Adolescent Treatment EffectivenessWhat we have learned (so far)

Michael Dennis, Ph.D. Chestnut Health Systems, Normal, IL

Presentation at the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment

May 25, 2011, Rockville, MD

Goals

To take stock of how far we have come as a field, particularly in the last few years

To identify reoccurring themes that represent what we have learn (so far)

To focus on the road ahead

EarlyEarly Adolescent Treatment Work

Source: Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003)

Worth Street Narcotic Clinic in NY – 743 youth

Federal Narcotic Farms in Lexington, KY & Fort Worth, TX 440/yr

Riverside Hospital in NYC – 250 youth

Teen Addiction Hospital Wards in several cities

Drug Abuse Reporting Program (DARP)- 5,405 youth (587 followed)

Treatment Outcome Prospective Study (TOPS)-1042 youth (256 followed)

Services Research Outcome Study (SROS) - 156 youth

1910

1920

1930

1940

1950

1960

1970

1980

1990

1996

National Treatment Improvement Evaluation Study (NTIES) - 236 youth

Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A) - 3,382 youth (1,785 followed)

What these early studies taught us

• Treatment of adolescents with adult models and/or mixed with adults does not work and is actually associated with drop out and increased use

• Need to modify models to be more developmentally appropriate for youth

• Need for assess and treat a wider range of problems including victimization, co-occurring mental health and education needs

• Need to modify materials to be more concrete and use examples relevant to youth

Major limits through 1997

• Lack of standardized and evidenced based assessment and treatment limited the reliability of what was done

• Participation, treatment completion, and followup rates were often low limiting the validity of what could be learned

• The lack of any manualized evidenced based adolescent approaches limited the ability to disseminate and replicate what did work

• Difficult for clinicians, evaluators and/or researchers to work together or even enter the field

6

CSAT’s 10+ Year Investment in ImprovingAdolescent Treatment Effectiveness

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

Big Changes

• Over 80% participation, use of evidenced based assessment, use of evidenced based intervention, and follow-up

• Have pooled data from 21,531 adolescents (12-17), 3,153 young adults (18-25) and 1,695 adults (26+) assessed with the Global Appraisal of Individual Needs (GAIN), including 88% with one more follow-up

• Data made available for program evaluation and secondary analysis, and helped to generate over 200 publications

• Have supported the creation and evaluation of over 20 adolescent treatment manuals

• Several System level grants

Big Changes - Continued

• Funded large scale replications of three major evidenced based practices– Motivational Enhancement Therapy/ Cognitive Behavior

Therapy (MET/CBT) in the 36 site EAT program and multiple independent grants

– Adolescent Community Reinforcement Approach (A-CRA) and Assertive Continuing Care (ACC) in the 78 Site AAFT program and multiple independent grants

• Also funded multiple state and independent grants to replicate other evidenced based practices including– Family Support Network (FSN)– Motivational Interviewing– Multidimensional Family Therapy (MDFT)– Multi-Systemic Therapy (MST)– Seven Challenges (7C)

9

CSAT Sites with adolescent clients 12-17 and included in the 2009 Summary Analytic GAIN Data Set

AK

ALAR

AZ

CACO

CTDC

DE

FL

GA

HI

IA

ID

ILIN

KSKY

LA

MA

MD

ME

MI

MN

MO

MS

MT

NC

ND

NE

NH

NJ

NM

NV

NY

OH

OK

OR

PARI

SC

SD

TN

TX

UTVA

VTWA

WI

WV

WY

PRVI

JTDCOJJDP

ATM

TCE

AAFT

CYT

ART

EAT

OJJDP-BIRTSCY

YORP

10

Demographic Characteristics

*Any Hispanic ethnicity separate from race group

51%

82%

33%

39%

26%

18%

18%

16%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Single Parent

15 to 17 Years Old

12 to 14 Years Old

Hispanic*

Mixed/Other

Caucasian

African American

Female

CSAT data is diverse with

large numbers of females

minorities, and younger

adolescents

Sources: CSAT 2009 SA data set Adolescent Subset (n=19,145).

11

Youth are involved in multiple systems placing competing demands on them and potentially in

conflict with each other

9%

22%

33%

40%

68%

73%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Employed

Controlled environment

Prior Substance Abuse Treatment

Prior Mental Health Treatment

Current justice system involvement

In School

Source: CSAT 2009 SA Data Set Adolescent Subset (n=19,108)

12

Multiple Clinical Problems are the NORM!

