Slide 1

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 2

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 3

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 4

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 5

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 6

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 7

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 8

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 9

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 10

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 11

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 12

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 13

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 14

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 15

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 16

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 17

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 18

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 19

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 20

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 21

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 22

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 23

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 24

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 25

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 26

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 27

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 28

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 29

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 30

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 31

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 32

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 33

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 34

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 35

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 36

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 37

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 38

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 39

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 40

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 41

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 42

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 43

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 44

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 45

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 46

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 47

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 48

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others


Slide 49

Using the GAIN Recommendation and
Referral Summary (GRRS) to Support
Clinical Decision-making
Michael L. Dennis, Ph.D.
Dionna Christian
GAIN Coordinating Center (GCC)
Chestnut Health Systems, Bloomington, IL
Presentation for SAMHSA’s
Center for Substance Abuse Treatment (CSAT)
Adolescent Treatment Grantee meeting,
Baltimore, MD, February 23-25, 2004.

ACKNOWLEDGEMENT
The development of the GAIN Recommendation and Referral Summary was
supported with funds from the Center for Substance Abuse Treatment
(Contract no. 270-2003-00006), Robert Wood Johnson Foundation (Grant
no. 47266), and the National Institute on Alcohol Abuse and Alcoholism
(Grant no. R01 AA10368). It would not have happened without the input
from dozens of grantees (particularly Susan Godley and the staff of Chestnut
Health System’s Bloomington, IL adolescent treatment unit) and additional
hard work of several individual beta testers (who proofread over two dozen
G-RRS against original interviews and made many invaluable suggestions for
improving it) and the grants that sponsored their work, this includes: Lora
Passetti, Matt Orndorff, Jenny Hammond and Bobbie Jo Allen from Chestnut
Health Systems (CSAT grant no TI14456), Doug Smith from University of
Iowa (CSAT grant no TI13354), Alex Kuprion from Seven Counties (CSAT
grant no TI13345), Benjamin Chambers and Wayne Scott from Multnomah
County (RWJF grant no 45054), and Robert Ketterlinus from Philadelphia
Health Management Corporation (CSAT grant no TI14376). The information
and the opinions expressed herein are solely those of the authors and do not
represent official positions of the government, RWJF, or any other
organization. The opinions are those of the author do not reflect official
positions of the government . Available on-line at www.chestnut.org/li/apss

The Progression of
Substance Use Problems

•
•
•
•
•
•
•
•

Multiple Problem Clients
Clinical Disorder
Problem Use
Frequent Use
Bingeing
Opportunistic Use
Experimentation
No Use

Multiple Co-occurring Problems Are the
Norm and Increase
Level
Care
C o-occu rrinwith
g P rob lem
s b y L evelof
of C
are
100

88
80

80

78

68

70

65

56

60
44

52

47

52

44

43

35

36

40
21

25

21

20
0
C onduct
D isorder

O utpatient

ADHD

M ajor

G eneralized

T raum atic

A ny C o-

D epressive

A nxiety

S tress

O ccuring

D isorder

D isorder

D isorder

D isorder

L ong T erm R esidential

S hort T erm R esidential

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies

Severity is Related to Other Problems
100%

80%

71%
57%

60%
42%

37%

40%

30%
22%

20%

25%
13%

22%

5%
0%
Health Problem
Distress*

Acute Mental
Distress*

Acute
Traumatic
Distress*

Abuse/Partial Remission (n=322)
Source: Tims et al 2002

Attention
Deficit
Hyperactivity
Disorder*

Conduct
Disorder*

Past Year Dependence (n=278)
* p<.05

Objectives
1. Provide an overview of how to use the GAIN
Recommendation and Referral Summary (GRRS) to support clinical decision-making.
2. Review procedures of downloading, installing and
customizing the G-RRS
3. Discuss issues in implementing the G-RRS

Part I
Overview of how to use the
GAIN Recommendation and Referral
Summary (G-RRS) to support clinical
decision-making

GAIN
The Global Appraisal of Individual Needs or “GAIN”
is actually a series of standardized instruments designed
to integrate the assessment for both clinical (e.g.,
diagnosis, bio-psycho-social assessment, placement,
and treatment planning) and program evaluation
(needs assessment, clustering, fidelity, outcomes, and
benefit cost) purposes.

