The Current Renaissance of Adolescent Treatment

1
The Current Renaissance of Adolescent Treatment

• Michael Dennis, Ph.D.
• Chestnut Health Systems,
• Bloomington, IL
• Presentation at Illinois Adolescent Addiction
  Training Institute, July 16 - July 20
• 2007, Illinois State University, Bloomington
  Illinois. The content of this presentations are
  based on treatment research funded by the
  Center for Substance Abuse Treatment (CSAT),
  Substance Abuse and Mental Health Services
  Administration (SAMHSA) under contract
  270-2003-00006 and several individual grants. The
  opinions are those of the author and do not
  reflect official positions of the consortium or
  government. Available on line at
  www.chestnut.org/LI/Posters or by contacting Joan
  Unsicker at 720 West Chestnut, Bloomington, IL
  61701, phone [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org

2
Goals of this Presentation

1. Epidemiological Course To examine the
   prevalence, course, and consequences of
   adolescent substance use and co-occurring
   disorders and the unmet need for treatment
2. The Treatment System To summarize major trends
   in the adolescent treatment system and the
   variability by state
3. Evidence Based Practice To highlight what it
   takes to move the field towards evidenced-based
   practice related to assessment, treatment,
   program evaluation and planning
4. Treatment Effectiveness To present the findings
   from several recent treatment outcome studies on
   substance abuse treatment research, trauma and
   violence/crime.

3
Part 1 Epidemiological Course To examine the
prevalence, course, and consequences of
adolescent substance use and co-occurring
disorders and the unmet need for treatment
4
Severity of Past Year Substance Use/Disorders
(2002 U.S. Household Population age 12
235,143,246)
Dependence 5
Abuse 4
No Alcohol or
Regular AOD
Drug Use 32
Use 8
Any Infrequent
Drug Use 4
Light Alcohol
Use Only 47
Source 2002 NSDUH
5
Problems Vary by Age
NSDUH Age Groups
Increasing rate of non-users
100
Severity Category
90
No Alcohol or Drug Use
80
70
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
Dependence
0
65
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Source 2002 NSDUH and Dennis et al forthcoming
6
Higher Severity is Associated with Higher Annual
Cost to Society Per Person
4,000
Median (50th percentile)
3,500
3,000
2,500
2,000
1,500
1,000
725
406
500
231
231
0
0
0
No Alcohol or
Light Alcohol
Regular AOD
Any
Dependence
Abuse
Infrequent
Drug Use
Use Only
Drug Use
Use
Source 2002 NSDUH
7
Age of First Use Predicts Dependence an Average
of 22 years Later
100
Under Age 15
90
Aged 15-17
80
Aged 18 or older
71
70
63
62
60
51
48
with 1 Past Year Symptoms
50
45
41
39
37
40
34
30
30
23
20
10
0
Alcohol
Marijuana
Other Drugs
Tobacco
Pop.151,442,082
Pop.176,188,916
Pop.71,704,012
Pop.38,997,916
Tobacco, OR1.3,
Alcohol, OR1.9,
Marijuana, OR1.5,
Other, OR1.5,
Pop.151,442,082
Pop.176,188,916
Pop.71,704,012
Pop.38,997,916
OR1.49
OR2.74
OR2.45
OR2.65
Source Dennis, Babor, Roebuck Donaldson
(2002) and 1998 NHSDA
plt.05
8
Substance Use Careers Last for Decades
1.0
Median of 27 years from first use to 1 years
abstinence
.9
Cumulative Survival
.8
.7
Years from first use to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
30
25
20
15
10
5
0
Source Dennis et al., 2005
9
Substance Use Careers are Longer the Younger the
Age of First Use
Age of 1st Use Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
.6
.5
under 15
.4
15-20
.3
.2
21
.1
0.0
plt.05 (different from 21)
30
25
20
15
10
5
0
Source Dennis et al., 2005
10
Substance Use Careers are Shorter the Sooner
People Get to Treatment
Year to 1st Tx Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
20
.6
.5
.4
.3
10-19
.2
.1
0.0
0-9
plt.05 (different from 20)
30
25
20
15
10
5
0
Source Dennis et al., 2005
11
Treatment Careers Last for Years
1.0
.9
Cumulative Survival
.8
Median of 3 to 4 episodes of treatment over 9
years
.7
Years from first Tx to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
25
20
15
10
5
0
Source Dennis et al., 2005
12
The Growing Incidence of Adolescent Marijuana
Use 1965-2002
Source OAS (2004). Results from the 2003
National Survey on Drug Use and Health National
Findings. Rockville, MD SAMHSA.
http//oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.p
df
13
Importance of Perceived Risk
Risk Availability
Marijuana Use
Source Office of Applied Studies. (2000). 1998
NHSDA
14
Actual Marijuana Risk

• From 1980 to 1997 the potency of marijuana in
  federal drug seizures increased three fold.
• The combination of alcohol and marijuana has
  become very common and appears to be synergistic
  and leads to much higher rates of problems than
  would be expected from either alone.
• Combined marijuana and alcohol users are 4 to 47
  times more likely than non-users to have a wide
  range of dependence, behavioral, school, health
  and legal problems.
• Marijuana and alcohol are the leading substances
  mentioned in arrests, emergency room admissions,
  autopsies, and treatment admissions.

15
Substance Use in the Community
Source Dennis and McGeary (1999) and 1997 NHSDA
16
Consequences of Substance Use
Source Dennis, Godley and Titus (1999) and 1997
NHSDA
17
Need for Treatment ( of 24,753,586 Adolescents
in the U.S. Household Population)
10
15
20
25
0
5
14.9
Tobacco
17.8
Alcohol
10.7
Alcohol Binge
?--------Past Month Use------?
11.5
Any Drug Use
8.1
Marijuana Use
5.7
Any Non-Marijuana Drug Use
8.9
Past Year AOD Dependence or Abuse
Less than 1 in 10 getting treatment
0.7
Any Treatment (From NHSDA)
88 of adolescents are treated in the public
system
0.6
Public Treatment (From TEDS)
Source NSDUH and TEDS (see state level
estimates in appendix)
18
Adolescent AOD Dependence/Abuse
Up 27 from 7 in 1995
Prevalence 6.0 to 8.4 8.5 to 9.0 9.1 to
9.9 10.0 to 14.6 U.S.Avg.8.9 IL8.1
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf ) and Kilpatrick et al, 2000.
19
Unmet Treatment Need Adolescent ( of AOD
Dependence/Abuse without any private/public
treatment)
9 in 10 Untreated
Prevalence 82.4 to 90.1 90.2 to 92.3 92.4 to
94.2 94.3 to 98.0 U.S.Avg.92.2 IL92.5
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf )
20
Summary Points on Epidemiological Course

