Transcript Preliminary data from the Persistent Effects of Treatment

History and Data on
Juvenile Treatment Drug Courts
Michael L. Dennis, Ph.D.
Chestnut Health Systems
Normal, IL
Presentation at the Center for Substance Abuse Treatment (CSAT)
Juvenile Treatment Drug Court (JTDC) Orientation Meeting,
Baltimore, MD, December 13, 2010. This presentation was supported by
data and funds from SAMHSA/ CSAT contract no. 270-07-0191. It is
available electronically at www.chestnut.org/li/posters. The opinions are
those of the author and do not reflect official positions of the government.
Please address comments or questions to the author at
[email protected] or 309-451-7801.
1
The Goals of this Presentation are to:
1. Illustrate why it is so important to intervene with
juvenile drug users
2. Review what we know about juvenile treatment
drug courts (JTDC) so far
3. Compare JTDC to regular adolescent outpatient
(AOP) in terms of who is served, what services
they receive and their treatment outcomes
4. Examine other lessons from juvenile justice and
adolescent treatment studies to date.
2
Alcohol and Other Drug Abuse, Dependence and
Problem Use Peaks at Age 20
100
90
80
70
Percentage
60
Over 90% of
use and
problems
start between
the ages of
12-20
People with drug
dependence die an
average of 22.5 years
sooner than those
without a diagnosis
It takes decades before
most recover or die
Severity Category
Other drug or
heavy alcohol use
in the past year
50
40
30
Alcohol or Drug Use
(AOD) Abuse or
Dependence in the
past year
20
10
0
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
Age
3
Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000
Adolescents who use weekly or more often
are more likely during the past year to have ..
0%
been arrested
dropped out of school
been admitted to an emergency room
gotten into physical fights
have conduct disorder
engaged in illegal activity
Source: Dennis, White & Ives, 2009
20%
40%
1%
23%
6%
60%
80%
100%
No or
Infrequent Use
Weekly or
25%
More Use
17%
33%
11%
47%
13%
57%
17%
69%
4
Adolescent Brain
Development Occurs from the
Inside to Out and
Front
Photo courtesy offrom
the NIDABack
Web site.to
From
A
Slide Teaching Packet: The Brain and the
Actions of Cocaine, Opiates, and Marijuana.
pain
5
Prolonged Substance Use Injures The Brain:
Healing Takes Time
Normal levels of
brain activity in PET
scans show up in
yellow to red
Reduced brain
activity after regular
use can be seen
even after 10 days
of abstinence
Normal
10 days of abstinence
After 100 days of
abstinence, we can
see brain activity
“starting” to recover
100 days of abstinence
Source: 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.
6
Other Life Course Reasons
to Focus on Adolescents
• People who start using under age 15 use 60% more years than
those who start over age 18
• Entering treatment within the first 9 years of initial use leads
to 57% fewer years of substance use than those who do not
start treatment until after 20 years of use
• Relapse is common and it takes an average of 3 to 4 treatment
admissions over 8 to 9 years before half reach recovery
• Of all people with abuse or dependence 2/3rds do eventually
reach a state of recovery
• Monitoring and early re-intervention with adults has been
shown to cut the time from relapse to readmission by 65%,
increase abstinence and improve long term outcomes
Source: Dennis et al., 2005, 2007; Scott & Dennis 2009
7
What Is Treatment?
