Title: Victimization, Trauma, and Suicidality Among Adolescents Presenting for Substance Abuse Treatment
1Victimization, Trauma, and Suicidality Among
Adolescents Presenting for Substance Abuse
Treatment
- Michael 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 following grantees (TI11320, TI11324,
TI11317, TI11321, TI11323, TI11874, TI11424,
TI11894, TI11871, TI11433, TI11423, TI11432,
TI11422, TI11892, TI11888, TI013313, TI013309,
TI013344, TI013354, TI013356, TI013305, TI013340,
TI130022, TI03345, TI012208, TI013323, TI14376,
TI14261, TI14189,TI14252, TI14315, TI14283,
TI14267, TI14188, TI14103, TI14272, TI14090,
TI14271, TI14355, TI14196, TI14214, TI14254,
TI14311, TI15678, TI15670, TI15486, TI15511,
TI15433, TI15479, TI15682, TI15483, TI15674,
TI15467, TI15686, TI15481, TI15461, TI15475,
TI15413, TI15562, TI15514, TI15672, TI15478,
TI15447, TI15545, TI15671)). several individual
grants. 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 (309) 827-6026, fax (309)
829-4661, e-Mail junsicker_at_Chestnut.Org
2Goals of this Presentation
- Demonstrate the feasibility and desirability of
measuring victimization at intake with the GAINs
General Victimization Scale (GVS) - Show that victimization is common and varies in
severity - Examine the how the severity of victimization
(measured with GVS) is correlated with with level
of care, demographic characteristics, substance
use severity, relapse potential, HIV risk, mental
health, and crime/violence - Examine the implications of traumatic
victimization for treatment outcome and matching
3Introduction
- Victimization (including physical, sexual, and
emotional abuse) are the norm for adolescents
presenting to substance abuse treatment. - Yet staff often express concerns that they do not
have the tools for screening that screening
might disrupt rapport (leading to early drop out
or mandated reporting) and that they lack the
resources to do anything about victimization. - This is at odds with expert recommendations
(CSAT, 1993, 1999, 2000 Dennis Stevens, 2003
Dennis, 2004) that have consistently encouraged
early systematic screening and intervention among
adolescents entering substance abuse treatment.
4Prevalence Rates of Victimization
- It is estimated that 826,000 to 3,000,000 (3-12)
adolescents (age 12 to 17) have been victimized
(DHHS, 2001 Sedlack Broadhurst, 1996). - Among adolescents presenting for substance abuse
treatment, the rates ranged from 40 to 80 -
varying by gender, timing, definition, and level
of care (Dennis Stevens, 2003) . - 39 of male 59 of females acknowledged a
lifetime history of physical or sexual
victimization when interviewed a few questions in
DATOS-A a month after intake (Grella Joshi,
2003). - 48 of the males and 80 of the females
acknowledged a lifetime history of physical,
sexual, or emotional victimization when
interviewed with the GAIN at intake (Titus,
Dennis, White, Scott Funk, 2003).
