Screening and Assessment:
Lessons from RWJF’ s
Reclaiming Futures Projects
Michael Dennis, Ph.D.
Chestnut Health Systems,
Bloomington, IL
On line webinar Presentation for Reclaiming Futures, March 28, 2009. This presentation was
supported by a Grant from the Robert Woods Johnson Foundation (RWJF) and reports on
treatment & research funded by them as well as Center for Substance Abuse Treatment (CSAT),
Substance Abuse and Mental Health Services Administration (SAMHSA) under contracts 2702003-00006 and 270-07-0191, as well as several individual CSAT, NIAAA, NIDA and private
foundation 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 Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761,
phone 309-451-7801, fax 309-451-7765, e-Mail: [email protected] Questions about the
GAIN can also be sent to [email protected]
Goals of this Presentation are to
1. Summarize the physical and chronic nature of
substance use disorders, why the justice system cares
and why adolescence is just a critical time period
2. Describe the need for standardizing how we identify
juveniles with behavioral health issues
3. Explaining how to decide what is needed on the
continuum of screening to assessment
4. Illustrate how the differences in what this looks like
in terms what you receive at client and program level
using data from 5 of the original Reclaiming Futures
Sites
5. Discuss implications for program planing and policy
2
Short Term Impact of Substance Use on the Brain
(PET Scan Minutes After Using Cocaine)
Rapid rise in brain
activity after taking
cocaine
Actually ends up lower
than they started
Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon
brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR,
Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377.
3
Recovery from cumulative use takes more time
(PET Scan Activity Days After Using Cocaine)
With repeated use,
there is a cumulative
effect of reduced
brain activity which
requires increasingly
more stimulation (i.e.,
tolerance)
Normal
Cocaine Abuser (10 days)
Even after 100 days
of abstinence
activity is still low
Cocaine Abuser (100 days)
Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain
metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer
D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers.
Synapse 14:169-177, 1993.
4
The effects on the brain can be long lasting
(Serotonin Present in Cerebral Cortex Neurons )
Reduced in response to excessive use
Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine
Still not back to
normal after 7 years
5
The Costs of Substance Use

Drug use costs the U.S. over $181 billion a year,
primarily due to productivity loss, and health care and
crime costs (Harwood, 2000)

Abuse of alcohol, tobacco, and other drugs, kills more
Americans than any other class of health behavior
(Mokdad et al 2004)

Of the 20,196 deaths from overdose in 2004, 358 (2%)
were from alcohol and 19,838 (98%) were from other
drugs, with 9798 (49%) from opioids. (MMWR, 2007)

Of the 23.2 million people (9.5% of the U.S. population)
who had substance disorders in 2005, only 2.2 million
(0.9%) received any treatment (OAS, 2006)
6
Overlap with Crime and Civil Issues





Committing property crime, drug related crimes, gang
related crimes, prostitution, and gambling to trade or get
the money for alcohol or other drugs
Committing more impulsive and/or violent acts while
under the influence of alcohol and other drugs
Crime levels peak between ages of 15-20 (periods or
increased stimulation and low impulse control in the
brain)
Adolescent crime is still the main predictor of adult
crime
Parent substance use is intertwined with child
maltreatment and neglect – which in turn is associated
with more use, mental health problems and perpetration
of violence on others
7
Potential Cost Savings of Expanding Diversion
to Treatment Programs in Justice Settings

Currently treating about 55,000 people in these
diversion programs and drug courts at a cost of $515
million with an average return on investment (ROI) of
$2.14 per dollar

The ROI is higher (2.71) for those with more crime

It is estimated that there are at least twice as many people
in need of drug court as getting it