• Motivational interviewing and other protocols to help them
understand how their problems are related to their substance
use and that they are solvable
• Detoxification and medication to reduce pain/risk of
withdrawal and relapse, including tobacco cessation
• Evaluation of antecedents and consequences of use
• Group, individual or family outpatient including relapse
prevention planning
• More systemic family approaches
• Proactive urine monitoring
• Motivational incentives / contingency management
• Residential, intensive outpatient (IOP) and other types of
structured environments to reduce short term risk of relapse
• Access to communities of recovery for long term support,
including 12-step, recovery coaches, recovery schools,
recovery housing, workplace programs
• Continuing care, phases for multiple admission
8
% of Household Population
While Substance Use Disorders are Common,
Treatment Participation Rates Are Low
Few Get Treatment:
1 in 19 adolescents,
1 in 21 young adults,
25% 1 in 12 adults
20.9%
Over 88% of adolescent and
young adult treatment and
over 50% of adult treatment
is publicly funded
20%
Much of the private
funding is limited to
30 days or less and
authorized day by
day or week by week
15%
10%
7.8%
7.2%
5%
1.0%
0.4%
0.5%
0%
12 to 17
18 to 25
26 or older
Abuse or Dependence in past year
Treatment in past year
9
Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH
Other Problems With the U.S. Treatment System
•
Less than 75% stay the 90 days recommended by
NIDA (half less than 50 days)
•
Less than half are positively discharge
•
Less than 10% leaving higher levels of care are
transferred to outpatient continuing care
•
The majority of programs do NOT use
standardized assessment, evidenced based
treatment, track the clinical fidelity of the treatment
they provide or monitor their own performance in
terms of client outcomes
•
Average staff education is an Associate Degree
•
Staff stay on the job an average of 2 years
10
Screening & Brief Inter.(1-2 days)
In-prison Therap. Com. (28 weeks)
Outpatient (18 weeks)
Intensive Outpatient (12 weeks)
Treatment Drug Court (46 weeks)
Residential (13 weeks)
Methadone Maintenance (87 weeks)
Therapeutic Community (33 weeks)
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$0
What does an episode of treatment cost?
$407
• $750 per night in Detox
$1,249
• $1,115 per night in hospital
$1,132
• $13,000 per week in intensive
care for premature baby
$1,384
• $27,000 per robbery
$2,486
• $67,000 per assault
$2,907
$4,277
$14,818
$22,000 / year
to incarcerate
an adult
$30,000/
child-year in
foster care
Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004
$70,000/year to
keep a child in
detention
11
Investing in Treatment has a Positive
Annual Return on Investment (ROI)
• Substance abuse treatment has been shown to
have a ROI within the year of between $1.28
to $7.26 per dollar invested
• Best estimates are that Treatment Drug Courts
have an average ROI of $2.14 to $2.71 per
dollar invested
This also means that for every dollar treatment
is cut, we lose more money than was saved.
Source: Bhati et al., (2008); Ettner et al., (2006)
12
Background Juvenile Justice System
and Substance Use
• About half of the youth in the juvenile justice system
have drug related problems (Office of Juvenile
Justice and Delinquency Prevention (OJJDP), 2001;
Teplin et al., 2002).
• Juvenile justice systems are the leading source of
referral among adolescents entering treatment for
substance use problems (Dennis et al., 2003; Dennis,
White & Ives, 2009)
• By late 2004, there were 357 juvenile treatment drug
courts and the number of courts has continued to
grow at a rate of 30-50% per year.
Source: Dennis, White & Ives, 2009
13
What are the Recommended Components of a
Juvenile Treatment Drug Court?
1. Formal Screening Process for early identification and referral
for substance use and other disorders/needs
2. Multidimensional standardized assessment to guide clinical
decision making related to diagnosis, treatment planning,
placement and outcome monitoring
3. Interdisciplinary treatment drug court team
4. Comprehensive non-adversarial team-developed treatment plan,
including youth and family
5. Continuum of substance-abuse treatment and other
rehabilitative services to address the youths needs
6. Use of Evidenced Based Treatment Practices
Source: Adapted from Henggeler (2007) and the National Association of Drug Court Professionals
(NADCP, 1997) principals for drug court.
14
What are the Recommended Components of a
Juvenile Treatment Drug Court? (continued)
6.
Monitoring progress through urine screens and weekly
interdisciplinary treatment drug court team staffings
7.
Feedback to the judge followed by graduated performancebased rewards and sanctions
8.
Reducing judicial involvement from weekly to monthly with
evidence of favorable behavior change over a year or longer
9.
Advanced agreement between parties on how on assessment
information will be used to avoid self incrimination
10. Use of information technology to connect parties and
proactively monitor implementation at the client and program
level
Source: Adapted from Henggeler (2007) and the National Association of Drug Court Professionals
(NADCP, 1997) principals for drug court.
15
What Level of Evidenced is Available on the
Effectiveness of Drug Courts?
