Title: Characteristics, Needs, Services and Outcomes of Juvenile Treatment Drug Courts compared to Adolescent Outpatient and Adult Treatment Drug Courts
1Characteristics, Needs, Services and Outcomes of
Juvenile Treatment Drug Courts compared to
Adolescent Outpatient and Adult Treatment Drug
Courts
- Melissa Ives, MSW, Kate Moritz, MA,
- Michael L. Dennis, Ph.D.
- Chestnut Health Systems, Normal, IL
Presentation at the National Association of Drug
Court Professionals (NADCP) Conference
Washington, DC, July 18, 2011
2Notes
- This presentation was supported by data and funds
from SAMHSA/ CSAT contract no. 270-07-0191. It is
available electronically at www.chestnut.org/li/po
sters - The opinions are those of the author and do not
reflect official positions of the government.
Please address comments or questions to the
authors at mives_at_chestnut.org - 309-451-7819 or
kmoritz_at_chestnut.org 309-451-7831
3The Goals of this Presentation are to
- Illustrate why it is so important to intervene
with juvenile drug users - Review what we know about juvenile treatment drug
courts (JTDC) so far - Compare JTDC to regular adolescent outpatient
(AOP) in terms of who is served, what services
they receive and their treatment outcomes - Examine initial comparison of JTDC to Adult
Treatment Drug Courts (ATDC) and Family Drug
Courts (FDC)
4Alcohol and Other Drug Abuse, Dependence and
Problem Use Peaks at Age 20
100
People with drug dependence die an average of
22.5 years sooner than those without a diagnosis
90
Percentage
80
70
60
Severity Category
50
Other drug or heavy alcohol use in the past year
40
30
Alcohol or Drug Use (AOD) Abuse or Dependence
in the past year
20
10
0
65
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Age
Source 2002 NSDUH and Dennis Scott, 2007,
Neumark et al., 2000
5Adolescents who use weekly or more often are more
likely during the past year to have ...
- Source Dennis McGeary, 1999
6Adolescent Brain Development Occurs from the
Inside to Out and from Back to Front
Photo courtesy of the NIDA Web site. From A Slide
Teaching Packet The Brain and the Actions of
Cocaine, Opiates, and Marijuana.
7Life Course Reasons to Focus on Adolescents
- People who start using substances under age 15
use 60 more years than those who start over age
18. - Entering treatment within the first 9 years of
initial use leads to 57 fewer years of substance
use than those who do not start treatment until
after 20 years of use. - Relapse is common and it takes an average of 3 to
4 treatment admissions over 8 to 9 years before
half reach recovery. - Of all people with abuse or dependence 2/3rds do
eventually reach a state of recovery. - Monitoring and early re-intervention with adults
has been shown to cut the time from relapse to
readmission by 65, increase abstinence and
improve long term outcomes.
Source Dennis et al., 2005, 2007 Scott
Dennis 2009
8While Substance Use Disorders are Common,
Treatment Participation Rates Are Low
Over 88 of adolescent and young adult treatment
and over 50 of adult treatment is publicly
funded
Much of the private funding is limited to 30 days
or less and authorized day by day or week by week
Source OAS, 2009 2006, 2007, and 2008 NSDUH
9What does an episode of treatment cost (median)?
- 750 per night in Detox
- 1,115 per night in hospital
- 13,000 per week in intensive
- care for premature baby
- 27,000 per robbery
- 67,000 per assault
22,000/year to incarcerate an adult
70,000/year to keep a child in detention
30,000/ child-year in foster care
Source French et al., 2008 Chandler et al.,
2009 Capriccioso, 2004
10Investing in Treatment has a Positive Annual
Return on Investment (ROI)
- Substance abuse treatment has been shown to have
a ROI within the year of between 1.28 to 7.26
per dollar invested. - Best estimates are that Treatment Drug Courts
have an average ROI of 2.14 to 2.71 per dollar
invested.
This also means that for every dollar treatment
is cut, we lose more money than was saved.
Source Bhati et al., 2008 Ettner et al., 2006
11Background Juvenile Justice System and Substance
Use
- Between a quarter and two thirds of the youth in
the juvenile justice system have drug related
problems (Office of Juvenile Justice and
Delinquency Prevention (OJJDP), 2001 Teplin et
al., 2002, Chassin, 2008, Wasserman et al. 2010).