Investing the $1 billion to treat them would likely produce
a ROI of $2.17 billion to society
Source: Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of
Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban
Institute.
8
Severity of Past Year Substance Use/Disorders by age
NSDUH Age Groups
100
90
80
Adolescent
Onset
Remission
Increasing
rate of nonusers
70
Severity Category
No Alcohol or Drug Use
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
0
Dependence
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
(2002 U.S. Household Population
age 12+= 235,143,246)
Source: 2002 NSDUH; Dennis & Scott 2007
9
Crime & Violence by Substance Severity
60%
Age 12-17
50%
Severity is related to
other violence/crime
problems
40%
30%
20%
10%
0%
Serious Fight Fighting with
At School
Group
Dependence (3.9%)
Weekly AOD Use (6.4%)
Light Alc Use (12.4%)
Source: NSDUH 2006
Sold Drugs
Attacked with Stole (>$50)
intent to harm
Carried
Handgun
Abuse (4.2%)
Any Drug or Heavy Alc Use (8.8%)
No PY AOD Use (64.3%)
10
Family, Vocational & MH by Substance Severity
60%
Age 12-17
50%
As well as other
School and Mental
Health Problems
40%
30%
20%
10%
0%
10 or More
Disliked School
Arguments with
Parents
Dependence (3.9%)
Weekly AOD Use (6.4%)
Light Alc Use (12.4%)
Source: NSDUH 2006
GPA = D or
lower
Major
Depression
Any MH
Treatment
Abuse (4.2%)
Any Drug or Heavy Alc Use (8.8%)
No PY AOD Use (64.3%)
11
Main reasons
for using are to
get pleasure or
dull pain
Adolescent Brain
Development Occurs from the
Inside to Out and
from Back to Front
pain
Photo courtesy of the NIDA Web site. From A
Slide Teaching Packet: The Brain and the
Actions of Cocaine, Opiates, and Marijuana.t
12
Substance Use Careers Last for Decades
1.0
.9
Median of 27
years from
first use to 1+
years
abstinence
.8
Cumulative Survival
.7
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
30
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
13
Substance Use Careers are
Longer the Younger the Age of First Use
1.0
.9
Age of
1st Use
Groups
.8
Cumulative Survival
.7
.6
.5
under 15*
.4
15-20*
.3
.2
21+
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
* p<.05
(different
from 21+)
14
Substance Use Careers are
Shorter the Sooner People Get to Treatment
1.0
.9
Year to
1st Tx
Groups
.8
Cumulative Survival
.7
20+
.6
.5
.4
Reducing the years
of use and its
associated problems
by over a decade
.3
.2
.1
0.0
0
5
10
15
10-19*
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
0-9*
* p<.05
(different
from 20+)15
Treatment Careers Last for Years
1.0
Median of 3 to 4
episodes of treatment
over 9 years
.9
.8
Cumulative Survival
.7
Over 2/3rds
eventually
get better
(which is
better than
most major
DSM
disorders)
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
Years from first Tx to 1+ years abstinence
Source: Dennis et al., 2005
16
Several Recent Reviews and over 22 Experiments
and Quasi-Experiments Have Demonstrated That

A growing range of drug treatment courts are being found
effective and cost effective

More assertive continuing care can increase adherence
with continuing care expectations

Recovery management checkups can identify people who
have relapsed and get them back to treatment faster

That doing each improves short and long term outcomes

That the rate of improve effects went up as interventions
when from less than 3 months (38%) to 3 to 12 months
(44%) to more than 12 months (100%)
Source: Bhati et al 2008; Dennis et al 2003, 2007, Godley et al 2002, 2007; Marlowe, 2008; McKay, in
press; Scott et al 2005, in press
The Movement to Increase Screening

Screening, Brief Intervention and Referral to Treatment
(SBIRT) has been shown to be effective in identifying people
not currently in treatment, initiating treatment/change and
improving outcomes (see http://sbirt.samhsa.gov/ )

The US Preventive Services Task Force (USPSTF, 2004;
2007), National Quality Forum (NQF, 2007), and Healthy
People 2010 have each recommended regular screening, brief
intervention, and referral to treatment (SBIRT) for tobacco
and alcohol abuse in general medical settings for everyone

The latter two also recommend SBIRT for drug use in high
risk populations (e.g., adolescents, pregnant and post partum
women, people with HIV, and people with co-occurring
psychiatric conditions)

