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State of the Art of Adolescent Substance Abuse Treatment

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Title: State of the Art of Adolescent Substance Abuse Treatment


1
State of the Art of Adolescent Substance Abuse
Treatment
  • Michael Dennis, Ph.D.
  • Chestnut Health Systems,
  • Bloomington, IL
  • Presentation at Juvenile Justice Conference on
    Alcohol Other (AOD) Treatment for Adolescents,
    Thursday, April 27, 2006, Marlborough
    Massachusetts. 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 and 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

2
Goals of this Presentation
  1. Epidemiological Course To examine the
    prevalence, course, and consequences of
    adolescent substance use and co-occurring
    disorders and the unmet need for treatment
  2. The Treatment System To summarize major trends
    in the adolescent treatment system and the
    variability by state
  3. Evidence Based Practice To highlight what it
    takes to move the field towards evidenced-based
    practice related to assessment, treatment,
    program evaluation and planning

AFTER BREAK 4. Part 4 Treatment Effectiveness
To present the findings from several recent
treatment outcome studies on substance abuse
treatment research, trauma and violence/crime.
3
Part 1 Epidemiological Course To examine the
prevalence, course, and consequences of
adolescent substance use and co-occurring
disorders and the unmet need for treatment
4
Severity of Past Year Substance Use/Disorders
(2002 U.S. Household Population age 12
235,143,246)
Dependence 5
Abuse 4
No Alcohol or
Regular AOD
Drug Use 32
Use 8
Any Infrequent
Drug Use 4
Light Alcohol
Use Only 47
Source 2002 NSDUH
5
Problems Vary by Age
NSDUH Age Groups
Increasing rate of non-users
100
Severity Category
90
No Alcohol or Drug Use
80
70
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
Dependence
0
65
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Source 2002 NSDUH and Dennis et al forthcoming
6
Higher Severity is Associated with Higher Annual
Cost to Society Per Person
4,000
Median (50th percentile)
3,500
3,000
2,500
2,000
1,500
1,000
725
406
500
231
231
0
0
0
No Alcohol or
Light Alcohol
Regular AOD
Any
Dependence
Abuse
Infrequent
Drug Use
Use Only
Drug Use
Use
Source 2002 NSDUH
7
Age of First Use Predicts Dependence an Average
of 22 years Later
100
Under Age 15
90
Aged 15-17
80
Aged 18 or older
71
70
63
62
60
51
48
with 1 Past Year Symptoms
50
45
41
39
37
40
34
30
30
23
20
10
0
Alcohol
Marijuana
Other Drugs
Tobacco
Pop.151,442,082
Pop.176,188,916
Pop.71,704,012
Pop.38,997,916
Tobacco, OR1.3,
Alcohol, OR1.9,
Marijuana, OR1.5,
Other, OR1.5,
Pop.151,442,082
Pop.176,188,916
Pop.71,704,012
Pop.38,997,916
OR1.49
OR2.74
OR2.45
OR2.65
Source Dennis, Babor, Roebuck Donaldson
(2002) and 1998 NHSDA
plt.05
8
Substance Use Careers Last for Decades
1.0
Median of 27 years from first use to 1 years
abstinence
.9
Cumulative Survival
.8
.7
Years from first use to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
30
25
20
15
10
5
0
Source Dennis et al., 2005
9
Substance Use Careers are Longer the Younger the
Age of First Use
Age of 1st Use Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
.6
.5
under 15
.4
15-20
.3
.2
21
.1
0.0
plt.05 (different from 21)
30
25
20
15
10
5
0
Source Dennis et al., 2005
10
Substance Use Careers are Shorter the Sooner
People Get to Treatment
Year to 1st Tx Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
20
.6
.5
.4
.3
10-19
.2
.1
0.0
0-9
plt.05 (different from 20)
30
25
20
15
10
5
0
Source Dennis et al., 2005
11
Treatment Careers Last for Years
1.0
.9
Cumulative Survival
.8
Median of 3 to 4 episodes of treatment over 9
years
.7
Years from first Tx to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
25
20
15
10
5
0
Source Dennis et al., 2005
12
The Growing Incidence of Adolescent Marijuana
Use 1965-2002
Source OAS (2004). Results from the 2003
National Survey on Drug Use and Health National
Findings. Rockville, MD SAMHSA.
http//oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.p
df
13
Importance of Perceived Risk
Risk Availability
Marijuana Use
Source Office of Applied Studies. (2000). 1998
NHSDA
14
Actual Marijuana Risk
  • From 1980 to 1997 the potency of marijuana in
    federal drug seizures increased three fold.
  • The combination of alcohol and marijuana has
    become very common and appears to be synergistic
    and leads to much higher rates of problems than
    would be expected from either alone.
  • Combined marijuana and alcohol users are 4 to 47
    times more likely than non-users to have a wide
    range of dependence, behavioral, school, health
    and legal problems.
  • Marijuana and alcohol are the leading substances
    mentioned in arrests, emergency room admissions,
    autopsies, and treatment admissions.

15
Substance Use in the Community
Source Dennis and McGeary (1999) and 1997 NHSDA
16
Consequences of Substance Use
Source Dennis, Godley and Titus (1999) and 1997
NHSDA
17
Need for Treatment ( of 24,753,586 Adolescents
in the U.S. Household Population)
10
15
20
25
0
5
14.9
Tobacco
17.8
Alcohol
10.7
Alcohol Binge
?--------Past Month Use------?
11.5
Any Drug Use
8.1
Marijuana Use
5.7
Any Non-Marijuana Drug Use
8.9
Past Year AOD Dependence or Abuse
Less than 1 in 10 getting treatment
0.7
Any Treatment (From NHSDA)
88 of adolescents are treated in the public
system
0.6
Public Treatment (From TEDS)
Source NSDUH and TEDS (see state level
estimates in appendix)
18
Adolescent AOD Dependence/Abuse
Up 27 from 7 in 1995
Prevalence 6.0 to 8.4 8.5 to 9.0 9.1 to
9.9 10.0 to 14.6 U.S.Avg.8.9 MA11.2
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf ) and Kilpatrick et al, 2000.
19
Unmet Treatment Need Adolescent ( of AOD
Dependence/Abuse without any private/public
treatment)
9 in 10 Untreated
Prevalence 82.4 to 90.1 90.2 to 92.3 92.4 to
94.2 94.3 to 98.0 U.S.Avg.92.2 MA97.7
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf )
20
Of 13,530 Urine Panels Done by DYS in 2005, 51
were positive.
Of those that were, they were positive for
.
100
Marijuana is the most common and easiest to detect
89
90
80
70
60
50
Less common hard to detect Often more severe
than opioids
40
30
20
6
4
10
1
1
0
0
Cocaine
Benzodia- zepines
Ecstasy Panels
Opiates
THC
Amphet- amines
Source Commonwealth of Massachusetts Department
of Youth Services (DYS)
21
Summary Points on Epidemiological Course
  • Consequences go up as severity increases from use
    to multiple substance use, abuse, and dependence.
  • Substance use disorders typically on-set during
    adolescence and last for decades.
  • The earlier the age of onset, the longer the
    course of substance use
  • The earlier treatment is received, the shorter
    the course of substance use
  • Marijuana has become the leading substance
    problem
  • Less than 1 in 10 adolescents with substance
    abuse or dependence problems receive treatment
  • Over 88 are treated in the public system