5Multiple Types of Victimization Measured by the
GAINs General Victimization Scale (GVS)
Sexual Physical,
Sexual, Physical,
Emotional
Emotional, 16
16
none
None
Sexual
43
43
Sexual 6
6
Physical
Physical
Emotional
Emotional, 6
6
Physical Only
Emotional
Emotional
Physical Only
23
6
6
23
Source Titus et al, 2003
6Additional Traumagenic Factors Measured by GVS
0
10
20
30
40
50
60
70
80
90
100
Abused before 18
Repeated abuse
Multiple abusers
Abused by trusted person
Afraid for life
Abuse resulted in sex
No one believed the abuse
Boys
Girls
Worried about weapon attack
Worried about physical abuse
Worried about sexual abuse
Worried about emotional abuse
Source Titus et al, 2003
All significant
at plt.05
7CSAT Adolescent Treatment (AT) Programs
Reordered by Level of Care and Severity
- EAT Effective Adolescent Treatment (2003-2007
n975) replicating the CYT MET/CBT intervention
in early intervention, school and outpatient
settings(22 of 36 grants Bradley, Brown,
Clayton,Curry, Davis, Dillon, Dodge, Kressler,
Kincaid, Levine, Levy, Locario, Mason, Moore,
Rajaee-Moore, Paull, Payton, Rezende, Taylor,
Tims, Turner, Vincent) - CYT Cannabis Youth Treatment (1997-2001 n600)
Experiments with adolescent outpatient/intensive
outpatient (5 grants Babor, Dennis, Diamond,
Godley, Tims) - TCE Targeted Capacity Expansion (2002-2007
n189) evaluation of intensive outpatient
programs and some residential treatment (2 of 12
grants Tims, Lloyd) - SCY Strengthening Communities-Youth (2002-2007
n1120) evaluations of early intervention,
outpatient, intensive outpatient and some
residential (11 of 12 grants Beach, Bolland,
Dahl, Gerstel, Godley, Hall, Hutchinson, Keehn,
Murphy, Noonan, Panzarella) - ATM Adolescent Treatment Model (1998-2002
n1468) evaluations of outpatient, short and long
term residential (10 grants Batttjes, Fishman,
Godley, Liddle, Morral, Perry, Sabin, Shane,
Stevens-2) - ART Adolescent Residential Treatment (2003-2006
n1179) evaluations of residential treatment
enhancements and continuing care (17 grants
Beach, Fishman, Flores, Gay, Gnazzo, Hatch,
Hurtig, Lane, Law, Manov, May, Miley, Nordquist,
Snipes, Urquahart, Whitmore, Zammarelli)
8CSAT AT Program Common Data Set
- The working CSAT adolescent treatment data set
including data on 5,468 adolescents from 67 local
evaluations (current through quarterly data
submission cycle ending in December 2004) - All data collected with the Global Appraisal of
Individual Needs (GAIN) using centrally trained
and certified staff - Outcome data through 12 months available on over
90 of CYT and ATM clients and over 80 of others
due in on-going programs - Programs include several standardized protocols
based on both research and practice (ACC, ACRA,
ATM, FFT, FSN, Matrix, MET/CBT, MDFT, MST) - Local evaluations include several experiments and
quasi experiments - Several workgroups working on common themes
across programs (African American, Co-morbidity,
Family, Native American/Indian, Spanish
translation/workforce) - Data being shared with several secondary analysis
grantees and panel presentations for this week
9GVS Goes up With Level of Care
100
10
20
30
40
50
60
70
80
90
0
Early Intervention
Outpatient
Other
Intensive Outpatient
Medium Term Residential
Resid. Continuing Care
Long Term Residential
Short Term Residential
Low
Mod.
High
Source CSAT AT Common GAIN Data set
10GVS Goes up With Several Characteristics
100
10
20
30
40
50
60
70
80
90
0
Total
Female
In Controlled
Environment
Mixed Race
Homeless/ Runaway
21-25 Year Olds
Low
Mod.
High
Source CSAT AT Common GAIN Data set
11GVS predicts higher substance use severity in
multiple measures
100
Low
Mod.
High
90
80
70
60
50
40
30
20
10
0
(3.6)
of Use (3.3)
(4.1)
Prior
(3.9)
of AOD (1.7)
(2.2)
AOD
1st Use
under 10
Severe
5 Years
Dependence
Treatment
Withdrawal
Weekly Use
Source CSAT AT Common GAIN Data set
(Odds Ratios odds for High over odds for Low)
12GVS predicts greater readiness to change, but
higher relapse risks
100
Low
Mod.
High
90
80
70
60
50
40
30
20
10
0
(3.1)
in home (1.9)
in Home (2.6)
among
among
Believes
treatment
peers (2.3)
peers (1.4)
peers (1.8)
peers (1.8)
needed (2.0)
work/school
work/school
among social
among social
AOD problem
Acknowledges
Regular Drug Use
Regular Alcohol Use
Readiness
Source CSAT AT Common GAIN Data set
(Odds Ratios odds for High over odds for Low)
13GVS predicts higher HIV/STI risk in the 90 days
before intake
100
Low
Mod.
