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State of the Art of Adolescent Substance Abuse Treatment
Michael Dennis, Ph.D.Chestnut Health Systems, Bloomington, ILPresentation at “Juvenile Justice Conference on Alcohol & Other (AOD) Treatment for Adolescents”, Thursday, April 27, 2006, Marlborough Massachusetts. The content of this presentations are based on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270-2003-00006 and several individual grants. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: junsicker@Chestnut.Org
2
1. Epidemiological Course: To examine the prevalence, course, and consequences of adolescent substance use and co-occurring disorders and the unmet need for treatment
2. The Treatment System: To summarize major trends in the adolescent treatment system and the variability by state
3. Evidence Based Practice: To highlight what it takes to move the field towards evidenced-based practice related to assessment, treatment, program evaluation and planning
Goals of this Presentation
AFTER BREAK4. Part 4 Treatment Effectiveness: To present the findings
from several recent treatment outcome studies on substance abuse treatment research, trauma and violence/crime.
3
Part 1 Epidemiological Course: To examine the prevalence, course,
and consequences of adolescent substance use and co-occurring
disorders and the unmet need for treatment
4
Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246)
Dependence 5%
Abuse 4%
Regular AOD Use 8%
Any Infrequent Drug Use 4%
Light Alcohol Use Only 47%
No Alcohol or Drug Use
32%
Source: 2002 NSDUH
5
Problems Vary by Age
Source: 2002 NSDUH and Dennis et al forthcoming
0
10
20
30
40
50
60
70
80
90
100
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
65+
No Alcohol or Drug Use
Light Alcohol Use Only
Any Infrequent Drug Use
Regular AOD Use
Abuse
Dependence
NSDUH Age Groups
Severity CategoryAdolescent
OnsetRemission
Increasing rate of non-
users
6
Higher Severity is Associated with Higher Annual Cost to Society Per Person
Source: 2002 NSDUH
$0$231 $231
$725$406
$0$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
No Alcohol orDrug Use
Light Alcohol
Use Only
AnyInfrequentDrug Use
Regular AODUse
Abuse Dependence
Median (50th percentile)
$948
$1,613
$1,078$1,309
$1,528
$3,058Mean (95% CI)
This includes people who are in recovery, elderly, or do not use
because of health problems Higher Costs
7
Age of First Use Predicts Dependence an Average of 22 years Later
Source: Dennis, Babor, Roebuck & Donaldson (2002) and 1998 NHSDA
3945
63
71
3734
51
62
30
23
41
48
0
10
20
30
40
50
60
70
80
90
100
Tobacco, OR=1.3*,Pop.=151,442,082
Alcohol, OR=1.9*,Pop.=176,188,916
Marijuana, OR=1.5*,Pop.=71,704,012
Other, OR=1.5*, Pop.=38,997,916
% w
ith
1+ P
ast Y
ear
Sym
ptom
s
Under Age 15
Aged 15-17
Aged 18 or older
Tobacco: Pop.=151,442,082
OR=1.49*
Alcohol: Pop.=176,188,916
OR=2.74*
* p<.05
Marijuana:Pop.=71,704,012
OR=2.45*
Other Drugs:Pop.=38,997,916
OR=2.65*
8
Substance Use Careers Last for Decades C
um
ula
tive
Su
rviv
al
Years from first use to 1+ years abstinence302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median of 27 years from
first use to 1+ years
abstinence
Source: Dennis et al., 2005
9
Substance Use Careers are Longer the Younger the Age of First Use
Cu
mu
lati
ve S
urv
ival
Years from first use to 1+ years abstinence
under 15*
21+
15-20*
Age of 1st UseGroups
* p<.05 (different from 21+)
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Source: Dennis et al., 2005
10
Substance Use Careers are Shorter the Sooner People Get to Treatment
Cu
mu
lati
ve S
urv
ival
20+
0-9*
10-19*
Year to 1st TxGroups
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
* p<.05 (different from 20+)Source: Dennis et al., 2005
Years from first use to 1+ years abstinence
11
Treatment Careers Last for Years C
um
ula
tive
Su
rviv
al
Years from first Tx to 1+ years abstinence2520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median of 3 to 4 episodes of treatment over 9 years
Source: Dennis et al., 2005
12
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.pdf
The Growing Incidence of Adolescent Marijuana Use: 1965-2002
Adult Initiation Relatively Stable
Adolescent Initiation Rising
13
Importance of Perceived Risk
Source: Office of Applied Studies. (2000). 1998 NHSDA
Mar
ijua
na
Use
Ris
k &
Ava
ilab
ilit
y
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.
17
Need for Treatment (% of 24,753,586 Adolescents in the U.S. Household Population)
Source: NSDUH and TEDS (see state level estimates in appendix)
8.9%
0.7%
0.6%
5.7%
8.1%
11.5%
10.7%
14.9%
17.8%
0% 5% 10%
15%
20%
25%
Tobacco
Alcohol
Alcohol Binge
Any Drug Use
Marijuana Use
Any Non-Marijuana Drug Use
Past Year AOD Dependence or Abuse
Any Treatment (From NHSDA)
Public Treatment (From TEDS)
--
----
--P
ast M
onth
Use
----
--
Less than 1 in 10 getting treatment
88% of adolescents are treated in the
public system
18
Adolescent AOD Dependence/Abuse
Prevalence6.0 to 8.4%8.5 to 9.0%9.1 to 9.9%10.0 to 14.6%U.S.Avg.=8.9%MA=11.2%
Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 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/2k3State/2k3SAE.pdf ) and Kilpatrick et al, 2000.
Up 27% from 7% in 1995
19
Unmet Treatment Need Adolescent (% of AOD Dependence/Abuse without any private/public treatment)
Prevalence82.4 to 90.1%90.2 to 92.3%92.4 to 94.2%94.3 to 98.0%U.S.Avg.=92.2%MA=97.7%
Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 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/2k3State/2k3SAE.pdf )
9 in 10 Untreated
20
Of 13,530 Urine Panels Done by DYS in 2005, 51% were positive.
Source: Commonwealth of Massachusetts Department of Youth Services (DYS)
.
89%
6% 4% 1% 0%1%0%
10%20%30%40%50%60%70%80%90%
100%
THC Amphet-amines
Cocaine Benzodia-zepines
Ecstasy Panels
Opiates
Of those that were, they were positive for…
Marijuana is the most common and easiest to detect
Less common & hard to detect; Often more severe than opioids
21
Summary Points on Epidemiological Course
Consequences go up as severity increases from use to multiple substance use, abuse, and dependence.
Substance use disorders typically on-set during adolescence and last for decades.
The earlier the age of onset, the longer the course of substance use
The earlier treatment is received, the shorter the course of substance use
Marijuana has become the leading substance problem Less than 1 in 10 adolescents with substance abuse or
dependence problems receive treatment Over 88% are treated in the public system
22
Part 2 The Treatment System: To summarize major trends in the
adolescent treatment system and the variability by state
23
Adolescent Treatment Admissions have increased by 61% over the past decade
Source: Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS)http://www.samhsa.gov/oas/dasis.htm
61% increase from95,271 in 1993
to 153,251 in 2003
24
Change in Public Sector Admissions (%=(2003-1993)/1993)
ChangeNot available-96 to -7%-8 to +33%+34 to +116%+117 to +337%U.S.Avg.=+61%MA=-12%
Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 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/2k3State/2k3SAE.pdf )
Both Cause &
Consequence
25
Change in Focal Substances*: 1993 to 2003
Source: Treatment Episode Data Set (TEDS) 1993-2003.
