Moving Adolescent Treatment to Evidenced-Based Practice

1. Moving Adolescent Treatment to Evidenced-Based Practice Michael Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL Part of the continuing education workshop, “Advancing the Field of Adolescent Substance Abuse Treatment”, Hamden, CT, April 22, 2005. Sponsored by the Department of Children and Families Substance Abuse Division. 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 using data provided by the following grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888, TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340, TI130022, TI03345, TI012208, TI013323, TI14376, TI14261, TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272, TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678, TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674, TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514, TI15672, TI15478, TI15447, TI15545, TI15671)). 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

2. Goals of this Presentation • Provide a brief introduction on the move to evidenced based practice (ECP) • Summarize the recent growth in adolescent substance abuse treatment and research • Introduce a common data set of adolescent treatment programs using the Global Appraisal of Individual Needs (GAIN) that is being used by CSAT’s adolescent grantees and which has provided data to support the planning of many of recent papers and presentations

3. 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 substance use and its negative consequences among those who are abusing or dependent, • reduce the likelihood of relapse for those who are recovering, and • reduce risks for initiating drug use among those not yet using, NIDA Blue Ribbon Panel on Health Services Research (see www.nida.nih.gov )

4. 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 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

5. 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, practitioner’s are more interested in identifying which of several treatments to use for a given type of patient – but few such studies have been done • When research practices have been identified, they are often not adopted because practitioner’s often lack the appropriate materials, training and resources to know when or how to implement best practices

6. 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

7. 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

8. 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

9. Growing Infrastructure • Increasing availability and use of standardized assessment to help focus and improve clinical practice • Growing number of manualized protocols designed for replication and use in practice • CSAT increasingly encouraging and/or requiring the use of standardized assessment, manuals, training, and quality assurance practices to ensure adherence • ATTCs collaborating with CSAT, NIDA and NIAAA to train individual staff • Growing Literature • GAIN/ JMATE workgroups (Gender, Spanish, African American, Asian, LGBT, Juvenile Justice, Comorbidity, Strength Based, Substance-specific, Intervention-specific, Trainers, Data Managers, MIS, Evaluators ) There is a list of above resources at the end of these handouts

10. How we are building a common knowledge base about what is working for whom through • Pooling data across multiple evaluations and programs • Identifying common factors and principals that appear to hold across interventions • Having peer reviewed panels review and rate the strength of evidence on the effectiveness and generalizability of specific interventions • Conducting formal meta analysis of a groups of similar interventions that have been replicated and evaluated several times

11. Reoccurring Themes… • Severity and specificity of problem subgroup • Manualized and replicable 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)

12. Global Appraisal of Individual Needs (GAIN) • The GAIN family of instruments were developed through a 10 year collaboration of researchers, clinicians, policy makers, and IT specialists • They provide a standardized approach to measuring: • Eligibility/need (i.e., screening), • DSM/ICD Diagnosis, • ASAM level of care Placement, • Study/State/Federal Reporting, • Treatment Planning, • Severity/Case Mix, • Change in Functioning, Service Utilization, and other Outcomes, and • Economic Cost and Benefits of treatment • Includes 103 scales and over 2000 created variables, had good reliability/validity, 174 agencies and over four dozen scientists working with it More information is available at www.chestnut.org/li/gain

13. Adolescent and Adult Treatment Program GAIN Clinical Collaborators CSAT Co-occurring Disorder (CD) Studies Other Collaborators Cannabis Youth Treatment (CYT) RWJF Reclaiming Futures Program Other RWJF Grantees Adolescent Treatment Model (ATM) NIAAA/NIDA Other Grantees Strengthening Communities for Youth (SCY) Other Grants/Contracts Adolescent Residential Treatment (ART) State, county, or agency systems Other states, counties, or agencies proposing or considering it Effective Adolescent Treatment (EAT) Young Offender Re-Entry Program (YORP) Targeted Capacity Expansion (TCE) grants

14. Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN) Studies with Publications Currently Coming Out • 1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A) • 1995-1997 Drug Abuse Treatment Outcome Study (DOMS) • 1997-2000 CSAT’s Cannabis Youth Treatment (CYT) experiments • 1998-2003 NIAAA/CSAT’s 15 individual research grants • 1998-2003 CSAT’s 10 Adolescent Treatment Models (ATM) • 2000-2003 CSAT’s Persistent Effects of Treatment Study (PETS-A) • 2002-2007 CSAT’s 12 Strengthening Communities for Youth (SCY) • 2002-2007 RWJF’s 10 Reclaiming Futures (RF) diversion projects • 2002-2007 CSAT’s 12+ Targeted Capacity Expansion TCE/HIV • 2003-2009 NIDA’s 14 individual research grants and CTN studies • 2003-2006 CSAT’s 17 Adolescent Residential Treatment (ART) • 2003-2008 NIDA’s Criminal Justice Drug Abuse Treatment Study (CJ-DATS) • 2003-2007 CSAT’s 36 Effective Adolescent Treatment (EAT) • 2004-2007 NIAAA/CSAT’s study of diffusion of innovation

15. 74,670 ..and we are still growing Since 1997, the data has been pooled to create one of the largest benchmark data sets in the field 90,000 80,000 70,000 57,360 60,000 Cumulative GAIN Interviews (observations) 50,000 32,054 40,000 30,000 17,464 20,000 10,000 0 Prior to FY2003 FY2004 FY2005 FY2006 ~ Half of all Adolescent Treatment Data One of the Largest Data Sets in the Field with 1+ year follow-up (2nd only to ASI) Largest Combined Adolescent Data Set

16. CSAT AT Program Common Data Set • The working CSAT adolescent treatment data set including data on 5,468 adolescents from 67 local evaluations (current through quarterly data submission cycle ending in December 2004) • All data collected with the Global Appraisal of Individual Needs (GAIN) using centrally trained and certified staff • Outcome data through 12 months available on over 90% of CYT and ATM clients and over 80% of others “due” in on-going programs • Programs include several standardized protocols based on both research and practice (ACC, ACRA, ATM, FFT, FSN, Matrix, MET/CBT, MDFT, MST) • Local evaluations include several experiments and quasi experiments • Several workgroups working on common themes across programs (African American, Co-morbidity, Family, Native American/Indian, Spanish translation/workforce) • Data being shared with several secondary analysis grantees and panel presentations for this week

17. CSAT Adolescent Treatment (AT) Programs Reordered by Level of Care and Severity • EAT: Effective Adolescent Treatment (2003-2007; n=975) replicating the CYT MET/CBT intervention in early intervention, school and outpatient settings(22 of 36 grants: Bradley, Brown, Clayton,Curry, Davis, Dillon, Dodge, Kressler, Kincaid, Levine, Levy, Locario, Mason, Moore, Rajaee-Moore, Paull, Payton, Rezende, Taylor, Tims, Turner, Vincent) • CYT: Cannabis Youth Treatment (1997-2001; n=600) Experiments with adolescent outpatient/intensive outpatient (5 grants: Babor, Dennis, Diamond, Godley, Tims) • TCE: Targeted Capacity Expansion (2002-2007; n=189) evaluation of intensive outpatient programs and some residential treatment (2 of 12 grants: Tims, Lloyd) • SCY: Strengthening Communities-Youth (2002-2007; n=1120) evaluations of early intervention, outpatient, intensive outpatient and some residential (11 of 12 grants: Beach, Bolland, Dahl, Gerstel, Godley, Hall, Hutchinson, Keehn, Murphy, Noonan, Panzarella) • ATM: Adolescent Treatment Model (1998-2002; n=1468) evaluations of outpatient, short and long term residential (10 grants: Batttjes, Fishman, Godley, Liddle, Morral, Perry, Sabin, Shane, Stevens-2) • ART: Adolescent Residential Treatment (2003-2006; n=1179) evaluations of residential treatment enhancements and continuing care (17 grants: Beach, Fishman, Flores, Gay, Gnazzo, Hatch, Hurtig, Lane, Law, Manov, May, Miley, Nordquist, Snipes, Urquahart, Whitmore, Zammarelli)

