Presentation at the SAMHSA/OJJDP Expert Panel on Juvenile Justice and Adolescent Substance Abuse Treatment, December 7, 2006, Rockville, MD. This presentations was developed with support

from the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270-2003-00006 and uses data from several individual grants. The opinions are those of the author and do not reflect official positions of the

consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-

4661, e-Mail: junsicker@Chestnut.Org

Part 2. Institution-Based Treatment for Adolescents With Substance Use/Co-Occurring Disorders

FacilitatorMichael L. Dennis, Ph.D. Chestnut Health Systems

Bloomington, IL

The literature• In Lipsey’s (1997, 2001) meta analyses of juvenile delinquency

literature and updated literature searches revealed no major randomized trials of adolescent substance abuse treatment in detention or other institutionalized juvenile justice settings

• Lipsey’s meta analysis of juvenile justice institutional programs found that:

– On average they had 5.6 distinguishable components– While the average program had little to no effect, the best quartile

of programs reduced recidivism by 30% or more,

• Could be predicted based on whether the program– 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

Program components associated with average or better effects on recidivism

BETTER/BEST• Behavior management • Group counseling• Individual counseling• Interpersonal skills training

AVERAGE OR BETTER• Family counseling • Cognitive-behavioral therapy • Employment/job training

AVERAGE OR WORSE• “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)

No differences by race

No “iatrogenic” or “peer contagion” effect of group

treatment

Source: Adapted from Lipsey et al 2001

Specific Evidenced Based Interventions that Typically do Better than Practice in Reducing

Recidivism (29% vs. 40%)

• Aggression Replacement Training (ART)• Reasoning & Rehabilitation (RR)• Moral Reconation Therapy (MRT)• Thinking for a Change (TC)• Interpersonal Social Problem Solving (ISPS)• Multisystemic Therapy (MST)• Functional Family Therapy (FFT)• Multidimensional Family Therapy (MDFT)• Adolescent Community Reinforcement Approach (ARCA)• Motivational Enhancement Therapy/ Cognitive Behavior

Therapy (MET/CBT) combinations and Other manualized CBT

Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004

NOTE: There is generally little or no differences in mean effect size between these brand names

Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)

The effect of a well implemented weak program is

as big as a strong program implemented poorly

The best is to have a strong

program implemented

well

Thus one should optimally pick the strongest intervention that one can

implement wellSource: Adapted from Lipsey, 1997, 2001

Data from 14 CSAT Young Offender Re-Entry Program (YORP) grants (N=1066)

• 85% Male

• 84% Minority (45% Hispanic, 20% African American, 15% Mixed)

• 92% Age 15 or older (27% 18 or older)

• 70% Below the poverty line (54% below half the poverty line)

• 64% From Single Parent Households

• 42% With a history of being homeless or running away

• 73% With 3 or more years of use (40% with 5 or more)

• 90% Self reporting criteria for substance disorders (40% past year dependence; 38% with prior SA treatment)

• 58% Self reporting criteria for co-occurring mental health disorders (32% with prior MH treatment)

Co-occurring Psychiatric Conditions

\2 Post traumatic distress, acute traumatic distress or disorders of extreme stress not otherwise specified

41%

34%

9%

21%

22%

58%

49%

41%

37%

31%

9%

17%

19%

49%

41%

31%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Any Past Year Internal Disorder

Major Depression Disorder

Generalized Anxiety Disorder

Suicidal Thoughts or Actions

Traumatic Distress Disorder\2

Any Past Year External Disorder

Conduct Disorder

Attention Deficit-Hyperactivity Disorder

1 DC Total 2 YORP TotalCompared to 246 adolescent entering juvenile drug courts in 6 CSAT sites

Pattern of Maltreatment/Victimization

\3 Reporting 4 or more of the following: types of victimization, traumagenic factors (e.g., multiple people, someone they trusted, fearing for life, sexual penetration, people didn't believe them) or continuing fear it will reoccur

62%

60%

43%

36%

19%

20%

75%

74%

57%

37%

12%

20%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Any history of victim.or current worries

Lifetime History ofVictimization

High Levels ofVictimization\3

Past Year

Past 90 Days

Current worry aboutvictimization

1 DC Total 2 YORP Total

Pattern of Crime & Violence (towards others)

\4 Physical assault of another person within the past year. \5 Self report of or arrests related to vandalism, forgery, bad checks, shop lifting, theft, robbery, auto theft.\6 Self report of or arrests related to assault, aggravated assault with a weapon, rape, murder, and arson\7 Self report of or arrests related to driving under the influence, manufacture or distribution, prostitution, gang involvement

82%

74%

67%

48%

51%

52%

85%

81%

65%

53%

53%

50%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Any Violence or IllegalActivity

Acts of PhysicalViolence\4

Any Illegal Activity

Property crimes\5

Interpersonal crimes\6

Drug related crimes\7

1 DC Total 2 YORP Total

No. of Problems* by Severity of Victimization

Source: CSAT AT Common GAIN Data set (odds for High over odds for Low)

