screening and assessment: lessons from rwjf’ s reclaiming futures projects michael dennis, ph.d....

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: [email protected] Questions about the GAIN can also be sent to [email protected]

mailto:[email protected]

mailto:[email protected]

2

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

Goals of this Presentation are to

3

Short Term Impact of Substance Use on the BrainShort Term Impact of Substance Use on the Brain(PET Scan Minutes After Using Cocaine)(PET Scan Minutes After Using Cocaine)

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 1989;4(4):371-377.

Rapid rise in brain activity after taking

cocaine

Actually ends up lower than they started

4

Normal

Cocaine Abuser (10 days)

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 11:184-190, 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 14:169-177, 1993.

Recovery from cumulative use takes more time Recovery from cumulative use takes more time (PET Scan Activity Days After Using Cocaine)(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)

Even after 100 days of abstinence

activity is still low

5Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

The effects on the brain can be long lasting(Serotonin Present in Cerebral Cortex Neurons )

Reduced in response to excessive use Still not back to normal after 7 years

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

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

Overlap with Crime and Civil Issues

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

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

Source: 2002 NSDUH; Dennis & Scott 2007

(2002 U.S. Household Population age 12+= 235,143,246)

10

Crime & Violence by Substance Severity

0%

10%

20%

30%

40%

50%

60%

Serious FightAt School

Fighting withGroup

Sold Drugs Attacked withintent to harm

Stole (>$50) CarriedHandgun

Dependence (3.9%) Abuse (4.2%)

Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)

Light Alc Use (12.4%) No PY AOD Use (64.3%)

Source: NSDUH 2006

Age 12-17

Severity is related to other violence/crime

problems

11

Family, Vocational & MH by Substance Severity

Source: NSDUH 2006

0%

10%

20%

30%

40%

50%

60%

10 or MoreArguments with

Parents

Disliked School GPA = D orlower

MajorDepression

Any MHTreatment

Dependence (3.9%) Abuse (4.2%)

Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)

Light Alc Use (12.4%) No PY AOD Use (64.3%)

Age 12-17

As well as other School and Mental Health Problems

12

Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.t

pain

Adolescent Brain Development Occurs from the

Inside to Out and from Back to Front

Main reasons for using are to get pleasure or

dull pain

13

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

14

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


15

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

Reducing the years of use and its

associated problems by over a decade

16

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

Over 2/3rds eventually get better(which is

better than most major

DSM disorders)


Median of 3 to 4 episodes of treatment

over 9 years

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

http://sbirt.samhsa.gov/



19

Places vary in the rate of problems (Past Year Substance Abuse or Dependence)

Source: OAS, 2006

There is even

variation within DC

(an area less than 10 square

miles) and of course within

individuals

20

Crime/Violence and Substance Problems Interact to Predict Any 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

21

Crime/Violence and Substance Problems Interact Differently to Predict Recidivism to Violent Crime

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

22

Mental Health Comorbidity Among Girls in Detention

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

Multiple Problems

are the norm

http://www.ncjrs.gov/pdffiles1/ojjdp/210331.pdf

23

Mental Health Comorbidity Among Boys in Detention

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

While there are gender differences,

the differences are often

degrees of variation

http://www.ncjrs.gov/pdffiles1/ojjdp/210331.pdf

24

Number of Major Clinical Problems by System of Care

45% 44% 46%56%

46%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total In School In workforce In ChildWelfare

In Juv.Justice

0 to 1

2 to 4

5 or more

Source: Dennis et al in 2008; CSAT 2007 AT Outcome Data Set (n=12,824)

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

25

Number of Problems is Related to Level of Care

39%50% 55%

67%78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Outpatient(OR=1)

IntensiveOutpatient(OR=1.6)

Long TermResidential(OR=1.9)

Med. TermResidential(OR=3.2)

Short TermResidential(OR=5.5)

0 to 1

2 to 4

5 or more


Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824)

Clients entering Short Term Residential

(usually dual diagnosis) have 5.5 times higher

odds of having 5+ major problems*

26

15%

45%

70%

0%10%20%30%40%50%60%70%80%90%

100%

Low (OR 1.0)

Mod.(OR=4.6)

High(OR=13.2)

NoneOneTwoThreeFourFive+

No. of Prob. is related to the Severity of Victimization

Severity of Victimization


Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824)

