Transcript Slide 1

Challenges and Strategies for
Implementing Evidence-based
Family Treatments in Complex
Settings: Working within the
Juvenile Justice System
Cynthia L. Rowe, Ph.D., Howard A. Liddle, Ed.D., and
Gayle A. Dakof, Ph.D.
Center for Treatment Research on Adolescent Drug Abuse
University of Miami Miller School of Medicine
Presented at the American Family Therapy Association (AFTA) 8th Clinical
Research Conference, “Evidence-based Family Treatments: Improving Family
Therapy and Research by Advancing Clinician and Researcher Collaborations;”
Miami Lakes, FL; February 23rd, 2007
Overview
 What are the specific challenges of our
work within the juvenile justice system?
 How have we addressed these challenges
to successfully implement evidence-based
family treatments within complex systems?
 Is there any evidence that implementing
evidence-based family treatments in realworld settings improves youths’ outcomes?
 What are the current pressing questions?
“ Instead of helping, we are writing off these young
Americans, we are releasing them without
attending to their needs for substance abuse
treatment and other services, punishing them
without providing help to get back on track.”
-- Joseph A. Califano, CASA, 2004
Four of every five children and teen
arrestees in state juvenile justice
systems have some involvement with
drugs and alcohol
Only 3.6 percent of these
juvenile justice involved youth
receive any type of treatment
CASA 2004
“I have been there. I have
witnessed the deplorable
conditions forced upon these
young people. The system must
be changed to address the needs
of these juveniles and prevent
them from living a life crime and
drug addiction.”
- Charles W. Colson, Founder and Chairman of
the Board, Prison Fellowship, the world's largest
outreach to prisoners, ex-prisoners, crime victims
and their families.
“The juvenile courts of our country
have become the leading service
delivery system for children and
youth with substance abuse
problems, not by choice, but by
necessity.”
- Reclaiming Futures: A model for judicial leadership (2006).
Multiple Interacting Problems of
Juvenile Offenders
 Serious substance abuse: 60 - 80% of
incarcerated samples
 Violent offenses: 70% of repeat offenders
 Co-occurring mental health problems:
75% have a DSM disorder + CD and SUD
 Family disruption, conflict, and chaos
 School problems: 85% suspended/80% LD
 Negative peers/ gang involvement
 High-risk sexual behavior
Antisocial Behavior Over Time
 Early childhood risk factors and family
problems set the stage
 Antisocial behavior compromises
emotional and social development
 Long-term deficits across domains
 Family-based intervention during
adolescence may halt the progression
of drug abuse and antisocial behavior
Assessment and Intervention
in the Juvenile Justice System
 Youth screened at intake centers
 Screening conducted to determine level of risk
 Youth at lowest risk placed in diversion
programs – few are empirically supported
 Comprehensive assessments conducted with
moderate and high risk youth
 Highest risk youth stay in detention 3-21 days
 Disposition may involve court-ordered
treatment as part of probation or drug court
DJJ System Challenges
 JACs and facilities overcrowded/understaffed
 Assessments not conducted with all teens at
risk due to limited resources
 Services for youth in JJ settings are limited
and few have any empirical basis
 Families rarely involved in treatment
 Little coordination/follow-through between JJ
facilities and treatment programs
 Bottom line: Most juvenile offenders don’t
receive services at all – positive outcomes in
the DJJ system are truly “against all odds”
Barriers to Implementing
Effective Family Treatments
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Focus is on punishment – not treatment
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“Too many cooks” (DA/SA, PD, judge, PO)
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Deep and pervasive pessimism about families
– belief that “boot camp” is helpful
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Disconnect between research, clinical, and
DJJ systems – different theories of change,
different agendas, and different masters
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Treatment models not seen as credible/ seen
as too complex to integrate within system
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Lack of resources to fully implement the
models and sustain them over time
Evidence-based Family
Treatments for Young Offenders
 Multifaceted problems require multicomponent
assessment and intervention strategy
 Families and other systems are primary
contexts for development and change
 Effective interventions go beyond a unidimensional theory of change
 Multidimensional approaches address risk and
protective factors within the individual teen,
the parent, family system, and school, court,
and other systems
“Today, we have solid evidence showing that
rehabilitation works and is cost-effective. Studies by
the Washington State Institute for Public Policy
found proven treatment programs are a good
investment. For example, Functional Family Therapy
reduced recidivism by 38 percent, saving the taxpayers $10 for every dollar spent.”
-- Jonathon Fanton, President, MacArthur Foundation
Multisystemic Therapy for Youth
in Juvenile Drug Court
 Henggeler et al (2006) reported successful
implementation of MST within the juvenile
drug court program
 Family Court + TAU and Drug Court + TAU
performed poorly in comparison to combined
effects of the 2 MST conditions (MST + Drug
Court; MST + CM + Drug Court)
Multidimensional Family Therapy
with Drug Abusing Juveniles in
Detention
 Assess youth immediately in detention
 MDFT therapist intervenes with youth in
detention and parents in their home
 Continue MDFT after release, building upon
foundation established in detention
 Incorporates HIV/STD prevention
 Targets multiple domains of functioning
 Collaboration with PO, judge, PD
Multidimensional Family Therapy
in Juvenile Drug Court
 MDFT is currently being tested within MiamiDade’s Juvenile Drug Court program
 MDFT therapists work collaboratively with
the court and probation officers to ensure
compliance with the program
 Outcomes expected to be better than drug
court + standard group treatment
 Incorporates HIV/STD prevention
 Outcomes targeted across domains (e.g.,
individual, family, school functioning)
Implementing Evidence-based
Family Treatments: “Are we
doing our own model?”
