Transcript 1-The_Current_Renaissance_of_Adolescent_Treatment_4-27

State of the Art of Adolescent
Substance Abuse Treatment
Michael Dennis, Ph.D.
Chestnut Health Systems,
Bloomington, IL
Presentation at “Juvenile Justice Conference on Alcohol & Other (AOD) Treatment
for Adolescents”, Thursday, April 27, 2006, Marlborough Massachusetts. The
content of this presentations are based on treatment & research funded by the Center
for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health
Services Administration (SAMHSA) under contract 270-2003-00006 and several
individual grants. The opinions are those of the author and do not reflect official
positions of the consortium or government. Available on line at
www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail:
[email protected]
Goals of this Presentation
1.
Epidemiological Course: To examine the prevalence,
course, and consequences of adolescent substance use
and co-occurring disorders and the unmet need for
treatment
2.
The Treatment System: To summarize major trends in
the adolescent treatment system and the variability by
state
3.
Evidence Based Practice: To highlight what it takes to
move the field towards evidenced-based practice related
to assessment, treatment, program evaluation and
planning
AFTER BREAK
4. Part 4 Treatment Effectiveness: To present the findings
from several recent treatment outcome studies on
substance abuse treatment research, trauma and
violence/crime.
2
Part 1 Epidemiological Course:
To examine the prevalence, course,
and consequences of adolescent
substance use and co-occurring
disorders and the unmet need for
treatment
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
4
Problems Vary by Age
NSDUH Age Groups
100
90
80
Adolescent
Onset
Remission
Increasing
rate of nonusers
70
Severity Category
No Alcohol or Drug Use
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
0
Dependence
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
Source: 2002 NSDUH and Dennis et al forthcoming
5
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
6
Age of First Use Predicts Dependence
an Average of 22 years Later
100
Under Age 15
% with 1+ Past Year Symptoms
90
Aged 15-17
80
Aged 18 or older
71
70
63
62
60
51
50
40
45
39 37
30
30
48
41
34
23
20
10
0
Tobacco:
Alcohol:
Pop.=151,442,082
Tobacco,
OR=1.3*, Pop.=176,188,916
Alcohol, OR=1.9*,
Pop.=151,442,082
Pop.=176,188,916
OR=1.49*
OR=2.74*
Source:
Marijuana:
Other Drugs:
Pop.=71,704,012
Marijuana, OR=1.5*, Pop.=38,997,916
Other, OR=1.5*,
Pop.=71,704,012 OR=2.65*
Pop.=38,997,916
OR=2.45*
* p<.05
Dennis, Babor, Roebuck & Donaldson (2002) and 1998 NHSDA
7
Substance Use Careers Last for Decades
1.0
.9
Median of 27
years from
first use to 1+
years
abstinence
.8
Cumulative Survival
.7
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
30
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
8
Substance Use Careers are
Longer the Younger the Age of First Use
1.0
.9
Age of
1st Use
Groups
.8
Cumulative Survival
.7
.6
.5
under 15*
.4
15-20*
.3
.2
21+
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
* p<.05
(different
from 21+)
9
Substance Use Careers are
Shorter the Sooner People Get to Treatment
1.0
.9
Year to
1st Tx
Groups
.8
Cumulative Survival
.7
20+
.6
.5
.4
.3
.2
10-19*
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
0-9*
* p<.05
(different
from 20+)10
Treatment Careers Last for Years
1.0
.9
.8
Median of 3
to 4 episodes
of treatment
over 9 years
Cumulative Survival
.7
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
Years from first Tx to 1+ years abstinence
Source: Dennis et al., 2005
11
The Growing Incidence of Adolescent
Marijuana Use: 1965-2002
Adolescent
Initiation Rising
Adult Initiation
Relatively Stable
Source: OAS (2004). Results from the 2003 National Survey on Drug Use and Health: National Findings.
Rockville, MD: SAMHSA. http://oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.pdf
12
Risk & Availability
Marijuana Use
Importance of Perceived Risk
Source: Office of Applied Studies. (2000). 1998 NHSDA
13
Actual Marijuana Risk




From 1980 to 1997 the potency of marijuana in
federal drug seizures increased three fold.
The combination of alcohol and marijuana has
become very common and appears to be synergistic
and leads to much higher rates of problems than
would be expected from either alone.
Combined marijuana and alcohol users are 4 to 47
times more likely than non-users to have a wide
range of dependence, behavioral, school, health and
legal problems.
Marijuana and alcohol are the leading substances
mentioned in arrests, emergency room admissions,
autopsies, and treatment admissions.
14
Substance Use in the Community
No Alcohol/
Marijuana
use 60%
Yearly
Alcohol
Use 15%
Monthly
Alcohol
Use 7%
Weekly
Alcohol
Use 2%
Marijuana
Use Only
1%
Yearly
Marijuana &
Alcohol Use
6%
Monthly
Marijuana &
Alcohol Use
4%
Weekly
Marijuana &
Alcohol Use
4%
Source: Dennis and McGeary (1999) and 1997 NHSDA
15
Consequences of Substance Use
100
77
80
69
67
57
60
51
47
44
40
47
29
13
20
0
11
0 1
25
15
33
28
17
23
17
11
6
1
0
% 1+
% 1+
% Clinical
Symptom of Symptom of Behavior
Alcohol
Cannabis
Problems
Disorder
Disorder
% Physical
Fight
% Out of
School
% with 1+
ER in the
past year
% Any
Illegal
Activity
% 1+
Arrests
No Past Year Alcohol or Marijuana Use
Weekly Alcohol Use
Weekly Marijuana Use (with Alcohol Use)
Source: Dennis, Godley and Titus (1999) and 1997 NHSDA
16
Need for Treatment
--------Past Month Use------
17.8%
Alcohol
10.7%
Alcohol Binge
11.5%
Any Drug Use
8.1%
Marijuana Use
Any Non-Marijuana Drug Use
5.7%
Past Year AOD Dependence or Abuse
Public Treatment (From TEDS)
25%
14.9%
Tobacco
Any Treatment (From NHSDA)
20%
15%
10%
5%
0%
(% of 24,753,586 Adolescents in the U.S. Household Population)
8.9%
0.7%
0.6%
Source: NSDUH and TEDS (see state level estimates in appendix)
Less than 1 in 10
getting treatment
88% of adolescents
are treated in the
public system
17
Adolescent AOD Dependence/Abuse
Up 27%
from 7%
in 1995
Prevalence
6.0 to 8.4%
8.5 to 9.0%
9.1 to 9.9%
10.0 to 14.6%
U.S.Avg.=8.9%
MA=11.2%
Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on
Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse
and Mental Health Services Administration, Office of Applied Studies (retrieved from
http://oas.samhsa.gov/2k3State/2k3SAE.pdf ) and Kilpatrick et al, 2000.
18
Unmet Treatment Need Adolescent
(% of AOD Dependence/Abuse without any private/public treatment)
9 in 10
Untreated
Prevalence
82.4 to 90.1%
90.2 to 92.3%
92.4 to 94.2%
94.3 to 98.0%
U.S.Avg.=92.2%
MA=97.7%
Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on
Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse
and Mental Health Services Administration, Office of Applied Studies (retrieved from
http://oas.samhsa.gov/2k3State/2k3SAE.pdf )
19
Of 13,530 Urine Panels Done by DYS in
2005, 51% were positive.
Of those that were, they. were positive for…
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Marijuana is the
most common and
easiest to detect
89%
Less common & hard to detect;
Often more severe than opioids
THC
6%
4%
1%
1%
Amphetamines
Cocaine
Benzodiazepines
Opiates
0%
Ecstasy
Panels
Source: Commonwealth of Massachusetts Department of Youth Services (DYS)
20
Summary Points on Epidemiological Course