22
Part 2 The Treatment System To summarize major
trends in the adolescent treatment system and the
variability by state
23
Adolescent Treatment Admissions have increased
by 61 over the past decade
Source Office of Applied Studies 1992- 2002
Treatment Episode Data Set (TEDS) http//www.samhs
a.gov/oas/dasis.htm
24
Change in Public Sector Admissions
((2003-1993)/1993)
Both Cause Consequence
Change Not available -96 to -7 -8 to 33 34 to
116 117 to 337 U.S.Avg.61 MA-12
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf )
25
Change in Focal Substances 1993 to 2003
150,000
400
125,000
300
100,000
200
75,000
100
50,000
0
25,000
-100
0
-200
Other\e
Alcohol
1993
Stimulants
Inhalants
Hallucinogens
Cocaine/Crack
Other
Amphetamines
Heroin/Opiates
Marijuana/Hash
2003
Methamphetamines
TEDS Primary, Secondary or Tertiary problem
Source Treatment Episode Data Set (TEDS)
1993-2003.
26
Presenting Substances MA vs. US
Cocaine higher 20 or higher in DE TX
Methamphetamine 20 or higher in AZ,
CA,ID,MN,NV,WA
Opiates 20 or higher in MA NM
Other Amphetamines 20 or higher in OR
Source Primary, Secondary or Tertiary, from
Treatment Episode Data Set (TEDS) 1993-2003.
27
Change in Referral Sources 1993-2003
90,000
140
JJ referrals have doubled, are 53 of 2003
admissions and driving growth
80,000
120
70,000
100
60,000
80
50,000
40,000
60
30,000
40
20,000
20
10,000
-
0
1993
School
Self/Family
Other
Community
2003
Other SA Tx
Agency
Other Health
Care
Employee/EAP
Juvenile Justice
Change
Source Treatment Episode Data Set (TEDS)
1993-2003.
28
Referral Sources MA vs. US
Lower Rate of Juvenile Justice Referrals
Lower Rate of School Referrals
Higher Rate of Self/Parent Referrals
Source Treatment Episode Data Set (TEDS)
1993-2003.
29
Change in Level of Care
IOP has had the fastest growth
150,000
400
125,000
300
Residential has grown, but slower than expected
100,000
200
75,000
100
50,000
0
25,000
-100
0
-200
Outpatient
Intensive
Detox
Short-term
Long-term
1993
Outpatient
Residential
Residential
2003
Source Treatment Episode Data Set (TEDS)
1993-2003.
30
Level of Care MA vs. US
Similar on Regular Outpatient
Source Treatment Episode Data Set (TEDS)
1993-2003.
31
Severity Goes up with Level of Care
STR Higher on Dependence
100
90
80
70
60
50
40
30
20
10
0
Weekly use
First used
Prior Treatment
Case Mix Index (Avg)
Dependence
at intake
under age 15
Outpatient
Intensive Outpatient
Detoxification
Long-term Residential
Short-term Residential
Source Treatment Episode Data Set (TEDS)
1993-2003.
32
Other Characteristics
0
10
20
30
40
50
60
70
80
90
70
Male
58
Caucasian
System dominated by male, white, 15 to 17 year
olds
19
African American
17
Hispanic
6
Other
83
15 to 17 years old
63
9 to 11 yrs education
57
Student
16
Employed
22
Psychological Problems
2
Pregnant at Admission
1
Homeless/Runaway
Source Treatment Episode Data Set (TEDS)
1993-2003.
33
Most Lack of Standardized Assessment for
  • Substance use disorders (e.g., abuse, dependence,
    withdrawal), readiness for change, relapse
    potential and recovery environment
  • Common mental health disorders (e.g., conduct,
    attention deficit-hyperactivity, depression,
    anxiety, trauma, self-mutilation and suicidality)
  • Crime and violence (e.g., inter-personal
    violence, drug related crime, property crime,
    violent crime)
  • HIV risk behaviors (needle use, sexual risk,
    victimization)
  • Child maltreatment (physical, sexual, emotional)

34
Median Length of Stay is only 50 days
Median Length of Stay

Total
50 days
(61,153 discharges)
Less than 25 stay the 90 days or longer time
recommended by NIDA Researchers
LTR
49 days
(5,476 discharges)
STR
21 days
(5,152 discharges)
Level of Care
Detox
3 days
(3,185 discharges)
IOP
46 days
(10,292 discharges)
Outpatient
59 days
(37,048 discharges)
0
30
60
90
Source Data received through August 4, 2004 from
23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD,
ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies
(OAS 2005). Treatment Episode Data Set (TEDS)
2002. Discharges from Substance Abuse Treatment
Services, DASIS Series S-25, DHHS Publication
No. (SMA) 04-3967, Rockville, MD Substance Abuse
and Mental Health Services Administration.
Retrieved from http//wwwdasis.samhsa.gov/teds02/2
002_teds_rpt_d.pdf .
35
53 Have Unfavorable Discharges
Despite being widely recommended, only 10 step
down after intensive treatment
Source Data received through August 4, 2004 from
23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD,
ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies
(OAS 2005). Treatment Episode Data Set (TEDS)
2002. Discharges from Substance Abuse Treatment
Services, DASIS Series S-25, DHHS Publication
No. (SMA) 04-3967, Rockville, MD Substance Abuse
and Mental Health Services Administration.
Retrieved from http//wwwdasis.samhsa.gov/teds02/2
002_teds_rpt_d.pdf .
36
Summary of Problems in the Treatment System
  • The public systems is changing size, referral
    source, and focus often in different directions
    by state
  • Major problems are not reliably assessed (if at
    all)
  • Less than 50 stay 50 days (7 weeks)
  • Less the 25 stay the 3 months recommended by
    NIDA researchers
  • Less than half have positive discharges
  • After intensive treatment, less than 10 step
    down to outpatient care
  • While JJ involvement is common, little is known
    about the rate of initiation after detention

