Characteristics, Needs, Services and Outcomes of Juvenile Treatment Drug Courts compared to Adolescent Outpatient and Adult Treatment Drug Courts

1
Characteristics, 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
2
Notes

• 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

3
The Goals of this Presentation are to

1. Illustrate why it is so important to intervene
   with juvenile drug users
2. Review what we know about juvenile treatment drug
   courts (JTDC) so far
3. Compare JTDC to regular adolescent outpatient
   (AOP) in terms of who is served, what services
   they receive and their treatment outcomes
4. Examine initial comparison of JTDC to Adult
   Treatment Drug Courts (ATDC) and Family Drug
   Courts (FDC)

4
Alcohol 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
5
Adolescents who use weekly or more often are more
likely during the past year to have ...

• Source Dennis McGeary, 1999

6
Adolescent 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.
7
Life 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
8
While 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
9
What 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
10
Investing 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
11
Background 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
12
What 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
13
What 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
14
Findings 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?

15
Juvenile 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
16
Adolescent 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
17
Demographics
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
18
Crime 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
19
Intensity 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
20
Environmental Risk Factors
JTDC less likely to have use in home and
victimization
Source Ives et al., 2010 plt.05
21
Substance 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
22
Substance Use Disorders
JTDC similar on substance use disorders
Source Ives et al., 2010 plt.05
23
Substance 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
24
Other 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
25
HIV Risk Behaviors (past 90 days)
JTDC more likely have multiple sexual partners
Source Ives et al., 2010 plt.05
26
Number 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
27
Matching 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
28
Treatment 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
29
Substance Abuse Treatment (intake to 3 months)
JTDC received more days of any treatment IOP,
also more satisfaction
Source Ives et al., 2010 plt.05
30
Range 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
31
Mental Health Treatment Received(intake to 3
months)
No differences in MH treatmentmost is driven by
medication
Source Ives et al., 2010 plt.05
32
Other 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
33
Comparison 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)
34
Strengths 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

35
Findings from JTDC and ATDC/FDC Multi-Site Quasi
Experiment

• Initial Comparison

36
Findings 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?

37
Adult 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
38
Juvenile 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
39
Demographics
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
40
Crime 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
41
Intensity 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
42
Environmental 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
43
Substance 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
44
Substance 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
45
Substance Treatment History
JTDC less likely to report each of these
treatment history items.
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05
46
Other 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
47
HIV 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
48
Number 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
49
JTDC and ATDC/FDC Comparison Treatment
50
Type 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
51
Treatment 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
52
Substance 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
53
Range 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
54
Mental 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
55
Other 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
56
JTDC and ATDC/FDC Comparison Outcomes
57
Comparison 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.
58
Outcome Status Across Waves
ATDC/FDC
JTDC
Source CSAT 2010 Horizontal dataset ATDC and
FDC sites plt.05 or 6-month if
missing 3-month
59
In 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
60
Strengths 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

61
Major 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

62
Impact 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
63
Evidence-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
64
Evidence-Based Practices Can be SIMPLE On-site
proactive urine testing can be used to reduce
false negatives by more than half
65
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
66
References

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  Evidence on the Prospects of Expanding Treatment
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References (continued)

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  s.htm7.3.1
• Office of Applied Studies (OAS, 2006). Substance
  Abuse and Mental Health Services
  Administration.(SAMHSA) National Survey on Drug
  Use and Health, 2006 Computer file.
  ICPSR21240-v4. Ann Arbor, MI Inter-university
  Consortium for Political and Social Research
  distributor, 2009-08-12.
• Office of Applied Studies. 2008. Substate
  estimates from the 2004-2006 National Surveys on
  Drug Use and Health. Substance Abuse and Mental
  Health Services Administration.
• Office of Juvenile Justice and Delinquency
  Prevention (OJJDP). (May 2001). Juvenile Drug
  Court Program. Department of Justice, OJJDP,
  Washington, DC. NCJ 184744.
• Scott, C. K., Dennis, M. L. (2009). Results
  from Two Randomized Clinical Trials evaluating
  the impact of Quarterly Recovery Management
  Checkups with Adult Chronic Substance Users.
  Addiction.
• Scott, C. K., Dennis, M. L., Funk, R.R. (2008).
  Predicting the relative risk of death over 9
  years based on treatment completion and duration
  of abstinence . Poster 119 at the College of
  Problems on Drug Dependence (CPDD) Annual
  Meeting, San Juan, PR, June 16, 2008. Available
  at http//www.chestnut.org/li/posters
• Scott, C. K., Foss, M. A., Dennis, M. L.
  (2005). Pathways in the relapse, treatment, and
  recovery cycle over three years. Journal of
  Substance Abuse Treatment, 28, S61-S70.
• 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
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• Wasserman, G. A., McReynolds, L. S. Schwalbe, C.
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Resources 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