20%

41%

80%

48%

33%

63%

11%

24%

14%

34%

27%0% 10

%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Alcohol

Cannabis

Other drug disorder

Depression

Anxiety

Trauma

ADHD

CD

Suicide

Victimization

Violence/ illegal activity

Source: CSAT 2009 Summary Analytic Data Set (n=20,826)

13

The Number of Clinical Problems is related to Level of Care

41% 45%53%

65%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Outpatient IntensiveOutpatient

OP Cont.Care

Long TermResid.

Short TermResid.

None

One

Two

Three

Four

Five Plus

Source: CSAT 2009 Summary Analytic Data Set (n=21,332)

Significantly more likely to

have 5+ problems (OR=5.8)

14

46%

71%

15%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low (0) Moderate (1-3) High (4-15)

None

One

Two

Three

Four

Five to Twelve

The Number of Major Clinical Problemsis highly related to Victimization

Source: CSAT 2009 Summary Analytic Data Set (n=21,784)

Significantly more likely to

have 5+ problems (OR=13.9)

15

Past 90 day HIV Risk Behaviors are more Related to Sexual Activity than Needle Use

63%

2%

20%

19%

26%

30%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sexually Active

Multiple Sex Partners

Any Unprotected Sex

High Risk Sex*

Victimized

Any Needle Use

*Based on 1+ times had sex while intoxicated, with an injection drug user, with a man who had sex with men, with someone who was HIV positive, or traded sex for goods (n=415)

Source: CSAT 2009 SA Data Set Adolescent Subset (n=18,674)

Also important to recognize the role of

interpersonal violence as a HIV risk factor – particularly for girls

Individual Strengths

89%

44%

33%

73%

73%

67%

59%

59%

49%

75%

6.20

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Avearge No. of Strenths (0-10)

0 2 4 6 8 10

Doing well at close friends

Listening, caring or comm. w/ others

Sports, exercise, physical activity

Doing well at with your family

Problem solving and figuring things out

Drawing, painting,  design or other art

Doing well at school or training

Working or playing with computers

Music, dancing, acting, other perf. art

Doing well at work

Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)

Sources of Social Support

90%85%

79%77%77%71%

71%57%

53%6.57

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Average No. of Sources (0-9)

0 2 4 6 8

Doing well at close friends

Listening, caring or comm. w/ others

Sports, exercise, physical activity

Doing well at with your family Problem solving and figuring things out

Drawing, painting,  design or other art

Doing well at school or training

Working or playing with computers Music, dancing, acting, other perf. art

Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)

18

Potential Mentors in the Recovery Environment

52%

75%

25%

18%

58%

41%

30%

16%

63%

46%

29%

16%

4.6

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

None involved in fighting

None involved in illegal activity

Been in treatment

Currently in recovery

None involved in fighting

None involved in illegal activity

Been in treatment

Currently in recovery

None involved in fighting

None involved in illegal activity

Been in treatment

Currently in recovery

Average Attributes (0-12)

0 2 4 6 8 10 12

Hom

eS

choo

l or

Wor

kS

ocia

l P

eers

Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)

Major Predictors of Bigger Effects Found in Multiple Meta Analyses (Lipsey, 1997, 2005)

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

Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice

Studies in Lipsey Meta Analysis

Source: Adapted from Lipsey, 1997, 2005

Average Practice

The more features, the lower

the recidivism

Evidenced Based Treatment (EBT) that Typically do Better than Usual Practice in

Reducing Juvenile Use & Recidivism

• Adolescent Community Reinforcement Approach (A-CRA)• Aggression Replacement Training (ART)• Assertive Continuing Care (ACC)• Cognitive Behavior Therapy (CBT)• Functional Family Therapy (FFT)• Moral Reconation Therapy (MRT)• Thinking for a Change (TFC)• Interpersonal Social Problem Solving (ISPS)• Motivational Interviewing (MI)

Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004

Evidenced Based Treatment (EBT) that Typically do Better than Usual Practice in

Reducing Juvenile Use & Recidivism

• Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT)

• Multi Systemic Therapy (MST)• Multidimensional Family Therapy (MDFT)• Reasoning & Rehabilitation (RR)• Seven Challenges (7C)

Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004

No evidence of an iatrogenic effect of group treatment

Small or no differences in mean effect size between these brand names

Other Common Findings

Low structure and ad hoc “treatment as usual” does not do as well as evidenced based practice