Consequences go up as severity increases from use
to multiple substance use, abuse, and dependence.
Substance use disorders typically on-set during
adolescence and last for decades.
The earlier the age of onset, the longer the course
of substance use
The earlier treatment is received, the shorter the
course of substance use
Marijuana has become the leading substance
problem
Less than 1 in 10 adolescents with substance
abuse or dependence problems receive treatment
Over 88% are treated in the public system
21
Part 2 The Treatment System:
To summarize major trends in the
adolescent treatment system and the
variability by state
22
Adolescent Treatment Admissions have
increased by 61% over the past decade
180,000
Public Treatment Admissions
160,000
140,000
120,000
61% increase from
95,271 in 1993
to 153,251 in 2003
100,000
80,000
60,000
40,000
20,000
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year of Admission
Source: Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS)
http://www.samhsa.gov/oas/dasis.htm
23
Change in Public Sector Admissions
(%=(2003-1993)/1993)
Both
Cause &
Consequence
Change
Not available
-96 to -7%
-8 to +33%
+34 to +116%
+117 to +337%
U.S.Avg.=+61%
MA=-12%
Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on
Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse
and Mental Health Services Administration, Office of Applied Studies (retrieved from
http://oas.samhsa.gov/2k3State/2k3SAE.pdf )
24
Methamphetamines
& Opiates Rare but
Growing Fast
Change in Focal Substances*: 1993 to 2003
46%
75,000
36%
44%
19%
100,000
300%
138%
125,000
400%
310%
253%
111%
150,000
100%
61%
growth
0%
25,000
-66%
-56%
50,000
-100%
*TEDS Primary, Secondary or Tertiary problem
Source: Treatment Episode Data Set (TEDS) 1993-2003.
Other\e
Inhalants
Stimulants
Other
Amphetamines
Methamphetamines
Hallucinogens
Heroin/Opiates
Cocaine/Crack
Marijuana/Hash
-200%
Alcohol
0
Marijuana
and Alcohol
Most
Common
200%
1993
2003
Change
Most other drugs
admissions grew
slower than expected
25
Presenting Substances: MA vs. US
Similar on
Marijuana,
Higher on Alcohol
100%
90%
MA
U.S.
80%
Cocaine higher; 20%
or higher in DE & TX
70%
60%
50%
40%
Opiates 20% or
higher in MA & NM
30%
Methamphetamine 20%
or higher in
AZ, CA,ID,MN,NV,WA
20%
Other Amphetamines
20% or higher in OR
10%
Other\e
Inhallants
Stimulants
Other
Amphetamines
Methamphetamines
Hallucinogens
Heroin/Opiates
Cocaine/Crack
Marijuana/Hash
Alcohol
0%
Source: Primary, Secondary or Tertiary, from Treatment Episode Data Set (TEDS) 1993-2003.
26
Change in Referral Sources: 1993-2003
JJ referrals have doubled, are
53% of 2003 admissions and
driving growth
70,000
114%
80,000
140%
115%
90,000
120%
100%
60,000
Other sources of Referral have
grown, but less than expected
50,000
80%
60%
40%
12%
20,000
37%
37%
5%
30,000
41%
40,000
10,000
61%
growth
20%
Employee/EAP
Other Health
Care
Other SA Tx
Agency
Other
Community
Self/Family
School
0%
Juvenile Justice
-
1993
2003
Change
Source: Treatment Episode Data Set (TEDS) 1993-2003.
27
Referral Sources: MA vs. US
100%
90%
80%
Lower Rate of
Juvenile Justice
Referrals
70%
MA
Lower Rate
of School
Referrals
60%
50%
U.S.
Higher Rate of
Self/Parent
Referrals
40%
30%
20%
10%
Source: Treatment Episode Data Set (TEDS) 1993-2003.
Other Health
Care Provider
Other Substance
Abuse
Treatment
Agency
Other
Community
Referral
Self/Family
School
Criminal Justice
System
0%
28
Change in Level of Care
208%
125,000
IOP has had the
fastest growth
56%
75,000
66%
100,000
400%
Residential has
grown, but
slower than
expected
300%
200%
100%
19%
50,000
30%
150,000
82% of Adolescents
are treated in
Outpatient Settings
0%
25,000
-100%
0
-200%
Outpatient
Intensive
Outpatient
Detox
Short-term Long-term
Residential Residential
61%
growth
1993
2003
Change
Source: Treatment Episode Data Set (TEDS) 1993-2003.
29
Level of Care: MA vs. US
100%
90%
Similar on Regular
Outpatient
MA
U.S.
80%
But little IOP
or Short Term
Residential
70%
60%
Higher on Detox &
Long Term
Residential
50%
40%
30%
20%
10%
Source: Treatment Episode Data Set (TEDS) 1993-2003.
Short-term
Residential
Long-term
Residential
Detox
Intensive
Outpatient
Outpatient
0%
30
Severity Goes up with Level of CareBaseline
STR: Higher
on
Dependence
100%
90%
80%
70%
Detox:
Detox:
Higher
Higher on
Use,
but
on
Use
lower on
prior tx
Severity Goes
up with Level
of Care
60%
50%
40%
30%
20%
10%
0%
Weekly use
at intake
First used
under age 15
Outpatient
Long-term Residential
Dependence
Prior
Treatment
Case Mix
Index (Avg)
Intensive Outpatient
Detoxification
Short-term Residential
Source: Treatment Episode Data Set (TEDS) 1993-2003.
31
Other Characteristics
0%
10%
20%
30%
40%
50%
60%
70%
Male
80%
90%
70%
Caucasian
58%
African American
System dominated
by male, white,
15 to 17 year olds
19%
Hispanic
17%
Other
6%
15 to 17 years old
83%
9 to 11 yrs education
63%
Student
57%
Employed
16%
Psychological Problems
22%
Pregnant at Admission
2%
Homeless/Runaway
1%
Source: Treatment Episode Data Set (TEDS) 1993-2003.
These numbers are
artificially low
because of how they
are measured
32
Most Lack of Standardized Assessment for…





Substance use disorders (e.g., abuse, dependence,
withdrawal), readiness for change, relapse
potential and recovery environment
Common mental health disorders (e.g., conduct,
attention deficit-hyperactivity, depression,
anxiety, trauma, self-mutilation and suicidality)
Crime and violence (e.g., inter-personal violence,
drug related crime, property crime, violent crime)
HIV risk behaviors (needle use, sexual risk,
victimization)
Child maltreatment (physical, sexual, emotional)
33
Median Length of Stay is only 50 days
Level of Care
Median Length of Stay
Total
(61,153 discharges)
50 days
LTR
(5,476 discharges)
49 days
STR
(5,152 discharges)
21 days
Detox
(3,185 discharges)
3 days
IOP
(10,292 discharges)
Less than
25% stay the
90 days or
longer time
recommended
by NIDA
Researchers
46 days
Outpatient
(37,048 discharges)
59 days
0
30
60
90
Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment
Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration.
Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .
34
53% Have Unfavorable Discharges
Despite being widely
recommended, only
10% step down after
intensive treatment
Total
(61,153 discharges)
LTR
(5,476 discharges)
STR
(5,152 discharges)
Detox
(3,185 discharges)
IOP
(10,292 discharges)
Outpatient
(37,048 discharges)
0%
Completed
20%
Transferred
40%
60%
ASA/ Drop out
80%
100%
AD/Terminated
Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment
Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration.
Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .
35
Summary of Problems in the Treatment System







The public systems is changing size, referral
source, and focus – often in different directions by
state
Major problems are not reliably assessed (if at all)
Less than 50% stay 50 days (~7 weeks)
Less the 25% stay the 3 months recommended by
NIDA researchers
Less than half have positive discharges
After intensive treatment, less than 10% step
down to outpatient care
While JJ involvement is common, little is known
about the rate of initiation after detention
36
Part 3 Evidence Based Practice:
To highlight what it takes to move the
field towards evidenced-based practice
related to assessment, treatment,
program evaluation and planning
37
Context

The field is increasingly facing demands from payers,
policymakers, and the public at large for “evidence-based
practices (EBP)” which can reliably produce practical and
cost-effective interventions, therapies and medications
that will
– reduce risks for initiating drug use among those not yet
using,
– reduce substance use and its negative consequences
among those who are abusing or dependent, and
– reduce the likelihood of relapse for those who are
recovering
NIDA Blue Ribbon Panel on Health Services Research
(see www.nida.nih.gov )
38
General Behavioral Health Practice

Accumulating evidence indicates that most of the
theories and approaches that are used within the
community of practitioners are unsupported by
empirical evidence of effects

Various lists of 70 or so “proven” empirically supported
therapies (ESTs) have proven to be relatively infeasible
because they have rarely been compared with each other
and generally have not been tested with the clinically
diverse samples found in community based settings

Need for a new method of integrating scientific evidence
and the realities of practice is called for.
Source: Beutler, 2000
39
Problems and Barriers in SA Tx

People with multiple substance use and multiple cooccurring problems are the norm of severity in practice,
but are often excluded from research

Individualization of treatment content/duration is the
norm in practice, but research based protocols typically
involves fixed components/length that are not as
appropriate for heterogeneous problems

No treatment is not considered a ethical or significant
option, practitioner’s are more interested in identifying
which of several treatments to use for a given type of
patient – but few such studies have been done

When research practices have been identified, they are
often not adopted because practitioner’s often lack the
appropriate materials, training and resources to know
when or how to implement them
40
Randomized Clinical Trials (RCT) are to
Evidence Based Practice (EBP) like
Self-reports are to Diagnosis





They are only as good as the questions asked (and
then only if done in a reliable/valid way)
They are an efficient and logical place to start
But they can be limited or biased and need to be
combined with other information
Just because the person does not know something
(or the RCT has not be done), does not mean it is
not so
Synthesizing them with other information usually
makes them better
41
So what does it mean to move the field
towards Evidence Based Practice (EBP)?

Introducing reliable and valid assessment 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, and long term program planning

Introducing explicit intervention protocols that are
– 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

Having the ability to evaluate performance and outcomes
– For the same program over time,
– Relative to other interventions
42
Reoccurring Themes in the Examples…





Severity and specificity of problem subgroup
Manualized and replicable assessment and
treatment protocols
Relative strength of intervention for a specific
problem
Adherence and implementation of intervention
Evaluation of outcomes targeted by the
intervention (a.k.a., logic modeling)
43
The Current Renaissance of
Adolescent Treatment Research
Feature
1930-1997
1997-2005
Tx Studies*
16
Over 200
Random/Quasi
9
44
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
44
Adolescent Treatment Research
Currently Being Published

