Science
Law
Beyond a
Reasonable
Doubt
STRONGER
Clear and
Convincing
Evidence
Preponderance
of the Evidence
Probable
Cause
Reasonable
Suspicion
Meta Analyses of Experiments/ Quasi
Experiments (Summary v Predictive,
Specificity, Replicated, Consistency)
Dismantling/ Matching study (What worked for
whom)
Experimental Studies (Multi-site, Independent,
Replicated, Fidelity, Consistency)
Quasi-Experiments (Quality of Matching, Multisite, Independent, Replicated, Consistency)
Pre-Post (multiple waves), Expert Consensus
Correlation and Observational studies
Case Studies, Focus Groups
Pre-data Theories, Logic Models
Anecdotes, Analogies
16
Source: Marlowe 2008
What Level of Evidenced is Available on the
Effectiveness of Drug Courts?
Science
Law
Beyond a
Reasonable
Doubt
STRONGER
Clear and
Convincing
Evidence
Preponderance
of the Evidence
Probable
Cause
Reasonable
Suspicion
Adult
Drug Treatment
Courts:Quasi
5 meta analyses
Meta
Analyses
of Experiments/
of 76 studies(Summary
found crime
reduced 7-26% with
Experiments
v Predictive,
$1.74 Replicated,
to $6.32 return
on investment
Specificity,
Consistency)
Dismantling/
Matching
study
for
DWI Treatment
Courts:
one(What
quasi worked
experiment
whom)
and five observational studies positive findings
Experimental Studies (Multi-site, Independent,
Family Drug
Treatment
Courts: one multisite
Replicated,
Fidelity,
Consistency)
quasi experiment(Quality
with positive
findingsMultifor
Quasi-Experiments
of Matching,
parent and child
site, Independent, Replicated, Consistency)
Pre-Post
(multiple
waves), Expert
Juvenile
Drug Treatment
CourtsConsensus
– one 2006
Correlation
andone
Observational
studies
experiment,
in press large
multisite quasiCase
Studies, &
Focus
Groups
experiment,
several
small studies with similar
Pre-data
Theories,
Logic
or better
effects
thanModels
regular adolescent
outpatient treatment
Anecdotes, Analogies
17
Source: Marlowe 2008
Juvenile Treatment Drug Court Effectiveness
• Low levels of successful program completion among
youths in drug courts was noticeable in several early
studies (Applegate & Santana, 2000; Miller, Scocas
& O’Connell, 1998; Rodriguez & Webb, 2004)
• Youths in drug court treatment were no more likely
to recidivate over a two-year post-release period than
youths being treated in an adolescent substance abuse
treatment program (Sloan, Smykla & Rush, 2004).
• In a randomized controlled trial, a JTDC was found
to be more effective than traditional family court
with community service in reducing adolescent
substance abuse (particularly when using evidencebased treatment) and criminal involvement during
treatment (Henggeler, et al., 2006)
18
Change in Substance Use By Condition*
Family
Court w
community
service
Drug Court
(d=0.8)
Drug Court
plus MultiSystemic
Therapy
(MST) (d=1.4)
Pre-Intake
Source: Henggeler et al 2006
4 months
12 months
Drug Court
plus MST &
contingency
Management
(d=1.6)
*p < .05
19
Change in General Delinquency By Condition*
Family
Court w
community
service
Drug Court
plus MST &
contingency
Management
(d=0.80)
Drug Court
plus MultiSystemic
Therapy
(MST)
(d=0.80)
Pre-Intake
Source: Henggeler et al 2006
4 months
12 months
Drug Court
(d=0.90)
*p < .05
20
Strengths & Limits of
Henggeler et al 2006
• Strengths
– Random assignment
– Replicable evidenced based practice
– High fidelity implementation
– Multiple follow-up waves
– Self report, urine test & records
• Limits
– Single site
– Small sample size (29-37 per condition)
– Differences at intake in spite of randomization
– Variation in findings by outcome measure
21
Findings from Ives et al (in press)
Multi-Site Quasi Experiment
• How do the severity & needs of youth in
Juvenile Treatment Drug Courts (JTDC)
compare to those Adolescent Outpatient
(AOP)
• Controlling for these differences, how do
they compare in terms of
– The services they receive?