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD,

CD, victimization, violence/ illegal activity)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low (31%) Moderate (17%) High (51%)

Five or More

Four

Three

Two

One

None

Those with high lifetime levels of

victimization have 117 times higher

odds of having 5+ major problems*

GAIN General Victimization Scale Score (Row %)

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 AT Outcome Data Set (n-9,276)

0

30

60

90

Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Day

s of

Ab

stin

ence

(of

90)

Outpatient (+20%, -2%)

Residential(+69%, -15%)

Post Corr/Res (+2%, -6%)

Treatment Outcomes by Level of Care: Recovery*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Per

cen

t in

Pas

t M

onth

Rec

over

y* Outpatient (+79%, -1%)

Residential(+143%, +17%)

Post Corr/Res (+220%, +18%)

* Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change)

Source: CSAT AT Outcome Data Set (n-9,276)

Questions

1. Given the dearth of research on evidenced based practices in juvenile institutions, which related practices are likely to be the most useful to try/study?

2. What are the key implementation issues that are likely to be essential in this setting? (e.g.., workforce, resources, length of detention)

3. Given the heterogeneity of clinical and behavioral problems, how do we identify and address the right issues for each adolescent?

4. Given the high rate of victimization and it association with co-occurring psychiatric, crime and violence problems – what can we do to provide interventions (e.g.., Anger Management, CBITS) to improve the adolescents sense of safety, teach coping skills and/or prepare them for re-entry?

5. How can we change policies and/ or train the workforce to better facilitate the above?

6. What strategies can help to provide continuity of care? (e.g., information sharing, joint staffing, transfer processes)

Appendix: Detailed Data on Needs• 2004-2006 Data from 20 CSAT JJ grantees

– 246 entering juvenile drug courts in 6 sites: Laredo, TX, San Antonio, TX, Belmont, CA, Tarzana, CA, Pontiac, MI, Birmingham, AL

– 1066 existing detention in 14 sites: San Jose, CA, Boston, MA, San Antonio, TX, Long Beach, CA, Racine, WI, San Diego, CA, Huntington, WV, Tucson, AZ, El Paso, TX, Pinellas Park, FL, Fort Collins, CO, Washington, DC, Cleveland, OH, Smyrna, GA

• Relative to those entering community substance abuse treatment, they are – Slightly lower on substance use severity– Similar on mental health severity– Slightly higher on crime, violence, and environmental

problems

Demographics

22%

83%

1%

0%

8%

17%

57%

17%

0%

19%

80%

15%

84%

1%

3%

20%

16%

45%

15%

1%

8%

65%

27%1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Female

Minority status

American Indian/Alaska Native

Asian

African American\Black

Caucasian\White

Hispanic

Mixed

Other

Less than 15 years

15-17 years

18+ years

1 DC Total 2 YORP Total

Living Situation

24%

20%

29%

22%

4%

52%

26%

10%

31%

54%

16%

23%

6%

2%

64%

11%

9%

42%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Very poor (0-49%)

Poor (50-99%)

Working class (100-299%)

Upper middle class (300-999%)

Upper class (1000%+)

Single parent family

Weekly Alcohol Use in Home

Weekly Drug Use in Home

Ever Homeless/Runaway

1 DC Total 2 YORP Total

Peer Alcohol and Drug Use

\1 Spent time in the past year with 1 or more people at work/school who got drunk weekly\2 Spent time in the past year with 1 or more people socially who got drunk weekly\3 Spent time in the past year with 1 or more people at work/school (or socially) who used drugs quarterly

39%

48%

44%

52%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Regular Peer AlcoholUse

at Work/School\1

Regular Peer AlcoholUse\2

Regular Peer Drug Useat Work/School\3

Regular Peer DrugUse\3

1 DC Total 2 YORP Total

Environment

\4 During the past 90 days\5 Attacked with a weapon, beaten to the point of bruises or broken bones, sexually assaulted, or emotionally abused.'\6 Count of types of victimization and the number of traumagenic factors (GVS) is 4 or more.

88%

26%

99%

96%

51%

60%

43%

19%

85%

13%

100%

94%

92%

74%

57%

12%

0% 20% 40% 60% 80% 100%

In school \4

Employed\4

Any CJ Involvement

Current CJ Involvement\4

Controlled Environment\4

Ever Been Victimized\5

High Levels of Victimization\6

Victimization (P90)\4

1 DC Total 2 YORP Total

History of Substance Use

7%

82%

11%

0%

4%

42%

36%

18%

11%

76%

12%

1%

2%

25%

33%

40%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Under 10

Age 10-14

Age 15-17

Age 18 or older

Less than 1

1-2 years

3-4 years

5 or more years

1 DC Total 2 YORP Total

Age of First Use

Years of Use

Past 90 Day Substance Use

65%

15%

46%

50%

3%

2%

9%

2%

32%

28%

7%

18%

2%

1%

2%

0%

84%

27%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Weekly use of anything

Weekly Alcohol Use\2

Weekly Tobacco Use\2

Weekly Marijuana Use\2

Weekly Crack/Cocaine Use\2

Weekly Heroin/Opiod Use\2

Weekly Other Drug Use\2

Any past 90 day needle use

13+ Days in Controlled Environment\2

1 DC Total 2 YORP Total\2 During the past 90 days

Substance Problem

26%

71%

33%

50%

91%

88%

32%

22%

79%

60%

35%

90%

70%

16%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Perceives AOD as aproblem\3