1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of Adol. (DATOS-A)
1995-1997 Drug Abuse Treatment Outcome Study (DOMS)
1997-2000 CSAT’s Cannabis Youth Treatment (CYT) experiments
1998-2003 NIAAA/CSAT’s 15 individual research grants
1998-2003 CSAT’s 10 Adolescent Treatment Models (ATM)
2000-2003 CSAT’s Persistent Effects of Treatment Study (PETS-A)
2002-2007 CSAT’s 12 Strengthening Communities for Youth (SCY)
2002-2007 RWJF’s 10 Reclaiming Futures (RF) diversion projects
2002-2007 CSAT’s 12+ Targeted Capacity Expansion TCE/HIV
2003-2009 NIDA’s 14 individual research grants and CTN studies
2003-2006 CSAT’s 17 Adolescent Residential Treatment (ART)
2003-2008 NIDA’s Criminal Justice Drug Abuse Treatment Study (CJ-DATS)
2003-2007 CSAT’s 38 Effective Adolescent Treatment (EAT)
2004-2007 NIAAA/CSAT’s study of diffusion of innovation
2004-2009 CSAT 22 Young Offender Re-entry Programs (YORP)
2005-2008 CSAT 20 Juvenile Drug Court (JDC)
2005-2008 CSAT 16 State Adolescent Coordinator (SAC) grants
Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN)
45
Adolescent and Adult Treatment Program
GAIN Clinical Collaborators
Number of
GAIN Sites
30 to 60
10 to 29
2 to 9
1
One or more state or county wide systems uses the GAIN
07/05
One or more state or county wide systems considering using the GAIN
46
Common Hierarchical Structure of the
GAIN’s Psychopathology Scales
General Individual Severity Scale (GISS)
Substance Problem Scale (SPS)
Substance Issues Index (SII)
Substance Abuse Scale (SAS)
Substance Dependence Scale (SDS)
Behavior Complexity Scale (BCS)
Inattentiveness Disorder Scale (IDS)
Hyperactivity-Impulsivity Scale (HIS)
Conduct Disorder Scale (CDS)
Internal Mental Distress Scale (IMDS)
Somatic Symptom Index (SSI)
Depression Symptom Scale (DSS)
Homicidal/Suicidal Thought Index (HSTI)
Anxiety/Fear Symptom Scale (AFSS)
Traumatic Distress Scale (TDS)
Crime/Violence Scale (CVS)
General Conflict Tactic Scale (GCTS)
Property Crime Scale (PCS)
Interpersonal Crime Scale (ICS)
Drug Crime Scale (DCS)
Confirmatory factor analysis demonstrates that this is reliable overall and stable across adults and
adolescents, outpatient & residential (confirmatory fit index =.97; Root Mean Square Error=.04)
47
GAIN Short Screen (GAIN-SS)






Administration Time: 5 minutes
Training Requirements: Minimal
Mode: Self or staff administered
Purpose: Designed for use in general populations or where
there is less control to identify who has a disorder warranting
further assessment or behavioral intervention, measuring
change in the same, and comparing programs
Scales: The total scale (20-symptoms) and its 4 subscales (5symptoms each) for internal disorders (somatic, depression,
suicide, anxiety, trauma, behavioral disorders (ADHD, CD),
substance use disorders (abuse, dependence), and
crime/violence (interpersonal violence, property crime, drug
related crime) can be used to generate symptom counts for the
past month to measure change, past year to identify current
disorders and lifetime to serve as covariates/validity checks.
Reports: There are currently no reports.
48
GAIN Short Screen (GAIN-SS)
100%
Low Mod.
High
Prevalence (% 1+ disorder)
90%
Sensitivity (% w disorder above)
80%
Specificity (% w/o disorder below)
(n=6194 adolescents)
70%
60%
50%
40%
30%
99% prevalence, 91%
sensitivity, & 89%
specificity at
3 or more symptoms
20%
10%
Using a higher cut
point increases
prevalence and
specificity, but
decreases sensitivity
0%
0
1
2
3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Total Disorder Screener (TDScr)
Total score has alpha of
.85 and is correlated .94
Source: Dennis et al 2005 GSS manual
with full GAIN version
49
GSS Performance by Subscale and Disorders
Screener/Disorder
Internal Disorder Screener (0-5)
Any Internal Disorder
Major Depression
Generalized Anxiety
SuicideIdeation
Mod/High Traumatic Stress
External Disorder Screener (0-5)
Any External Disorder
AD, HD or Both
Conduct Disorder
Substance Use Disorder Screener (0-5)
Any Substance Disorder
Dependence
Abuse
Crime Violence Screener (0-5)
Any Crime/Violence
High Physical Conflict
Mod/High General Crime
Total Disorder Screener (0-5)
Any Disorder
Any Internal Disorder
Any External Disorder
Any Substance Disorder
Any Crime/Violence
Prevalence
1+
3+
Sensitivity
1+
3+
Specificity
1+
3+
81%
56%
32%
24%
60%
99%
87%
56%
43%
82%
94%
98%
100%
100%
94%
55%
72%
83%
84%
60%
71%
54%
44%
41%
55%
99%
94%
83%
79%
90%
88%
65%
78%
97%
82%
91%
98%
99%
98%
67%
78%
70%
75%
51%
62%
96%
85%
90%
96%
65%
30%
100%
87%
13%
96%
100%
89%
68%
91%
25%
73%
30%
14%
100%
82%
28%
88%
31%
85%
99%
46%
100%
94%
100%
94%
49%
70%
51%
76%
38%
71%
99%
77%
100%
97%
58%
68%
89%
68%
99%
63%
75%
92%
73%
99%
100%
100%
99%
100%
91%
98%
99%
92%
96%
47%
8%
10%
20%
10%
89%
28%
37%
51%
32%
Low (0),
Moderate (1-2),
and High (3+)
cut points can
be used to
identify the
need for specific
types of
interventions
Moderate can be
targeted where
resources allow
or where a more
assertive
approach is
desired
Mod/Hi can be
used to evaluate
program
delivery/referral
50
GAIN Quick (GAIN-Q)






Administration Time: 20-30 minutes
Training Requirements: 1 day (train the trainer)
Mode: Generally Staff Administered on Computer (can be
done on paper or self administered)
Purpose: Designed for use in targeted populations to support
brief intervention or referral for further assessment or
behavioral intervention
Scales: The GQ has total scale (99-symptoms) and 15
subscales (including more detailed versions of the GSS scales
and subscales plus scales for service utilization, sources of
psychosocial stress, and health problems). All scales focus on
the past year only and it is primarily used to support
motivational interviewing or for a one time assessment (though
there is a shorter follow-up version).
Reports: Summary narrative report and a graphic individual
profile to support clinical decision making.
51
Anxiety Symptom Index
Suicide Risk Index
Depression Symptom Index
0.6
0.4
0.2
0.0
-0.2
-0.4
-0.6
TC (n=288)
Source: Titus et al, 2003; ATM data
STR (n=604)
Substance Use and Abuse
Substance Problem Index
Substance Dependence Index
OP/IOP (n=513)
External Behavior Index
General Crime Index
Conduct DisorderAggression Index
Attention-Hyperactivity
Disorder Index
Internal Behavior Index
Z score from mean
The GAIN-Quick can Predict Level of Care
Good reliability (alpha over .9 on main scales, .7 on
subscales) and correlated .9 or higher with full GAIN scale
52
GQ Example:
Site difference in 4 Detention Sites
Percent
100%
90%
Santa Cruz, CA
80%
Portland, OR
70%
Chicago, IL
60%
Dayton, OH
50%
40%
30%
20%
10%
0%
General
Stress
Health
Source: 2005 Reclaiming Futures Data (n=508)
Internalizing
Externalizing
Substance
Use
53
GQ Example:
Link to Recent Victimization in 4 detention sites
Percent
100%
90%
Santa Cruz, CA
80%
Portland, OR
70%
Chicago, IL
60%
Dayton, OH
50%
40%
30%
20%
10%
0%
Victimization in the Past Year
Source: 2005 Reclaiming Futures Data (n=508)
Current worry about
victimization
54
GAIN Initial (GAIN-I)





Administration Time: Core version 60-90 minutes/Full version 120-160
minutes (depending on severity and inclusion of GPRA module)
Training Requirements: 3.5 days (train the trainer) plus recommend formal
certification program (administration certification within 3 months of
training; local trainer certification within 6 months of training)
Mode: Generally Staff Administered on Computer (can be done on paper or
self administered)
Purpose: Designed to provide a standardized biopsychosocial for people
presenting to a substance abuse treatment using DSM-IV for diagnosis,
ASAM for placement, and needing to meet common (CARF, JCAHO,
insurance, CDS/TEDS, Medicaid, CSAT, NIDA) requirements for
assessment, diagnosis, placement, treatment planning, accreditation,
performance/outcome monitoring, economic analysis, program planning and
to support referral/communications with other systems
Scales: The GI has 9 sections (access to care, substance use, physical health,
risk and protective behaviors, mental health, recovery environment, legal,
vocational, and staff ratings) that include 103 long (alpha over .9) and short
(alpha over .7) scales, summative indices, and over 2000 created variables to
support clinical decision making and evaluation. It is also modularized to
support customization
55
GAIN-I’s Main Reports

GAIN Referral and Recommendation Summary (GRRS): A
text-based narrative in MS Word designed to be edited and shared
with specialists, clinical staff from other agencies, insurers and lay
people.

Individual Clinical Profile (ICP): A more detailed report in MS
Access designed to help triage problems and help the clinician go
back to the GAIN for more details if necessary (generally not
edited or shared).

Personal Feedback Reports (PFR): A text based summary to
support the motivational interviewing or MET based on the GAIN-I
(or GAIN-Q).

Validity Reports: A list of potential problems and areas for
clarification and.

