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Screening and Assessment: Lessons from RWJF

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Screening and Assessment: Lessons from RWJF s Reclaiming Futures Projects Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL On line webinar ... – PowerPoint PPT presentation

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Title: Screening and Assessment: Lessons from RWJF


1
Screening and Assessment Lessons from RWJF s
Reclaiming Futures Projects
  • Michael Dennis, Ph.D.
  • Chestnut Health Systems,
  • Bloomington, IL
  • On line webinar Presentation for Reclaiming
    Futures, March 28, 2009. This presentation was
    supported by a Grant from the Robert Woods
    Johnson Foundation (RWJF) and reports on
    treatment research funded by them as well as
    Center for Substance Abuse Treatment (CSAT),
    Substance Abuse and Mental Health Services
    Administration (SAMHSA) under contracts
    270-2003-00006 and 270-07-0191, as well as
    several individual CSAT, NIAAA, NIDA and private
    foundation 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
    Michael Dennis, Chestnut Health Systems, 448
    Wylie Drive, Normal, IL 61761, phone
    309-451-7801, fax 309-451-7765, e-Mail
    mdennis_at_Chestnut.Org Questions about the GAIN
    can also be sent to gaininfo_at_chestnut.org

2
Goals of this Presentation are to
  1. Summarize the physical and chronic nature of
    substance use disorders, why the justice system
    cares and why adolescence is just a critical time
    period
  2. Describe the need for standardizing how we
    identify juveniles with behavioral health issues
  3. Explaining how to decide what is needed on the
    continuum of screening to assessment
  4. Illustrate how the differences in what this looks
    like in terms what you receive at client and
    program level using data from 5 of the original
    Reclaiming Futures Sites
  5. Discuss implications for program planing and
    policy

3
Short Term Impact of Substance Use on the
Brain (PET Scan Minutes After Using Cocaine)
Rapid rise in brain activity after taking cocaine
Actually ends up lower than they started
Photo courtesy of Nora Volkow, Ph.D. Mapping
cocaine binding sites in human and baboon brain
in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL,
Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J,
Bendreim B, Gatley ST. et al. Synapse
19894(4)371-377.
4
Recovery from cumulative use takes more time
(PET Scan Activity Days After Using Cocaine)
With repeated use, there is a cumulative effect
of reduced brain activity which requires
increasingly more stimulation (i.e., tolerance)
Normal
Cocaine Abuser (10 days)
Even after 100 days of abstinence activity is
still low
Cocaine Abuser (100 days)
Photo courtesy of Nora Volkow, Ph.D. Volkow ND,
Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey
SL. Long-term frontal brain metabolic changes in
cocaine abusers. Synapse 11184-190, 1992 Volkow
ND, Fowler JS, Wang G-J, Hitzemann R, Logan J,
Schlyer D, Dewey 5, Wolf AP. Decreased dopamine
D2 receptor availability is associated with
reduced frontal metabolism in cocaine abusers.
Synapse 14169-177, 1993.
5
The effects on the brain can be long
lasting(Serotonin Present in Cerebral Cortex
Neurons )
Still not back to normal after 7 years
Reduced in response to excessive use
Image courtesy of Dr. GA Ricaurte, Johns Hopkins
University School of Medicine
6
The Costs of Substance Use
  • Drug use costs the U.S. over 181 billion a year,
    primarily due to productivity loss, and health
    care and crime costs (Harwood, 2000)
  • Abuse of alcohol, tobacco, and other drugs, kills
    more Americans than any other class of health
    behavior (Mokdad et al 2004)
  • Of the 20,196 deaths from overdose in 2004, 358
    (2) were from alcohol and 19,838 (98) were from
    other drugs, with 9798 (49) from opioids. (MMWR,
    2007)
  • Of the 23.2 million people (9.5 of the U.S.
    population) who had substance disorders in 2005,
    only 2.2 million (0.9) received any treatment
    (OAS, 2006)

7
Overlap with Crime and Civil Issues
  • Committing property crime, drug related crimes,
    gang related crimes, prostitution, and gambling
    to trade or get the money for alcohol or other
    drugs
  • Committing more impulsive and/or violent acts
    while under the influence of alcohol and other
    drugs
  • Crime levels peak between ages of 15-20 (periods
    or increased stimulation and low impulse control
    in the brain)
  • Adolescent crime is still the main predictor of
    adult crime
  • Parent substance use is intertwined with child
    maltreatment and neglect which in turn is
    associated with more use, mental health problems
    and perpetration of violence on others

