Transcript What do we know and where do we go from here

Creating a Recovery Oriented and Better
Adolescent Treatment System in King County
Michael Dennis, Ph.D.
Chestnut Health Systems, Normal, IL
September 23-24, 2010
Presentation for the King County Substance Abuse and Mental Health Sr. Staff at the
Recovery Cafe. This presentation was supported by King County. The author would
like to thank Dennis Deck for providing the tables of 2009 SAPISP data. The
presentation also reports on treatment & research funded by the Center for Substance
Abuse Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA) under contract 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 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]
Parts of this Presentation
1.
Understanding Addiction as a Chronic Condition and
its Implications for Public Health and Safety
2. No Wrong Door: The Move Toward Screening, Brief
Intervention, and Referral to (Long-Term) Treatment
3.
Trends in Washington State Publicly Funded
Treatment: 1999 to 2009 Target Data
4.
Highlight What It Takes to Move the Field Toward
Evidence-Based Practice Related to Assessment,
Treatment, Program Evaluation, and Planning
5. Preliminary Findings from King County: 2004 to 2010
6.
Common Treatment Planning Needs, Strengths, Social
Support and Potential Mentoring of King County
Adolescents
2
Part 1 Understanding Addiction as
a Chronic Condition and its
Implications for Public
Health and Safety
3
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%
No Alcohol or
Drug Use
32%
Light Alcohol
Use Only 47%
Source: 2002 NSDUH, Dennis & Scott 2007
Problems Vary by Age
NSDUH Age Groups
100
90
80
70
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
50
No Alcohol or Drug Use
Light Alcohol Use Only
Any Infrequent Drug Use
Regular AOD Use
40
30
20
Abuse
Dependence
10
0
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
Source: 2002 NSDUH and Dennis & Scott 2007
Higher Severity is Associated with
Higher Annual Cost to Society Per Person
$4,000
Median (50th percentile)
$3,500
Mean (95% CI)
$3,000
$2,500
$2,000
$1,500
$3,058
This includes people who are in
recovery, elderly, or do not use
because of health problems
$1,613
Higher
Costs
$1,528
$1,309
$1,078
$1,000
$725
$406
$500
$0
$948
$0
$0
No
Alcohol or
Drug Use
Light
Alcohol
Use Only
$231
$231
Any
Infrequent
Drug Use
Regular
AOD
Use
Abuse
Dependence
Source: 2002 NSDUH
Crime & Violence by Substance Severity
60%
Substance use severity is
related to crime and violence
50%
Adolescents 12-17
40%
30%
20%
10%
0%
Serious Fight Fighting with
At School
Group
Dependence (3.9%)
Weekly AOD Use (6.4%)
Light Alc Use (12.4%)
Source: NSDUH 2006
Sold Drugs
Attacked with Stole (>$50)
intent to harm
Carried
Handgun
Abuse (4.2%)
Any Drug or Heavy Alc Use (8.8%)
No PY AOD Use (64.3%)
Family, Vocational & MH by Substance Severity
60%
..as well as family, school
and mental health
problems
50%
Adolescents 12-17
40%
30%
20%
10%
0%
10 or More
Disliked School
Arguments with
Parents
Dependence (3.9%)
Weekly AOD Use (6.4%)
Light Alc Use (12.4%)
Source: NSDUH 2006
GPA = D or
lower
Major
Depression
Any MH
Treatment
Abuse (4.2%)
Any Drug or Heavy Alc Use (8.8%)
No PY AOD Use (64.3%)
Brain Activity on PET Scan After
Using Cocaine
Rapid rise in brain
activity after taking
cocaine
Actually ends up
lower than they
started
Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon
brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR,
Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377.
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.
Reduced in response to excessive use
Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine
Still not back to
normal after 7 years
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
Percent still using
People Entering Publicly Funded
Treatment Generally Use For Decades
It takes 27 years
before half reach
1 or more years of
abstinence or die
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
Source: Dennis et al., 2005
30
Percent still using
The Younger They Start,
The Longer They Use
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Age of
First Use*
under 15
60% longer
15-20
21+
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
Source: Dennis et al., 2005
30
* p<.05
Percent still using
The Sooner They Get The Treatment,
The Quicker They Get To Abstinence
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Years to first
Treatment
Admission*
20 or
more
years
57% quicker
10 to 19
years
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
Source: Dennis et al., 2005
30
0 to 9
years
•p<.05
After Initial Treatment…

Relapse is common, particularly for those who:
– Are Younger
– Have already been to treatment multiple times
– Have more mental health issues or pain

It takes an average of 3 to 4 treatment admissions
over 9 years before half reach a year of abstinence

