Evaluating the Impact of Adding the Reclaiming Futures Approach to Juvenile Treatment Drug Courts

1. Evaluating the Impact of Adding the Reclaiming Futures Approachto Juvenile Treatment Drug Courts Michael L. Dennis, Ph.D., Chestnut Health Systems, Normal, IL (On behalf of the Juvenile Drug Court Reclaiming Futures National Program Office and Evaluation Team) Presentation at the 8th Annual Metro East Meth+ Other Drugs Conference, Belleville, IL, April 25, 2013. Supported by the Reclaiming Futures/Juvenile Drug Court Evaluation under Library of Congress contract no. LCFRD11C0007 to University of Arizona Southwest Institute for Research on Women, Chestnut Health Systems & Carnevale Associates The development of this presentation is funded by the Office of Juvenile Justice and Delinquency Prevention (OJJDP) through an interagency agreement with the Library of Congress – contract number LCFRD11C0007. The views expressed here are the authors and do not necessarily represent the official policies of OJJDP or the Library of Congress; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.,

2. Presentation will be available from • www.chestnut.org\li\posters

3. Purpose • 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 a newer Reclaiming Futures version of JTDC in terms of their impact on substance use, recovery, emotional problems, illegal activity and costs to society

4. Background

5. Adolescence is the Age of Onset Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Source: 2010 NSDUH, Neumark et al., 2000)

6. Adolescence Use Related to Range of Problems Source: Dennis & McGeary, 1999; OAS, 1995

7. Importance for Life Course People who start using 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%, increasing abstinence and improving long term outcomes. Source: Dennis et al., 2005, 2007; Scott & Dennis 2009

8. What Is Treatment? Motivational interviewing and other protocols to help them understand how their problems are related to their substance use and that they are solvable. Detoxification and medication to reduce pain/risk of withdrawal and relapse, including tobacco cessation. Evaluation of antecedents and consequences of use. Group, individual or family outpatient including relapse prevention planning and cognitive behavior therapie. More systemic family approaches. Proactive urine monitoring. Motivational incentives / contingency management. Residential, intensive outpatient (IOP) and other types of structured environments to reduce short term risk of relapse. Access to communities of recovery for long term support, including 12-step, recovery coaches, recovery schools, recovery housing, workplace programs. Continuing care, phases for multiple admission.

9. The Treatment Gap by Age Higher rates of unmet need in general; Less than 1 in 13 adolescents and young adults getting treatment Highest rates among young adults Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2012). National Survey on Drug Use and Health, 2009. [Computer file] ICPSR29621-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-02-10. doi:10.3886/ICPSR29621.v2. Retrieved from http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/29621/detail .

10. Health Disparities by Gender Yet girls have more unmet need represent only about 1/3rd of the teens in treatment Unlike adults, among adolescents girls have higher need Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2012). National Survey on Drug Use and Health, 2009. [Computer file] ICPSR29621-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-02-10. doi:10.3886/ICPSR29621.v2. Retrieved from http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/29621/detail .

11. Other Problems in the U.S. Adolescent Treatment System Only 67% stay the 45 days minimum recommended by ONC Only 56% are positively discharged or transferred Only 43% stay the 90 days recommended by research Only 23% leaving higher levels of care are transferred to outpatient continuing care. The majority of programs do NOT use standardized assessment, evidenced-based treatment, track the clinical fidelity of the treatment they provide, or monitor health disparities in service delivery or client outcomes Varied staff education with a median of less than BA. Average of 30-32% staff turnover every year Most lack or are just starting the multi-year process of setting up electronic medical records Source: SAMHSA 2012 & Institute of Medicine (2006).