• Consequences go up as severity increases from use
  to multiple substance use, abuse, and dependence.
• Substance use disorders typically on-set during
  adolescence and last for decades.
• The earlier the age of onset, the longer the
  course of substance use
• The earlier treatment is received, the shorter
  the course of substance use
• Marijuana has become the leading substance
  problem
• Less than 1 in 10 adolescents with substance
  abuse or dependence problems receive treatment
• Over 88 are treated in the public system

21
Part 2 The Treatment System To summarize major
trends in the adolescent treatment system and the
variability by state
22
Adolescent Treatment Admissions have increased
by 61 over the past decade
Source Office of Applied Studies 1992- 2002
Treatment Episode Data Set (TEDS) http//www.samhs
a.gov/oas/dasis.htm
23
Change in Public Sector Admissions
((2003-1993)/1993)
IL Adol Admissions down slightly
Both Cause Consequence
Change Not available -96 to -7 -8 to 33 34 to
116 117 to 337 U.S.Avg.61 IL65
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf )
24
Change in Focal Substances 1993 to 2003
150,000
400
125,000
300
100,000
200
75,000
100
50,000
0
25,000
-100
0
-200
Other\e
Alcohol
1993
Stimulants
Inhalants
Hallucinogens
Cocaine/Crack
Other
Amphetamines
Heroin/Opiates
Marijuana/Hash
2003
Methamphetamines
TEDS Primary, Secondary or Tertiary problem
Source Treatment Episode Data Set (TEDS)
1993-2003.
25
Presenting Substances IL vs. US
Similar on Alcohol
100
90
IL
U.S.
80
70
Lower on other substances
60
50
40
30
20
10
0
Other\e
Alcohol
Stimulants
Inhalants
Hallucinogens
Cocaine/Crack
Amphetamines
Heroin/Opiates
Other
Marijuana/Hash
Methamphetamines
Source Primary, Secondary or Tertiary, from
Treatment Episode Data Set (TEDS) 1993-2003.
26
Change in Referral Sources 1993-2003
90,000
140
JJ referrals have doubled, are 53 of 2003
admissions and driving growth
80,000
120
70,000
100
60,000
80
50,000
40,000
60
30,000
40
20,000
20
10,000
-
0
1993
School
Self/Family
Other
Community
2003
Other SA Tx
Agency
Other Health
Care
Employee/EAP
Juvenile Justice
Change
Source Treatment Episode Data Set (TEDS)
1993-2003.
27
Referral Sources IL vs. US
Higher on Juvenile Justice Referrals
Lower on Agency to Agency Referrals
Source Treatment Episode Data Set (TEDS)
1993-2003.
28
Change in Level of Care
IOP has had the fastest growth
150,000
400
125,000
300
Residential has grown, but slower than expected
100,000
200
75,000
100
50,000
0
25,000
-100
0
-200
Outpatient
Intensive
Detox
Short-term
Long-term
1993
Outpatient
Residential
Residential
2003
Source Treatment Episode Data Set (TEDS)
1993-2003.
29
Level of Care IL vs. US
Source Treatment Episode Data Set (TEDS)
1993-2003.
30
Severity Goes up with Level of Care
STR Higher on Dependence
100
90
80
70
60
50
40
30
20
10
0
Weekly use
First used
Prior Treatment
Case Mix Index (Avg)
Dependence
at intake
under age 15
Outpatient
Intensive Outpatient
Detoxification
Long-term Residential
Short-term Residential
Source Treatment Episode Data Set (TEDS)
1993-2003.
31
Other Characteristics
0
10
20
30
40
50
60
70
80
90
70
Male
58
Caucasian
System dominated by male, white, 15 to 17 year
olds
19
African American
17
Hispanic
6
Other
83
15 to 17 years old
63
9 to 11 yrs education
57
Student
16
Employed
22
Psychological Problems
2
Pregnant at Admission
1
Homeless/Runaway
Source Treatment Episode Data Set (TEDS)
1993-2003.
32
Most Lack of Standardized Assessment for

• Substance use disorders (e.g., abuse, dependence,
  withdrawal), readiness for change, relapse
  potential and recovery environment
• Common mental health disorders (e.g., conduct,
  attention deficit-hyperactivity, depression,
  anxiety, trauma, self-mutilation and suicidality)
• Crime and violence (e.g., inter-personal
  violence, drug related crime, property crime,
  violent crime)
• HIV risk behaviors (needle use, sexual risk,
  victimization)
• Child maltreatment (physical, sexual, emotional)

33
Median Length of Stay is only 50 days
Median Length of Stay

Total
50 days
(61,153 discharges)
Less than 25 stay the 90 days or longer time
recommended by NIDA Researchers
LTR
49 days
(5,476 discharges)
STR
21 days
(5,152 discharges)
Level of Care
Detox
3 days
(3,185 discharges)
IOP
46 days
(10,292 discharges)
Outpatient
59 days
(37,048 discharges)
0
30
60
90
Source Data received through August 4, 2004 from
23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD,
ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies
(OAS 2005). Treatment Episode Data Set (TEDS)
2002. Discharges from Substance Abuse Treatment
Services, DASIS Series S-25, DHHS Publication
No. (SMA) 04-3967, Rockville, MD Substance Abuse
and Mental Health Services Administration.
Retrieved from http//wwwdasis.samhsa.gov/teds02/2
002_teds_rpt_d.pdf .
34
53 Have Unfavorable Discharges
Despite being widely recommended, only 10 step
down after intensive treatment
Source Data received through August 4, 2004 from
23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD,
ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies
(OAS 2005). Treatment Episode Data Set (TEDS)
2002. Discharges from Substance Abuse Treatment
Services, DASIS Series S-25, DHHS Publication
No. (SMA) 04-3967, Rockville, MD Substance Abuse
and Mental Health Services Administration.
Retrieved from http//wwwdasis.samhsa.gov/teds02/2
002_teds_rpt_d.pdf .
35
Summary of Problems in the Treatment System

• The public systems is changing size, referral
  source, and focus often in different directions
  by state
• Major problems are not reliably assessed (if at
  all)
• Less than 50 stay 50 days (7 weeks)
• Less the 25 stay the 3 months recommended by
  NIDA researchers
• Less than half have positive discharges
• After intensive treatment, less than 10 step
  down to outpatient care
• While JJ involvement is common, little is known
  about the rate of initiation after detention