Yet over 2/3rds do eventually abstain

Treatment predicts who starts abstinence

Self help engagement predicts who stays abstinent
Source: Dennis et al., 2005, Scott et al 2005
.
The Likelihood of Sustaining Abstinence
Another Year Grows Over Time
After 1 to 3 years of
abstinence, 2/3rds will
make it another year
100%
% Sustaining Abstinence
Another Year
90%
80%
70%
60%
Only a third of
people with
1 to 12 months of
abstinence will
sustain it
another year
86%
After 4 years of
abstinence,
about 86% will
make it
another year
66%
50%
40%
36%
30%
20%
10%
0%
1 to 12 months
1 to 3 years
Duration of Abstinence
Source: Dennis, Foss & Scott (2007)
4 to 7 years
But even after 7 years
of abstinence, about
14% relapse each year
What does recovery look like on average?
1-12 Months
Duration of Abstinence
1-3 Years
4-7 Years
• More clean and sober friends
• Less illegal activity and
incarceration
• Less homelessness, violence and
victimization
• Less use by others at home, work,
and by social peers
• Virtual elimination of illegal activity and illegal
income
• Better housing and living situations
• Increasing employment and income
• More social and spiritual support
• Better mental health
• Housing and living situations continue to improve
• Dramatic rise in employment and income
• Dramatic drop in people living below the poverty line
Source: Dennis, Foss & Scott (2007)
Deaths in the next 12 months
Sustained Abstinence Also Reduces
The Risk of Death
The Risk of Death
goes down with
years of sustained
abstinence
Users/Early
Abstainers
more likely
to die in
the next 12
months
It takes 4 or
more years of
abstinence for
risk to get
down to
community
levels
(Matched on Gender,
Race & Age)
Source: Scott, Dennis, Simeone & Funk (forthcoming)
Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication
8%
7%
Generalized Anxiety Dis.
Posttraumatic Stress Dis.
Agoraphobia
Other Specific Phobia
13%
2%
5%
12%
7%
Adult Separation Anxiety
Social Phobia
Panic Disorder
2%
31%
19%
Major Depressive Epi.
Dysthymia
Bi-Polar I or II
Any Anxiety Disorder:
20%
37%
Any Mood Disorder:
4%
8%
Intermittent Explosive
Internalizing Disorder
8%
10%
Oppositional Defiant
ADHD
10%
25%
13%
8%
15%
Conduct Disorder
Externalizing Disorder
Drug Disorder
Alcohol Disorder
Any Substance Disorder
47%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Any Disorder
Prevalence of Lifetime Disorders and
Past Year Remission in the US
Lifetime Disorder
Past Year Remission
42%
41%
Panic Disorder
Agoraphobia
Other Specific Phobia
30%
44%
48%
48%
39%
Social Phobia
Posttraumatic Stress Dis.
Generalized Anxiety Dis.
Adult Separation Anxiety
Any Anxiety Disorder:
31%
43%
71%
57%
Major Depressive Epi.
Dysthymia
Bi-Polar I or II
41%
Internalizing Disorder
56%
45%
Intermittent Explosive
Any Mood Disorder:
50%
58%
89%
89%
77%
83%
66%
ADHD
Oppositional Defiant
Conduct Disorder
Externalizing Disorder
Drug Disorder
Alcohol Disorder
Any Substance Disorder
44%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Any Disorder
Past Year Recovery “Rates” (Remission/Lifetime)
by Disorders in the US
Past Year
Recovery Rate
Comorbidity is Common in Household Population
3 to 16
Disorders
18%
2 Disorders
10%
(28%/46% Any)=
61% Co-occurring
Lifetime
Pattern of Disorders
Substance
Only
3%
None
54%
1 Disorder
18%
Externalizing
Only
5%
Internalizing
Only
21%
None
48%
Sub.+Ext
1%
Lifetime
Number of Disorders
(13%/16% SUD)=
81% Co-occurring
Source: Dennis,
Scott, Funk & Chan forthcoming;
Sub.+Int
4%
Sub. + Ext. +
Int.
8%
Ext.+Int.
10%
National Co morbidity Study Replication
Pattern of Disorders
Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication
16%
Sub. + Ext. + Int.
24%
Externalizing+Internalizing
Substance+Externalizing
26%
41%
Internalizing Only
Substance+Internalizing
65%
Externalizing Only
None
19%
3 to 16 Disorders
Number of Disorders
Past Year
Recovery Rate
51%
68%
Substance Only
50%
2 Disorders
1 Disorder
None
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
64%
The problem is the higher the comorbidity, the less likely
people are to reach Recovery (no past year symptoms)
Adolescents Have Complex
Pathways to Recovery
Incarcerated
(41% stable)
4%
17%
Avg of 48% change
status each quarter
18%
4%
16%
17%
In the
Community
Using
(60% stable)
What predicts who
enters and maintains
recovery?
27%
In Recovery
(61% stable)
21%
9%
22%
24%
In Treatment
(45% stable)
Source: 2009 CSAT AT data set; unique n = 11,710
14%
Treatment is the
most likely path
to recovery
Risk and Protective Factors Associated with
Transitioning to/Remaining in Recovery

Risk Factors
– Older
– Male
– Caucasian
– Substance Problems
– Substance Frequency
– Repeated Treatment
– Mental Health Problems
– Illegal Activity
– Employment
Source: 2009 CSAT Adolescent Treatment Dataset

Protective Factors
– Younger
– Female
– Racial Minority
– Recent Treatment
– Number of Drug Screens
– Attend 12 Step Meetings
– Positive Social Peers
– Positive Recovery
Environment
– School Attendance/
Conduct
Percent in Past Month Recovery*
Recovery* by Level of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
CC
better
OP &
Resid
Similar
Pre-Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
* 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 Adolescent Treatment Outcome Data Set (n-9,276)
Opportunities to Better Support
Adolescent Recovery
Evidenced Based Recovery Services for
Adolescents (1-2 Clinical Trials)
 Telephone Counseling (Kaminer et al., 2008)
 Assertive Continuing Care (Godley et al., 2007; 2010)
 Motivational Incentives (Godley et al., forthcoming)
Other Promising Recovery Services
 Alcohol/Drug Test Monitoring
 CRAFT (Meyers & Smith, 2005) family recovery
support groups
 Recovery Schools
 Adolescent-focused self help groups
 Technology-based Recovery Supports (e.g., social
networking, self-monitoring, e-therapy)
Part 2. No Wrong Door:
The Move Toward
Screening, Brief
Intervention, and Referral
to (Long-Term) Treatment
28
Substance Use Disorders are Common,
But Treatment Participation Rates Are Low:
United States (US)
Over 88% of adolescent and
Few Get Treatment:
1 in 19 adolescents,
1 in 21 young adults,
25%
1 in 12 adults
young adult treatment and
over 50% of adult treatment
is publicly funded
20.9%
20%
15%
10%
7.8%
7.2%
5%
0.4%
1.0%
Much of the private
funding is limited to 30
days or less and
authorized day by day
or week by week
0.5%
0%
12 to 17
18 to 25
26 or older
Abuse or Dependence in past year
Treatment in past year
Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH
Substance Use Disorders are Common,
But Treatment Participation Rates Are Low:
Washington State
Similar rates for young
adults: 1 in 18
25%
20%
15%
10%
21.4%
Similar problems
rate, and more
treatment
participation for
adults:
1 in 10
Higher rates for
adolescents :
1 in 10
8.6%
7.7%
5%
0.79%
1.17%
0.75%
0%
12 to 17
18 to 25
26 or older
Abuse or Dependence in past year
Treatment in past year
Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH
Substance Use Disorders are Common,
But Treatment Participation Rates Are Low:
Seattle & King County, WA
25%
20%
15%
10%
5%
Similar problem
rate but better
Treatment Rate:
1 in 6
adolescents
High higher problems rate, but
better treatment rates for
23.0%
young adults, 1 in 15;
Similar for adults: 1 in 9
9.4%
8.5%
1.7%
1.5%
1.0%
0%
12 to 17
18 to 25
26 or older
Abuse or Dependence in past year
Treatment in past year
Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH
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
$0
SBIRT models popular due
to ease of implementation
and low cost
$10,000
Cost of Substance Abuse Treatment Episode
$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
Investing in Treatment has a Positive Annual
Return on Investment (ROI)

Substance abuse treatment has been shown to
have a ROI of between $1.28 to $7.26 per dollar
invested