8
Potential Cost Savings of Expanding Diversion to
Treatment Programs in Justice Settings
  • Currently treating about 55,000 people in these
    diversion programs and drug courts at a cost of
    515 million with an average return on investment
    (ROI) of 2.14 per dollar
  • The ROI is higher (2.71) for those with more
    crime
  • It is estimated that there are at least twice as
    many people in need of drug court as getting it
  • Investing the 1 billion to treat them would
    likely produce a ROI of 2.17 billion to society
  • Source Bhati et al (2008) To Treat or Not To
    Treat Evidence on the Prospects of Expanding
    Treatment to Drug-Involved Offenders.
    Washington, DC Urban Institute.

9
Severity of Past Year Substance Use/Disorders 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
(2002 U.S. Household Population age 12
235,143,246)
65
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Source 2002 NSDUH Dennis Scott 2007
10
Crime Violence by Substance Severity
Age 12-17
Source NSDUH 2006
11
Family, Vocational MH by Substance Severity
Age 12-17
As well as other School and Mental Health Problems
Source NSDUH 2006
12
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.t
13
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
14
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
15
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
Reducing the years of use and its associated
problems by over a decade
.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
16
Treatment Careers Last for Years
Median of 3 to 4 episodes of treatment over 9
years
1.0
.9
Cumulative Survival
.8
Over 2/3rds eventually get better (which is
better than most major DSM disorders)
.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
17
Several Recent Reviews and over 22 Experiments
and Quasi-Experiments Have Demonstrated That
  • A growing range of drug treatment courts are
    being found effective and cost effective
  • More assertive continuing care can increase
    adherence with continuing care expectations
  • Recovery management checkups can identify people
    who have relapsed and get them back to treatment
    faster
  • That doing each improves short and long term
    outcomes
  • That the rate of improve effects went up as
    interventions when from less than 3 months (38)
    to 3 to 12 months (44) to more than 12 months
    (100)
  • Source Bhati et al 2008 Dennis et al 2003,
    2007, Godley et al 2002, 2007 Marlowe, 2008
    McKay, in press Scott et al 2005, in press

18
The Movement to Increase Screening
  • Screening, Brief Intervention and Referral to
    Treatment (SBIRT) has been shown to be effective
    in identifying people not currently in treatment,
    initiating treatment/change and improving
    outcomes (see http//sbirt.samhsa.gov/ )
  • The US Preventive Services Task Force (USPSTF,
    2004 2007), National Quality Forum (NQF, 2007),
    and Healthy People 2010 have each recommended
    regular screening, brief intervention, and
    referral to treatment (SBIRT) for tobacco and
    alcohol abuse in general medical settings for
    everyone
  • The latter two also recommend SBIRT for drug use
    in high risk populations (e.g., adolescents,
    pregnant and post partum women, people with HIV,
    and people with co-occurring psychiatric
    conditions)
  • RWJF, OJJDP, CSAT and NIDA are each funding
    several projects to develop and evaluate models
    for doing this