37
Part 3 Evidence Based Practice To highlight
what it takes to move the field towards
evidenced-based practice related to assessment,
treatment, program evaluation and planning
38
Context
  • The field is increasingly facing demands from
    payers, policymakers, and the public at large for
    evidence-based practices (EBP) which can
    reliably produce practical and cost-effective
    interventions, therapies and medications that
    will
  • reduce risks for initiating drug use among those
    not yet using,
  • reduce substance use and its negative
    consequences among those who are abusing or
    dependent, and
  • reduce the likelihood of relapse for those who
    are recovering
  • NIDA Blue Ribbon Panel on Health Services
    Research
  • (see www.nida.nih.gov )

39
General Behavioral Health Practice
  • Accumulating evidence indicates that most of the
    theories and approaches that are used within the
    community of practitioners are unsupported by
    empirical evidence of effects
  • Various lists of 70 or so proven empirically
    supported therapies (ESTs) have proven to be
    relatively infeasible because they have rarely
    been compared with each other and generally have
    not been tested with the clinically diverse
    samples found in community based settings
  • Need for a new method of integrating scientific
    evidence and the realities of practice is called
    for.
  • Source Beutler, 2000

40
Problems and Barriers in SA Tx
  • People with multiple substance use and multiple
    co-occurring problems are the norm of severity in
    practice, but are often excluded from research
  • Individualization of treatment content/duration
    is the norm in practice, but research based
    protocols typically involves fixed
    components/length that are not as appropriate for
    heterogeneous problems
  • No treatment is not considered a ethical or
    significant option, practitioners are more
    interested in identifying which of several
    treatments to use for a given type of patient
    but few such studies have been done
  • When research practices have been identified,
    they are often not adopted because practitioners
    often lack the appropriate materials, training
    and resources to know when or how to implement
    them

41
Randomized Clinical Trials (RCT) are to Evidence
Based Practice (EBP) like Self-reports are to
Diagnosis
  • They are only as good as the questions asked (and
    then only if done in a reliable/valid way)
  • They are an efficient and logical place to start
  • But they can be limited or biased and need to be
    combined with other information
  • Just because the person does not know something
    (or the RCT has not be done), does not mean it is
    not so
  • Synthesizing them with other information usually
    makes them better

42
So what does it mean to move the field towards
Evidence Based Practice (EBP)?
  • Introducing reliable and valid assessment that
    can be used
  • At the individual level to immediately guide
    clinical judgments about diagnosis/severity,
    placement, treatment planning, and the response
    to treatment
  • At the program level to drive program evaluation,
    needs assessment, and long term program planning
  • Introducing explicit intervention protocols that
    are
  • Targeted at specific problems/subgroups and
    outcomes
  • Having explicit quality assurance procedures to
    cause adherence at the individual level and
    implementation at the program level
  • Having the ability to evaluate performance and
    outcomes
  • For the same program over time,
  • Relative to other interventions

43
Reoccurring Themes in the Examples
  • Severity and specificity of problem subgroup
  • Manualized and replicable assessment and
    treatment protocols
  • Relative strength of intervention for a specific
    problem
  • Adherence and implementation of intervention
  • Evaluation of outcomes targeted by the
    intervention (a.k.a., logic modeling)

44
The Current Renaissance of Adolescent Treatment
Research
Feature 1930-1997 1997-2005
Tx Studies 16 Over 200
Random/Quasi 9 44
Tx Manuals 0 30
QA/Adherence Rare Common
Std Assessment Rare Common
Participation Rates Under 50 Over 80
Follow-up Rates 40-50 85-95
Methods Descriptive/Simple More Advanced
Economic Some Cost Cost, CEA, BCA
Published and publicly available
45
Adolescent Treatment Research Currently Being
Published
  • 1994-2000 NIDAs Drug Abuse Treatment Outcome
    Study of Adol. (DATOS-A)
  • 1995-1997 Drug Abuse Treatment Outcome Study
    (DOMS)
  • 1997-2000 CSATs Cannabis Youth Treatment (CYT)
    experiments
  • 1998-2003 NIAAA/CSATs 15 individual research
    grants
  • 1998-2003 CSATs 10 Adolescent Treatment Models
    (ATM)
  • 2000-2003 CSATs Persistent Effects of Treatment
    Study (PETS-A)
  • 2002-2007 CSATs 12 Strengthening Communities for
    Youth (SCY)
  • 2002-2007 RWJFs 10 Reclaiming Futures (RF)
    diversion projects
  • 2002-2007 CSATs 12 Targeted Capacity Expansion
    TCE/HIV
  • 2003-2009 NIDAs 14 individual research grants
    and CTN studies
  • 2003-2006 CSATs 17 Adolescent Residential
    Treatment (ART)
  • 2003-2008 NIDAs Criminal Justice Drug Abuse
    Treatment Study (CJ-DATS)
  • 2003-2007 CSATs 38 Effective Adolescent
    Treatment (EAT)
  • 2004-2007 NIAAA/CSATs study of diffusion of
    innovation
  • 2004-2009 CSAT 22 Young Offender Re-entry
    Programs (YORP)
  • 2005-2008 CSAT 20 Juvenile Drug Court (JDC)
  • 2005-2008 CSAT 16 State Adolescent Coordinator
    (SAC) grants