RWJF, OJJDP, CSAT and NIDA are each funding several
projects to develop and evaluate models for doing this
18
Places vary in the rate of problems
(Past Year Substance Abuse or Dependence)
There is
even
variation
within DC
(an area less
than 10
square
miles) and of
course
within
individuals
Source: OAS, 2006
19
Crime/Violence and Substance Problems Interact
to Predict Any Recidivism
Crime/
Violence
predicted
recidivism
80%
60%
40%
20%
Crime and
Violence
Scale
0%
Knowing both was the
best predictor
Source: CYT & ATM Data
12 month recidivism
100%
Substance
Problem
Scale
Substance Problem
Severity predicted
recidivism
20
100%
80%
Crime/
Violence
predicted
violent
recidivism
60%
40%
20%
Crime and
Violence
Scale
0%
Knowing both was the
best predictor
Source: CYT & ATM Data
12 month recidivism
To violent crime or arrest
Crime/Violence and Substance Problems Interact
Differently to Predict Recidivism to Violent Crime
Substance
Problem
Scale
(Intake) Substance
Problem Severity did
not predict violent
recidivism
21
Mental Health Comorbidity Among Girls in Detention
Multiple
Problems
are the
norm
Source: Teplin, LA, Abram, KM, McCelland, GM, Mericle, AA, Dulcan, MK, and Washburn, JJ (2006) Psychiatric Disorders of
Youth in Detention. Washington, DC: OJJDP. Retrieved from http://www.ncjrs.gov/pdffiles1/ojjdp/210331.pdf
22
Mental Health Comorbidity Among Boys in Detention
While there
are gender
differences,
the
differences
are often
degrees of
variation
Source: Teplin, LA, Abram, KM, McCelland, GM, Mericle, AA, Dulcan, MK, and Washburn, JJ (2006) Psychiatric Disorders of
Youth in Detention. Washington, DC: OJJDP. Retrieved from http://www.ncjrs.gov/pdffiles1/ojjdp/210331.pdf
23
Number of Major Clinical Problems by System of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
0 to 1
56%
45%
44%
46%
46%
2 to 4
10%
5 or more
0%
Total
In School
In workforce
Source: Dennis et al in 2008;
CSAT 2007 AT Outcome Data Set (n=12,824)
In Child
Welfare
*
In Juv.
Justice
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
24
Number of Problems is Related to Level of Care
100%
90%
0 to 1
80%
2 to 4
70%
60%
5 or more
50%
40%
67%
30%
20%
50%
78%
55%
39%
10%
0%
Outpatient
(OR=1)
Intensive
Outpatient
(OR=1.6)
Long Term
Residential
(OR=1.9)
Source: Dennis et al 2009; CSAT 2007 Adolescent
Treatment Outcome Data Set (n=12,824)
Med. Term
Residential
(OR=3.2)
*
Short Term
Residential
(OR=5.5)
Clients entering
Short Term
Residential
(usually dual
diagnosis) have
5.5 times higher
odds of having 5+
major problems*
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
25
No. of Prob. is related to the Severity of Victimization
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None
One
Two
Three
Four
Five+
70%
45%
15%
Low
(OR 1.0)
Mod.
(OR=4.6)
High
(OR=13.2)
Those with high
lifetime levels of
victimization
have 13 times
higher odds of
having 5+ major
problems*
Severity of Victimization
Source: Dennis et al 2009; CSAT 2007 Adolescent
Treatment Outcome Data Set (n=12,824)
*
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
26
Continuum of Measurement (Common Measures)
Quick
Comprehensive Special
More Extensive / Longer/ Expensive
Screener

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

Specialized Assessment
–
–
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
27
Key Work Force / System Issues to Consider
When Selecting Assessment