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 we saved.
Source: Bhati et al., (2008); Ettner et al., (2006)
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
SBIRT for drug use in high-risk populations (e.g., adolescents,
pregnant and postpartum women, people with HIV, and people with
co-occurring psychiatric conditions)
CSAT and NIDA are both funding several demonstration and
research projects to develop and evaluate models for doing
this
Washington State mandated screening in all adolescent and
adult substance abuse treatment, mental health, justice, and
child welfare programs
36
GAIN Short Screener (GAIN-SS)




Administration Time: A 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
– ease 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
Scales: Four screeners for Internalizing Disorders,
Externalizing Disorders, Substance Disorders, and
Crime/Violence Disorders, and a Total Disorder Screener
GAIN Short Screener (GAIN-SS) (continued)



Response Set: Recency of 20 problems rated past month (3), 212 months ago (2), more than a year ago (1), never (0)
Interpretation: Combined by cumulative time period as:
− Past-month count (3s) to measure 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 as 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 webbased GAIN ABS or ASP application for local hosting
Source: Dennis, Chan, and Funk (2006)
Comorbidity
is common
12%
12%
Substance Abuse Student Assistance
Treatment
Programs
(n=8,213)
(n=8,777)
Either
Juvenile Justice
(n=2,024)
High on Mental Health
Mental Health
Treatment (10,937)
High on Substance
12%
11%
46%
35%
61%
60%
73%
62%
75%
75%
Problems could be easily identified
40%
37%
86%
83%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
77%
67%
57%
47%
Adolescent Rates of High (2+) Scores on Mental Health
(MH) or Substance Abuse (SA) Screener by Setting
in Washington State
Children's
Administration
(n=239)
High on Both
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
Adolescent Client Validation of Hi Co-occurring from
GAIN Short Screener vs Clinical Records
by Setting in Washington State
Substance Abuse
Treatment (n=8,213)
Juvenile Justice
(n=2,024)
GAIN Short Screener
Mental Health
Treatment (10,937)
9%
11%
15%
12%
34%
35%
56%
Two page measure closely approximated all found
in the clinical record after the next two years
47%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Children's
Administration
(n=239)
Clinical Indicators
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
Where in the System Are the Adolescents with Mental
Health, Substance Abuse, and Co-occurring?
2/3 of the teens with mental
health issues are seen in
substance abuse treatment or
student assistance programs
0
5,000
10,000
15,000
20,000
25,000
Any Behavioral
Health (n=22,879)
Mental Health
(21,568)
Substance Abuse
Need (10,464)
Co-occurring
(9,155)
Substance Abuse Treatment
Juvenile Justice
Children's Administration
Student assistance programs
represent 1/3 of the
behavioral health system
Student Assistance Program
Mental Health Treatment
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
4%
3%
17%
17%
18%
17%
Lower than expected
rates of SA in mental
health and children’s
admin
69%
69%
44%
51%
31%
64%
43%
53%
31%
65%
51%
46%
78%
73%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
81%
68%
69%
56%
Adult Rates of High (2+) Scores on Mental Health
(MH) or Substance Abuse (SA) Screener
by Setting in Washington State
Substance
Abuse
Treatment
(n=75,208)
Either
Eastern State
Hospital
(n=422)
Corrections:
Community
(n=2,723)
High on Mental Health
Corrections:
Prison
(n=7,881)
Mental Health
Treatment
(55,847)
High on Substance
Childrens
Administration
(n=1,238)
High on Both
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
Any Behavioral Health (n=106,818)
More mental
health treated
in substance
abuse
treatment
Mental Health (n=94,832)
Substance Abuse (n=67,115)
Co-Occurring (n=55,128)
Substance Abuse Treatment
Corrections: Community
Mental Health Treatment
Eastern State Hospital
Corrections: Prison
Childrens Administration
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
120,000
100,000
80,000
60,000
40,000
20,000
0
Where in the System Are the Adults with Mental
Health, Substance Abuse, and Co-occurring?
Higher rate in clinical record in mental health and
children’s administration. But that was based on
-“any use” vs. “week use + abuse/dependence”
- and 2 years vs. past year
3%
17%
22%
39%
59%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
56%
Adult Client Validation of Hi Co-occurring from
GAIN Short Screener vs Clinical Records
by Setting in Washington State
Substance Abuse Treatment
(n=75,208)
Mental Health Treatment
(55,847)
GAIN Short Screener
Childrens Administration
(n=1,238)
Clinical Indicators
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
Student Assistance Prevention and
Intervention Services Program (SAPISP)






Core funding is funneled from DASA via OSPI and combined
with a variety of other local, state, and federal funding sources
(e.g., DFSCA, SSHS, SPF-SIG).
13 grantees (the nine ESDs and four largest school districts)
hire specialists to serve about 75% of MS and HS statewide.
Specialists conduct some primary prevention activities and
serve about 16,000 students specifically referred for
assistance related to mental health, alcohol or drug use,
tobacco use, or other behavioral problems.
Screening using the GAIN-SS was first implemented in the
2007-2008 school year.
Reporting is optional for “Quick” referrals that are seen only
once or twice.
Data presented here are for the 2008 to 2009 school year.
Total Disorder Screener Severity
Disorder Screener for Adolescents
by Level ofTotal
Care
Outpatient and student
asst. prog. are similar
% within Level of Care
11%
(median
Lo Mod. High ->
Residential (n=1,965)
10%
6.0
vs.
6.4)
w
OP/IOP (n=2,499)
9%
SAP (n=10,649)
8%
7%
6%
5%
4%
Residential
3%
median
2%
(10.5) is
higher
1%
0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Well
targeted
Total Disorder Sceener (TDScr) Score
95% 1+
85% 3+
About 30% of OP and SAP are in the high
Source: SAPISP 2009 data and Dennis et al., 2006 severity range more typical of residential
46
SAPISP Results: Statewide (n = 10,924)
18%
5%
4%
12%
15%
17%
44%
40%
6%
6%
8%
23%
13%
Source: SAPISP 2009 data
30%
72%
16%
3
11%
17%
4
9%
6%
8%
5+
Crime/
Violence (CV)
13%
9%
4%
1%
No of Prob.
8%
1
Substance
Disorder
19%
28%
Externalizing
Disorder
18%
0
2
20%
Internalizing
Disorder
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
SAP Similar to Residential on Mental Health
but like OP on Substance use and crime
47
GAIN-SS Can Also Be Used for Monitoring
20
12+ Mon.s ago (#1s)
2-12 Mon.s ago (#2s)
Past Month (#3s)
Lifetime (#1,2,or 3)
16
12
10
11
9
9
10
Track gap between
prior and current
lifetime problems to
identify
underreporting
8
8
3
4
2
2
0
Intake
3
6
9
12
15
18
21
24
Mon Mon Mon Mon Mon Mon Mon Mon
Track progress in
reducing current
(past month)
symptoms)
Total Disorder Screener (TDScr)
Monitor for relapse
Translations

Chestnut has led the translations of the GAIN SS, Quick and
Full from into English and Spanish versions and maded
available in hard and electronic versions.