46
Adolescent and Adult Treatment Program GAIN
Clinical Collaborators
Number of GAIN Sites
30 to 60
10 to 29
2 to 9
1
07/05
One or more state or county wide systems uses the
GAIN One or more state or county wide systems
considering using the GAIN
47
Common Hierarchical Structure of the GAINs
Psychopathology Scales
General Individual Severity Scale (GISS)
Internal Mental Distress Scale (IMDS)
Substance Problem Scale (SPS)
Substance Issues Index (SII)
Somatic Symptom Index (SSI)
Substance Abuse Scale (SAS)
Depression Symptom Scale (DSS)
Substance Dependence Scale (SDS)
Homicidal/Suicidal Thought Index (HSTI)
Anxiety/Fear Symptom Scale (AFSS)
Traumatic Distress Scale (TDS)
Behavior Complexity Scale (BCS)
Crime/Violence Scale (CVS)
Inattentiveness Disorder Scale (IDS)
General Conflict Tactic Scale (GCTS)
Property Crime Scale (PCS)
Hyperactivity-Impulsivity Scale (HIS)
Interpersonal Crime Scale (ICS)
Conduct Disorder Scale (CDS)
Drug Crime Scale (DCS)
Confirmatory factor analysis demonstrates that
this is reliable overall and stable across adults
and adolescents, outpatient residential
(confirmatory fit index .97 Root Mean Square
Error.04)
48
GAIN Short Screen (GAIN-SS)
  • Administration Time 5 minutes
  • Training Requirements Minimal
  • Mode Self or staff administered
  • Purpose Designed for use in general populations
    or where there is less control to identify who
    has a disorder warranting further assessment or
    behavioral intervention, measuring change in the
    same, and comparing programs
  • Scales The total scale (20-symptoms) and its 4
    subscales (5-symptoms each) for internal
    disorders (somatic, depression, suicide, anxiety,
    trauma, behavioral disorders (ADHD, CD),
    substance use disorders (abuse, dependence), and
    crime/violence (interpersonal violence, property
    crime, drug related crime) can be used to
    generate symptom counts for the past month to
    measure change, past year to identify current
    disorders and lifetime to serve as
    covariates/validity checks.
  • Reports There are currently no reports.

49
GAIN Short Screen (GAIN-SS)
Low Mod. High
100
Prevalence ( 1 disorder)
90
Sensitivity ( w disorder above)
80
Specificity ( w/o disorder below)
70
(n6194 adolescents)
60
Using a higher cut point increases prevalence
and specificity, but decreases sensitivity
50
40
30
99 prevalence, 91 sensitivity, 89
specificity at 3 or more symptoms
20
10
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total Disorder Screener (TDScr)
Total score has alpha of .85 and is correlated
.94 with full GAIN version
Source Dennis et al 2005 GSS manual
50
GSS Performance by Subscale and Disorders

Prevalence

Sensitivity

Specificity

Screener/Disorder


1

3

1

3

1

3

Low (0), Moderate (1-2), and High (3) cut points
can be used to identify the need for specific
types of interventions
Internal Disorder Screener (0-5)

Any Internal Disorder

81

99

94

55

71

99

Major Depression

56

87

98

72

54

94

Generalized Anxiety

32

56

100

83

44

83

Suicide
Ideation

24

43

100

84

41

79

Mod/High Traumatic Stress

60

82

94

60

55

90


External Disorder Screener (0-5)
Any External Disorder

88

97

98

67

75

96

AD, HD or Both

65

82

99

78

51

85

Conduct Disorder

78

91

98

70

62

90

Substance Use Disorder Screener (0-5)

Moderate can be targeted where resources allow or
where a more assertive approach is desired
Any Substance Disorder

96

100

96

68

73

100

Dependence

65

87

100

91

30

82

Abuse

30

13

89

25

14

28

Crime Violence Screener (0-5)

Any Crime/Violence

88

99

94

49

76

99

High Physical Conflict

31

46

100

70

38

77

Mod/High General Crime

85

100

94

51

71

100

Total Disorder Screener (0-5)
Mod/Hi can be used to evaluate program
delivery/referral
Any Disorder

97

99

99

91

47

89

Any Internal Disorder

58

63

100

98

8

28

Any External Disorder

68

75

100

99

10

37

Any Substance Disorder

89

92

99

92

20

51

Any Crime/Violence
68

73

100

96

10

32












51
GAIN Quick (GAIN-Q)
  • Administration Time 20-30 minutes
  • Training Requirements 1 day (train the trainer)
  • Mode Generally Staff Administered on Computer
    (can be done on paper or self administered)
  • Purpose Designed for use in targeted populations
    to support brief intervention or referral for
    further assessment or behavioral intervention
  • Scales The GQ has total scale (99-symptoms) and
    15 subscales (including more detailed versions of
    the GSS scales and subscales plus scales for
    service utilization, sources of psychosocial
    stress, and health problems). All scales focus
    on the past year only and it is primarily used to
    support motivational interviewing or for a one
    time assessment (though there is a shorter
    follow-up version).
  • Reports Summary narrative report and a graphic
    individual profile to support clinical decision
    making.

52
The GAIN-Quick can Predict Level of Care
0.6
Z score from mean
0.4
0.2
0.0
-0.2
-0.4
-0.6
Disorder Index
Aggression Index
Suicide Risk Index
Conduct Disorder-
General Crime Index
Anxiety Symptom Index
Internal Behavior Index
Attention-Hyperactivity
External Behavior Index
Substance Use and Abuse
Substance Problem Index
Depression Symptom Index
Substance Dependence Index
TC (n288)
STR (n604)
OP/IOP (n513)
Good reliability (alpha over .9 on main scales,
.7 on subscales) and correlated .9 or higher with
full GAIN scale
Source Titus et al, 2003 ATM data
53
GQ Example Site difference in 4 Detention Sites
Source 2005 Reclaiming Futures Data (n508)
54
GQ Example Link to Recent Victimization in 4
detention sites
Source 2005 Reclaiming Futures Data (n508)
55
GAIN Initial (GAIN-I)
  • Administration Time Core version 60-90
    minutes/Full version 120-160 minutes (depending
    on severity and inclusion of GPRA module)
  • Training Requirements 3.5 days (train the
    trainer) plus recommend formal certification
    program (administration certification within 3
    months of training local trainer certification
    within 6 months of training)
  • Mode Generally Staff Administered on Computer
    (can be done on paper or self administered)
  • Purpose Designed to provide a standardized
    biopsychosocial for people presenting to a
    substance abuse treatment using DSM-IV for
    diagnosis, ASAM for placement, and needing to
    meet common (CARF, JCAHO, insurance, CDS/TEDS,
    Medicaid, CSAT, NIDA) requirements for
    assessment, diagnosis, placement, treatment
    planning, accreditation, performance/outcome
    monitoring, economic analysis, program planning
    and to support referral/communications with other
    systems
  • Scales The GI has 9 sections (access to care,
    substance use, physical health, risk and
    protective behaviors, mental health, recovery
    environment, legal, vocational, and staff
    ratings) that include 103 long (alpha over .9)
    and short (alpha over .7) scales, summative
    indices, and over 2000 created variables to
    support clinical decision making and evaluation.
    It is also modularized to support customization

