Transcript Slide 1

Characteristics, Needs and Strengths of
Substance Using Youth by Level of
Involvement in the Juvenile Justice System
Michael L. Dennis, Melissa Ives, Chestnut Health Systems (CHS), Normal, IL
Randy Muck, Center for Substance Abuse Treatment (CSAT), Substance Abuse
and Mental Health Services Administration (SAMHSA), Rockville, MD
Laura Nissen, Ph.D. Reclaiming Futures National Program Office, Regional
Research Institute, Portland State University (PSU), Portland, OR
Presentation at the Reclaiming Futures
Leadership Institute, May 18 – 19, 2011,
Miami, FL
Acknowledgement and
Contact Information
• This paper was supported by the Reclaiming Futures National
Program Office, Regional Research Institute, Portland State
University, and Substance Abuse and Mental Health Services
Administration (SAMHSA) Center for Substance Abuse
Treatment (CSAT) contract 270-07-0191 using data from the
2009 CSAT Adolescent Treatment data set (for a fullest of 128
grantees, see www.chestnut.org/li/gain/#Data_Summaries_and_Reports ).
• Opinions are those of the author and not official positions of
the government
• Available from www.chestnut.org/li/posters
• Please direct comments to Michael Dennis, Chestnut Health
Systems, 448 Wylie Drive, Normal, IL 61761, 309-451-7801,
[email protected] .
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
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 ..
been arrested
)OR=29.6(
gotten into physical fights
)OR=7.2(
dropped out of school
)OR=5.2(
gone to an emergency room
)OR=2.4(
Source: Dennis, White & Ives, 2009
60%
80%
23%
1%
69%
engaged in illegal activity
)OR=10.9(
have conduct disorder
)OR=8.9(
40%
20%
0%
17%
57%
13%
47%
11%
25%
6%
Weekly or More Use
33%
17%
No/Infrequent Use
100%
Substance Use Disorders are Common, but
Treatment Participation Rates Are Low in U.S.
Few Get Treatment:
1 in 19 adolescents,
1 in 21 young adults,
25%
1 in 12 adults
Over 88% of adolescent and
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
The Need for Systematic
Behavioral Screening
• About half of the youth in the juvenile justice system
have substance use problems
• the juvenile justice systems is the leading source of
referral among adolescents entering treatment for
substance use problems
• Recent studies have generally suggested that 67-70% of
the youth in juvenile justice settings have one or more
substance or mental disorders (79% with 2 or more, 61%
3 or more)
• This has led to multiple calls for systematic screening of
youth in the justice system for substance use and other
psychiatric disorders
Goals
1. Describe the characteristics, treatment planning
needs, and strengths of youth by their level of
involvement in the juvenile justice system
2. Illustrate how victimization is related to other
problems
3. Demonstrate how juvenile justice based
treatment can replicate the outcomes of
adolescent outpatient treatment
4. Draw out the policy implications for improving
the juvenile justice system and reclaiming futures
grantees
Global Appraisal of Individual Needs
(GAIN)
• The GAIN is one of the assessment tools used for
screening juveniles (and adults) in the justice, substance
abuse, and mental health treatment systems
• The GAIN is explicitly designed to generate information
to support clinical decision making at the individual level
and program planning at the agency level
• It is actually a family of evidence-based assessment
instruments (ranging from 5 minutes to 2 hours in
length), web-based software applications, training,
coaching, and monitoring protocols that are in use in
over 1500 agencies in 48 states and half a dozen other
countries and have generated over 200 peer reports and
publications
Methods
• The GAIN data were collected between 2002 and 2009 by 128
SAMHSA/CSAT grantees in 90 locations
• All sites collected at least the data in the CSAT Core version
(n=17,335) and a subset went on to collect optional items on
things like strengths (n=6,681)
• All data were collected as part of general, clinical practice or
specific research studies under each treatment site’s
respective voluntary consent procedures.
• All sites received standardized training and quality assurance
on their GAIN data collection to facilitate comparison with
other grantees collecting GAIN data.
• Data pooled for secondary analysis are under the terms of
data sharing agreements and the supervision of Chestnut
Health System’s Institutional Review Board.
