assessment and treatment of adolescents michael l. dennis, ph.d. chestnut health systems normal, il...

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. 270-07-0191. 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.

http://www.chestnut.org/li/posters

mailto:[email protected]

2

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

Goals of this Presentation are to

3

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%

Light Alcohol Use Only 47%

No Alcohol or Drug Use

32%

Source: 2002 NSDUH, Dennis & Scott 2007

4

Problems Vary by Age

Source: 2002 NSDUH and Dennis & Scott 2007

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

No Alcohol or Drug Use

Light Alcohol Use Only

Any Infrequent Drug Use

Regular AOD Use

Abuse

Dependence

NSDUH Age Groups

Severity Category

Over 90% of use and

problems start between the ages of

12-20

It takes decades before most recover or die

People with drug dependence die an

average of 22.5 years sooner than those

without a diagnosis

5

Higher Severity is Associated with Higher Annual Cost to Society Per Person

Source: 2002 NSDUH

$0$231 $231

$725$406

$0$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

No Alcohol orDrug Use

Light Alcohol

Use Only

AnyInfrequentDrug Use

Regular AODUse

Abuse Dependence

Median (50th percentile)

$948

$1,613

$1,078$1,309

$1,528

$3,058Mean (95% CI)

This includes people who are in recovery, elderly, or do not use

because of health problems Higher Costs

6

Crime & Violence by Substance Severity

0%

10%

20%

30%

40%

50%

60%

Serious FightAt School

Fighting withGroup

Sold Drugs Attacked withintent to harm

Stole (>$50) CarriedHandgun

Dependence (3.9%) Abuse (4.2%)

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

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

Source: NSDUH 2006

Adolescents 12-17Substance use severity is related to crime and violence

7

Family, Vocational & MH by Substance Severity

Source: NSDUH 2006

0%

10%

20%

30%

40%

50%

60%

10 or MoreArguments with

Parents

Disliked School GPA = D orlower

MajorDepression

Any MHTreatment

Dependence (3.9%) Abuse (4.2%)

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

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

Adolescents 12-17..as well as family, school

and mental health problems

8

7.8%

20.9%

7.2%

0.5%1.0%0.4%0%

5%

10%

15%

20%

25%

12 to 17 18 to 25 26 or older

Abuse or Dependence in past yearTreatment in past year

Substance Use Disorders are Common,But Treatment Participation Rates Are Low

Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH

Over 88% of adolescent and young adult treatment and

over 50% of adult treatment is publicly funded

Few Get Treatment: 1 in 19 adolescents,

1 in 21 young adults, 1 in 12 adults

Much of the private funding is limited to 30

days or less and authorized day by day

or week by week

9

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

http://sbirt.samhsa.gov/

10

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

11

Factor Structure of GAIN Measures of Psychopathology and Behavior

Source: Dennis, Chan, and Funk (2006)

12

77% 86

%

73%

75%

61%67

%

83%

62%

75%

60%

57%

40% 46

%

12%

12%

47%

37%

35%

12%

11%

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

100%

Substance AbuseTreatment(n=8,213)

Student AssistancePrograms(n=8,777)

Juvenile Justice(n=2,024)

Mental HealthTreatment (10,937)

Children'sAdministration

(n=239)

Either High on Mental Health High on Substance 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/

Washington State Results with GAIN Short Screener: Adolescent

Problems could be easily identified & Comorbidity common

http://publications.rda.dshs.wa.gov/1392/

13

35%

12%

11%

56%

34%

15%

9%

47%

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

100%

Substance AbuseTreatment (n=8,213)

Juvenile Justice(n=2,024)

Mental HealthTreatment (10,937)

Children'sAdministration

(n=239)

GAIN Short Screener Clinical Indicators


Adolescent Client Validation of Hi Co-occurring from GAIN Short Screener vs Clinical Records

by Setting in Washington State

Two page measure closely approximated all found in the clinical record after the next two years


14

0 5,000 10,000 15,000 20,000 25,000

Any BehavioralHealth (n=22,879)

Mental Health(21,568)

Substance AbuseNeed (10,464)

Co-occurring(9,155)

Substance Abuse Treatment Student Assistance ProgramJuvenile Justice Mental Health TreatmentChildren's Administration

Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-occurring?


