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Adolescent Treatment Effectiveness What we have learned (so far)

Adolescent Treatment Effectiveness What we have learned (so far). Michael Dennis, Ph.D. Chestnut Health Systems, Normal, IL. Presentation at the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment May 25, 2011, Rockville, MD. Goals.

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Adolescent Treatment Effectiveness What we have learned (so far)

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  1. Adolescent Treatment EffectivenessWhat we have learned (so far) Michael Dennis, Ph.D. Chestnut Health Systems, Normal, IL Presentation at the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment May 25, 2011, Rockville, MD

  2. Goals To take stock of how far we have come as a field, particularly in the last few years To identify reoccurring themes that represent what we have learn (so far) To focus on the road ahead

  3. Early Adolescent Treatment Work Source: Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003) Worth Street Narcotic Clinic in NY –743 youth 1910 1920 1930 1940 1950 1960 1970 1980 1990 1996 Federal Narcotic Farms in Lexington, KY & Fort Worth, TX 440/yr Riverside Hospital in NYC –250 youth Teen Addiction Hospital Wards in several cities Drug Abuse Reporting Program (DARP)- 5,405 youth (587 followed) Treatment Outcome Prospective Study (TOPS)-1042 youth (256 followed) Services Research Outcome Study (SROS) - 156 youth National Treatment Improvement Evaluation Study (NTIES) - 236 youth Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A) - 3,382 youth (1,785 followed)

  4. What these early studies taught us • Treatment of adolescents with adult models and/or mixed with adults does not work and is actually associated with drop out and increased use • Need to modify models to be more developmentally appropriate for youth • Need for assess and treat a wider range of problems including victimization, co-occurring mental health and education needs • Need to modify materials to be more concrete and use examples relevant to youth

  5. Major limits through 1997 • Lack of standardized and evidenced based assessment and treatment limited the reliability of what was done • Participation, treatment completion, and followup rates were often low limiting the validity of what could be learned • The lack of any manualized evidenced based adolescent approaches limited the ability to disseminate and replicate what did work • Difficult for clinicians, evaluators and/or researchers to work together or even enter the field

  6. CSAT’s 10+ Year Investment in ImprovingAdolescent Treatment Effectiveness 1997-2001, Cannabis Youth Treatment (CYT) – 600 youth 1998-2001, Adolescent Treatment Models (ATM) -1334 youth 1998-2004, CSAT/NIAAA experiments – several hundred youth 2000-2002, Persistent Effects of Treatment Study of Adolescents (PETS-A) - 1200 youth 2001-2003, CSAT/RWJF Reclaiming Futures, 445 youth 2002-2007, Strengthening Communities for Youth (SCY) – 2,249 youth 2002-2012, Targeted Capacity Expansion (TCE) – 1,417 youth 2003-2006, Adolescent Residential Treatment (ART) – 1,458 youth 2003-2007, Effective Adolescent Treatment (EAT) – 5,854 youth 2004-2009, Co-occurring State Infrastructure Grants (COSIG) -system 2004-2009, Young Offender Re-entry Program (YORP) – 1,597 youth 2005-2008, State Adolescent Coordinator (SAC) -system 2005-2010, Juvenile Treatment Drug Court (JTDC) – 1,678 youth 2006-2010, Adolescent Assertive Family Tx (AAFT)-2,769 youth 2007-2011, Brief Interventions and Referrals to Treatment (BIRT) and other Office of Juvenile Justice and Delinquency Prevention and Robert Woods Johnson Foundation (OJJDP/RWJF)- 315 youth 2010- Currently working to extend work in collaboration with CSAP, ED, DOL, HRSA, and OJJDP 6

  7. Big Changes • Over 80% participation, use of evidenced based assessment, use of evidenced based intervention, and follow-up • Have pooled data from 21,531 adolescents (12-17), 3,153 young adults (18-25) and 1,695 adults (26+) assessed with the Global Appraisal of Individual Needs (GAIN), including 88% with one more follow-up • Data made available for program evaluation and secondary analysis, and helped to generate over 200 publications • Have supported the creation and evaluation of over 20 adolescent treatment manuals • Several System level grants

  8. Big Changes - Continued • Funded large scale replications of three major evidenced based practices • Motivational Enhancement Therapy/ Cognitive Behavior Therapy (MET/CBT) in the 36 site EAT program and multiple independent grants • Adolescent Community Reinforcement Approach (A-CRA) and Assertive Continuing Care (ACC) in the 78 Site AAFT program and multiple independent grants • Also funded multiple state and independent grants to replicate other evidenced based practices including • Family Support Network (FSN) • Motivational Interviewing • Multidimensional Family Therapy (MDFT) • Multi-Systemic Therapy (MST) • Seven Challenges (7C)