Data from 128 Grantees
in 90 Locations Around the U.S.
NH
WA
MT
VT
ND
OR
MN
ID
WY
CA
SD
AZ
IA
IL
IL
KS
OK
NM
MO
MO
AR
AR
PA
OH
OH
DC
IN
WV
WVVA
VA
KY
NC
NC
TN
SC
MS AL
TX
AK
NY
MI
MI
UT
CO
MA
WI
NE
NV
ME
GA
LA
FL
HI
RI
CT
NJ
DE
MD
Intensity of Justice System Involvement
(n=17,335)
100%
80%
60%
40%
20%
0%
1889 (11%) In detention for 30 or more
days
950 (6%) In detention for 14 to 29 days
4618 (27%) On probation or parole for 14
or more days with 1 or more drug screens
3141 (18%) Other levels of probation,
parole or detention
2627 (15%) Othe Juvenile Justice status
974 (6%) Past arrest, Juvenile Just. status
3014 (18%) Past year illegal activity
(including substance use)
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Males more likely to have
higher intensity
Detention 30+ days
Detention 14-29 days
Male
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
Female
Past JJ status
Past year illegal act
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hispanic, Mixed, & AA more likely to
have higher intensity
Detention 30+ days
Detention 14-29 days
African American
Prob/parole 14+ days
w/ 1+ drug screens
Caucasian
Other prob/ parole/
detention
Hispanic
Mixed
Being Caucasian
associated with
lower intensity
Other
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Other JJ status
Past JJ status
Past year illegal act
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Older Youth
have higher intensity
Detention 30+ days
Detention 14-29 days
under 14
Prob/parole 14+ days
w/ 1+ drug screens
14-15 years
Other prob/ parole/
detention
Other JJ status
Past JJ status
16-17 years
Past year illegal act
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Being from a Single Parent Family and
Runaway associated with higher intensity
Detention 30+ days
Detention 14-29 days
Single
Parent
Family
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
Ever
Runaway or
been
Homeless
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past JJ status
Past year illegal act
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Being in School or Employed
associated with lower intensity
Detention 30+ days
Detention 14-29 days
In School
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
Employed
Past JJ status
Past year illegal act
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Any and Each Type of Crime
associated with higher intensity
Detention 30+ days
Detention 14-29 days
Any Illegal activity
Prob/parole 14+ days
w/ 1+ drug screens
Property crime
Other prob/ parole/
detention
Other JJ status
Interpersonal crime
Past JJ status
Drug crime
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past year illegal act
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Regular Alcohol Use at Home
associated with lower intensity
Detention 30+ days
Detention 14-29 days
Weekly
Alcohol Use in
homeb
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
Weekly
Drug Use in
homeb
Past JJ status
Past year illegal act
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Drug Use by Peers at School/Work
associated with lower intensity
Detention 30+ days
Detention 14-29 days
School/Work
Peers Weekly
Intoxication
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
School/Work
Peers Regular
Drug use
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past JJ status
Past year illegal act
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Regular Alcohol Use by Social Peers
associated with higher intensity
Detention 30+ days
Detention 14-29 days
Social Peers
Weekly
Intoxication
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
Social Peers
Weekly
Regular Drug
use
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past JJ status
Past year illegal act
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Any and Severity of Lifetime Victimization
associated with higher intensity
Detention 14-29 days
Lifetime
Victimization
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
High Severity
Victimization
Lifetime
Victimization
in Past 90
days
Detention 30+ days
Other JJ status
Past JJ status
Recent victimization
related to lower
intensity
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past year illegal act
First Use
under15
Lifetime
Dependence
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Early Use, Dependence and Tx History
associated with higher intensity
Detention 30+ days
Detention 14-29 days
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
Past JJ status
Prior AOD
Treatment
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past year illegal act
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Recent Weekly Use and Withdraw
associated with lower intensity
Detention 30+ days
Detention 14-29 days
Any Weekly
AOD Use
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
Any
withdrawalpast week
Past JJ status
Past year illegal act
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Weekly Use of Tobacco, Marijuana and Alcohol
the most common across intensity
Detention 30+ days
Detention 14-29 days
Tobacco Use
Prob/parole 14+ days
w/ 1+ drug screens
Marijuana
Use
Other prob/ parole/
detention
Other JJ status
Alcohol Use
Other drug
Use
Specific Geographic
locations have high rates of
opioid, methamphetamine
and/or cocaine use
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past JJ status
Past year illegal act
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Mental Health Disorders associated with
more extreme high & low intensity
Detention 30+ days
Any Mental Disorder
Detention 14-29 days
Major Depressive Disorder
Prob/parole 14+ days
w/ 1+ drug screens
Generalized Anxiety Disorder
Other prob/ parole/
detention
Other JJ status
Any homicidal/ suicidal
thoughts
Traumatic Stress Disorder
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past JJ status
Past year illegal act
Conduct
Disorder
AD/HD
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Mental Health Disorders associated with
more extreme high & low intensity (cont.)