Marijuana and Alcohol
Most Common
Methamphetamines & Opiates Rare but
Growing Fast
Most other drugs admissions grew
slower than expected
0
25,000
50,000
75,000
100,000
125,000
150,000
Alc
ohol
Mar
ijua
na/H
ash
Coc
aine
/Cra
ck
Her
oin/
Opi
ates
Hal
luci
noge
ns
Met
ham
phet
amin
es
Oth
erA
mph
etam
ines
Sti
mul
ants
Inha
lant
s
Oth
er\e
-200%
-100%
0%
100%
200%
300%
400%
1993
2003
-56%
61% growth
253%
310%
46%
138%
-66%
36%
44%
19%
111%
Change
*TEDS Primary, Secondary or Tertiary problem
26
Presenting Substances: MA vs. US
Source: Primary, Secondary or Tertiary, from Treatment Episode Data Set (TEDS) 1993-2003.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%A
lcoh
ol
Mar
ijua
na/H
ash
Coc
aine
/Cra
ck
Her
oin/
Opi
ates
Hal
luci
noge
ns
Met
ham
phet
amin
es
Oth
erA
mph
etam
ines
Sti
mul
ants
Inha
llan
ts
Oth
er\e
MA U.S.
Similar on Marijuana,
Higher on Alcohol
Methamphetamine 20% or higher in
AZ, CA,ID,MN,NV,WA
Other Amphetamines 20% or higher in OR
Cocaine higher; 20% or higher in DE & TX
Opiates 20% or higher in MA & NM
27
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
Juve
nile
Jus
tice
Sch
ool
Sel
f/F
amil
y
Oth
erC
omm
unit
y
Oth
er S
A T
xA
genc
y
Oth
er H
ealt
hC
are
Em
ploy
ee/E
AP
0%
20%
40%
60%
80%
100%
120%
140%
1993
2003
Change
Change in Referral Sources: 1993-2003
Source: Treatment Episode Data Set (TEDS) 1993-2003.
JJ referrals have doubled, are 53% of 2003 admissions and
driving growth
Other sources of Referral have grown, but less than expected
41%
37%
12%
37%
114%
115%
5%
61% growth
28
Referral Sources: MA vs. US
Source: Treatment Episode Data Set (TEDS) 1993-2003.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cri
min
al J
usti
ceS
yste
m Sch
ool
Sel
f/F
amil
y
Oth
erC
omm
unit
yR
efer
ral
Oth
er S
ubst
ance
Abu
seT
reat
men
tA
genc
y
Oth
er H
ealt
hC
are
Pro
vide
r
MA U.S.
Higher Rate of Self/Parent Referrals
Lower Rate of Juvenile Justice
Referrals
Lower Rate of School Referrals
29
Change in Level of Care
Source: Treatment Episode Data Set (TEDS) 1993-2003.
0
25,000
50,000
75,000
100,000
125,000
150,000
Outpatient IntensiveOutpatient
Detox Short-termResidential
Long-termResidential
-200%
-100%
0%
100%
200%
300%
400%
1993
2003
61% growth
19%
30%
66%
56%
208%
Change
82% of Adolescents are treated in
Outpatient Settings
IOP has had the fastest growth
Residential has grown, but slower than expected
30
Level of Care: MA vs. US
Source: Treatment Episode Data Set (TEDS) 1993-2003.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Out
patie
nt
Inte
nsiv
eO
utpa
tient
Det
ox
Lon
g-te
rmR
esid
entia
l
Sho
rt-t
erm
Res
iden
tial
MA U.S.
Similar on Regular Outpatient
But little IOP or Short Term
Residential
Higher on Detox & Long Term Residential
31
Severity Goes up with Level of Care
Source: Treatment Episode Data Set (TEDS) 1993-2003.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Weekly useat intake
First usedunder age 15
Dependence Prior Treatment
Case Mix Index (Avg)
Outpatient Intensive Outpatient DetoxificationLong-term Residential Short-term Residential
STR: Higher on
Dependence
Baseline Severity Goes up with Level
of CareDetox: Higher on Use
Detox: Higher on Use, but lower on prior tx
32
Other Characteristics
70%
58%
19%
17%
6%
83%
63%
57%
16%
22%
2%
1%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Male
Caucasian
African American
Hispanic
Other
15 to 17 years old
9 to 11 yrs education
Student
Employed
Psychological Problems
Pregnant at Admission
Homeless/Runaway
Source: Treatment Episode Data Set (TEDS) 1993-2003.
These numbers are artificially low
because of how they are measured
System dominated by male, white,
15 to 17 year olds
33
Most Lack of Standardized Assessment for…
Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment
Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidality)
Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime)
HIV risk behaviors (needle use, sexual risk, victimization)
Child maltreatment (physical, sexual, emotional)
34
Median Length of Stay is only 50 days
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/teds02/2002_teds_rpt_d.pdf .
0 30 60 90
Outpatient(37,048 discharges)
IOP(10,292 discharges)
Detox(3,185 discharges)
STR(5,152 discharges)
LTR(5,476 discharges)
Total(61,153 discharges)
Lev
el o
f C
are
Median Length of Stay
50 days
49 days
46 days
59 days
21 days
3 days
Less than 25% stay the
90 days or longer time
recommended by NIDA
Researchers
35
53% Have Unfavorable Discharges
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/teds02/2002_teds_rpt_d.pdf .
0% 20% 40% 60% 80% 100%
Outpatient(37,048 discharges)
IOP(10,292 discharges)
Detox(3,185 discharges)
STR(5,152 discharges)
LTR(5,476 discharges)
Total(61,153 discharges)
Completed Transferred ASA/ Drop out AD/Terminated
Despite being widely recommended, only 10% step down after intensive treatment
36
Summary of Problems in the Treatment System
The public systems is changing size, referral source, and focus – often in different directions by state
Major problems are not reliably assessed (if at all) Less than 50% stay 50 days (~7 weeks) Less the 25% stay the 3 months recommended by
NIDA researchers Less than half have positive discharges After intensive treatment, less than 10% step down
to outpatient care While JJ involvement is common, little is known
about the rate of initiation after detention
37
Part 3 Evidence Based Practice: To highlight what it takes to move the field towards evidenced-based practice
related to assessment, treatment, program evaluation and planning
38
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 )
Context
39
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
General Behavioral Health Practice
40
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, practitioner’s 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 practitioner’s often lack the appropriate materials, training and resources to know when or how to implement them
Problems and Barriers in SA Tx
41
Randomized Clinical Trials (RCT) are to Evidence Based Practice (EBP) like Self-reports are to Diagnosis
They are only as good as the questions asked (and then only if done in a reliable/valid way)
They are an efficient and logical place to start But they can be limited or biased and need to be
combined with other information Just because the person does not know something
(or the RCT has not be done), does not mean it is not so
Synthesizing them with other information usually makes them better
42
So what does it mean to move the field towards Evidence Based Practice (EBP)?