– Their treatment outcomes?
22
Juvenile Treatment Drug Court (JTDC) Sample
• Cohort of 13 CSAT JTDC grantee sites using the GAIN in
Laredo, TX, San Antonio, TX, Belmont, CA, Tarzana, CA,
Pontiac, MI, Birmingham, AL, San Jose, CA, Austin, TX,
Peabody, MA, Providence, RI, Detroit, MI, Philadelphia,
PA, and Basin, WY.
• Intake data collected from these sites on N=1,786
adolescents between January 2006 through March 31, 2009.
• The records were limited to clients who:
– Received outpatient treatment (N=1,445), and
– Had attained 6 months post-intake (N=1,265)
• For the analysis, only those with at least one follow-up
assessment (89%) were used for a final N=1,120
• 86% received evidence-based treatment
Source: Ives et al., in press
23
Adolescent Outpatient (AOP) Sample
• Clients receiving AOP treatment from 75 CSAT-funded sites
using the GAIN and providing outpatient treatment in 29
states from five grant programs (N=10,037).
• Intake data collected from these sites on n=10,037 adolescents
between September 2002 and August 2008.
•
The records were limited to clients who:
– Received outpatient treatment (all), and
– Had attained 6 months post-intake (N=8,604)
• For the analysis, only those with at least one follow-up
assessment (88%) were used for a final N=7,560
• 93% received evidence-based treatment.
JTDC & AOP were significantly different on 36 of 69
measures of characteristics, severity and treatment need
Source: Ives et al., in press
24
Demographics
Female
AOP Unweighted
(N=7560)
Caucasian*
African American
JTDC
(N=1120)
Hispanic*
Mixed/Other*
JTDC less likely
to be Caucasian,
older, employed,
& in trouble at
school/work;
more likely to be
Hispanic/ Mixed,
Behind in school,
0-14 years
15-17 years*
18+ years*
Single Parent
In School in past 90 days
Behind < 1 year*
Expelled or Dropped out
Employed in psat 90 days*
Trouble at work or school*
0%
20%
40%
60%
80%
100%
25
Source: Ives et al., in press
* p<.05
Crime and Violence
Lifetime Justice Sys. Involvement
Current Justice Sys. Involvement
In controlled environment-P90d*
JTDC more likely have
been in a controlled
environment 13+ days,
engaged in illegal
activity (overall & drug
related)
13+ days in cont. eviron.-P90d*
Any physical violence
Any Illegal activity*
Any property crime
AOP Unweighted
(N=7560)
JTDC
(N=1120)
Any interpersonal crime
Any drug crime*
0%
Source: Ives et al., in press
20%
40%
60%
80% 100%
26
* p<.05
Intensity of Juvenile Justice System Involvement
In detention/jail 30+ days*
AOP Unweighted
(N=7560)
In detention/jail 14-29 days
JTDC
(N=1120)
Prob/parole 14+ days w/ 1+ drug screens
Other prob/parole/deten.*
Other JJ/CJ status*
JTDC more likely to be
in other JJ status and
less likely to have no JJ
status
Past arrest/JJ/CJ status
Past year illegal activity/SA use*
0%
Source: Ives et al., in press
10%
20%
30%
40%
50%
27
* p<.05
Environmental Risk Factors
Weekly Alcohol Use in Home *
AOP Unweighted
(N=7560)
Weekly Drug Use in Home*
JTDC
(N=1120)
Work/School Peers Weekly Intoxication
Social Peers Weekly Intoxication
Work/School Peers Regular Drug use
Social Peers Weekly Regular Drug use
Ever Homeless or Runaway
JTDC less likely
to have use in
home and
victimization
Lifetime Victimization*
High Severity Victimization Lifetime*
Victimization in Past 90d*
0%
Source: Ives et al., in press
20%
40%
60%
80%
100%
28
* p<.05
Substance Use
First Use under Age of 15*
Weekly Tobacco Use*
JTDC more likely
to have started
sooner, use more
often and to use
marijuana; Less
likely to use
tobacco
Weekly Any Substance Use*