Detention 30+ days
Detention 14-29 days
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
Any prior
mental health
treatment
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past JJ status
Past year illegal act
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
HIV Risk Behaviors
associated with higher intensity
Detention 30+ days
Detention 14-29 days
Any sexual
activity
Prob/parole 14+ days
w/ 1+ drug screens
Multiple
sexual
partners
Other prob/ parole/
detention
Other JJ status
Unprotected
sex
Past JJ status
Needle Use
Risk Primarily
Coming from Sex,
Not Needle Use
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Past year illegal act
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Having 3 or more clinical problems is
associated with higher intensity
84%
Detention 30+ days
84%
Detention 14-29 days
74%
Prob/parole 14+ days w/ 1+ drug screens
Other prob/ parole/ detention
67%
Other JJ status
66%
76%
Past JJ status
But even at the
lowest intensity, most
have 3 or more major
clinical problems
64%
Past year illegal act
None
1
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
2
3 to 15
$14,000
$12,000
$10,000
$8,000
$6,000
$4,000
$2,000
$0
Quarterly Costs to Society* Prior to Intake
associated with higher intensity
Detention 30+ days
Detention 14-29 days
$10,149
Average
Quarterly
Costs to
Society
(Prior to
Intake)
$6,746
$4,065
$2,633
Prob/parole 14+ days
w/ 1+ drug screens
Other prob/ parole/
detention
Other JJ status
$2,410
$2,544
$1,832
Past JJ status
Past year illegal act
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335) in 2009 dollars
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$0
Many SBIRT, School,
Workplace and other early
intervention programs
focus on brief intervention
$10,000
Cost of Substance Abuse Treatment Episode
• $750 per night in Detox
Screening & Brief Inter.(1-2 days) $407
• $1,115 per night in hospital
In-prison Therap. Com. (28 weeks) $1,249
• $13,000 per week in intensive
Outpatient (18 weeks) $1,132
care for premature baby
Intensive Outpatient (12 weeks) $1,384
• $27,000 per robbery
Treatment Drug Court (46 weeks) $2,486
• $67,000 per assault
Residential (13 weeks) $2,907
$4,277
Methadone Maint. (87 weeks)
Adol. Residential (13 weeks)
$10,228
$14,818
Therapeutic Com. (33 weeks)
$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)
SAMHSA/CSAT’s Adolescent Clients
• As part of SAMHSA/CSAT contract 270-07-0191, data were
pooled on clients from 148 local evaluations, recruited
between 1997 to 2009 and followed quarterly for 6 to 12
months (over 80% completion).
• In 2009 dollars, the 16,915 adolescents averaged $3,908 in
costs to taxpayers in the 90 days before intake ($15,633 in the
year before intake).
• This would be $3.9 Million per 1,000 adolescents served.
• Within 12 months, the cost of treatment provided by CSAT
grantees was offset by reductions in other costs producing a
net benefit to taxpayers of $4,592 per adolescent.