Wilderness programs have mixed effects

Treating adolescents like adults and in boot camp causes harm on average

Relapse is still common and there is a need for on-going support, monitoring and when necessary re-intervention

Similarity of Clinical Outcomes : Cannabis Youth Treatment (CYT)

Source: Dennis et al., 2004

200

220

240

260

280

300

Tot

al d

ays

abst

inen

t.

over

12

mon

ths

0%

10%

20%

30%

40%

50%

Per

cent

in R

ecov

ery

. at

Mon

th 1

2

Total Days Abstinent* 269 256 260 251 265 257

Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19

MET/ CBT5 (n=102)

MET/ CBT12

FSN (n=102)

MET/ CBT5 (n=99)

ACRA (n=100)

MDFT (n=99)

Trial 1 Trial 2

* n.s.d., effect size f=0.06** n.s.d., effect size f=0.12

* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16

Not significantly different by condition.

But better than the average for OP in ATM (200 days of

abstinence)

Moderate to large differences in Cost-Effectiveness by Condition

Source: Dennis et al., 2004

$0

$4

$8

$12

$16

$20

Cos

t per

day

of

abst

inen

ce o

ver

12 m

onth

s

$0

$4,000

$8,000

$12,000

$16,000

$20,000

Cos

t per

per

son

in r

ecov

ery

at m

onth

12

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

MET/ CBT5

MET/ CBT12

FSN MET/ CBT5

ACRA MDFT

* p<.05 effect size f=0.48** p<.05, effect size f=0.72

Trial 1 Trial 2

* p<.05 effect size f=0.22 ** p<.05, effect size f=0.78

MET/CBT5 and 12 did better

than FSN

ACRA did better than MET/CBT5, and both did better than MDFT

Suggest the need to consider cost-effectiveness of treatment approaches

Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)

The effect of a well implemented weak program is

as big as a strong program implemented poorly

The best is to have a strong

program implemented

well

Thus one should optimally pick the strongest intervention that one can

implement wellSource: Adapted from Lipsey, 1997, 2005

27

Change in Abstinence by level of Quality Assurance: Adolescent Community Reinforcement Approach (A-CRA)

4%

24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Training Only Training, Coaching,Certification, Monitoring

% P

oin

t C

han

ge in

Ab

stin

ence

Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)

Effects associated with Coaching, Certification

and Monitoring (OR=7.6)

Which general approaches address co-occurring mental health/trauma issues?

• Nine Treatment Outpatient Approaches • Seven Challenges (Schwebel, 2004) (n=114)• Chestnut Health Systems (CHS; Godley et al. 2002)

Treatment (n=192)• Adolescent Community Reinforcement Approach (A-CRA;

Godley et al., 2001) -CYT/AAFT (n=2144) and -Other (n=276)• Multi-Systemic Therapy (MST; Henggeler et al., 1998)

(n=85)• Multi-Dimensional Family Therapy (MDFT; Liddle, 2002)

(n=258)• Motivational Enhancement Therapy-Cognitive Behavior

Therapy (METCBT; Sampl & Kadden, 2001)-CYT/EAT (n=5262) and -Other (n=878)

• Family Support Network (FSN; Hamilton et al., 2001) (n=369)

28

Two sets of outcomes

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

29

Change (post-pre) Effect Size for Emotional Problems by Type of Treatment

-0.5

4

-0.4

3

-0.4

5 -0.3

9

-0.3

7

-0.3

7

-0.3

4 -0.2

9

-0.2

9

-0.1

8

-0.2

8

-0.1

9

-0.3

2

-0.1

9

-0.1

5

-0.2

1 -0.1

3 -0.0

8

-0.0

8

-0.0

9

-0.1

4

-0.2

2

-0.0

4

-0.1

3

-0.1

2 -0.0

8

-0.1

6

-0.80

-0.60

-0.40

-0.20

0.00

0.20

SevenChallenges

(n=114)

CHSTreatment(n=192)

A-CRA-CYT/AAFT

(n=2144) MST(n=85)

MDFT(n=258)

METCBT-CYT/EAT(n=5262)

METCBT-Other

(n=878) FSN

(n=369)

A-CRA-Other

(n=276)

Cha

nge

Eff

ect S

ize

d ((

mea

n fo

llow

-up

- m

ean

inta

ke)/

std

dev

. int

ake)

