An evidence-based substance abuse preventive intervention for youth with psychiatric disorders: Initial results

1. An evidence-based substance abuse preventive intervention for youth with psychiatric disorders: Initial results J. Randy Koch, Ph.D. American Public Health Association Philadelphia, PA November 11, 2009

2. Presenter Disclosures J. Randy Koch No Relationships to Disclose (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

3. Presentation Overview • Intervention Development—Community Development Team • Study #1—Feasibility Assessment • Study #2—Pilot Study

4. Background and Rationale • Higher prevalence rates of tobacco and other substance use among youth with mental health problems • Two to four times more prevalent than other youth (Ramsey, et al., 2002; Moolchan, et al., 2000) • Gap in current literature • No studies have examined differential effects of prevention programs between youth with and without MH disorders • No programs designed and tested specifically for this population

5. Goal • Design/adopt and pilot test a tobacco and other substance use preventive intervention for youth receiving community-based mental health services • Determine implementation feasibility (e.g., recruitment, attendance, coordination with Tx) • Test research protocol (e.g., measures) • If warranted, refine the intervention in preparation for a randomized controlled trial (RCT)

6. Community Development Team Process—Yr 1 • Guides the development/selection of the intervention • Team composed of mental health practitioners, prevention specialists, parents and youth (n = 10) • Paid $50 per meeting attended • Seven monthly meetings during first year

7. CDT Results • Major recommendations made by the CDT for intervention components/content and design • Family focused • Program duration/intensity • Coordination with treatment • Literature review using guidance of the CDT to select potentially appropriate programs • Selected Strengthening Families Program

8. The Strengthening Families Program • The program is educational and skill building in focus • Designed to enhance parenting competencies, youth pro-social behavior, and youth peer-resistance skills • Manualized--uses videos and structured exercises • Seven weekly sessions--Youth and parents participate first in a family meal, then in separate groups for the first hour and then a family group for the second hour (Spoth, Redmond, & Shin, 2001; Spoth, Redmond, Shin & Azevedo, 2004).

9. Study 1—Fall 2007 • Design: Pre-Post, intervention group only • Two sites • One rural, public behavioral health agency (n = 5) • One urban, university-based child mental health clinic (n= 6) • Facilitators were certified—most had several years of experience • Jointly trained and weekly conference calls to provide consistency across sites • Participant Eligibility Criteria • Age: 10 to 14 • Parents and youth who are currently or have received MH services in the past 12 months • None had ever been treated for an SUD

10. Measures • Implementation Fidelity and Process • Program facilitators • Parent and youth • MH Therapist • Outcomes • Outcomes—Youth • Outcomes—Parent

11. Outcomes Assessed (examples) • Youth perceptions of smoking (“look cool,” “have more fun,” etc.) • Likelihood of resisting negative peer pressure • Likelihood of refusing a drink of alcohol • Alcohol refusal skills • Parental involvement • Parental monitoring and supervision • Externalizing problem behavior • Internalizing problem behavior • Tobacco, alcohol and marijuana use

12. Youth Characteristics • N = 11 • Age: range 10 to 14 yrs; Mean = 11.5 yrs • White: 55% (VT = 67%); VCU = 40%) • Male: 55% (VT = 50%; VCU = 60%) • MH Disorder (based on medications) • ADHD = 7 (63.6%) • Depression = 1 (9%) • Anxiety = 1 (9%) • Unknown = 2

13. Study 1 -- Results • Youth Attendance Rate: 70/77 = 90.9% Parent Satisfaction (5 pt. Likert-type scale) • Videos were useful: M = 4.2 • Discussions were useful: M = 4.3 • Leaders--Easy to get along with: M = 4.4 • Leaders—Knowledgeable: M = 4.2 • Leaders--Led good discussions: M = 4.3