High turnover workforce with variable education
background related to diagnosis, placement and
treatment planning.
Heterogeneous needs and severity characterized by
multiple problems, chronic relapse, and multiple
episodes of care
Lack of access to or use of data at the program
level to guide immediate clinical decisions, billing
and program planning
Missing or misrepresented data that needs to be
minimized and incorporated into interpretations
28
Issue
Instrument Feature
Protocol Feature
Outcome
High Turnover Workforce
with Variable Education
• Standardized approach to asking
questions across domains
• Questions spelled out and simple
question format
• Lay wording mapped onto expert
standards for given area
• Built in transition statements, prompts,
and checks for inconsistent and missing
information.
• Responses to frequently asked questions
• Multiple training resources
• Formal training and certification
protocols on administration, clinical
interpretation, data management, project
coordination, local, regional, and
national “trainers”
• Above focuses on consistency across
populations, level of care, staff and time
• On-going quality assurance and data
monitoring for the reoccurrence or
problems at the staff (site or item) level
• Availability of technical assistance
Improved Reliability and
Efficiency
Heterogeneous Needs
and Severity
• Multiple domains
• Focus on most common problems
• Participant self description of
characteristics, problems, needs,
personal strengths and resources
• Behavior recency, breadth, frequency
• Utilization lifetime, recency and
frequency
• Dimensional measures
• Interpretative cut points
• Items and cut points mapped onto DSM
for diagnosis, ASAM for placement, and
to multiple standards and evidencebased practices for treatment planning
• Computer generated scoring and reports
• Treatment planning recommendations
and links to evidence-based practice
• Basic and advanced clinical
interpretation training and certification
Comprehensive Assessment
Global Appraisal of Individual Needs (GAIN)
Logic Model as an Example
29
Issue
Instrument Feature
Protocol Feature
Outcome
Lack of Access to or use of
Data at the Program Level
• Data immediately available to support
clinical decision making for a case
• Data can be transferred to other clinical
information system to support billing,
progress reports, treatment planning and
on-going monitoring
• Data can be exported and cleaned to
support further analyses
• Data can be pooled with other sites to
facilitate comparison and evaluation
• PC and (soon) web based software
applications and support
• Formal training and certification on
using data at the individual level and
data management at the program level
• Data routine pooled to support
comparisons across programs and
secondary analysis
• Over two dozen scientists working with
data to link to evidence-based practice
Improved Program Planning
and Outcomes
Missing or
Misrepresented Data
• Assurances, time anchoring, definitions,
transition, and question order to reduce
confusion and increase valid responses
• Cognitive impairment check
• Validity checks on missing, bad,
inconsistency and unlikely responses
• Validity checks for atypical and overly
random symptom presentations
• Validity ratings by staff
• Training on optimizing clinical rapport
• Training on time anchoring
• Training answering questions, resolving
vague or inconsistent responses,
following assessment protocol and
accurate documentation.
• Utilization and documentation of other
sources of information
• Post hoc checks for on-going site, staff
or item problems
Improved Validity
Global Appraisal of Individual Needs (GAIN)
Logic Model as an Example
30
Questions So Far?
For the rest of the session we will focus on doing
two things simultaneously

Demonstrating the difference in the depth and
and breadth of information you get with
different levels of assessment

Doing this by using findings from the first cohort
of RWJF Reclaiming Future sites to also review
what they learned
31
GAIN Clinical Collaborators
Adolescent and Adult Treatment Program
New Hampshire
Washington
Montana
North
Dakota
Oregon
Vermont
Minnesota
South
Dakota
Idaho
Massachusetts
Wisconsin
New York
Michigan
Wyoming
Nebraska
Nevada
Pennsylvania
Iowa
Illinois Indiana
Ohio
Utah
Colorado
California
Maine
W. Virginia
Kansas
Delaware
Virginia
Missouri
Kentucky
North Carolina
Tennessee
Oklahoma
Arizona
New Mexico
Arkansas
Mississippi
Texas
Maryland
District Of Columbia
South Carolina
Number of GAIN Sites
Georgia
Alabama
0
1 to 10
11 to 25
Louisiana
Alaska
Florida
Hawaii
Rhode Island
Connecticut
New Jersey
26 to 130
GAIN State System
GAIN-SS State or
County System
Puerto Rico
Virgin Islands
10/08
32
Across measures, the GAIN has a Common
Factor Structure of Psychopathology
Source: Dennis, Chan, and Funk (2006)
33
GAIN-Short Screener (GSS): Overview




Administration Time: A 3- to 5-minute screener
Purpose: Used in general populations to
– identify or rule-out clients who will be identified as
having any behavioral health disorders on the 60-120 min
versions of the GAIN
– triage area of problem
– serve as a simple measure of change
– Easy for administration and interpretation by staff with
minimal training or direct supervision
Mode: Designed for self- or staff-administration, with paper
and pen, computer, or on the web
Translations: English, with translations with us into Spanish
and by collaborators into several languages including French,
Hmong, Japanese, Mandarin, Pilipino, Portuguese, and
Vietnamese so far
34
GAIN-Short Screener (GSS): Overview (continued)



Scales: Four screeners for Internalizing Disorders, Externalizing
Disorders, Substance Disorders, Crime/Violence, and a Total
Response Set: Recency of 20 problems rated past month (3), 212 months ago (2), more than a year ago (1), never (0)
Interpretation: Combined by cumulative time period as:
–
–
–
–
–
–
–

