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

Evaluating the Impact of Adding the Reclaiming Futures Approach to Juvenile Treatment Drug Courts. Michael L. Dennis, Ph.D., Kate Moritz, M.A., Rachel Meckley, Nora Jones, M.S., Chestnut Health Systems, Normal, IL

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

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  1. Evaluating the Impact of Adding the Reclaiming Futures Approach to Juvenile Treatment Drug Courts Michael L. Dennis, Ph.D., Kate Moritz, M.A., Rachel Meckley, Nora Jones, M.S., Chestnut Health Systems, Normal, IL Susan Richardson, Cora Crary, Laura Nissen, Ph.D., Reclaiming Futures National Program Office, Portland State, University, Portland, OR Mac Prichard, M.P.A., Liz Wu, Prichard Communications, Portland, OR May 8, 2012 Report to Kristin Schubert, Robert Woods Johnson Foundation, Reclaiming Futures; Robert Vincent, Substance Abuse and Mental Health Services Administration; and Gwendolyn Williams, Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs

  2. Acknowledgement Analysis for this presentation was supported by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) contract 270-07-0191 using data provided by 27 Juvenile Treatment Drug Court (JTDC) grantees funded by SAMHSA , Office of Juvenile Justice and Delinquency Prevention (OJJDP), and/or Reclaiming Futures (TI17433, TI17434, TI17446, TI17475, TI17484, TI17476, TI17486, TI17490, TI17517, TI17523, TI17535; 655371, 655372, 655373, (TI22838, TI22856, TI22874, TI22907, TI23025, TI23037, TI20921, TI20925, TI20920, TI20924, TI20938, TI20941) The authors thank these grantees and their participants for agreeing to share their data to support this secondary analysis as well as the following people for assistance in preparing and/or feedback on the presentation: Jimmy Carlton, Michael French, Mark Fulop, Lori Howell, Pamela Ihnes, Rachel Kohlbecker, Kathryn McCollister, Daniel Merrigan, Scott Olsen. The opinions about this data are those of the authors and do not reflect official positions of the government or individual grantees. Please direct correspondence to Michael L. Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61701, mdennis@chestnut.org 309-451-7801. This presentation is available at www.gaincc.org/presentations

  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 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+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Age Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000

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

  7. Other Life Course Reasons to Focus on Adolescents 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 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 Few Get Treatment: 1 in 20 adolescents, 1 in 18 young adults, 1 in 11 adults 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: 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. Other Problems With the U.S. Treatment System Less than 75% stay the 90 days recommended by NIDA (half less than 50 days) Less than half are positively discharged Less than 10% 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 their own performance in terms of client outcomes Average staff education is an Associate Degree Staff stay on the job an average of 2 years Source: Institute of Medicine (2006). Improving the Quality of Health Care for Mental and Substance-Use Conditions . National Academy Press.  Retrieved from http://www.nap.edu/catalog.php?record_id=11470

  11. The Cost of Treatment Episode vs. Consequences 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

  12. 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 • 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 This also means that for every dollar treatment is cut, it costs society more money than was saved within the same year Source: Bhati et al., (2008); Ettner et al., (2006), GAO (2012), Lee et al (2012)

  13. Juvenile Justice System 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). By late 2004, there were 357 juvenile treatment drug courts (JTDC) and the number of courts has continued to grow at a rate of 30-50% per year. • Source: Dennis, White & Ives, 2009

  14. Recommended Components JTDC Formal screening process for early identification and referral for substance use and other disorders/needs Multidimensional standardized assessment to guide clinical decision-making related to diagnosis, treatment planning, placement and outcome monitoring Interdisciplinary-treatment drug court team Comprehensive non-adversarial team-developed treatment plan, including youth and family Continuum of substance-abuse treatment and other rehabilitative services to address the youths needs Use of evidence-based treatment practices

  15. Recommended Components JTDC (cont.) Monitoring progress through urine screens and weekly interdisciplinary-treatment drug court team staffings Feedback to the judge followed by graduated performance-based rewards and sanctions Reducing judicial involvement from weekly to monthly with evidence of favorable behavior change over a year or longer Advanced agreement between parties on how on assessment information will be used to avoid self-incrimination Use of information technology to connect parties and proactively monitor implementation at the client and program level Source: National Association of Drug Court Professionals, 1997; Henggeler et al., 2006; Ives et al., 2010.

