Melissa Ives, MSW, Kate Moritz, MA, Michael L. Dennis, Ph.D. Chestnut Health Systems, Normal, IL

1. Characteristics, Needs, Services and Outcomes of Juvenile Treatment Drug Courts compared to Adolescent Outpatient and Adult Treatment Drug Courts Melissa Ives, MSW, Kate Moritz, MA, Michael L. Dennis, Ph.D. Chestnut Health Systems, Normal, IL Presentation at the National Association of Drug Court Professionals (NADCP) Conference Washington, DC, July 18, 2011

2. Notes • This presentation was supported by data and funds from SAMHSA/ CSAT contract no. 270-07-0191. It is available electronically at www.chestnut.org/li/posters • The opinions are those of the author and do not reflect official positions of the government. Please address comments or questions to the authors at mives@chestnut.org - 309-451-7819 or kmoritz@chestnut.org – 309-451-7831

3. The Goals of this Presentation are to: • Illustrate why it is so important to intervene with juvenile drug users • Review what we know about juvenile treatment drug courts (JTDC) so far • Compare JTDC to regular adolescent outpatient (AOP) in terms of who is served, what services they receive and their treatment outcomes • Examine initial comparison of JTDC to Adult Treatment Drug Courts (ATDC) and Family Drug Courts (FDC)

4. Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20 100 People with drug dependence die an average of 22.5 years sooner than those without a diagnosis 90 Percentage 80 70 60 Severity Category 50 Other drug or heavy alcohol use in the past year 40 30 Alcohol or Drug Use (AOD) Abuse or Dependence in the past year 20 10 0 65+ 21-29 30-34 35-49 50-64 12-13 14-15 16-17 18-20 Age Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000

5. Source: Dennis & McGeary, 1999 Adolescents who use weekly or more often are more likely during the past year to have ...

6. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.

7. Life Course Reasons to Focus on Adolescents • People who start using substances under age 15 use 60% more years than those who start over age 18. • Entering treatment within the first 9 years of initial use leads to 57% fewer years of substance use than those who do not start treatment until after 20 years of use. • Relapse is common and it takes an average of 3 to 4 treatment admissions over 8 to 9 years before half reach recovery. • Of all people with abuse or dependence 2/3rds do eventually reach a state of recovery. • Monitoring and early re-intervention with adults has been shown to cut the time from relapse to readmission by 65%, increase abstinence and improve long term outcomes. Source: Dennis et al., 2005, 2007; Scott & Dennis 2009

8. Few Get Treatment: 1 in 19 adolescents, 1 in 21 young adults, 1 in 14 adults While Substance Use Disorders are Common, Treatment Participation Rates Are Low Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Much of the private funding is limited to 30 days or less and authorized day by day or week by week Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH

9. What does an episode of treatment cost (median)? • $750 per night in Detox • $1,115 per night in hospital • $13,000 per week in intensive • care for premature baby • $27,000 per robbery • $67,000 per assault $22,000/year to incarcerate an adult $70,000/year to keep a child in detention $30,000/ child-year in foster care Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004

10. Investing in Treatment has a Positive Annual Return on Investment (ROI) • Substance abuse treatment has been shown to have a ROI within the year of between $1.28 to $7.26 per dollar invested. • Best estimates are that Treatment Drug Courts have an average ROI of $2.14 to $2.71 per dollar invested. This also means that for every dollar treatment is cut, we lose more money than was saved. Source: Bhati et al., 2008; Ettner et al., 2006

11. Background Juvenile Justice System and Substance Use • Between a quarter and two thirds of the youth in the juvenile justice system have drug related problems (Office of Juvenile Justice and Delinquency Prevention (OJJDP), 2001; Teplin et al., 2002, Chassin, 2008, Wasserman et al. 2010). • Juvenile justice systems are the leading source of referral among adolescents entering treatment for substance use problems (Dennis et al., 2003; Dennis, White & Ives, 2009). • By late 2004, there were 357 juvenile treatment drug courts and the number of courts has continued to grow at a rate of 30-50% per year. Source: Dennis, White & Ives, 2009

