Assessment and Treatment
of Adolescents
Michael L. Dennis, Ph.D.
Chestnut Health Systems
Normal, IL
Presentation at the Pacific Asia Judges Science and Technology Seminar,
November 10-12, 2010, Hyatt Regency Hotel, Tumon, Guam. This
presentation was supported by funds from and data from NIDA grants no.
R01 DA15523, R37-DA11323, R01 DA021174, and CSAT contract no. 27007-0191. It is available electronically at www.chestnut.org/li/posters . The
opinions are those of the author do not reflect official positions of the
government. Please address comments or questions to the author at Chestnut
Health Systems, 448 Wylie Drive, Normal, IL 61761
[email protected] or 309-451-7801.
Goals of this Presentation are to
1. Examine the prevalence, course, and
consequences of adolescent substance use
2. Highlight what it takes to move the field
towards evidenced-based practice
3. Present the findings from several recent
treatment needs assessment and outcome
studies on adolescent substance abuse
treatment
2
Severity of Past Year Substance Use/Disorders
(2002 U.S. Household Population age 12+= 235,143,246)
Dependence 5%
Abuse 4%
Regular AOD
Use 8%
Any Infrequent
Drug Use 4%
No Alcohol or
Drug Use
32%
Light Alcohol
Use Only 47%
Source: 2002 NSDUH, Dennis & Scott 2007
3
Problems Vary by Age
NSDUH Age Groups
100
90
80
70
60
Over 90% of
use and
problems
start between
the ages of
12-20
People with drug
dependence die an
average of 22.5 years
sooner than those
without a diagnosis
It takes decades before
most recover or die
Severity Category
50
No Alcohol or Drug Use
Light Alcohol Use Only
Any Infrequent Drug Use
Regular AOD Use
40
30
20
Abuse
Dependence
10
0
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
Source: 2002 NSDUH and Dennis & Scott 2007
4
Higher Severity is Associated with
Higher Annual Cost to Society Per Person
$4,000
Median (50th percentile)
$3,500
Mean (95% CI)
$3,000
$2,500
$2,000
$1,500
$3,058
This includes people who are in
recovery, elderly, or do not use
because of health problems
$1,613
Higher
Costs
$1,528
$1,309
$1,078
$1,000
$725
$406
$500
$0
$948
$0
$0
No
Alcohol or
Drug Use
Light
Alcohol
Use Only
$231
$231
Any
Infrequent
Drug Use
Regular
AOD
Use
Abuse
Dependence
Source: 2002 NSDUH
5
Crime & Violence by Substance Severity
60%
Substance use severity is
related to crime and violence
50%
Adolescents 12-17
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%)
6
Family, Vocational & MH by Substance Severity
60%
..as well as family, school
and mental health
problems
50%
Adolescents 12-17
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%)
7
Substance Use Disorders are Common,
But Treatment Participation Rates Are Low
Few Get Treatment:
1 in 19 adolescents,
1 in 21 young adults,
25%
1 in 12 adults
Over 88% of adolescent and
young adult treatment and
over 50% of adult treatment
is publicly funded
20.9%
Much of the private
funding is limited to 30
days or less and
authorized day by day
or week by week
7.2%
20%
15%
10%
7.8%
5%
0.4%
1.0%
0.5%
0%
12 to 17
18 to 25
26 or older
Abuse or Dependence in past year
Treatment in past year
Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH
8
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 SBIRT for tobacco,
alcohol and increasingly drugs

CSAT and NIDA are both funding several demonstration and
research projects to develop and evaluate models for doing this

Washington State mandated screening in all adolescent and
adult substance abuse treatment, mental health, justice, and
child welfare programs with the 5 minute Global Appraisal of
Individual Needs (GAIN) short screener
9
Overview of the GAIN-Short Screener (GSS)