19
Places vary in the rate of problems (Past Year
Substance Abuse or Dependence)
There is even variation within DC (an area less
than 10 square miles) and of course within
individuals
Source OAS, 2006
20
Crime/Violence and Substance Problems Interact
to Predict Any 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
21
Crime/Violence and Substance Problems Interact
Differently to Predict Recidivism to Violent Crime
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
22
Mental Health Comorbidity Among Girls in Detention
Multiple Problems are the norm
Source Teplin, LA, Abram, KM, McCelland, GM,
Mericle, AA, Dulcan, MK, and Washburn, JJ (2006)
Psychiatric Disorders of Youth in Detention.
Washington, DC OJJDP. Retrieved from
http//www.ncjrs.gov/pdffiles1/ojjdp/210331.pdf
23
Mental Health Comorbidity Among Boys in Detention
While there are gender differences, the
differences are often degrees of variation
Source Teplin, LA, Abram, KM, McCelland, GM,
Mericle, AA, Dulcan, MK, and Washburn, JJ (2006)
Psychiatric Disorders of Youth in Detention.
Washington, DC OJJDP. Retrieved from
http//www.ncjrs.gov/pdffiles1/ojjdp/210331.pdf
24
Number of Major Clinical Problems by System of
Care
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source Dennis et al in 2008
CSAT 2007 AT Outcome Data Set (n12,824)
25
Number of Problems is Related to Level of Care
Clients entering Short Term Residential (usually
dual diagnosis) have 5.5 times higher odds of
having 5 major problems
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source Dennis et al 2009 CSAT 2007 Adolescent
Treatment Outcome Data Set (n12,824)
26
No. of Prob. is related to the Severity of
Victimization
Those with high lifetime levels of victimization
have 13 times higher odds of having 5 major
problems
Severity of Victimization
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source Dennis et al 2009 CSAT 2007 Adolescent
Treatment Outcome Data Set (n12,824)
27
Continuum of Measurement (Common Measures)
  • Screening to Identify Who Needs to be Assessed
    (5-10 min)
  • Focus on brevity, simplicity for administration
    scoring
  • Needs to be adequate for triage and referral
  • GAIN Short Screener for SUD, MH Crime
  • ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD
  • SCL, HSCL, BSI, CANS for Mental Health
  • LSI, MAYSI, YLS for Crime
  • Quick Assessment for Targeted Referral (20-30
    min)
  • Assessment of who needs a feedback, brief
    intervention or referral for more specialized
    assessment or treatment
  • Needs to be adequate for brief intervention
  • GAIN Quick
  • ADI, ASI, SASSI, T-ASI, MINI
  • Comprehensive Biopsychosocial (1-2 hours)
  • Used to identify common problems and how they are
    interrelated
  • Needs to be adequate for diagnosis, treatment
    planning and placement of common problems
  • GAIN Initial (Clinical Core and Full)
  • CASI, A-CASI

More Extensive / Longer/ Expensive
Screener Quick
Comprehensive Special
28
Key Work Force / System Issues to Consider When
Selecting Assessment
  • High turnover workforce with variable education
    background related to diagnosis, placement and
    treatment planning.
  • Heterogeneous needs and severity characterized by
    multiple problems, chronic relapse, and multiple
    episodes of care
  • Lack of access to or use of data at the program
    level to guide immediate clinical decisions,
    billing and program planning
  • Missing or misrepresented data that needs to be
    minimized and incorporated into interpretations

29
Global Appraisal of Individual Needs (GAIN)
Logic Model as an Example
Issue
Instrument Feature
Protocol Feature
Outcome
  • Standardized approach to asking questions across
    domains
  • Questions spelled out and simple question format
  • Lay wording mapped onto expert standards for
    given area
  • Built in transition statements, prompts, and
    checks for inconsistent and missing information.
  • Responses to frequently asked questions
  • Multiple training resources
  • Formal training and certification protocols on
    administration, clinical interpretation, data
    management, project coordination, local,
    regional, and national trainers
  • Above focuses on consistency across populations,
    level of care, staff and time
  • On-going quality assurance and data monitoring
    for the reoccurrence or problems at the staff
    (site or item) level
  • Availability of technical assistance

High Turnover Workforce with Variable Education
Improved Reliability and Efficiency
  • Multiple domains
  • Focus on most common problems
  • Participant self description of characteristics,
    problems, needs, personal strengths and resources
  • Behavior recency, breadth, frequency
  • Utilization lifetime, recency and frequency
  • Dimensional measures
  • Interpretative cut points
  • Items and cut points mapped onto DSM for
    diagnosis, ASAM for placement, and to multiple
    standards and evidence- based practices for
    treatment planning
  • Computer generated scoring and reports
  • Treatment planning recommendations and links to
    evidence-based practice
  • Basic and advanced clinical interpretation
    training and certification

Heterogeneous Needs and Severity
Comprehensive Assessment
30
Global Appraisal of Individual Needs (GAIN)
Logic Model as an Example
Issue
Instrument Feature
Protocol Feature
Outcome
  • Data immediately available to support clinical
    decision making for a case
  • Data can be transferred to other clinical
    information system to support billing, progress
    reports, treatment planning and on-going
    monitoring
  • Data can be exported and cleaned to support
    further analyses
  • Data can be pooled with other sites to facilitate
    comparison and evaluation
  • PC and (soon) web based software applications and
    support
  • Formal training and certification on using data
    at the individual level and data management at
    the program level
  • Data routine pooled to support comparisons across
    programs and secondary analysis
  • Over two dozen scientists working with data to
    link to evidence-based practice