12. What Level of Evidence is Available on the Effectiveness of Drug Courts? Science Law Meta Analyses of Experiments/ Quasi Experiments (Summary v Predictive, Specificity, Replicated, Consistency) Dismantling/ Matching study (What worked for whom) Experimental Studies (Multi-site,Independent,Replicated, Fidelity, Consistency) Quasi-Experiments (Quality of Matching, Multi-site,Independent,Replicated, Consistency) Pre-Post (multiple waves), Expert Consensus Correlation and Observational studies Case Studies, Focus Groups Pre-data Theories, Logic Models Anecdotes, Analogies STRONGER Beyond a Reasonable Doubt Clear and Convincing Evidence Preponderance of the Evidence Probable Cause Reasonable Suspicion Source: Marlowe 2008

13. What Level of Evidence is Available on the Effectiveness of Drug Courts? Science Law Meta Analyses of Experiments/ Quasi Experiments (Summary v Predictive, Specificity, Replicated, Consistency) Dismantling/ Matching study (What worked for whom) Experimental Studies (Multi-site,Independent,Replicated, Fidelity, Consistency) Quasi-Experiments (Quality of Matching, Multi-site,Independent,Replicated, Consistency) Pre-Post (multiple waves), Expert Consensus Correlation and Observational studies Case Studies, Focus Groups Pre-data Theories, Logic Models Anecdotes, Analogies STRONGER Beyond a Reasonable Doubt Adult Drug Treatment Courts: 5 meta analyses of 76 studies found crime reduced 7-26% with $1.74 to $6.32 return on investment Clear and Convincing Evidence DWI Treatment Courts: one quasi experiment and five observational studies positive findings Preponderance of the Evidence Family Drug Treatment Courts: one multisite quasi experiment with positive findings for parent and child Probable Cause Juvenile Drug Treatment Courts – one 2006 experiment, one large multisite quasi-experiment, & several small studies with similar or better effects than regular adolescent outpatient treatment Reasonable Suspicion Source: Marlowe 2008

14. Findings from Ives et al., (2010) Multi-Site Quasi Experiment • This article is available online at: http://www.ndci.org/publications/drug-court-review/fall-2010 • Questions asked: • How do the severity & needs of youth in Juvenile Treatment Drug Courts (JTDC) compare to those in Adolescent Outpatient (AOP) • Controlling for these differences, how do these groups compare in terms of • The services they receive? • Their treatment outcomes?

15. Juvenile Treatment Drug Court (JTDC) Sample • Cohort of 13 CSAT JTDC grantee sites using the GAIN in Laredo, TX, San Antonio, TX, Belmont, CA, Tarzana, CA, Pontiac, MI, Birmingham, AL, San Jose, CA, Austin, TX, Peabody, MA, Providence, RI, Detroit, MI, Philadelphia, PA, and Basin, WY. • Intake data collected from these sites on N=1,786 adolescents between January 2006 through March 31, 2009. • The records were limited to clients who: • Received outpatient treatment (N=1,445), and • Had attained 6 months post-intake (N=1,265) • For the analysis, only those with at least one follow-up assessment (89%) were used for a final N=1,120. • 86% received evidence-based treatment. Source: Ives et al., 2010

16. Adolescent Outpatient (AOP) Sample • Clients receiving AOP treatment from 75 CSAT-funded sites using the GAIN and providing outpatient treatment in 29 states from five grant programs (N=10,037). • Intake data collected from these sites on N=10,037 adolescents between September 2002 and August 2008. • The records were limited to clients who: • Received outpatient treatment (all), and • Had attained 6 months post-intake (N=8,604) • For the analysis, only those with at least one follow-up assessment (88%) were used for a final N=7,560 • 93% received evidence-based treatment. JTDC & AOP were significantly different on 36 of 69 measures of characteristics, severity and treatment need Source: Ives et al., 2010

17. Demographics JTDC less likely to be Caucasian, multiracial, older, employed, & in trouble at school/work; more likely to be Hispanic, behind in school Source: Ives et al., 2010 * p<.05