Introducing reliable and valid assessment that can be used – At the individual level to immediately guide clinical judgments
about diagnosis/severity, placement, treatment planning, and the response to treatment
– At the program level to drive program evaluation, needs assessment, and long term program planning
Introducing explicit intervention protocols that are– Targeted at specific problems/subgroups and outcomes– Having explicit quality assurance procedures to cause adherence
at the individual level and implementation at the program level
Having the ability to evaluate performance and outcomes – For the same program over time, – Relative to other interventions
43
Reoccurring Themes in the Examples…
Severity and specificity of problem subgroup Manualized and replicable assessment and
treatment protocols Relative strength of intervention for a specific
problem Adherence and implementation of intervention Evaluation of outcomes targeted by the
intervention (a.k.a., logic modeling)
44
The Current Renaissance of Adolescent Treatment Research
Feature 1930-1997 1997-2005
Tx Studies* 16 Over 200
Random/Quasi 9 44
Tx Manuals* 0 30+
QA/Adherence Rare Common
Std Assessment* Rare Common
Participation Rates Under 50% Over 80%
Follow-up Rates 40-50% 85-95%
Methods Descriptive/Simple More Advanced
Economic Some Cost Cost, CEA, BCA
* Published and publicly available
45
Adolescent Treatment Research Currently Being Published 1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of Adol. (DATOS-A) 1995-1997 Drug Abuse Treatment Outcome Study (DOMS) 1997-2000 CSAT’s Cannabis Youth Treatment (CYT) experiments 1998-2003 NIAAA/CSAT’s 15 individual research grants 1998-2003 CSAT’s 10 Adolescent Treatment Models (ATM) 2000-2003 CSAT’s Persistent Effects of Treatment Study (PETS-A) 2002-2007 CSAT’s 12 Strengthening Communities for Youth (SCY) 2002-2007 RWJF’s 10 Reclaiming Futures (RF) diversion projects 2002-2007 CSAT’s 12+ Targeted Capacity Expansion TCE/HIV 2003-2009 NIDA’s 14 individual research grants and CTN studies 2003-2006 CSAT’s 17 Adolescent Residential Treatment (ART) 2003-2008 NIDA’s Criminal Justice Drug Abuse Treatment Study (CJ-DATS) 2003-2007 CSAT’s 38 Effective Adolescent Treatment (EAT) 2004-2007 NIAAA/CSAT’s 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
Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN)
46
Number of GAIN Sites
Adolescent and Adult Treatment Program GAIN Clinical Collaborators
30 to 6010 to 292 to 91
One or more state or county wide systems uses the GAIN
One or more state or county wide systems considering using the GAIN
07/05
47
Common Hierarchical Structure of the GAIN’s Psychopathology Scales
Substance Issues Index (SII)Substance Abuse Scale (SAS)Substance Dependence Scale (SDS)
Substance Problem Scale (SPS)
Somatic Symptom Index (SSI)Depression Symptom Scale (DSS)Homicidal/Suicidal Thought Index (HSTI)Anxiety/Fear Symptom Scale (AFSS)Traumatic Distress Scale (TDS)
Internal Mental Distress Scale (IMDS)
Inattentiveness Disorder Scale (IDS)Hyperactivity-Impulsivity Scale (HIS)Conduct Disorder Scale (CDS)
Behavior Complexity Scale (BCS)
General Conflict Tactic Scale (GCTS)Property Crime Scale (PCS)Interpersonal Crime Scale (ICS)Drug Crime Scale (DCS)
Crime/Violence Scale (CVS)
General Individual Severity Scale (GISS)
Confirmatory factor analysis demonstrates that this is reliable overall and stable across adults and adolescents, outpatient & residential (confirmatory fit index =.97; Root Mean Square Error=.04)
48
GAIN Short Screen (GAIN-SS) Administration Time: 5 minutes Training Requirements: Minimal Mode: Self or staff administered Purpose: Designed for use in general populations or where there is less control
to identify who has a disorder warranting further assessment or behavioral intervention, measuring change in the same, and comparing programs
Scales: The total scale (20-symptoms) and its 4 subscales (5-symptoms each) for internal disorders (somatic, depression, suicide, anxiety, trauma, behavioral disorders (ADHD, CD), substance use disorders (abuse, dependence), and crime/violence (interpersonal violence, property crime, drug related crime) can be used to generate symptom counts for the past month to measure change, past year to identify current disorders and lifetime to serve as covariates/validity checks.
Reports: There are currently no reports.
49
GAIN Short Screen (GAIN-SS)
Total Disorder Screener (TDScr)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Prevalence (% 1+ disorder)
Sensitivity (% w disorder above)
Specificity (% w/o disorder below)
(n=6194 adolescents)
Low Mod. High
99% prevalence, 91% sensitivity, & 89%
specificity at 3 or more symptoms
Using a higher cut point increases prevalence and specificity, but
decreases sensitivity
Total score has alpha of .85 and is
correlated .94 with full GAIN version
Source: Dennis et al 2005 GSS manual
50
GSS Performance by Subscale and Disorders
Prevalence Sensitivity Specificity Screener/Disorder 1+ 3+ 1+ 3+ 1+ 3+ 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) 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)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%
Low (0), Moderate (1-2), and High (3+) cut points can
be used to identify the need
for specific types of
interventions
Moderate can be targeted where resources allow or where a more
assertive approach is
desired
Mod/Hi can be used to evaluate
program delivery/referral
51
GAIN Quick (GAIN-Q) Administration Time: 20-30 minutes Training Requirements: 1 day (train the trainer) Mode: Generally Staff Administered on Computer (can be done on paper
or self administered) Purpose: Designed for use in targeted populations to support brief
intervention or referral for further assessment or behavioral intervention Scales: The GQ has total scale (99-symptoms) and 15 subscales
(including more detailed versions of the GSS scales and subscales plus scales for service utilization, sources of psychosocial stress, and health problems). All scales focus on the past year only and it is primarily used to support motivational interviewing or for a one time assessment (though there is a shorter follow-up version).
Reports: Summary narrative report and a graphic individual profile to support clinical decision making.
52
The GAIN-Quick can Predict Level of Care
Source: Titus et al, 2003; ATM data
-0.6
-0.4
-0.2
0.0
0.2
0.4
0.6
Depre
ssio
n S
ym
pto
m Index
Suic
ide R
isk
Index
Anxie
ty S
ym
pto
m Index
Inte
rnal B
ehavio
r In
dex
Att
enti
on-H
ypera
ctiv
ity
Dis
ord
er
Index
Conduct
Dis
ord
er-
Aggre
ssio
n Index
Genera
l C
rim
e Index
Exte
rnal B
ehavio
r In
dex
Subst
ance
Use
and A
buse
Subst
ance
Dependence
Index
Subst
ance
Pro
ble
m Index
TC (n=288) STR (n=604) OP/IOP (n=513)
Good reliability (alpha over .9 on main scales, .7 on subscales) and correlated .9 or higher with full GAIN scale
Z s
core
fro
m m
ean
53
GQ Example: Site difference in 4 Detention Sites
Source: 2005 Reclaiming Futures Data (n=508)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
GeneralStress
Health Internal-izing
External-izing
SubstanceUse
Per
cent
Santa Cruz, CA
Portland, OR
Chicago, IL
Dayton, OH
54
GQ Example: Link to Recent Victimization in 4 detention sites
Source: 2005 Reclaiming Futures Data (n=508)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Victimization in the Past Year Current worry aboutvictimization
Per
cent
Santa Cruz, CA
Portland, OR
Chicago, IL
Dayton, OH
55
GAIN Initial (GAIN-I) Administration Time: Core version 60-90 minutes/Full version 120-160 minutes (depending
on severity and inclusion of GPRA module) Training Requirements: 3.5 days (train the trainer) plus recommend formal certification
program (administration certification within 3 months of training; local trainer certification within 6 months of training)
Mode: Generally Staff Administered on Computer (can be done on paper or self administered) Purpose: Designed to provide a standardized biopsychosocial for people presenting to a
substance abuse treatment using DSM-IV for diagnosis, ASAM for placement, and needing to meet common (CARF, JCAHO, insurance, CDS/TEDS, Medicaid, CSAT, NIDA) requirements for assessment, diagnosis, placement, treatment planning, accreditation, performance/outcome monitoring, economic analysis, program planning and to support referral/communications with other systems
Scales: The GI has 9 sections (access to care, substance use, physical health, risk and protective behaviors, mental health, recovery environment, legal, vocational, and staff ratings) that include 103 long (alpha over .9) and short (alpha over .7) scales, summative indices, and over 2000 created variables to support clinical decision making and evaluation. It is also modularized to support customization
56
GAIN-I’s Main Reports GAIN Referral and Recommendation Summary (GRRS): A text-based
narrative in MS Word designed to be edited and shared with specialists, clinical staff from other agencies, insurers and lay people.
Individual Clinical Profile (ICP): A more detailed report in MS Access designed to help triage problems and help the clinician go back to the GAIN for more details if necessary (generally not edited or shared).
Personal Feedback Reports (PFR): A text based summary to support the motivational interviewing or MET based on the GAIN-I (or GAIN-Q).
Validity Reports: A list of potential problems and areas for clarification and.
Other: Custom reports to word, excel or transferring data from/to other data systems.