12. The Cost of Treatment (and unmet need) SBIRT models popular due to ease of implementation and low cost • $750 per night in Medical 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 $70,000/year to keep a child in detention $22,000 / year to incarcerate an adult $30,000/ child-year in foster care Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars

13. Return on Investment (ROI) This also means that for every dollar treatment is cut, it costs society more money than was saved within the same year. Substance abuse treatment has been shown to have a ROI within the year of between $1.28 to $7.26 per dollar invested. GAO’s recent review of 11 drug court studies found that the net benefit ranged from positive $47,852 to negative $7,108 per participant. Best estimates are that Treatment Drug Courts have an average ROI of $2.14 to $3.69 per dollar invested when considering only service costs. Source: Bhati, et al., (2008); Ettner, et al., (2006), GAO (2012), Lee, et al., (2012)

14. Juvenile Justice and Substance Use About half 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). 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; Ives et al 2010). By 2009 there were 476 juvenile treatment drug courts (JTDC) in approximately 16% of the Counties in the US and they were growing at a rate of 4% per year (Huddleston & Marlowe, 2011) • Source: Dennis, White & Ives, 2009

15. Source: Dennis, White & Ives, 2009

16. Source: Dennis, White & Ives, 2009

17. Source: Dennis, White & Ives, 2009

18. Reclaiming Futures (RF)“more treatment, better treatment, beyond treatment” RF is a “systems change” approach to improving the access and quality of substance use and mental health services to youth in the juvenile justice systemboth in general and specifically applied to JTDC here. RF was adapted from the system of care frameworks from the children’s mental health movement to be inclusive, continuous, strength- and culturally-based and rely upon both family and community strengths. RF’s goals are to stimulate the development of interdisciplinary professional and community teams to install evidence-based and culturally relevant screening, assessment, appropriate integrated care coordination, treatment and developmentally appropriate recovery support systems following engagement in the justice and treatment systems. RF provides access to a “community of practice” with other sites around the US to help mentor, coach and collaborate in a mutual development and continuous learningprocess

19. Reclaiming Futures (RF) - continued“more treatment, better treatment, beyond treatment” • RF sites commit to a process of rigorous system “redesign” to increase availability, • quality of substance and mental health services, • integration of related graduated sanctions and incentives, and • post-justice/post-treatment positive youth development opportunities. • RF teaches how sites how to use • community engagement to develop innovative partnerships with a wide range of community stakeholders (e.g., businesses, faith communities, civic organizations, and service organizations, schools). • essential youth development activities to decrease stigma and increase a youth’s sense of aspirational possibilities for his/her life • RF thus incorporates and compliments the 16 strategies for JTDC and 10 key components of DC in general, and impacts the whole system

20. Level of Evidence is Available on Drug Courts Science Law STRONGER Beyond a Reasonable Doubt 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 Clear and Convincing Evidence Preponderance of the Evidence Probable Cause Reasonable Suspicion Source: Marlowe 2008, Ives et al 2010

21. Level of Evidence is Available on Drug Courts Science Law STRONGER Beyond a Reasonable Doubt 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 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 2010 large multisite quasi-experiment, & several small studies with similar or better effects than regular adolescent outpatient treatment Reasonable Suspicion Source: Marlowe 2008, Ives et al 2010

22. Juvenile Treatment Drug Court Effectiveness Low levels of successful program completion among youths in drug courts was noticeable in several early studies (Applegate & Santana, 2000; Miller, Scocas & O’Connell, 1998; Rodriguez & Webb, 2004). JTDC was found to be more effective than traditional family court with community service in reducing adolescent substance abuse (particularly when using evidence-based treatment) and criminal involvement during treatment (Henggeler et al., 2006). JTDC youth did as well or better than matched youth treated in community based treatment (Sloan, Smykla & Rush, 2004; Ives et al., 2010). But still much room for improvement.

23. Methods

24. GAIN Initial (GAIN-I) Administration Time: Core version 60-90 minutes; full version 110-140 minutes (depending on severity). Training Requirements: 3.5 days (train the trainer) plus recommend formal certification program (Administration certification within 3 months of training; Local Trainer certification within 6 months of training); advanced clinical interpretation recommended for clinical supervisors and lead clinicians. Mode: Generally staff-administered on computer (can be done on paper or self-administered with proctor). Purpose: Designed to provide a standardized biopsychosocial for people presenting to a substance abuse treatment using DSM-IV for diagnosis and ASAM for placement and needing to meet common requirements (CARF, COA, JCAHO, insurance, CDS/TEDS, Medicaid, CSAT, NIDA) for assessment, diagnosis, placement, treatment planning, accreditation, performance/outcome monitoring, economic analysis, program planning, and supporting referral/communications with other systems.