Lack of Access to or use of Data at the Program
Level
Improved Program Planning and Outcomes
  • Assurances, time anchoring, definitions,
    transition, and question order to reduce
    confusion and increase valid responses
  • Cognitive impairment check
  • Validity checks on missing, bad, inconsistency
    and unlikely responses
  • Validity checks for atypical and overly random
    symptom presentations
  • Validity ratings by staff
  • Training on optimizing clinical rapport
  • Training on time anchoring
  • Training answering questions, resolving vague or
    inconsistent responses, following assessment
    protocol and accurate documentation.
  • Utilization and documentation of other sources of
    information
  • Post hoc checks for on-going site, staff or item
    problems

Missing or Misrepresented Data
Improved Validity
31
Questions So Far?
  • For the rest of the session we will focus on
    doing
  • two things simultaneously
  • Demonstrating the difference in the depth and and
    breadth of information you get with different
    levels of assessment
  • Doing this by using findings from the first
    cohort of RWJF Reclaiming Future sites to also
    review what they learned

32
GAIN Clinical Collaborators Adolescent and Adult
Treatment Program
New Hampshire
Washington
Vermont
Maine
North
Montana
Dakota
Minnesota
Oregon
Massachusetts
South
Wisconsin
Idaho
Dakota
New York
Michigan
Wyoming
Rhode Island
Pennsylvania
Iowa
Connecticut
Nebraska
Ohio
Nevada
New Jersey
Indiana
Illinois
Utah
W. Virginia
Delaware
Colorado
California
Kansas
Virginia
Missouri
Kentucky
Maryland
North Carolina
Tennessee
District Of Columbia
Oklahoma
New Mexico
Arkansas
South Carolina
Arizona
Number of GAIN Sites
Georgia
Mississippi
0
Alabama
1 to 10
Texas
11 to 25
Louisiana
26 to 130
Alaska
GAIN State System
Florida
GAIN-SS State or
County System
Hawaii
Virgin Islands
Puerto Rico
10/08
33
Across measures, the GAIN has a Common Factor
Structure of Psychopathology
Source Dennis, Chan, and Funk (2006)
34
GAIN-Short Screener (GSS) Overview
  • Administration Time A 3- to 5-minute screener
  • Purpose Used in general populations to
  • identify or rule-out clients who will be
    identified as having any behavioral health
    disorders on the 60-120 min versions of the GAIN
  • triage area of problem
  • serve as a simple measure of change
  • Easy for administration and interpretation by
    staff with minimal training or direct supervision
  • Mode Designed for self- or staff-administration,
    with paper and pen, computer, or on the web
  • Translations English, with translations with us
    into Spanish and by collaborators into several
    languages including French, Hmong, Japanese,
    Mandarin, Pilipino, Portuguese, and Vietnamese so
    far

35
GAIN-Short Screener (GSS) Overview (continued)
  • Scales Four screeners for Internalizing
    Disorders, Externalizing Disorders, Substance
    Disorders, Crime/Violence, and a Total
  • Response Set Recency of 20 problems rated past
    month (3), 2-12 months ago (2), more than a year
    ago (1), never (0)
  • Interpretation Combined by cumulative time
    period as
  • Past month count (3s) to measure of change
  • Past year count (2s or 3s) to predict diagnosis
  • Lifetime count (1s, 2s or 3s) as a measure of
    peak severity
  • Can be classified within time period low (0),
    moderate (1-2) or high (3)
  • Can also be used to classify remission as
  • Early (lifetime but not past month)
  • Sustained (lifetime but not past year)
  • Reports Narrative, tabular, and graphical
    reports built into web based GAIN ABS and/or ASP
    application for local hosting

36
Internalizing Disorder Screening (IDScr)
Externalizing Disorder Screening (EDScr)
37
Substance Disorder Screening (SDScr)
Crime/violence Disorder Screening (CVScr)
38
GAIN Short Screener Profile of 2 Recl. Futures
Sites(Range based on 0/1-2/3 Symptoms)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
39
GAIN Short Screener Number of Problems Mod/Hi
93 endorsed one or more problems (40 4 or more)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
40
GAIN SS Psychometric Properties
Low Mod. High
100
Prevalence ( 1 disorder)
90
Sensitivity ( w disorder above)
80
Specificity ( w/o disorder below)
70
(n6194 adolescents)
60
Using a lower cut point increases prevalence and
specificity, but decreases sensitivity
50
40
At 3 or more symptoms we get 99 prevalence, 91
sensitivity, 89 specificity
30
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 2006
41
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