Chestnut is currently collaborating with other researchers
translating all measures into French in Quebec and Portuguese
in Brazil

King County collaborators have also translated hard copies of
the GAIN SS into 19 languages (Arabic, Cambodian, Farsi,
French, Hindi, Indonesian, Korean, Laotian, Mandarin
(simple and traditional), Marathi, Mongolian , Portuguese,
Punjabi, Russian, Somali, Spanish, Tagalog, Vietnamese)

Others have translated the GAIN SS into American Sign
Language (ASL), Hindi, Portuguese, Punjabi, Vietnamese
CHS TRANSLATION CONTACT: Janet Titus <[email protected]>
Implications
 The GAIN Short Screener can readily identify youth
in need of behavioral health treatment and
distinguish the type of need
 While the Student Assistance Program (SAP) system
was originally set up largely targeted at substance
use, mental health problems are more common and it
plays it is a large and important part of the behavioral
health system
 The GAIN SS has the potential to help with
identification, referral, and monitoring of cases
 The availability of multiple translations and paired
down software for referral sources and self
administration should open additional doors.
50
Residential
(OR=1.1, 1.5)
US
Washington
OP
(OR=1.1, 0.9)
37%
33%
36%
36%
36%
33%
48%
IOP
(OR=2.0, 2.0)
*Seattle, Tacoma-Bellevue Metro
Source: OAS 2007 TEDS-D, 2007
Little Better than
Average AMA/ASR
Discharge Rates in OP
32%
48%
Worse than Average
AMA/ASR Discharge
Rates in Residential
& IOP
36%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
28%
29%
AMA/ASR Discharge
Comparison of Against Medical Advice (AMA) /
At Staff Request (ASR) Adol. Discharge Rates
Total
(OR=1.1, 1.2)
Seattle Metro*
Residential
(OR=2.0, 1.3)
US
IOP
(OR=1.2, 1.2)
Washington
*Seattle, Tacoma-Bellevue Metro
Source: OAS 2007 TEDS-D, 2007
OP
(OR=1.5, 1.1)
19%
16%
23%
16%
22%
17%
25%
21%
24%
Better than Average Transfer Rates in
Residential, IOP & OP
19%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
16%
26%
Transfers
Comparison of Adolescent
Transfer Rates
Total
(OR=1.5, 1.2)
Seattle Metro*
Is this Good Enough?
 To reach 1 in 6 adolescents and 1 in 15 young
adults in need?
 To keep only 39% of youth in treatment at least
the 90 days recommended by experts?
 To have 37% leave against medical advice or at
staff request?
 To have 19-25% less step down before release
from residential or IOP?
59
Part 4.
Highlight What It Takes to
Move the Field Toward
Evidence-Based Practice
Related to Assessment,
Treatment, Program
Evaluation, and Planning
So what does it mean to move the field
toward evidence-based practice (EBP)?

Introducing explicit intervention protocols that
– Are targeted at specific problems/subgroups and outcomes
– Have 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

Introducing reliable and valid assessments 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, performance monitoring, and long-term program
planning
The Current Renaissance of
Adolescent Treatment Research
Feature
1930-1997
1997-2010
Tx Studies*
16
Over 300
Random/Quasi
9
Over 66
Tx Manuals*
0
30+
QA/Adherence
Rare
Common
Std Assessment*
Rare
Common
Under 50%
Over 80%
40-50%
85-95%
Methods
Descriptive/Simple
More Advanced
Economic
Some Cost
Cost, CEA, BCA
Participation Rates
Follow-up Rates
* Published and publicly available
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
Impact of the Numbers of Favorable
Features on Recidivism (509 JJ studies)
Average
practice
Source: Adapted from Lipsey, 1997, 2005
Recidivism
drops the
more factors
present
Cognitive Behavioral Therapy (CBT) Interventions
that Typically Do Better Than Usual Practice in
Reducing Recidivism (29% vs. 40%)












Adolescent Community Reinforcement Approach (ACRA)
Aggression Replacement Training
Assertive Continuing Care
Brief Strategic Family Therapy (BSFT)
Interpersonal Social Problem Solving
Functional Family Therapy (FFT)
MET/CBT combinations and other manualized CBT
Moral Reconation Therapy
Multidimensional Family Therapy (MDFT)
Multisystemic Therapy (MST)
Reasoning & Rehabilitation
Thinking for a Change
NOTE: There is generally little or no differences in mean
effect size between these brand names
Source: Adapted from Lipsey et al., 2001; Waldron et al., 2001; Dennis et al., 2004
Other Protocols Targeted at Specific Issues:









Detoxification services and medication, particularly
related to opioid and methamphetamine use
Tobacco cessation
Adolescent psychiatric services related to depression,
anxiety, ADHD, and conduct disorder
Trauma, suicide ideation, and parasuicidal behavior
Need for child maltreatment interventions (not just
reporting protocols)
HIV intervention to reduce high-risk pattern of sexual
behavior
Anger management
Problems with family, school, work, and probation
Recovery coaches, recovery schools, recovery housing,
and other adolescent oriented self-help groups/services
On-Site Proactive Urine Testing Can Be Used
to Reduce False Negatives by More Than Half
Reduction in
false negative
reports at no
additional cost
Effects grow
when
protocol is
repeated
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
Change in Abstinence (6 Mo-Intake)
after Adolescent Community Reinforcement Approach
(A-CRA) by Degree of Implementation Monitoring
% Point Change in Abstinence
100%
90%
Effects associated with
intensity of quality
assurance and
monitoring
80%
70%
60%
50%
40%
36%
24%
30%
20%
4%
10%
0%
CYT
AAFT
Other
(high monitoring)
(mod. monitoring)
(training only)
Source: CSAT 2008 SA data set subset to 6-month follow-up (n = 1,961)
70
Implications of Implementation Science

Can identify complex and simple protocols that
improve outcomes

Interventions have to be reliably delivered in
order to achieve reliable outcomes