25. GAIN Initial (GAIN-I) (continued) • Scales: The GAIN-I has 9 sections (access to care, substance use, physical health, risk and protective behaviors, mental health, recovery environment, legal, vocational, and staff ratings) that include 103 long (alpha over .9) and short (alpha over .7) scales, summative indices, and over 3,000 created variables to support clinical decision-making and evaluation. It is also modularized to support customization. • Response Set: Breadth (past-year symptom counts for behavior and lifetime for utilization), recency (48 hours, 3-7 days, 1-4 weeks, 2-3 months, 4-12 months, 1+ years, never), and prevalence (past 90 days); patient and staff ratings. • Interpretation: • Items can be used individually or to create specific diagnostic or treatment planning statements. • Items can be summed into scales or indices for each behavior problem or type of service utilization. • All scales, indices, and selected individual items have interpretative cut points to facilitate clinical interpretation and decision making.

26. Cost to Society • Costs of Service Utilization (conservative) based on the frequency of using tangible services (e.g., behavioral, physical and mental health care utilization, days in detention, probation, parole) in the 12 months before and after intake valued by economists (French et al., 2003; Salomé et al., 2003), adjusted for inflation to 2010 dollars and summed. • Costs of Crime (tangible & intangible) based on the frequency of committing crimes (e.g., property crime, interpersonal crime, drug/other crime) in the 12 months before and after intake valued on tangible and intangible costs by economists (McCollister et al., 2010), adjusted for inflation to 2010 dollars and summed.

27. Service Utilization Unit Costs (conservative)

28. Cost of Crime (tangible & intangible) \a Including the 2011 est. cost to the victim, justice system, and criminal career. \b Including the 2011 est. cost of pain & suffering, prorated risk of homicide. \c Total is the sum of 2011 est. cost less any uncorrected risk-of-homicide crime victim cost SOURCE: McCollister, K. E., French, M. T., & Fang, F. (2010).

29. Juvenile Treatment Drug Court (JTDC) Cohort of 16 CSAT grantee sites using the GAIN in Box Elder, MT; Buffalo, NY; Laredo, TX; San Antonio, TX (2); San Rafael, CA;Belmont, CA; Tarzana, CA; Pontiac, MI; San Jose, CA; Austin, TX; Peabody, MA; Providence, RI; Detroit, MI; Philadelphia, PA, & Viera, FL. Intake data collected on1,934 adolescents from these sites between January 2006 through November 2011 Analysis on 1,351 (79% of 1712 due) adolescents with 1+ follow-up at 3, 6, and 12-months post intake.

30. Reclaiming Futures JTDC (RF-JTDC) Cohort of 10 grantee CSAT and/or OJJDP sites using the GAIN in Cherokee Nation, OK; Denver, CO; Greene County,MO; Hardin County, OH; Hocking County, OH; Nassau County, NY; & Seattle, WA; Snohomish County, WA; Travis County, TX; & Ventura County, CA. Intake data cllected on 811 adolescents from these sites between January 2008 through December 2011 Analysis on 556 (89% of 625 due) adolescents with 1+ follow-up at 3, 6, and 12-months post intake.

31. Matching with Propensity Score Weights A comparison of 63 intake characteristics found that 26 (41%) differed significantly between JTDC and RF-JTDC. To make a stronger quasi-experimental comparisons of the groups, we controlled for these differences by using them to create propensity score that reflected how similar the people in the JTDC comparison group were to those in the RF-JTDC. After propensity score weighting of the JTDC group, 19 (73%) of the of the original 26 differences were eliminated 6 (23%) were reduced but still statistically significant (having high count of multi-morbidity*, high health problems*, prior mental health treatment*, 1+ year behind in school**, Hispanic**, Caucasian*), and 1 (4%) was slightly enlarged (Expelled or dropped out of school*) *RF-JTDC higher **JTDC higher