42
GAIN SS Total Score is Correlated With Level Of
Care Placement
43
GAIN SS Can Also be Used for Monitoring
20
12 mon.s ago (1s)
2-12 Mon.s ago (2s)
16
Past Month (3s)
Lifetime (1,2,or 3)
11
12
10
10
9
9
8
8
3
4
2
2
0
Intake
3
6
9
12
15
18
21
24
Mon
Mon
Mon
Mon
Mon
Mon
Mon
Mon
Total Disorder Screener (TDScr)
Monitor for Relapse
44
GAIN Quick (GQ) Overview
  • Administration Time 20-30 minutes (depending on
    severity and wether reasons for quiting module
    used)
  • Training Requirements 1 day (train the trainer)
    plus certification within 1-2 months
  • Mode Generally Staff Administered on Computer
    (can be done on paper or self administered with
    proctor)
  • Purpose Designed for use in targeted populations
    to support brief intervention or referral for
    further assessment or behavioral intervention
  • Translation English, with translations with us
    into Spanish by Chestnut and by collaborators
    being translated into French and Portuguese so far

45
GAIN Quick (GQ) Overview (Continued)
  • 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). Lifeimt
  • Response Set Breadth (past year symptom counts
    for behavior and lifetime for utilization) and
    Prevalence (past 90 days)
  • Interpretation
  • Items can be used individually or to create
    specific diagnostic or treatment planning
    statements
  • Items can be summed into scales or indices for
    each behavior problem or and for recent service
    utilization overall
  • All scales, indices and selected individual items
    have interpretative cut-points to facilitate
    clinical interpretation and decision making
  • Reports Narrative, tabular, graphical, validity
    and motivational interviewing reports built into
    web based GAIN ABS Program level reports
    available in SPSS/Excel

46
GAIN Quick Profile of 4 Reclaiming Futures Sites
(Range based on 0-24 / 25-74 / 75-100 of
Symptoms)
More detail within each area
Risk Stress Health
Source Reclaiming Futures Chicago, IL, Dayton,
OH, Portland, OR and Santa Cruz, CA
sites (n475).
Summary Measure
47
GAIN Quick Number of Problems Mod/Hi
97 endorsed one or more problems (69 4 or more
problems)
Source Reclaiming Futures Chicago, IL, Dayton,
OH, Portland, OR and Santa Cruz, CA
sites (n475).

48
GAIN Quick (GQ) In Transition
  • Strengths Length, Range of topics, Efficiently
    Categorize, Narrative reports to support
    screening, brief intervention, and referral to
    treatment
  • Problems
  • Lacks scales to support analyses or outcomes
    related to change over time
  • Item response choices do not provide information
    about lifetime problems or problems that have
    occurred in finer gradations of time within the
    past year
  • Current Personal Feedback Report focuses only on
    substance use and does not address the other
    content areas of the GAIN-Q
  • Only about 60 of the items can be directly
    imported into the GAIN-I
  • Cut points do not map onto GAIN I or clinical
    criteria well
  • Plans for Version 3
  • Keep focus on screening, brief intervention and
    referral to treatment
  • Subsume GSS and add similar screeners in other
    GAIN Q areas with recency response to address
    change and lifetime issues
  • Create a summary measure for days items to
    address change issues
  • Create reasons for change items in each area to
    support breif intervention, reducing number of
    items in substance use
  • Make all questions importable into full GAIN
  • Plans for Version 4 Add computer adaptive
    testing (CAT) component to get at more detailed
    diagnosis

49
GAIN Initial (GAIN-I) Overview
  • Administration Time Core version 60-90
    minutes/Full version 110-140 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) Advanced clinical
    interpretation recommended for clinical
    supervisors
  • Mode Generally Staff Administered on Computer
    (can be done on paper or self administered with
    proctor)
  • 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, COA, 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
  • Translation English, with translations with us
    into Spanish by Chestnut and by collaborators
    being translated into French and Portuguese so far

50
GAIN Initial (GAIN-I) Overview (Continued)
  • 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 3000 created variables to
    support clinical decision making and evaluation.
    It is also modularized to support customization
  • Response Set Breadth (past year symptom counts
    for behavior and lifetime for utilization),
    Recency (48 hours, 3-7 days, 1-4 weeks, 2-3
    months, 4-12 months, 1 years, never) and
    Prevalence (past 90 days), patient and staff
    ratings
  • Interpretation
  • Items can be used individually or to create
    specific diagnostic or treatment planning
    statements
  • Items can be summed into scales or indices for
    each behavior problem or type of service
    utilization
  • All scales, indices and selected individual items
    have interpretative cut-points to facilitate
    clinical interpretation and decision making
  • Reports Narrative, tabular, validity and
    motivational interviewing reports built into web
    based GAIN ABS New Narrative report include
    placement and treatment planning statements
    Program level reports available in SPSS/Excel