Those with high lifetime levels of

victimization have 13 times higher odds of

having 5+ major problems*

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

Specialized Assessment– Additional assessment by a specialist (e.g., psychiatrist, MD, nurse,

spec ed) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan

– CIDI, DISC, KSADS, PDI, SCAN

Screener Quick C

omprehensive S

pecial

More E

xtensive / Longer/ E

xpensive

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

Het

erog

eneo

us N

eeds

an

d S

ever

ity

• 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

Com

preh

ensi

ve A

sses

smen

t

Issue Instrument Feature Protocol Feature Outcome

Hig

h T

urno

ver

Wor

kfor

cew

ith

Var

iabl

e E

duca

tion

• 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

Impr

oved

Rel

iabi

lity

and

E

ffic

ienc

y

30

Issue Instrument Feature Protocol Feature Outcome

Mis

sing

or

Mis

repr

esen

ted

Dat

a

• 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

Impr

oved

Val

idit

y

Lac

k of

Acc

ess

to o

r us

e of

D

ata

at th

e P

rogr

am L

evel • 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 Im

prov

ed P

rogr

am P

lann

ing

and

Out

com

es

Global Appraisal of Individual Needs (GAIN) Logic Model as an Example

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 CollaboratorsAdolescent and Adult Treatment Program

10/08

GAIN State System

Virgin Islands

01 to 1011 to 25

26 to 130

Indiana

Kansas

MaineMontana

NebraskaNevada

North Dakota

Puerto Rico

Hawaii

New Mexico

South Dakota

Alabama

Arkansas

Iowa

Oklahoma

Rhode Island

South CarolinaDistrict Of ColumbiaTennessee

Utah

Louisiana

W. Virginia

Minnesota

Wisconsin

New Jersey

North Carolina

Alaska

Delaware

Maryland

Pennsylvania

Georgia

KentuckyVirginia

MichiganNew York

Oregon

Colorado

Texas

New Hampshire

Connecticut

Illinois

Missouri

Arizona

Florida

Ohio

Vermont

Idaho

Massachusetts

California

Washington

Wyoming

GAIN-SS State or County System

Number of GAIN SitesMississippi

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

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

GAIN-Short Screener (GSS): Overview (continued)

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)

33% 37%48%

38%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

InternalizingDisorderScreener

ExternalizingDisorderScreener

SubstanceDisorderScreener

Crime/ViolenceScreener

TotalDisorderScreener

Low

Mod.

High

Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)

39

GAIN Short Screener Number of Problems Mod/Hi

40%

22%

22%

9%7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No. ofProblems

No SR prob

1 Prob.

2 Probs.

3 Probs.

4 Probs.


93% endorsed one or more problems

(40% 4 or more)

40

GAIN SS Psychometric Properties

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

At 3 or more symptoms we get 99% prevalence, 91% sensitivity, & 89% specificity

Using a lower 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 2006

41

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

42

GAIN SS Total Score is Correlated With Level Of Care Placement

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

TDScr Score

% w

ithi

n L

evel

of

Car

e an

d A

ge G

roup OP/IOP (n=2499)

Residential (n=1965)

Low

Mod High ->OP/IOP

Median=6.0Residential

Median=10.5

43

GAIN SS Can Also be Used for Monitoring

109

11

910

8

32 2

0

4

8

12

16

20

Intake 3Mon

6Mon

9Mon

12Mon

15Mon

18Mon

21Mon

24Mon

Total Disorder Screener (TDScr)

12+ mon.s ago (#1s)

2-12 Mon.s ago (#2s)

Past Month (#3s)

Lifetime (#1,2,or 3)

Track Gap Between Prior and current

Lifetime Problems to identify “under

reporting”

Track progress in reducing current

(past month) symptoms)

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)

18% 24%

26%

29%

22% 29

%

25%

28%

5%24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%G

ener

al F

acto

rs

Sour

ces

of S

tres

s

Hea

lth

Dis

tres

s

*Gen

eral

Lif

e P

rob

Dep

ress

ion

Suic

ide

Ris

k

Anx

iety

-Tra

uma

Sx

*Int

erna

lizi

ng

Hyp

er-I

natt

enti

on

Con

duct

Dis

orde

r

Gen

eral

Cri

me

*Ext

erna

lizi

ng

AO

D U

se &

Abu

se

AO

D D

epen

denc

e

Subs

tanc

e P

robl

em

*Tot

al S

core

Low (0-24%)

Mod (25-75%)

High (76-100%)

Source: Reclaiming Futures Chicago, IL, Dayton, OH, Portland, OR and Santa Cruz, CA sites (n=475). * Summary Measure

RiskStressHealth

More detail within

each area

47

GAIN Quick Number of Problems Mod/Hi

69%

13%

8%8%3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No. ofProblems

No SR prob

1 Prob.

2 Probs.

3 Probs.

4 Probs.

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 (n=475).