56
GAIN-Is Main Reports
  • GAIN Referral and Recommendation Summary (GRRS)
    A text-based narrative in MS Word designed to be
    edited and shared with specialists, clinical
    staff from other agencies, insurers and lay
    people.
  • Individual Clinical Profile (ICP) A more
    detailed report in MS Access designed to help
    triage problems and help the clinician go back to
    the GAIN for more details if necessary (generally
    not edited or shared).
  • Personal Feedback Reports (PFR) A text based
    summary to support the motivational interviewing
    or MET based on the GAIN-I (or GAIN-Q).
  • Validity Reports A list of potential problems
    and areas for clarification and.
  • Other Custom reports to word, excel or
    transferring data from/to other data systems.

57
Other Measures
  • Collateral versions of all three measures
  • Follow-up versions of all three measures
  • Spanish Translation of all three measures
  • Native American Module
  • CSAT, State, Organization, Program, and Project
    Specific (aka CORE) versions
  • Ability to customize by site within prescribed
    parameters

Over 4 dozen scientist using the data to develop
additional clinical guidance on diagnosis,
placement, treatment planning, treatment
effectiveness and economic analysis
More information is available at
www.chestnut.org/li/gain
58
CSAT Adolescent Treatment (AT) Outcome Data Set
  • Recruitment 1998-2005 (updated annually)
  • Sample The 2005 CSAT adolescent treatment data
    set included data with 1 to 4 follow-ups on 9,276
    unique adolescents from 72 local evaluations
  • Levels of Care Early Intervention, Outpatient,
    Intensive Outpatient, Short, Moderate Long term
    Residential, Corrections Based and Post
    Residential Outpatient Continuing Care
  • Instrument Global Appraisal of Individual Needs
    (GAIN) (see www.chestnut.org/li/gain)
  • Follow-up Over 80 follow-up 3, 6, 9 12 months
    post intake
  • Funding CSAT contract 270-2003-00006 and 72
    individual grants

59
Current CSAT AT Outcome Data Set by Grant
Program (n9,276)
CYT Cannabis Youth Treatment (1997-2001 600
from 4 grants)
YORP Young Offender Re-entry Project
(2004-2008 79 from 3 grants)
ATM Adolescent Treatment Model (1998-2002
1,776 from 10 grants)
EAT Effective Adolescent Treatment (2003-2007
3,325 from 27 grants)
SCY Strengthening Communities-Youth
(2002-2007 1,804 from 11 grants)
ART Adolescent Residential Treatment
(2003-2006 1,429 from 16 grants)
TCE Other Targeted Capacity Expansion
(2002-2007 263 from 1 grant)

Source CSAT AT Outcome Data Set
60
Geographic Location of Sites
NH
WA
VT
ME
MT
ND
MN
OR
MA
NY
ID
WI
SD
MI
WY
RI
IA
PA
CT
NE
OH
NJ
NV
DC
IN
UT
IL
CA
CO
WV
VA
DE
DC
KS
MO
KY
MD
NC
TN
AR
AZ
OK
NM
SC
GA
AL
MS
Program
ART
TX
LA
EAT
AK
SCY
FL
TCE
YORP
HI
PR
61
Demographics
62
Clinical Severity
63
Primary, Secondary or Tertiary SUD Problems
64
Level of Care
65
Recovery Environment
Source CSAT AT Outcome Data Set (n9,276
adolescents)
66
Past 90 day HIV Risk Behaviors
Source CSAT AT Outcome Data Set (n9,276
adolescents)
67
Weekly or More Often Use in the Past 90 Days
Source CSAT AT Outcome Data Set (n9,276
adolescents)
68
Substance Use Problems
Source CSAT AT Outcome Data Set (n9,276
adolescents)
69
Co-Occurring Psychiatric Problems
Source CSAT AT Outcome Data Set (n9,276
adolescents)
70
Past Year Violence Crime
Dealing, manufacturing, prostitution, gambling
(does not include simple possession or
use) Source CSAT AT Outcome Data Set (n9,276
adolescents)
71
Intensity of Juvenile Justice System Involvement
17 In detention/jail 14 days
Highest severity for Long Term Residential
(followed by STR, IOP, OP)
25 On probation or parole 14 days
w/ 1 drug screens
16 Other JJ status
17 Other probation/parole/detention
Source CSAT 2004 AT Common GAIN Data set (n
5,468 adolescents from 67 local evaluations)
72
Multiple Problems are the Norm
100
In fact, over half present acknowledging 5
major problems
90
80
Five to Twelve
70
60
50
40
Four
30
Few present with just one problem (the focus of
traditional research)
Three
Most acknowledge 1 problems
20
Two
10
One
None
0
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source CSAT AT Common GAIN Data set
73
No. of Problems by Severity of Victimization
100
Those with high lifetime levels of victimization
have 117 times higher odds of having 5 major
problems
90
80
70
60
50
Five or More
Four
40
Three
30
Two
20
One
None
10
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD,
CD, victimization, violence/ illegal activity)
0
Low (31)
Moderate (17)
High (51)
GAIN General Victimization Scale Score (Row )
Source CSAT AT Common GAIN Data set (odds for
High over odds for Low)
74
Treatment Outcomes by Level of Care Days of AOD
Abstinence
Percentages in parentheses are the treatment
outcome (intake to 12 month change) and the
stability of the outcomes (3months to 12 month
change) Source CSAT AT Outcome Data Set
(n-9,276)
75
Treatment Outcomes by Level of Care Recovery
Recovery defined as no past month use, abuse,
or dependence symptoms while living in the
community. Percentages in parentheses are the
treatment outcome (intake to 12 month change) and
the stability of the outcomes (3months to 12
month change) Source CSAT AT Outcome Data Set
(n-9,276)
76
Other Assessment and Treatment Resources
  • Assessment Instruments
  • GAIN Coordinating Center at www.chestnut.org/li/ga
    in
  • CSAT TIP 3 at http//www.athealth.com/practitioner
    /ceduc/health_tip31k.html
  • NIAAA Assessment Handbook at http//www.niaaa.nih
    .gov/publications/instable.htm
  • Treatment Programs
  • CSAT CYT, ATM, ACC and other treatment manuals at
    www.chestnut.org/li/apss/csat/protocols and on
    CDs provided
  • SAMHSA Knowledge Application Program (KAP) at
    http//kap.samhsa.gov/products/manuals
  • NCADI at www.health.org
  • National Registry of Effective Prevention
    Programs Substance Abuse and Mental Health
    Services Administration (SAMHSA), Department of
    Health and Human Services http//www.modelprogra
    ms.samhsa.gov