18. Level of Care 100% Other Resid. Continuing Care 80% Long Term Residential 60% Med. Term Residential Short Term Residential 40% Intensive Outpatient 20% Outpatient Early Intervention 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

19. Gender 100% 90% 80% Male 70% 60% 50% 40% 30% Female 20% 10% While few individual studies can break out females, this data set has 1497 (so far) 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

20. Race 100% Other 90% Mixed 80% Native American/ 70% Alaskan 60% Hispanic 50% Caucasian/White 40% Asian/Pacific Islander 30% 20% African American 10% 0% Across sites there are 300 or more for all subgroups but Asian (so far) EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

21. Age 100% 21-25 90% 80% 70% 18-20 60% 50% 40% 15-17 30% 20% 0-14 10% 921 Under 14 and 377 young adults 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

22. Other Characteristics 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Single Parent 50% Homeless or 39% Runaway Employed 34% In School 86% Juvenile Justice Involvement 70% Recently in a Controlled Environment 45% Source: CSAT AT Common GAIN Data set

23. Years of Use 100% 5+ Years 90% 80% 70% 3-4 Years 60% 50% 40% 1-2 Years 30% 20% 10% Less than 1 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

24. Substance Use Severity (based on self-report) 100% 90% Dependence 80% 70% 60% 50% Abuse 40% 30% 20% Subclinical use/problems 10% 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

25. Weekly/Daily Substance Use Pattern 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 65% Any AOD Use 52% Marijuana 20% Alcohol In our data and in TEDS, 1 in 5 did not use in the month before intake – hence the use of 90 day window and measures of pre-CE use 5% Cocaine/Crack 3% Heroin/Opioids 8% Other Drugs 14 or more days in Controlled Environment 30% Source: CSAT AT Common GAIN Data set

26. Prior Substance Abuse Treatment 100% 90% Two or more 80% 70% 60% 50% One 40% 30% 20% None 10% 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

27. Mixed Problem Recognition 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Acknowledges AOD problem 35% Believes treatment needed 81% Self reports meets abuse/dependence 92% criteria Gives one or more 99% reasons to quit Source: CSAT AT Common GAIN Data set

28. High Risk Recovery Environments 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% In home 29% among work/ school peers 52% Regular alcohol use among social peers 61% 17% In home among work/ school peers 67% Regular drug use among social peers 79% Source: CSAT AT Common GAIN Data set

29. Patterns of Co-Occurring Disorders 100% Both Internal & External 90% Disorders 80% 70% External Disorder(s) 60% Only 50% Internal 40% Disorder(s) 30% only 20% Neither 10% 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

30. Interventions need to be more specific 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Any Internal Disorder 49% Depressive Disorder 38% Anxiety Disorder 21% 28% Trauma Related Disorder 32% Any Self Mutilation Any homicidal/ suicidal thoughts 28% 67% Any External Disorder Conduct Disorder 59% Attention Deficit-Hyperactivity Disorder (ADHD) Within a diagnosis there are also mild to severe subgroups 48% Source: CSAT AT Common GAIN Data set

31. Also High Rates of HIV/STI risk behaviors 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 81% Sexual Activity Victimization 57% Lifetime 16% Needle Use Sexual Activity 61% Sex Under AOD Influence 51% Multiple Sex Partners 35% Past 90 Days Unprotected Sex 29% Victimization 23% Needle Use 4% Source: CSAT AT Common GAIN Data set

32. Severity of Victimization History 100% High (4-15 on General Victimization Scale [GVS] *) 90% 80% 70% Moderate (Any Lifetime, 1-3 on GVS*) 60% 50% Low (No History) 40% 30% * Based on lifetime history and current fear of 4 types of victimization (attached with a weapon, beaten, sexually assaulted, emotionally abused), and 8 trauma factors (under 18, someone trusted, multiple people, multiple times, sexual penetration, fear for life, no one believed when reported) 20% 10% 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