A 3- to 5-minute screener
Used in general populations to identify or rule-out
clients who will be identified as having a behavioral
health disorders on the 60-120 min versions of the
GAIN
Easy for use by staff with minimal training or direct
supervision
Provides a measure of change
Designed for self- or staff-administration, with paper
and pen, computer, or on the web
Translated by collaborators into several languages
including French, Japanese, Portuguese, and Spanish
so far
10
Factor Structure of GAIN Measures of
Psychopathology and Behavior
Source: Dennis, Chan, and Funk (2006)
11
Substance Abuse Student Assistance
Treatment
Programs
(n=8,213)
(n=8,777)
Either
Juvenile Justice
(n=2,024)
High on Mental Health
Mental Health
Treatment (10,937)
High on Substance
12%
11%
12%
12%
40%
37%
46%
35%
61%
60%
73%
62%
75%
75%
Problems could be easily identified
& Comorbidity common
86%
83%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
77%
67%
57%
47%
Washington State Results with
GAIN Short Screener: Adolescent
Children's
Administration
(n=239)
High on Both
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
12
Adolescent Client Validation of Hi Co-occurring from
GAIN Short Screener vs Clinical Records
by Setting in Washington State
Substance Abuse
Treatment (n=8,213)
Juvenile Justice
(n=2,024)
GAIN Short Screener
Mental Health
Treatment (10,937)
9%
11%
15%
12%
34%
35%
56%
Two page measure closely approximated all found
in the clinical record after the next two years
47%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Children's
Administration
(n=239)
Clinical Indicators
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
13
Where in the System are the Adolescents with Mental
Health, Substance Abuse and Co-occurring?
0
5,000
10,000
15,000
20,000
25,000
Any Behavioral
Health (n=22,879)
Mental Health
(21,568)
Substance Abuse
Need (10,464)
SAP+ SA
Treatment
Over half of
system
Co-occurring
(9,155)
Substance Abuse Treatment
Juvenile Justice
Children's Administration
School Assistance
Programs (SAP) largest
part of BH/MH system;
2nd largest of SA & Cooccurring systems
Student Assistance Program
Mental Health Treatment
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
14
Full GAIN measure
Construct Validity of
GSS Internalizing Disorder Screener
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% Days with MH
problem
Mod/High on
Emotional Problem
Scale (EPS)
Mod/High on
Internal Mental
Distress Scale
(IMDS)
Internalizing Disorder Screener (IDScr)
0
1
2
3
4
5
Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)
15
Construct Validity of
GSS Externalizing Disorder Screener
Full GAIN measure
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% Days with
behavioral
problems
Mod/High on
High on Behavior
Emotional Problem Complexity Scale
Scale (EPS)
(BCS)
Externalizing Disorder Screener (EDScr)
0
1
2
3
4
5
Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)
16
Construct Validity of
GSS Substance Disorder Screener
100%
90%
Full GAIN measure
80%
70%
60%
50%
40%
30%
20%
10%
0%
% Days of
AOD use
Past Year Abuse or
Dependence
Past Year
Dependence
Substance Disorder Screener (SDScr)
0
1
2
3
4
5
Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)
17
Construct Validity of
GSS Crime/Violence Screener
Full GAIN measure
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% Days of illegal
activities
Mod/High on
Illegal Activity
Scale (IAS)
High on
Crime/Violence
Scale (CVS)
Crime and Violence Screener (CVScr)
0
1
2
3
4
5
Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)
18
Total Disorder Screener Severity
Disorder Screener for Adolescents
by Level ofTotal
Care:
Adolescents
Outpatient
Median=6.0
(30% at 10+)
% within Level of Care
11%
Lo Mod. High ->
Residential (n=1,965)
10%
w
9%
OP/IOP (n=2,499)
8%
7%
6%
5%
4%
Residential
3%
Median= 10.5
2%
(59% at 10+)
1%
0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Few
missed
Total Disorder Sceener (TDScr) Score
(1/2-3%)
Source: SAPISP 2009 Data and Dennis et al 2006
19
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
20
Use of a short common screener can

Provide immediate clinical feedback that is a
good approximation of diagnosis and be used to
guide placement and treatment planning

Can be used repeatedly to track change

Support evaluation and planning at program or
state level (e.g., needs, case mix, services needed)

Provide practice based evidence to guide future
clinical decision

Be incorporated into health risk/ wellness
assessments and/or school surveys
21
In practice we need a 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, 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
22
CIDI, DISC, KSADS, PDI, SCAN
Longer assessments identify more
areas to address in treatment planning
100%
90%
7%
9%
3%
8%
8%
22%
13%
80%
70%
1%
0%
98%
0 Reported
1 Prob.
69%
60%
50%
1%
1%
3%
94%
22%
2 Probs.
40%
30%
40%
3 Probs.
20%
10%
4 Probs.
0%
GAIN SS GAIN Q GAIN Q GAIN I
(v2)
(v3 -Beta)
5 min.
20 min
30 min
1-2 hr
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
Most substance
users have
multiple
problems
23
Major Predictors of Bigger Effects
Found in Multiple Meta Analyses
1.
A strong intervention protocol based on
prior evidence
2.
Quality assurance to ensure protocol
adherence and project implementation
3.
Proactive case supervision of individual
4.
Triage to focus on the highest severity
subgroup
24
Impact of the numbers of these Favorable
features on Recidivism in 509 Juvenile
Justice Studies in Lipsey Meta Analysis
Average
Practice
Source: Adapted from Lipsey, 1997, 2005
The more
features,
the lower
the
recidivism
25
Evidenced Based Treatment (EBT) that
Typically do Better than Usual Practice in
Reducing Juvenile Recidivism (29% vs. 40%)