CSAT’s

Adolescent Treatment Program
Grantees and Collaborators

CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees

Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees

Main Interpretative Reports
to Support Diagnosis, Placement,
and Treatment Planning
• GAIN Referral and Recommendation
Summary (G-RRS) - Text based narrative in MS
Word designed to be edited and shared with
specialist, clinical staff from other agencies,
insurers and lay people.
• Individual Clinical Profile (ICP) – 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)

G-RRS Organization
1. Presenting Concerns and Identifying Information
2. DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4. Substance Use Diagnoses and Treatment History
(ASAM criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6. Summary Recommendation

General
•
•
•
•

Can use the client name, initials or another term supplied by the
person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The G-RRS comes out in a MS Word Document file (*.doc)
that can be read, edited and saved by most word processing
programs.
The report include three types of prompts identifying areas
where counselors:
1.

•

2.
3.

Often add additional information or comments from other sources of
information
Have to reconcile and finalize potentially conflicting diagnoses
Have to make preliminary treatment planning recommendations

The ICP report parallels the G-RRS and provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.

General - Continued
•

The G-RRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.

•

The G-RRS can only generate reports using the data collected.

•

A G-RRS based on the full (90-120 minute) version of the
GAIN contains more details (e.g., name of school, employer,
probation officer) than a G-RRS based on the core (60-90
minute) version of the GAIN.

•

Sites can add in questions that are not in their core but that they
want to have for the G-RRS.

•

Sites can also remove sections of the report that they do not
want and/or modify some of the labels (e.g., signature lines)

1. Presenting Concerns and
Identifying Information
• Basic demographics (age, race, gender, marital status,
children), appearance/disabilities, source and reason
for referral, current living and vocational status
• Provides fixed coded responses plus the clients
verbatim words (IN CAPS).

• Prompts to add any additional information related to
–
–
–
–
–
–

reason for referral,
custody arrangements,
living situation,
current address,
parents' marital status,
addresses of relevant parents/guardians

• Full version includes

2. DSM-IV/ICD-9 Diagnoses
• Self Reports Based Measures and Codes for
–

Summary of current treatment, medication and
allergies to aid interpretation
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling to
criteria, screening for mood/anxiety disorders, suicide
risk, traumatic distress
Axis 2. Screening for personality disorders by cluster
Axis 3. Lifetime history by ICD-9 area and check for common
drug-health interactions
Axis 4. Traumatic victimization, check for major axis IV biopsycho-social stressors, and checks for other highstress events

Diagnosis – Continued
• Other
– Also reports the additional staff diagnoses reported on
GAIN Diagnosis page
– Ability to document Axis 5 Past year and Past 90 day staff
ratings for GAF, SOFAS, GARF
– Ability to acknowledge other sources of information
– Can collapse, modify or delete diagnoses
– Prompt to reconcile and confirm diagnoses
– ICP the rules why each diagnosis, specifier and rule out was
printed
– The manual lists all diagnoses, specifiers and rule outs that
were checked, including the rules for when they are to be
printed

3. Evaluation Procedure
• Reviews type of administration, environmental
context, ratings of the client’s behaviors during the
meeting, validity concerns and any addition source of
information reported on the GAIN’s diagnosis page.
• Prompt to enter any other sources of information
consulted as part of evaluation (e.g. urine test results,
records, referral letters, family assessments, probation
reports, etc)

4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
• Detailed text narrative age of first use, preferred substance,
substances for which the client perceives a need for treatment
• For each DSM-IV substance use disorder diagnosis (in order of
clinical severity from the S9 grid)
–
–
–
–

Diagnosis and specific symptoms reported in the past month, year
and lifetime
Recency, frequency and peak amount of use
(if collected) the date and amount of last use (required for some
insurance)
Where a class of drugs (e.g., amphetamines), the specific drugs
reported

• A list of other substance used (but for which diagnosistic criteria
are not met) and prompt to add more identified through
biometric (e.g., urine, saliva, hair) testing or collateral reports.
• History of substance abuse treatment, including (if collected) a
detailed treatment history (program, level of care, intake and
discharge date)

5. Placement (ASAM PPC-2R Criteria B)
• Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment

• General
–
–

–
–
–

ICP gives code for why each text statements suggesting the need for a
higher level of care was printed
ICP gives scale scores with triaged ranges (low, moderate, high score)
by areas of ASAM
ICP gives days of behavior and service utilization reported in each
section of the GAIN
GAIN manual lists all statements evaluated
Treatment planning embedded by section

Conceptualization of Treatment
Planning Need for Each ASAM area
Problem Severity

None
Past
Current
Treatment History

None

Past

Current

No Problem

Monitor
(relapse
prevention)