Other: Custom reports to word, excel or transferring data from/to
other data systems.
56
Other Measures






Collateral versions of all three measures
Follow-up versions of all three measures
Spanish Translation of all three measures
Native American Module
CSAT, State, Organization, Program, and
Project Specific (aka CORE) versions
Ability to customize by site within prescribed
parameters
Over 4 dozen scientist using the data to develop additional
clinical guidance on diagnosis, placement, treatment planning,
treatment effectiveness and economic analysis
More information is available at www.chestnut.org/li/gain
57
CSAT Adolescent Treatment (AT)
Outcome Data Set
Recruitment:
1998-2005 (updated annually)
Sample:
The 2005 CSAT adolescent treatment data set
included data with 1 to 4 follow-ups on 9,276
unique adolescents from 72 local evaluations
Levels of Care:
Early Intervention, Outpatient, Intensive
Outpatient, Short, Moderate & Long term
Residential, Corrections Based and Post
Residential Outpatient Continuing Care
Instrument:
Global Appraisal of Individual Needs (GAIN)
(see www.chestnut.org/li/gain)
Follow-up:
Over 80% follow-up 3, 6, 9 & 12 months post
intake
Funding:
CSAT contract 270-2003-00006 and 72 individual
grants
58
Current CSAT AT Outcome Data Set
by Grant Program (n=9,276)
YORP: Young Offender Re-entry
Project (2004-2008;
79 from 3 grants)
EAT: Effective
Adolescent Treatment
(2003-2007; 3,325
from 27 grants)
ART: Adolescent
Residential Treatment
(2003-2006; 1,429
from 16 grants)
Source: CSAT AT Outcome Data Set
CYT: Cannabis Youth Treatment
(1997-2001; 600 from 4 grants)
ATM: Adolescent
Treatment Model
(1998-2002; 1,776
from 10 grants)
SCY: Strengthening
Communities-Youth
(2002-2007; 1,804
from 11 grants)
TCE: Other Targeted Capacity
Expansion (2002-2007;
263 from 1 grant)
59
Geographic Location of Sites
NH
WA
MT
VT
ND
ME
MN
OR
MA
ID
NY
WI
SD
MI
WY
RI
IA
PA
NE
CT
OH
NV
UT
CA
IL
CO
KS
WV
MO
VA
OK
NM
MD
NC
AR
SC
MS
TX
AL
GA
Program
ART
EAT
SCY
TCE
YORP
LA
AK
FL
HI
DE
DC
KY
TN
AZ
NJ
DC
IN
PR
60
100%
90%
80%
70%
60%
CSAT (n=7,226)
58%
Caucasian
42%
16%
17%
Hispanic
15 to 17 years old
TEDS (n=153,251)
19%
18%
African American
12 to 14 years old
50%
30%
29%
Female
Mixed/Other
40%
30%
20%
10%
0%
Demographics
6%
23%
17%
20%
83%
73%
61
First used under
age 15
Prior Treatment
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Clinical Severity
82%
74%
33%
37%
TEDS (n=153,251)
CSAT (n=7,226)
Weekly use at
intake
50%
Past Year
Dependence
48%
53%
Criminal Justice
System
61%
53%
68%
62
Meth/amphetamines
100%
90%
80%
70%
60%
50%
40%
25%
82%
Marijuana/Hash
Heroin/Opiates
30%
57%
Alcohol
Cocaine/Crack
20%
10%
0%
Primary, Secondary or Tertiary SUD
Problems
60%
8%
5%
4%
3%
7%
7%
TEDS (n=153,251)
Any Other
6%
2%
CSAT (n=7,226)
63
100%
90%
80%
70%
60%
50%
40%
30%
20%
0%
10%
Level of Care
68%
Outpatient
71%
14%
Intensive Outpatient
Short Term Resid
(<30 days)
Includes 9% in continuing
care outpatient (CCOP) after
residential treatment or
detention
8%
9%
2%
TEDS (n=153,251)
9%
Long Term Resid
19%
CSAT (n=7,226)
64
100%
90%
80%
70%
60%
57%
Social Peers Getting Drunk Weekly+
49%
School/Work Peers Getting Drunk Weekly+
28%
Others at Home Getting Drunk Weekly+
74%
Social Peers Using Drugs
65%
School/Work Peers Using Drugs
Others at Home Using Drugs
50%
40%
30%
20%
10%
0%
Recovery Environment
14%
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
65
100%
90%
80%
70%
84%
Sexually active
38%
Sex Under the Influence of AOD
32%
Multiple Sex partners
26%
Any Unprotected Sex
Victimized Physically, Sexually, or
Emotionally
Any Needle use
60%
50%
40%
30%
20%
10%
0%
Past 90 day HIV Risk Behaviors
21%
3%
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
66
100%
18%
Alcohol
All Other Drugs
90%
48%
Marijuana
Heroin/Opioids
80%
61%
Any Substance
Crack/Other Cocaine
70%
60%
50%
40%
30%
20%
10%
0%
Weekly or More Often Use in the Past 90 Days
4%
2%
7%
Tobacco
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
55%
67
100%
90%
80%
84%
Past Year Substance Diagnosis
53%
Any Past Year Dependence
31%
Any withdrawal symptoms in the past week
Severe withdrawal (11+ symptoms) in past week
70%
60%
50%
40%
30%
20%
10%
0%
Substance Use Problems
8%
Can Give 1+ Reasons to Quit
99%
37%
Any prior substance abuse treatment
Acknowledges having an AOD problem
Client believes Need ANY Treatment
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
30%
24%
68
100%
54%
Conduct Disorder
45%
Attention Deficit/Hyperactivity Disorder
37%
Major Depressive Disorder
26%
Traumatic Stress Disorder
17%
59%
Ever Physical, Sexual or Emotional Victimization
47%
High severity victimization (GVS>3)
31%
Ever Homeless or Runaway
25%
Any homicidal/suicidal thoughts past year
Any Self Mutilation
90%
79%
Any Co-occurring Psychiatric
General Anxiety Disorder
80%
70%
60%
50%
40%
30%
20%
10%
0%
Co-Occurring Psychiatric Problems
16%
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
69
69%
Physical Violence
66%
Any Illegal Activity
51%
Any Property Crimes
Any Interpersonal/ Violent Crime
49%
45%
84%
Lifetime Juvenile Justice Involvement
68%
Current Juvenile Justice involvement
1+/90 days In Controlled Environment
100%
82%
Any violence or illegal activity
Other Drug Related Crimes*
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Past Year Violence & Crime
39%
*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
70
Intensity of Juvenile Justice System
Involvement
17% Past year illegal
activity/SA use
17% In detention/jail
14+ days
Highest severity
for Long Term
Residential
(followed by
STR, IOP, OP)
8% Past arrest/
JJ status
25% On probation or
parole 14+ days
w/ 1+ drug
screens
16% Other JJ status
17% Other probation/parole/detention
Source: CSAT 2004 AT Common GAIN Data set (n= 5,468 adolescents from 67 local evaluations)
71
Multiple Problems* are the Norm
100%
90%
80%
70%
Five to
Twelve
In fact, over
half present
acknowledging 5+
major problems
60%
50%
40%
30%
Most
20%
acknowledge
10% 1+ problems
0%
Four
Three
Two
One
None
Few present with
just one problem
(the focus of
traditional
research)
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization,
violence/ illegal activity)
Source: CSAT AT Common GAIN Data set
72
No. of Problems* by Severity of Victimization
100%
Those with high
lifetime levels of
victimization have
117 times higher
odds of having 5+
major problems*
90%
80%
70%
60%
50%
Five or More
40%
Four
Three
30%
Two
20%
One
10%
None
0%
Low (31%)
Moderate (17%)
High (51%)
GAIN General Victimization Scale Score (Row %)
Source: CSAT AT Common GAIN Data set (odds for High over odds for Low)
* (Alcohol, cannabis, or
other drug disorder,
depression, anxiety,
trauma, suicide, ADHD,
CD, victimization,
violence/ illegal activity)
73
Treatment Outcomes by Level of Care:
Days of AOD Abstinence*
Days of Abstinence (of 90)
90
60
30
Outpatient (+20%, -2%)
Residential(+69%, -15%)
Post Corr/Res (+2%, -6%)
0
Pre-Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
* 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 AT Outcome Data Set (n-9,276)
74
Percent in Past Month Recovery*
Treatment Outcomes by Level of Care:
Recovery*
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
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 AT Outcome Data Set (n-9,276)
75
Other Assessment and Treatment Resources

Assessment Instruments
– GAIN Coordinating Center at www.chestnut.org/li/gain
– CSAT TIP 3 at
http://www.athealth.com/practitioner/ceduc/health_tip31k.html
– NIAAA Assessment Handbook at
http://www.niaaa.nih.gov/publications/instable.htm

Treatment Programs
– CSAT CYT, ATM, ACC and other treatment manuals at
www.chestnut.org/li/apss/csat/protocols and on CDs provided
– SAMHSA Knowledge Application Program (KAP) at
http://kap.samhsa.gov/products/manuals
– NCADI at www.health.org
– National Registry of Effective Prevention Programs
Substance Abuse and Mental Health Services Administration
(SAMHSA), Department of Health and Human Services :
http://www.modelprograms.samhsa.gov
76
Other Resources (continued)



Implementing Evidenced Based Practice
– Central East ATTC Evidence Based Practice Resource Page
http://www.ceattc.org/nidacsat_bpr.asp?id=LGBT
– Northwest Frontier ATTC Best Practices in Addiction Treatment:
A Workshop Facilitator's Guide
http://www.nattc.org/resPubs/bpat/index.html
– Turning Knowledge into Practice: A Manual for Behavioral Health
Administrators and Practitioners About Understanding and
Implementing Evidence-Based Practices
http://www.tacinc.org/index/viewPage.cfm?pageId=114
– Evidence-Based Practices: An Implementation Guide for CommunityBased Substance Abuse Treatment Agencies
http://www.uiowa.edu/~iowapic/files/EBP%20Guide%20%20Revised%205-03.pdf
– National Center for Mental Health and Juvenile Justice Evidence Based
Practice resource list at http://www.ncmhjj.com/EBP/default.asp
Society for Adolescent Substance Abuse Treatment Effectiveness
(SASATE) www.chestnut.org/li/apss/sasate
2006 Joint Meeting on Adolescent Substance Abuse Treatment
Effectiveness http://www.mayatech.com/cti/jmate/
–
next meeting March 27-29, 2006, Baltimore, MD
77
What are the pitfalls of EBP?