High
90
Relative to Mod.
80
70
60
50
40
30
20
10
0
Sex (2.7)
Needle Use
(4.8)
(2.5)
Activity (0.8)
Partners (2.0)
(2.1)
Sexual
Unprotected
Multiple Sex
Worries about
Victimization
victimization
Source CSAT AT Common GAIN Data set
(Odds Ratios odds for High over odds for Low)
14GVS has its strongest relationship with internal
disorders
100
Low
Mod.
High
90
80
70
60
50
40
30
20
10
0
(5.2)
(6.5)
Disorder (6.1)
Disorder (5.2)
Disorder (9.6)
Anxiety Disorder
Mutilation (3.5)
Any Self
Depressive
Any Internal
Any homicidal/
Trauma Related
suicidal thoughts
Source CSAT AT Common GAIN Data set
(Odds Ratios odds for High over odds for Low)
15GVS is also related to external/impulse control
disorders
100
Low
Mod.
High
90
80
70
60
50
40
30
20
10
0
ADHD (3.7)
(4.7)
(4.7)
Disorder
Conduct
Disorder
And Internal (6.7)
External
Any External
Source CSAT AT Common GAIN Data set
(Odds Ratios odds for High over odds for Low)
16GVS is also related to Crime and Violence
100
Low
Mod.
High
90
80
70
60
50
40
30
20
10
0
Crime (4.6)
Crimes (3.0)
(4.4)
Crimes (3.1)
Physical
Property
or illegal
Violence
year (2.8)
Any Illegal
activity (3.6)
Interpersonal
Activity-past
Any violence
Drug Related
Source CSAT AT Common GAIN Data set
(Odds Ratios odds for High over odds for Low)
17GVS is consequently related to the total number
of major problems
100
90
80
70
60
50
40
30
20
10
0
1 Problem
4 Problems
5 or more
2 Problems
3 Problems
Problems (117.2)
Low
Mod.
High
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source CSAT AT Common GAIN Data set
(Odds Ratios odds for High over odds for Low)
18Victimization and Gender Interact with Substance
Use Outcomes
Male
Female
60
50
40
Days of 90
30
20
10
0
Pre-Treatment
Post-Discharge
Pre-Treatment
Post-Discharge
Low
Clinical
Acute
Source Titus, Dennis, et al., 2003
19Victimization Also Interacts with Level of Care
CHS Outpatient
CHS Residential
40
35
30
25
Marijuana Use (Days of 90)
20
15
10
5
0
Intake
6 Months
Intake
6 Months
OP -High
OP - Low/Mod
Resid-High
Resid - Low/Mod.
Source Funk, et al., 2003
20How do CHS OPs high GVS outcomes compare with
other OP programs on average?
1.00
CYT Total (n217 d0.51)
0.80
0.60
ATM Total (n284 d0.41)
0.40
CHSOP (n57 d0.18)
0.20
Z-Score on Substance Frequency Scale (SFS)
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
Source CYT and ATM Outpatient Data Set
21Which 5 OP Programs Did the Best with High GVS
adolescents?
1.00
0.80
0.60
0.40
0.20
Z-Score on Substance Frequency Scale (SFS)
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
Source CYT and ATM Outpatient Data Set
22Which 5 OP Programs Did the Best with High GVS
adolescents?