Need for initial or
low invasive
treatment

Monitor
(check
understanding
of problem)

Monitor
(relapse
prevention)

Need for reintervention and
possibly more
intensive treatment

Readiness to
Step down or
Discharge

Responding to
treatment,
Monitor for
discharge

Not responding,
needs more
intensive/ different
treatment

B1. Acute Alcohol/Drug Intoxication
and Withdrawal Potential
• Lifetime history of withdrawal and seizures
• Current (past week) withdrawal scale score and symptoms
endorsed
• Recency of use, with flags on use in the past 48 hours
• Frequency of use, with flags on any daily use (45+/90 days)
and weekly use of opioids (13+/90 days)
• Lifetime history of detoxification and days of
detoxification in the past 90 days.
• Prompt to recommend one of the following:
– Monitor for change in intoxication or withdrawal symptoms,
– Ambulatory detoxification services related to withdrawal,
– Inpatient detoxification services related to current
intoxication and withdrawal.

B2. Biomedical Conditions and Complications
• Overall Health and Pain Assessment (includes allergies)
• Nutrition and Exercise (includes body mass index and eating
disorder behaviors)

• Sexual Activity and Orientation (includes preferences,
activity, and contraceptive use)

• Treatment History for Health Problems (lifetime and past 90
day use of hospitals, emergency rooms, outpatient surgery,
outpatient treatment, and medication; in full, current treatment
duration and provider)

• Prompt to recommend one of the following:

– Monitoring for change physical health (and medication
compliance)
– the following specific accommodations for medical
conditions required to participate in treatment: List out
– a more detailed medical assessment (including nutritional
guidance),
– referral for the following specific medical services: List out.

B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
• Emotional Conditions (internal mental distress scale score,
past 12 month symptoms related to somatic, depression, suicide,
anxiety, or trauma disorders; recency and prevalence of
problems, suicide risk).
• Behavioral Conditions (behavior complexity scale score, past
12 month symptoms related to inattention, hyperactivity, and
conduct disorders; recency and prevalence of problems).
• Arguing and Aggression (past 12 month symptoms of oral and
physical violence; recency and prevalence of problems)

• Illegal Activity and Juvenile Justice Systems Involvement

(lifetime and past 90 day number and type of arrests; recency
and prevalence of being on/in probation, parole, detention, jail,
house arrest, electronic monitoring; current status; prompt to
enter next court date or other important legal system date; receny
and type of illegal activity engaged in during the past year,
prevalence of illegal activity and relationship to substance use).

B3. Continued
• Cognitive Conditions (including Cognitive Impairment Score
at the time of the evaluation, involvement in special education,
and any other observed indications of cognitive impairment or
developmental disabilities)

• Treatment History for Emotional, Behavioral, or Cognitive
Problems (prior diagnoses; lifetime and past 90 day use of
mental hospitals, emergency rooms, outpatient treatment, and
medication; in full, current treatment duration and provider)

• Prompt to recommend one of the following:

– monitoring for change in mental health (and medication
compliance)
– the following specific accommodations for psychological
conditions required to participate in treatment: List out
– a more detailed psychological assessment
– referral for the following specific psychological services:
List out

B4. Readiness to Change
• Perceived pressure to be in treatment and source of
pressure
• Treatment Motivation scale score
• Treatment Resistance scale score
• (if collected) Reasons for Quitting (RFQ) given,
perceived ability to stop (or stay abstinent).
• Note: RFQ typically only used the Personal Feedback
Report is also being used in MET/CBT or other MI
• Prompt to recommend one of the following:

– monitoring for change in readiness for change
– the following assistance to help address treatment
resistance: list out
– individual motivational enhancement sessions
– the following specific services to help maintain motivation
to stay in recovery: list out

B5. Relapse, Continued Use, or
Continued Problem Potential
• List of individual risk factors that predict continued
use/problems or relapse, including
–
–
–
–
–
–

Low self-efficacy to resist
Low problem orientation (i.e., helplessness)
Daily use of anything or weekly use of opioids
Using substances to forget about traumatic memories
First used substances or got drunk under the age of 15
Reporting 3 or more symptoms of dependence/abuse in the
past month
– Continued substance use despite prior treatment

• Prompt to recommend one of the following:
–
–
–
–

monitoring for change in relapse potential
relapse prevention skills groups
increased structure to reduce environmental risks of relapse
the following specific steps to reduce continued use/relapse
potential: list out

B6. Recovery Environment
• Family/Home Environment (including who they live with,
level of clients involvement with parents and own children, use
in the home and time in a controlled environment)
• School and Work Environment (including recency and
prevalence of school and work, problems there in the past 12
months, pattern of grades, income spend on alcohol/drugs and if
collected, the name of school/employer and type of job
• Social Network Environment (For each of above and peers
that they spend most of their social time with, the extent to
which people in living, vocational and social circles were getting
drunk, using drugs, committing illegal activity, fighting,
vocationally engaged, had a treatment history, and considered
themselves in recovery)

• Sources of Social Support (if collected, open-end and closed list)
• Personal Strengths (if collected, open-end and closed list).