Simple targeted protocols can make a big
difference

Need for reliable assessment of need,
implementation, and outcomes
Interfacing with Electronic Health
Records and Performance Measures
PFP
NIATX
NOMS
CSAT
WCG
NQF
Initiation: Treatment within 2 weeks of diagnosis
X X
X X X
Engagement: 2 additional sessions within 30 days
X X
X X X
Continuing Care: Any treatment 90-180 days out
X
X
X
Detox Transfer: Starting treatment within 2 weeks
X
X
Residential Step Down: Starting OP Tx w/in 2wks
X
Evidenced Based Practice: From NREP/Other lists
Within Cost Bands: see French et al 2009
X
X X
X
X X
* NQF: National Quality Forum; WCG: Washington Circle Group; CSAT: Center for
Substance Abuse Treatment evaluations; NOMS: National Outcome Monitoring
System; NIATX: Network for the Improvement of Addiction Treatment; PFP: Pay for
Performance evaluations
Newer NQF Standards of Care






Annual screening for tobacco, alcohol and other
drugs using systematic methods
Referral for further multidimensional assessment to
guide patient-centered treatment planning
Brief intervention, referral to treatment and
supportive services where needed
Pharmacotherapy to help manage withdrawal,
tobacco, alcohol and opioid dependence
Provision of empirically validated psychosocial
interventions
Monitoring and the provision of continuing care
Source: www.tresearch.org/centers/nqf_docs/NQF_Crosswalk.pdf
Exploring Need, Unmet Need, and Targeting of
Mental Health Services in AAFT
At Intake . No/Low
After 3 mon
Any Treatment
Mod/High
Need
Need
6
218
Total
224
218/224=97% to targeted
No Treatment
205
553
758
553/771=72%
unmet need
Total
211
771
982
771/982=79% in need
Size of the problem
Extent to which services are not reaching those in most need
Extent to which services are currently being targeted
Mental Health Problem (at Intake) vs.
Any MH Treatment by 3 Months
97%
100%
90%
80%
79%
72%
70%
60%
50%
40%
30%
20%
10%
0%
% of Clients With
Mod/High Need
(n=771/982)*
% w Need but No Service % of Services Going to
After 3 months
Those in Need
(n=553/771)
(n=218/224)
*3+ on ASAM dimension B3 criteria
Source: 2008 CSAT AAFT Summary Analytic Data Set
Why Do We Care about Unmet Need?

If we subset to those in need, getting mental
health services predicts reduced mental health
problems

Both psychosocial and medication interventions
are associated with reduced problems

If we subset to those NOT in need, getting mental
health services does NOT predict change in
mental health problems
Conversely, we also care about services being
poorly targeted to those in need.
Residential Treatment Need (at Intake) vs.
7+ Residential Days at 3 Months
100%
90%
80%
70%
60%
50%
40%
30%
90%
Opportunity to
redirect
existing funds
through better
targeting
52%
36%
20%
10%
0%
% of Clients With
Mod/High Need
(n=349/980)*
% w Need but No
% of Services Going to
Service After 3 months Those in Need (n=34/66)
(n=315/349)
Source: 2008 CSAT AAFT Summary Analytic Data Set
Part 5. Preliminary Findings from
King County: 2004 to 2010\
88
Washington Youth Served by Treatment are
already costing society