77
Other Resources (continued)
  • Implementing Evidenced Based Practice
  • Central East ATTC Evidence Based Practice
    Resource Page http//www.ceattc.org/nidacsat_bpr.a
    sp?idLGBT
  • Northwest Frontier ATTC Best Practices in
    Addiction Treatment A Workshop Facilitator's
    Guide http//www.nattc.org/resPubs/bpat/index.html
  • Turning Knowledge into Practice A Manual for
    Behavioral Health Administrators and
    Practitioners About Understanding and
    Implementing Evidence-Based Practices
    http//www.tacinc.org/index/viewPage.cfm?pageId11
    4
  • Evidence-Based Practices An Implementation Guide
    for Community-Based Substance Abuse Treatment
    Agencies http//www.uiowa.edu/iowapic/files/EBP2
    0Guide20-20Revised205-03.pdf
  • National Center for Mental Health and Juvenile
    Justice Evidence Based Practice resource list at
    http//www.ncmhjj.com/EBP/default.asp
  • Society for Adolescent Substance Abuse Treatment
    Effectiveness (SASATE) www.chestnut.org/li/apss/s
    asate
  • 2006 Joint Meeting on Adolescent Substance Abuse
    Treatment Effectiveness http//www.mayatech.com/ct
    i/jmate/
  • next meeting March 27-29, 2006, Baltimore, MD

78
What are the pitfalls of EBP?
  • EBP generally causes some staff turnover
  • EBP often shines a light on staff or work place
    problems that would otherwise be ignored
  • EBP often impact a wide range of existing
    procedures and policies requiring modification
    and provoking resistance
  • EBP (and most organizational changes) will fail
    without good senior staff leadership
  • EBP typically require going for more funds from
    grant or other funders
  • On-going needs assessment will create demand for
    more change and more EBP

79
Summary of Evidenced Based Practice Section
  • Achieving reliable outcomes requires reliable
    measurement, protocol delivery and on-going
    performance monitoring.
  • The GAIN is one measure that is being widely used
    by CSAT grantees and others trying to address
    gaps in current knowledge and move the field
    towards evidenced based practice.
  • Standardized and more specific assessment helps
    to draw out treatment planning implications of
    readiness for change, recovery environment,
    relapse potential, psychopathology,
    crime/violence, and HIV risks.
  • Adolescents entering more intensive levels of
    care typically have higher severity.
  • Multiple problems and child maltreatment are the
    norm and are closely related to each other.
  • There is a growing number of standardized
    assessment tools, treatment protocols and other
    resources available to support evidenced based
    practices.

80
Part 4 Treatment Effectiveness To present the
findings from several recent treatment outcome
studies on substance abuse treatment research,
trauma and violence/crime.
81
Meta Analysis of 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
82
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
83
Most programs have small effects but 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
  • 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
  • The nothing works claim that rehabilitative
    programs for juvenile offenders are ineffective
    is false

Source Adapted from Lipsey, 1997, 2005
84
Major Predictors of Bigger Effects
  • Chose a strong intervention protocol based on
    prior evidence
  • Used quality assurance to ensure protocol
    adherence and project implementation
  • Used proactive case supervision of individual
  • Used triage to focus on the highest severity
    subgroup

85
Impact of the numbers of Favorable features on
Recidivism (509 JJ studies)
Usual Practice has little or no effect
Source Adapted from Lipsey, 1997, 2005
86
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
87
Program types with average or better effects on
recidivism
  • AVERAGE OR BETTER BETTER/BEST
  • Preadjudication
  • Drug/alcohol therapy Interpersonal skills
    training
  • Parent training Employment/job training
  • Tutoring Group counseling
  • Probation
  • Drug/alcohol therapy Cognitive-behavioral
    therapy
  • Family counseling Interpersonal
    skills training
  • Mentoring Parent training
  • Tutoring
  • Institutionalized
  • Family counseling Behavior management
  • Cognitive-behavioral therapy Group counseling
  • Employment/job training
    Individual counseling
  • Interpersonal skills training

Source Adapted from Lipsey, 1997, 2005
88
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 There is 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
89
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
90
CYT
Cannabis Youth Treatment Randomized Field Trial
Coordinating Center Chestnut Health Systems,
Bloomington, IL, and Chicago, IL University
of Miami, Miami, FL University of Conn. Health
Center, Farmington, CT
Sites Univ. of Conn. Health Center, Farmington,
CT Operation PAR, St. Petersburg, FL Chestnut
Health Systems, Madison County, IL Childrens
Hosp. of Philadelphia, Phil. ,PA
Sponsored by Center for Substance Abuse
Treatment (CSAT), Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services
91
Context Circa 1997
  • Cannabis had become more potent, was associated
    with a wide of problems (particularly when
    combined with alcohol), and had become the
    leading substances mentioned in arrests,
    emergency room admissions, autopsies, and
    treatment admissions (doubling in in 5 years)
  • Over 80 of adolescents with Cannabis problems
    were being seen in outpatient setting
  • The median length of stay was 6 weeks, with only
    25 making it 3 months
  • There were no published manuals targeting
    adolescent marijuana users in outpatient
    treatment
  • The purpose of CYT was to manualize five
    promising protocols, field test their relative
    effectiveness, cost, and benefit-cost and provide
    them to the field