36
Part 3 Evidence Based Practice To highlight
what it takes to move the field towards
evidenced-based practice related to assessment,
treatment, program evaluation and planning
37
Context

• The field is increasingly facing demands from
  payers, policymakers, and the public at large for
  evidence-based practices (EBP) which can
  reliably produce practical and cost-effective
  interventions, therapies and medications that
  will
• reduce risks for initiating drug use among those
  not yet using,
• reduce substance use and its negative
  consequences among those who are abusing or
  dependent, and
• reduce the likelihood of relapse for those who
  are recovering
• NIDA Blue Ribbon Panel on Health Services
  Research
• (see www.nida.nih.gov )

38
General Behavioral Health Practice

• Accumulating evidence indicates that most of the
  theories and approaches that are used within the
  community of practitioners are unsupported by
  empirical evidence of effects
• Various lists of 70 or so proven empirically
  supported therapies (ESTs) have proven to be
  relatively infeasible because they have rarely
  been compared with each other and generally have
  not been tested with the clinically diverse
  samples found in community based settings
• Need for a new method of integrating scientific
  evidence and the realities of practice is called
  for.
• Source Beutler, 2000

39
Problems and Barriers in SA Tx

• People with multiple substance use and multiple
  co-occurring problems are the norm of severity in
  practice, but are often excluded from research
• Individualization of treatment content/duration
  is the norm in practice, but research based
  protocols typically involves fixed
  components/length that are not as appropriate for
  heterogeneous problems
• No treatment is not considered a ethical or
  significant option, practitioners are more
  interested in identifying which of several
  treatments to use for a given type of patient
  but few such studies have been done
• When research practices have been identified,
  they are often not adopted because practitioners
  often lack the appropriate materials, training
  and resources to know when or how to implement
  them

40
Randomized Clinical Trials (RCT) are to Evidence
Based Practice (EBP) like Self-reports are to
Diagnosis

• They are only as good as the questions asked (and
  then only if done in a reliable/valid way)
• They are an efficient and logical place to start
• But they can be limited or biased and need to be
  combined with other information
• Just because the person does not know something
  (or the RCT has not be done), does not mean it is
  not so
• Synthesizing them with other information usually
  makes them better

41
So what does it mean to move the field towards
Evidence Based Practice (EBP)?

• Introducing reliable and valid assessment that
  can be used
• At the individual level to immediately guide
  clinical judgments about diagnosis/severity,
  placement, treatment planning, and the response
  to treatment
• At the program level to drive program evaluation,
  needs assessment, and long term program planning
• Introducing explicit intervention protocols that
  are
• Targeted at specific problems/subgroups and
  outcomes
• Having explicit quality assurance procedures to
  cause adherence at the individual level and
  implementation at the program level
• Having the ability to evaluate performance and
  outcomes
• For the same program over time,
• Relative to other interventions

42
Reoccurring Themes in the Examples

• Severity and specificity of problem subgroup
• Manualized and replicable assessment and
  treatment protocols
• Relative strength of intervention for a specific
  problem
• Adherence and implementation of intervention
• Evaluation of outcomes targeted by the
  intervention (a.k.a., logic modeling)

43
The Current Renaissance of Adolescent Treatment
Research
Feature 1930-1997 1997-2006
Tx Studies 16 Over 200
Random/Quasi 9 Over 56
Tx Manuals 0 30
QA/Adherence Rare Common
Std Assessment Rare Common
Participation Rates Under 50 Over 80
Follow-up Rates 40-50 85-95
Methods Descriptive/Simple More Advanced
Economic Some Cost Cost, CEA, BCA
Published and publicly available
44
Adolescent Treatment Research Currently Being
Published

• 1994-2000 NIDAs Drug Abuse Treatment Outcome
  Study of Adol. (DATOS-A)
• 1995-1997 Drug Abuse Treatment Outcome Study
  (DOMS)
• 1997-2000 CSATs Cannabis Youth Treatment (CYT)
  experiments
• 1998-2003 NIAAA/CSATs 15 individual research
  grants
• 1998-2003 CSATs 10 Adolescent Treatment Models
  (ATM)
• 2000-2003 CSATs Persistent Effects of Treatment
  Study (PETS-A)
• 2002-2007 CSATs 12 Strengthening Communities for
  Youth (SCY)
• 2002-2007 RWJFs 10 Reclaiming Futures (RF)
  diversion projects
• 2002-2007 CSATs 12 Targeted Capacity Expansion
  TCE/HIV
• 2003-2009 NIDAs 14 individual research grants
  and CTN studies
• 2003-2006 CSATs 17 Adolescent Residential
  Treatment (ART)
• 2003-2008 NIDAs Criminal Justice Drug Abuse
  Treatment Study (CJ-DATS)
• 2003-2007 CSATs 38 Effective Adolescent
  Treatment (EAT)
• 2004-2007 NIAAA/CSATs study of diffusion of
  innovation
• 2004-2009 CSAT 22 Young Offender Re-entry
  Programs (YORP)
• 2005-2008 CSAT 20 Juvenile Drug Court (JDC)
• 2005-2008 CSAT 16 State Adolescent Coordinator
  (SAC) grants
• 2006-2010 CSAT 33 Adolescent Assertive Family
  Treatment

45
GAIN Clinical Collaborators Adolescent and Adult
Treatment Program
DC
7/07
46
CSAT Adolescent Treatment (AT)Outcome Data Set

• Recruitment 1998-2006 (updated annually)
• Sample The 2006 CSAT adolescent treatment data
  set included data with 1 to 4 follow-ups on
  12,690 adolescents from 96 local evaluations
• Levels of Care Early Intervention, Outpatient,
  Intensive Outpatient, Short, Moderate Long term
  Residential, Corrections Based and Post
  Residential Outpatient Continuing Care
• Instrument Global Appraisal of Individual Needs
  (GAIN) (see www.chestnut.org/li/gain)
• Follow-up Over 80 follow-up 3, 6, 9 12 months
  post intake
• Funding CSAT contract 270-2003-00006 and 72
  individual grants

47
Current CSAT AT Outcome Data Set by Grant Program
DC Drug Court (2005-2009 524 from 6 grants)
CYT Cannabis Youth Treatment (1997-2001 600
from 4 grants)
YORP Young Offender Re-entry Project (2004-2008
524 from 14 grants)
ATM Adolescent Treatment Model (1998-2002
1,429 from 10 grants)
SCY Strengthening Communities-Youth
(2002-2007 2,292 from 11 grants)
EAT Effective Adolescent Treatment (2003-2007
5,255 from 27 grants)
TCE Other Targeted Capacity Expansion
(2002-2009 523 from 8 grant)