18. Crime and Violence JTDC more likely have been in a controlled environment 13+ days, engaged in illegal activity (overall & drug related) Source: Ives et al., 2010 * p<.05

19. Intensity of Juvenile Justice System Involvement JTDC more likely to be in other detention status and less likely to have no JJ status Source: Ives et al., 2010 * p<.05 **< 1 year ago

20. Environmental Risk Factors JTDC less likely to have use in home and victimization Source: Ives et al., 2010 * p<.05

21. Substance Use JTDC more likely to have started younger, to use any drug or marijuana weekly; and less likely to use tobacco Source: Ives et al., 2010 * p<.05

22. Substance Use Disorders JTDC similar on substance use disorders Source: Ives et al., 2010 * p<.05

23. Substance Treatment History JTDC more likely to have been in treatment before, to see a need for treatment and to be ready to quit Source: Ives et al., 2010 * p<.05

24. Other Major Co-Occurring Clinical Problems JTDC less likely to have health or internalizing disorders and more likely to be/gotten someone pregnant Source: Ives et al., 2010 * p<.05

25. HIV Risk Behaviors (past 90 days) JTDC more likely have multiple sexual partners Source: Ives et al., 2010 * p<.05

26. Number of Major Clinical Problems** JTDC slightly less severe on psychopathology – relative to waiting for them to enter treatment on their own, JTDC is a form of early intervention **Count of marijuana use disorder, alcohol use disorder, any other drug use disorder, internalizing problems including: depression, anxiety, homicidal/suicidal thoughts, and trauma, externalizing problems including conduct disorder and ADHD, Lifetime victimization, past year acts of physical violence or past year illegal activity. Source: Ives et al., 2010 * p<.05

27. Matching with Propensity Scores • Using logistic regression to predict the likelihood (propensity) of each AOP client being a JTDC client based on the 69 intake characteristics, we weighted the AOP group to match the JTDC group in terms of these characteristics and sample size. • This produced two groups with equal sample sizes (N=1,120). • The number of significant differences dropped from 39 to 3 of 69 intake variables. • Those in JTDC were still significantly: • Less likely to be African American (OR=0.77) • More likely to be Hispanic (OR=1.44) and on other probation, parole, or detention (OR=1.37) Source: Ives et al., 2010

28. Treatment System Involvement JTDC less likely to initiate within 2 weeks, but more likely to be in treatment 6 weeks and 3 months later Source: Ives et al., 2010 * p<.05

29. Substance Abuse Treatment (intake to 3 months) JTDC received more days of any treatment & IOP, also more satisfaction Source: Ives et al., 2010 * p<.05

30. Range of Substance Abuse Treatment Content(Intake to 3 months) JTDC more likely to receive a broader range of services – particularly family and external wrap-around services Source: Ives et al., 2010 * p<.05

31. Mental Health Treatment Received(intake to 3 months) No differences in MH treatment—most is driven by medication Source: Ives et al., 2010 * p<.05

32. Other Environmental Interventions Across Systems (intake to 3 months) JTDC received more urine tests and went to self-help more often Source: Ives et al., 2010 * p<.05

33. Substance Use* ( d=-0.45, -0.57) Illegal Activity (d=-0.11, -0.02) Emotional Problems (d=-0.32, -0.22) Trouble w/ Family (d= -0.23, -0.18) In Controlled Environment (d=-0.02, -0.08) Comparison of Treatment Outcomes(Days of ..) Both Reduced Use; JTDCmore than AOP (d between= -0.24) Both Meaningfully Reduced Emotional Problems Others Outcomes Not Significantly Different Post-Pre d (AOP, JTDC) Source: Ives et al., 2010 *p<.05 change greater for JTDC vs AOP (d=-0.24)

34. Strengths & Limits ofIves et al., (2010) • Strengths • Multisite quasi experiment • Differences at intake eliminated on most variables • Replicable evidence-based practice • Multiple follow-up waves • Large sample size and high follow-up rates • Limits • Not randomized • Disproportionately Hispanic youth • Unknown fidelity of implementation • Not sufficient numbers of specific evidence-based practices to compare

35. Findings from JTDC and ATDC/FDC Multi-Site Quasi Experiment Initial Comparison

36. Findings from JTDC and ATDC/FDC Multi-Site Quasi Experiment • How adults in Adult or Family Treatment Drug Courts (ATDC/FDC) compare to adolescents in Juvenile Treatment Drug Courts (JTDC) in terms of • Their characteristics, severity & needs • The services they receive? • Their treatment outcomes?