Using the GAIN we are able estimate the cost to society of
tangible services (e.g., health care utilization, days in
detention, probation, parole, days of missed school) in
2009 dollars for the 90 days before intake
The 5,076 adolescents served in King County between
2004-2010 the average Quarterly cost society $1,721.09
($6,884 per year)
As a cohort, they cost $8,736,253 in the quarter before
they were admitted and $34,945,011 in the year before
they were admitted
Thus the county is targeting a group with a high potential
to offset their costs to society (or cost you more if you cut
back on them)
2010 King County Adolescent Data Set by Provider
Group 4
Group 3
Friends of Youth,
2.9% (n = 149)
Youth Eastside Services,
16.0% (n = 814)
Sound Mental Health,
1.6% (n = 80)
Group1
Consejo Counseling & Referral
Services, 0.8% (n = 43)
Therapeutic Health Services
& CYFS, 3.6% (n = 182)
Group 2
Integrated Counseling
Services,
4.1% (n = 210)
Asian Counseling and
Referral Service,
2.6% (n = 134)
Other Programs, 3.1%
(n = 157) Group 3
Center for Human
Services, 22.7%
(n = 1,152)
WA Asian Pacific
Islander Families Against
SA, 10.6% (n = 539)
Auburn Youth Resources,
13.3% (n = 677)
Ruth Dykeman Youth and
Family Services, 3.5% (n = 117)
Northshore Youth & Family
Services, 1.2% (n = 59) Kent Youth and Family Services, 5.8%
Source: King County Adolescent Data Set 7/31/2010 (n = 5,076)
90
(n = 293)
Sample Size & Comorbidity Index
by Severity Group
3000
51
Clients
2500
1500
50
41
2000
40
31
21
30
1330
20
1000
500
60
Comorbidity Index
3031
10
225
80
0
0
Group 1 Group 2 Group 3 Group 4
Number of Clients
Comorbidity Index
Source: King County Adolescent Data Set 7/31/2010 (n = 4,666)
91
Female
African American
51%
15%
26+ years
100%
90%
80%
Sample is
predominately
Male, Caucasian,
and age 15-17
27%
17%
15-17 years
18-25 years
70%
12%
Mixed/Other
12-14 years
60%
29%
Caucasian
Hispanic*
50%
40%
30%
20%
10%
0%
Demographic Characteristics
63%
12%
7%
*Any Hispanic ethnicity separate from race group
Source: King County Adolescent Data Set 7/31/2010 (n = 4,861)
92
Race by Severity Group
100%
90%
Male
80%
70%
60%
58%
70%
73%
69%
Female
50%
40%
30%
20%
10%
43%
30%
27%
31%
Most severe
group more
likely to be
Female
0%
Group 1 Group 2 Group 3 Group 4
King County Adolescent Data Set 7/31/2010 (n = 4,576)
93
Most severe group more
likely to be Mixed
Race by Severity Group
100%
4%
6%
12%
2%
80%
1%
Other
2% 38%
Mixed
18%
19%
2%
7%
Native American
12%
60%
47%
4%
45%
40%
0%
Hispanic
Caucasian
66%
45%
10%
20%
3%
African American
Asian
26%
12%
3%
6%
6%
1% 11%
Group 1 Group 2 Group 3 Group 4
King County Adolescent Data Set 7/31/2010 (n = 4,576)
Least severe group
more likely to be
Hispanic or African
American
94
Age by Severity Group
100%
90%
12%
7%
11%
12%
80%
3%
11%
17%
70%
60%
26+ years
18-25 years
51%
57%
50%
64%
15-17 years
59%
40%
30%
20%
10%
12-14 years
35%
31%
18%
13%
0%
Group 1 Group 2 Group 3 Group 4
King County Adolescent Data Set 7/31/2010 (n = 4,576)
Middle groups
most likely to
be older
95
Anything
100%
90%
80%
70%
57%
Alcohol
17%
Cannabis
40%
Cocaine
2%
Opioid
3%
5%
Other Drugs
Needle Use
60%
50%
40%
30%
20%
10%
0%
Pattern of Weekly Use (13+ / 90 Days):
2%
Tobacco
Controlled Environment
Source: King County 7/31/2010 (n = 4,987)
45%
16%
96
3 or More Years of Use
48%
21%
Any Withdrawal Symptoms in the Past Week
3%
87%
Can Give 1+ Reasons to Quit
61%
Client Believes Need ANY Treatment
Any Prior Substance Abuse Treatment
Source: King County 7/31/2010 (n = 4,912)
100%
50%
Any Past Year Dependence
Acknowledges Having an AOD Problem
90%
76%
Past Year Substance Diagnosis
Severe Withdrawal (11+ Symptoms) in Past
Week
80%
70%
60%
50%
40%
30%
20%
10%
0%
Substance Use Severity
27%
28%
97
Past-Year Substance Severity by Severity Group
100%
No Use
90%
80%
Use
70%
60%
Abuse
50%
40%
30%
57%
44%
20%
Dependence
48%
30%
10%
0%
Group 1
Group 2
Source: King County 7/31/2010 (n = 4,549)
Group 3
Group 4
Low group
least likely to
be dependent
98
Any Co-Occurring Psychiatric
11%
Ever Physical, Sexual or Emotional Victimization
61%
42%
High Severity Victimization (GVS>3)
Ever Homeless or Runaway
Source: King County 7/31/2010 (n = 4,949)
100%
28%
22%
Traumatic Stress Disorder
Prior Mental Health Treatment
90%
36%
Major Depressive Disorder
Any Self Mutilation*
80%
42%
Attention Deficit/Hyperactivity Disorder
Any Homicidal/Suicidal Thoughts Past Year
70%
59%
Conduct Disorder
General Anxiety Disorder
60%
50%
40%
30%
20%
10%
0%
Co-Occurring Psychiatric Problems
36%
17%
11%
37%
*(n=2,875)
99
Co-Occurring Psychiatric Diagnoses*
by Severity Group
100%
None
90%
One
80%
75%
71%
70%
Two
Three
60%
Four
54%
50%
Five
40%
33%
30%
*Count of Conduct
Disorder, ADHD/ADD
Major Depressive
Disorder, Traumatic Stress
Disorder,
and Generalized
Co-occurring
Anxiety Disorder
20%
10%
0%
Group 1
Group 2
Source: King County 7/31/2010 (n = 4,586)
Group 3
Group 4
psychiatric more
common with
higher severity
(OR=6.1) 100
Single Parent
Employed
100%
90%
80%
70%
60%
50%
47%
15%
In School
Ever Homeless or
Runaway
40%
30%
20%
10%
0%
Environment Characteristics
67%
16%
*Any Hispanic ethnicity separate from race group
King County Adolescent Data Set 7/31/2010 (n = 4,861)
101
Housing Status at Intake by Severity Group
100%
Housed
90%
80%
70%
Doubled up with
Friend/Relative
60%
Other
50%
Inpatient
40%
30%
Detention
20%
10%
7%
8%
10%
14%
0%
Group 1 Group 2 Group 3 Group 4
King County Adolescent Data Set 7/31/2010 (n = 4,576)
Higher severity
less likely to be
housed in
community
(OR=0.5) 102
Recovery Environment - Home
Family History of
Substance Use
72%
Weekly Alcohol
Use at Home
26%
Weekly Drug Use
at Home
9%
Weekly Family
Problems
Source: King County 7/31/2010 (n = 4,881)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
20%
103
Social Peers Getting Drunk Weekly+
25%
70%
School/Work Peers Using Drugs
60%
Source: King County 7/31/2010 (n = 4,849)
100%
39%
Social Peers Using Drugs
Others at Home Using Drugs
90%
80%
70%
48%
School/Work Peers Getting Drunk
Weekly+
Others at Home Getting Drunk
Weekly+
60%
50%
40%
30%
20%
10%
0%
Recovery Environment - Peers
23%
104
Ever attacked w/ gun, knife, other weapon
Ever hurt by striking/beating
Abused emotionally
Ever forced sex acts against your will/anyone
Age of 1st abuse < 18
Any with more than one person involved
Any several times or for long time
Was person family member/trusted one
Were you afraid for your life/injury
People you told not believe you/help you