Weekly Alcohol Use
Weekly Marijuana Use*
Weekly Other drug Use
Weekly Crack/Cocaine Use
AOP Unweighted
(N=7560)
Weekly Heroin Use
JTDC
(N=1120)
Weekly Other drug use
0%
20%
40%
60%
80%
100%
29
Source: Ives et al., in press
* p<.05
Substance Use Disorders
Any Lifetime Dependence or Abuse
Any Lifetime Dependence
Any Lifetime Abuse
Any Past Year Substance Use Disorder
JTDC similar on
substance use
disorders
Any Past Year Dependence
Any Past Year Abuse
Any lifetime withdrawal symptoms
AOP Unweighted
(N=7560)
Any withdrawal symptoms in the past week
JTDC
(N=1120)
Any acute withdrawal symptoms in the past week
0%
Source: Ives et al., in press
20%
40%
60%
80%
100%
30
* p<.05
Substance Treatment History
Any Prior Substance
Abuse Treatment*
AOP Unweighted
(N=7560)
JTDC
(N=1120)
Multiple prior
treatment episodes
Self Perceived
Substance Problem
JTDC more likely
to have been in
treatment before
and to be ready to
quit
Self Percieved Need
for Treatment
Ready to quit (of those
who have not quit)*
Ready to remain
abstinent (of those who
have quit)*
0%
20%
40%
60%
80%
100%
31
Source: Ives et al., in press
* p<.05
Other Major Co-Occurring Clinical Problems
High health problems-P90d*
AOP Unweighted
(N=7560)
Pregnant/got someone pregnant-PY*
JTDC
(N=1120)
Any co-occurring pyschiatric disorder
Any Internalizing Disorder*
Major Depressive Disorder*
JTDC less likely
to have health or
internalizing
disorders
Generalized Anxiety Disorder
Any homocidal/suicidal thoughts*
Traumatic Stress Disorder*
Any Externalizing Disorder
Conduct Disorder
AD/HD
Any prior mental health treatment*
0%
20%
40%
60%
80%
100%
32
Source: Ives et al., in press
* p<.05
HIV Risk Behaivors (past 90 days)
Any sexual
activity in Past 90
days
Multiple sexual
partners
Any uprotected
sexual activity in
Past 90 days
AOP Unweighted
(N=7560)
JTDC
(N=1120)
Needle Risk
0%
Source: Ives et al., in press
20%
40%
60%
80%
100%
* p<.05
33
Number of Major Clinical Problems*
No
problems*
AOP Unweighted
(N=7560)
JTDC
(N=1120)
1 problem*
2 problems
3 to 12
problems*
0%
20% 40%
60% 80% 100%
*Count of marijuana use
disorder, alcohol use disorder,
any other drug use disorder,
internalizing problems
including: depression, anxiety,
homicidal/suicidal thoughts, and
trauma, externalizing problems
including conduct disorder and
ADHD, Lifetime victimization,
past year acts of physical
violence or past year illegal
activity.
JTDC slightly less severe on psychopathology – relative to waiting for
them to come on their own, it is a form of early intervention
Source: Ives et al., in press
* p<.05
34
Matching with Propensity Scores
• Using logistic regression to predict the likelihood
(propensity) of each AOP client being a JTDC client
based on the 69 intake characteristics, we weighted
the AOP group to match the JTDC group in terms of
these characteristics and sample size.
• This produced two groups with equal sample sizes
(n=1,120) and reduced the number of significant
differences from 39 to 3 Of 69 intake variables
• Those in JTDC were still significantly
– Less likely to be African American (OR=0.77)
– More likely to be Hispanic (OR=1.44) and on other
probation, parole, or detention (OR=1.37)
Source: Ives et al., in press
35
Treatment System Involvement
0%
20%
40%
60%
Initiation
within 2 wk*
Positive System
Status 6+ mon.s
100%
85%
75%
87%
94%
Engagement for
6+ wks*
Continuing
Care 3+mons. *
80%
57%
64%
59%
54%
AOP Weighted
(N=1120)
JTDC
(N=1120)
JTDC less likely to initiate within 2 weeks, but more likely to be in
treatment 6 weeks and 3 months later.
