from Lipsey, 1997, 2005
36
Some Programs Have Negative or No Effects on
recidivism

• Scared Straight and similar shock incarceration
  program
• Boot camps mixed had bad to no effect
• Routine practice had no or little (d.07 or 6
  reduction in recidivism)
• Similar effects for minority and white (not
  enough data to comment on males vs. females)
• The common belief that treating anti-social
  juveniles in groups would lead to more
  iatrogenic effects appears to be false on
  average (i.e., relapse, violence, recidivism for
  groups is no worse then individual or family
  therapy)

Source Adapted from Lipsey, 1997, 2005
37
Some programs have large effects

• One-fourth of the studies show recidivism
  reductions of 30 or more, that is, a recidivism
  rate of .35 or less for the treatment group
  compared to .50 for the control group
• Features associated with Larger effects
• Administered to higher risk juveniles
• One of the more effective program types
• Implemented well (Amount of service above the
  overall median and no indication of service
  delivery problems)
• Juveniles were under proactive juvenile justice
  system supervision

Source Adapted from Lipsey, 1997, 2005
38
Program types with average or better effects on
recidivism

• BETTER THAN AVERAGE AVERAGE OR BETTER
• Preadjudication
• Interpersonal skills training Drug/alcohol
  therapy
• Parent training Employment/job training
• Tutoring Group counseling
• Probation
• Cognitive-behavioral therapy Drug/alcohol
  therapy
• Family counseling Interpersonal skills training
• Mentoring Parent training
• Tutoring
• Institutionalized
• Behavior management Family counseling
• Cognitive-behavioral therapy Group counseling
• Employment/job training
  Individual counseling
• Interpersonal skills training

Source Adapted from Lipsey, 1997, 2005
39
Cognitive Behavioral Therapy (CBT) Interventions
that Typically do Better than Practice in
Reducing Recidivism (29 vs 40)

• Aggression Replacement Training
• Reasoning Rehabilitation
• Moral Reconation Therapy
• Thinking for a Change
• Interpersonal Social Problem Solving
• Multisystemic Therapy
• Functional Family Therapy
• Multidimensional Family Therapy
• Adolescent Community Reinforcement Approach
• MET/CBT combinations and Other manualized CBT
• NOTE Generally little or no differences in mean
  effect size between these brand names

Source Adapted from Lipsey et al 2001, Waldron
et al, 2001, Dennis et al, 2004
40
Implementation is Essential (Reduction in
Recidivism from .50 Control Group Rate)
Thus one should optimally pick the strongest
intervention that one can implement well
Source Adapted from Lipsey, 1997, 2005
41
Impact of the numbers of Favorable features on
Recidivism
Source Adapted from Lipsey, 1997, 2005
42
Lipseys Conclusions

• Research shows that intervention programs can be
  very effective for reducing the recidivism of
  juvenile offenders, even in routine practice
• Program selection and strong implementation are
  critical otherwise effects quickly slide to zero
  (or worse)
• What evidence we have about the effects of
  programs in routine practice indicates that most
  are not very effective there is plenty of room
  for improvement

43
Resources and References

• Copy of these slides and handouts
• http//www.chestnut.org/LI/Posters/
• References cited
• Dennis, M. L., Godley, S. H., Diamond, G., Tims,
  F. M., Babor, T., Donaldson, J., Liddle, H.,
  Titus, J. C., Kaminer, Y., Webb, C., Hamilton,
  N., Funk, R. (2004). The Cannabis Youth
  Treatment (CYT) Study Main Findings from Two
  Randomized Trials. Journal of Substance Abuse
  Treatment, 27, 197-213.
• Dennis, M. L., Titus, J. C., White, M., Unsicker,
  J., Hodgkins, D. (2003). Global Appraisal of
  Individual Needs (GAIN) Administration guide for
  the GAIN and related measures. (Version 5 ed.).
  Bloomington, IL Chestnut Health Systems. Retrieve
  from http//www.chestnut.org/li/gain
• Dennis, M.L., White, M.K. (2003). The
  effectiveness of adolescent substance abuse
  treatment a brief summary of studies through
  2001, (prepared for Drug Strategies adolescent
  treatment handbook). Bloomington, IL Chestnut
  Health Systems. On line Available at
  http//www.drugstrategies.org
• Dennis, M. L. and White, M. K. (2004).
  Predicting residential placement, relapse, and
  recidivism among adolescents with the GAIN.
  Poster presentation for SAMHSA's Center for
  Substance Abuse Treatment (CSAT) Adolescent
  Treatment Grantee Meeting Feb 24 Baltimore,
  MD. 2004 Feb.
• Godley, M. D., Kahn, J. H., Dennis, M. L.,
  Godley, S. H., Funk, R. R. (2005). The
  stability and impact of environmental factors on
  substance use and problems after adolescent
  outpatient treatment. Psychology of Addictive
  Behaviors.
• Lipsey, M. W. (1997). What can you build with
  thousands of bricks? Musings on the cumulation of
  knowledge in program evaluation. New Directions
  for Evaluation, 76, 7-24.
• Lipsey, M.W. (2005). What Works with Juvenile
  Offenders Translating Research into Practice.
  Adolescent Treatment Issues Conference, February
  28, Tampa, FL
• Lipsey, M.W., Chapman, G.L., Landenberger, N.A.
  (2001).  Cognitive-Behavioral Programs for
  Offenders.  The ANNALS of the American Academy of
  Political and Social Science, 578(1), 144-157
• Waldron, H. B., Slesnick, N., Brody, J. L.,
  Turner, C. W., Peterson, T. R. (2001).
  Treatment outcomes for adolescent substance abuse
  at four- and seven-month assessments. Journal of
  Consulting and Clinical Psychology, 69(5),
  802-812.
• White, M. K., Funk, R., White, W., Dennis, M.
  (2003). Predicting violent behavior in adolescent
  cannabis users The GAIN-CVI. Offender Substance
  Abuse Report, 3(5), 67-69.