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/statistical rules)

31%19%15%

7%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sub.

Use

/In

duce

dP

rob.

Abu

se

Dep

ende

nce

Sub.

Pro

b.P

ast

Yea

r

Low

Mod.

High


52

GAIN Initial Profile: Substance Problems by Time(Range based range of clinical/logical/statistical rules)

39%31%

13%2%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sub.

Pro

b.L

ifet

ime

Sub.

Pro

b.P

ast

Yea

r

Sub.

Pro

b.P

ast

Mon

th

Wit

hdra

wal

Sx P

ast

Wee

k

Low

Mod.

High


53

GAIN Initial Profile: Motivation and Readiness(Range based range of clinical/logical/statistical rules)

0% 7%19%

32%

76%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Self

-E

ffic

acy

Tre

atm

ent

Res

ista

nce

Tre

atm

ent

Pre

ssur

e

Tre

atm

ent

Mot

ivat

ion

Pro

blem

Ori

enta

tion

Low

Mod.

High


54

GAIN Initial Profile: Crime/Violence(Range based range of clinical/logical/statistical rules)

25% 33%

5% 8%

51%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%V

iol.

Con

flic

t-T

acti

c

Pro

pert

yC

rim

e

Inte

rper

sona

lC

rim

e

Dru

g C

rim

e

Cri

me

Vio

lenc

e

Low

Mod.

High


55

GAIN Initial Profile: Environmental Risk(Range based range of clinical/logical/statistical rules)

39%

64%54%

28%

0%

10%20%

30%

40%50%

60%

70%

80%90%

100%

Liv

ing

Env

.R

isk

Voc

atio

nal

Env

. Ris

k

Soci

al E

nv.

Ris

k

Env

iron

men

tal

Ris

k

Low

Mod.

High


56

GAIN Initial Profile: Internalizing Disorders(Range based range of clinical/logical/statistical rules)

3%15%

1% 9% 9%24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Som

atic

Dep

ress

ion

Suci

de R

isk

Anx

iety

-F

ear

Tru

ama

Inte

rnal

izin

g

Low

Mod.

High


57

GAIN Initial Profile: Externalizing Disorders(Range based range of clinical/logical/statistical rules)

20%12% 14% 20%

0%

10%20%

30%

40%50%

60%

70%

80%90%

100%

Inat

tent

iven

ess

Hyp

erac

tivi

ty-

impl

usiv

e

Con

duct

Dis

orde

r

Ext

erna

lizi

ng

Low

Mod.

High


58

GAIN Initial Profile: Personality Disorders(Range based range of clinical/logical/statistical rules)

53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cau

tiou

s(C

lust

er A

)

Impl

usiv

e(C

lust

er B

)

Wor

ryin

g(C

lust

er C

)

Tot

alP

erso

nali

ty

Low

Mod.

High


59

GAIN Initial Profile: General Factors / Stress(Range based range of clinical/logical/statistical rules)

26%44%

10% 12%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Em

ploy

men

tP

rob.

S

choo

lP

rob.

Vic

tim

izat

ion

P

erso

nA

xis

IV

O

ther

Axi

sIV

Low

Mod.

High


60

GAIN Initial Profile: Other Problem Scales(Range based range of clinical/logical/statistical rules)

12%2% 4%

17%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hea

lth

Gam

blin

g

Soci

alSu

ppor

t

Lif

eSa

tisf

acti

on

Low

Mod.

High


61

GAIN Initial Profile: Measures of Behavior Change (Range based range of clinical/logical/statistical rules)

41%

3% 10% 14%

41%23%

3%4%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Su

bsta

nce

Use

Hea

lth

Em

otio

ns

Rec

over

yE

nvir

onm

ent

Ille

gal

Act

ivit

y

Scho

ol

Wor

k

Fin

anci

al

Low

Mod.