EBP generally causes some staff turnover

EBP often shines a light on staff or work place problems
that would otherwise be ignored

EBP often impact a wide range of existing procedures and
policies – requiring modification and provoking resistance

EBP (and most organizational changes) will fail without
good senior staff leadership

EBP typically require going for more funds from grant or
other funders

On-going needs assessment will create demand for more
change and more EBP
78
Summary of Evidenced Based Practice Section






Achieving reliable outcomes requires reliable measurement,
protocol delivery and on-going performance monitoring.
The GAIN is one measure that is being widely used by CSAT
grantees and others trying to address gaps in current knowledge
and move the field towards evidenced based practice.
Standardized and more specific assessment helps to draw out
treatment planning implications of readiness for change,
recovery environment, relapse potential, psychopathology,
crime/violence, and HIV risks.
Adolescents entering more intensive levels of care typically have
higher severity.
Multiple problems and child maltreatment are the norm and are
closely related to each other.
There is a growing number of standardized assessment tools,
treatment protocols and other resources available to support
evidenced based practices.
79
Part 4 Treatment Effectiveness:
To present the findings from several
recent treatment outcome studies on
substance abuse treatment research,
trauma and violence/crime.
80
Meta Analysis of the Effectiveness of
Programs for Juvenile Offenders
N of
Offender Sample
Studies
Preadjudication (prevention)
178
Probation
216
Institutionalized
90
Aftercare
25
Total
509
Source: Adapted from Lipsey, 1997, 2005
81
Most Programs are actually
a mix of components
Average of 5.6 components distinguishable in program
descriptions from research reports
Intensive supervision
Prison visit
Restitution
Community service
Wilderness/Boot camp
Tutoring
Individual counseling
Group counseling
Family counseling
Parent counseling
Recreation/sports
Interpersonal skills
Source: Adapted from Lipsey, 1997, 2005
Anger management
Mentoring
Cognitive behavioral
Behavior modification
Employment training
Vocational counseling
Life skills
Provider training
Casework
Drug/alcohol therapy
Multimodal/individual
Mediation
82
Most programs have small effects
but those effects are not negligible

The median effect size (.09) represents a reduction of the
recidivism rate from .50 to .46

Above that median, most of the programs reduce
recidivism by 10% or more

One-fourth of the studies show recidivism reductions of
30% or more, that is, a recidivism rate of .35 or less for the
treatment group compared to .50 for the control group

The “nothing works” claim that rehabilitative programs
for juvenile offenders are ineffective is false
Source: Adapted from Lipsey, 1997, 2005
83
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
84
Impact of the numbers of Favorable
features on Recidivism (509 JJ studies)
Usual
Practice
has little
or no
effect
Source: Adapted from Lipsey, 1997, 2005
85
Some Programs Have Negative or
No Effects on recidivism

“Scared Straight” and similar shock incarceration
program

Boot camps mixed – had bad to no effect

Routine practice – had no or little (d=.07 or 6% reduction
in recidivism)

Similar effects for minority and white (not enough data to
comment on males vs. females)

The common belief that treating anti-social juveniles in
groups would lead to more “iatrogenic” effects appears to
be false on average (i.e., relapse, violence, recidivism for
groups is no worse then individual or family therapy)
Source: Adapted from Lipsey, 1997, 2005
86
Program types with average or better
effects on recidivism
AVERAGE OR BETTER
BETTER/BEST
Preadjudication
Drug/alcohol therapy
Interpersonal skills training
Parent training
Employment/job training
Tutoring
Group counseling
Probation
Drug/alcohol therapy
Cognitive-behavioral therapy
Family counseling
Interpersonal skills training
Mentoring
Parent training
Tutoring
Institutionalized
Family counseling
Behavior management
Cognitive-behavioral therapy
Group counseling
Employment/job training
Individual counseling
Source: Adapted from Lipsey, 1997, 2005
Interpersonal skills training
87
Cognitive Behavioral Therapy (CBT) Interventions
that Typically do Better than Practice in Reducing
Recidivism (29% vs. 40%)










Aggression Replacement Training
Reasoning & Rehabilitation
Moral Reconation Therapy
Thinking for a Change
Interpersonal Social Problem Solving
Multisystemic Therapy
Functional Family Therapy
Multidimensional Family Therapy
Adolescent Community Reinforcement Approach
MET/CBT combinations and Other manualized CBT
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
88
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
89
CYT
Cannabis Youth Treatment
Randomized Field Trial
Coordinating Center:
Chestnut Health Systems, Bloomington, IL,
and Chicago, IL
University of Miami, Miami, FL
University of Conn. Health Center, Farmington, CT
Sites:
Univ. of Conn. Health Center, Farmington, CT
Operation PAR, St. Petersburg, FL
Chestnut Health Systems, Madison County, IL
Children’s Hosp. of Philadelphia, Phil. ,PA
Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA), U.S. Department of Health and Human Services
Context Circa 1997

Cannabis had become more potent, was associated with a
wide of problems (particularly when combined with alcohol),
and had become the leading substances mentioned in arrests,
emergency room admissions, autopsies, and treatment
admissions (doubling in in 5 years)

Over 80% of adolescents with Cannabis problems were being
seen in outpatient setting

The median length of stay was 6 weeks, with only 25%
making it 3 months

There were no published manuals targeting adolescent
marijuana users in outpatient treatment

The purpose of CYT was to manualize five promising
protocols, field test their relative effectiveness, cost, and
benefit-cost and provide them to the field
Source: Dennis et al, 2002
91
Two Effectiveness Experiments
Trial 1
Incremental Arm
Trial 2
Alternative Arm
Randomly Assigns to:
Randomly Assigns to:
MET/CBT5
MET/CBT5
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (12 weeks)
FSN
Family Support Network
Plus MET/CBT12 (12 weeks)
Source: Dennis et al, 2002
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
ACRA
Adolescent Community
Reinforcement Approach(12 weeks)
MDFT
Multidimensional Family Therapy
(12 weeks)
92
Contrast of the Treatment Structures
MET/
CBT5
MET/
CBT12
FSN
ACRA
MDFT
Individual Adolescent Sessions
2
2
2
10
6
CBT Group Sessions
3
10
10
2
3
2
6
22
14
15
As
needed
As
needed
As
needed
Type of Service
Individual Parent Sessions
Family Sessions/Home Visits
4
Parent Education Sessions
6
Total Formal Sessions
5
12
Case management/
Other Contacts
Total Expected Contacts
5
12
22+
14+
15+
Total Expected Hours
5
12
22+
14+
15+
Total Expected Weeks
6-7
12-13
12-13
12-13
12-13
Source: Diamond et al, 2002
93
Actual Treatment Received by Condition
ACRA and MDFT
both rely on
individual, family and
case
management
And
MDFT
instead
using
moreof group
14
family therapy
With ACRA
using more
11
individual
therapy
23
10
10
5
5
Case
Management
Family
Counseling
Collateral only
Days
Hours
25
FSN adds multi
family group,
family
20 home visits
and more case
MET/CBT12
adds 7 management
more
15 of
sessions
group
Multi-Family
group
Multi-Participant
Group
5
Participant only
0
MET/
CBT5
MET/
CBT12
MET/
CBT12 +
FSN
Incremental Arm
Source: Dennis et al, 2004
MET/
CBT5
ACRA
MDFT
Alternative Arm
94
Average Cost Per Client-Episode of Care
Average Episode Cost ($US) of Treatment
$4,000
$3,500
$3,000
Integrating
|--------------------------------------------Economic Cost-------------------------------------------|-------Director Estimate-----|
family therapy
was
less
Less
than
Less than
$3,495
$3,322
expensive
average
average
adding
forthan
6 weeks
for 12it weeks
$2,500
$1,984
$1,776
$2,000
$1,559
$1,500
$1,126
$1,413
$1,197
$1,000
$500
$-
Source: French et al., 2002
95
Implementation of Evaluation

Over 85% of eligible families agreed to participate

Quarterly follow-up of 94 to 98% of the adolescents from 3to 12-months (88% all five interviews)

Collateral interviews were obtained at intake, 3- and 6months on over 92-100% of the adolescents interviewed

Urine test data were obtained at intake, 3, 6, 30 and 42
months 90-100% of the adolescents who were not
incarcerated or interviewed by phone (85% or more of all
adolescents).

Long term follow-up completed on 90% at 30-months

Self reported marijuana use largely in agreement with
urine test at 30 months (13.8% false negative, kappa=.63)