Aggression Replacement Training
Reasoning & Rehabilitation
Moral Reconation Therapy
Thinking for a Change
Interpersonal Social Problem Solving
MET/CBT combinations and Other manualized CBT
Multisystemic Therapy (MST)
Functional Family Therapy (FFT)
Multidimensional Family Therapy (MDFT)
Adolescent Community Reinforcement Approach (ACRA)
Assertive Continuing Care
NOTE: There is generally little or no differences in mean
effect size between these brand names
Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004
26
On-site proactive urine testing can be used to
reduce false negatives by more than half
27
Implementation is Essential
(Reduction in Recidivism from .50 Control Group Rate)
The best is to
have a strong
program
implemented
well
Thus one should optimally pick the
strongest intervention that one can
implement well
Source: Adapted from Lipsey, 1997, 2005
The effect of a well
implemented weak program is
as big as a strong program
implemented poorly
28
% Point Change in Abstinence
Percentage Change in Abstinence (6 mo-Intake) by
level of Adolescent Community Reinforcement
Approach (A-CRA) Quality Assurance
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Effects associated with
intensity of quality
assurance and
monitoring (OR=13.5)
36%
24%
4%
Training Only
Training,
Coaching,
Monitoring
Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)
Clinical Trial
Onsite Protocol
Monitors
29
So what does it mean to move towards
Evidence Based Practice (EBP)?

Introducing explicit intervention protocols that are
– Targeted at specific problems/subgroups and outcomes
– Having explicit quality assurance procedures to cause
adherence at the individual level and implementation at the
program level

Introducing reliable and valid assessment that can be used
– At the individual level to immediately guide clinical judgments
about diagnosis/severity, placement, treatment planning, and
the response to treatment
– At the program level to drive program evaluation, needs
assessment, performance monitoring and long term program
planning

Having the ability to evaluate client and program outcomes
– For the same person or program over time,
– Relative to other people or interventions
30
Key Challenges to Delivery of Quality
Care in Behavioral Health Systems
1. High turnover workforce with variable education
background related to diagnosis, placement,
treatment planning and referral to other services
2. Heterogeneous needs and severity characterized
by multiple problems, chronic relapse, and multiple
episodes of care over several years
3. Lack of access to or use of data at the program
level to guide immediate clinical decisions, billing
and program planning
4. Missing, bad or misrepresented data that needs to
be minimized and incorporated into interpretations
5. Lack of Infrastructure that is needed to support
implementation and fidelity
31
1. High Turnover Workforce with Variable Education





Questions spelled out and
simple question format
Lay wording mapped onto
expert standards for given area
Built in definitions, transition
statements, prompts, and
checks for inconsistent and
missing information.
Standardized approach to
asking questions across
domains
Range checks and skip logic
built into electronic
applications




Formal training and certification
protocols on administration,
clinical interpretation, data
management, 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 training resources,
responses to frequently asked
questions, and technical
assistance
Outcome: Improved Reliability and Efficiency
32
2. Heterogeneous Needs and Severity






Multiple domains
Focus on most common
problems
Participant self description of
characteristics, problems,
needs, personal strengths and
resources
Behavior problem recency,
breadth , and frequency
Utilization lifetime, recency
and frequency
Dimensional measures to
measure change with
interpretative cut points to
facilitate decisions




Items and cut points mapped
onto DSM for diagnosis,
ASAM for placement, and to
multiple standards and
evidence- based practices for
treatment planning
Computer generated scoring
and reports to guide decisions
Treatment planning
recommendations and links to
evidence-based practice
Basic and advanced clinical
interpretation training and
certification
Outcome: Comprehensive Assessment
33
3. 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 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 routinely pooled to
support comparisons across
programs and secondary
analysis
Over three dozen scientists
already working with data to
link to evidence-based practice
Outcome: Improved Program Planning and Outcomes
34
4. Missing, Bad 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
Outcome: Improved Validity
35
5. Lack of Infrastructure
Development
Direct Services
Training and quality assurance
on administration, clinical
interpretation, data
management, follow-up and
project coordination

Clinical Product Development

Software Development

Collaboration with IT vendors
(e.g., WITS)

Data management


Evaluation and data available
for secondary analysis
Over 36 internal & external
scientists and students

Workgroups focused on
specific subgroup, problem, or
treatment approach

Labor supply (e.g., consultant
pool, college courses)


Software support

Technical assistance and back
up to local trainer/expert
Outcome: Implementation with Fidelity
36
Some Common Record Based
Performance Measures
PFP
NIATX
NOMS
CSAT
WCG
NQF
Initiation: Treatment within 2 weeks of diagnosis
X X
X X X
Engagement: 2 additional sessions within 30 days
X X
X X X
Continuing Care: Any treatment 90-180 days out
X
X
X
Detox Transfer: Starting treatment within 2 weeks
X
X
Residential Step Down: Starting OP Tx w/in 2wks
X
Evidenced Based Practice: From NREP/Other lists
Within Cost Bands: see French et al 2009
X
X X
X
X X
* NQF: National Quality Forum; WCG: Washington Circle Group; CSAT: Center for
Substance Abuse Treatment evaluations; NOMS: National Outcome Monitoring
System; NIATX: Network for the Improvement of Addiction Treatment; PFP: Pay for
Performance evaluations
37
Newer NQF Standards of Care