Emotional Problem Scale Days of traumatic memories Days of victimization

Four best on mental health outcomes include 7 challenges,

CHS, A-CRA, & MST

Change (post-pre) Effect Size for Core Treatment Outcomes by Type of Treatment

-0.5

4

-0.4

3

-0.4

5 -0.3

9

-0.3

7

-0.3

7

-0.3

4 -0.2

9

-0.2

9

-0.6

2

-0.6

5

-0.4

3

-0.4

5

-0.5

0

-0.3

8 -0.3

3

-0.4

7

-0.3

6-0.3

0

-0.3

7

-0.4

2

-0.4

3 -0.3

8 -0.3

3 -0.2

6

-0.5

1

-0.4

8

-0.1

5 -0.1

1

-0.2

8

-0.3

9

-0.3

8

-0.1

7

-0.1

9

-0.2

9 -0.2

3

0.00 0.

04

-0.2

3

-0.3

8

-0.1

8 -0.1

1

-0.1

7

-0.3

0

-0.1

8

-0.3

2

-0.3

0

-0.3

6

-0.4

1 -0.3

6

-0.2

7

-0.2

6

-0.3

7 -0.3

1

-0.80

-0.60

-0.40

-0.20

0.00

0.20

SevenChallenges

(n=114)

CHSTreatment(n=192)

A-CRA-CYT/AAFT

(n=2144) MST(n=85)

MDFT(n=258)

METCBT-CYT/EAT(n=5262)

METCBT-Other

(n=878) FSN

(n=369)

A-CRA-Other

(n=276)

Cha

nge

Eff

ect S

ize

d ((

mea

n fo

llow

-up

- m

ean

inta

ke)/

std

dev

. int

ake)

Emotional Problem Scale Substance Problem Scale Substance Frequency Scale

HIV Risk Scale Illegal Activity Scale Average

Four best on treatment outcomes include A-CRA, MST, MDFT, & FSN

Findings

• All programs reduced mental health / trauma problems with 4 doing particularly well: 7 challenges, CHS, A-CRA, & MST

• All programs reduced general outcomes on average, with 4 doing particularly well: A-CRA, MST, MDFT, FSN

– All more assertive/family/systemic programs – All have formal training, quality assurance, monitoring &

technical assistance• Where we could break in two (A-CRA & MET/CBT), programs

with more training, quality assurance, monitoring and technical assistance did better than those with less

• A-CRA with a mix of BA/MA did as well as MST which targets MA level therapists and family therapists that are often in short supply

• While it is not as effective, the shortest & least expensive (MET/CBT5) still has positive effects

• CSAT Funding large scale dissemination of A-CRA • and MET/CBT 32

Adolescents Have Complex Pathways to Recovery

In the Community

Using (60% stable)

In Treatment (45% stable)

In Recovery (61% stable)

Incarcerated(41% stable)

Source: 2009 CSAT AT data set; unique n = 11,710

Avg of 48% change status each quarter

18%

16%

22%17%

27%

14%

17%

24%

21%9 %

4%4%

Treatment is the most likely path

to recovery

What predicts who enters and maintains

recovery?

Change occurs in ever possible direction

Risk and Protective Factors Associated with Transitioning to/Remaining in Recovery

• Risk Factors– Older – Male– Caucasian– Substance Problems – Substance Frequency– Repeated Treatment– Mental Health Problems– Illegal Activity– Employment

• Protective Factors– Younger– Female– Racial Minority – Recent Treatment – Number of Drug Screens– Attend 12 Step Meetings– Positive Social Peers– Positive Recovery

Environment– School Attendance/ Conduct

Source: 2009 CSAT Adolescent Treatment Dataset

Recovery* by Level of Care

•Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT Adolescent Treatment Outcome Data Set (n-9,276)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Per

cent

in P

ast

Mon

th R

ecov

ery* Outpatient (+79%, -1%)

Residential(+143%, +17%)

Post Corr/Res (+220%, +18%)

OP & Resid

Similar

CC better

Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17)

Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60 70 80 90

Days after Residential (capped at 90)

Per

cen

t of

Clie

nts

Cont.CareAdmis.