57
Other Measures
Collateral versions of all three measures Follow-up versions of all three measures Spanish Translation of all three measures Native American Module CSAT, State, Organization, Program, and
Project Specific (aka CORE) versions Ability to customize by site within prescribed
parametersOver 4 dozen scientist using the data to develop additional
clinical guidance on diagnosis, placement, treatment planning, treatment effectiveness and economic analysis
More information is available at www.chestnut.org/li/gain
58
CSAT Adolescent Treatment (AT)Outcome Data Set
Recruitment: 1998-2005 (updated annually)
Sample: The 2005 CSAT adolescent treatment data set included data with 1 to 4 follow-ups on 9,276 unique adolescents from 72 local evaluations
Levels of Care: Early Intervention, Outpatient, Intensive Outpatient, Short, Moderate & Long term Residential, Corrections Based and Post Residential Outpatient Continuing Care
Instrument: Global Appraisal of Individual Needs (GAIN) (see www.chestnut.org/li/gain)
Follow-up: Over 80% follow-up 3, 6, 9 & 12 months post intake
Funding: CSAT contract 270-2003-00006 and 72 individual grants
59
Current CSAT AT Outcome Data Set by Grant Program (n=9,276)
SCY: Strengthening Communities-Youth (2002-2007; 1,804 from 11 grants)
TCE: Other Targeted Capacity Expansion (2002-2007; 263 from 1 grant)
ART: Adolescent Residential Treatment (2003-2006; 1,429 from 16 grants)
EAT: Effective Adolescent Treatment (2003-2007; 3,325 from 27 grants)
YORP: Young Offender Re-entry Project (2004-2008; 79 from 3 grants)
CYT: Cannabis Youth Treatment (1997-2001; 600 from 4 grants)
ATM: Adolescent Treatment Model (1998-2002; 1,776from 10 grants)
Source: CSAT AT Outcome Data Set
60
Geographic Location of Sites
ART
EATSCYTCEYORP
AK
AL
ARAZ
CA CODC
DE
FL
GA
HI
IA
ID
IN
KS
LA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UTVA
WA
WV
WY
PR
VT
WI
IL
KY
MA
CT
DC
Program
61
Demographics
30%
19%
58%
16%
6%
17%
83%
18%
42%
17%
23%
20%
73%
29%0% 10
%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Female
African American
Caucasian
Hispanic
Mixed/Other
12 to 14 years old
15 to 17 years old
TEDS (n=153,251)
CSAT (n=7,226)
62
Clinical Severity
82%
33%
50%
48%
53%
37%
61%
53%
68%
74%0% 10
%
20%
30%
40%
50%
60%
70%
80%
90%
100%
First used underage 15
Prior Treatment
Weekly use atintake
Past YearDependence
Criminal JusticeSystem
TEDS (n=153,251)
CSAT (n=7,226)
63
Primary, Secondary or Tertiary SUD Problems
57%
82%
8%
4%
7%
6%
60%
5%
3%
7%
2%
25%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Alcohol
Marijuana/Hash
Cocaine/Crack
Heroin/Opiates
Meth/amphetamines
Any Other
TEDS (n=153,251)
CSAT (n=7,226)
64
68%
14%
9%
9%
8%
2%
19%
71%0% 10
%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Outpatient
Intensive Outpatient
Short Term Resid(<30 days)
Long Term ResidTEDS (n=153,251)
CSAT (n=7,226)
Level of Care
Includes 9% in continuing care outpatient (CCOP) after
residential treatment or detention
65
Recovery Environment
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
57%
49%
28%
74%
65%
14%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Social Peers Getting Drunk Weekly+
School/Work Peers Getting Drunk Weekly+
Others at Home Getting Drunk Weekly+
Social Peers Using Drugs
School/Work Peers Using Drugs
Others at Home Using Drugs
66
Past 90 day HIV Risk Behaviors
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
84%
38%
32%
26%
21%
3%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sexually active
Sex Under the Influence of AOD
Multiple Sex partners
Any Unprotected Sex
Victimized Physically, Sexually, orEmotionally
Any Needle use
67
Weekly or More Often Use in the Past 90 Days
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
61%
48%
18%
4%
2%
7%
55%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any Substance
Marijuana
Alcohol
Crack/Other Cocaine
Heroin/Opioids
All Other Drugs
Tobacco
68
Substance Use Problems
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
84%
53%
31%
8%
37%
30%
24%
99%0% 10
%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Past Year Substance Diagnosis
Any Past Year Dependence
Any withdrawal symptoms in the past week
Severe withdrawal (11+ symptoms) in past week
Can Give 1+ Reasons to Quit
Any prior substance abuse treatment
Acknowledges having an AOD problem
Client believes Need ANY Treatment
69
Co-Occurring Psychiatric Problems
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
79%
54%
45%
37%
26%
17%
59%
47%
31%
25%
16%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any Co-occurring Psychiatric
Conduct Disorder
Attention Deficit/Hyperactivity Disorder
Major Depressive Disorder
Traumatic Stress Disorder
General Anxiety Disorder
Ever Physical, Sexual or Emotional Victimization
High severity victimization (GVS>3)
Ever Homeless or Runaway
Any homicidal/suicidal thoughts past year
Any Self Mutilation
70
Past Year Violence & Crime
*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
82%
69%
66%
51%
49%
45%
84%
68%
39%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any violence or illegal activity
Physical Violence
Any Illegal Activity
Any Property Crimes
Other Drug Related Crimes*
Any Interpersonal/ Violent Crime
Lifetime Juvenile Justice Involvement
Current Juvenile Justice involvement
1+/90 days In Controlled Environment
71
Intensity of Juvenile Justice System Involvement
Source: CSAT 2004 AT Common GAIN Data set (n= 5,468 adolescents from 67 local evaluations)
17% In detention/jail 14+ days
25% On probation or parole 14+ days w/ 1+ drug screens
17% Other probation/parole/detention
16% Other JJ status
8% Past arrest/ JJ status
17% Past year illegal activity/SA use
Highest severity for Long Term
Residential (followed by
STR, IOP, OP)
72
Multiple Problems* are the Norm
Source: CSAT AT Common GAIN Data set
NoneOne
Two
Three
Four
Five to Twelve
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Most acknowledge 1+ problems
Few present with just one problem
(the focus of traditional research)
In fact, over half present
acknowledging 5+ major problems
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
73
No. of Problems* by Severity of Victimization
Source: CSAT AT Common GAIN Data set (odds for High over odds for Low)
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD,
CD, victimization, violence/ illegal activity)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Low (31%) Moderate (17%) High (51%)
Five or More
Four
Three
Two
One
None
Those with high lifetime levels of
victimization have 117 times higher
odds of having 5+ major problems*
GAIN General Victimization Scale Score (Row %)
74
Treatment Outcomes by Level of Care: Days of AOD Abstinence*
* Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change)
Source: CSAT AT Outcome Data Set (n-9,276)
0
30
60
90
Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Day
s of
Ab
stin
ence
(of
90)
Outpatient (+20%, -2%)
Residential(+69%, -15%)
Post Corr/Res (+2%, -6%)
75
Treatment Outcomes by Level of Care: Recovery*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Per
cen
t in
Pas
t M
onth
Rec
over
y* Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
* Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change)
Source: CSAT AT Outcome Data Set (n-9,276)
76
Other Assessment and Treatment Resources
Assessment Instruments – GAIN Coordinating Center at www.chestnut.org/li/gain – CSAT TIP 3 at
http://www.athealth.com/practitioner/ceduc/health_tip31k.html – NIAAA Assessment Handbook at
http://www.niaaa.nih.gov/publications/instable.htm
Treatment Programs– CSAT CYT, ATM, ACC and other treatment manuals at
www.chestnut.org/li/apss/csat/protocols and on CDs provided– SAMHSA Knowledge Application Program (KAP) at
http://kap.samhsa.gov/products/manuals – NCADI at www.health.org – National Registry of Effective Prevention Programs
Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov
77
Other Resources (continued) Implementing Evidenced Based Practice
– Central East ATTC Evidence Based Practice Resource Page http://www.ceattc.org/nidacsat_bpr.asp?id=LGBT
– 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?pageId=114
– Evidence-Based Practices: An Implementation Guide for Community-Based Substance Abuse Treatment Agencies http://www.uiowa.edu/~iowapic/files/EBP%20Guide%20-%20Revised%205-03.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/sasate
2006 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/jmate/
– next meeting March 27-29, 2006, Baltimore, MD
78
What are the pitfalls of EBP?