- Juvenile justice systems are the leading source
of referral among adolescents entering treatment
for substance use problems (Dennis et al., 2003
Dennis, White Ives, 2009). - By late 2004, there were 357 juvenile treatment
drug courts and the number of courts has
continued to grow at a rate of 30-50 per year.
Source Dennis, White Ives, 2009
12What Level of Evidence is Available on the
Effectiveness of Drug Courts?
Science
Law
Meta Analyses of Experiments/ Quasi Experiments
(Summary v Predictive, Specificity, Replicated,
Consistency) Dismantling/ Matching study (What
worked for whom) Experimental Studies
(Multi-site, Independent, Replicated, Fidelity,
Consistency) Quasi-Experiments (Quality of
Matching, Multi-site, Independent, Replicated,
Consistency) Pre-Post (multiple waves), Expert
Consensus Correlation and Observational
studies Case Studies, Focus Groups Pre-data
Theories, Logic Models Anecdotes, Analogies
STRONGER
Beyond a Reasonable Doubt
Clear and Convincing Evidence
Preponderance of the Evidence
Probable Cause
Reasonable Suspicion
Source Marlowe 2008
13What Level of Evidence is Available on the
Effectiveness of Drug Courts?
Science
Law
Meta Analyses of Experiments/ Quasi Experiments
(Summary v Predictive, Specificity, Replicated,
Consistency) Dismantling/ Matching study (What
worked for whom) Experimental Studies
(Multi-site, Independent, Replicated, Fidelity,
Consistency) Quasi-Experiments (Quality of
Matching, Multi-site, Independent, Replicated,
Consistency) Pre-Post (multiple waves), Expert
Consensus Correlation and Observational
studies Case Studies, Focus Groups Pre-data
Theories, Logic Models Anecdotes, Analogies
STRONGER
Beyond a Reasonable Doubt
Adult Drug Treatment Courts 5 meta analyses of
76 studies found crime reduced 7-26 with 1.74
to 6.32 return on investment
Clear and Convincing Evidence
DWI Treatment Courts one quasi experiment and
five observational studies positive findings
Preponderance of the Evidence
Family Drug Treatment Courts one multisite quasi
experiment with positive findings for parent and
child
Probable Cause
Juvenile Drug Treatment Courts one 2006
experiment, one large multisite quasi-experiment,
several small studies with similar or better
effects than regular adolescent outpatient
treatment
Reasonable Suspicion
Source Marlowe 2008
14Findings from Ives et al., (2010) Multi-Site
Quasi Experiment
- This article is available online at
- http//www.ndci.org/publications/drug-court-review
/fall-2010 - Questions asked
- How do the severity needs of youth in Juvenile
Treatment Drug Courts (JTDC) compare to those in
Adolescent Outpatient (AOP) - Controlling for these differences, how do these
groups compare in terms of - The services they receive?
- Their treatment outcomes?
15Juvenile Treatment Drug Court (JTDC) Sample
- Cohort of 13 CSAT JTDC grantee sites using the
GAIN in Laredo, TX, San Antonio, TX, Belmont, CA,
Tarzana, CA, Pontiac, MI, Birmingham, AL, San
Jose, CA, Austin, TX, Peabody, MA, Providence,
RI, Detroit, MI, Philadelphia, PA, and Basin, WY.
- Intake data collected from these sites on N1,786
adolescents between January 2006 through March
31, 2009. - The records were limited to clients who
- Received outpatient treatment (N1,445), and
- Had attained 6 months post-intake (N1,265)
- For the analysis, only those with at least one
follow-up assessment (89) were used for a final
N1,120. - 86 received evidence-based treatment.
Source Ives et al., 2010
16Adolescent Outpatient (AOP) Sample
- Clients receiving AOP treatment from 75
CSAT-funded sites using the GAIN and providing
outpatient treatment in 29 states from five grant
programs (N10,037). - Intake data collected from these sites on
N10,037 adolescents between September 2002 and
August 2008. - The records were limited to clients who
- Received outpatient treatment (all), and
- Had attained 6 months post-intake (N8,604)
- For the analysis, only those with at least one
follow-up assessment (88) were used for a final
N7,560 - 93 received evidence-based treatment.