Source Dennis et al, 2002
92
Two Effectiveness Experiments
Trial 2
Trial 1
Incremental Arm
Alternative Arm
Source Dennis et al, 2002
93
Contrast of the Treatment Structures
Individual Adolescent Sessions
CBT Group Sessions
Individual Parent Sessions
Family Sessions/Home Visits
Parent Education Sessions
Total Formal Sessions
Case management/ Other Contacts
Total Expected Contacts
Total Expected Hours
Total Expected Weeks
Source Diamond et al, 2002
94
Actual Treatment Received by Condition
ACRA and MDFT both rely on individual, family and
case management instead of group
FSN adds multi family group, family home visits
and more case management
And MDFT using more family therapy
MET/CBT12 adds 7 more sessions of group
With ACRA using more individual therapy
Source Dennis et al, 2004
95
Average Episode Cost (US) of Treatment
--------------------------------------------Econo
mic Cost------------------------------------------
--------- Director Estimate-----
4,000
3,322
3,500
3,000
2,500
Average Cost Per Client-Episode of Care
1,984
2,000
1,559
1,413
1,500
1,197
1,126
1,000
500
-
ACRA (12.8 weeks)
MET/CBT5 (6.8 weeks)
MET/CBT5 (6.5 weeks)
MET/CBT12 (13.4 weeks)
FSN (14.2 weeks w/family)
MDFT(13.2 weeks w/family)
Source French et al., 2002
96
Implementation of Evaluation
  • Over 85 of eligible families agreed to
    participate
  • Quarterly follow-up of 94 to 98 of the
    adolescents from 3- to 12-months (88 all five
    interviews)
  • Collateral interviews were obtained at intake, 3-
    and 6-months on over 92-100 of the adolescents
    interviewed
  • Urine test data were obtained at intake, 3, 6, 30
    and 42 months 90-100 of the adolescents who were
    not incarcerated or interviewed by phone (85 or
    more of all adolescents).
  • Long term follow-up completed on 90 at 30-months
  • Self reported marijuana use largely in agreement
    with urine test at 30 months (13.8 false
    negative, kappa.63)
  • Good reliability (alphas over .85 on main scales)
    and correlations with collateral reports (r.4 to
    .7)

Source Dennis et al, 2002, 2004
97
Adolescent Cannabis Users in CYT were as or More
Severe Than Those in TEDS
Source Tims et al, 2002
98
Demographic Characteristics
Source Tims et al, 2002
99
Institutional Involvement
100
87
80
62
60
47
40
25
20
0
In school
Employed
Current JJ
Coming from
Involvement
Controlled
Environment
Source Tims et al, 2002
100
Patterns of Substance Use

100
73
80
71
60
40
17
20
9
0
Weekly Alcohol
Weekly
Weekly
Significant Time
Tobacco Use
Cannabis Use
Use
in Controlled
Environment
Source Tims et al, 2002
101
Multiple Problems were the NORM
Self-Reported in Past Year
Source Dennis et al, 2004
102
Substance Use Severity was Related to Other
Problems
100
80
71
57
60
42
37
40
30
25
22
22
20
13
5
0
Health Problem
Acute Mental
Acute
Attention
Conduct
Distress
Distress
Traumatic
Deficit
Disorder
Distress
Hyperactivity
Disorder
Past Year Dependence (n278)
Other (n322)
plt.05
Source Tims et al 2002
103
CYT Increased Days Abstinent and Percent in
Recovery
90
90
Days Abstinent
80
80
Percent in Recovery
70
70
60
60
50
50
Days Abstinent Per Quarter
in Recovery at the End of the Quarter
40
40
30
30
20
20
10
10
0
0
Intake
3
6
9
12
no use, abuse or dependence problems in the past
month while in living in the community
Source Dennis et al., 2004
104
Similarity of Clinical Outcomes by Conditions
Not significantly different by condition.
Trial 1
Trial 2
300
50
.
280
40
.
260
30
over 12 months
at Month 12
Total days abstinent
Percent in Recovery
240
20
220
10
200
0
MET/ CBT5
MET/
FSN
MET/ CBT5
ACRA
MDFT
(n102)
CBT12
(n102)
(n99)
(n100)
(n99)
269
256
260
251
265
257
Total Days Abstinent
0.28
0.17
0.22
0.23
0.34
0.19
Percent in Recovery
n.s.d., effect size f0.06
n.s.d., effect size f0.06
n.s.d., effect size f0.12
n.s.d., effect size f0.16
Source Dennis et al., 2004
105
Moderate to large differences in
Cost-Effectiveness by Condition
Trial 2
Trial 1
20
20,000
16
16,000
12
12,000
Cost per person in recovery
at month 12
over 12 months
Cost per day of abstinence
8
8,000
4
4,000
0
0
MET/
MET/ CBT5
FSN
MET/ CBT5
ACRA
MDFT
CBT12
4.91
6.15
15.13
9.00
6.62
10.38
CPDA
CPPR
3,958
7,377
15,116
6,611
4,460
11,775
plt.05 effect size f0.48
plt.05 effect size f0.22
plt.05, effect size f0.72
plt.05, effect size f0.78
Source Dennis et al., 2004
106
Cost Per Person in Recovery at 12 and 30 Months
After Intake by CYT Condition