Annual screening for tobacco, alcohol and other
drugs using systematic methods
Referral for further multidimensional assessment to
guide patient-centered treatment planning
Brief intervention, referral to treatment and
supportive services where needed
Pharmacotherapy to help manage withdrawal,
tobacco, alcohol and opioid dependence
Provision of empirically validated psychosocial
interventions
Monitoring and the provision of continuing care
Source: www.tresearch.org/centers/nqf_docs/NQF_Crosswalk.pdf
38
Assessment combined with treatment records
can make better performance measures
Mental Health Need
at Intake
No/Low
Mod/High
Treatment Received
in the first 3 months
Any Treatment
6
218
Total
224
218/224=97% to targeted
No Treatment
205
553
758
Total
211
771
982
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
39
Mental Health Problem (at intake) vs.
Any MH Treatment by 3 months
97%
100%
90%
80%
79%
72%
70%
60%
50%
40%
30%
20%
10%
0%
% of Clients With
Mod/High Need
(n=771/982)*
% w Need but No Service % of Services Going to
After 3 months
Those in Need
(n=553/771)
(n=218/224)
Source: 2008 CSAT AAFT Summary Analytic Dataset
40
Why Do We Care About Unmet Need?

If we subset to those in need, getting mental
health services predicts reduced mental health
problems

Both psychosocial and medication interventions
are associated with reduced problems

If we subset to those NOT in need, getting mental
health services does NOT predict change in
mental health problems
Conversely, we also care about services being
poorly targeted to those in need.
41
Residential Treatment need (at intake) vs.
7+ Residential days at 3 months
100%
90%
80%
70%
60%
50%
40%
30%
90%
Opportunity to
redirect
existing funds
through better
targeting
52%
36%
20%
10%
0%
% of Clients With
Mod/High Need
(n=349/980)*
% w Need but No
% of Services Going to
Service After 3 months Those in Need (n=34/66)
(n=315/349)
Source: 2008 CSAT AAFT Summary Analytic Dataset
42
Will be using data from the Global Appraisal of
Individual Needs (GAIN) Collaborators
NH
WA
MT
VT
MN
ND
ME
MA
OR
ID
WY
NV
CA
UT
WI
SD
MI
NE
CO
KS
AZ
OK
NM
TX
AK
NY
PA
IA
NJ
OH
DE
WV
MO
VA
MD
KY
DC
NC
TN
State or
No of
AR
SC
GAIN Sites Regional System
GA
GAIN-Short
None (Yet)
MS AL
Screener
1 to 14
GAIN-Quick
LA
15 to 30
IL IN
FL
HI
RI
CT
More in BZ, CA,
CN, JP, MX
31 to 165
GAIN-Full
VI
PR
3/10 43
…as well as 6 provinces of Canada and 6
other countries
Number of GAIN Sites
None (Yet)
1 to 14
Canada
15 to 30
31 to 165
State or Regional
System
GAIN-Short
Screener
YT
NT
BC
GAIN-Quick
NU
GAIN-Full
NF
AB
SK
MB
QC
PE
ON
NB
NS
44
Some numbers as of June 2010

1,501 Licensed GAIN administrative units from 49
states (all by ND) and 7 countries

3,270 users in 396 Agencies using GAIN ABS

60,380 intake assessments (largest in field)

22,045 (88% w 1+ follow-up) from 278 CSAT
grantees

22 states, 12 Federal, 6 Canadian provinces, 6 other
countries, and 3 foundations mandate or strongly
encourage its use

4 dozen researchers have published 179 GAINrelated research publications to date
45
The GAIN is ..