32. Results: Baseline Needs

33. Count of Major Clinical Problems at Intake: RF-JTDC Source: RF-JTDC (weighted n=556)

34. Number of Clinical Problems: JTDC vs. RF-JTDC *Based on count of self reporting criteria to suggest alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity Source: JTDC vs. RF-JTDC (weighted n=1112)

35. General Victimization Scale: RF-JTDC (Number of 15 items endorsed) Source: RF-JTDC (weighted n=556)

36. Major Clinical Problems* by Victimization: RF-JTDC *Based on count of self reporting criteria to suggest alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity Source: RF-JTDC (weighted n=556)

37. Severity of Victimization: JTDC vs. RF-JTDC Source: JTDC vs. RF-JTDC (weighted n=1112)

38. Age of Onset: JTDC Source: JTDC (weighted n=556)

39. Age of Onset: RF-JTDC RF-JTDC Early Onset and Higher Prevalence of Mental Health and Victimization Source: RF-JTDC (weighted n=556)

40. Results: Services

41. Days of Services Received* Substance Abuse Treatment Mental Health Treatment Physical Health Treatment Juvenile Justice System *Days of Substance Abuse (SA), Mental Health (MH), Physical Health (PH) treatment and Juvenile Justice System (JJS) Involvement (primarily days on probation (>70% of total days).) \a p<.05 that post minus pre change is statistically significant \b p<.05 that year after values for Reclaiming Futures JTDC is higherthan the average for other JTDC Source: JTDC vs. RF-JTDC (weighted n=1112)

42. Average Annual Cost of Service Utilization* *Behavioral, physical, mental health treatment, incarceration, probation and parole. Subset to records with valid responses at both time periods. Source: JTDC vs. RF-JTDC (weighted n=1112)

43. SA Treatment Retention: JTDC vs. RF-JTDC \a Initiating treatment within 14 days of GAIN interview (JTDC significantly higher than RF-JTDC) \b Engaged in treatment at least 30 days and at least 3 + days of actual treatment (R-JTDC significantly higher than JTDC) \c Received any treatment 90 to 180 days post intake interview (not statistically different) \d Any days of self help in the year post intake interview (JTDC significantly higher than RF-JTDC) Source: JTDC vs. RF-JTDC (weighted n=1112)

44. Level of Care: JTDC vs. RF-JTDC* *OP: Outpatient, IOP: Intensive Outpatient; STR: Short Term Residential; M-LTR: Medium to Long Term Residential; CC-OP Continuing Care Outpatient. Distribution of clients by Level of Care is significantly different between JTDC and RF-JTDC. Source: JTDC vs. RF-JTDC (weighted n=1112)

45. Type of Treatment: JTDC vs. RF-JTDC \a,b \a A-CRA/ ACC: Adolescent Community Reinforcement Approach/ Assertive Continuing Care; MET/CBT: Motivational Enhancement Therapy/Cognitive Behavior Therapy; 7C: Seven Challenges; EBTx: Other evidenced based treatment approaches; Local manual but not replicated; Other all else. \b Distribution of clients by Type of Treatment is significantly different between JTDC and RF-JTDC. Source: JTDC vs. RF-JTDC (weighted n=1112)

46. Discharge Status: JTDC vs. RF-JTDC \a \a JJS: Juvenile justice system; AMA: Against medical advice; ASR: At staff request. \b Difference represents a small significant effect (Cohen’s d>.2) Source: JTDC vs. RF-JTDC (weighted n=1112)

47. Results: Outcomes

48. Change in Days of Abstinence \a \a Days of abstinence s while living in the community; If coming from detention at intake, based on the days before detention. \b Change within condition is statistically & clinically significant for both JTDC and RF-JTDC \c Amount of change is significantly better for RF-JTDC than JTDC Source: JTDC vs. RF-JTDC (weighted n=1112)

49. Change in Being in Early Recovery \a \a No past month use, abuse or dependence symptoms while living in the community. \b Change within condition is statistically & clinically significant for both JTDC and RF-JTDC Source: JTDC vs. RF-JTDC (weighted n=1112)

50. Change in Days of Victimization \a \a Number of days victimized (physically, sexually, or emotionally ) in past year. Source: JTDC vs. RF-JTDC (weighted n=1112)