14. Study 1 – Results (cont’d) Youth Satisfaction(5 pt. Likert-type scale) • Videos were useful: M = 3.5 • Discussions were useful: M = 3.6 • Leaders--Easy to get along with: M = 3.5 • Leaders--Led good discussions: M = 3.5 • Pre-Post Measures • There were few significant differences and no overall trends

15. Study 1 Conclusions • Although challenging, it is possible to identify and recruit from this population • It is possible to maintain participation -- all participants completed the program and the post assessments • Facilitator reports indicate the program was generally implemented as designed, but there were some challenges with the use of written exercises, especially for youth with ADHD and learning disabilities • Given the behavioral problems of some youth, need to incorporate behavioral management interventions • Given the challenges presented by this population, it was not usually possible to cover all the material for each session in the time allotted • Parents and youths reported overall satisfaction with the program, although there were significant site differences

16. Study 2 – Fall 2008 • Design: Pre-Post- 3 month Follow-up, randomized control group (one site) • Matched on gender and age • Control group received informational brochures during weeks 1, 3, 5 and 7 • Two sites – Same sites as Study 1 • One rural, public behavioral health agency (n = 5) • One urban, university-based child mental health clinic • Participant Eligibility Criteria—Same as Study 1 • Age: 10 to 14 • Parents and youth who are currently or have received MH services in the past 12 months • None had ever been treated for an SUD

17. SFP Adaptations • Eliminated active games from the youth sessions • Added an assistant to youth, parent and family sessions • Provided additional incentives for youth for positive behavior • Provided assistance in writing for learning disabled youth • Established rules for disruptive behavior with consequences

18. Participant Characteristics

19. Participant Characteristics--DX • ADHD = 12 • Mood Disorder = 4 • Anxiety = 1 • OCD = 2 • Unknown = 9 Note: Based on medications prescribed

20. Attendance

21. Results Pre to Post Due to the small sample size, effect sizes were calculated to determine the magnitude of change from pre-test to post-test and post-test to follow-up between treatment and controls Moderate to large effect sizes were found for many of the outcome measures Most notable were on measures of alcohol refusal, alcohol resistance, impairment, and parenting

22. Example of Pre to Post Results: Alcohol Refusal Skills (Child Report) Note: Lower scores on this measure indicate higher levels of alcohol refusal

23. Results Post to Follow-up Similar trends were observed between treatment and controls from post-test to follow-up Continued improvement on measures of parenting, impairment, and alcohol refusal New changes were revealed on measures of peer resistance, marijuana refusal, and cigarette refusal

24. Example of Post to Follow-up Results: Impairment Rating Scale Item 3 Note: This item asks parents to rate how their child’s problems affect their academic progress

25. Attendance Effects Attendance was variable across sessions and site It is hypothesized that attendance, in other words treatment exposure, may have impacted treatment outcomes Analysis of effect sizes revealed that on some measures (e.g., IRS, BASC subscales, APQ subscales) there were large to moderate changes seen for those who attended at least 80% of sessions while those attending less than 80% were either deteriorating or remaining stable

26. Conclusions • Results are promising and are an early indication that SFP may be an appropriate prevention program for use with a mental health population • First “successful” implementation of SFP with this population? • Further research with larger samples should be conducted • Future research should also strive for high attendance as this appears to effect Tx outcomes

27. Christine Brady, MS, Ohio University Steve Evans, PhD, Ohio University Fatima El Omari, MD, VCU Humphrey Fellow Dawn Fitzelle, BS, VCU J. Randy Koch, PhD, VCU Crystal Lynn Duncan Lane, Virginia Tech Sally Mays, MS, VCU Peggy S. Meszaros, PhD, Virginia Tech Brian Meyer, PhD, VCU Desiree Molina, PhD, VCU Humphrey Fellow James Pritchett, LCSW, NRVCSB Joey Sadler, MS, Ohio University Martha J. Wunsch, MD, FAAP, Virginia Tech Research Team

28. Funded by the Virginia Tobacco Settlement Foundation