  9. AAFT ART ATM CYT EAT OJJDP OJJDP-BIRT SCY TCE YORP CSAT Sites with adolescent clients 12-17 and included in the 2009 Summary Analytic GAIN Data Set NH WA VT ME MT ND MN OR MA ID NY WI SD WY MI RI IA PA NE CT NJ OH NV DC IN UT CA IL DE WV VA MO KS CO MD KY NC TN OK AZ NM JTDC SC AR GA AL MS TX LA AK FL HI PR VI 9

  10. Demographic Characteristics CSAT data is diverse with large numbers of females minorities, and younger adolescents *Any Hispanic ethnicity separate from race group Sources: CSAT 2009 SA data set Adolescent Subset (n=19,145). 10

  11. Youth are involved in multiple systems placing competing demands on them and potentially in conflict with each other Source: CSAT 2009 SA Data Set Adolescent Subset (n=19,108) 11

  12. Multiple Clinical Problems are the NORM! Source: CSAT 2009 Summary Analytic Data Set (n=20,826) 12

  13. The Number of Clinical Problems is related to Level of Care Significantly more likely to have 5+ problems (OR=5.8) Source: CSAT 2009 Summary Analytic Data Set (n=21,332) 13

  14. The Number of Major Clinical Problemsis highly related to Victimization Significantly more likely to have 5+ problems (OR=13.9) Source: CSAT 2009 Summary Analytic Data Set (n=21,784) 14

  15. Past 90 day HIV Risk Behaviors are more Related to Sexual Activity than Needle Use Also important to recognize the role of interpersonal violence as a HIV risk factor – particularly for girls *Based on 1+ times had sex while intoxicated, with an injection drug user, with a man who had sex with men, with someone who was HIV positive, or traded sex for goods (n=415) Source: CSAT 2009 SA Data Set Adolescent Subset (n=18,674) 15

  16. Individual Strengths Doing well at close friends Listening, caring or comm. w/ others Sports, exercise, physical activity Doing well at with your family Problem solving and figuring things out Doing well at school or training Working or playing with computers Music, dancing, acting, other perf. art Drawing, painting,  design or other art Doing well at work Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)

  17. Sources of Social Support Doing well at close friends Listening, caring or comm. w/ others Sports, exercise, physical activity Doing well at with your family Problem solving and figuring things out Doing well at school or training Working or playing with computers Music, dancing, acting, other perf. art Drawing, painting,  design or other art Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)

  18. Potential Mentors in the Recovery Environment Home School or Work Social Peers Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681) 18

  19. Major Predictors of Bigger Effects Found in Multiple Meta Analyses (Lipsey, 1997, 2005) • A strong intervention protocol based on prior evidence • Quality assurance to ensure protocol adherence and project implementation • Proactive case supervision of individual • Triage to focus on the highest severity subgroup

  20. Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis The more features, the lower the recidivism Average Practice Source: Adapted from Lipsey, 1997, 2005

  21. Evidenced Based Treatment (EBT) that Typically do Better than Usual Practice in Reducing Juvenile Use & Recidivism • Adolescent Community Reinforcement Approach (A-CRA) • Aggression Replacement Training (ART) • Assertive Continuing Care (ACC) • Cognitive Behavior Therapy (CBT) • Functional Family Therapy (FFT) • Moral Reconation Therapy (MRT) • Thinking for a Change (TFC) • Interpersonal Social Problem Solving (ISPS) • Motivational Interviewing (MI) Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004

  22. Evidenced Based Treatment (EBT) that Typically do Better than Usual Practice in Reducing Juvenile Use & Recidivism • Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT) • Multi Systemic Therapy (MST) • Multidimensional Family Therapy (MDFT) • Reasoning & Rehabilitation (RR) • Seven Challenges (7C) No evidence of an iatrogenic effect of group treatment Small or no differences in mean effect size between these brand names Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004

  23. Other Common Findings Low structure and ad hoc “treatment as usual” does not do as well as evidenced based practice Wilderness programs have mixed effects Treating adolescents like adults and in boot camp causes harm on average Relapse is still common and there is a need for on-going support, monitoring and when necessary re-intervention