EBP generally causes some staff turnover EBP often shines a light on staff or work place problems
that would otherwise be ignored EBP often impact a wide range of existing procedures and
policies – requiring modification and provoking resistance EBP (and most organizational changes) will fail without
good senior staff leadership EBP typically require going for more funds from grant or
other funders On-going needs assessment will create demand for more
change and more EBP
79
Summary of Evidenced Based Practice Section
Achieving reliable outcomes requires reliable measurement, protocol delivery and on-going performance monitoring.
The GAIN is one measure that is being widely used by CSAT grantees and others trying to address gaps in current knowledge and move the field towards evidenced based practice.
Standardized and more specific assessment helps to draw out treatment planning implications of readiness for change, recovery environment, relapse potential, psychopathology, crime/violence, and HIV risks.
Adolescents entering more intensive levels of care typically have higher severity.
Multiple problems and child maltreatment are the norm and are closely related to each other.
There is a growing number of standardized assessment tools, treatment protocols and other resources available to support evidenced based practices.
80
Part 4 Treatment Effectiveness: To present the findings from several recent treatment outcome studies on substance abuse treatment research,
trauma and violence/crime.
81
Meta Analysis of the Effectiveness of Programs for Juvenile Offenders
N of
Offender Sample Studies
Preadjudication (prevention) 178
Probation 216
Institutionalized 90
Aftercare 25
Total 509
Source: Adapted from Lipsey, 1997, 2005
82
Most Programs are actually a mix of components
Average of 5.6 components distinguishable in program descriptions from research reports
Intensive supervisionPrison visitRestitutionCommunity serviceWilderness/Boot campTutoringIndividual counselingGroup counselingFamily counselingParent counselingRecreation/sportsInterpersonal skills
Anger managementMentoringCognitive behavioralBehavior modificationEmployment trainingVocational counselingLife skillsProvider trainingCaseworkDrug/alcohol therapyMultimodal/individualMediation
Source: Adapted from Lipsey, 1997, 2005
83
Most programs have small effectsbut those effects are not negligible
The median effect size (.09) represents a reduction of the recidivism rate from .50 to .46
Above that median, most of the programs reduce recidivism by 10% or more
One-fourth of the studies show recidivism reductions of 30% or more, that is, a recidivism rate of .35 or less for the treatment group compared to .50 for the control group
The “nothing works” claim that rehabilitative programs for juvenile offenders are ineffective is false
Source: Adapted from Lipsey, 1997, 2005
84
Major Predictors of Bigger Effects
1. Chose a strong intervention protocol based on prior evidence
2. Used quality assurance to ensure protocol adherence and project implementation
3. Used proactive case supervision of individual
4. Used triage to focus on the highest severity subgroup
85
Impact of the numbers of Favorable features on Recidivism (509 JJ studies)
Source: Adapted from Lipsey, 1997, 2005
Usual Practice has little
or no effect
86
Some Programs Have Negative or No Effects on recidivism
“Scared Straight” and similar shock incarceration program
Boot camps mixed – had bad to no effect
Routine practice – had no or little (d=.07 or 6% reduction in recidivism)
Similar effects for minority and white (not enough data to comment on males vs. females)
The common belief that treating anti-social juveniles in groups would lead to more “iatrogenic” effects appears to be false on average (i.e., relapse, violence, recidivism for groups is no worse then individual or family therapy)
Source: Adapted from Lipsey, 1997, 2005
87
Program types with average or better effects on recidivism
AVERAGE OR BETTER BETTER/BEST
Preadjudication
Drug/alcohol therapy Interpersonal skills training
Parent training Employment/job training
Tutoring Group counseling
Probation
Drug/alcohol therapy Cognitive-behavioral therapy
Family counseling Interpersonal skills training
Mentoring Parent training
Tutoring
Institutionalized
Family counseling Behavior management
Cognitive-behavioral therapy Group counseling
Employment/job training Individual counseling
Interpersonal skills trainingSource: Adapted from Lipsey, 1997, 2005
88
Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Practice in Reducing Recidivism (29% vs. 40%)
Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving Multisystemic Therapy Functional Family Therapy Multidimensional Family Therapy Adolescent Community Reinforcement Approach MET/CBT combinations and Other manualized CBT
Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004
NOTE: There is generally little or no differences in mean effect size between these brand names
89
Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)
The effect of a well implemented weak program is
as big as a strong program implemented poorly
The best is to have a strong
program implemented
well
Thus one should optimally pick the strongest intervention that one can
implement wellSource: Adapted from Lipsey, 1997, 2005
CYT Cannabis Youth Treatment Randomized Field Trial
Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services
Coordinating Center:Chestnut Health Systems, Bloomington, IL, and Chicago, ILUniversity of Miami, Miami, FLUniversity of Conn. Health Center, Farmington, CT
Sites:Univ. of Conn. Health Center, Farmington, CTOperation PAR, St. Petersburg, FLChestnut Health Systems, Madison County, ILChildren’s Hosp. of Philadelphia, Phil. ,PA
91
Context Circa 1997 Cannabis had become more potent, was associated with a wide of
problems (particularly when combined with alcohol), and had become the leading substances mentioned in arrests, emergency room admissions, autopsies, and treatment admissions (doubling in in 5 years)
Over 80% of adolescents with Cannabis problems were being seen in outpatient setting
The median length of stay was 6 weeks, with only 25% making it 3 months
There were no published manuals targeting adolescent marijuana users in outpatient treatment
The purpose of CYT was to manualize five promising protocols, field test their relative effectiveness, cost, and benefit-cost and provide them to the field
Source: Dennis et al, 2002
92
Randomly Assigns to:
MET/CBT5Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (12 weeks)
FSN
Family Support Network
Plus MET/CBT12 (12 weeks)
Trial 2Trial 1Incremental Arm Alternative Arm
Two Effectiveness Experiments
ACRAAdolescent Community
Reinforcement Approach(12 weeks)
MDFTMultidimensional Family Therapy
Randomly Assigns to:
MET/CBT5Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
(12 weeks)
Source: Dennis et al, 2002
93
Contrast of the Treatment Structures
Individual Adolescent Sessions
CBT Group Sessions
Individual Parent Sessions
Family Sessions/Home Visits
Parent Education Sessions
Total Formal Sessions
Type of ServiceMET/CBT5
MET/CBT12 FSN ACRA MDFT
2
3
5
2
10
12
2
10
4
6
22
10
2
2
14
6
3
6
15
Case management/Other Contacts
As needed
As needed
As needed
Total Expected Contacts 5 12 22+ 14+ 15+
Total Expected Hours 5 12 22+ 14+ 15+
Total Expected Weeks 6-7 12-13 12-13 12-13 12-13
Source: Diamond et al, 2002
94
5
10
5
11
14
23
0
5
10
15
20
25
MET/CBT5
MET/CBT12
MET/CBT12 +
FSN
MET/CBT5
ACRA MDFT
Hou
rs
Day
s
CaseManagement
FamilyCounseling
Collateral only
Multi-Familygroup
Multi-ParticipantGroup
Participant only
Incremental Arm Alternative Arm
Actual Treatment Received by Condition
Source: Dennis et al, 2004
MET/CBT12 adds 7 more sessions of
group
FSN adds multi family group,
family home visits and more case management
ACRA and MDFT both rely on
individual, family and case management instead of group
With ACRA using more individual therapy
And MDFT using more
family therapy
95
$1,559$1,413
$1,984
$3,322
$1,197$1,126
$-
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
MET/C
BT5 (6.8
wee
ks)
MET/C
BT12 (1
3.4 w
eeks
)
FSN (14.2
wee
ks w
/family
)
MET/C
BT5 (6.5
wee
ks)
ACRA (12.8
wee
ks)
MDFT(1
3.2 w
eeks
w/fa
mily)
$1,776
$3,495
NTIES E
st (6
.7 wee
ks)
NTIES E
st.(1
3.1 w
eeks
)
Ave
rage
Cos
t P
er C
lien
t-E
pis
ode
of C
are
|--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----|
Average Episode Cost ($US) of Treatment
Source: French et al., 2002
Less than average
for 6 weeks
Less than average
for 12 weeks
Integrating family therapy
was less expensive
than adding it
96
Implementation of Evaluation Over 85% of eligible families agreed to participate Quarterly follow-up of 94 to 98% of the adolescents from 3- to
12-months (88% all five interviews) Collateral interviews were obtained at intake, 3- and 6-months
on over 92-100% of the adolescents interviewed Urine test data were obtained at intake, 3, 6, 30 and 42 months
90-100% of the adolescents who were not incarcerated or interviewed by phone (85% or more of all adolescents).