School Assistance Programs (SAP) largest part of BH/MH system; 2nd largest of SA & Co-

occurring systemsSAP+ SA Treatment

Over half of system


15

Construct Validity of GSS Internalizing Disorder Screener

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

100%

% Days with MHproblem

Mod/High onEmotional Problem

Scale (EPS)

Mod/High onInternal MentalDistress Scale

(IMDS)

Internalizing Disorder Screener (IDScr)

Fu

ll G

AIN

mea

sure

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 Externalizing Disorder Screener

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Days withbehavioralproblems

Mod/High onEmotional Problem

Scale (EPS)

High on BehaviorComplexity Scale

(BCS)

Externalizing Disorder Screener (EDScr)

Fu

ll G

AIN

mea

sure

0 1 2 3 4 5


17

Construct Validity of GSS Substance Disorder Screener

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Days of AOD use

Past Year Abuse orDependence

Past YearDependence

Substance Disorder Screener (SDScr)

Fu

ll G

AIN

mea

sure

0 1 2 3 4 5


18

Construct Validity of GSS Crime/Violence Screener

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Days of illegalactivities

Mod/High onIllegal Activity

Scale (IAS)

High onCrime/Violence

Scale (CVS)

Crime and Violence Screener (CVScr)

Fu

ll G

AIN

mea

sure

0 1 2 3 4 5


19

0%1%2%3%4%5%6%7%8%9%

10%11%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Total Disorder Sceener (TDScr) Score

% w

ithi

n L

evel

of

Car

e

Residential (n=1,965)

OP/IOP (n=2,499)

Low

Mod. High ->

19

Total Disorder Screener Severity by Level of Care: Adolescents

Source: SAPISP 2009 Data and Dennis et al 2006

Residential Median= 10.5(59% at 10+)

Outpatient Median=6.0(30% at 10+)

Few missed

(1/2-3%)

20

GAIN SS Can Also be Used for Monitoring

109

11

910

8

32 2

0

4

8

12

16

20

Intake 3Mon

6Mon

9Mon

12Mon

15Mon

18Mon

21Mon

24Mon

Total Disorder Screener (TDScr)

12+ Mon.s ago (#1s)

2-12 Mon.s ago (#2s)

Past Month (#3s)

Lifetime (#1,2,or 3)

Track Gap Between Prior and current

Lifetime Problems to identify “under

reporting”

Track progress in reducing current

(past month) symptoms)

Monitor for Relapse

21

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

22

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

23

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

23

5 min. 20 min 30 min 1-2 hr

24

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

25

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

26

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

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

NOTE: There is generally little or no differences in mean effect size between these brand names

27

On-site proactive urine testing can be used to reduce false negatives by more than half

28

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

2929

Percentage Change in Abstinence (6 mo-Intake) by level of Adolescent Community Reinforcement Approach (A-CRA) Quality Assurance

4%

24%36%

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

100%

Training Only Training,Coaching,

Monitoring

Clinical TrialOnsite Protocol

Monitors

% P

oint

Cha

nge

in A

bsti

nenc

e

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

Effects associated with intensity of quality

assurance and monitoring (OR=13.5)

30

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

31

Key Challenges to Delivery of Quality Care in Behavioral Health Systems1. 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

32

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

33

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

34

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

35

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

36

5. Lack of Infrastructure

Direct Services

Training and quality assurance on administration, clinical interpretation, data management, follow-up and project coordination

Data management

Evaluation and data available for secondary analysis

Software support

Technical assistance and back up to local trainer/expert

Development

Clinical Product Development

Software Development

Collaboration with IT vendors (e.g., WITS)

Over 36 internal & external scientists and students

Workgroups focused on specific subgroup, problem, or treatment approach

Labor supply (e.g., consultant pool, college courses)

Outcome: Implementation with Fidelity

37

Some Common Record Based Performance Measures

* 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

NQ

F

WC

G

CS

AT

NO

MS

NIA

TX P

FP

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 X X X X

Within Cost Bands: see French et al 2009 X X

38

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 careSource: www.tresearch.org/centers/nqf_docs/NQF_Crosswalk.pdf

39Source: 2008 CSAT AAFT Summary Analytic Dataset

553/771=72%unmet need

218/224=97% to targeted

771/982=79% in need

Assessment combined with treatment records can make better 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

40

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

41

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.