Relapse

Assertive Continuing Care (ACC) can Improved General Aftercare Adherence

Source: Godley et al 2002, 2007

0% 10%

20%

30%

40%

50%

60%

70%

80%

Weekly Tx Weekly 12 step meetings

Regular urine tests

Contact w/probation/school

Follow up on referrals*

ACC * p<.05

90%

100%

Relapse prevention*

Communication skills training*

Problem solving component*

Meet with parents 1-2x month*

Weekly telephone contact*

Referrals to other services*

Discuss probation/school compliance*

Adherence: Meets 7/12 criteria*

UCC

High GCCA Improves Early (0-3 mon.) Abstinence

Source: Godley et al 2002, 2007

24%

36% 38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*)

Low (0-6/12) GCCA

43%

55% 55%

High (7-12/12) GCCA * p<.05

0%10%20%30%40%50%60%70%80%90%

100%Pr

e-co

ntro

lled

envi

ronm

ent

Rele

ase

(initi

al)

3m 6m

<18 years18-25 years26+ years

Percent of Days Abstinent from AOD in Offender Re-entry Programs by Age

Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)

Limit of current GPRA, starts measurement at release and does not control for or even measure time in a

controlled environment

Comparison of Treatment Outcomes: Adolescent Outpatient (AOP) vs.

Juvenile Treatment Drug Court (JTDC)

Source: Ives et al., in press *p<.05 change greater for JTDC vs AOP (d=-0.24)

0

5

10

15

20

25

30

35

Inta

ke

6 m

onth

s*

Inta

ke

6 m

onth

s*

Inta

ke

6 m

onth

s*

Inta

ke

6 m

onth

s*

Inta

ke

6 m

onth

s*

Day

s ou

t of

90

Day

s AOP Weighted(n=1120) JTDC(n=1120)

Substance Use*

( d=-0.45, -0.57)

Emotional Problems

(d=-0.32, -0.22)

Trouble w/ Family

(d= -0.23, -0.18)

In Controlled Environment

(d=-0.02, -0.08)

Illegal Activity

(d=-0.11, -0.02)

Post-Pre d (AOP, JTDC)

JTDC Reduced Use More than AOP

(d between= -0.24)

Others Outcomes Not Significantly Different

Outcome Data has also been used to make comparison groups for

• GPRA, NOMS and other outcomes by gender, race, age, level of care, type of evidenced based practice, and program

• CYT interventions vs. regular outpatient treatment• Post residential treatment recovery support services vs.

aftercare as usual• Opioid Users vs. Alcohol/Marijuana Users• Transitional Age Youth vs. adolescents & adults• Impact of experience and certification on GAIN quality• Deaf and hard of hearing vs. hearing• Gender, Race and Ethnicity differences• in the response to A-CRA

$407$1,249$1,132$1,384$2,486$2,907$4,277

$10,228$14,818

$0 $10,

000

$20,

000

$30,

000

$40,

000

$50,

000

$60,

000

$70,

000

Screening & Brief Inter.(1-2 days)In-prison Therap. Com. (28 weeks)

Outpatient (18 weeks)Intensive Outpatient (12 weeks)

Treatment Drug Court (46 weeks)Residential (13 weeks)

Methadone Maint. (87 weeks)Adol. Residential (13 weeks)Therapeutic Com. (33 weeks)

Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004

Cost of Substance Abuse Treatment Episode

$22,000 / year to incarcerate

an adult

$30,000/ child-year in foster care

$70,000/year to keep a child in

detention

• $750 per night in Detox• $1,115 per night in hospital • $13,000 per week in intensive care for premature baby• $27,000 per robbery• $67,000 per assault

Many SBIRT, School, Workplace and other early

intervention programs focus on brief intervention

Quarterly Costs to Society* associated with higher intensity of justice system involvement

$10,149

$6,746

$4,065

$2,633

$2,410

$2,544

$1,832$0

$2,0

00

$4,0

00

$6,0

00

$8,0

00

$10,

000

$12,

000

$14,

000

AverageQuarterlyCosts toSociety(Prior toIntake)

Past year illegal act

Past JJ status

Other JJ status

Other prob/ parole/detention

Prob/parole 14+ daysw/ 1+ drug screens

Detention 14-29 days

Detention 30+ days

Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335) in 2009 dollars

Investing in Treatment has a Positive Annual Return on Investment (ROI)

• Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested

• Treatment drug courts have an average ROI of $2.14 to $2.71 per dollar invested

Source: Bhati et al., (2008); Ettner et al., (2006)

This also means that for every dollar treatment is cut, we lose more money than we saved.

SAMHSA/CSAT’s Adolescent Clients• Data were pooled on clients from 148 local evaluations,

recruited between 1997 to 2009 and followed quarterly for 6 to 12 months (over 80% completion).

• In 2009 dollars, the 16,915 adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake).