Source: Ives et al., in press
*p <.05
36
Substance Abuse Treatment
(intake to 3 months)
0
5
10
14.7
4.7
6.2
Times in SA OP
Days in SA IOP*
2.2
Nights in SA Residential
2.4
2.6
Treatment Satisfaction Scale (mean)*
20
9.9
Days in Any SA Treatment*
Days in other SA Tx
15
5.9
0.7
0.1
AOP Weighted
(N=1120)
JTDC
(N=1120)
12.8
13.4
JTDC received more days of any treatment & IOP, also more satisfaction
Source: Ives et al., in press
*p <.05
37
Range of Substance Abuse Treatment Content
(Intake to 3 months)
0
2
4
Direct Services
Received
Family Services
Received*
External Services
Received*
Treatment
Received Scale*
6
4.4
4.3
1.2
1.6
8
10
12
AOP Weighted
(N=1120)
JTDC
(N=1120)
3.0
3.8
8.6
9.7
JTDC more likely to receive a broader range of services – particularly
family and external wrap around services
Source: Ives et al., in press
*p <.05
38
Mental Health Treatment Received
(intake to 3 months)
0
2
Days of any
Mental Health
6
8
10
8.2
7.7
7.9
Days on MH Meds
Times in MH OP
4
7.6
0.7
0.3
Nights in MH 0.06
hospital
0.02
Source: Ives et al., in press
AOP Weighted
(N=1120)
JTDC
(N=1120)
*p <.05
39
Other Environmental Inteventions
Across Systems (intake to 3 months)
0
5
10
15
Days of structured activity with out
substance use
14.2
17.2
4.6
Times urine/breath analysis*
10.5
8.9
8.2
Days in a controlled environment
4.1
3.9
Days incarcerated
2.6
3.5
Days of self-help
Any self-help*
20
0.13
0.25
AOP Weighted
(N=1120)
JTDC
(N=1120)
JTDC received more urine tests and went to self help more often
Source: Ives et al., in press
*p <.05
40
Comparison of Treatment Outcomes
(Days of ..)
35
30
Days out of 90 Days
AOP Weighted
(n=1120)
JTDC
(n=1120)
JTDC Reduced Use
More than AOP
(d between= -0.24)
25
Others Outcomes
Not Significantly Different
20
15
10
5
Substance
Use*
( d=-0.45, -0.57)
Emotional
Problems
(d=-0.32, -0.22)
Trouble w/
Family
(d= -0.23, -0.18)
In Controlled
Environment
(d=-0.02, -0.08)
6 months*
Intake
6 months*
Intake
6 months*
Intake
6 months*
Intake
6 months*
PostPre d
(AOP,
JTDC)
Intake
0
Illegal
Activity
(d=-0.11, -0.02)
41
Source: Ives et al., in press
*p<.05 change greater for JTDC vs AOP (d=-0.24)
Strengths & Limits of
Ives et al in press
• Strengths
– Multisite quasi assignment
– Differences at intake eliminated on most variables
– Replicable evidenced based practice
– Multiple follow-up waves
– Large sample size and high follow-up rates
• Limits
– Not randomized
– Disproportionately Hispanic youth
– Unknown fidelity of implementation
– Not sufficient numbers of specific evidenced based
practices to compare
42
Major Predictors of Bigger Effects
Found in Multiple Meta Analyses
(Lipsey, 1997, 2005)
1. A strong intervention protocol based on prior
evidence
2. Quality assurance to ensure protocol adherence
and project implementation
3. Proactive case supervision of individual
4. Triage to focus on the highest severity subgroup
43
Impact of the numbers of these Favorable
features on Recidivism in 509 Juvenile Justice
Studies in Lipsey Meta Analysis
Average
Practice
Source: Adapted from Lipsey, 1997, 2005
The more
features,
the lower
the
recidivism
44
Evidenced Based Treatment (EBT) that
Typically do Better than Usual Practice in
Reducing Juvenile Use & Recidivism
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Adolescent Community Reinforcement Approach (A-CRA)
Aggression Replacement Training (ART)
Assertive Continuing Care (ACC)
Cognitive Behavior Therapy (CBT)
Functional Family Therapy (FFT)
Moral Reconation Therapy (MRT)
Thinking for a Change (TFC)
Interpersonal Social Problem Solving (ISPS)
Motivational Enhancement Therapy/Cognitive Behavior Therapy
(MET/CBT)
Motivational Interviewing (MI)
Multi Systemic Therapy (MST)
Multidimensional Family Therapy (MDFT)
Reasoning & Rehabilitation (RR)
Seven Challenges (7C)
Small or no differences in mean effect size between these brand names
45
Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004
Cannabis Youth Treatment (CYT):
Similarity of Clinical Outcomes
Trial 2
Trial 1
300
50%
280
40%
260
30%
240
20%
But better than the
average for OP in220
ATM (200 days of
200
abstinence)
10%
MET/ CBT5
(n=102)
MET/
CBT12
FSN
(n=102)
MET/ CBT5
(n=99)
ACRA
(n=100)
MDFT
(n=99)
Total Days Abstinent*
269
256
260
251
265
257
Percent in Recovery**
0.28
0.17
0.22
0.23
0.34
0.19
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.12
Source: Dennis et al., 2004
Percent in Recovery .