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Multi-level assessment/intervention strategy
Negotiating multiple alliances
Collaborative approach
Assessing and reading feedback
Planning and flexibility are complementary
Accept “rough around the edges” outcomes
Actively shaping and directing the process
Maintaining intensity and focus
Addressing Barriers to
Implementation
 Start with what juvenile justice authorities feel
needs to change
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Multisystemic assessment of context
Identify multiple levels of system/ subsystem units
Assess by joining system
Involve jj folks and the providers at all levels in
assessing, planning, and implementing EBP
Work as a team with jj system and providers
Emphasize the efficacy of the approach in ways
that are concrete and meaningful
SIMPLIFY and protocolize the approach
Addressing Barriers (cont.)
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Communicate clearly about the intervention
and the outcomes being achieved
Discuss how new treatment fits in/augments
existing system and practices
Be creative in providing incentives for change
Discuss and address obstacles to change in a
realistic, non-defensive way
Reinforce knowledge gained with providers
Create opportunities for providers to practice
skills, give feedback, and get feedback from
them about intervention’s fit and any obstacles
Transporting MDFT into an
Adolescent Day Treatment Program
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NIDA-funded project attempting to implement
MDFT within an existing day treatment
program for drug abusing young offenders
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Day treatment program set in a large, complex
public hospital system
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Interrupted time-series design with 4 phases:
Baseline, Training, Implementation, and
Durability
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First systematic study of the integration of
MDFT in an existing drug treatment program
Study Aims
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Clinical Practices: Determine whether providers
could implement MDFT with adequate fidelity
within the day treatment program
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Program Changes: Determine whether the
program could be transformed based on MDFT
principles and interventions
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Client Changes: Determine whether MDFT
implementation would positively impact youths’
outcomes across domains of functioning
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Durability: Determine whether changes could be
sustained without MDFT trainers
Study Phases
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Phase I. Baseline: Assessment of provider
practices, program environment, and client
outcomes
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Phase II. Training: Work with all staff in day
treatment program and larger system
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Phase III. Implementation: Continue expert
supervision and booster trainings as needed;
Assess impact of training
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Phase IV. Durability: MDFT experts withdraw;
Assess sustainability of approach
Adolescent Day Treatment Program
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Multicomponent program/multidisciplinary staff
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Behaviorally oriented “levels approach”
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School through alternative education program
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Group therapy daily and recreational activities
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Psychiatric evaluation and intervention
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Individual therapy weekly
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Family therapy “as needed”
Implementation Approach
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Guiding principle: Isomorphism between
training approach and therapy model
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Collaboration/ Consultation
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Empowering clinical staff and redefining roles
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Conceptualizing change at different levels of
system and in different domains
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Modeling interventions, practice, and feedback
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Increasing staff accountability
Outcomes
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Clinical Practices (Adherence to MDFT):
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Changes in sessions and contacts (parameters)
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Changes within sessions (interventions)
Program Changes:
Changes in adolescents’ perceptions of program
environment
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Client Changes:
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Drug use, externalizing/internalizing symptoms
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Arrests and placements in controlled settings
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Involvement with delinquent peers
Increases in Sessions over
Study Phases
More individual
sessions on
days attended in
Implementation
and Durability
0.3
0.25
More family
sessions on days
attended in
Implementation
and Durability
0.2
Baseline
Implementation
0.15
Durability
0.1
0.05
0
Individual Sessions
Family Sessions
Increases in Contacts over
Study Phases
More DJJ contacts in
Implementation than
Baseline
Average Number of Weekly Contacts
0.8
Slight decrease in
DJJ contacts in
Durability
0.6
Baseline
More contacts with
schools in
Implementation and
Durability
0.4
0.2
0
DJJ Contacts
School Contacts
Implementation
Durability
Adherence to MDFT Interventions
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Coding of therapists’ charts revealed more focus on