JTDC AOP were significantly different on 36 of
69 measures of characteristics, severity and
treatment need
Source Ives et al., 2010
17Demographics
JTDC less likely to be Caucasian, multiracial,
older, employed, in trouble at school/work
more likely to be Hispanic, behind in school
Source Ives et al., 2010 plt.05
18Crime and Violence
JTDC more likely have been in a controlled
environment 13 days, engaged in illegal activity
(overall drug related)
Source Ives et al., 2010 plt.05
19Intensity of Juvenile Justice System Involvement
JTDC more likely to be in other detention status
and less likely to have no JJ status
Source Ives et al., 2010 plt.05 lt 1 year
ago
20Environmental Risk Factors
JTDC less likely to have use in home and
victimization
Source Ives et al., 2010 plt.05
21Substance Use
JTDC more likely to have started younger, to use
any drug or marijuana weekly and less likely to
use tobacco
Source Ives et al., 2010 plt.05
22Substance Use Disorders
JTDC similar on substance use disorders
Source Ives et al., 2010 plt.05
23Substance Treatment History
JTDC more likely to have been in treatment
before, to see a need for treatment and to be
ready to quit
Source Ives et al., 2010 plt.05
24Other Major Co-Occurring Clinical Problems
JTDC less likely to have health or internalizing
disorders and more likely to be/gotten someone
pregnant
Source Ives et al., 2010 plt.05
25HIV Risk Behaviors (past 90 days)
JTDC more likely have multiple sexual partners
Source Ives et al., 2010 plt.05
26Number of Major Clinical Problems
JTDC slightly less severe on psychopathology
relative to waiting for them to enter treatment
on their own, JTDC is a form of early
intervention
Count of marijuana use disorder, alcohol use
disorder, any other drug use disorder,
internalizing problems including depression,
anxiety, homicidal/suicidal thoughts, and trauma,
externalizing problems including conduct disorder
and ADHD, Lifetime victimization, past year acts
of physical violence or past year illegal
activity.
Source Ives et al., 2010 plt.05
27Matching with Propensity Scores
- Using logistic regression to predict the
likelihood (propensity) of each AOP client being
a JTDC client based on the 69 intake
characteristics, we weighted the AOP group to
match the JTDC group in terms of these
characteristics and sample size. - This produced two groups with equal sample sizes
(N1,120). - The number of significant differences dropped
from 39 to 3 of 69 intake variables. - Those in JTDC were still significantly
- Less likely to be African American (OR0.77)
- More likely to be Hispanic (OR1.44) and on other
probation, parole, or detention (OR1.37)
Source Ives et al., 2010
28Treatment System Involvement
JTDC less likely to initiate within 2 weeks, but
more likely to be in treatment 6 weeks and 3
months later
Source Ives et al., 2010 plt.05
29Substance Abuse Treatment (intake to 3 months)
JTDC received more days of any treatment IOP,
also more satisfaction
Source Ives et al., 2010 plt.05
30Range of Substance Abuse Treatment
Content(Intake to 3 months)
JTDC more likely to receive a broader range of
services particularly family and external
wrap-around services
Source Ives et al., 2010 plt.05
31Mental Health Treatment Received(intake to 3
months)
No differences in MH treatmentmost is driven by
medication
Source Ives et al., 2010 plt.05
32Other Environmental Interventions Across Systems
(intake to 3 months)
JTDC received more urine tests and went to
self-help more often
Source Ives et al., 2010 plt.05
33Comparison of Treatment Outcomes(Days of ..)
Both Reduced Use JTDC more than AOP (d
between -0.24)
Both Meaningfully Reduced Emotional Problems
Others Outcomes Not Significantly Different
Post-Pre d (AOP, JTDC)
Source Ives et al., 2010 plt.05 change greater
for JTDC vs AOP (d-0.24)
34Strengths Limits ofIves et al., (2010)
- Strengths
- Multisite quasi experiment
- Differences at intake eliminated on most
variables - Replicable evidence-based practice
- Multiple follow-up waves
- Large sample size and high follow-up rates
- Limits
- Not randomized
- Disproportionately Hispanic youth
- Unknown fidelity of implementation
- Not sufficient numbers of specific evidence-based
practices to compare
35Findings from JTDC and ATDC/FDC Multi-Site Quasi
Experiment
36Findings from JTDC and ATDC/FDC Multi-Site Quasi
Experiment
- How adults in Adult or Family Treatment Drug
Courts (ATDC/FDC) compare to adolescents in
Juvenile Treatment Drug Courts (JTDC) in terms of - Their characteristics, severity needs
- The services they receive?
- Their treatment outcomes?