at Month 12
Total days abstinent
over 12 months
.
Not significantly different
by condition.
0%
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.16
46
Moderate to large differences
in Cost-Effectiveness by Condition
$16
$20,000
$16,000
$12
$12,000
$8
$8,000
$4
$4,000
$0
MET/
CBT5
MET/
CBT12
CPDA*
$4.91
CPPR**
$3,958
$0
FSN
MET/
CBT5
ACRA
MDFT
$6.15
$15.13
$9.00
$6.62
$10.38
$7,377
$15,116
$6,611
$4,460
$11,775
* p<.05 effect size f=0.48
** p<.05, effect size f=0.72
Source: Dennis et al., 2004
Cost per person in recovery
at month 12
Cost per day of abstinence
over 12 months
$20
ACRA did better than
MET/CBT5,
and both did
Trial 2
better than MDFT
MET/CBT5 and
Trial 1
12 did better
than FSN
* p<.05 effect size f=0.22
** p<.05, effect size f=0.78
47
Evidenced Based Practices Can be SIMPLE:
On-site proactive urine testing can be used to reduce false
negatives by more than half
48
Implementation is Essential
(Reduction in Recidivism from .50 Control Group Rate)
The best is to
have a strong
program
implemented
well
Thus one should optimally pick the
strongest intervention that one can
implement well
Source: Adapted from Lipsey, 1997, 2005
The effect of a well
implemented weak program is
as big as a strong program
implemented poorly
49
% Point Change in Abstinence
Percentage Change in Abstinence (6 mo-Intake) by
level of Adolescent Community Reinforcement
Approach (A-CRA) Quality Assurance
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Effects associated with
Coaching, Certification
and Monitoring (OR7.6)
24%
4%
Training Only
Training, Coaching,
Certification, Monitoring
50
Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)
50
Progressive Continuum of Measurement
(common measures)
Quick
Comprehensive Special
More Extensive / Longer / Expensive
Screener
•
•
•
•
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, and 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, MATE
Specialized assessment (additional time per area)
– 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
51
Any Illegal Activity can be better predicted by
using Intake Severity on Crime/Violence and
Substance Problem Scales
Knowing both is a better predictor
(high –high group is 5.5 times more
likely than low low)
Any Ilegal Activity
(months1-6)
Intake Crime/
Violence Severity
Predicts Recidivism
60%
58%
40%
20%
46%
53%
33%
44%
27%
36%
26%
20%
High
0%
Intake Substance
Problem Severity
Predicts
Recidivism
While there is
risk, most (4280%) actually
do not commit
additional crime
Mod
High
Mod
Low
Crime/Violence Scale
(Intake)
Low
Substance
Problem Scale
(Intake)
Source: CSAT 2008 V5 dataset Adolescents aged 12-17 with 3 and/or 6 month follow-up (N=9006)
52
Outcomes May be Hidden by Multi-Dimensional
Subgroups: Example of HIV Risk Outcomes
0.01
0.00
0.00
0.20
Unprotected Sex Acts (f=.14)
Days of Victimization (f=.22)
-0.39
-0.29
-0.40
-0.60
-0.08
-0.20
-0.03
-0.10
-0.02
0.00
-0.04
Cohen's Effect Size d
0.15
0.10
0.20
0.27
0.40
-0.80
-0.69
Days of Needle Use (f=1.19)
A.