• This would be $3.9 Million per 1,000 adolescents served.• Within 12 months, the cost of treatment provided by CSAT

grantees was offset by reductions in other costs producing a net benefit to taxpayers of $4,592 per adolescent.

Economic Benefit to Society of SAMHSA/CSAT Funded Treatment by Level of Care

Adolescent Level of Care

Year before intake

Year after

Intakea

One Year

Savingsb

Outpatient $10,993 $10,433 $560

Intensive Outpatient $20,745 $15,064 $5,682

Outpatient Continuing Care $34,323 $17,000 $17,323

Long Term Residential $27,489 $26,656 $833

Short Term Residential $25,255 $21,900 $3,355

Total $15,633 $13,642 $1,992

\a Includes the cost of treatment\b Year after intake (including treatment) - year before treatment

In practice we need a Continuum of Measurement (Common Measures)

• Screening to Identify Who Needs to be “Assessed” (5-10 min)– Focus on brevity, simplicity for administration & scoring– Needs to be adequate for triage and referral– GAIN Short Screener for SUD, MH & Crime– ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD– SCL, HSCL, BSI, CANS for Mental Health– LSI, MAYSI, YLS for Crime

• Quick Assessment for Targeted Referral (20-30 min)– Assessment of who needs a feedback, brief intervention or referral for more

specialized assessment or treatment– Needs to be adequate for brief intervention– GAIN Quick – ADI, ASI, SASSI, T-ASI, MINI

• Comprehensive Biopsychosocial (1-2 hours) – Used to identify common problems and how they are interrelated– Needs to be adequate for diagnosis, treatment planning and placement of

common problems– GAIN Initial (Clinical Core and Full)– CASI, A-CASI, MATE

• Specialized Assessment (additional time per area)– Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed)

may be needed to rule out a diagnosis or develop a treatment plan or individual education plan

– CIDI, DISC, KSADS, PDI, SCAN

Screener Quick C

omprehensive S

pecial

More E

xtensive / Longer/ E

xpensive

Longer assessments identify more areas to address in treatment planning

40%

69%

94%98%

22%

13%

3% 0%

22%

8%

1% 0%

9%8%

1% 1%3% 1% 1%7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

GAIN SS GAIN Q(v2)

GAIN Q(v3 -Beta)

GAIN I

0 Reported

1 Prob.

2 Probs.

3 Probs.

4 Probs.

Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)

Most substance users have multiple problems

5 min. 20 min 30 min 1-2 hr

Source: 2008 CSAT AAFT Summary Analytic Dataset

553/771=72%unmet need

218/224=97% to targeted

771/982=79% in need

Importance of Targeting on Performance Measures

Size of the Problem

Extent to which services are currently being targeted

Extent to which services are not reaching those in most need

Treatment Received in the first 3 months

Mental Health Need at Intake

No/Low Mod/High Total

Any Treatment 6 218 224

No Treatment 205 553 758

Total 211 771 982

Mental Health Problem (at intake) vs. Any MH Treatment by 3 months

79%

97%

72%

0%10%20%30%40%50%60%70%80%90%

100%

% of Clients WithMod/High Need

(n=771/982)*

% w Need but No ServiceAfter 3 months

(n=553/771)

% of Services Going toThose in Need(n=218/224)

Source: 2008 CSAT AAFT Summary Analytic Dataset

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.

Residential Treatment need (at intake) vs. 7+ Residential days at 3 months

36%

52%

90%

0%10%20%30%40%50%60%70%80%90%

100%

% of Clients WithMod/High Need

(n=349/980)*

% w Need but NoService After 3 months

(n=315/349)

% of Services Going toThose in Need (n=34/66)

Opportunity to redirect

existing funds through better

targeting

Source: 2008 CSAT AAFT Summary Analytic Dataset

AK

ALAR

AZ

CACO

CTDC

DE

FL

GA

HI

IA

ID

IL IN

KS KY

LA

MA

MD

ME

MIMN

MO

MS

MT

NC

ND

NE

NH

NJ

NM

NV

NY

OH

OK

OR

PARI

SC

SD

TN

TX

UTVA

VTWA

WI

WV

WY

CSAT

2010 SAMHSA/CSAT Grantee Data Set(185 sites)

23 Programs185 Sites

26,390 clients

PR

VI

AK

AL

ARAZ

CACO

DC

FL

GA

HI

IA

ID

IL IN

KS KY

LA

ME

MI

MN

MO

MS

MT

NC

ND

NE

NH

NM

NV

NY

OH

OK

OR

PA

SC

SD

TN

TX

UT

VA

VTWA

WI

WV

WY

CSAT Other 2011

Expanded Data Set (2010 CSAT + 120 Other Sites)