  24. But better than the average for OP in ATM (200 days of abstinence) Similarity of Clinical Outcomes : Cannabis Youth Treatment (CYT) Not significantly different by condition. Trial 2 Trial 1 300 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 (n=102) CBT12 (n=102) (n=99) (n=100) (n=99) 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 f=0.06 * n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.12 ** n.s.d., effect size f=0.16 Source: Dennis et al., 2004

  25. ACRA did better than MET/CBT5, and both did better than MDFT MET/CBT5 and 12 did better than FSN 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 MET/ CBT5 FSN ACRA MDFT CBT12 $4.91 $6.15 $15.13 $9.00 $6.62 $10.38 CPDA* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 CPPR** * p<.05 effect size f=0.48 * p<.05 effect size f=0.22 ** p<.05, effect size f=0.72 ** p<.05, effect size f=0.78 Suggest the need to consider cost-effectiveness of treatment approaches Source: Dennis et al., 2004

  26. Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate) The best is to have a strong program implemented well The effect of a well implemented weak program is as big as a strong program implemented poorly Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

  27. Change in Abstinence by level of Quality Assurance: Adolescent Community Reinforcement Approach (A-CRA) Effects associated with Coaching, Certification and Monitoring (OR=7.6) Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961) 27

  28. Which general approaches address co-occurring mental health/trauma issues? • Nine Treatment Outpatient Approaches • Seven Challenges (Schwebel, 2004) (n=114) • Chestnut Health Systems (CHS; Godley et al. 2002) Treatment (n=192) • Adolescent Community Reinforcement Approach (A-CRA; Godley et al., 2001) -CYT/AAFT (n=2144) and -Other (n=276) • Multi-Systemic Therapy (MST; Henggeler et al., 1998) (n=85) • Multi-Dimensional Family Therapy (MDFT; Liddle, 2002) (n=258) • Motivational Enhancement Therapy-Cognitive Behavior Therapy (METCBT; Sampl & Kadden, 2001)-CYT/EAT (n=5262) and -Other (n=878) • Family Support Network (FSN; Hamilton et al., 2001) (n=369) 28

  29. Two sets of outcomes • Mental Health • Emotional Problems Scale • Days of Victimization • Days of Traumatic Memories • Other Outcomes • Substance Problems Scale • Substance Frequency Scale • Illegal Activities Scale • HIV Risk Change Index • Average Across 29

  30. Change (post-pre) Effect Size for Emotional Problems by Type of Treatment Four best on mental health outcomes include 7 challenges, CHS, A-CRA, & MST

  31. Change (post-pre) Effect Size for Core Treatment Outcomes by Type of Treatment Four best on treatment outcomes include A-CRA, MST, MDFT, & FSN

  32. Findings • All programs reduced mental health / trauma problems with 4 doing particularly well: 7 challenges, CHS, A-CRA, & MST • All programs reduced general outcomes on average, with 4 doing particularly well: A-CRA, MST, MDFT, FSN • All more assertive/family/systemic programs • All have formal training, quality assurance, monitoring & technical assistance • Where we could break in two (A-CRA & MET/CBT), programs with more training, quality assurance, monitoring and technical assistance did better than those with less • A-CRA with a mix of BA/MA did as well as MST which targets MA level therapists and family therapists that are often in short supply • While it is not as effective, the shortest & least expensive (MET/CBT5) still has positive effects • CSAT Funding large scale dissemination of A-CRA • and MET/CBT 32

  33. 4% 4% 16% 17% 27% 18% 21% 9 % 14% 22% 24% 17% Treatment is the most likely path to recovery Adolescents Have Complex Pathways to Recovery What predicts who enters and maintains recovery? Change occurs in ever possible direction Incarcerated (41% stable) In the In Recovery Community (61% stable) Using (60% stable) Avg of 48% change status each quarter In Treatment (45% stable) Source: 2009 CSAT AT data set; unique n = 11,710

  34. Risk Factors Older Male Caucasian Substance Problems Substance Frequency Repeated Treatment Mental Health Problems Illegal Activity Employment Protective Factors Younger Female Racial Minority Recent Treatment Number of Drug Screens Attend 12 Step Meetings Positive Social Peers Positive Recovery Environment School Attendance/ Conduct Risk and Protective Factors Associated with Transitioning to/Remaining in Recovery Source: 2009 CSAT Adolescent Treatment Dataset

  35. Recovery* by Level of Care 100% Outpatient (+79%, -1%) 90% Residential(+143%, +17%) 80% Post Corr/Res (+220%, +18%) 70% CC better 60% Percent in Past Month Recovery* 50% OP & Resid Similar 40% 30% 20% 10% 0% Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12 • 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 Adolescent Treatment Outcome Data Set (n-9,276)