Trial 1 (n299)
Trial 2 (n297)
Cost Per Person in Recovery (CPPR)
30,000
ACRA Effect Largely Sustained
25,000
20,000
15,000
10,000
5,000
0
MET/ CBT5
MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
6,437
10,405
24,725
27,109
8,257
14,222
CPPR at 30 months
3,958
7,377
15,116
6,611
4,460
11,775
CPPR at 12 months
Plt.0001, Cohens f 1.42 and 1.77 at 12
months Plt.0001, Cohens f 0.76 and 0.94 at 30
months
Source Dennis et al., 2003 forthcoming
107
Change in Quarterly Costs to Society (12 months
minus Intake)
30,000
30,000
25,000
25,000
20,000
20,000
15,000
15,000
10,000
10,000
5,000
5,000
-
-
(5,000)
(5,000)
(10,000)
(10,000)
(15,000)
(15,000)
Cond x Site 4 sig reduction, 2 sig Incr, 6 no
sig dif (low power)
(20,000)
(20,000)
Three sites went down significantly, one went up
significantly
(25,000)
(25,000)
MET/
MET/
FSN
MET/
ACRA
MDFT
Average
CBT5
CBT12
CBT5
Source Dennis et al., 2004
108
Cumulative Recovery Pattern at 30 months
5 Sustained
Recovery
37 Sustained
19 Intermittent,
Problems
currently in
recovery
39 Intermittent,
currently not in
recovery
The Majority of Adolescents Cycle in and out of
Recovery
Source Dennis et al, forthcoming
109
Environmental Factors are also the Major
Predictors of Relapse
AOD use in the home, family problems,
homelessness, fighting, victimization, self help
group participation, structure activities
Baseline
Family
.32
.77
.18
Conflict
Recovery
Environment
-.54
Risk
-.13
.17
.58
.74
Family
.22
.32
Substance-
-.09
Cohesion
Substance
.43
Related
Use
Problems
.32
.82
.19
.11
Social
Social
.19
-.08
.22
Support
Risk
Baseline
Baseline
Model Fit CFI.97 to .99 RMSEA.04 to .06
.21
Peer AOD use, fighting, illegal activity,
treatment, recovery, vocational activity
Baseline
Source Godley et al (2005)
110
Crime/Violence and Substance Problems Interact
to Predict Recidivism
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
111
Crime/Violence and Substance Problems Interact
to Predict Violent Crime or Arrest
12 month recidivism To violent crime or arrest
Crime and Violence Scale
Substance Problem Scale
High
High
Mod.
Mod.
(Intake) Substance Problem Severity did not
predict violent recidivism
Low
Low
Source CYT ATM Data
112
Post Script on CYT
  • The CYT interventions provide replicable models
    of brief (1.5 to 3 month) treatments that can be
    used to help the field maintain quality while
    expanding capacity.
  • While a good start, the CYT interventions were
    still not an adequate dose of treatment for the
    majority of adolescents including many who
    continued to vacillate in and out of recovery
    after discharge from CYT.
  • Descriptive, outcome and economic analyses have
    been published
  • All five interventions are currently being used
    in subsequent experiments
  • The MET/CBT5 intervention is currently being
    replicated in a 38 site study and ACRA will be
    replicated in a multisite study slated to be
    funded next year.
  • Over 40,000 copies of the CYT manuals have been
    distributed by NCADI and as many electronic
    copies have been distributed by CD or the website

113
Findings from the Assertive Continuing Care
(ACC) Experiment
  • 183 adolescents admitted to residential substance
    abuse treatment
  • Treated for 30-90 days inpatient, then discharged
    to outpatient treatment
  • Random assignment to usual continuing care (UCC)
    or assertive continuing care (ACC)
  • Over 90 follow-up 3, 6, 9 months post
    discharge

Source Godley et al 2002, forth coming
114
Time to Enter Continuing Care and Relapse after
Residential Treatment (Age 12-17)
100
90
80
70
Relapse
60
Percent of Clients
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source Godley et al., 2004 for relapse and 2000
Statewide Illinois DARTS data for CC admissions
115
ACC Enhancements
  • Continue to participate in UCC
  • Home Visits
  • Sessions for adolescent, parents, and together
  • Sessions based on ACRA manual (Godley, Meyers et
    al., 2001)
  • Case Management based on ACC manual (Godley et
    al, 2001) to assist with other issues (e.g., job
    finding, medication evaluation)

116
Assertive Continuing Care (ACC) Hypotheses
Assertive Continuing Care
117
ACC Improved Adherence
100
20
30
10
40
50
60
70
80
90
0
Weekly
Tx
Weekly 12 step meetings
Relapse prevention
Communication skills training
Problem solving component
Regular urine tests
Meet with parents 1-2x month
Weekly telephone contact
Contact w/probation/school
Referrals to other services
Follow up on referrals
Discuss probation/school compliance
Adherence Meets 7/12 criteria
Source Godley et al 2002, forthcoming
118
GCCA Improved Early (0-3 mon.) Abstinence
100
90
80
70
60
50
38
36
40
30
24
20
10
0
Any AOD (OR2.16)
Alcohol (OR1.94)
Marijuana (OR1.98)
Low (0-6/12) GCCA
Source Godley et al 2002, forthcoming
119
Early (0-3 mon.) Abstinence Improved Sustained
(4-9 mon.) Abstinence
100
90
80
70
60
50
40
30
22
22
19
20
10
0
Any AOD (OR11.16)
Alcohol (OR5.47)
Marijuana (OR11.15)
Early(0-3 mon.) Relapse
Source Godley et al 2002, forthcoming
120
Post script on ACC
  • The ACC intervention improved adolescent
    adherence to the continuing care expectations of
    both residential and outpatient staff doing so
    improved the rates of short term abstinence and,
    consequently, long term abstinence.
  • Despite these GAINs, many adolescents in ACC (and
    more in UCC) did not adhere to continuing care
    plans.
  • The ACC preliminary findings are published and
    the main findings are currently under review.
  • Several CSAT grantees are also seeking to
    replicate ACC as part of the Adolescent
    Residential Treatment (ART) program.
  • A second ACC experiment is currently under way to
    evaluate whether providing contingency management
    will further improve outcomes.
  • The ACC manual is being distributed via the
    website and the CD you have been provided.

121
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122
Context Circa 1998-99
  • Few research studies of existing treatment
    programs and no published manuals to support
    replication for the few studies that were done
  • Not clear whether research based treatment
    protocols were any better than what the better
    programs were already doing
  • The purpose of ATM was to manualize existing
    programs that appeared promising, then to
    evaluate them using the same measures and methods
    as CYT (allowing quasi-experimental comparisons)

123
Normal Adolescent Development
  • Biological changes in the body, brain, and
    hormonal systems that continue into mid-to-late
    20s.
  • Shift from concrete to abstract thinking.
  • Improvements in the ability to link causes and
    consequences (particularly strings of events over
    time).
  • Separation from a family-based identity and the
    development of peer- and individual-based
    identities.
  • Increased focus on how one is perceived by peers.
  • Increasing rates of sensation seeking/trying new
    things.
  • Development of impulse control and coping skills.
  • Concerns about avoiding emotional or physical
    violence.

124
Key Adaptation for Adolescents
  • Examples need to be altered to relevant
    substances, situations, and triggers
  • Consequences have to be altered to things of
    concern to adolescents
  • Most ado
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