Perceives need for ANYtreatment

Ready to remainabstinent (100%)

Ready to quit (80% ormore)

LifetimeAbuse/Dependence

Past YearAbuse/Dependence

Past MonthAbuse/Dependence

1 DC Total 2 YORP Total\3 Do you currently feel that you have any problems related to alcohol or drug use?

Presenting Severity

1%

12%

39%

4%

45%

46%

31%

4%

1%

29%

27%

7%

36%

32%

13%

2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

No Use

Use

Abuse

Dependence

Physiological Dependence

Any lifetime

Any past week

Acute past week

1 DC Total 2 YORP Total

Pre

sen

ting

(Pas

t Y

ear)

S

ever

ity

With

draw

al

Prior Treatment Episodes

68%

32%

17%

15%

62%

38%

24%

14%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

None

Any

One

Two or more

1 DC Total 2 YORP Total

Co-occurring Psychiatric Conditions

\2 Post traumatic distress, acute traumatic distress or disorders of extreme stress not otherwise specified

41%

34%

9%

21%

22%

58%

49%

41%

37%

31%

9%

17%

19%

49%

41%

31%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Any Past Year Internal Disorder

Major Depression Disorder

Generalized Anxiety Disorder

Suicidal Thoughts or Actions

Traumatic Distress Disorder\2

Any Past Year External Disorder

Conduct Disorder

Attention Deficit-Hyperactivity Disorder

1 DC Total 2 YORP Total

Pattern and Tx of Psychiatric Conditions

32%

10%

32%

27%

33%

42%

9%

28%

21%

32%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Neither

Internal only

Both

External only

Any prior MHtreatment

1 DC Total 2 YORP Total

Pattern of Maltreatment/Victimization

\3 Reporting 4 or more of the following: types of victimization, traumagenic factors (e.g., multiple people, someone they trusted, fearing for life, sexual penetration, people didn't believe them) or continuing fear it will reoccur

62%

60%

43%

36%

19%

20%

75%

74%

57%

37%

12%

20%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Any history of victim.or current worries

Lifetime History ofVictimization

High Levels ofVictimization\3

Past Year

Past 90 Days

Current worry aboutvictimization

1 DC Total 2 YORP Total

Other HIV Risks

2%

68%

33%

34%

0%

44%

17%

21%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Any past 90 day needleuse

Any past 90 day sexualexperience

Any past 90 dayunprotected sex

Multiple sexualpartners in past 90

days

1 DC Total 2 YORP Total

Pattern of Crime & Violence (towards others)

\4 Physical assault of another person within the past year. \5 Self report of or arrests related to vandalism, forgery, bad checks, shop lifting, theft, robbery, auto theft.\6 Self report of or arrests related to assault, aggravated assault with a weapon, rape, murder, and arson\7 Self report of or arrests related to driving under the influence, manufacture or distribution, prostitution, gang involvement

82%

74%

67%

48%

51%

52%

85%

81%

65%

53%

53%

50%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Any Violence or IllegalActivity

Acts of PhysicalViolence\4

Any Illegal Activity

Property crimes\5

Interpersonal crimes\6

Drug related crimes\7

1 DC Total 2 YORP Total

Errata

• References Cited:Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C.,

Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment, 27, 197-213.

Lipsey, M. W. (1997). What can you build with thousands of bricks? Musings on the cumulation of knowledge in program evaluation. New Directions for Evaluation, 76, 7-23.

Lipsey, M. W., Chapman, G. L., & Landenberger, N. A. (2001). Cognitive-behavioral programs for offenders. The Annals of the American Academy of Political and Social Science, 578, 144-157.

Waldron, H. B., Slesnick, N., Brody, J. L., Turner, C. W., & Peterson, T. R. (2001). Treatment outcomes for adolescent substance abuse at four- and seven-month assessments. Journal of Consulting and Clinical Psychology, 69, 802-813.

• Assessment Instruments – GAIN Coordinating Center at www.chestnut.org/li/gain – CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html – NIAAA Assessment Handbook at http://www.niaaa.nih.gov/publications/instable.htm

• Treatment Programs– CSAT CYT, ATM, ACC and other treatment manuals at www.chestnut.org/li/apss/csat/protocols and

on CDs provided– SAMHSA Knowledge Application Program (KAP) at http://kap.samhsa.gov/products/manuals – NCADI at www.health.org – National Registry of Effective Prevention Programs

Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov

• Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) www.chestnut.org/li/apss/sasate

• 2006 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/jmate/ April 25-27, 2007, Washington< DC