33. Victimization interacts with MH problems 100% Both Internal & External 90% Disorders 80% 70% External Disorder(s) 60% Only 50% Internal 40% Disorder(s) 30% only 20% Neither 10% 0% Low Moderate High Total Severity of Victimization Source: CSAT AT Common GAIN Data set

34. Intensity of Juvenile Justice System Involvement 100% In detention/ jail 14+ days 90% On prob./ parole 14+ days w/ 1+ drug screens 80% 70% 60% Other probation, parole, detention 50% Other JJ status 40% 30% Past arrest/ JJ status 20% Past year illegal 10% activity/SA use 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

35. It is NOT just about possession… 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Past Year Any violence or 86% illegal activity Physical Violence 72% Property Crimes 58% 57% Drug Related Crime Interpersonal 51% Crimes Source: CSAT AT Common GAIN Data set

36. Generalizability of research focused on a single problem Need to focus on multiple problems clients 100% Number of 12 Major Clinical Problems* 90% 80% 5 or more 70% Problems 60% 4 Problems 50% 3 Problems 40% 2 Problems 30% 1 Problem 20% * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) 10% 0% EAT CYT TCE SCY ATM ART Total Source: CSAT AT Common GAIN Data set

37. Victimization, trauma and helplessness Self mutilation, para-suicidal and suicidal behaviors Anger management, violence and crime How to help their kids access mental health services (typically for internal disorders) when availability is limited Managing ADHD and impulsivity How to get parents involved in treatment and continuing care Tobacco, opioids, and methamphetamine use, Working with schools, probation, families Females, Males, African Americans, Native Americans, Spanish Speaking adolescents and their families HIV, STI, and Liver risk How to make interventions more assertive and strength based Evaluation issues like follow-up, data management, & analysis Workforce development, including peer-to-peer on specific treatment approaches and other job functions like MIS Areas where staff wanted more specific knowledge and interventions

38. 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

39. Resources • Assessment Instruments • CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html • NIAAA Assessment Handbook,http://www.niaaa.nih.gov/publications/instable.htm • GAIN Coordinating Center www.chestnut.org/li/gain • Treatment Programs • CSAT CYT, ATM, ACC and other treatment manuals at www.chestnut.org/li/apss/csat/protocols or www.chestnut.org/li/bookstore • SAMHSA at http://kap.samhsa.gov/products/manuals/cyt/index.htm or 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.modelprograms.samhsa.gov

40. Resources • Implementing Evidenced based practice • Central East ATTC Evidence Based Practice Resource Pagehttp://www.ceattc.org/nidacsat_bpr.asp?id=LGBT • Northwest Frontier ATTC Best Practices in Addiction Treatment: A Workshop Facilitator's Guidehttp://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 Practiceshttp://www.tacinc.org/index/viewPage.cfm?pageId=114 • Evidence-Based Practices: An Implementation Guide for Community-Based Substance Abuse Treatment Agencieshttp://www.uiowa.edu/~iowapic/files/EBP%20Guide%20-%20Revised%205-03.pdf • National Center for Mental Health and Juvenile Justice Evidence Based Practice resource list athttp://www.ncmhjj.com/EBP/default.asp • 2005 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/csatsasatepost/ • Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE)www.chestnut.org/li/apss/sasate

41. References Cited Here Beutler, L. E. (2000). David and Goliath When empirical and clinical standards of practice meet. American Psychologist, 55, 997-1007. Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28 (2S), S49-S60 . Dennis, M.L., & White, M.K. (2003). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through 2001, (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems. [On line] Available at http://www.drugstrategies.org Dennis, M. L. and White, M. K. (2004). Predicting residential placement, relapse, and recidivism among adolescents with the GAIN. Poster presentation for SAMHSA's Center for Substance Abuse Treatment (CSAT) Adolescent Treatment Grantee Meeting; Feb 24; Baltimore, MD. 2004 Feb. White, M. K., Funk, R., White, W., & Dennis, M. (2003). Predicting violent behavior in adolescent cannabis users The GAIN-CVI. Offender Substance Abuse Report, 3(5), 67-69. White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2), 24-28.