Past month count (3s) to measure of change
Past year count (2s or 3s) to predict diagnosis
Lifetime count (1s, 2s or 3s) as a measure of peak severity
Can be classified within time period low (0), moderate (1-2) or high (3)
Can also be used to classify remission as
Early (lifetime but not past month)
Sustained (lifetime but not past year)
Reports: Narrative, tabular, and graphical reports built into web
based GAIN ABS and/or ASP application for local hosting
35
Internalizing Disorder Screening (IDScr)
Externalizing Disorder Screening (EDScr)
36
Substance Disorder Screening (SDScr)
Crime/violence Disorder Screening (CVScr)
37
GAIN Short Screener Profile of 2 Recl. Futures Sites
(Range based on 0/1-2/3+ Symptoms)
100%
90%
Low
80%
70%
60%
50%
Mod.
40%
81%
30%
20%
48%
33%
37%
38%
High
10%
0%
Internalizing Externalizing
Disorder
Disorder
Screener
Screener
Substance
Disorder
Screener
Crime/
Violence
Screener
Total
Disorder
Screener
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
38
GAIN Short Screener Number of Problems Mod/Hi
100%
90%
7%
9%
No SR prob
22%
1 Prob.
22%
2 Probs.
80%
70%
93% endorsed one or
more problems
(40% 4 or more)
60%
50%
40%
30%
40%
3 Probs.
20%
4 Probs.
10%
0%
No. of
Problems
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
39
GAIN SS Psychometric Properties
100%
Low Mod.
High
Prevalence (% 1+ disorder)
90%
Sensitivity (% w disorder above)
80%
Specificity (% w/o disorder below)
(n=6194 adolescents)
70%
60%
50%
40%
20%
At 3 or more
symptoms we get
99% prevalence,
10%
91% sensitivity, &
89% specificity
30%
Using a lower cut
point increases
prevalence and
specificity, but
decreases sensitivity
0%
0
1
2
3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Total Disorder Screener (TDScr)
Total score has alpha of
.85 and is correlated .94
Source: Dennis et al 2006
with full GAIN version
40
GSS Performance by Subscale and Disorders
Screener/Disorder
Internal Disorder Screener (0-5)
Any Internal Disorder
Major Depression
Generalized Anxiety
Suicide Ideation
Mod/High Traumatic Stress
External Disorder Screener (0-5)
Any External Disorder
AD, HD or Both
Conduct Disorder
Substance Use Disorder Screener (0-5)
Any Substance Disorder
Dependence
Abuse
Crime Violence Screener (0-5)
Any Crime/Violence
High Physical Conflict
Mod/High General Crime
Total Disorder Screener (0-5)
Any Disorder
Any Internal Disorder
Any External Disorder
Any Substance Disorder
Any Crime/Violence
Prevalence
1+
3+
Sensitivity
1+
3+
Specificity
1+
3+
81%
56%
32%
24%
60%
99%
87%
56%
43%
82%
94%
98%
100%
100%
94%
55%
72%
83%
84%
60%
71%
54%
44%
41%
55%
99%
94%
83%
79%
90%
88%
65%
78%
97%
82%
91%
98%
99%
98%
67%
78%
70%
75%
51%
62%
96%
85%
90%
96%
65%
30%
100%
87%
13%
96%
100%
89%
68%
91%
25%
73%
30%
14%
100%
82%
28%
88%
31%
85%
99%
46%
100%
94%
100%
94%
49%
70%
51%
76%
38%
71%
99%
77%
100%
97%
58%
68%
89%
68%
99%
63%
75%
92%
73%
99%
100%
100%
99%
100%
91%
98%
99%
92%
96%
47%
8%
10%
20%
10%
89%
28%
37%
51%
32%
Low (0),
Moderate (1-2),
and High (3+)
cut points can
be used to
identify the
need for specific
types of
interventions
Moderate can be
targeted where
resources allow
or where a more
assertive
approach is
desired
Mod/Hi can be
used to evaluate
program
delivery/referral
41
GAIN SS Total Score is Correlated With
Level Of Care Placement
Total Disorder Screener for Adolescents
% within Level of Care and Age Group
11%
Lo
10% w
9%
Mod
High ->
OP/IOP
Median=6.0
Residential
Median=10.5
OP/IOP (n=2499)
Residential (n=1965)
8%
7%
6%
5%
4%
3%
2%
1%
0%
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20
TDScr Score
42
GAIN SS Can Also be Used for Monitoring
20
12+ mon.s ago (#1s)
2-12 Mon.s ago (#2s)
Past Month (#3s)
Lifetime (#1,2,or 3)
16
12
10
11
9
9
10
Track Gap Between
Prior and current
Lifetime Problems to
identify “under
reporting”
8
8
3
4
2
2
0
Intake
3
6
9
12
15
18
21
24
Mon Mon Mon Mon Mon Mon Mon Mon
Track progress in
reducing current
(past month)
symptoms)
Total Disorder Screener (TDScr)
Monitor for Relapse
43
GAIN Quick (GQ) : Overview