drugs during sessions in the Baseline phase (p<.05)
Therapists focused on school issues and adolescents’
thoughts and feelings about themselves more in the
Implementation and Durability phases (p’s<.01)
Therapists in Implementation and Durability addressed
more core MDFT content themes per session than
sessions in Baseline (p<.05)
Ratings of sessions revealed significant increases in
adherence to MDFT interventions over phases
(adolescent-focused, family-focused, and
engagement/reconnection interventions all p < .05)
Changes in Session Content
over Study Phases
100
Proportion of Sessions
80
More focus on self
in Implementation
and Durability
More focus
on drugs
in Baseline
More focus on
school in
Implementation
and Durability
Baseline
60
Implementation
Durability
40
20
0
Drugs
Self
School
Changes in Program Environment
Adolescents felt the
program was more
organized in
Implementation than
Baseline
8
Adolescents felt the
program had a more
practical orientation in
Implementation and
Durability
7
Adolescents felt
staff were more
clear about
rules/expectations
in Implementation
and Durability
6
5
Baseline
4
Implementation
Durability
3
2
1
Cl
ar
ity
Pr
ac
ti c
al
O
rd
er
0
Results: Client Outcomes
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LGM used to compare drug use, externalizing, and
internalizing trajectories between intake and 9 months
for youth in the 3 study phases
Youth decreased drug use more rapidly in
Implementation and Durability phases than youth in
Baseline (p’s<.05)
Youth in Implementation and Durability decreased their
externalizing and internalizing symptoms more rapidly
than youth in Baseline (p<.05) according to self-report
Youth improved more rapidly in internalizing (p<.05)
and externalizing symptoms (p=.01) in Durability
relative to Baseline according to parent reports
Change in Self-Reported
Externalizing Problems
Youth in
Implementation and
Durability improved
more rapidly than
youth in Baseline
80
70
Baseline
Implementation
Durability
60
50
Intake
1 Month
Discharge
9 Months
Change in Self-Reported
Internalizing Problems
Youth in
Implementation and
Durability improved
more rapidly than
youth in Baseline
60
Baseline
Implementation
50
Durability
40
Intake
1 Month
Discharge
9 Months
Percent in Controlled Environment
at Follow-up over Study Phases
39
40
35
30
25
Baseline
Implementation
20
Durability
15
10
5
0
8
0
Summary of Findings
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Clinical Practices: Therapists implemented MDFT in
accordance with treatment parameters and
interventions
Program Environment: Program was more practical,
individually focused, organized, and clear following
training in MDFT
Client Outcomes: Youths’ drug use, internalizing and
externalizing symptoms, peer delinquency, and
placements were reduced following MDFT training
Durability: Staff continued to use MDFT and to
demonstrate outcomes with youth a year after MDFT
experts withdrew
Implications of Findings
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Evidence-based family treatment was
successfully implemented within a complex
hospital system, overcoming many obstacles
Implementation was successful in impacting
all three levels of outcomes (provider,
program, client)
Implementation successfully created lasting
change in fundamental areas of provider and
program functioning that impacted client
outcomes
Current Pressing Questions
 How can evidence-based family treatments
be integrated within residential settings?
 Can protocols and training components be
simplified to help juvenile justice workers at
different levels implement key interventions?
 What can these approaches offer to make
progress on challenges of workforce
development/retention?
 How can methods be improved to measure
whether we’re “doing our model?”
Resources for Working with Drug
Abusing Juvenile Offenders
Barnoski, R. (2002). Monitoring vital signs: Integrating a standardized assessment into
Washington State’s Juvenile Justice System. In R. Corrado et al. (Eds.), Multi-problem violent
youth. IOS Press.
Brown, D., Maxwell, S., DeJesus, E., & Schiraldi, V. (2002). Barriers and promising
approaches to workforce and youth development for young offenders. The Annie E. Casey
Foundation, Baltimore, MD.
CASA (2004). Criminal neglect: Substance abuse, juvenile justice and the children left
behind.
Grisso, T. (1998). Forensic evaluation of juvenile offenders: A manual for practice.
Sarasota, FL. Professional Resource Press.
Hoge, R., & Andrews, D. (1996). Assessing the youthful offender: Issues and techniques.
New York: Plenum Press.
Liddle, H. (2002). Multidimensional Family Therapy Treatment (MDFT) for adolescent
cannabis users. Volume 5 of the Cannabis Youth Treatment (CYT) manual series. Rockville, MD:
Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services.
NIDA (1999). Principles of Drug Addiction Treatment: A research-based guide. (NIH
publication 99-4180). Rockville, MD.
NIDA (2006). Principles of Drug Abuse Treatment for Criminal Populations: A researchbased guide. (NIH publication 06-5316). Rockville, MD.
OJJDP (1995). Guide for implementing the comprehensive strategy for serious, violent,
and chronic juvenile offenders. Washington, DC: OJJDP.
Reclaiming Futures Fellowship Report (2006). A model for judicial leadership:
Community responses to juvenile substance abuse. Reclaiming Futures.
Acknowledgements
We gratefully acknowledge the National Institute on Drug
Abuse for supporting this work through many grants,
including the Criminal Justice Drug Abuse Treatment
Studies (CJDATS: Grant No. 5 U01 DA16193; P50 DA; H.
Liddle, PI), “Family-based Juvenile Drug Court Services”
(Grant no. 1 R01 DA17478; G. Dakof, PI), and our
“Bridging” study (Grant No. R01 DA3089, H. Liddle, P.I.).
We are also indebted to the many therapists and the teens
and families who have participated in these studies to
develop and test MDFT over more than 20 years.
Please see our website for more information on the Center’s
program of research: www.miami.edu/ctrada or contact me
at [email protected] for more details.