SAMHSA/CSAT’s Adolescents Clients
Economic Benefit by Level of Care
Adolescent Level of Care
Year
before
intake
Year
after
Intakea
One
Year
Savingsb
Outpatient
$10,993
$10,433
$560
Intensive Outpatient
$20,745
$15,064
$5,682
Outpatient Continuing Care
$34,323
$17,000
$17,323
Long Term Residential
$27,489
$26,656
$833
Short Term Residential
$25,255
$21,900
$3,355
Total
$15,633
$13,642
$1,992
\a Includes the cost of treatment
\b Year after intake (including treatment) - year before treatment
Residential treatment referral
Child maltreatment
Dissatisfaction with environment
Vocational assistance
Housing situation
Recent victimization
Worried about being victimized
Coordinating care w DCFS/CPS
Substance use in public housing
School or GED program
Vocational counseling or placement
Recent work problems
78%
61%
53%
31%
24%
19%
17%
11%
8%
8%
8%
5%
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
100%
80%
60%
40%
20%
0%
Treatment Planning Needs that
increase with intensity
91%
Attended school in the past 90 days
67%
Coping with psycho-social stressors
58%
Recent school problems
48%
Family fighting in the home
31%
Substance use in the home
25%
Attended work in the past 90 days
Financial counseling
100%
80%
60%
40%
0%
20%
Treatment Planning Needs that
decrease with intensity
6%
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)
Doing well at close friends
89%
Listening, caring or comm. w/ others
75%
Sports, exercise, physical activity
73%
Doing well at with your family
73%
Problem solving and figuring things out
67%
Doing well at school or training
59%
Working or playing with computers
59%
Music, dancing, acting, other perf. art
49%
44%
Drawing, painting, design or other art
Doing well at work
33%
Avearge No. of Strenths (0-10)
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Individual Strengths
6.20
0
2
4
6
8
10
Variation in Strengths by Intensity
• Those that tend increase with intensity include
–
–
–
–
–
Doing well at sports, exercise, physical activity
Doing well at with your family
Doing well at school or training
Doing well at music, dancing, acting, other performing art
Drawing, painting, design or other art activities
• That tend to decrease with intensity include
–
–
–
–
–
Doing well at close friends
Listening, caring or communicating with others
Problem solving and figuring things out
Working or playing with computers
Doing well at work
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sources of Social Support
Doing well at close friends
Listening, caring or comm. w/ others
90%
85%
79%
77%
77%
71%
71%
57%
53%
Sports, exercise, physical activity
Doing well at with your family
Problem solving and figuring things out
Doing well at school or training
Working or playing with computers
Music, dancing, acting, other perf. art
Drawing, painting, design or other art
Average No. of Sources (0-9)
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
6.57
0
2
4
6
8
Variation in Social Support by Intensity
• Those that tend increase with intensity include
– Family members/close partners
– Professional counselor/health provider
• That tend to decrease with intensity include
–
–
–
–
–
–
–
Friends to hang out with
Someone to talk with to about emotions
Someone to help cope with problems
Legal hobby or activity
People at work/school to help get assignments done
People at work/school to help with day to day things
Friends/colleagues from other schools or companies
Social
Peers
School or
Work
Home
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
Average Attributes (0-12)
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Potential Mentors in the
Recovery Environment
52%
75%
25%
18%
58%
41%
30%
16%
63%
46%
29%
16%
4.6
0
2
4
6
8
10
12
Variation in Potential Mentors by Intensity
• Those that tend increase with intensity include
–
–
–
–
Home Peers: Know any in recovery
School/Work Peers: Know any in recovery
Home Peers: Know any in treatment
Home Peers: None involved in shouting, arguing or fighting
most weeks
• That tend to decrease with intensity include
–
–
–
–
Social Peers: Know any in recovery
Social Peers: Know any in treatment