Administration Time: 20-30 minutes (depending on
severity and wether reasons for quiting module used)

Training Requirements: 1 day (train the trainer) plus
certification within 1-2 months

Mode: Generally Staff Administered on Computer
(can be done on paper or self administered with
proctor)

Purpose: Designed for use in targeted populations to
support brief intervention or referral for further
assessment or behavioral intervention

Translation: English, with translations with us into
Spanish by Chestnut and by collaborators being
translated into French and Portuguese so far
44
GAIN Quick (GQ): Overview (Continued)




Scales: The GQ has total scale (99-symptoms) and 15 subscales
(including more detailed versions of the GSS scales and subscales plus
scales for service utilization, sources of psychosocial stress, and health
problems). All scales focus on the past year only and it is primarily
used to support motivational interviewing or for a one time assessment
(though there is a shorter follow-up version). Lifeimt
Response Set: Breadth (past year symptom counts for behavior and
lifetime for utilization) and Prevalence (past 90 days)
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 and for recent service utilization overall
– All scales, indices and selected individual items have interpretative
cut-points to facilitate clinical interpretation and decision making
Reports: Narrative, tabular, graphical, validity and motivational
interviewing reports built into web based GAIN ABS; Program level
reports available in SPSS/Excel
45
GAIN Quick Profile of 4 Reclaiming Futures Sites
(Range based on 0-24% / 25-74% / 75-100% of Symptoms)
Source: Reclaiming Futures Chicago, IL, Dayton, OH, Portland,
OR and Santa Cruz, CA sites (n=475).
25%
28%
AOD Dependence
Substance Problem
High
(76-100%)
*Total Score
29%
AOD Use & Abuse
29%
General Crime
22%
26%
Conduct Disorder
*Externalizing
24%
Hyper-Inattention
*Internalizing 5%
18%
Anxiety-Trauma Sx
Suicide Risk
Depression
*General Life Prob
Health Distress
24%
Mod
(25-75%)
Sources of Stress
Risk
Stress
Health
Low
(0-24%)
General Factors
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
More
detail
within
each area
* Summary Measure
46
GAIN Quick Number of Problems Mod/Hi
100%
90%
80%
70%
60%
3%
8%
8%
13%
No SR prob
1 Prob.
69%
2 Probs.
50%
97% endorsed one or
more problems
(69% 4 or more
problems)
40%
3 Probs.
30%
20%
4 Probs.
10%
0%
No. of
Problems
Source: Reclaiming Futures Chicago, IL, Dayton, OH, Portland,
OR and Santa Cruz, CA sites (n=475).
47
GAIN Quick (GQ): In Transition




Strengths: Length, Range of topics, Efficiently Categorize, Narrative reports
to support screening, brief intervention, and referral to treatment
Problems:
– Lacks scales to support analyses or outcomes related to change over time
– Item response choices do not provide information about lifetime
problems or problems that have occurred in finer gradations of time
within the past year
– Current Personal Feedback Report focuses only on substance use and
does not address the other content areas of the GAIN-Q
– Only about 60% of the items can be directly imported into the GAIN-I
– Cut points do not map onto GAIN I or clinical criteria well
Plans for Version 3:
– Keep focus on screening, brief intervention and referral to treatment
– Subsume GSS and add similar screeners in other GAIN Q areas with
recency response to address change and lifetime issues
– Create a summary measure for days items to address change issues
– Create reasons for change items in each area to support breif intervention,
reducing number of items in substance use
– Make all questions importable into full GAIN
Plans for Version 4: Add computer adaptive testing (CAT) component to get
at more detailed diagnosis
48
GAIN Initial (GAIN-I): Overview





Administration Time: Core version 60-90 minutes/Full version 110140 minutes (depending on severity and inclusion of GPRA module)
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
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, ASAM for placement, and needing to meet common
(CARF, COA, JCAHO, insurance, CDS/TEDS, Medicaid, CSAT,
NIDA) requirements for assessment, diagnosis, placement, treatment
planning, accreditation, performance/outcome monitoring, economic
analysis, program planning and to support referral/communications
with other systems
Translation: English, with translations with us into Spanish by
Chestnut and by collaborators being translated into French and
Portuguese so far
49
GAIN Initial (GAIN-I): Overview (Continued)