A family of instruments ranging from screening,
to quick assessment to a full Biopsychosocial and
monitoring tools
Designed to integrate clinical and research
assessment
Designed to support clinical decision making at
the individual client level
Designed to support evaluation and planning at
program level
Designed to support secondary analyses and
comparisons across individuals and programs
The GAIN is NOT an electronic health record (EHR), but a
component that can interface with and support EHRs.
46
EHR can provide practice based evidence:
Lessons from a Decade of GAIN data from CSAT Grants
NH
WA
MT
VT
ND
MN
OR
MA
ID
WY
CA
NV
ME
SD
WI
IA
NE
PA
DC
VA
IN OH
UT
CO
NY
MI
KS
MO
IL
NM
SC
AR
MS
TX
NC
TN
OK
NJ
DE
MD
KY
AZ
CT
AL
GA
LA
FL
AK
HI
PR VI
RI
AAFT
ART
ATDC
BIRT
JTDC
EARMARK
EAT
FDC
JDC
OJJDP
ORP
RCF
SAC
SCAN
SCY
TCE
YORP47
47
2009 CSAT Data Set by Age
18 Years or
Older (18+)
12.7%,
(n=2,793)
Under 15 Years
Old (<15) 16.1%,
(n=3,547)
15-17 Years
Old 71.2%,
(n=15,705)
Source: CSAT 2009 Summary Analytic Data Set (n=22,045)
48
Diagnosis Time Period Matters
100%
90%
13%
No Use
19%
80%
70%
30%
32%
60%
63%
50%
Use
Abuse
40%
30%
57%
20%
48%
10%
18%
Dependence
18%
0%
Lifetime
Past Year
Source: CSAT 2009 Summary Analytic Data Set (n=21,659)
Past Month
49
100%
90%
80%
Past Year Substance Diagnosis
3 or More Years of Use
57%
54%
Weekly Use
Any Past Year Dependence
48%
24%
Any Withdrawal Symptoms in the Past Week
Severe Withdrawal (11+ Symptoms)
80%
70%
60%
50%
40%
30%
20%
10%
0%
Definition of Substance Use Severity Matters
5%
93%
Can Give 1+ Reasons to Quit*
72%
Client Believes Need ANY Treatment
Acknowledges Having an AOD Problem
26%
Any Prior Substance Abuse Treatment
34%
Source: CSAT 2009 Summary Analytic Data Set (n=21,816)
*(n=11,066)
50
Alcohol
33%
Other drug disorder
27%
34%
Depression
100%
90%
80%
14%
24%
Trauma
ADHD
41%
CD
Suicide
70%
20%
Cannabis
Anxiety
60%
50%
40%
30%
20%
10%
0%
Multiple Clinical Problems are the NORM!
48%
11%
Victimization
Violence/ illegal activity
Source: CSAT 2009 Summary Analytic Data Set (n=20,826)
63%
80%
51
The Number of Clinical Problems is related to
Level of Care (over lapping but different mix)
100%
90%
None
80%
One
70%
Two
60%
Three
50%
80%
40%
65%
30%
20%
Four
41%
45%
53%
Five to Twelve
10%
0%
OP
IOP
CC-OP
LTR
Source: CSAT 2009 Summary Analytic Data Set (n=21,332)
STR
Significantly
more likely to
have 5+ problems
(OR=5.8)
52
The Number of Major Clinical Problems
But this is the
is highly related to Victimization
issue staff least
like to ask about!
100%
None
90%
80%
One
70%
Two
60%
Three
50%
40%
71%
30%
10%
Five to Twelve
46%
20%
15%
0%
Low (0)
Moderate (1-3)
Four
High (4-15)
Source: CSAT 2009 Summary Analytic Data Set (n=21,784)
Significantly more
likely to have 5+
problems
(OR=13.9)
53
Ever attacked w/ gun, knife, other weapon
Ever hurt by striking/beating
Abused emotionally
Ever forced sex acts against your will/anyone
Age of 1st abuse < 18
Any with more than one person involved
Any several times or for long time
Was person family member/trusted one
Were you afraid for your life/injury
People you told not believe you/help you
Result in oral, vaginal, anal sex
Currently worried someone attack
Currently worried someone beat/hurt
Currently worried someone abuse emotionally
Currently worried someone force sex acts
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Overcoming Staff Reluctance with
General Victimization Scale
40%
35%
29%
7%
57%
32%
31%
26%
19%
11%
6%
10%
9%
8%
1%
Source: CSAT 2009 Summary Analytic Data Set (n=19,318)
54
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
B1. Intoxication/Withdrawal Treatment Plan Needs
39%
Any Detox or withdrawal services
22%
Ambulatory Detox (Risk/Mild)
17%
Non-opioid Meds
Opiate Meds
Monitoring withdrawal and AOD meds
compliance
1%
1%
Source: CSAT 2009 Summary Analytic Data Set (n=17,392)
55
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
B2. Biomedical Treatment Plan Needs
Tobacco cessation
60%
Accom. for medical conditions
33%
Discuss compliance w/ prescribed meds
29%
Compliance with meds for PH probs
17%
Discuss ER/hospitalization history
16%
Currently treated for med problem
11%
Tetanus shot
6%
Eating disorder
4%
Treatment of infectious diseases
Accommodations current pregnancy
1%
1%
Reduce sexual behavior risk
Reduce needle use/risk
78%
3%
Source: CSAT 2009 Summary Analytic Data Set (n=17,392)
56
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
B3. Psychological Treatment Plan Needs
Any Co-occuring
72%
Consq of behavior control problems
68%
Refer to anger management
59%
Suicidal risk intervention