1.00
0.80
0.60
0.40
0.20
CHSOP (n57 d0.18)
Z-Score on Substance Frequency Scale (SFS)
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
Source CYT and ATM Outpatient Data Set
23Other approaches specifically targeting trauma
- Cognitive Behavioral Intervention for Trauma in
Schools (CBITS) Manual (Lisa H. Jaycox Ph.D.,
2004) www.sopriswest.com or jaycox_at_rand.org - Seeking Safety A Treatment Manual for PTSD and
Substance Abuse (Najavits, 2002)
www.seekingsafety.org or from Guilford Press
(800-365-7006) - Trauma Adaptive Recovery Group Education
Therapy Model for Adolescents (TARGET-A Ford et
al., 2000, Ford, Mahoney Russo, 2004) from
www.ptsdfreedom.org or ford_at_psychiatry.uchc.edu - Dialectical Behavior Therapy for Adolescents
(DBT-A Rathus, Miller, Linehan, in press) from
- School-Based Trauma/Grief Group Psychotherapy
Program (SPARCS Layne, Saltzman, Pynoos, et
al., 2000) from Ruth_at_bascom.com
24Concluding Comments
- Victimization is the norm among adolescents
presenting for substance abuse treatment - Victimization can and should be comprehensively
assessed at intake - The severity of traumatic victimization is highly
correlated with a wide range of substance use,
HIV risk behaviors, mental health, and
crime/violence problems. - Higher levels of victimization interact with
treatment effectiveness - Substance abuse treatment programs vary in their
effectiveness at dealing with trauma - More interventions are need to specifically
target victimization and trauma - It is Time to Stop Ignoring the Elephant in our
Counseling Room
25Resources and References
- Copy of these slides and handouts are at
http//www.chestnut.org/LI/Posters/ , see also
www.mayatech - Information on the GAIN is at www.chestnut.org/li/
gain - Information on the adolescent treatment manuals
discussed are at www.chestnut.org/li/apss/csat/pro
tocols - References cited
- Dennis, M.L. (2004). Traumatic victimization
among adolescents in substance abuse treatment
Time to stop ignoring the elephant in our
counseling rooms. Counselor, April, 36-40. - Dennis, M. L., Stevens, S. J., (Eds.). (2003).
Maltreatment issues and outcomes of adolescents
enrolled in substance abuse treatment special
issue. Journal of Child Maltreatment, 8(1) 3-6.
See http//www.sagepub.com/journalIssue.aspx?pid
15jiid6072 - 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 - Funk, R. R., McDermeit, M., Godley, S. H.,
Adams, L. (2003). Maltreatment issues by level of
adolescent substance abuse treatment The extent
of the problem at intake and relationship to
early outcomes. Journal of Child Maltreatment, 8,
36-45. - Grella, C. E., Joshi, V. (2003). Treatment
processes and outcomes among adolescents with a
history of abuse who are in drug treatment.
Journal of Child Maltreatment, 8(1) 7-18. - Jaycox, L.H., Stein, B., Kataoka, S., Wong, M.,
Fink, A., Escudera, P. Zaragoza, C. (2002).
Violence exposure, PTSD, and depressive symptoms
among recent immigrant school children. Journal
of the American Academy of Child and Adolescent
Psychiatry, 41(9) 1104-1110.
26References Continued
- Kataoka, S., Stein, B. D., Jaycox, L. H., Wong,
M., Escuerdo, P., Tu, W., Zaragosa, C., Fink,
A. (2003). A school-based mental health program
for traumatized Latino immigrant children.
Journal of the American Academy of Child and
Adolescent Psychiatry, 42(3), 311-318. - Najavits, L. (2002). Seeking Safety A Treatment
Manual for PTSD and Substance Abuse. New York,
NY Guilford Press. Aavailalbe from
www.seekingsafety.org or 800-365-7006. - Schwebel, R. (2004) The Seven Challenges Manual.
Available from www.sevenchallenges.com or
rschwebel_at_sevenchallenges.com - Stein, B.D., Jaycox, L.H., Kataoka, S.H., Wong,
M., Tu, W., Eliot, M.N., Fink, A. (2003). A
mental health intervention for school children
exposed to violence A randomized controlled
trial. Journal of the American Medical
Association, 290(5), 603-611. - Titus, J.C., Dennis, M.L., White, W.L., Scott,
C.K., Funk, R.R. (2003). Gender Differences in
Victimization Severity and Outcomes Among
Adolescents Treated for Substance Abuse. Journal
of Child Maltreatment, 8(1), 19-35. - U.S. Department of Health and Human Services.
(2001). Child Maltreatment 1999. Washington, DC
U.S. Government Printing Office.