Scales: The GI 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 3000 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 cutpoints to facilitate clinical interpretation and decision making
Reports: Narrative, tabular, validity and motivational interviewing
reports built into web based GAIN ABS; New Narrative report include
placement and treatment planning statements; Program level reports
available in SPSS/Excel
50
GAIN Initial Profile: Substance Problems Past Year
(Range based range of clinical/logical/statistical rules)
100%
90%
Low
80%
70%
60%
Mod.
50%
40%
30%
High
20%
19%
Sub. Prob.
Past Year
7%
Sub. Use/
Induced
Prob.
0%
15%
Dependence
10%
Abuse
31%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
51
GAIN Initial Profile: Substance Problems by Time
(Range based range of clinical/logical/statistical rules)
100%
90%
Low
80%
70%
60%
Mod.
50%
40%
30%
39%
10%
High
31%
13%
Sub. Prob.
Past Month
Sub. Prob.
Past Year
Sub. Prob.
Lifetime
0%
2%
Withdrawal
Sx Past
Week
20%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
52
GAIN Initial Profile: Motivation and Readiness
(Range based range of clinical/logical/statistical rules)
100%
90%
Low
80%
70%
60%
Mod.
50%
40%
76%
30%
High
20%
32%
10%
Problem
Orientation
Treatment
Motivation
Treatment
Pressure
7%
Treatment
Resistance
0%
SelfEfficacy
0%
19%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
53
GAIN Initial Profile: Crime/Violence
(Range based range of clinical/logical/statistical rules)
Low
Mod.
51%
8%
Drug Crime
High
Crime
Violence
5%
Interpersonal
Crime
33%
Property
Crime
25%
Viol.
ConflictTactic
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
54
GAIN Initial Profile: Environmental Risk
(Range based range of clinical/logical/statistical rules)
Low
Mod.
64%
54%
39%
High
Environmental
Risk
Social Env.
Risk
28%
Vocational
Env. Risk
Living Env.
Risk
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
55
GAIN Initial Profile: Internalizing Disorders
(Range based range of clinical/logical/statistical rules)
100%
90%
Low
80%
70%
60%
50%
40%
Mod.
30%
20%
Sucide Risk
Depression
1%
9%
9%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
Internalizing
3%
Truama
15%
Somatic
0%
High
24%
AnxietyFear
10%
56
GAIN Initial Profile: Externalizing Disorders
(Range based range of clinical/logical/statistical rules)
Low
12%
14%
20%
Conduct
Disorder
Externalizing
20%
Hyperactivityimplusive
Mod.
Inattentiveness
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
High
57
GAIN Initial Profile: Personality Disorders
(Range based range of clinical/logical/statistical rules)
100%
90%
Low
80%
70%
60%
Mod.
50%
40%
30%
53%
20%
High
10%
Total
Personality
Worrying
(Cluster C)
Implusive
(Cluster B)
Cautious
(Cluster A)
0%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
58
GAIN Initial Profile: General Factors / Stress
(Range based range of clinical/logical/statistical rules)
100%
90%
80%
Low
70%
60%
50%
40%
30%
Mod.
44%
20%
10%
0%
High
10%
12%
Person
Axis IV
Other Axis
IV
Victimization
School
Prob.
Employment
Prob.
26%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
59
GAIN Initial Profile: Other Problem Scales
(Range based range of clinical/logical/statistical rules)
100%
90%
Low
80%
70%
60%
Mod.
50%
40%
30%
High
20%
2%
4%
Life
Satisfaction
Health
0%
17%
Social
Support
12%
Gambling
10%
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
60
GAIN Initial Profile: Measures of Behavior Change
(Range based range of clinical/logical/statistical rules)
100%
90%
80%
Low
70%
60%
50%
Mod.
40%
30%
Work
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
Financial
3%
4%
School
Substance
Use
14%
High
23%
Illegal
Activity
3%
0%
10%
Recovery
Environment
41%
Emotions
41%
Health
20%
10%
61
GAIN Initial Number of Problems Mod/Hi
100%
90%
98%
No SR prob
80%
70%
1 Prob.
60%
2 Probs.
50%
99.4% endorsed one or
more problems
(98.4% 4 or more)
40%
30%
3 Probs.
20%
10%
4 Probs.
0%
No. of
Problems
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
62
GAIN Treatment Planning/Placement Grid
Problem Recency/Severity