50 Programs305 Sites

58,934 clients

PR

VI

CT

DE

MA

MD

NJ

RI

2011 Expanded Data Set

Age 11-17 (N=34,627)

18-25 (N=8,746)

26+ (N=14,805)

Total (N=58,934)

Female 28% 38% 45% 34%

Minority 58% 44% 45% 52%Prior Treatment 29% 49% 66% 42%

First use under 15 82% 59% 46% 69%Ever Homeless 10% 28% 44% 21%Any Victimization 52% 63% 68% 6%Veteran 0% 1% 6% 2%

More in BZ, CA, CN, JP, MX

ID

ILMO

ND

VI

ME

OK

PR

SD

AR

KS

MS

MT

NM

WVIN

AL

AK

IA

MN

NJNV

RI

SC

UT

HI

LA

DENE

TN

PA

VT

VADC

MI

COKY

GA

OH

OR

MD

AZ

TX

NY

NH

WI

CA

NC

CT

FL

MA

WA

WY

No. of GAIN Sites

None (Yet)

1 to 14

15 to 30

31 to 165

All GAIN Collaborators in the U.S (1700 agencies in 48 states, 6 Canadian provinces and 6 other contries)

State or Regional System

GAIN Short Screener

GAIN Quick

GAIN Full

3/10 56

Recent Initiatives

• 2 page GAIN short screener already implemented in a dozen states, translated into 19 languages and spreading fast

• Using web-based GAIN & ACRA training modules to reduced the duration of off-site training, to provide support for local trainers to train new staff, and to be used in college course to prepare the work force coming out

• Computer based support for clinical decision making related to diagnosis, treatment planning, and placement using narrative and graphical reports

• Up grading site profiles to more closely reflect the individual reports so that clinicians and evaluators are speaking the same language

• GAIN evaluation manual and training to help local evaluators and others interested in secondary analysis use the data at the program or group level

• Linkage to multiple HIT systems

Recent Initiatives (Continued)

• Monitoring assessment and treatment sessions to measure and improve fidelity

• Randomized trial of therapist performance incentives to improve implementation/fidelity and client outcomes

• Expansion of A-CRA/ACC modules targeting trauma and HIV risk behaviors• Addition of A-CRA/ACC supervisor training• Analysis of health disparities by gender, race, age, pregnancy, and

disabilities• Multi-cultural training on how to adapt training and assessment to better

serve clientele• Revisions to GAIN Quick (25-30 min) to better support screening, brief

intervention, and referral to treatment in behavioral health settings (e.g., SAP, EAP,DCF, Justice) where there are health, stress, mental health, substance use and crime/violence issues

New Initiatives

• Testing the GAIN Q in school and justice settings• Testing ability to recruit, train and certify staff on GAIN & A-CRA

with incentives but without SAMHSA/CSAT grants to demonstrate the feasibility of transferring the technology to state and local governments

• Doing reviews of school based behavioral health intervention research in the literature and in SAMHSA/CSAT demonstrations to understand how they are similar/different from community based adolescent treatment

• Created a CSAT + non-CSAT analytic file that can be used to better understand the needs of smaller groups (e.g. Emerging adults, Mixed Race, Vets, GLBTQ)

• Demonstrate the feasibility of using the web-based training modules as part of College Courses to better prepare the work force

Potential AOD Screening & Intervention Sites for Adolescents Age 12 to 17

Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]

4% 0%

29%

5% 1%

34%

96%

8% 3%

45%

93%

9% 12%

43%

95%

90%

0%10%20%30%40%50%60%70%80%90%

100%

Hosptial SubstanceAbuse Tx

EmergencyDept.