B6. Continued
• Spirituality (including religious affliation, strength and
centrality of spiritual believes)

• Satisfaction with Environment (extent satisfied with living
situation, family, sexual partners, work/school, free time
activities, coping/support)
• Victimization (Lifetime history, severity, recency and current
fears about being attached with a weapon, beaten, sexually
abuse, or emotionally abused; Prompt to comment on any
reports/follow-up done)

• Prompt to recommend one of the following:

– monitoring for change in recovery environment
– a residential or more structured treatment setting to
temporarily control environmental risks
– the following specific steps to reduce recovery environment
risks: list out
– the following specific steps to take further advantages of
sources of support/personal strengths: list out

6. Summary Recommendation
• Summary of current systems clients is involved in and
that treatment needs to be be coordinated with
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them.
– comment on need to coordinate care with other treatment or
agencies.

• Signatures
• Staff notes from assessment

Using the ICP to help with the G-RRS
• Identify the criteria on which the diagnosis or
statement is made
• Examining scale scores in a given area to better
understand the severity or what is going on

• Complete breakout of demographics, behaviors,
service utilization
• More detailed information for treatment planning

Individual Clinical Profile (ICP)
Organization
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)

4.
5.
6.
7.

ASAM placement flags
ASAM placement profile worksheet
Behaviors and Service Utilization
Treatment Planning Worksheet (including client and staff
rating or urgency, what the client has asked for help with, and
things that most agencies/accrediting agencies would expect to
be in the treatment plans)
Note – this is an access report, not intended for general
distribution and only reports on data that was collected

[Notes] on why the statements were printed
Notice the
addition of the
conditions why
statement was
printed.
Key:
Tx-treatment
Sx-Symptom
3+ 3 or more
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1

ICP Demographics section
lists out code and all values
Example of CodeResponse label

Gives status even
if none or
negative

Cannot give page
numbers as it
varies by version
– but can jump
directly there in
ABS with
variable name

From Phillip ICP page 3

ICP ASAM Flags bulleted out
Minimal Criteria
for level of care
and basis for
printing the
statement
Red flags
indicating the need
for more services
in the area or a
higher level of
care and the basis
for printing the
statement
Manual has a list
of all statements
evaluated
From Phillip ICP page 5

ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file as
more on purpose,
interpretation, source,
and psychometrics

From Phillip ICP page 6

Simple Behavior/Utilization Measures

Left side gives
behaviors in the
past 90 days
Right side gives
utilization in the
past 90 days
Organized by
Section of the GAIN
Gives page number,
item number
-- skipped,
RF refused
DK don’t know

From Phillip ICP page 9

Help with Treatment Planning
Compares Client
and Staff
Urgency Ratings
Circle Score and
Connect Dots
Specific things
the client has
asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10

X
X
X
X
X
X
X

X

GI Scales and Variable File
• 1000+ page electronic encyclopedia in MS Excel with
documentation for each GAIN scale, subscale, index, created
variable/text statements used in the G-RRS, ICP and our
research to date
• For each variable, documentation includes:
–
–
–
–
–
–
–
–
–
–
–
–
–

Scale/variable name (and any related/earlier versions)
Time Period(s) covered
Section of the GAIN
Question (items, page in full version)
Scale measurement type (Cut-points for triage)
Purpose (s)
Short Description
Interpretation
Supplemental References on source, norms, psychometrics
Comments
GAIN V5 SPSS Syntax:
Prior SPSS Syntax: (if different)
Actual questions (from version 5)

Key Methodological Work Underway
• ASAM placement recommendations based on expert
and statistical models
• Identification of multi-problem clusters or “Code
types”
• Modeling Change over time in relations to the
treatment hinge and the cycle of relapse, treatment reentry and recovery
• Propensity score models to predict outcomes and serve
as a synthetic “average treatment” comparison group