51
GAIN Initial Profile Substance Problems Past
Year(Range based range of clinical/logical/statis
tical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
52
GAIN Initial Profile Substance Problems by
Time(Range based range of clinical/logical/statis
tical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
53
GAIN Initial Profile Motivation and
Readiness(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
54
GAIN Initial Profile Crime/Violence(Range based
range of clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
55
GAIN Initial Profile Environmental Risk(Range
based range of clinical/logical/statistical
rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
56
GAIN Initial Profile Internalizing
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
57
GAIN Initial Profile Externalizing
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
58
GAIN Initial Profile Personality
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
59
GAIN Initial Profile General Factors /
Stress(Range based range of clinical/logical/stat
istical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
60
GAIN Initial Profile Other Problem Scales(Range
based range of clinical/logical/statistical
rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
61
GAIN Initial Profile Measures of Behavior Change
(Range based range of clinical/logical/statistica
l rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
62
GAIN Initial Number of Problems Mod/Hi
99.4 endorsed one or more problems (98.4 4 or
more)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
63
GAIN Treatment Planning/Placement Grid
Problem Recency/Severity Problem Recency/Severity Problem Recency/Severity Problem Recency/Severity
None Past Current (past 90 days) Low-Mod High Severity Current (past 90 days) Low-Mod High Severity
Treatment History None Past Current . 1. No Problem 2. Past problem Consider monitoring and relapse prevention. 3. Low/Moderate problems Not in treatment Consider initial or low invasive treatment. 4. Severe problems Not in treatment Consider a more intensive treatment or intervention strategies.
Treatment History None Past Current . 0. Not Logical Check under- standing of problem or lying and recode. 2. Past problem Consider monitoring and relapse prevention. 3. Low/Moderate problems Not in treatment Consider initial or low invasive treatment. 4. Severe problems Not in treatment Consider a more intensive treatment or intervention strategies.
Treatment History None Past Current . 0. Not Logical Check under- standing of problem or lying and recode. 5. No current problems Currently in treatment Review for step down or discharge. 6. Low/Moderate problems Currently in treatment Review need to continue or step up. 7. Severe problems Currently in treatment Review need for more intensive or assertive levels.
Current for Dimension B1 Past 7 days
64
Reclaiming Futures as or more severe than
Regular Adolescent Treatment
Source King County Adolescent Treatment
(n1860) vs. Reclaiming Futures (n404)
65
OtherCommon TreatmentPlanningNeeds
  • RF Need more help w coming from Cont. Env.
  • Case management
  • Evnrionmental Risk
  • Child Maltreatment
  • Behavior control
  • Anger Management
  • Vocational Issues
  • Detox/Withdrawal
  • Self Help Support
  • Scheduling

Source King County Adolescent Treatment
(n1860) vs. Reclaiming Futures (n404)
66
Variance Explained in 10 NOMS Outcomes
Percent of Variance Explained
0
5
10
15
20
25
30
35
26
No AOD Use
24
No AOD related Prob.
11
No Health Problems
25
No Mental Health Prob.
15
No Illegal Activity
33
No JJ System Involve.
26
Living in Community
18
No Family Prob.
14
Vocationally Engaged
8
Social Support
24
Count of above
\1 Past month \2 Past 90 days All
statistically Significant
Source CSAT 2007 AT Outcome Data Set (n11,013)
67
Best Level of Care Cluster A Low - Low
(n1,025)
Source CSAT 2007 AT Outcome Data Set (n11,013)
68
Best Level of Care Cluster C Mod-Mod (n1209)
Source CSAT 2007 AT Outcome Data Set (n11,013)
69
Best Level of Care Cluster F Hi-Hi (CC) (n968)
Source CSAT 2007 AT Outcome Data Set (n11,013)
70
Best Level of Care Cluster G Hi-Mod (Env/PH)
(n749)
Source CSAT 2007 AT Outcome Data Set (n11,013)
71
Conclusions
  • Substance use disorders have a physical,
    developmental, and chronic nature and are of
    particular relevance to the juvenile justice
    system
  • Standardized assessment is needed because there
    are multiple overlapping and complex problems
  • There is a continuum of measurement from
    screening to comprehensive assessment
  • Moving along this continuum requires more
    investment, but also gives more information to
    the individual, clinician and program

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