  16. Level of Evidenced is Available on 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, Ives et al 2010

  17. Level of Evidenced is Available on 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 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

  18. 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

  19. Methods

  20. Juvenile Treatment Drug Court (JTDC) Grants (n=1,934) • Juvenile Treatment Drug Court (DC) • Original cohort of 11 CSAT 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 March 2009 with 1+ follow-up at 3, 6, and 12-months post intake • Juvenile Treatment Drug Court (JTDC) • Cohort of 6 CSAT grantee sites using the GAIN in San Antonio, TX; Seattle, WA; San Rafael, CA; Buffalo, NY; Box Elder, MT; and Viera, FL • Intake data collected from these sites on N=163 Adolescents between January and November 2011 with 1+ follow-up at 3, 6, and 12-months post intake

  21. Reclaiming Futures JTDC (RF-JTDC) Grants (n=811) • Reclaiming Futures – Office of Juvenile Justice and Delinquency Prevention (RF-OJJDP) • Cohort of 3 grantee sites using the GAIN in Greene County, MO; Hocking County, OH; and Nassau County, NY • Intake data collected from these sites on N=457 adolescents between January 2008 through December 2011 with 1+ follow-up at 3, 6, and 12-months post intake • Reclaiming Futures – Juvenile Drug Court (RF-JDC) • Cohort of 6 grantee sites using the GAIN in Hardin County, OH; Snohomish County, WA; Travis County, TX; Ventura County, CA; Cherokee Nation, OK; and Denver, CO • Intake data collected from these sites on N=354 adolescents between January 2010 through December 2011 with 1+ follow-up at 3, 6, and 12-months post intake

  22. 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

  23. 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

  24. Cost to Society • Costs of Service Utilization (conservative) • The frequency of using tangible services (e.g., health care utilization, days in detention, probation, parole, days of missed school) 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) • 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

  25. Service Utilization Unit Costs (conservative)

  26. Cost of Crime (tangible & intangible) \a Including the cost to the victim, justice system, and criminal career \b Including the cost of pain & suffering, prorated risk of homicide

  27. Results: Baseline Needs

  28. Count of Major Clinical Problems at Intake: 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: CSAT 2010 SA Data Set subset to 1+ Follow ups

  29. Number of Clinical Problems: JTDC vs. RF-JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  30. General Victimization Scale: RF-JTDC *Mean of 15 items Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  31. 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: CSAT 2010 SA Data Set subset to 1+ Follow ups

  32. Severity of Victimization: JTDC vs. RF-JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  33. Age of Onset: JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  34. Age of Onset: RF-JTDC RF JTDC Early Onset and Higher Prevalence of Mental Health and Victimization Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  35. Results: Services

  36. Services Received *Days of Substance Abuse (SA), Mental Health (MH), Physical Health (PH) treatment and Juvenile Justice System Involvement \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is betterthan the average for other JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  37. Increase in Average Cost of Service Utilization \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is betterthan the average for other JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  38. Treatment Initiation*: JTDC vs. RF-JTDC *Initial GAIN interview was administered within 14 days before to seven days after admission to Treatment \c Other JTDC has significantly higher rate than RF-JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  39. Engagement*: JTDC vs. RF-JTDC *In initial Treatment 30+ days and reported 3+ days of Treatment \d RF-JTDC has significantly higher rate than Other JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  40. Continuing Care*: JTDC vs. RF-JTDC *Received Treatment 90-180 days post intake Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  41. 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: CSAT 2010 SA Data Set subset to 1+ Follow ups

  42. Type of Treatment*: JTDC vs. RF-JTDC *A-CRA: Adolescent Community Reinforcement Approach; ACC: Assertive Continuing Care; MET/CBT: Motivational Enhancement Therapy/ Cognitive Behavior Therapy; EBTx: Other evidenced based treatment approaches with outcome data.. Distribution of clients by Type of Treatment is significantly different between JTDC and RF-JTDC. Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  43. Length of Stay*: JTDC vs. RF-JTDC *Distribution of clients by Length of Stay is significantly different between JTDC and RF-JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  44. Any Self Help Activity: JTDC vs. RF-JTDC \c Other JTDC has significantly higher rate than RF-JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  45. Results: Outcomes

  46. Change in Days of Abstinence* * Days of abstinence from alcohol and other drugs while living in the community; If coming from detention at intake, based on the 90 days before detention. \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is betterthan the average for other JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  47. Change in Being in Early Recovery* * No past month use, abuse or dependence symptoms while living in the community \a p<.05 that post minus pre change is statistically significant Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  48. Change in Emotional Problems Scale* *Proportional average of recency and days of emotional problems (bothered, kept from responsibilities, disturbed by memories, paying attention, self-control) in past 90 \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is betterthan the average for other JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  49. Change in Days of Victimization* *Number of days victimized (physically, sexually, or emotionally ) in past 90 \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is betterthan the average for other JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

  50. Change in Illegal Activities Scale* *Recency and days (during the past 90) of illegal activity and supporting oneself financially with illegal activity \a p<.05 that post minus pre change is statistically significant Source: CSAT 2010 SA Data Set subset to 1+ Follow ups

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