State of the Art of Treating Adolescent Substance Use Disorders: Course, Treatment System, and Evidence Based Practices

1
State of the Art of Treating Adolescent
Substance Use Disorders Course, Treatment
System, and Evidence Based Practices

• Michael Dennis, Ph.D.
• Chestnut Health Systems,
• Bloomington, IL
• Presentation at 2005 State Adolescent
  Coordinators (SAC) Grantee Orientation Meeting,
  November 28-30, 2005, Baltimore, MD. 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 [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org

2
Four Parts of this Presentation

1. Epidemiological Course Examining the
   prevalence, course, and consequences of
   adolescent substance use and co-occurring
   disorders and the unmet need for treatment
2. The Treatment System Summarizing major trends
   in the adolescent treatment system and the
   variability by state
3. Evidence Based Practice Highlighting what it
   takes to move the field towards evidenced based
   practice related to assessment, treatment,
   program evaluation and planning
4. Treatment Effectiveness Findings from four
   recent treatment outcome studies.

3
Part 1 Epidemiological Course Examining 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 SAC Grantee
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 SAC Grantee
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
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

21
Part 2 The Treatment System Summarizing major
trends in the adolescent treatment system and
the variability by state
22
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
23
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 SAC Grantee
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 )
24
Change in Focal Substances
150,000
400
310
111
253
125,000
300
100,000
200
19
138
44
61 growth
36
75,000
100
46
50,000
0
25,000
-100
-56
-66
0
-200
Other\e
Alcohol
1993
Stimulants
Inhalants
Hallucinogens
Cocaine/Crack
Other
Amphetamines
Heroin/Opiates
Marijuana/Hash
2003
Methamphetamines
Change
TEDS Primary, Secondary or Tertiary problem
Source Treatment Episode Data Set (TEDS)
1993-2003.
25
Prevalence of Focal Problems Vary by State
100
100
80
80
60
60
Methamphetamine 20 or higher in AZ,
CA,ID,MN,NV,WA
40
40
Cocaine 20 or higher in DE TX
Other Amphetamines 20 or higher in OR
20
20
Opiates 20 or higher in MA NM
0
0
Other\e
Heroin/
Opiates
Alcohol
Stimulants
Inhalants
Marijuana/
Hash
Hallucinogens
Meth-
amphetamines
Other
Amphetamines
Cocaine/ Crack
Source Treatment Episode Data Set (TEDS)
1993-2003.
26
Change in Referral Sources
JJ referrals have doubled, are 53 of 2003
admissions and driving growth
61 growth
Source Treatment Episode Data Set (TEDS)
1993-2003.
27
Change in Level of Care
IOP has had the fastest growth
150,000
400
125,000
300
Residential has grown, but slower than expected
208
100,000
200
66
56
75,000
100
61 growth
50,000
0
30
19
25,000
-100
0
-200
Outpatient
Intensive
Detox
Short-term
Long-term
1993
Outpatient
Residential
Residential
2003
Change
Source Treatment Episode Data Set (TEDS)
1993-2003.
28
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.
29
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.
30
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)

31
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 .
32
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 .
33
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

34
Part 3 Evidence Based Practice Highlighting
what it takes to move the field towards evidenced
based practice related to assessment, treatment,
program evaluation and planning
35
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 )

36
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

37
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

38
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

39
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

40
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)

41
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
42
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

43
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
44
Progressive Assessment Approach

• GAIN Short Screener (2 pages, 5 min) for use in a
  general population or as fast/simple measure
  severity
• of substance use disorders is needed.
• Screening for Targeted Referral
• Assessment of who needs crisis or brief
  intervention (e.g., by SAP, doctor) vs. more
  detailed assessment and specialized
  treatment/referral
• Decision rules about where to send may be more
  complex (e.g., substance abuse, mental health,
  both)
• Comprehensive Biopsychosocial
• Used to identify common problems and how they are
  interrelated
• Requires more skill in administration and even
  more in interpretation
• Specialized Assessment
• The bio-psycho-social may identify areas where
  additional assessment by a specialist (e.g.,
  psychiatrist, school counselor) may be needed to
  rule out a diagnosis or develop a treatment plan
  or individual education plan
• Program Level Assessment
• For program management, evaluation, and planning

45
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)
46
GAIN Short Screen (GAIN-SS)

• Administration Time 4-5 minute
• 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.

47
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
48
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












49
GAIN Quick (GAIN-Q)

• Administration Time 20-30 minute
• Training Requirements ½ day
• 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.

50
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
51
GAIN Initial (GAIN-I)

• Administration Time 90 (core) to 120 (full)
  minute
• Training Requirements 3 days review/feedback
  on 2 to 6 tapes (or direct observations) over 1
  to 2 months formal certification program for
  administration and trainers
• 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

52
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.