Validity Checks
Currently Available
• Staff ratings of understanding, misrepresentation,
appearance/behaviors during assessment, and
context
• Consistency Reports
• Counts of missing/refused items
• Out of normative responses on time, key items
Additional Scales in the Works
• Inconsistency scale
• Endorsing rare items (faking bad/general severity)
• Not endorsing common items (faking good/a
typical profile)
• Predicting false negative relative to urine tests

Other Computer Generated
Clinical Reports
• GAIN-Q Referral and Recommendation Summary
(GRRS) – text based summary to support preliminary
diagnosis and placement based on the GAIN-Quick
• Personal Feedback Reports (PFR) – text based summary
to support the motivational interviewing component of
MET/CBT based on the GAIN-I or GAIN-Q
• Validity reports to identify areas for clarification and
potential problems
• Other site specific clinical reports (e.g., pre-filling existing
paperwork like a health assessment, TEDS report etc)
• Data elements can be transferred into existing MIS and
used in other reports/systems as well.

GAIN/ABS just part of a
Trans-Enterprise MIS
Appt
Tracking

Service
Logs

Mgmt
Reports

School
MIS

Host MIS

Welfar
e
MIS

Host
Acct
Sys

Assessment
Building
System:

Host
Lab

Evaluato
r or Data
Manager
GRL, Other
Data

GAIN, Screener
And Other
Measures

JJS
MIS

Cross Site
Evaluation

Part II
Downloading and Installing the
G-RRS application
(see Dionna’s presentation)

Part III
Implementing the G-RRS

Implementation Issues
• While many staff will be very excited about
having the G-RRS help them do paper
work, there are several issues that will need
to be resolved on a site-by-site basis.
• We recommend starting with a small team
of people (from multiple agencies if a
complex project) that can try using the GRRS and think through how it interacts with
existing systems, requirements, and policies
during a 4 to 8 week start up phase.

Some Likely Questions
• Who will run the report? (Do they have the necessary
hardware and software?)
• How will the report get to the clinician that needs to
use it?
• How does this clinician get access to the ICP and full
GAIN when they need it?
• Where will the reports be saved (and what security
safeguards are in place to protect documents with
private health information)?
• Does the report need a signature (e.g, from the person
or persons responsible for finalizing the diagnosis,
placement and treatment plans)? If so, who needs to
sign it and by when?
• When does the report need to be in the clinical file?
(How does the report get into the clinical file?)

Some Likely Questions
• Who edits the report/needs training on how to edit the
report?
• Where can the information needed to fill in the
prompts be found? Does the site want to drop or
change the wording of some prompts?
• What parts of the report (if any) should be expanded
or deleted routinely? (If deleted routinely, should they
just be deleted from the template?)
• Who needs to approve implementation of the report?
• Who needs to be notified that the report will be
implemented (e.g., records staff, counselors)?
• Who will be the point person within the site to ask
questions about the G-RRS? (typically a GAIN
trainer, ABS administrator or clinical coordinator).
• See also FAQs in hand out on install G-RRS
applications

Getting Help
• Manuals and forms on line at the Adolescent Program Support Site
(www.chestnut.org/li/apss ) or the generic GAIN
(www.chestnut.org/li/gain ) or ABS (www.chestnut.org/li/abs )
websites.
• For questions related to installing or modifying the G-RRS or ABS in
general, contact our ABS SUPPORT team at [email protected]
or call Dionna Christian at 309-820-3543 ext. 83400.
• For questions on administering the GAIN, specific GAIN items,
interpreting the GAIN, or questions on QA, contact our GAIN
SUPPORT team at [email protected] or call Michelle White at
309-820-3543 ext. 83439.
• For GAIN or ABS license questions, contact Joan Unsicker at
[email protected] or
• 309-820-3543 ext. 83413.
• For GAIN, GRL, WAI or TxSI data submission questions, contact
Melissa Ives at [email protected] or 309-820-3543 ext. 83408.
• For other information or information on holding a future training in
your area, to answer any questions not covered above, or if you have
problems using any of the above contact information, contact Michelle
White at [email protected] or 309-820-3543 ext 83439.

Contact Information
Michael L. Dennis, Ph.D.
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Website: www.chestnut.org/li/GAIN
GAIN Training Coordinator:
Michelle White at 309-827-6026 or mwhite@chestnut
These slides are available from the Adolescent Program Support Site
(www.chestnut.org/li/APSS ) for CSAT/RWJF grantees
and GAIN site (www.chestnut.org/li/gain) for others