Good reliability (alphas over .85 on main scales) and
correlations with collateral reports (r=.4 to .7)
Source: Dennis et al, 2002, 2004
96
Adolescent Cannabis Users in CYT were
as or More Severe Than Those in TEDS*
% of A dm issions.
100%
85%
80%
78%
71%
60%
47%
46%
40%
26%
26% 26%
20%
0%
First used
under age
15
D ependence W eekly or
more use at
intake
CYT Outpatient(n=600)
Prior
T reatment
TE DS Outpatient (n=16,480)
* Adolescents w ith m arijuana problem s adm itted to outpatient treatm ent
Source: Tims et al, 2002
97
Demographic Characteristics
100%
83%
80%
62%
55%
60%
40%
50%
30%
17%
15%
20%
0%
Female
Source: Tims et al, 2002
Male
African Caucasian Under 15
American
15 to 16
Single
parent
family
98
Institutional Involvement
100%
87%
80%
62%
60%
47%
40%
25%
20%
0%
In school
Source: Tims et al, 2002
Employed
Current JJ
Involvement
Coming from
Controlled
Environment
99
Patterns of Substance Use
100%
80%
73%
71%
60%
40%
17%
20%
9%
0%
Weekly
Tobacco Use
Source: Tims et al, 2002
Weekly Alcohol Significant Time
Weekly
Cannabis Use
Use
in Controlled
Environment
100
Multiple Problems were the NORM
Self-Reported in Past Year
0%
20%
40%
60%
80% 100%
86%
Any Marijuana Use Disorder
Any Alcohol Use Disorder
Other Substance Use Disorders
Any Internal Disorder
37%
12%
25%
Any External Disorder
61%
Lifetime History of Victimization
60%
Acts of Physical Violence
66%
Any (other) Illegal Activity
83%
Three to Twelve Problems
83%
Source: Dennis et al, 2004
101
Substance Use Severity was
Related to Other Problems
100%
80%
71%
57%
60%
42%
40%
37%
30%
25%
22%
22%
20%
13%
5%
0%
Health Problem
Distress*
* p<.05
Acute Mental
Distress*
Acute
Traumatic
Distress*
Past Year Dependence (n=278)
Source: Tims et al 2002
Attention
Deficit
Hyperactivity
Disorder*
Conduct
Disorder*
Other (n=322)
102
90
Days Abstinent
80
Days Abstinent Per Quarter
90%
80%
Percent in Recovery
70
70%
60
60%
50
50%
40
40%
30
30%
20
20%
10
10%
0
0%
Intake
3
6
9
% in Recovery at the End of the Quarter
CYT Increased Days Abstinent
and Percent in Recovery*
12
*no use, abuse or dependence problems in the past month while in living in the community
Source: Dennis et al., 2004
103
Similarity of Clinical Outcomes
by Conditions
Trial 2
Trial 1
300
50%
280
40%
260
30%
240
20%
But better than the
average for OP in220
ATM (200 days of
200
abstinence)
10%
MET/ CBT5
(n=102)
MET/
CBT12
FSN
(n=102)
MET/ CBT5
(n=99)
ACRA
(n=100)
MDFT
(n=99)
Total Days Abstinent*
269
256
260
251
265
257
Percent in Recovery**
0.28
0.17
0.22
0.23
0.34
0.19
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.12
Source: Dennis et al., 2004
Percent in Recovery .
at Month 12
Total days abstinent
over 12 months
.
Not significantly different
by condition.
0%
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.16
104
Moderate to large differences
in Cost-Effectiveness by Condition
$16
$20,000
$16,000
$12
$12,000
$8
$8,000
$4
$4,000
$0
$0
MET/ CBT5
MET/
CBT12
FSN
MET/ CBT5
ACRA
MDFT
CPDA*
$4.91
$6.15
$15.13
$9.00
$6.62
$10.38
CPPR**
$3,958
$7,377
$15,116
$6,611
$4,460
$11,775
* p<.05 effect size f=0.48
** p<.05, effect size f=0.72
Source: Dennis et al., 2004
Cost per person in recovery
at month 12
Cost per day of abstinence
over 12 months
$20
ACRA did better than
MET/CBT5,
and both did
Trial 2
better than MDFT
MET/CBT5 and
Trial 1
12 did better
than FSN
* p<.05 effect size f=0.22
** p<.05, effect size f=0.78
105
Recovery (CPPR)
Cost Per Person in
Cost Per Person in Recovery at 12 and 30
Months After Intake by CYT Condition
Stability of
Trial 1 (n=299)
MET/CBT-5
findings
$30,000 MET/CBT-5, -12
mixed atand
30 months
ACRA more
Trial 2 (n=297)
ACRA Effect
Largely Sustained
$25,000 cost effective at
$20,000
12 months
$15,000
$10,000
$5,000
$0
MET/ CBT5 MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
CPPR at 30 months**
$6,437
$10,405
$24,725
$27,109
$8,257
$14,222
CPPR at 12 months*
$3,958
$7,377
$15,116
$6,611
$4,460
$11,775
* P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months
** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months
Source: Dennis et al., 2003; forthcoming
Integrated family therapy (MDFT)
was more cost effective than adding
it on top of treatment (FSN) at 30
months
106
Change in Quarterly Costs to Society
(12 months minus Intake)
$30,000
No Significant Difference
by Condition
$25,000
Significant Reduction in
Cost to Society Overall
$30,000
$25,000
$20,000
$20,000
$15,000
$15,000
$10,000
$10,000
$5,000
$5,000
$-
$-
$(5,000)
$(5,000)
$(10,000)
$(10,000)
$(15,000)
$(15,000)
Cond
Site: down
4 sig significantly,
reduction,
Three
sitesxwent
2 sig
Incr,
6 no
dif (low power)
one
went
upsig
significantly
$(20,000)
$(25,000)
MET/
CBT5
MET/
CBT12
Source: Dennis et al., 2004
FSN
MET/
CBT5
$(20,000)
$(25,000)
ACRA MDFT Average
107
Cumulative Recovery Pattern at 30 months
5% Sustained
Recovery
37% Sustained
Problems
19% Intermittent,
currently in
recovery
39% Intermittent,
currently not in
recovery
The Majority of Adolescents
Cycle in and out of Recovery
Source: Dennis et al, forthcoming
108
Environmental Factors are also
the Major Predictors of Relapse
AOD use in the home, family
problems, homelessness, fighting,
victimization, self help group
participation, structure activities
Family
Conflict
-.54
.18
-.13
Family
Cohesion
-.09
Baseline
.32
.77
Recovery
Environment
Risk
.17
.22
.32
.82
.19
Social
Support
-.08
Peer AOD use, fighting,
illegal activity,
treatment, recovery,
vocational activity
The effects of adolescent
treatment are mediated by the
extent to which they lead to
actual changes in the recovery
environment or peer group
Social
Risk
.21
Baseline
.32
Substance
Use
.11
.19
Baseline
.58
.74
.43
SubstanceRelated
Problems
.22
Baseline
Model Fit
CFI=.97 to .99
RMSEA=.04 to .06
Source: Godley et al (2005)
109
Crime/Violence and Substance Problems
Interact to Predict Recidivism
Crime/
Violence
predicted
recidivism
80%
60%
40%
20%
Crime and
Violence
Scale
0%
Knowing both was the
best predictor
Source: CYT & ATM Data
12 month recidivism
100%
Substance
Problem
Scale
Substance Problem
Severity predicted
recidivism
110
100%
80%
Crime/
Violence
predicted
violent
recidivism
60%
40%
20%
Crime and
Violence
Scale
0%
Knowing both was the
best predictor
Source: CYT & ATM Data
12 month recidivism
To violent crime or arrest
Crime/Violence and Substance Problems
Interact to Predict Violent Crime or Arrest
Substance
Problem
Scale
(Intake) Substance
Problem Severity did
not predict violent
recidivism
111
Post Script on CYT

The CYT interventions provide replicable models of brief (1.5 to 3
month) treatments that can be used to help the field maintain
quality while expanding capacity.

While a good start, the CYT interventions were still not an
adequate dose of treatment for the majority of adolescents –
including many who continued to vacillate in and out of recovery
after discharge from CYT.

Descriptive, outcome and economic analyses have been published

All five interventions are currently being used in subsequent
experiments

The MET/CBT5 intervention is currently being replicated in a 38
site study and ACRA will be replicated in a multisite study slated
to be funded next year.

Over 40,000 copies of the CYT manuals have been distributed by
NCADI and as many electronic copies have been distributed by
CD or the website
112
Findings from the
Assertive Continuing Care (ACC)
Experiment

183 adolescents admitted to residential
substance abuse treatment

Treated for 30-90 days inpatient, then
discharged to outpatient treatment

Random assignment to usual continuing care
(UCC) or “assertive continuing care” (ACC)

Over 90% follow-up 3, 6, & 9 months post
discharge
Source: Godley et al 2002, forth coming
Time to Enter Continuing Care and Relapse
after Residential Treatment (Age 12-17)
100%
Percent of Clients
90%
80%
70%
Relapse
60%
50%
Cont.
Care
Admis.
40%
30%
20%
10%
0%
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
114
ACC Enhancements

Continue to participate in UCC

Home Visits

Sessions for adolescent, parents, and together

Sessions based on ACRA manual (Godley, Meyers
et al., 2001)

Case Management based on ACC manual (Godley
et al, 2001) to assist with other issues (e.g., job
finding, medication evaluation)
115
Assertive Continuing Care (ACC)
Hypotheses
Assertive
Continuin
g Care
General
Continuin
g Care
Adherence
Early
Abstinence
Sustained
Abstinence
Relative to UCC, ACC will increase General
Continuing Care Adherence (GCCA)
GCCA (whether due to UCC or ACC) will be
associated with higher rates of early abstinence
Early abstinence will be associated with higher
rates of long term abstinence.
116
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ACC Improved Adherence
Weekly Tx
Weekly 12 step meetings
Relapse prevention*
Communication skills training*
Problem solving component*
Regular urine tests
Meet with parents 1-2x month*
Weekly telephone contact*
Contact w/probation/school
Referrals to other services*
Follow up on referrals*
Discuss probation/school compliance*
Adherence: Meets 7/12 criteria*
Source: Godley et al 2002, forthcoming
UCC
ACC
* p<.05
117
GCCA Improved Early (0-3 mon.) Abstinence
100%
90%
80%
70%
60%
55%
50%
43%
36%
40%
30%
55%
38%
24%
20%
10%
0%
Any AOD (OR=2.16*)
Low (0-6/12) GCCA
Source: Godley et al 2002, forthcoming
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Marijuana (OR=1.98*)
* p<.05
118
Early (0-3 mon.) Abstinence Improved
Sustained (4-9 mon.) Abstinence
100%
90%
80%
73%
69%
70%
59%
60%
50%
40%
30%
20%
19%
22%
22%
10%
0%
Any AOD (OR=11.16*)
Alcohol (OR=5.47*)
Early(0-3 mon.) Relapse
Early (0-3 mon.) Abstainer
Source: Godley et al 2002, forthcoming
Marijuana (OR=11.15*)
* p<.05
119
Post script on ACC

The ACC intervention improved adolescent adherence to the
continuing care expectations of both residential and outpatient
staff; doing so improved the rates of short term abstinence and,
consequently, long term abstinence.

Despite these GAINs, many adolescents in ACC (and more in
UCC) did not adhere to continuing care plans.

The ACC preliminary findings are published and the main
findings are currently under review.

Several CSAT grantees are also seeking to replicate ACC as part
of the Adolescent Residential Treatment (ART) program.

A second ACC experiment is currently under way to evaluate
whether providing contingency management will further improve
outcomes.