53
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
54
CSAT Adolescent Treatment Cooperative Data Set

• Recruitment 1998-2004
• Sample The 2004 CSAT adolescent treatment data
  set included data on 5,468 adolescents from 67
  local evaluations (and is growing exponentially
  in people, sites, and number of follow-ups)
• Levels of Care Adolescent EI, OP, IOP, STR,
  LTR, CC
• Instrument Global Appraisal of Individual Needs
  (GAIN)
• Follow-up Over 85 follow-up 3, 6, 9 months
• post discharge
• Funding CSAT contract 270-2003-00006 and
  multiple individual grants

55
Demographic Characteristics
100
10
20
30
40
50
60
70
80
90
0
Male
74
Am. Native
6
Asian
1
300 or more adolescents in each subgroup
African Am.
17
White
45
Hispanic
15
Mixed/Other
16
Under 14
17
15-17
76
18 to 25
7
Source CSAT AT Common GAIN Data set
56
Other Characteristics
100
10
20
30
40
50
60
70
80
90
0
50
Single Parent
Homeless or
39
Runaway
34
Employed
86
In School
Recently in a Controlled Environment
45
Juvenile Justice Involvement
75
Source CSAT AT Common GAIN Data set
57
Weekly/Daily Substance Use Pattern
100
10
20
30
40
50
60
70
80
90
0
65
Any AOD Use
52
Marijuana
20
Alcohol
In our data and in TEDS, 1 in 5 did not use in
the month before intake hence the use of 90 day
window and measures of pre-CE use
5
Cocaine/Crack
3
Heroin/Opioids
8
Other Drugs
14 or more days in Controlled Environment
30
Source CSAT AT Common GAIN Data set
58
Severity of Substance Use Disorders
100
10
20
30
40
50
60
70
80
90
0
Self reported abuse/ dependence
88
86
First use under 15
65
Weekly or more AOD use
58
Past Year Dependence
Prior Substance Abuse Tx
43
34
Past week withdrawal
Past week severe withdrawal
12
11
First use under 10
Source CSAT AT Common GAIN Data set
59
Mixed Problem Recognition
100
10
20
30
40
50
60
70
80
90
0
Acknowledges AOD problem
35
Believes treatment needed
81
Self reports 1
abuse/dependence
92
Problem criteria
Gives one or more
99
reasons to quit
Source CSAT AT Common GAIN Data set
60
High Risk Recovery Environments
100
10
20
30
40
50
60
70
80
90
0
29
In home
among work/ school peers
52
Regular alcohol use
among social peers
61
17
In home
among work/ school peers
67
Regular drug use
among social peers
79
Source CSAT AT Common GAIN Data set
61
High Rates of Other Psychiatric Problems
100
10
20
30
40
50
60
70
80
90
0
49
Any Internal Disorder
Depressive Disorder
38
21
Anxiety Disorder
28
Trauma Related Disorder
32
Any Self Mutilation
Any homicidal/ suicidal thoughts
28
67
Any External Disorder
Conduct Disorder
59
With External Disorders more prominent in
Adolescents
Attention Deficit-Hyperactivity Disorder (ADHD)
48
Source CSAT AT Common GAIN Data set
62
Psychiatric Problems Increase with Level of Care
100
88
80
78
80
70
68
65
56
60
52
52
47
44
44
43
35
36
40
25
21
21
20
0
Conduct
ADHD
Major
Generalized
Traumatic
Any Co-
Disorder
Depressive
Anxiety
Stress
Occurring
Disorder
Disorder
Disorder
Disorder
Outpatient
Long Term-Residential
Short-Term Residential
Source CSATs Cannabis Youth Treatment (CYT) and
Adolescent Treatment Model (ATM)
63
High rate of crime and violence
100
10
20
30
40
50
60
70
80
90
0
Past Year
Any violence or
86
illegal activity
72
Physical Violence
58
Property Crimes
57
Drug Related Crime
Interpersonal/violent
51
Crimes
Source CSAT AT Common GAIN Data set
64
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)
65
High Rates of HIV/STI risk behaviors
100
10
20
30
40
50
60
70
80
90
0
81
Sexual Activity
57
Victimization
Lifetime
16
Needle Use
61
Sexual Activity
Sex Under AOD Influence
51
Multiple Sex Partners
35
Past 90 Days
Unprotected Sex
29
23
Victimization
4
Needle Use
Source CSAT AT Common GAIN Data set
66
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
67
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)
68
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
  ProgramsSubstance Abuse and Mental Health
  Services Administration (SAMHSA), Department of
  Health and Human Services http//www.modelprogra
  ms.samhsa.gov

69
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

70
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

71
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

72
Part 4 Treatment Effectiveness Findings from
four recent treatment outcome studies
73
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
74
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
75
Two Effectiveness Experiments
Trial 2
Trial 1
Incremental Arm
Alternative Arm
Source Dennis et al, 2002
76
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
77
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
78
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
79
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
80
Adolescent Cannabis Users in CYT were as or More
Severe Than Those in TEDS
Source Tims et al, 2002
81
Demographic Characteristics
Source Tims et al, 2002
82
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
83
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
84
Multiple Problems were the NORM
Self-Reported in Past Year
Source Dennis et al, 2004
85
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
86
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
87
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
88
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
89
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
90
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
91
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
Source Dennis et al forthcoming
92
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)
93
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
94
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
95
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

96
(No Transcript)
97
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)

98
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.