School/Work Peers: Know any in treatment
Social Peers: None involved in shouting, arguing or fighting
most weeks
– School Work Peers: None involved in shouting, arguing or
fighting most weeks
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Environment with No One Involved Illegal activity
most common in the middle of intensity
Detention 30+ days
Detention 14-29 days
Home Peers
Prob/parole 14+ days
w/ 1+ drug screens
Social Peers
Other prob/ parole/
detention
Other JJ status
Past JJ status
School/Work
Peers
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
Past year illegal act
General Victimization Scale:
Example from Offender Re-entry Program (ORP)
58.25%
48%
Ever attacked w/ gun, knife, other weapon
Ever hurt by striking/beating
28%
Abused emotionally
10%
Ever forced sex acts against your will/anyone
65%
Age of 1st abuse < 18
45%
39%
Any with more than one person involved
Any several times or for long time
27%
30%
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
Curently worried someone attack
Currently worried someone beat/hurt
Currently worried someone abuse emotionally
Currently worried someone force sex acts
13%
9%
13%
9%
6%
1%
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)
Psychiatric Disorders by
Severity of Victimization
60%
General
Anxiety
Disorder
(OR=5.6)
40%
40%
23%
26%
4%
6%
Traumatic
Stress
Disorder
(OR=6.8)
21%
26%
7%
13%
10%
19%
30%
15%
21%
40%
20%
High
41%
Moderate
34%
50%
Low
0%
Major
Depressive
Disorder
(OR=3.9)
Attention
Deficit/
Hyperactivity
(OR=2.5)
Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)
Conduct
Disorder
(OR=2.2)
Type of Crime By
Severity of Victimization
100%
Substance
Use Only
Other Crime
80%
60%
Violent Crime
40%
20%
30%
40%
45%
Low
Severity
Moderate
Severity
High
Severity
0%
Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)
High victimization
group more likely
(OR=1.9) to report
violent crime than
low group
GAIN-I Main Scale Problem Profile
0%
20%
40%
Physical Health Conditions
Current Withdrawal
Financial Problem
Environmental Stress
Personal Sources of Stress
Health Problem Symptoms
Internalizing Disorders Sx
Personality Disorders Sx
HIV Risk Behaviors
Externalizing Disorder Sx
Substance Problem Sx
Crime and Violence Sx
Average No. of High/Mod Prob.
60%
80%
100%
5.38
0
1
2
High
3
4
5
6
7
Moderate
Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)
8
9 10 11 12
Low
GAIN-I Main Scales Problem Count By
Severity of Victimization
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None
1 to 2
3 to 6
7 to 12
45%
11%
Low Severity
(N=763)
25%
Mod Severity
(N=532)
High Severity
(N=1664)
Source: CSAT 2010 YORP and ORP studies only (N = 2,966)
High
victimization
group more
likely (OR=6.6)
to have 7 to 13
problems than
low group
47
Victimization and Level of Care Interact to
Predict Outcomes
Marijuana Use (Days of 90)
40
CHS Outpatient
CHS Residential
Traumatized groups
35have higher severity
30
25
20
15
10
High trauma group
does not respond to OP
5
0
Intake
OP -High
6 Months
OP - Low/Mod
Source: Funk, et al., 2003
Both groups respond to
residential treatment
Intake
Resid-High
6 Months
Resid - Low/Mod.
Comparison of Treatment Outcomes:
Adolescent Outpatient (AOP) vs.
Juvenile
Treatment Drug Court (JTDC)
JTDC
Reduced Use
More than AOP
(d between= -0.24)
Days out of 90 Days
35
Others Outcomes
Not Significantly Different
30
25
20
AOP Weighted
(n=1120)
JTDC
(n=1120)
15
10
5
Substance
Use*
( d=-0.45, -0.57)
Emotional
Problems
(d=-0.32, -0.22)
Source: Ives et al., in press
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)
*p<.05 change greater for JTDC vs AOP (d=-0.24)
In practice we need a 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 & 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
Longer assessments identify more
areas to address in treatment planning
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 GAIN I
(v2)
(v3 -Beta)
5 min.
20 min
30 min
1-2 hr
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
Most substance
users have
multiple
problems
How does this relate to the move towards
Evidence Based Practice (EBP)?