Long term follow-up completed on 90% at 30-months Self reported marijuana use largely in agreement with urine test
at 30 months (13.8% false negative, kappa=.63) Good reliability (alphas over .85 on main scales) and
correlations with collateral reports (r=.4 to .7)
Source: Dennis et al, 2002, 2004
97
Adolescent Cannabis Users in CYT were as or More Severe Than Those in TEDS*
Source: Tims et al, 2002
85%
46%
26%
78%
26%
47%
26%
71%
0%
20%
40%
60%
80%
100%
First usedunder age
15
Dependence Weekly ormore use at
intake
PriorTreatment
% o
f A
dm
issi
on
s
.
CYT Outpatient(n=600) TEDS Outpatient (n=16,480)* Adolescents with marijuana problems admitted to outpatient treatment
98
Demographic Characteristics
Source: Tims et al, 2002
62%
15%
55%50%
30%
83%
17%
0%
20%
40%
60%
80%
100%
Female Male AfricanAmerican
Caucasian Under 15 15 to 16 Singleparentfamily
99
Institutional Involvement
25%
87%
47%
62%
0%
20%
40%
60%
80%
100%
In school Employed Current JJInvolvement
Coming fromControlled
Environment
Source: Tims et al, 2002
100
Patterns of Substance Use
9%17%
71%73%
0%
20%
40%
60%
80%
100%
Weekly Tobacco Use
WeeklyCannabis Use
Weekly AlcoholUse
Significant Timein ControlledEnvironment
Source: Tims et al, 2002
101
Multiple Problems were the NORM
86%
37%
12%
25%
61%
60%
66%
83%
83%
0% 20% 40% 60% 80% 100%
Any Marijuana Use Disorder
Any Alcohol Use Disorder
Other Substance Use Disorders
Any Internal Disorder
Any External Disorder
Lifetime History of Victimization
Acts of Physical Violence
Any (other) Illegal Activity
Three to Twelve Problems
Self-Reported in Past Year
Source: Dennis et al, 2004
102
Substance Use Severity was Related to Other Problems
* p<.05
Source: Tims et al 2002
71%
57%
25%
42%
30%37%
22%
5%
13%
22%
0%
20%
40%
60%
80%
100%
Health ProblemDistress*
Acute MentalDistress*
AcuteTraumaticDistress*
AttentionDeficit
HyperactivityDisorder*
ConductDisorder*
Past Year Dependence (n=278) Other (n=322)
103
CYT Increased Days Abstinent and Percent in Recovery*
Source: Dennis et al., 2004
0
10
20
30
40
50
60
70
80
90
Intake 3 6 9 12
Day
s A
bsti
nent
Per
Qua
rter
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
% in
Rec
over
y at
the
End
of
the
Qua
rter
Days Abstinent
Percent in Recovery
*no use, abuse or dependence problems in the past month while in living in the community
104
Similarity of Clinical Outcomes by Conditions
Source: Dennis et al., 2004
200
220
240
260
280
300
Tot
al d
ays
abst
inen
t.
over
12
mon
ths
0%
10%
20%
30%
40%
50%
Per
cent
in R
ecov
ery
. at
Mon
th 1
2
Total Days Abstinent* 269 256 260 251 265 257
Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19
MET/ CBT5 (n=102)
MET/ CBT12
FSN (n=102)
MET/ CBT5 (n=99)
ACRA (n=100)
MDFT (n=99)
Trial 1 Trial 2
* n.s.d., effect size f=0.06** n.s.d., effect size f=0.12
* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16
Not significantly different by condition.
But better than the average for OP in ATM (200 days of
abstinence)
105
Moderate to large differences in Cost-Effectiveness by Condition
Source: Dennis et al., 2004
$0
$4
$8
$12
$16
$20
Cos
t per
day
of
abst
inen
ce o
ver
12 m
onth
s
$0
$4,000
$8,000
$12,000
$16,000
$20,000
Cos
t per
per
son
in r
ecov
ery
at m
onth
12
CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38
CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775
MET/ CBT5MET/
CBT12FSN MET/ CBT5 ACRA MDFT
* p<.05 effect size f=0.48** p<.05, effect size f=0.72
Trial 1 Trial 2
* p<.05 effect size f=0.22 ** p<.05, effect size f=0.78
MET/CBT5 and 12 did better
than FSN
ACRA did better than MET/CBT5, and both did better than MDFT
106
Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition
Source: Dennis et al., 2003; forthcoming
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
CPPR at 30 months** $6,437 $10,405 $24,725 $27,109 $8,257 $14,222
CPPR at 12 months* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775
MET/ CBT5 MET/ CBT12 FSNM MET/ CBT5 ACRA MDFT
Trial 1 (n=299) Trial 2 (n=297)
Cos
t P
er P
erso
n in
Rec
over
y (C
PP
R)
* P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months
Stability of MET/CBT-5
findings mixed at 30 months
MET/CBT-5, -12 and ACRA more cost effective at
12 months
Integrated family therapy (MDFT) was more cost effective than
adding it on top of treatment (FSN) at 30 months
ACRA Effect Largely Sustained
107
Change in Quarterly Costs to Society(12 months minus Intake)
Source: Dennis et al., 2004
$(25,000)
$(20,000)
$(15,000)
$(10,000)
$(5,000)
$-
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
MET/CBT5
MET/CBT12
FSN MET/CBT5
ACRA MDFT Average
$(25,000)
$(20,000)
$(15,000)
$(10,000)
$(5,000)
$-
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000Significant Reduction in Cost to Society Overall
Three sites went down significantly, one went up significantly
No Significant Difference by Condition
Cond x Site: 4 sig reduction, 2 sig Incr, 6 no sig dif (low power)
108
Cumulative Recovery Pattern at 30 months
Source: Dennis et al, forthcoming
37% Sustained Problems
5% Sustained Recovery
19% Intermittent, currently in
recovery
39% Intermittent, currently not in
recovery
The Majority of Adolescents Cycle in and out of Recovery
109
Environmental Factors are also the Major Predictors of Relapse
RecoveryEnvironment
Risk
SocialRisk
FamilyConflict
FamilyCohesion
SocialSupport
SubstanceUse
Substance-RelatedProblems
Baseline
Baseline
Baseline Baseline
.32.18
-.13
.21
-.08
.32
.19
.22
.32
.22
.17
.11
.43
.77
.82
.74 .58
-.54
-.09
.19
Source: Godley et al (2005)
Model Fit CFI=.97 to .99 RMSEA=.04 to .06
AOD use in the home, family problems, homelessness, fighting,
victimization, self help group participation, structure activities
Peer AOD use, fighting, illegal activity,
treatment, recovery, vocational activity
The effects of adolescent treatment are mediated by the extent to which they lead to actual changes in the recovery environment or peer group
110
Crime/Violence and Substance Problems Interact to Predict Recidivism
Low
Mod.