99
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 adolescents do not recognize their substance
  use as a problem and are being mandated to
  treatment
• All materials need to be converted from abstract
  to concrete concepts

• Co-morbid problems (mental, trauma, legal) are
  the norm and often predate substance use
• Treatment has to take into account the multiple
  systems (family, school, welfare, criminal
  justice)
• Less control of life and recovery environment
• Less aftercare and social support
• Complicated staffing needs

100
Program Evaluation Data
Level of Care Clinics Clinics Adolescents 1 FU
Outpatient/ Intensive Outpatient (OP/IOP) Outpatient/ Intensive Outpatient (OP/IOP) 8 560 96
Long Term Residential (LTR) Long Term Residential (LTR) 4 390 98
Short Term Residential (STR) Short Term Residential (STR) 4 594 97
Total Total 16 1544 97
Completed follow-up calculated as 1
interviews over those due-done, with site varying
between 2-4 planned follow-up interviews. Of
those due and alive, 89 completed with 2
follow-ups, 88 completed 3 and 78 completed
4. Both LTR and STR include programs using CD
and therapeutic community models
101
Length of Stay Varies by Level of Care
100
Long Term Residential (median154 days n222)
Short Term Residential (median31 days n589)
Outpatient (median 88 days n554)
About half of those in OP stay 90 or more days
50
Percent Still in Treatment
0
0
30
60
90
120
150
180
210
240
270
300
330
360
390
Over half the STR say more than 30 days
Length of Stay
Source Adolescent Treatment Model (ATM) Data
102
Adolescents more likely to transfer
Source Adolescent Treatment Model (ATM) Data
103
Years of Use
Source Adolescent Treatment Model (ATM) data
104
Patterns of Weekly (13/90) Use
100
83
80
72
71
61
57
56
60
43
40
29
20
14
20
9
7
4
4
1
0
OP/IOP (n560)
LTR (n390)
STR (n594)
Weekly use of anything
Weekly Marijuana Use
Weekly Alcohol Use
Weekly Crack/Cocaine Use
Weekly Heroin/Opioid Use
Source Adolescent Treatment Model (ATM) data
105
Substance Use Severity
Source Adolescent Treatment Model (ATM) data
106
Change in Substance Frequency Indexby Level of
Care\a
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t
for time effect, \s for site effect, and \ts for
time x site effect.
107
Change in Substance Problem Indexby Level of
Care\a
LTR more like OP on symptoms count
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
108
Percent in Recovery (no past month use or
problems while living in the community)
Longer term outcomes are similar on substance use
\a Source Adolescent Treatment Model (ATM)
data Levels of cares coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t
for time effect, \s for site effect, and \ts for
time x site effect.
109
Multiple Co-occurring Problems Were the Norm and
Increased with Level of Care
100
88
80
78
80
70
68
65
56
60
52
52
47
44
44
43
35
36
40
25
21
21
20
0
Conduct
ADHD
Major
Generalized
Traumatic
Any Co-
Disorder
Depressive
Anxiety
Stress
Occurring
Disorder
Disorder
Disorder
Disorder
Outpatient
Long Term Residential
Short Term Residential
Source CSATs Cannabis Youth Treatment (CYT) and
Adolescent Treatment Model (ATM),
110
Change in Emotional Problem Indexby Level of
Care\a
Note the lack of a hinge Effect is generally
indirect (via reduced use) not specific
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
111
Pattern of SA Outcomes is Related to the Pattern
of Psychiatric Multi-morbidity
2 Co-occurring 1 Co-occurring
No Co-occurring
Multi-morbid Adolescents start the highest,
change the most, and relapse the most
Number of Past Month Substance Problems
0
6
12
3
Months Post Intake (Residential only)
Source Shane et al 2003, PETSA data
112
Broad Range of Past Year Illegal Activity
100
95
93
93
86
85
90
82
81
81
80
78
74
80
71
69
68
65
70
60
50
40
30
20
10
0
OP/IOP (n560)
LTR (n390)
STR (n594)
Any illegal activity
Property crimes
Interpersonal crimes
Drug related crimes
Acts of physical violence
Source Adolescent Treatment Model (ATM) data
113
Change in Illegal Activity Indexby Level of
Care\a
Residential Treatments have a specific effect
Outpatient Treatments has an indirect effect
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
114
High Rates of Victimization were the Norm
Source Adolescent Treatment Model (ATM) data
115
Victimization and Level of Care Interact to
Predict Outcomes
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
116
How 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 d