Result in oral, vaginal, anal sex
Currently worried someone attack
Currently worried someone beat/hurt
Currently worried someone abuse emotionally
Currently worried someone force sex acts
Source: King County 7/31/2010 (n = 4,874)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
General Victimization Scale
34%
36%
35%
8%
55%
27%
31%
26%
17%
10%
6%
7%
7%
8%
1%
105
Victimization by Severity Group
100%
90%
Low
80%
70%
60%
Moderate
50%
40%
63%
30%
52%
20%
10%
29%
37%
0%
Group 1
High
Group 2
Source: King County 7/31/2010 (n = 4,543)
Group 3
Group 4
High severity
victimization
more likely with
higher severity
(OR=4.2)106
Sexually Active
100%
90%
80%
70%
60%
50%
40%
30%
20%
0%
10%
Past 90-Day HIV Risk Behaviors
56%
22%
Multiple Sex Partners
Any Unprotected Sex
26%
High Risk Sex*
27%
20%
Victimized
Worried - Forced Sex Acts**
1%
Any Needle Use
2%
*Based on 1+ times had sex while intoxicated, with an injection drug user, with a man who had sex
with men, with someone who was HIV positive, or traded sex for goods (n = 415)
**Different time frame - current worries.
Source: King County 7/31/2010 (n = 4,424)
107
Sex Partners* by Severity Group
100%
90%
No Sexual
Partners
80%
70%
One
Sexual
Partner
60%
50%
40%
30%
43%
20%
10%
18%
21%
24%
Group 1
Group 2
Group 3
0%
Source: King County 7/31/2010 (n = 4,417)
Multiple
Sexual
Partners
The likelihood of
multiple sexual
partners varies
Group 4
with higher
*In the past
90 days
severity
(OR=3.4)
108
Physical Violence
51%
Any Illegal Activity
42%
Other Drug Related Crimes*
Any Interpersonal/ Violent Crime
100%
90%
32%
23%
24%
58%
Lifetime Juvenile Justice Involvement
Current Juvenile Justice involvement
1+/90 days In Controlled Environment
80%
62%
Any Violence or Illegal Activity
Any Property Crimes
70%
60%
50%
40%
30%
20%
10%
0%
Past-Year Violence & Crime
44%
33%
*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)
Source: King County 07/31/2010 (n = 4,574)
109
Type of Crime by Severity Group
100%
Drug Use
only
90%
80%
Other
Crime*
70%
60%
Violent
Crime
50%
40%
30%
44%
20%
10%
34%
19%
22%
0%
Group 1
Group 2
Source: King County 07/31/2010 (n = 3,982)
Group 3
Group 4
The likelihood of
violent crime
varies with higher
severity (OR=3.3)
*Other crime includes
vandalism, possession
of stolen goods,
forgery, and theft.
110
Intensity of Juvenile Justice System Involvement
In Detention/Jail 30+ Days
3.5%
In Detention/
Jail 14-29 Days
2.4%
Past-Year Illegal
Activity/SA Use
46.5%
On Probation/
Parole 14+
Days w/1+Drug
Screens 11.6%
Other Probation, Parole,
or Detention 10%
Other JJ/CJ Status
17.5%
Source: King County 07/31/2010 (n = 3,951)
Past Arrest/JJ/CJ
Status 8.5%
111
Intensity of Justice System Involvement
by Severity Group
100%
Past year illegal
activity/SA use
90%
80%
Past arrest/JJ/CJ
status
70%
Other JJ/CJ status
64%
60%
54%
53%
50%
3
40%
37%
30%
Other prob/ parole/
detention
On prob/ parole 14+
days w/ 1+ drug screens
20%
In detention/jail 14-29
days
10%
In detention/jail 30+
days
0%
Group 1 Group 2 Group 3 Group 4
Source: King County 07/31/2010 (n = 3,913)
The intensity of justice
system involvement
varies with higher
severity (OR=3.2) 112
Alcohol
100%
90%
80%
70%
42%
Cannabis
55%
Other drug disorder
24%
28%
Depression
Anxiety
11%
22%
Trauma
ADHD
60%
50%
40%
30%
20%
10%
0%
Major Clinical Problems at Intake
11%
CD
Suicide
36%
42%
Victimization
61%
Violence/ illegal activity
62%
Source: King County 08/31/2009 (n = 4,964)
113
Count Number of Problems* Mod/Hi: King County
Over 90%
self-report
one or more
major
clinical
problems
Over half
report 4 or
more major
clinical
problems
100%
10%
None
11%
One
70%
13%
Two
60%
13%
50% 53%
40%
Three
12%
90%
80%
30%
20%
10%
41%
Four
Five to
Twelve
0%
Total
* (Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD,
CD, victimization, violence/ illegal activity)
Source: King County 07/31/2010 (n = 3102)
114
Number of Major Clinical Problems*
at Intake by Gender
100%
None
90%
80%
One
70%
60%
Two
50%
Three
40%
30%
20%
38%
48%
10%
Four
Five to Twelve
0%
Male
(OR=1.0)
Source: King County 07/31/2010 (n = 4,627)
Female
(OR=1.5)
*Based on count of self-reporting
criteria to suggest alcohol,
cannabis, or other drug disorder,
depression, anxiety, trauma,
suicide, ADHD, CD, victimization,
violence/illegal activity
115
Number of Major Clinical Problems*
at Intake by Race
100%
None
90%
80%
One
70%
Two
60%
50%
Three
40%
Four
30%
20%
10%
32%
39%
42%
44%
White
(OR=1.5)
Other
(OR=1.7)
Five to
Twelve
0%
African Am. Hispanic
(OR=1.0) (OR=1.3)
Source: King County 07/31/2010 (n = 4,576)
*Based on count of selfreporting criteria to suggest
alcohol, cannabis, or other
drug disorder, depression,
anxiety, trauma, suicide,
ADHD, CD, victimization,
violence/illegal activity
116
Number of Major Clinical Problems*
at Intake by Age
100%
90%
None
80%
One
70%
Two
60%
50%
Three
40%
Four
30%
20%
37%
42%
42%
12-14
(OR=1.0)
15-17
(OR=1.2)
18+
(OR=1.2)
Five to Twelve
10%
0%
Source: King County 07/31/2010 (n = 4,633)
*Based on count of self-reporting
criteria to suggest alcohol,
cannabis, or other drug disorder,
depression, anxiety, trauma,
suicide, ADHD, CD, victimization,
violence/illegal activity
117
Number of Major Clinical Problems*
at Intake by Severity Group
100%
None
90%
80%
One
70%
Two
60%
Three
50%
Four
40%
66%
30%
53%
20%
10%
36%
20%
0%
Group 1
(OR=1.0)
Group 2
(OR=2.2)
Source: King County 07/31/2010 (n = 4,666)
Group 3
(OR=4.4)
Group 4
(OR=7.7)
Five to
Twelve
*Based on count of selfreporting criteria to suggest
alcohol, cannabis, or other
drug disorder, depression,
anxiety, trauma, suicide,
ADHD, CD, victimization,
violence/illegal activity
118
Number of Major Clinical Problems*
at Intake by Level of Victimization
100%
90%
None
80%
One
70%
Two
60%
50%
Three
40%
69%
30%
43%
20%
10%
Five to Twelve
12%
0%
Low
(OR=1.0)
Moderate
(OR=5.3)
Source: King County 07/31/2010 (n = 4,934)
Four
High
(OR=15.9)
*Based on count of selfreporting criteria to suggest
alcohol, cannabis, or other
drug disorder, depression,
anxiety, trauma, suicide,
ADHD, CD, victimization,
violence/ illegal activity
119
Part 6. Common Treatment
Planning Needs, Strengths,
Social Support and
Potential Mentoring of King
County Adolescents
120
GAIN Treatment Planning/Placement Grid
Problem Recency/Severity
None
Current (past 90 days)*
Past
Low-Mod
| High Severity
None
1. No Problem
Consider monitoring
and relapse prevention.
Past
Consider initial or low
invasive treatment.
4. Severe problems;
Not in treatment