ART Adolescent Residential Treatment (2003-2006
1,899 from 16 grants)
Source CSAT 2006 AT Outcome Data Set (n12,601)
48
Level of Care (n12,601)
Source CSAT 2006 AT Outcome Data Set (n12,601)
49
Type of Treatment (n12,601)
Data Prior to current AAFT program
replicating A-CRA
Source CSAT 2006 AT Outcome Data Set (n12,601)
50
Demographics
Source CSAT 2006 AT Outcome Data Set (n12,601)
51
Recovery Environment
Source CSAT 2006 AT Outcome Data Set (n12,601)
52
Past 90 day HIV Risk Behaviors
Source CSAT 2006 AT Outcome Data Set (n12,601)
53
Weekly or More Often Use in the Past 90 Days
Source CSAT 2006 AT Outcome Data Set (n12,601)
54
Substance Use Problems
Source CSAT 2006 AT Outcome Data Set (n12,601)
55
Co-Occurring Psychiatric Problems
Source CSAT 2006 AT Outcome Data Set (n12,601)
56
Past Year Violence Crime
Dealing, manufacturing, prostitution, gambling
(does not include simple possession or
use) Source CSAT 2006 AT Outcome Data Set
(n12,601)
57
Intensity of Juvenile Justice System Involvement
Source CSAT 2006 AT Outcome Data Set (n12,601)
58
Relationship of Level of Care to theNumber of
Major Clinical Problems
Source CSAT 2006 AT Outcome Data Set
(n12,601) Odds Ratio (OR) of having 5 of 12
problems (Alcohol, cannabis, or other drug
disorder, depression, anxiety, trauma, suicide,
ADHD, CD, victimization, violence/ illegal
activity)
59
Relationship of Victimization to theNumber of
Major Clinical Problems
Source CSAT 2006 AT Outcome Data Set
(n12,601) Odds Ratio (OR) of having 5 of 12
problems (Alcohol, cannabis, or other drug
disorder, depression, anxiety, trauma, suicide,
ADHD, CD, victimization, violence/ illegal
activity)
60
Treatment Outcomes by Level of Care Days of AOD
Abstinence
Percentages in parentheses are the treatment
outcome (intake to 12 month change) and the
stability of the outcomes (3months to 12 month
change) Source CSAT 2006 AT Outcome Data Set
(n12,601)
61
Treatment Outcomes by Level of Care Recovery
Recovery defined as no past month use, abuse,
or dependence symptoms while living in the
community. Percentages in parentheses are the
treatment outcome (intake to 12 month change) and
the stability of the outcomes (3months to 12
month change) Source CSAT 2006 AT Outcome Data
Set (n12,601)
62
Regular Outpatient vs. Evidenced Based Practices
from CYT Days Abstinent
Percentages in parentheses are the treatment
outcome (intake to 12 month change) and the
stability of the outcomes (3months to 12 month
change) Source CSAT 2007 AT Outcome Data Set
(n8,902 adolescents in outpatient)
63
What are the pitfalls of EBP?

• EBP generally causes some staff turnover
• EBP often shines a light on staff or work place
  problems that would otherwise be ignored
• EBP often impact a wide range of existing
  procedures and policies requiring modification
  and provoking resistance
• EBP (and most organizational changes) will fail
  without good senior staff leadership
• EBP typically require going for more funds from
  grant or other funders
• On-going needs assessment will create demand for
  more change and more EBP

64
Summary of Evidenced Based Practice Section

• Achieving reliable outcomes requires reliable
  measurement, protocol delivery and on-going
  performance monitoring.
• The GAIN is one measure that is being widely used
  by CSAT grantees and others trying to address
  gaps in current knowledge and move the field
  towards evidenced based practice.
• Standardized and more specific assessment helps
  to draw out treatment planning implications of
  readiness for change, recovery environment,
  relapse potential, psychopathology,
  crime/violence, and HIV risks.
• Adolescents entering more intensive levels of
  care typically have higher severity.
• Multiple problems and child maltreatment are the
  norm and are closely related to each other.
• The GAIN is one of a growing number of
  standardized assessment tools, treatment
  protocols and other resources available to
  support evidenced based practices.

65
Part 4 Treatment Effectiveness To present the
findings from several recent treatment outcome
studies on substance abuse treatment research,
trauma and violence/crime.
66
CYT
Cannabis Youth Treatment Randomized Field Trial
Coordinating Center Chestnut Health Systems,
Bloomington, IL, and Chicago, IL University
of Miami, Miami, FL University of Conn. Health
Center, Farmington, CT
Sites Univ. of Conn. Health Center, Farmington,
CT Operation PAR, St. Petersburg, FL Chestnut
Health Systems, Madison County, IL Childrens
Hosp. of Philadelphia, Phil. ,PA
Sponsored by Center for Substance Abuse
Treatment (CSAT), Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services
67
Context Circa 1997

• Cannabis had become more potent, was associated
  with a wide of problems (particularly when
  combined with alcohol), and had become the
  leading substances mentioned in arrests,
  emergency room admissions, autopsies, and
  treatment admissions (doubling in in 5 years)
• Over 80 of adolescents with Cannabis problems
  were being seen in outpatient setting
• The median length of stay was 6 weeks, with only
  25 making it 3 months
• There were no published manuals targeting
  adolescent marijuana users in outpatient
  treatment
• The purpose of CYT was to manualize five
  promising protocols, field test their relative
  effectiveness, cost, and benefit-cost and provide
  them to the field

Source Dennis et al, 2002
68
Two Effectiveness Experiments
Trial 2
Trial 1
Incremental Arm
Alternative Arm
Source Dennis et al, 2002
69
Contrast of the Treatment Structures
Individual Adolescent Sessions
CBT Group Sessions
Individual Parent Sessions
Family Sessions/Home Visits
Parent Education Sessions
Total Formal Sessions
Case management/ Other Contacts
Total Expected Contacts
Total Expected Hours
Total Expected Weeks
Source Diamond et al, 2002
70
Actual Treatment Received by Condition
ACRA and MDFT both rely on individual, family and
case management instead of group
FSN adds multi family group, family home visits
and more case management
And MDFT using more family therapy
MET/CBT12 adds 7 more sessions of group
With ACRA using more individual therapy
Source Dennis et al, 2004
71
Average Episode Cost (US) of Treatment
--------------------------------------------Econo
mic Cost------------------------------------------
--------- Director Estimate-----
4,000
3,322
3,500
3,000
2,500
Average Cost Per Client-Episode of Care
1,984
2,000
1,559
1,413
1,500
1,197
1,126
1,000
500
-
ACRA (12.8 weeks)
MET/CBT5 (6.8 weeks)
MET/CBT5 (6.5 weeks)
MET/CBT12 (13.4 weeks)
FSN (14.2 weeks w/family)
MDFT(13.2 weeks w/family)
Source French et al., 2002
72
Implementation of Evaluation