School

% A

ny

Con

tact

No use in past yearLess than weekly useWeekly UseAbuse or dependence

Key potential of School Based Health Clinics being expand under health care reform

Why Schools Care

Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]

17%

13%

5% 5%

2%

30%

18%

4%

10%

6%

32%

22%

8%

12%

7%

28%

27%

9% 9%

5%

40%

31%

13% 16

%

9%

41%

41%

19% 21

%

13%

0%

10%

20%

30%

40%

50%

60%

10 or MoreArguments with

Parents

Disliked School GPA = D orlower

MajorDepression

Any MHTreatment

No PY AOD Use (64.3%) Light Alc Use (12.4%)

Any Drug or Heavy Alc Use (8.8%) Weekly AOD Use (6.4%)

Abuse (4.2%) Dependence (3.9%)

Substance use severity is related to family, school and

emotional problems

Why Society Cares if we fail to help in School

Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]

18%

12%

0%

5%

2% 2% 1%

21%

15%

1%

6%

4% 3% 3%

28%

22%

3%

11%

7%

3%

5%

36%

29%

12%

17%

12%

8%

11%

42%

39%

14%

20%

18%

9%

15%

48%

40%

34%

27%

27%

13%

23%

0%

10%

20%

30%

40%

50%

60%

SeriousFight AtSchool

Fightingwith Group

Sold Drugs Attackedwith intent

to harm

Stole(>$50)

CarriedHandgun

Any Arrests

No PY AOD Use (64.3%) Light Alc Use (12.4%)

Any Drug or Heavy Alc Use (8.8%) Weekly AOD Use (6.4%)

Abuse (4.2%) Dependence (3.9%)

Substance use severity is related to crime and violence

Evidenced Based Practices You Can Use Now

• General approaches to adolescent substance abuse treatment at www.chestnut.org/li/apss or http://www.nrepp.samhsa.gov/

• Guidance for ambulatory/outpatient detoxification at http://www.aafp.org/afp/2005/0201/p495.html

• Trauma informed therapy and sucide prevention at http://www.nctsn.org/nccts and http://www.sprc.org/

• Externalizing disorders medication & practices http://systemsofcare.samhsa.gov/ResourceGuide/ebp.html

• Tobacco cessation protocols for youth http://www.cdc.gov/tobacco/quit_smoking/cessation/youth_tobacco_cessation/index.htm

• HIV prevention with more focus on sexual risk and interpersonal victimization at http://www.who.int/gender/violence/en/ or http://www.effectiveinterventions.org/en/home.aspx

• For individual level strengths see http://www.chestnut.org/li/apss/CSAT/protocols/index.html

• For improving customer services http://www.niatx.net

Acknowledgement and Contact Information

• Borrowed slides from earlier presentations by myself, Randy Muck & Doreen Cavanaugh• This presentation was supported by analytic runs provided by Chestnut Health Systems for the

Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT) under Contracts 207-98-7047, 277-00-6500, 270-2003-00006 and 270-2007-00004C using data provided by the following 152 grantees: TI11317 TI11321 TI11323 TI11324 TI11422 TI11423 TI11424 TI11432 TI11433 TI11871 TI11874 TI11888 TI11892 TI11894 TI13190TI13305 TI13308 TI13313 TI13322 TI13323 TI13344 TI13345 TI13354 TI13356 TI13601 TI14090 TI14188 TI14189 TI14196 TI14252 TI14261 TI14267 TI14271 TI14272 TI14283 TI14311 TI14315 TI14376 TI15413 TI15415 TI15421 TI15433 TI15438 TI15446 TI15447 TI15458 TI15461 TI15466 TI15467 TI15469 TI15475 TI15478 TI15479 TI15481 TI15483 TI15485 TI15486 TI15489 TI15511 TI15514 TI15524 TI15524 TI15527 TI15545 TI15562 TI15577 TI15584 TI15586 TI15670 TI15671 TI15672 TI15674 TI15677 TI15678 TI15682 TI15686 TI16386 TI16400 TI16414 TI16904 TI16928 TI16939 TI16961 TI16984 TI16992 TI17046 TI17070 TI17071 TI17334 TI17433 TI17434 TI17446 TI17475 TI17476 TI17484 TI17486 TI17490 TI17517 TI17523 TI17535 TI17547 TI17589 TI17604 TI17605 TI17638 TI17646 TI17648 TI17673 TI17702 TI17719 TI17724 TI17728 TI17742 TI17744 TI17751 TI17755 TI17761 TI17763 TI17765 TI17769 TI17775 TI17779 TI17786 TI17788 TI17812 TI17817 TI17825 TI17830 TI17831 TI17864 TI18406 TI18587 TI18671 TI18723 TI19313 TI19323 TI655374.

• Any opinions about this data are those of the authors and do not reflect official positions of the government or individual grantees.

• Comments or questions can be addressed to Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761. Phone 1-309-451-7801; E-mail:

• mdennis@chestnut.org . More information on the GAIN is available • at www.chestnut.org/li/gain or by e-mailing gaininfo@chestnut.org .