  36. Cont. CareAdmis. 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

  37. UCC ACC * p<.05 Assertive Continuing Care (ACC) can Improved General Aftercare 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, 2007

  38. 55% 55% 43% High (7-12/12) GCCA * p<.05 High GCCA Improves Early (0-3 mon.) Abstinence 100% 90% 80% 70% 60% 50% 38% 36% 40% 30% 24% 20% 10% 0% Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA Source: Godley et al 2002, 2007

  39. Percent of Days Abstinent from AOD in Offender Re-entry Programs by Age Limit of current GPRA, starts measurement at release and does not control for or even measure time in a controlled environment Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)

  40. JTDC Reduced Use More than AOP (d between= -0.24) Comparison of Treatment Outcomes: Adolescent Outpatient (AOP) vs. Juvenile Treatment Drug Court (JTDC) Others Outcomes Not Significantly Different Post-Pre d (AOP, JTDC) Illegal Activity (d=-0.11, -0.02) Substance Use* ( d=-0.45, -0.57) Emotional Problems (d=-0.32, -0.22) Trouble w/ Family (d= -0.23, -0.18) In Controlled Environment (d=-0.02, -0.08) Source: Ives et al., in press *p<.05 change greater for JTDC vs AOP (d=-0.24)

  41. Outcome Data has also been used to make comparison groups for • GPRA, NOMS and other outcomes by gender, race, age, level of care, type of evidenced based practice, and program • CYT interventions vs. regular outpatient treatment • Post residential treatment recovery support services vs. aftercare as usual • Opioid Users vs. Alcohol/Marijuana Users • Transitional Age Youth vs. adolescents & adults • Impact of experience and certification on GAIN quality • Deaf and hard of hearing vs. hearing • Gender, Race and Ethnicity differences • in the response to A-CRA

  42. Cost of Substance Abuse Treatment Episode Many SBIRT, School, Workplace and other early intervention programs focus on brief intervention • $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 $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

  43. Quarterly Costs to Society* associated with higher intensity of justice system involvement Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335) in 2009 dollars

  44. Investing in Treatment has a Positive Annual Return on Investment (ROI) • Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested • 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 we saved. Source: Bhati et al., (2008); Ettner et al., (2006)

  45. SAMHSA/CSAT’s Adolescent Clients • Data were pooled on clients from 148 local evaluations, recruited between 1997 to 2009 and followed quarterly for 6 to 12 months (over 80% completion). • In 2009 dollars, the 16,915 adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake). • This would be $3.9 Million per 1,000 adolescents served. • Within 12 months, the cost of treatment provided by CSAT grantees was offset by reductions in other costs producing a net benefit to taxpayers of $4,592 per adolescent.

  46. Economic Benefit to Society of SAMHSA/CSAT Funded Treatment by Level of Care \a Includes the cost of treatment \b Year after intake (including treatment) - year before treatment

  47. In practice we need a Continuum of Measurement(Common Measures) More Extensive / Longer/ Expensive Screener Quick Comprehensive Special • Screening to Identify Who Needs to be “Assessed” (5-10 min) • Focus on brevity, simplicity for administration & scoring • Needs to be adequate for triage and referral • GAIN Short Screener for SUD, MH & Crime • ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD • SCL, HSCL, BSI, CANS for Mental Health • LSI, MAYSI, YLS for Crime • Quick Assessment for Targeted Referral (20-30 min) • Assessment of who needs a feedback, brief intervention or referral for more specialized assessment or treatment • Needs to be adequate for brief intervention • GAIN Quick • ADI, ASI, SASSI, T-ASI, MINI • Comprehensive Biopsychosocial (1-2 hours) • Used to identify common problems and how they are interrelated • Needs to be adequate for diagnosis, treatment planning and placement of common problems • GAIN Initial (Clinical Core and Full) • CASI, A-CASI, MATE • Specialized Assessment (additional time per area) • Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan • CIDI, DISC, KSADS, PDI, SCAN

  48. Longer assessments identify more areas to address in treatment planning Most substance users have multiple problems 5 min. 20 min 30 min 1-2 hr Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)

  49. Importance of Targeting on Performance Measures 218/224=97% to targeted 553/771=72% unmet need 771/982=79% in need Size of the Problem Extent to which services are not reaching those in most need Extent to which services are currently being targeted Source: 2008 CSAT AAFT Summary Analytic Dataset

  50. Mental Health Problem (at intake) vs. Any MH Treatment by 3 months Source: 2008 CSAT AAFT Summary Analytic Dataset

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