High
LowMod
.High0%
20%
40%
60%
80%
100%
Source: CYT & ATM Data
12 m
onth
rec
idiv
ism
Crime/ Violence predicted recidivism
Substance Problem Severity predicted
recidivismKnowing both was the
best predictor
Substance Problem
Scale
Crime and Violence
Scale
111
Crime/Violence and Substance Problems Interact to Predict Violent Crime or Arrest
Low
Mod.
High
LowMod
.High
Source: CYT & ATM Data
12 m
onth
rec
idiv
ism
T
o vi
olen
t cri
me
or a
rres
t
Substance Problem
Scale
Crime and Violence
Scale
0%
20%
40%
60%
80%
100%
Crime/ Violence predicted
violent recidivism
(Intake) Substance Problem Severity did
not predict violent recidivism
Knowing both was the best predictor
112
Post Script on CYT
The CYT interventions provide replicable models of brief (1.5 to 3 month) treatments that can be used to help the field maintain quality while expanding capacity.
While a good start, the CYT interventions were still not an adequate dose of treatment for the majority of adolescents – including many who continued to vacillate in and out of recovery after discharge from CYT.
Descriptive, outcome and economic analyses have been published All five interventions are currently being used in subsequent
experiments The MET/CBT5 intervention is currently being replicated in a 38 site
study and ACRA will be replicated in a multisite study slated to be funded next year.
Over 40,000 copies of the CYT manuals have been distributed by NCADI and as many electronic copies have been distributed by CD or the website
Findings from the Assertive Continuing Care (ACC)
Experiment
183 adolescents admitted to residential substance abuse treatment
Treated for 30-90 days inpatient, then discharged to outpatient treatment
Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC)
Over 90% follow-up 3, 6, & 9 months post discharge
Source: Godley et al 2002, forth coming
114
Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17)
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 10 20 30 40 50 60 70 80 90
Days after Residential (capped at 90)
Per
cen
t of
Clie
nts
Cont.CareAdmis.
Relapse
115
ACC Enhancements
Continue to participate in UCC
Home Visits
Sessions for adolescent, parents, and together
Sessions based on ACRA manual (Godley, Meyers et al., 2001)
Case Management based on ACC manual (Godley et al, 2001) to assist with other issues (e.g., job finding, medication evaluation)
116
Assertive Continuing Care (ACC)Hypotheses
Assertive Continuin
g Care
General Continuin
g Care Adherence
Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA)
Early Abstinence
GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence
Sustained Abstinence
Early abstinence will be associated with higher rates of long term abstinence.
117
ACC Improved Adherence
Source: Godley et al 2002, forthcoming
0% 10%
20%
30%
40%
50%
60%
70%
80%
Weekly Tx Weekly 12 step meetings
Regular urine tests
Contact w/probation/school
Follow up on referrals*
ACC * p<.05
90%
100%
Relapse prevention*
Communication skills training*
Problem solving component*
Meet with parents 1-2x month*
Weekly telephone contact*
Referrals to other services*
Discuss probation/school compliance*
Adherence: Meets 7/12 criteria*
UCC
118
GCCA Improved Early (0-3 mon.) Abstinence
Source: Godley et al 2002, forthcoming
24%
36% 38%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*)
Low (0-6/12) GCCA
43%
55% 55%
High (7-12/12) GCCA * p<.05
119
Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence
Source: Godley et al 2002, forthcoming
19% 22% 22%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*)
Early(0-3 mon.) Relapse
69%
59%
73%
Early (0-3 mon.) Abstainer * p<.05
120
Post script on ACC
The ACC intervention improved adolescent adherence to the continuing care expectations of both residential and outpatient staff; doing so improved the rates of short term abstinence and, consequently, long term abstinence.
Despite these GAINs, many adolescents in ACC (and more in UCC) did not adhere to continuing care plans.
The ACC preliminary findings are published and the main findings are currently under review.
Several CSAT grantees are also seeking to replicate ACC as part of the Adolescent Residential Treatment (ART) program.
A second ACC experiment is currently under way to evaluate whether providing contingency management will further improve outcomes.
The ACC manual is being distributed via the website and the CD you have been provided.
122
Context Circa 1998-99
Few research studies of existing treatment programs and no published manuals to support replication for the few studies that were done
Not clear whether research based treatment protocols were any better than what the better programs were already doing
The purpose of ATM was to manualize existing programs that appeared promising, then to evaluate them using the same measures and methods as CYT (allowing quasi-experimental comparisons)
123
Normal Adolescent Development
Biological changes in the body, brain, and hormonal systems that continue into mid-to-late 20s.
Shift from concrete to abstract thinking. Improvements in the ability to link causes and
consequences (particularly strings of events over time). Separation from a family-based identity and the
development of peer- and individual-based identities. Increased focus on how one is perceived by peers. Increasing rates of sensation seeking/trying new things. Development of impulse control and coping skills. Concerns about avoiding emotional or physical violence.
124
Key Adaptation for Adolescents
Examples need to be altered to relevant substances, situations, and triggers
Consequences have to be altered to things of concern to adolescents
Most 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
125
Program Evaluation Data
Level of Care Clinics Adolescents 1+ FU*
Outpatient/ Intensive Outpatient (OP/IOP)
8 560 96%
Long Term Residential (LTR)**
4 390 98%
Short Term Residential (STR)**
4 594 97%
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
126
Length of Stay Varies by Level of Care
Source: Adolescent Treatment Model (ATM) Data
0%
50%
100%0 30 60 90 120
150
180
210
240
270
300
330
360
390
Length of Stay
Per
cent
Sti
ll in
Tre
atm
ent
Long Term Residential (median=154 days; n=222)
Short Term Residential (median=31 days; n=589)
Outpatient (median= 88 days; n=554)
About half of those in OP stay 90 or more days
Over half the STR say more than 30 days
127
Adolescents more likely to transfer
Source: Adolescent Treatment Model (ATM) Data
0%
50%
100%0 30 60 90 120
150
180
210
240
270
300
330
360
390
Length of Stay
Perc
ent S
till i
n T
reat
men
t
Index Episode of Care (median=52 days; n=1380)
System Episode of Care (median=73 days; n=1380)
Length of Stay Across Episodes of care is about 50% longer
128
Years of Use
Source: Adolescent Treatment Model (ATM) data
3 0 1
3127
19
3339 37
33 33
43
0
10
20
30
40
50
60
70
80
90
100
OP/IOP (n=560) LTR (n=390) STR (n=594)
Less than 1 1-2 years 3-4 years 5 or more years
129
Patterns of Weekly (13+/90) Use
Source: Adolescent Treatment Model (ATM) data
61
71
83
56 57
72
20
29
43
4 714
1 49
0
20
40
60
80
100
OP/IOP (n=560) LTR (n=390) STR (n=594)
Weekly use of anything Weekly Marijuana Use
Weekly Alcohol Use Weekly Crack/Cocaine Use
Weekly Heroin/Opioid Use
7
21 17
Weekly Other Drug Use
29
4441
13+ Days in Controlled Environment
130
Substance Use Severity
Source: Adolescent Treatment Model (ATM) data
71
93
62
70
89
2925
7
35
27
10
75
0
10
20
30
40
50
60
70
80
90
100
OP/IOP (n=560) LTR (n=390) STR (n=594)
Lifetime Substance Dependence Past year Dependence
Lifetime Substance Abuse Past year Abuse
131
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, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
40
50
60
Intake 3 6 9 12
Months from Intake
STR\t,s,ts
LTR\t,ts
OP\t,s,ts
Residential programs start more severe, go down sharply,
but then come back over time
Note the sharp “hinge” in outcomes
during the active phase of AOD
treatment
Short- Term Resid. \t,s,ts
Long- Term Resid\t,ts
Outpatient\t,s
132
Change in Substance Problem Indexby Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