• Over 85 of eligible families agreed to
  participate
• Quarterly follow-up of 94 to 98 of the
  adolescents from 3- to 12-months (88 all five
  interviews)
• Collateral interviews were obtained at intake, 3-
  and 6-months on over 92-100 of the adolescents
  interviewed
• Urine test data were obtained at intake, 3, 6, 30
  and 42 months 90-100 of the adolescents who were
  not incarcerated or interviewed by phone (85 or
  more of all adolescents).
• Long term follow-up completed on 90 at 30-months
  
• Self reported marijuana use largely in agreement
  with urine test at 30 months (13.8 false
  negative, kappa.63)
• Good reliability (alphas over .85 on main scales)
  and correlations with collateral reports (r.4 to
  .7)

Source Dennis et al, 2002, 2004
73
Adolescent Cannabis Users in CYT were as or More
Severe Than Those in TEDS
Source Tims et al, 2002
74
Demographic Characteristics
Source Tims et al, 2002
75
Institutional Involvement
100
87
80
62
60
47
40
25
20
0
In school
Employed
Current JJ
Coming from
Involvement
Controlled
Environment
Source Tims et al, 2002
76
Patterns of Substance Use

100
73
80
71
60
40
17
20
9
0
Weekly Alcohol
Weekly
Weekly
Significant Time
Tobacco Use
Cannabis Use
Use
in Controlled
Environment
Source Tims et al, 2002
77
Multiple Problems were the NORM
Self-Reported in Past Year
Source Dennis et al, 2004
78
Substance Use Severity was Related to Other
Problems
100
80
71
57
60
42
37
40
30
25
22
22
20
13
5
0
Health Problem
Acute Mental
Acute
Attention
Conduct
Distress
Distress
Traumatic
Deficit
Disorder
Distress
Hyperactivity
Disorder
Past Year Dependence (n278)
Other (n322)
plt.05
Source Tims et al 2002
79
CYT Increased Days Abstinent and Percent in
Recovery
90
90
Days Abstinent
80
80
Percent in Recovery
70
70
60
60
50
50
Days Abstinent Per Quarter
in Recovery at the End of the Quarter
40
40
30
30
20
20
10
10
0
0
Intake
3
6
9
12
no use, abuse or dependence problems in the past
month while in living in the community
Source Dennis et al., 2004
80
Similarity of Clinical Outcomes by Conditions
Not significantly different by condition.
Trial 1
Trial 2
300
50
.
280
40
.
260
30
over 12 months
at Month 12
Total days abstinent
Percent in Recovery
240
20
220
10
200
0
MET/ CBT5
MET/
FSN
MET/ CBT5
ACRA
MDFT
(n102)
CBT12
(n102)
(n99)
(n100)
(n99)
269
256
260
251
265
257
Total Days Abstinent
0.28
0.17
0.22
0.23
0.34
0.19
Percent in Recovery
n.s.d., effect size f0.06
n.s.d., effect size f0.06
n.s.d., effect size f0.12
n.s.d., effect size f0.16
Source Dennis et al., 2004
81
Moderate to large differences in
Cost-Effectiveness by Condition
Trial 2
Trial 1
20
20,000
16
16,000
12
12,000
Cost per person in recovery
at month 12
over 12 months
Cost per day of abstinence
8
8,000
4
4,000
0
0
MET/
MET/ CBT5
FSN
MET/ CBT5
ACRA
MDFT
CBT12
4.91
6.15
15.13
9.00
6.62
10.38
CPDA
CPPR
3,958
7,377
15,116
6,611
4,460
11,775
plt.05 effect size f0.48
plt.05 effect size f0.22
plt.05, effect size f0.72
plt.05, effect size f0.78
Source Dennis et al., 2004
82
Cost Per Person in Recovery at 12 and 30 Months
After Intake by CYT Condition

Trial 1 (n299)
Trial 2 (n297)
Cost Per Person in Recovery (CPPR)
30,000
ACRA Effect Largely Sustained
25,000
20,000
15,000
10,000
5,000
0
MET/ CBT5
MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
6,437
10,405
24,725
27,109
8,257
14,222
CPPR at 30 months
3,958
7,377
15,116
6,611
4,460
11,775
CPPR at 12 months
Plt.0001, Cohens f 1.42 and 1.77 at 12
months Plt.0001, Cohens f 0.76 and 0.94 at 30
months
Source Dennis et al., 2003 forthcoming
83
Change in Quarterly Costs to Society(12 months
minus Intake)
30,000
30,000
25,000
25,000
20,000
20,000
15,000
15,000
10,000
10,000
5,000
5,000
-
-
(5,000)
(5,000)
(10,000)
(10,000)
(15,000)
(15,000)
Cond x Site 4 sig reduction, 2 sig Incr, 6 no
sig dif (low power)
(20,000)
(20,000)
Three sites went down significantly, one went up
significantly
(25,000)
(25,000)
MET/
MET/
FSN
MET/
ACRA
MDFT
Average
CBT5
CBT12
CBT5
Source Dennis et al., 2004
84
Cumulative Recovery Pattern at 30 months
5 Sustained
Recovery
37 Sustained
19 Intermittent,
Problems
currently in
recovery
39 Intermittent,
currently not in
recovery
The Majority of Adolescents Cycle in and out of
Recovery
Source Dennis et al, forthcoming
85
Environmental Factors are also the Major
Predictors of Relapse
AOD use in the home, family problems,
homelessness, fighting, victimization, self help
group participation, structure activities
Baseline
Family
.32
.77
.18
Conflict
Recovery
Environment
-.54
Risk
-.13
.17
.58
.74
Family
.22
.32
Substance-
-.09
Cohesion
Substance
.43
Related
Use
Problems
.32
.82
.19
.11
Social
Social
.19
-.08
.22
Support
Risk
Baseline
Baseline
Model Fit CFI.97 to .99 RMSEA.04 to .06
.21
Peer AOD use, fighting, illegal activity,
treatment, recovery, vocational activity
Baseline
Source Godley et al (2005)
86
Crime/Violence and Substance Problems Interact
to Predict Recidivism
12 month recidivism
100
80
60
40
20
Crime and Violence Scale
Substance Problem Scale
0
High
High
Mod.
Mod.
Low
Low
Source CYT ATM Data
87
Crime/Violence and Substance Problems Interact
to Predict Violent Crime or Arrest
12 month recidivism To violent crime or arrest
Crime and Violence Scale
Substance Problem Scale
High
High
Mod.
Mod.
(Intake) Substance Problem Severity did not
predict violent recidivism
Low
Low
Source CYT ATM Data
88
Post Script on CYT