Consider a more intensive
treatment or intervention
strategies.
0. Not Logical
Current
Treatment History
2. Past problem
3. Low/Moderate
problems;
Not in treatment
Check under- standing of
problem or lying and
recode.
5. No current
problems; Currently
in treatment
6. Low/Moderate
problems;
Currently in treatment
Review for step down or
discharge.
Review need to continue or
step up.
7. Severe problems;
Currently in treatment
Review need
for more intensive or
assertive levels.
.
* Current for Dimension B1 = Past 7 days
121
GAIN Placement Cells by ASAM Dimensions
0%
20%
40%
60%
80%
100%
Inconsistent
B1.Intox/Withd.
No problem
B2 Biomedical
B3.Psych/Beh
Past Problem
Low/Moderate
Problems
High Problems
B4.Readiness
No Problems in
Treatment
B5.Rel. Pot.
Low/Moderate
Problems in Treatment
B6.Environ.
High Problems in
Treatment
Source: King County 07/31/2010 (n = 4,861)
122
Detox/withdrawal
services
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
B1. Intoxication/Withdrawal Common Treatment
Planning Needs
41%
Ambulatory
Detox
22%
Meds for nonopioid
withdrawal &
relapse
17%
Meds for opiate
withdrawal &
relapse
1%
Monitoring
withdrawal &
AOD meds
compliance
1%
Source: King County 07/31/2010 (n = 5,013)
123
Tobacco cessation
100%
90%
80%
70%
28%
23%
Meds for physical
health problems
18%
Compliance with
MH meds
17%
ER/hospitalization
history
16%
Tetanus shot
14%
Current Tx for
medical problem
13%
Source: King County 07/31/2010 (n = 4,210)
60%
52%
Compliance with
PH meds
Accommodate
medical condition
50%
40%
30%
20%
10%
0%
B2. Biomedical Common Treatment Planning Needs
124
Behavior control
50%
Coordinate with justice system
46%
26%
Interpersonal illegal acts
Drug-related illegal activities
20%
Homicidal/suicidal risk
19%
Civil court
17%
Illegal activities
16%
Current Tx for psych problems
15%
Current meds for psych problems
15%
Arrest history
Source: King County 07/31/2010 (n = 4,309)
90%
100%
64%
Anger management
Problems w/ reading & writing
70%
80%
50%
60%
30%
40%
20%
10%
0%
B3. Psychological Common Treatment Planning
Needs
12%
11%
125
Any Tx Pressure
68%
Case management
68%
Review expectations for length of
Treatment
23%
13%
Dissatisfaction with past 90 day Tx
Source: King County 07/31/2010 (n = 3,030)
100%
39%
Tx required
Partner to understand Tx process
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
B4.Readiness Common Treatment Planning Needs
1%
126
100%
90%
80%
70%
60%
50%
64%
Recovery Coach
Cont. Care after
controlled
environment
18%
Significant time in
controlled
environment
16%
Discuss substance
abuse Tx history
40%
30%
20%
10%
0%
B5. Relapse Potential Common Treatment Planning
Needs
1%
Source: King County 07/31/2010 (n = 4,751)
127
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
B6. Environment Common Treatment Planning
Needs
Any school past 90 days
Coping with stress
Environmental risk
School problems
Need for change
Child maltreatment
Family fighting
Other vocational help
Substance use in the home
Employed past 90 days
Recent victimization
Coordinate for active duty
Housing situation
School or GED program
Worried about victimization
Financial counseling
Source: King County 07/31/2010 (n = 4,376)
76%
73%
73%
64%
62%
61%
40%
35%
33%
25%
20%
20%
18%
15%
13%
12%
128
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Individual Strengths
Doing well with close friends
90%
Listening, caring or communicating with
others
81%
Problem solving and figuring things out
75%
Doing well at sports, exercise, physical
activity
73%
Doing well at with your family
70%
Working or playing with computers
62%
Doing well at school or training
52%
Doing well at music, dancing, acting,
other performing art
Drawing, painting, design or other art
activities
50%
44%
38%
Doing well at work
Strength Self-Efficacy Index (10 items)
6.36
0
Source: King County 07/31/2010 (n = 3,147)
2
4
6
8
10
129
Strength Self-Efficacy Index
by Severity Groups
100%
10
9
8
7
6
5
4
3
2
1
0
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Group 1
Group 2
Source: King County 07/31/2010 (n = 2,803)
Group 3
Group 4
130
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Social Support Strengths
Friends to hang out with
93%
Family members/close partners
88%
Someone to talk to about emotions
85%
Legal hobby or activity
84%
Someone to help cope with problems
84%
People at work/school: Day to day things
75%
People at work/school: get assignments
73%
Friends/colleagues from other
companies/schools
64%
Professional counselor/health provider
51%
General Social Support Index (9 items)
6.99
0
Source: King County 07/31/2010 (n = 3,176)
2
4
6
8
131
General Social Support Index
by Severity Groups
100%
9
90%
8
80%
7
70%
6
60%
5
50%
4
40%
3
30%
2
20%
1
10%
0
0%
Group 1
Group 2
Group 3
Group 4
Less Social
Support in Least
Severe Group
Source: King County 07/31/2010 (n = 2,816)
132
Home
100%
25%
Know anyone in treatment
19%
65%
Little shouting, arguing or fighting most weeks
Critical
gap in
connection
to recovery
73%
community
43%
None involved in illegal activity
36%
Know anyone in treatment
19%
Know anyone in recovery
Little shouting, arguing or fighting most weeks
51%
None involved in illegal activity
30%
Know anyone in treatment
16%
Know anyone in recovery
Environmental Strengths Index (12 items)
5.09
0
Source: King County 07/31/2010 (n = 4,836)
90%
81%
None involved in illegal activity
Know anyone in recovery
Social
Peers
80%
70%
60%
Little shouting, arguing or fighting most weeks
School or
Work
60%
50%
40%
30%
20%
10%
0%
Potential Mentors in the Recovery Environment
2
4
6
8
10
12
133
Environmental Strengths Index by King
Co. Provider
100%
12
11
10
9
8
7
6
5
4
3
2
1
0
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Group 1
Group 2
Source: King County 07/31/2010 (n = 2,816)
Group 3
Group 4
134
Implications
 The GAIN provides a more detailed sense of the
problems and can be used to link these problems to
treatment planning and placement recommendations
 As a whole the system is very similar to the U.S.
treatment system, but the case mix and needs of
programs vary widely
 Adolescents face a wide range of challenges to their
recovery environment that need to be addressed
 There is a need for integration with other mental and
health (e.g., tobacco, STI) services to address
adolescent needs
 Ideally there is a need for treatment record and posttreatment outcome data on these programs and
135
clients
References
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