37Adult Treatment Drug Court (ATDC) and Family Drug
Court (FDC) Sample
- Cohort of 7 CSAT ATDC and 2 FDC grantee sites
using the GAIN in Jacksonville, FL, Clearwater,
FL, Gallipolis, OH, Reno, NV, Miami, FL, Memphis,
TN (ATDC sites) and Tampa, FL, Tucson, AZ (FDC
sites). - Intake data collected from these sites on N697
adults between April 2007 and October 2010. - Mean age 31.21 (s.d. 9.57 range 18-58
median28 mode24) - The records were limited to clients who
- Had attained 6 months post-intake (N457) , and
- Received outpatient treatment (N407)
- For the analysis, only those with at least one
follow-up assessment (88) were used for a final
N359 - 42 received evidence-based treatment
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites
38Juvenile Treatment Drug Court (JTDC) Sample
- Cohort of 11 CSAT JTDC grantee sites using the
GAIN in Laredo, TX, San Antonio, TX, Belmont, CA,
Tarzana, CA, Pontiac, MI, San Jose, CA, Austin,
TX, Peabody, MA, Providence, RI, Detroit, MI, and
Philadelphia, PA. - Intake data collected from these sites on N1,771
adolescents between January 2006 through June
2010. - Mean age 15.37 (s.d. 1.17 range 11-18
median16 mode16) - The records were limited to clients who
- Had attained 6 months post-intake (N1,560)
- Received outpatient treatment (N1,319), and
- For the analysis, only those with at least one
follow-up assessment (86) were used for a final
N1,134 - 81 received evidence-based treatment
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites
39Demographics
JTDC less likely to be female, Caucasian,
employed, in CWS, behind in school JTDC more
likely to be Hispanic, in school, in trouble at
school/work.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 Not HSgradATDC/FDC Behind
JTDC
40Crime and Violence
JTDC less likely to have been in a controlled
environment.
JTDC more likely have engaged in physical
violence and illegal activity (overall
interpersonal and property related).
No difference in drug crime or 13 days in a
controlled environment.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
41Intensity of Juvenile Justice System Involvement
JTDC more likely be in long-term detention or on
probation/parole and less likely to be in other
JJ status.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
42Environmental Risk Factors
JTDC more likely to have social or vocational
peer use.
ATDC more likely to have drug use in home,
homelessness and victimization.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
43Substance Use
JTDC more likely to have started sooner, use more
often and to use marijuana Less likely to use
heroin, cocaine or other drugs or tobacco.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 pre-controlled
environment
44Substance Use Disorders
JTDC more likely to report lifetime or past year
abuse and past week withdrawal.
JTDC less likely to report any lifetime or past
year dependence or lifetime withdrawal.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
45Substance Treatment History
JTDC less likely to report each of these
treatment history items.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
46Other Major Co-Occurring Clinical Problems
JTDC less likely to have health problems,
internalizing disorders or prior treatment More
likely to have externalizing disorders.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
47HIV Risk Behaviors (past 90 days)
JTDC more likely to have multiple partners, and
less likely to have had risky or unprotected sex
or needle use.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
48Number of Major Clinical Problems
Count of marijuana use disorder, alcohol use
disorder, any other drug use disorder,
internalizing problems including depression,
anxiety, homicidal/suicidal thoughts, and trauma,
externalizing problems including conduct disorder
and ADHD, Lifetime victimization, past year acts
of physical violence or past year illegal
activity.
JTDC slightly less severe on psychopathology.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
49JTDC and ATDC/FDC Comparison Treatment
50Type of Treatment provided
JTDC more likely to be treated with wider variety
of evidence-based protocols.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
51Treatment System Involvement
JTDC less likely to initiate within 2 weeks, to
be in any treatment 3 months post-admission, or
to have completed or still be in treatment.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
52Substance Abuse Treatment (intake to 3 months)
JTDC received fewer days of any treatment esp.
IOP days or medication.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 or 6-month if missing 3-month
53Range of Substance Abuse Treatment
Content(Intake to 3 months)
JTDC more likely to receive a broader range of
services particularly family and external wrap
around services
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 or 6-month if missing 3-month
54Mental Health Treatment Received(intake to 3
months)
JTDC less likely to receive mental health
services particularly medication
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 or 6-month if missing 3-month
55Other Environmental Interventions Across Systems
(intake to 3 months)
JTDC received fewer urine tests and went to
self-help less often, but were more likely to be
involved in substance-free structured activities
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 or 6-month if missing 3-month
56JTDC and ATDC/FDC Comparison Outcomes
57Comparison of Treatment Outcomes(Days of ..)