None
Current (past 90 days)*
Past
Low-Mod
| High Severity
None
1. No Problem
Consider monitoring
and relapse prevention.
Past
Consider initial or low
invasive treatment.
4. Severe problems;
Not in treatment
Consider a more intensive
treatment or intervention
strategies.
0. Not Logical
Current
Treatment History
2. Past problem
3. Low/Moderate
problems;
Not in treatment
Check under- standing
of problem or lying and
recode.
5. No current
problems;
Currently in
treatment
Review for step down or
discharge.
6. Low/Moderate
problems;
Currently in treatment
Review need to continue or
step up.
7. Severe problems;
Currently in treatment
Review need
for more intensive or
assertive levels.
.
* Current for Dimension B1 = Past 7 days
63
Reclaiming Futures as or more severe than
Regular Adolescent Treatment
ASAM B6.
Environ.
ASAM B5.
Rel. Pot.
ASAM B4.
Readiness
ASAM B3.
Psych/Beh
ASAM B2
Biomedical
ASAM B1.
Intox/Withd.
0%
20%
40%
60%
80%
100%
AT
RF
AT
RF
AT
RF
AT
RF
AT
RF
AT
RF
Inconsistent
No problem
Past Prob
Low/Mod Prob
High Prob
No Prob in Tx
L/M Prob in Tx
H Prob in Tx
Source: King County Adolescent Treatment (n=1860) vs. Reclaiming Futures (n=404)
64
Cont. Care
Case management
Environmental Risk
Copying with stress
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Strengths/Soc Sup.
Other
Common
Treatment
Planning
Needs
Getting into Treat.
Child Maltreatment
RF Need more help w
coming from Cont. Env.
-Case management
-Evnrionmental Risk
-Child Maltreatment
-Behavior control
-Anger Management
-Vocational Issues
-Detox/Withdrawal
-Self Help Support
-Scheduling
Need for Change
Behavior Control
School Problems
Anger Management
Other Vocational Help
Detox / Withdrawal
Recovery Coach
HIV intervention (Sex)
Tobacco Cessation
Self Help / Support
Job Placement
Family Fighting
Adolescent Treatment
Reclaiming Futures
Scheduling
Source: King County Adolescent Treatment (n=1860) vs. Reclaiming Futures (n=404)
65
Variance Explained in 10 NOMS Outcomes
Percent of Variance Explained
0%
5%
10%
15%
20%
25%
35%
26%
No AOD Use
24%
No AOD related Prob.
11%
No Health Problems
25%
No Mental Health Prob.
15%
No Illegal Activity
33%
No JJ System Involve.
26%
Living in Community
18%
No Family Prob.
14%
Vocationally Engaged
Social Support
30%
8%
Count of above
\2 Past 90 days *All statistically Significant
Past
month
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
24%
\1
66
Best Level of Care*:
L evel
of C are*:
Cluster A Low B-est
Low
(n=1,025)
C lu ster A L ow - L ow (n = 1,025)
120%
% B est P redicted O utcom es
99.6%
100%
80%
60%
40%
20%
0.4%
0%
O utpatient
H igher L O C
* B ased o n M ax im u m P red icted C o u n t o f P o sitiv e O u tco m es
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
67
Best Level of Care*:
Best Level
of Care*:
Cluster C Mod-Mod
(n=1209)
Cluster C Mod-Mod (n=1209)
90%
% Best Predicted Outcomes
80%
70%
60%
50%
40%
38.6%
30.2%
30%
23.6%
20%
7.6%
10%
0%
Outpatient
IOP
OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
68
Best Level of Care*:
Best Level of Care*:
Cluster F Hi-Hi
(n=968)
Cluster(CC)
F Hi-Hi
(CC) (n=968)
90%
81.5%
% Best Predicted Outcomes
80%
70%
60%
50%
40%
30%
20%
10%
9.9%
8.6%
0.0%
0%
Outpatient
IOP
OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
69
Best Level of Care*:
Best Level
of Care*:
Cluster G Hi-Mod
(Env/PH)
(n=749)
Cluster G Hi-Mod (Env/PH) (n=749)
100%
94.1%
90%
80%
70%
60%
50%
40%
30%
20%
10%
5.9%
0.0%
0%
Outpatient
IOP/OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
70
Conclusions
 Substance use disorders have a physical,
developmental, and chronic nature and are of
particular relevance to the juvenile justice system
 Standardized assessment is needed because there are
multiple overlapping and complex problems
 There is a continuum of measurement from screening
to comprehensive assessment
 Moving along this continuum requires more
investment, but also gives more information to the
individual, clinician and program
Questions?
71
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