• The CYT interventions provide replicable models
  of brief (1.5 to 3 month) treatments that can be
  used to help the field maintain quality while
  expanding capacity.
• While a good start, the CYT interventions were
  still not an adequate dose of treatment for the
  majority of adolescents including many who
  continued to vacillate in and out of recovery
  after discharge from CYT.
• Descriptive, outcome and economic analyses have
  been published
• All five interventions are currently being used
  in subsequent experiments
• The MET/CBT5 intervention has just been
  replicated in a 38 site study and ACRA is
  currently being replicated in a 33 site study.
• Over 60,000 copies of the CYT manuals have been
  distributed by NCADI and as many electronic
  copies have been distributed by CD or the website

89
(No Transcript)
90
Context Circa 1998-99

• Few research studies of existing treatment
  programs and no published manuals to support
  replication for the few studies that were done
• Not clear whether research based treatment
  protocols were any better than what the better
  programs were already doing
• The purpose of ATM was to manualize existing
  programs that appeared promising, then to
  evaluate them using the same measures and methods
  as CYT (allowing quasi-experimental comparisons)

91
Normal Adolescent Development

• Biological changes in the body, brain, and
  hormonal systems that continue into mid-to-late
  20s.
• Shift from concrete to abstract thinking.
• Improvements in the ability to link causes and
  consequences (particularly strings of events over
  time).
• Separation from a family-based identity and the
  development of peer- and individual-based
  identities.
• Increased focus on how one is perceived by peers.
• Increasing rates of sensation seeking/trying new
  things.
• Development of impulse control and coping skills.
• Concerns about avoiding emotional or physical
  violence.

92
Key Adaptation for Adolescents

• Examples need to be altered to relevant
  substances, situations, and triggers
• Consequences have to be altered to things of
  concern to adolescents
• Most adolescents do not recognize their substance
  use as a problem and are being mandated to
  treatment
• All materials need to be converted from abstract
  to concrete concepts

• Co-morbid problems (mental, trauma, legal) are
  the norm and often predate substance use
• Treatment has to take into account the multiple
  systems (family, school, welfare, criminal
  justice)
• Less control of life and recovery environment
• Less aftercare and social support
• Complicated staffing needs

93
Program Evaluation Data
Level of Care Clinics Clinics Adolescents 1 FU
Outpatient/ Intensive Outpatient (OP/IOP) Outpatient/ Intensive Outpatient (OP/IOP) 8 560 96
Long Term Residential (LTR) Long Term Residential (LTR) 4 390 98
Short Term Residential (STR) Short Term Residential (STR) 4 594 97
Total Total 16 1544 97
Completed follow-up calculated as 1
interviews over those due-done, with site varying
between 2-4 planned follow-up interviews. Of
those due and alive, 89 completed with 2
follow-ups, 88 completed 3 and 78 completed
4. Both LTR and STR include programs using CD
and therapeutic community models
94
Length of Stay Varies by Level of Care
100
Long Term Residential (median154 days n222)
Short Term Residential (median31 days n589)
Outpatient (median 88 days n554)
About half of those in OP stay 90 or more days
50
Percent Still in Treatment
0
0
30
60
90
120
150
180
210
240
270
300
330
360
390
Over half the STR say more than 30 days
Length of Stay
Source Adolescent Treatment Model (ATM) Data
95
Adolescents more likely to transfer
Source Adolescent Treatment Model (ATM) Data
96
Change in Substance Frequency Indexby Level of
Care\a
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t
for time effect, \s for site effect, and \ts for
time x site effect.
97
Change in Substance Problem Indexby Level of
Care\a
LTR more like OP on symptoms count
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
98
Percent in Recovery (no past month use or
problems while living in the community)
Longer term outcomes are similar on substance use
\a Source Adolescent Treatment Model (ATM)
data Levels of cares coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t
for time effect, \s for site effect, and \ts for
time x site effect.
99
Change in Emotional Problem Indexby Level of
Care\a
Note the lack of a hinge Effect is generally
indirect (via reduced use) not specific
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
100
Pattern of SA Outcomes is Related to the Pattern
of Psychiatric Multi-morbidity
2 Co-occurring 1 Co-occurring
No Co-occurring
Multi-morbid Adolescents start the highest,
change the most, and relapse the most
Number of Past Month Substance Problems
0
6
12
3
Months Post Intake (Residential only)
Source Shane et al 2003, PETSA data
101
Change in Illegal Activity Indexby Level of
Care\a
Residential Treatments have a specific effect
Outpatient Treatments has an indirect effect
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
102
High Rates of Victimization were the Norm
Source Adolescent Treatment Model (ATM) data
103
Victimization and Level of Care Interact to
Predict Outcomes
CHS Outpatient
CHS Residential
40
35
30
25
Marijuana Use (Days of 90)
20
15
10
5
0
Intake
6 Months
Intake
6 Months
OP -High
OP - Low/Mod
Resid-High
Resid - Low/Mod.
Source Funk, et al., 2003
104
How do CHS OPs high GVS outcomes compare with
other OP programs on average?
1.00
CYT Total (n217 d0.51)
0.80
0.60
ATM Total (n284 d0.41)
0.40
CHSOP (n57 d0.18)
0.20
Z-Score on Substance Frequency Scale (SFS)
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
Source CYT and ATM Outpatient Data Set
Dennis 2005
105
Which 5 OP programs did the best with high GVS
adolescents?
1.00
0.80
0.60
0.40
0.20
Z-Score on Substance Frequency Scale (SFS)
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
Source CYT and ATM Outpatient Data Set
Dennis 2005
106
Which 5 OP Programs, of similar severity, did
the best with high GVS adolescents?
1.00
0.80
0.60
0.40
0.20
CHSOP (n57 d0.18)
Z-Score on Substance Frequency Scale (SFS)
0.00
-0.20
-0.40
-0.60
Currently CHS is doing an experiment comparing
its regular OP with MET/CBT5
-0.80
-1.00
Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
Source CYT and ATM Outpatient Data Set
Dennis 2005
107
Post script on ATM