Change in Substance Problem Index Past Month T-Score (TSPIM) by Level of Care\a
40
50
60
Intake 3 6 9 12
Months from Intake
STR\t,s,ts
LTR\t,s,ts
OP\t,s,ts
LTR more like OP on symptoms
count
Short- Term Resid. \t,s,ts
Long- Term Resid\t,ts
Outpatient\t,s
133
Percent in Recovery (no past month use or problems while living in the community)
\a Source: Adolescent Treatment Model (ATM) data; Levels of cares coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
0%
20%
40%
60%
80%
100%
Intake 3 6 9 12
Months from Intake
STR\t,s,ts
LTR\t,ts
OP\t,s
Short- Term Resid. \t,s,ts
Long- Term Resid\t,ts
Outpatient\t,s
Longer term outcomes are
similar on substance use
134
Multiple Co-occurring Problems Were the Norm and Increased with Level of Care
Source: CSAT’s Cannabis Youth Treatment (CYT) and Adolescent Treatment Model (ATM),
44
2125
21
70
47 43
7880
65
88
56
3635
68
445252
0
20
40
60
80
100
ConductDisorder
ADHD MajorDepressiveDisorder
GeneralizedAnxietyDisorder
TraumaticStress
Disorder
Any Co-OccurringDisorder
Outpatient Long Term Residential Short Term Residential
135
Change in Emotional Problem Indexby Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
40
50
60
Intake 3 6 9 12
Months from Intake
STR\t,s,ts
LTR\t,s,ts
OP\t,s
Short- Term Resid. \t,s,ts
Long- Term Resid\t,ts
Outpatient\t,s
Note the lack of a hinge; Effect is generally indirect (via
reduced use) not specific
136
Pattern of SA Outcomes is Related to the Pattern of Psychiatric Multi-morbidity
Source: Shane et al 2003, PETSA data
Months Post Intake (Residential only)0 3 6 12
Nu
mb
er o
f P
ast
Mon
th S
ub
stan
ce P
rob
lem
s
2+ Co-occurring 1 Co-occurring No Co-occurring
Multi-morbid Adolescents start the highest, change the most, and relapse the most
137
Broad Range of Past Year Illegal Activity
Source: Adolescent Treatment Model (ATM) data
7478
82
69 7168
86
65
8580 81 81
939395
0
10
20
30
40
50
60
70
80
90
100
OP/IOP (n=560) LTR (n=390) STR (n=594)
Any illegal activity Property crimes Interpersonal crimes
Drug related crimes Acts of physical violence
138
Change in Illegal Activity Indexby Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
40
50
60
Intake 3 6 9 12
Months from Intake
STR\t,s,ts
LTR\t,ts
OP\s
Short- Term Resid. \t,s,ts
Long- Term Resid\t,ts
Outpatient\t,s
Residential Treatments have a specific effect
Outpatient Treatments has an indirect effect
139
High Rates of Victimization were the Norm
Source: Adolescent Treatment Model (ATM) data
71
82 84
52
6973
45
5662
2519
37
0
10
20
30
40
50
60
70
80
90
100
OP/IOP (n=560) LTR (n=390) STR (n=594)
Lifetime History of Victimization Acute Victimization
Past Year Victimization Past 90 Day Victimization
140
Victimization and Level of Care Interact to Predict Outcomes
Source: Funk, et al., 2003
0
5
10
15
20
25
30
35
40
Intake 6 Months Intake 6 Months
Mar
ijua
na U
se (
Day
s of
90)
OP -High OP - Low/Mod Resid-High Resid - Low/Mod.
CHS Outpatient CHS Residential Traumatized groups have higher severity
High trauma group does not respond to OP
Both groups respond to residential treatment
141
How do CHS OP’s high GVS outcomes compare with other OP programs on average?
Source: CYT and ATM Outpatient Data Set Dennis 2005
-1.00
-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Z-S
core
on
Sub
stan
ce F
requ
ency
Sca
le (
SF
S) CYT Total (n=217; d=0.51)
ATM Total (n=284; d=0.41)
CHSOP (n=57; d=0.18)
Other programs serve clients who have significantly
higher severity
And on average they have moderate effect sizes even
with high GVS
Green line is CHS OP’s High GVS adolescents; they have some initial gains but substantial relapse
142
Which 5 OP programs did the best with high GVS adolescents?
Source: CYT and ATM Outpatient Data Set Dennis 2005
-1.00
-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Z-S
core
on
Sub
stan
ce F
requ
ency
Sca
le (
SF
S) 7 Challenges (n=42; d=1.21)
Tucson Drug Court (n=27; d=0.65)
MET/CBT5a (n=34; d=0.62)
MET/CBT5b (n=40; d=0.55)
FSN/MET/CBT12 (n=34; d=0.53)
CHSOP (n=57; d=0.18)
The two best were used with much higher severity adolescents and
TDC was not manualized
Next we can check to see if they are any more similar in severity
143
-1.00
-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Z-S
core
on
Sub
stan
ce F
requ
ency
Sca
le (
SF
S)
MET/CBT5a (n=34; d=0.62)
MET/CBT5b (n=40; d=0.55)
FSN/MET/CBT12 (n=34; d=0.53)Epoch (n=72; d=0.33)
TSAT (n=66; d=0.35)CHSOP (n=57; d=0.18)
Which 5 OP Programs, of similar severity, did the best with high GVS adolescents?
Source: CYT and ATM Outpatient Data Set Dennis 2005
Trying MET/CBT5 because it is
stronger, cheaper, and easier to
implement
Not much improvement and they do not work quite as well
Currently CHS is doing an experiment comparing its regular OP with MET/CBT5
144
Post script on ATM
The ATM interventions represent a relatively unprecedented sharing of technology between programs and the rest of the field.
By choosing to use the GAIN instrumentation to facilitate comparisons to each other and CYT, the ATM investigators started a movement…over half of the current generation of studies are being pooled to make a common data set of over 7000 adolescents entering treatment (with follow-up data 3 to 12 months later) that is being used to support research on evidenced based practice.
Site and multisite level findings from ATM have been published and more work is under way – including methodological work on to integrate experimental, quasi-experimental and non-experimental findings in a meta analytic synthesis.
All of the manuals are published and distributed via website and the CDs provided.
146
A Fearless Appraisal… We are entering a renaissance of new knowledge in this area, but are only
reaching 1 of 10 in need
Several interventions work, but 2/3 of the adolescents are still having problems 12 months later
Effectiveness is related to severity, intervention strength, implementation/adherence, and how assertive we are in providing treatment
As other therapies have caught up technologically, there is no longer the clear advantage of family therapy found in early literature reviews
While there have been concerns about the potential iatrogenic effects of group therapy, the rates do not appear to be appreciably different from individual or family therapy if it is done well (important since group tx typically costs less)
Effectiveness was not consistently associated with the amount of therapy over a short period of time (6-12 weeks) but was related to longer term continuing care
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Recommendations for Further Developments…
We need to target the latter phases of treatment to impact the post-treatment recovery environment and/or social risk groups that are the main predictors of long term relapse
We need to move beyond focusing on acute episodes of care to focus on continuing care and a recovery management paradigm
We need to better understand the impact of involvement in juvenile justice system and how it can be harnessed to help
More work is need on the use of schools as a location for providing primary treatment (they have entrée to the population and appear to be the venue of choice) and recovery-schools to provide support for those coming out of residential treatment
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Common Strategies you can do NOW Standardize assessment and identify most common problems Pool knowledge about what staff have done in the past, whether it
worked, and what the barriers were Identify system barriers (e.g., criteria to local access case management,
mental health) that could be avoided if thought of in advance Identify existing materials that could help and make sure they are
readily available on site Identify promising strategies for working with the adolescent, parents,
or other providers Develop a 1-2 page checklist of things to do when this problem comes up Identify a more detailed protocol and trainer to address the problem,
then go for a grant to support implementation
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