High


62

GAIN Initial Number of Problems Mod/Hi

98%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No. ofProblems

No SR prob

1 Prob.

2 Probs.

3 Probs.

4 Probs.

99.4% endorsed one or more problems

(98.4% 4 or more)


63

GAIN Treatment Planning/Placement Grid

Problem Recency/Severity

None Past Current (past 90 days)*

Low-Mod | High Severity Treatm

ent History

Non

e Past C

urren

t .

1. No Problem

2. Past problem Consider monitoring and relapse prevention.

3. Low/Moderate problems; Not in treatmentConsider initial or low invasive treatment.

4. Severe problems;Not in treatment Consider a more intensive treatment or intervention strategies.

0. Not LogicalCheck under- standing of problem or lying and recode.

5. No current problems; Currently in treatmentReview for step down or discharge.

6. Low/Moderate problems; Currently in treatment Review need to continue or step up.

7. Severe problems; Currently in treatmentReview need for more intensive or assertive levels.

* Current for Dimension B1 = Past 7 days

64

0% 20% 40% 60% 80% 100%

AT

RF

AT

RF

AT

RF

AT

RF

AT

RF

AT

RF

AS

AM

B1.

Into

x/W

ithd.

AS

AM

B2

Bio

med

ical

AS

AM

B3.

Psy

ch/B

ehA

SA

M B

4.R

eadi

ness

AS

AM

B5.

Rel

. Pot

.A

SA

M B

6.E

nviro

n.

Inconsistent No problem Past Prob Low/Mod Prob High Prob No Prob in Tx L/M Prob in Tx H Prob in Tx

Reclaiming Futures as or more severe than Regular Adolescent Treatment

Source: King County Adolescent Treatment (n=1860) vs. Reclaiming Futures (n=404)

65

OtherCommon

TreatmentPlanning

Needs

Source: King County Adolescent Treatment (n=1860) vs. Reclaiming Futures (n=404)

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Strengths/Soc Sup.

Cont. Care

Case management

Environmental Risk

Copying with stress

Getting into Treat.

Child Maltreatment

Need for Change

Behavior Control

School Problems

Anger Management

Other Vocational Help

Detox / Withdrawal

Recovery Coach

HIV intervention (Sex)

Tobacco Cessation

Self Help / Support

Job Placement

Family Fighting

Scheduling

Adolescent Treatment

Reclaiming Futures

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

66

Variance Explained in 10 NOMS Outcomes

\1 Past month \2 Past 90 days *All statistically Significant

26%

24%

11%

25%

15%

33%

26%

18%

14%

8%

24%

0% 5% 10% 15% 20% 25% 30% 35%

No AOD Use

No AOD related Prob.

No Health Problems

No Mental Health Prob.

No Illegal Activity

No JJ System Involve.

Living in Community

No Family Prob.

Vocationally Engaged

Social Support

Count of above

Percent of Variance Explained

Source: CSAT 2007 AT Outcome Data Set (n=11,013)

67

Best Level of Care*: Cluster A Low - Low (n=1,025)


Best Level of Care*: Cluster A Low - Low (n=1,025)

99.6%

0.4%0%

20%

40%

60%

80%

100%

120%

Outpatient Higher LOC

% B

est

Pre

dic

ted O

utc

om

es

* Based on Maximum Predicted Count of Positive Outcomes

68

Best Level of Care*: Cluster C Mod-Mod (n=1209)


Best Level of Care*: Cluster C Mod-Mod (n=1209)

30.2%

7.6%

23.6%

38.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Outpatient IOP OPCC Residential

% B

est

Pre

dic

ted O

utc

om

es


69

Best Level of Care*: Cluster F Hi-Hi (CC) (n=968)


Best Level of Care*: Cluster F Hi-Hi (CC) (n=968)

81.5%

8.6%

0.0%

9.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Outpatient IOP OPCC Residential

% B

est

Pre

dic

ted O

utc

om

es


70

Best Level of Care*: Cluster G Hi-Mod (Env/PH) (n=749)


Best Level of Care*: Cluster G Hi-Mod (Env/PH) (n=749)

94.1%

5.9%0.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Outpatient IOP/OPCC Residential


71

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

Conclusions

Questions?

screening and assessment: lessons from rwjf’ s reclaiming futures projects michael dennis, ph.d....

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