37. Adult Treatment Drug Court (ATDC) and Family Drug Court (FDC) Sample • Cohort of 7 CSAT ATDC and 2 FDC grantee sites using the GAIN in Jacksonville, FL, Clearwater, FL, Gallipolis, OH, Reno, NV, Miami, FL, Memphis, TN (ATDC sites) and Tampa, FL, Tucson, AZ (FDC sites). • Intake data collected from these sites on N=697 adults between April 2007 and October 2010. • Mean age 31.21 (s.d. 9.57; range: 18-58; median=28; mode=24) • The records were limited to clients who: • Had attained 6 months post-intake (N=457) , and • Received outpatient treatment (N=407) • For the analysis, only those with at least one follow-up assessment (88%) were used for a final N=359 • 42% received evidence-based treatment Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites

38. Juvenile Treatment Drug Court (JTDC) Sample • Cohort of 11 CSAT JTDC grantee sites using the GAIN in Laredo, TX, San Antonio, TX, Belmont, CA, Tarzana, CA, Pontiac, MI, San Jose, CA, Austin, TX, Peabody, MA, Providence, RI, Detroit, MI, and Philadelphia, PA. • Intake data collected from these sites on N=1,771 adolescents between January 2006 through June 2010. • Mean age 15.37 (s.d. 1.17; range: 11-18; median=16; mode=16) • The records were limited to clients who: • Had attained 6 months post-intake (N=1,560) • Received outpatient treatment (N=1,319), and • For the analysis, only those with at least one follow-up assessment (86%) were used for a final N=1,134 • 81% received evidence-based treatment Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites

39. Demographics JTDC less likely to be female, Caucasian, employed, in CWS, behind in school; JTDC more likely to be Hispanic, in school, in trouble at school/work. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05 **Not HSgrad=ATDC/FDC; Behind =JTDC

40. Crime and Violence JTDC less likely to have been in a controlled environment. JTDC more likely have engaged in physical violence and illegal activity (overall interpersonal and property related). No difference in drug crime or 13+ days in a controlled environment. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05

41. Intensity of Juvenile Justice System Involvement JTDC more likely be in long-term detention or on probation/parole and less likely to be in other JJ status. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05

42. Environmental Risk Factors JTDC more likely to have social or vocational peer use. ATDC more likely to have drug use in home, homelessness and victimization. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites* p<.05

43. Substance Use JTDC more likely to have started sooner, use more often and to use marijuana; Less likely to use heroin, cocaine or other drugs or tobacco. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05 +pre-controlled environment

44. Substance Use Disorders JTDC more likely to report lifetime or past year abuse and past week withdrawal. JTDC less likely to report any lifetime or past year dependence or lifetime withdrawal. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05

45. Substance Treatment History JTDC less likely to report each of these treatment history items. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05

46. Other Major Co-Occurring Clinical Problems JTDC less likely to have health problems, internalizing disorders or prior treatment; More likely to have externalizing disorders. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05

47. HIV Risk Behaviors (past 90 days) JTDC more likely to have multiple partners, and less likely to have had risky or unprotected sex or needle use. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05

48. Number of Major Clinical Problems* *Count of marijuana use disorder, alcohol use disorder, any other drug use disorder, internalizing problems including: depression, anxiety, homicidal/suicidal thoughts, and trauma, externalizing problems including conduct disorder and ADHD, Lifetime victimization, past year acts of physical violence or past year illegal activity. JTDC slightly less severe on psychopathology. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05

49. JTDC and ATDC/FDC Comparison: Treatment

50. Evidence-based protocols Type of Treatment provided JTDC more likely to be treated with wider variety of evidence-based protocols. Source: CSAT 2010 Horizontal dataset: ATDC and FDC sites * p<.05