The ACC manual is being distributed via the website and the CD
you have been provided.
120
121
Context Circa 1998-99

Few research studies of existing treatment
programs and no published manuals to support
replication for the few studies that were done

Not clear whether research based treatment
protocols were any better than what the better
programs were already doing

The purpose of ATM was to manualize existing
programs that appeared promising, then to
evaluate them using the same measures and
methods as CYT (allowing quasi-experimental
comparisons)
122
Normal Adolescent Development








Biological changes in the body, brain, and hormonal
systems that continue into mid-to-late 20s.
Shift from concrete to abstract thinking.
Improvements in the ability to link causes and
consequences (particularly strings of events over
time).
Separation from a family-based identity and the
development of peer- and individual-based identities.
Increased focus on how one is perceived by peers.
Increasing rates of sensation seeking/trying new
things.
Development of impulse control and coping skills.
Concerns about avoiding emotional or physical
violence.
123
Key Adaptation for Adolescents

Examples need to be altered
to relevant substances,
situations, and triggers




Consequences have to be
altered to things of concern
to adolescents
Co-morbid problems
(mental, trauma, legal) are
the norm and often
predate substance use

Most adolescents do not
recognize their substance
use as a problem and are
being mandated to
treatment
Treatment has to take into
account the multiple
systems (family, school,
welfare, criminal justice)

Less control of life and
recovery environment

Less aftercare and social
support

Complicated staffing needs
All materials need to be
converted from abstract to
concrete concepts
124
Program Evaluation Data
Level of Care
Clinics Adolescents
1+ FU*
Outpatient/ Intensive
Outpatient (OP/IOP)
8
560
96%
Long Term Residential (LTR)**
4
390
98%
Short Term Residential
(STR)**
4
594
97%
Total
16
1544
97%
* Completed follow-up calculated as 1+ interviews over those due-done, with site varying
between 2-4 planned follow-up interviews. Of those due and alive, 89% completed with 2+
follow-ups, 88% completed 3+ and 78% completed 4.
** Both LTR and STR include programs using CD and therapeutic community models
125
Length of Stay Varies by Level of Care
100%
Long Term Residential (median=154 days; n=222)
Percent Still in Treatment
Short Term Residential (median=31 days; n=589)
Outpatient (median= 88 days; n=554)
About half of those in OP
stay 90 or more days
50%
Source:
390
360
330
300
270
240
210
180
150
120
90
60
Over half
the STR say
more than
30 days
30
0
0%
Length of Stay
Adolescent Treatment Model (ATM) Data
126
Adolescents more likely to transfer
100%
Index Episode of Care (median=52 days; n=1380)
Percent Still in Treatment
System Episode of Care (median=73 days; n=1380)
Length of Stay Across Episodes of
care is about 50% longer
50%
390
360
330
300
270
240
210
180
150
120
90
60
30
0
0%
Length of Stay
Source:
Adolescent Treatment Model (ATM) Data
127
Years of Use
Source: Adolescent Treatment Model (ATM) data
128
Patterns of Weekly (13+/90) Use
100
83
80
61
60
72
71
57
56
44
40
29
43
41
29
21
20
14
20
4 1
7
7
4
17
9
0
OP/IOP (n=560)
LTR (n=390)
Weekly use of anything
Weekly Alcohol Use
Weekly Heroin/Opioid Use
13+ Days in Controlled Environment
Source: Adolescent Treatment Model (ATM) data
STR (n=594)
Weekly Marijuana Use
Weekly Crack/Cocaine Use
Weekly Other Drug Use
129
Substance Use Severity
Source: Adolescent Treatment Model (ATM) data
130
Change in Substance Frequency Index
by Level of Care\a
Residential programs start more
severe, go down sharply,
but then come back over time
Note the sharp
“hinge” in outcomes
during the active
phase of AOD
treatment
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
131
Change in Substance Problem Index
by Level of Care\a
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
LTR more
like OP on
symptoms
count
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.132
Percent in Recovery (no past month use or
problems while living in the community)
Longer term
outcomes are
similar on
substance use
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of cares coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
133
Multiple Co-occurring Problems Were the
Norm and Increased with Level of Care
100
88
80
80
60
78
68
70
65
56
44
52
47
43
35
40
21
52
25
44
36
21
20
0
Conduct
Disorder
Outpatient
ADHD
Major
Depressive
Disorder
Generalized
Anxiety
Disorder
Long Term Residential
Traumatic
Stress
Disorder
Any CoOccurring
Disorder
Short Term Residential
Source: CSAT’s Cannabis Youth Treatment (CYT) and Adolescent Treatment Model (ATM),
134
Change in Emotional Problem Index
by Level of Care\a
Note the lack of a hinge;
Effect is generally indirect (via
reduced use) not specific
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.135
Pattern of SA Outcomes is Related to the
Pattern of Psychiatric Multi-morbidity
Number of Past Month
Substance Problems
Multi-morbid Adolescents
start the highest, change the
most, and relapse the most
0
3
6
2+ Co-occurring
1 Co-occurring
No Co-occurring
12
Months Post Intake (Residential only)
Source: Shane et al 2003, PETSA data
136
Broad Range of Past Year Illegal Activity
100
95
93
86
90
80
93
80
74
81
78
69
71
OP/IOP (n=560)
LTR (n=390)
65
70
85
82
81
68
60
50
40
30
20
10
0
Any illegal activity
Drug related crimes
Property crimes
Acts of physical violence
Source: Adolescent Treatment Model (ATM) data
STR (n=594)
Interpersonal crimes
137
Change in Illegal Activity Index
by Level of Care\a
Residential Treatments
have a specific effect
Outpatient Treatments
has an indirect effect
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.138
High Rates of Victimization were the Norm
Source: Adolescent Treatment Model (ATM) data
139
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.
140
How do CHS OP’s high GVS outcomes
compare with other OP programs on average?
Z-Score on Substance Frequency Scale (SFS)
1.00
0.80
0.60
0.40
CYT Total (n=217; d=0.51)
Other programs
serve clients who
have significantly
higher severity
ATM Total (n=284; d=0.41)
CHSOP (n=57; d=0.18)
0.20
0.00
And on average they have
moderate effect sizes even
with high GVS
-0.20
-0.40
-0.60
-0.80
-1.00
Green line is CHS OP’s High GVS adolescents;
they have some initial gains but substantial relapse
Intake
Mon 1-3
Source: CYT and ATM Outpatient Data Set
Mon 4-6
Dennis 2005
Mon 7-9
Mon 10-12
141
Which 5 OP programs did the best with
high GVS adolescents?
The two best were
used with much
higher severity
adolescents and
TDC was not
manualized
Z-Score on Substance Frequency Scale (SFS)
1.00
0.80
0.60
7 Challenges (n=42; d=1.21)
Tucson Drug Court (n=27; d=0.65)
MET/CBT5a (n=34; d=0.62)
MET/CBT5b (n=40; d=0.55)
0.40
FSN/MET/CBT12 (n=34; d=0.53)
0.20
CHSOP (n=57; d=0.18)
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
Next we can check to see if they are
any more similar in severity
Intake
Mon 1-3
Source: CYT and ATM Outpatient Data Set
Mon 4-6
Dennis 2005
Mon 7-9
Mon 10-12
142
Which 5 OP Programs, of similar severity,
did the best with high GVS adolescents?
Z-Score on Substance Frequency Scale (SFS)
1.00
MET/CBT5a (n=34; d=0.62)
0.80
MET/CBT5b (n=40; d=0.55)
Trying MET/CBT5
because it is
stronger, cheaper,
and easier to
implement
0.60
0.40
0.20
FSN/MET/CBT12 (n=34; d=0.53)
Epoch (n=72; d=0.33)
TSAT (n=66; d=0.35)
CHSOP (n=57; d=0.18)
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
Not much improvement and they do
not work quite as well
Intake
Mon 1-3
Source: CYT and ATM Outpatient Data Set
Mon 4-6
Dennis 2005
Currently CHS is doing an
experiment comparing its
regular OP with MET/CBT5
Mon 7-9
Mon 10-12
143
Post script on ATM

The ATM interventions represent a relatively unprecedented
sharing of technology between programs and the rest of the field.

By choosing to use the GAIN instrumentation to facilitate
comparisons to each other and CYT, the ATM investigators
started a movement…over half of the current generation of
studies are being pooled to make a common data set of over 7000
adolescents entering treatment (with follow-up data 3 to 12
months later) that is being used to support research on evidenced
based practice.

Site and multisite level findings from ATM have been published
and more work is under way – including methodological work on
to integrate experimental, quasi-experimental and nonexperimental findings in a meta analytic synthesis.