23%
Problems reading and writing
22%
Compliance with psych meds
17%
Currently treated for psych problem
16%
8%
Self-mutilation
Monitor self-mutilation
4%
Cognitive impairment
4%
Discuss lifetime mh hosp. history
1%
74%
Coordination with justice system
41%
Consq of interpersonal illegal acts
Consq of drug-related illegal acts
Discuss lifetime arrest history
31%
18%
Consq of other illegal acts
13%
Civil court proceedings
12%
Source: CSAT 2009 Summary Analytic Data Set (n=18,733)
57
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
B4.Readiness Treatment Plan Needs
Any Treatment Readiness Issues
81%
Wrap-around or case
management services
79%
Any pressure to be in treatment
73%
Required to go to treatment
63%
Reviw expectations for length of
treatment
Review dissatisfaction w/
treatment
Partner to understand
treatment process
16%
9%
3%
Source: CSAT 2009 Summary Analytic Data Set (n=9,169)
58
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
B5. Relapse Potential Treatment Plan Needs
High Relapse Potential
84%
Recovery coach or mentor
67%
Continuing Care after
controlled environment
30%
Significant time in controlled
environment
Discuss substance abuse
treatment history
28%
2%
Source: CSAT 2009 Summary Analytic Data Set (n=21,239)
59
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
B6. Environment Treatment Plan Needs
Attended school in past 90 days
85%
Coping with psycho-social
stressors
70%
Child maltreatment
63%
Recent school problems
56%
Dissatisfaction with
environment
54%
Family fighting in the home
Vocational or government
assistance
Substance use in the home
Employed in past 90 days
Housing situation
Source: CSAT 2009 Summary Analytic Data Set (n=14,952)
47%
32%
32%
29%
26%
60
NOMS: Early Treatment Outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
84%
Initiation within 14 days
76%
Evidenced Based Practice
Engagement for at least 6
weeks
72%
Any Continuing Care (91180 days)
58%
Substance Use-Abstinent/
Reduced 50% at 3 Months
66%
12 month cost within bands
for initial type of treatment
Source: CSAT 2009 SA Data Set subset to 1+ Follow ups (n=11,668)
100%
56%
61
76%
41%
Physical Health
44%
Mental Health
99%
Nights of Psychiatric Inpatient
80%
Illegal Activity
90%
Arrests
Housed in Community**
68%
Family/Home Problems
71%
47%
Vocational Problems
Social Support/Engagement
**The blue
bar represents Recovery Environment Risk
an increase
Quarterly Cost to Society
of 50% or no
problem
In Work/School**
100%
66%
Use
Abuse/Dependence Sx*
*This
variable
measures the
last 30 days.
All others
measure the
past 90 days
90%
80%
70%
60%
50%
40%
30%
20%
10%
Reduced 50%
or No
Problem
No Problem
0%
NOMS: Post Treatment Outcome (6-12 mo)
12%
17%
Source: CSAT 2009 SA Data Set subset to 1+ Follow ups
44%
89%
62
Use
19%
42%
Abuse/Dependence Sx*
Physical Health
37%
11%
Mental Health
98%
Nights of Psychiatric Inpatient
61%
Illegal Activity
78%
Arrests
Housed in Community
52%
Family/Home Problems
37%
33%
Vocational Problems
Social Support/Engagement
2%
Recovery Environment Risk
Quarterly Cost to Society
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
But Need to Control for the lack of Problems
at Intake
13%
5%
In Work/School
79%
* Variable measures the last 30 days. All others measure the past 90 days.
Source: CSAT 2009 SA Data Set subset to 1+ Follow ups
63
Change in Number of Positive NOMS Outcomes
(Last Follow up – Intake) 78% Improved in 1 or more areas
(29% in 5 or more)
100%
90%
Five or More
29%
80%
70%
12%
60%
50%
14%
40%
13%
30%
11%
20%
8%
6%
8%
10%
0%
Four
Three
Two
One
None
Negative one
Less than negative one
Total
Source: CSAT 2009 SA Data Set subset to 1+ Follow ups (n=18,770)
64
Any Illegal Activity can be better predicted by using Intake
Severity on Crime/Violence and Substance Problem Scales
Knowing both is a better predictor
(high –high group is 5.5 times more
likely than low low)
Any Ilegal Activity
(months1-6)
Intake Crime/
Violence Severity
Predicts Recidivism
60%
58%
40%
20%
46%
53%
33%
44%
27%
36%
26%
20%
High
0%
Intake Substance
Problem Severity
Predicts
Recidivism
While there is
risk, most (4280%) actually
do not commit
additional crime
Mod
High
Mod
Low
Crime/Violence Scale
(Intake)
Low
Substance
Problem Scale
(Intake)
Source: CSAT 2008 V5 dataset Adolescents aged 12-17 with 3 and/or 6 month follow-up (N=9006)
65
Outcomes May be Hidden by Subgroups:
Example of HIV Risk Outcomes
0.01
0.00
0.00
0.20
-0.40
Unprotected Sex Acts (f=.14)
-0.60
-0.39
-0.29
-0.08
-0.20
-0.03
-0.10
-0.02
0.00
-0.04
Cohen's Effect Size d
0.15
0.10
0.20
0.27
0.40
Days of Victimization (f=.22)