• EBP means introducing explicit intervention protocols
– Targeted at specific problems/subgroups and outcomes
– Having explicit quality assurance procedures to cause
adherence at the individual level and implementation at the
program level
• Reliable and valid assessment is needed that can be used to
– Immediately guide clinical judgments about
diagnosis/severity, placement, treatment planning, and the
response to treatment at the individual level
– Drive longer term program evaluation, needs assessment,
performance monitoring and program planning
– Allow evaluation of the same person or program over time
– Allow comparisons with other people or interventions
Major Predictors of Bigger Effects Found
in Multiple Meta Analyses
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
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
Evidenced Based Treatment (EBT) that Typically do
Better than Usual Practice in Reducing Juvenile
Recidivism (29% vs. 40%)
•
•
•
•
•
•
•
•
•
•
•
Aggression Replacement Training
Reasoning & Rehabilitation
Moral Reconation Therapy
Thinking for a Change
Interpersonal Social Problem Solving
MET/CBT combinations and Other manualized CBT
Multisystemic Therapy (MST)
Functional Family Therapy (FFT)
Multidimensional Family Therapy (MDFT)
Adolescent Community Reinforcement Approach (ACRA)
Assertive Continuing Care
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
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
Percentage Change in Abstinence (6 mo-Intake) by
level of Adolescent Community Reinforcement
Approach (A-CRA) Quality Assurance
% Point Change in Abstinence
100%
90%
80%
70%
Effects associated with
intensity of quality
assurance and
monitoring (OR=13.5)
60%
50%
36%
40%
30%
24%
20%
10%
4%
0%
Training Only
Training, Coaching,
Monitoring
Clinical Trial Onsite
Protocol Monitors
Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)
57
Importance of Targeting on
Performance Measures
Mental Health Need
at Intake
No/Low
Mod/High
Treatment Received
in the first 3 months
Any Treatment
6
218
Total
224
218/224=97% to targeted
No Treatment
205
553
758
Total
211
771
982
553/771=72%
unmet need
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
Source: 2008 CSAT AAFT Summary Analytic Dataset
Mental Health Problem (at intake) vs.
Any MH Treatment by 3 months
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
97%
79%
% of Clients With
Mod/High Need
(n=771/982)*
72%
% w Need but No Service % of Services Going to
After 3 months
Those in Need
(n=553/771)
(n=218/224)
Source: 2008 CSAT AAFT Summary Analytic Dataset
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%
20%
10%
0%
90%
Opportunity to
redirect
existing funds
through better
targeting
52%
36%
% 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 Dataset
Implications for AOD Treatment
• While a third reported some withdrawal symptoms, most
appeared more appropriate for ambulatory/outpatient
detoxification
• Multiple evidenced-based practices are now available for
outpatient, residential and continuing care treatment
• Most have multiple risk factors for relapse and a history of
prior treatment admissions, suggesting the need for on going
monitoring and continuing care.
• Given the low rates of people around them who are familiar
with treatment and recovery, it is also important to include
proactive linkages to recovery services and communities
through supports like recovery coaches or mentors.
Trauma, Crime and Other Issues
• Multiple co-occurring behavioral health problems were the
norm, suggesting the need for behavior health screening for
multiple conditions at the same time and integrated care
• High prevalence suggest the need for the need for formal
screening
• Focus program development/training on providing traumafocused and/or trauma-informed therapies
• Need for para-suicidal and suicidal behavior interventions
• Need for interventions targeting externalizing disorders,
anger, violence and crime
• Need for smoking cessation
• Need for HIV interventions targeting sex risk and
victimization
Potential Resources
•
•
•
•
•
•
•
•
•
Ambulatory/outpatient detoxification
http://www.aafp.org/afp/2005/0201/p495.html
Evidenced-based practices http://www.nrepp.samhsa.gov/
http://www.samhsa.gov/ebpwebguide/appendixB.asp ; www.chestnut.org/li/apss
Trauma-informed therapies http://www.nctsn.org/nccts
Para-suicidal and suicidal behaviors http://www.sprc.org/
Adolescent mental health systems of care
http://systemsofcare.samhsa.gov/ResourceGuide/ebp.html
Tobacco cessation
http://www.cdc.gov/tobacco/quit_smoking/cessation/youth_tobacco_cessation/i
ndex.htm
HIV intervention including trauma http://www.who.int/gender/violence/en/,
http://www.effectiveinterventions.org/en/home.aspx
Motivational and strength based approaches http://www.niatx.net
http://www.chestnut.org/li/apss/CSAT/protocols/index.html
Copy of this presentation – www.chestnut.org/li/posters