• The ATM interventions represent a relatively
  unprecedented sharing of technology between
  programs and the rest of the field.
• By choosing to use the GAIN instrumentation to
  facilitate comparisons to each other and CYT, the
  ATM investigators started a movementover half of
  the current generation of studies are being
  pooled to make a common data set of over 7000
  adolescents entering treatment (with follow-up
  data 3 to 12 months later) that is being used to
  support research on evidenced based practice.
• Site and multisite level findings from ATM have
  been published and more work is under way
  including methodological work on to integrate
  experimental, quasi-experimental and
  non-experimental findings in a meta analytic
  synthesis.
• All of the manuals are published and distributed
  via website and the CDs provided.

108
Findings from the Assertive Continuing Care
(ACC) Experiment

• 183 adolescents admitted to residential substance
  abuse treatment
• Treated for 30-90 days inpatient, then discharged
  to outpatient treatment
• Random assignment to usual continuing care (UCC)
  or assertive continuing care (ACC)
• Over 90 follow-up 3, 6, 9 months post
  discharge

Source Godley et al 2002, forth coming
109
Time to Enter Continuing Care and Relapse after
Residential Treatment (Age 12-17)
100
90
80
70
Relapse
60
Percent of Clients
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source Godley et al., 2004 for relapse and 2000
Statewide Illinois DARTS data for CC admissions
110
ACC Enhancements

• Continue to participate in UCC
• Home Visits
• Sessions for adolescent, parents, and together
• Sessions based on ACRA manual (Godley, Meyers et
  al., 2001)
• Case Management based on ACC manual (Godley et
  al, 2001) to assist with other issues (e.g., job
  finding, medication evaluation)

111
Assertive Continuing Care (ACC)Hypotheses
Assertive Continuing Care
112
ACC Improved Adherence
100
20
30
10
40
50
60
70
80
90
0
Weekly
Tx
Weekly 12 step meetings
Relapse prevention
Communication skills training
Problem solving component
Regular urine tests
Meet with parents 1-2x month
Weekly telephone contact
Contact w/probation/school
Referrals to other services
Follow up on referrals
Discuss probation/school compliance
Adherence Meets 7/12 criteria
Source Godley et al 2002, forthcoming
113
GCCA Improved Early (0-3 mon.) Abstinence
100
90
80
70
60
50
38
36
40
30
24
20
10
0
Any AOD (OR2.16)
Alcohol (OR1.94)
Marijuana (OR1.98)
Low (0-6/12) GCCA
Source Godley et al 2002, forthcoming
114
Early (0-3 mon.) Abstinence Improved Sustained
(4-9 mon.) Abstinence
100
90
80
70
60
50
40
30
22
22
19
20
10
0
Any AOD (OR11.16)
Alcohol (OR5.47)
Marijuana (OR11.15)
Early(0-3 mon.) Relapse
Source Godley et al 2002, forthcoming
115
Post script on ACC

• The ACC intervention improved adolescent
  adherence to the continuing care expectations of
  both residential and outpatient staff doing so
  improved the rates of short term abstinence and,
  consequently, long term abstinence.
• Despite these GAINs, many adolescents in ACC (and
  more in UCC) did not adhere to continuing care
  plans.
• The ACC preliminary findings are published and
  the main findings are currently under review.
• Several CSAT grantees are also seeking to
  replicate ACC as part of the Adolescent
  Residential Treatment (ART) program.
• A second ACC experiment is currently under way to
  evaluate whether providing contingency management
  will further improve outcomes.
• The ACC manual is being distributed via the
  website and the CD you have been provided.

116
Meta Analysis of the Effectiveness of Programs
for Juvenile Offenders

• 
  N of
• Offender Sample Studies
• Preadjudication (prevention) 178
• Probation 216
• Institutionalized 90
• Aftercare 25
• Total 509

Source Adapted from Lipsey, 1997, 2005
117
Most Programs are actually a mix of components

• Average of 5.6 components distinguishable in
  program descriptions from research reports

Intensive supervision Prison visit Restitution Com
munity service Wilderness/Boot camp Tutoring Indiv
idual counseling Group counseling Family
counseling Parent counseling Recreation/sports Int
erpersonal skills
Anger management Mentoring Cognitive
behavioral Behavior modification Employment
training Vocational counseling Life
skills Provider training Casework Drug/alcohol
therapy Multimodal/individual Mediation
Source Adapted from Lipsey, 1997, 2005
118
Most programs have small effectsbut those
effects are not negligible

• The median effect size (.09) represents a
  reduction of the recidivism rate from .50 to .46
• Above that median, most of the programs reduce
  recidivism by 10 or more
• One-fourth of the studies show recidivism
  reductions of 30 or more, that is, a recidivism
  rate of .35 or less for the treatment group
  compared to .50 for the control group
• The nothing works claim that rehabilitative
  programs for juvenile offenders are ineffective
  is false

Source Adapted from Lipsey, 1997, 2005
119
Major Predictors of Bigger Effects

• Chose a strong intervention protocol based on
  prior evidence
• Used quality assurance to ensure protocol
  adherence and project implementation
• Used proactive case supervision of individual
• Used triage to focus on the highest severity
  subgroup

120
Impact of the numbers of Favorable features on
Recidivism (509 JJ studies)
Usual Practice has little or no effect
Source Adapted from Lipsey, 1997, 2005
121
Some Programs Have Negative or No Effects on
recidivism

• Scared Straight and similar shock incarceration
  program
• Boot camps mixed had bad to no effect
• Routine practice had no or little (d.07 or 6
  reduction in recidivism)
• Similar effects for minority and white (not
  enough data to comment on males vs. females)
• The common belief that treating anti-social
  juveniles in groups would lead to more
  iatrogenic effects appears to be false on
  average (i.e., relapse, violence, recidivism for
  groups is no worse then individual or family
  therapy)

Source Adapted from Lipsey, 1997, 2005
122
Program types with average or better effects on
recidivism