ATDC/FDC meaningfully reduced at 6m
Intake and 6m not significantly different.
JTDC differs from ATDC/FDC at Intake and 6m for
all other outcomes
Both significantly reduced days of substance use.
Post-Pre d (ATDC/ FDC, JTDC)
Substance Use (d-0.77, -0.60)
Emotional Problems (d-0. 22, -0.17)
Trouble w/ Family (d -0.17, -0.19)
Illegal Activity (d-0.15, -0.06)
In Controlled Environment (d0.08, -0.07)
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 or 3 months if
missing 6 mo.
58Outcome Status Across Waves
ATDC/FDC
JTDC
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 or 6-month if
missing 3-month
59In Recovery
N (ATDC/ FDC, JTDC)
No past month substance use or problems while
living in the community.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites
60Strengths Limits ofthis information
- Strengths
- Multisite quasi assignment
- Multiple follow-up waves
- Large sample size and high follow-up rates
- Limits
- Not randomized
- Differences at intake not controlled
- Adult sites are mostly in the first or second
grant year - Disproportionately male in JTDC, female in ATDC
- Disproportionately Hispanic youth in JTDC,
Caucasian in ATDC - Unknown fidelity of implementation
- Not sufficient numbers of specific evidence-based
practices to compare
61Major Predictors of Bigger Effects Found in
Multiple Meta Analyses (Lipsey, 1997, 2005)
- A strong intervention protocol based on prior
evidence - Quality assurance to ensure protocol adherence
and project implementation - Proactive case supervision of individual
- Triage to focus on the highest severity subgroup
62Impact of the numbers of these Favorable features
on Recidivism in 509 Juvenile Justice Studies in
Lipsey Meta Analysis
The more features, the lower the recidivism
Average Practice
Source Adapted from Lipsey, 1997, 2005
63Evidence-Based Treatment (EBT) that Typically do
Better than Usual Practice in Reducing Juvenile
Use Recidivism
- Adolescent Community Reinforcement Approach
(A-CRA) - Aggression Replacement Training (ART)
- Assertive Continuing Care (ACC)
- Cognitive Behavior Therapy (CBT)
- Functional Family Therapy (FFT)
- Moral Reconation Therapy (MRT)
- Thinking for a Change (TFC)
- Interpersonal Social Problem Solving (ISPS)
- Motivational Enhancement Therapy/Cognitive
Behavior Therapy (MET/CBT) - Motivational Interviewing (MI)
- Multi Systemic Therapy (MST)
- Multidimensional Family Therapy (MDFT)
- Reasoning Rehabilitation (RR)
- Seven Challenges (7C)
Small or no differences in mean effect size
between these brand names
Source Adapted from Lipsey et al., 2001, 2010
Waldron et al., 2001, Dennis et al., 2004
64Evidence-Based Practices Can be SIMPLE On-site
proactive urine testing can be used to reduce
false negatives by more than half
65Implementation 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
66References
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Evidence on the Prospects of Expanding Treatment
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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),
802-813. - Wasserman, G. A., McReynolds, L. S. Schwalbe, C.
S. Keating, J. M. Jones, S. A. (2010)
Psychiatric Disorder, Comorbidity, and Suicidal
Behavior in Juvenile Justice Youth. Criminal
Justice and Behavior. 37(12) 1361-1376.
69Resources you can use now
- Cost-Effective evidence-based practices A-CRA
MET/CBT tracks here, more at www.chestnut.org/li/a
pss or http//www.nrepp.samhsa.gov/ - Most withdrawal symptoms appeared more
appropriate for ambulatory/outpatient
detoxification, see http//www.aafp.org/afp/2005/0
201/p495.html - Trauma informed therapy and suicide prevention at
http//www.nctsn.org/nccts and http//www.sprc.org
/ - Externalizing disorders medication practices
http//systemsofcare.samhsa.gov/ResourceGuide/ebp.
html - Tobacco cessation protocols for youth
http//www.cdc.gov/tobacco/quit_smoking/cessation/
youth_tobacco_cessation/index.htm - HIV prevention with more focus on sexual risk and
interpersonal victimization at http//www.who.int/
gender/violence/en/ or http//www.effectiveinterve
ntions.org/en/home.aspx - For individual level strengths see
http//www.chestnut.org/li/apss/CSAT/protocols/ind
ex.html - For improving customer services
http//www.niatx.net