All of the manuals are published and distributed via website and
the CDs provided.
144
Some Concluding Thoughts
145
A Fearless Appraisal…

We are entering a renaissance of new knowledge in this area, but are
only reaching 1 of 10 in need

Several interventions work, but 2/3 of the adolescents are still having
problems 12 months later

Effectiveness is related to severity, intervention strength,
implementation/adherence, and how assertive we are in providing
treatment

As other therapies have caught up technologically, there is no longer
the clear advantage of family therapy found in early literature reviews

While there have been concerns about the potential iatrogenic effects
of group therapy, the rates do not appear to be appreciably different
from individual or family therapy if it is done well (important since
group tx typically costs less)

Effectiveness was not consistently associated with the amount of
therapy over a short period of time (6-12 weeks) but was related to
longer term continuing care
146
Recommendations for Further Developments…

We need to target the latter phases of treatment to impact the
post-treatment recovery environment and/or social risk
groups that are the main predictors of long term relapse

We need to move beyond focusing on acute episodes of care
to focus on continuing care and a recovery management
paradigm

We need to better understand the impact of involvement in
juvenile justice system and how it can be harnessed to help

More work is need on the use of schools as a location for
providing primary treatment (they have entrée to the
population and appear to be the venue of choice) and
recovery-schools to provide support for those coming out of
residential treatment
147
Common Strategies you can do NOW







Standardize assessment and identify most common
problems
Pool knowledge about what staff have done in the past,
whether it worked, and what the barriers were
Identify system barriers (e.g., criteria to local access case
management, mental health) that could be avoided if
thought of in advance
Identify existing materials that could help and make sure
they are readily available on site
Identify promising strategies for working with the
adolescent, parents, or other providers
Develop a 1-2 page checklist of things to do when this
problem comes up
Identify a more detailed protocol and trainer to address the
problem, then go for a grant to support implementation
148
References
Babor, T. F., Webb, C. P. M., Burleson, J. A., & Kaminer, Y. (2002). Subtypes for classifying adolescents with marijuana use
disorders Construct validity and clinical implications. Addiction, 97(Suppl. 1), S58-S69.
Beutler, L. E. (2000). David and Goliath When empirical and clinical standards of practice meet. American Psychologist, 55,
997-1007.
Buchan, B. J., Dennis, M. L., Tims, F. M., & Diamond, G. S. (2002). Cannabis use: Consistency and validity of self report, onsite urine testing, and laboratory testing. Addiction, 97(Suppl. 1), S98-S108.
Bukstein, O.G., & Kithas, J. (2002) Pharmacologic treatment of substance abuse disorders. In Rosenberg, D., Davanzo, P.,
Gershon, S. (Eds.), Pharmacotherapy for Child and Adolescent Psychiatric Disorders, Second Edition, Revised and Expanded. NY,
NY: Marcel Dekker, Inc.
Dennis, M.L., (2002). Treatment Research on Adolescents Drug and Alcohol Abuse: Despite Progress, Many Challenges
Remain. Connections, May, 1-2,7, and Data from the OAS 1999 National Household Survey on Drug Abuse
Dennis, M.L. (2004). Traumatic victimization among adolescents in substance abuse treatment: Time to stop ignoring the
elephant in our counseling rooms. Counselor, April, 36-40.
Dennis, M.L., & Adams, L. (2001). Bloomington Junior High School (BJHS) 2000 Youth Survey: Main Findings. Bloomington,
IL: Chestnut Health Systems
Dennis, M. L., Babor, T., Roebuck, M. C., & Donaldson, J. (2002). Changing the focus The case for recognizing and treating
marijuana use disorders. Addiction, 97 (Suppl. 1), S4-S15.
Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003). The need for developing and evaluating adolescent
treatment models. In S.J. Stevens & A.R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary
Models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press and 1998 NHSDA.
Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C.,
Hamilton, N., & Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials.
Journal of Substance Abuse Treatment, 27, 197-213.
Dennis, M. L., Godley, S. and Titus, J. (1999). Co-occurring psychiatric problems among adolescents: Variations by treatment,
level of care and gender. TIE Communiqué (pp. 5-8 and 16). Rockville, MD: Substance Abuse and Mental Health Services
Administration, Center for Substance Abuse Treatment.
Dennis, M. L., Perl, H. I., Huebner, R. B., & McLellan, A. T. (2000). Twenty-five strategies for improving the design,
implementation and analysis of health services research related to alcohol and other drug abuse treatment. Addiction, 95, S281S308.
Dennis, M. L. and McGeary, K. A. (1999). Adolescent alcohol and marijuana treatment: Kids need it now. TIE Communiqué
(pp. 10-12). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal
of Substance Abuse Treatment, 28 (2S), S49-S60 .
149
References - continued
Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F., Webb, C., Kaminer, Y., Babor, T., Roebeck, M.
C., Godley, M. D., Hamilton, N., Liddle, H., Scott, C., & CYT Steering Committee. (2002). The Cannabis Youth Treatment (CYT)
experiment Rationale, study design, and analysis plans. Addiction, 97, 16-34..
Dennis, M. L., Titus, J. C., White, M., Unsicker, J., & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN)
Administration guide for the GAIN and related measures. (Version 5 ed.). Bloomington, IL Chestnut Health Systems. Retrieve from
http//www.chestnut.org/li/gain
Dennis, M.L., & White, M.K. (2003). The effectiveness of adolescent substance abuse treatment: a brief summary of studies
through 2001, (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems. [On
line] Available at http://www.drugstrategies.org
Dennis, M. L. and White, M. K. (2004). Predicting residential placement, relapse, and recidivism among adolescents with the
GAIN. Poster presentation for SAMHSA's Center for Substance Abuse Treatment (CSAT) Adolescent Treatment Grantee Meeting;
Feb 24; Baltimore, MD. 2004 Feb.
Diamond, G., Leckrone, J., & Dennis, M. L. (In press). The Cannabis Youth Treatment study: Clinical and empirical
developments. In R. Roffman, & R. Stephens, (Eds.) Cannabis dependence Its nature, consequences, and treatment . Cambridge, UK
Cambridge University Press.
Diamond, G., Panichelli-Mindel, S. M., Shera, D., Dennis, M. L., Tims, F., & Ungemack, J. (in press). Psychiatric syndromes in
adolescents seeking outpatient treatment for marijuana with abuse and dependency in outpatient treatment. Journal of Child and
Adolescent Substance Abuse.
French, M.T., Roebuck, M.C., Dennis, M.L., Diamond, G., Godley, S.H., Tims, F., Webb, C., & Herrell, J.M. (2002). The
economic cost of outpatient marijuana treatment for adolescents: Findings from a multisite experiment. Addiction, 97, S84-S97.
French, M. T., Roebuck, M. C., Dennis, M. L., Diamond, G., Godley, S. H., Liddle, H. A., and Tims, F. M. (2003). Outpatient
marijuana treatment for adolescents Economic evaluation of a multisite field experiment. Evaluation Review,27(4)421-459.
Funk, R. R., McDermeit, M., Godley, S. H., & Adams, L. (2003). Maltreatment issues by level of adolescent substance abuse
treatment The extent of the problem at intake and relationship to early outcomes. Journal of Child Maltreatment, 8, 36-45.
Godley, S. H., Dennis, M. L., Godley, M. D., & Funk, R. R. (2004). Thirty-month relapse trajectory cluster groups among
adolescents discharged from outpatient treatment. Addiction, 99 (s2), 129-139,
Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. (2002). Preliminary outcomes from the assertive
continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment, 23, 21-32.
Godley, S. H., Jones, N., Funk, R., Ives, M., and Passetti, L. L. (2004). Comparing Outcomes of Best-Practice and ResearchBased Outpatient Treatment Protocols for Adolescents. Journal of Psychoactive Drugs, 36, 35-48.
Godley, M. D., Kahn, J. H., Dennis, M. L., Godley, S. H., & Funk, R. R. (2005). The stability and impact of environmental
factors on substance use and problems after adolescent outpatient treatment. Psychology of Addictive Behaviors.
150
References - continued
Hser, Y., Grella, C. E., Hubbard, R. L., Hsieh, S. C., Fletcher, B. W., Brown, B. S., & Anglin, M. D. (2001). An evaluation of
drug treatments for adolescents in four U.S. cities. Archives of General Psychiatry, 58, 689-695.
Lewinsohn, P.M., Hops, H., Roberts, R.E., Seeley, J.R., Andrews, J.A. (1993). Adolescent psychopathology, I: prevalence and
incidence of depression and other DSM-III-R disorders in high school students. J Abn Psychol, 102, 133-144.
Lipsey, M. W. (1997). What can you build with thousands of bricks? Musings on the cumulation of knowledge in program
evaluation. New Directions for Evaluation, 76, 7-23.
National Academy of Sciences (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research.
Washington, DC: National Academy Press.
Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD: Substance
Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics.
Office of Applied Studies (OAS) (1999). Treatment Episode Data Set (TEDS) 1992-1997: National admissions to substance
abuse treatment services. Rockville, MD: Author. [Available online at <http://www.icpsr.umich.edu/SAMHDA>.]
Office of Applied Studies (OAS) (2000). Treatment Episode Data Set (TEDS) 1993-1998: National admissions to substance
abuse treatment services. Rockville, MD: Author. [Available on line at <http://www.icpsr.umich.edu/SAMHDA.html>.]
Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD: Substance
Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics
Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS) retrived from
http://www.samhsa.gov/oas/dasis.htm
Physician Leadership on National Drug Policy (PNLDP, 2002) Adolescent Substance Abuse: A Public Health Priority.
Providence, RI: Brown University. Retrieved from http://www.plndp.org/Physician_Leadership/Resources/resources.html
Shane, P., Jasiukaitis, P., & Green, R. S. (2003). Treatment outcomes among adolescents with substance abuse problems: The
relationship between comorbidities and post-treatment substance involvement. Evaluation and Program Planning, 26, 393-402.
Tims, F. M., Dennis, M. L., Hamilton, N., Buchan, B. J., Diamond, G. S., Funk, R., & Brantley, L. B. (2002). Characteristics and
problems of 600 adolescent cannabis abusers in outpatient treatment . Addiction, 97, 46-57.
Titus, J. C., Dennis, M. L., White, W. L., Scott, C. K., & Funk, R. R. (2003). Gender differences in victimization severity and
outcomes among adolescents treated for substance abuse. Journal of Child Maltreatment, 8, 19-35.
White, M. K., Funk, R., White, W., & Dennis, M. (2003). Predicting violent behavior in adolescent cannabis users The GAINCVI. Offender Substance Abuse Report, 3(5), 67-69.
White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment.
Counselor, 5(2), 24-28.
D. Wright & N. Sathe (2005). State Estimates of Substance Use from the 2002 - 2003 National Survey on Drug Use and Health,
Rockville, MD: OAS, SAMHSA (DHHS Publication No. SMA 05-3989, NSDUH Series H-26).
http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
151