• AVERAGE OR BETTER BETTER/BEST
• Preadjudication
• Drug/alcohol therapy Interpersonal skills
  training
• Parent training Employment/job training
• Tutoring Group counseling
• Probation
• Drug/alcohol therapy Cognitive-behavioral
  therapy
• Family counseling Interpersonal
  skills training
• Mentoring Parent training
• Tutoring
• Institutionalized
• Family counseling Behavior management
• Cognitive-behavioral therapy Group counseling
• Employment/job training
  Individual counseling
• Interpersonal skills training

Source Adapted from Lipsey, 1997, 2005
123
Cognitive Behavioral Therapy (CBT) Interventions
that Typically do Better than Practice in
Reducing Recidivism (29 vs. 40)

• Aggression Replacement Training
• Reasoning Rehabilitation
• Moral Reconation Therapy
• Thinking for a Change
• Interpersonal Social Problem Solving
• Multisystemic Therapy
• Functional Family Therapy
• Multidimensional Family Therapy
• Adolescent Community Reinforcement Approach
• MET/CBT combinations and Other manualized CBT

NOTE There is generally little or no
differences in mean effect size between these
brand names
Source Adapted from Lipsey et al 2001, Waldron
et al, 2001, Dennis et al, 2004
124
Implementation is Essential (Reduction in
Recidivism from .50 Control Group Rate)
Thus one should optimally pick the strongest
intervention that one can implement well
Source Adapted from Lipsey, 1997, 2005
125
Some Concluding Thoughts
126
A Fearless Appraisal

• We are entering a renaissance of new knowledge in
  this area, but are only reaching 1 of 10 in need
• Several interventions work, but 2/3 of the
  adolescents are still having problems 12 months
  later
• Effectiveness is related to severity,
  intervention strength, implementation/adherence,
  and how assertive we are in providing treatment
• As other therapies have caught up
  technologically, there is no longer the clear
  advantage of family therapy found in early
  literature reviews
• While there have been concerns about the
  potential iatrogenic effects of group therapy,
  the rates do not appear to be appreciably
  different from individual or family therapy if it
  is done well (important since group tx typically
  costs less)
• Effectiveness was not consistently associated
  with the amount of therapy over a short period of
  time (6-12 weeks) but was related to longer term
  continuing care

127
Recommendations for Further Developments

• We need to target the latter phases of treatment
  to impact the post-treatment recovery environment
  and/or social risk groups that are the main
  predictors of long term relapse
• We need to move beyond focusing on acute episodes
  of care to focus on continuing care and a
  recovery management paradigm
• We need to better understand the impact of
  involvement in juvenile justice system and how it
  can be harnessed to help
• More work is need on the use of schools as a
  location for providing primary treatment (they
  have entrée to the population and appear to be
  the venue of choice) and recovery-schools to
  provide support for those coming out of
  residential treatment

128
Common Strategies you can do NOW

• Standardize assessment and identify most common
  problems
• Pool knowledge about what staff have done in the
  past, whether it worked, and what the barriers
  were
• Identify system barriers (e.g., criteria to local
  access case management, mental health) that could
  be avoided if thought of in advance
• Identify existing materials that could help and
  make sure they are readily available on site
• Identify promising strategies for working with
  the adolescent, parents, or other providers
• Develop a 1-2 page checklist of things to do when
  this problem comes up
• Identify a more detailed protocol and trainer to
  address the problem, then go for a grant to
  support implementation

129
Other Assessment and Treatment Resources

• Assessment Instruments
• GAIN Coordinating Center at www.chestnut.org/li/ga
  in
• CSAT TIP 3 at http//www.athealth.com/practitioner
  /ceduc/health_tip31k.html
• NIAAA Assessment Handbook at http//www.niaaa.nih
  .gov/publications/instable.htm
• Treatment Programs
• CSAT CYT, ATM, ACC and other treatment manuals at
  www.chestnut.org/li/apss/csat/protocols and on
  CDs provided
• SAMHSA Knowledge Application Program (KAP) at
  http//kap.samhsa.gov/products/manuals
• NCADI at www.health.org
• National Registry of Effective Prevention
  ProgramsSubstance Abuse and Mental Health
  Services Administration (SAMHSA), Department of
  Health and Human Services http//www.modelprogra
  ms.samhsa.gov

130
Other Resources (continued)

• Implementing Evidenced Based Practice
• Central East ATTC Evidence Based Practice
  Resource Page http//www.ceattc.org/nidacsat_bpr.a
  sp?idLGBT
• Northwest Frontier ATTC Best Practices in
  Addiction Treatment A Workshop Facilitator's
  Guide http//www.nattc.org/resPubs/bpat/index.html
  
• Turning Knowledge into Practice A Manual for
  Behavioral Health Administrators and
  Practitioners About Understanding and
  Implementing Evidence-Based Practices
  http//www.tacinc.org/index/viewPage.cfm?pageId11
  4
• Evidence-Based Practices An Implementation Guide
  for Community-Based Substance Abuse Treatment
  Agencies http//www.uiowa.edu/iowapic/files/EBP2
  0Guide20-20Revised205-03.pdf
• National Center for Mental Health and Juvenile
  Justice Evidence Based Practice resource list at
  http//www.ncmhjj.com/EBP/default.asp
• Society for Adolescent Substance Abuse Treatment
  Effectiveness (SASATE) www.chestnut.org/li/apss/s
  asate
• Joint Meeting on Adolescent Substance Abuse
  Treatment Effectiveness http//www.mayatech.com/ct
  i/jmate/
• next meeting March 30-April 2, 2008, Baltimore,
  MD

131
References

• Babor, T. F., Webb, C. P. M., Burleson, J. A.,
  Kaminer, Y. (2002). Subtypes for classifying
  adolescents with marijuana use disorders
  Construct validity and clinical implications.
  Addiction, 97(Suppl. 1), S58-S69.
• Beutler, L. E. (2000). David and Goliath When
  empirical and clinical standards of practice
  meet. American Psychologist, 55, 997-1007.
• Buchan, B. J., Dennis, M. L., Tims, F. M.,
  Diamond, G. S. (2002). Cannabis use Consistency
  and validity of self report, on-site urine
  testing, and laboratory testing. Addiction,
  97(Suppl. 1), S98-S108.
• Bukstein, O.G., Kithas, J. (2002) Pharmacologic
  treatment of substance abuse disorders. In
  Rosenberg, D., Davanzo, P., Gershon, S. (Eds.),
  Pharmacotherapy for Child and Adolescent
  Psychiatric Disorders, Second Edition, Revised
  and Expanded. NY, NY Marcel Dekker, Inc.
• Dennis, M.L., (2002). Treatment Research on
  Adolescents Drug and