Low Risk
B.
C.
Mod. Risk
Mod. Risk
W/O Trauma With Trauma
D.
High Risk
Total
53
Source: Lloyd et al 2007
Longer Assessments Identify
More Areas of Need
100%
90%
7%
9%
3%
8%
8%
22%
13%
80%
70%
1%
0%
98%
0 Reported
1 Prob.
69%
60%
50%
1%
1%
3%
94%
22%
2 Probs.
40%
30%
40%
3 Probs.
20%
10%
4 Probs.
0%
GAIN SS GAIN Q GAIN Q
(v2)
(v3-Beta)
5 min.
20 min
30 min
GAIN I
1-2 hr
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n = 192)
Most substance
users have
multiple 54
problems
54
Alcohol
33%
Other drug disorder
27%
34%
Depression
100%
90%
80%
14%
24%
Trauma
ADHD
41%
CD
Suicide
70%
20%
Cannabis
Anxiety
60%
50%
40%
30%
20%
10%
0%
Multiple Clinical Problems are the NORM!
48%
11%
Victimization
Violence/ illegal activity
Source: CSAT 2009 Summary Analytic Data Set (n=20,826)
63%
80%
55
55
The Number of Clinical Problems
is related to Level of Care
100%
90%
None
80%
One
70%
60%
Two
50%
Three
80%
40%
65%
30%
20%
41%
45%
Four
53%
Five to Twelve
10%
0%
Outpatient
Intensive
Outpatient
Cont. Care
Outpatient
Long Term
Residential
Source: CSAT 2009 Summary Analytic Data Set (n=21,332)
Short Term
Residential
Significantly
more likely to
have 5+
problems
(OR=5.8) 56
56
The Number of Major Clinical Problems
But this is the
is highly related to Victimization
issue staff least
like to ask about!
100%
None
90%
80%
One
70%
Two
60%
Three
50%
40%
71%
30%
10%
Five to Twelve
46%
20%
15%
0%
Low (0)
Moderate (1-3)
Four
High (4-15)
Significantly more
likely to have 5+
problems
(OR=13.9)
Source: CSAT 2009 Summary Analytic Data Set (n=21,784)
57
57
90%
89%
87%
80%
Accessing Treatment
76%
Child Maltreatment
74%
Disatisfaction with Environment
73%
Behavior Control
School Problems
70%
66%
Anger Management
62%
Vocational Assistance
61%
Detox or Withdrawal
59%
Recovery Coach
58%
HIV risk reduction (sex)
57%
Tobacco Cessation
56%
Source: Reclaiming Futures (n = 192)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Other Common
Treatment
Continuing care
Planning Needs:
Case management
Reclaiming
Recovery Environment Risk
Futures
Coping w/ Psychosocial Stressors
58
Resources you can use now
• Cost-Effective evidenced based practices A-CRA & MET/CBT
tracks here, more at www.chestnut.org/li/apss or
http://www.nrepp.samhsa.gov/
• Most withdrawal symptoms appeared more appropriate for
ambulatory/outpatient detoxification, see
http://www.aafp.org/afp/2005/0201/p495.html
• Trauma informed therapy and sucide prevention at
http://www.nctsn.org/nccts and http://www.sprc.org/
• Externalizing disorders medication & practices
http://systemsofcare.samhsa.gov/ResourceGuide/ebp.html
• Tobacco cessation protocols for youth
http://www.cdc.gov/tobacco/quit_smoking/cessation/youth_toba
cco_cessation/index.htm
• HIV prevention with more focus on sexual risk and
interpersonal victimization at
http://www.who.int/gender/violence/en/ or
http://www.effectiveinterventions.org/en/home.aspx
• For individual level strengths see
http://www.chestnut.org/li/apss/CSAT/protocols/index.html
• For improving customer services http://www.niatx.net
59
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61