-0.80
-0.69
Days of Needle Use (f=1.19)
A.
Low Risk
Source: Lloyd et al 2007
B.
C.
Mod. Risk
Mod. Risk
W/O Trauma With Trauma
D.
High Risk
Total
66
CYT
Cannabis Youth Treatment
Randomized Field Trial
Coordinating Center:
Chestnut Health Systems, Bloomington, IL,
and Chicago, IL
University of Miami, Miami, FL
University of Conn. Health Center, Farmington, CT
Sites:
Univ. of Conn. Health Center, Farmington, CT
Operation PAR, St. Petersburg, FL
Chestnut Health Systems, Madison County, IL
Children’s Hosp. of Philadelphia, Phil. ,PA
Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA), U.S. Department of Health and Human Services
Cannabis Youth Treatment (CYT) Experiments
Trial 1
Incremental Arm
Trial 2
Alternative Arm
Randomly Assigns to:
Randomly Assigns to:
MET/CBT5
MET/CBT5
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (12 weeks)
FSN
Family Support Network
Plus MET/CBT12 (12 weeks)
Source: Dennis et al, 2002
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
ACRA
Adolescent Community
Reinforcement Approach(12 weeks)
MDFT
Multidimensional Family Therapy
(12 weeks)
68
Actual Treatment Received by Condition
23
FSN adds multi
family group,
family
home visits
20
and more case
MET/CBT12
adds 7 management
more
ACRA and MDFT
both rely on
individual, family and
case
management
And
MDFT
instead
using
moreof group
family therapy
With ACRA
using more
11
individual
therapy
Hours
15 of
sessions
group
10
10
5
Case
M anagement
Family
Counseling
14
Collateral only
Days
25
5
M ulti-Family
group
M ulti-P articipant
Group
5
P articipant only
0
M E T/
M E T/
M E T/
M E T/
CBT5
CBT12
CBT12 +
CBT5
ACRA
M DFT
FSN
In crem en tal Arm
Source: Dennis et al, 2004
Altern ative Arm
69
Average Cost Per Client-Episode of Care
Average Episode Cost ($US) of Treatment
$4,000
$3,500
$3,000
Integrating
|--------------------------------------------Economic Cost-------------------------------------------|-------Director Estimate-----|
family therapy
was
less
Less
than
Less than
$3,495
$3,322
expensive
average
average
adding
forthan
6 weeks
for 12it weeks
$2,500
$1,984
$1,776
$2,000
$1,559
$1,500
$1,126
$1,413
$1,197
$1,000
$500
$-
Source: French et al., 2002
70
90
Days Abstinent
80
Days Abstinent Per Quarter
90%
80%
Percent in Recovery
70
70%
60
60%
50
50%
40
40%
30
30%
20
20%
10
10%
0
0%
Intake
3
6
9
% in Recovery at the End of the Quarter
CYT Increased Days Abstinent
and Percent in Recovery*
12
*no use, abuse or dependence problems in the past month while in living in the community
Source: Dennis et al., 2004
71
Similarity of Clinical Outcomes
by Conditions
Trial 2
Trial 1
300
50%
280
40%
260
30%
240
20%
But better than the
average for OP in220
ATM (200 days of
200
abstinence)
10%
MET/ CBT5
(n=102)
MET/
CBT12
FSN
(n=102)
MET/ CBT5
(n=99)
ACRA
(n=100)
MDFT
(n=99)
Total Days Abstinent*
269
256
260
251
265
257
Percent in Recovery**
0.28
0.17
0.22
0.23
0.34
0.19
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.12
Source: Dennis et al., 2004
Percent in Recovery .
at Month 12
Total days abstinent
over 12 months
.
Not significantly different
by condition.
0%
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.16
72
Moderate to large differences
in Cost-Effectiveness by Condition
$16
$20,000
$16,000
$12
$12,000
$8
$8,000
$4
$4,000
$0
$0
MET/ CBT5
MET/
CBT12
FSN
MET/ CBT5
ACRA
MDFT
CPDA*
$4.91
$6.15
$15.13
$9.00
$6.62
$10.38
CPPR**
$3,958
$7,377
$15,116
$6,611
$4,460
$11,775
* p<.05 effect size f=0.48
** p<.05, effect size f=0.72
Source: Dennis et al., 2004
Cost per person in recovery
at month 12
Cost per day of abstinence
over 12 months
$20
ACRA did better than
MET/CBT5,
and both did
Trial 2
better than MDFT
MET/CBT5 and
Trial 1
12 did better
than FSN
* p<.05 effect size f=0.22
** p<.05, effect size f=0.78
73
Recovery (CPPR)
Cost Per Person in
Cost Per Person in Recovery at 12 and 30
Months After Intake by CYT Condition
Stability of
Trial 1 (n=299)
MET/CBT-5
findings
$30,000 MET/CBT-5, -12
mixed atand
30 months
ACRA more
Trial 2 (n=297)
ACRA Effect
Largely Sustained
$25,000 cost effective at
$20,000
12 months
$15,000
$10,000
$5,000
$0
MET/ CBT5 MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
CPPR at 30 months**
$6,437
$10,405
$24,725
$27,109
$8,257
$14,222
CPPR at 12 months*
$3,958
$7,377
$15,116
$6,611
$4,460
$11,775
* P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months
** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months
Source: Dennis et al., 2003; forthcoming
Integrated family therapy (MDFT)
was more cost effective than adding
it on top of treatment (FSN) at 30
months
74
Some Numbers as of 2010

Over 100,000 copies of manuals distributed

Large scale replications of MET/CBT5 (36 sites)
done and A-CRA (76 sites) under way

All interventions involved in multiple additional
trials and demonstration

Led to wide spread use of the GAIN in adolescent
treatment and pooling of data across grantees –
current n=22,000 (88% with 1+ follow-up)

Sanctuary Inc of Guam just won an Offender Reentry Grant from CSAT to use A-CRA, ACC &
GAIN last month
75
Comparison of 9 Adol Tx 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)
A-CRA-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)
MET/CBT-Other (n=878)
Family Support Network (FSN; Hamilton et al., 2001)
(n=369)
76
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
77
Change (post-pre) Effect Size for Emotional
ProblemsFigure
by 8.Type
Evidenced
Change of
(post-pre)
Effect Size forBased
EmotionalTreatment
Problems
by Type of Evidenced Based Treatment
Seven
Challenges
(n=114)
CHS
Treatment
(n=192)
A-CRACYT/AAFT
(n=2144)
MST
(n=85)
MDFT
(n=258)
METCBTCYT/EAT
(n=5262)
METCBTOther
(n=878)
FSN
(n=369)
A-CRAOther
(n=276)
-0.60
-0.29
-0.08
-0.16
-0.13
-0.08
-0.29
-0.34
-0.37
-0.21
-0.15
-0.13
-0.12
-0.04
-0.19
-0.37
-0.39
-0.32
-0.45
-0.43
-0.40
-0.22
-0.19
-0.14
-0.28
-0.18
-0.20
-0.09
-0.08
0.00
-0.54
Change Effect Size d
((mean follow-up - mean intake)/ std dev. intake)
0.20
Four best on mental health
outcomes include 7 challenges,
CHS, A-CRA, & MST
-0.80
Emotional Problem Scale
Days of traumatic memories
Days of victimization
78
Change (post-pre) Effect Size for Core Treatment
Figure 9.
Change
(post-pre)
Effect Size for Core
Treatment
Outcomes
Outcomes
by
Type
of Evidenced
Based
Treatment
CHS
A-CRATreatment CYT/AAFT
(n=192)
(n=2144)
MST
(n=85)
MDFT
(n=258)
-0.37
-0.38
-0.38
-0.36
Seven
Challenges
(n=114)
-0.39
-0.45
-0.43
-0.39
-0.38
-0.41
by Type of Evidenced Based Treatment
METCBTCYT/EAT
(n=5262)
METCBTOther
(n=878)
A-CRAOther
(n=276)
FSN
(n=369)
-0.29
-0.36
-0.48
-0.23
-0.18
-0.31
-0.29
-0.30
-0.37
-0.29
-0.47
-0.51
-0.34
-0.33
-0.26
-0.19
-0.17
-0.26
-0.27
-0.37
-0.38
-0.33
-0.18
-0.28
-0.23
-0.36
-0.45
-0.43
-0.42
-0.17
-0.11
0.04
-0.43
-0.37
-0.30
-0.11
0.00
-0.80
-0.50
-0.60
-0.65
-0.40
-0.30
-0.20
-0.32
-0.15
0.00
-0.54
-0.62
Change Effect Size d
((mean follow-up - mean intake)/ std dev. intake)
0.20
Four best on treatment outcomes include
A-CRA, MST, MDFT, & FSN
Emotional Problem Scale
Substance Problem Scale
Substance Frequency Scale
HIV Risk Scale
Illegal Activity Scale
Average
79
Recommendations



The two programs that appear best at optimizing
impact on emotional problems and other outcomes
are A-CRA and MST
While A-CRA targets a mix of BA and MA
therapists, MST targets MA level therapists and
family therapists that are often in short supply
Both have coordinating centers that provide training
and technical assistance, thought A-CRA’s is
subsidized by CSAT through its large replication in
over 76 sites
80
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