42

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

43

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

Will be using data from the Global Appraisal of Individual Needs (GAIN) Collaborators

State or Regional System

GAIN-Short Screener

GAIN-Quick

GAIN-Full

3/10 43

44

…as well as 6 provinces of Canada and 6 other countries

Canada

MB

NB

NT

PESK

YT

AB

NF

NS

QCBC

ON

NU

Number of GAIN Sites

None (Yet) 1 to 14

15 to 30 31 to 165

State or Regional System

GAIN-Short Screener

GAIN-Quick

GAIN-Full

45

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 GAIN-related research publications to date

45

46

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.

4747

EHR can provide practice based evidence: Lessons from a Decade of GAIN data from CSAT Grants

AK

ALAR

AZ

CACO

CT

DCDE

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

PR VI

AAFTARTATDCBIRTJTDCEARMARKEATFDCJDCOJJDPORPRCFSACSCANSCYTCEYORP

4848

2009 CSAT Data Set by Age

Source: CSAT 2009 Summary Analytic Data Set (n=22,045)

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)

4949

Diagnosis Time Period Matters

57%48%

18%

30%32%

18%

13%19%

63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Lifetime Past Year Past Month

No Use

Use

Abuse

Dependence


5050

Definition of Substance Use Severity Matters

80%

54%

24%

93%

34%

5%

26%

48%

57%

72%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Past Year Substance Diagnosis

3 or More Years of Use

Weekly Use

Any Past Year Dependence

Any Withdrawal Symptoms in the Past Week

Severe Withdrawal (11+ Symptoms)

Can Give 1+ Reasons to Quit*

Client Believes Need ANY Treatment

Acknowledges Having an AOD Problem

Any Prior Substance Abuse Treatment

Source: CSAT 2009 Summary Analytic Data Set (n=21,816) *(n=11,066)

5151

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


5252

The Number of Clinical Problems is related to Level of Care (over lapping but different mix)

41% 45%53%

65%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP CC-OP LTR STR

None

One

Two

Three

Four

Five to Twelve


Significantly more likely to

have 5+ problems (OR=5.8)

5353

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


Significantly more likely to have 5+

problems (OR=13.9)

But this is the issue staff least

like to ask about!

54

Overcoming Staff Reluctance with General Victimization Scale

40%

31%

6%10%

1%8%9%

26%

29%7%

57%32%

19%11%

35%

0%

10

%

20

%

30

%

40

%

50

%

60

%

70

%

80

%

90

%

10

0%

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

Source: CSAT 2009 Summary Analytic Data Set (n=19,318) 54

5555

B1. Intoxication/Withdrawal Treatment Plan Needs

39%

22%

17%

1%

1%

0%

10

%

20

%

30

%

40

%

50

%

60

%

70

%

80

%

90

%

10

0%

Any Detox or withdrawal services

Ambulatory Detox (Risk/Mild)

Non-opioid Meds

Opiate Meds

Monitoring withdrawal and AOD medscompliance


5656

B2. Biomedical Treatment Plan Needs

60%

33%

29%

17%

6%

1%

1%

78%

3%

4%

11%

16%

0%

10

%

20

%

30

%

40

%

50

%

60

%

70

%

80

%

90

%

10

0%

Tobacco cessation

Accom. for medical conditions

Discuss compliance w/ prescribed meds

Compliance with meds for PH probs

Discuss ER/hospitalization history

Currently treated for med problem

Tetanus shot

Eating disorder

Treatment of infectious diseases

Accommodations current pregnancy

Reduce sexual behavior risk

Reduce needle use/risk


5757

B3. Psychological Treatment Plan Needs

59%

23%

22%

31%

18%

13%

12%

41%

74%

1%

4%

4%

8%

16%

17%

68%

72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Co-occuring

Consq of behavior control problems

Refer to anger management

Suicidal risk intervention

Problems reading and writing

Compliance with psych meds

Currently treated for psych problem

Self-mutilation

Monitor self-mutilation

Cognitive impairment

Discuss lifetime mh hosp. history

Coordination with justice system

Consq of interpersonal illegal acts

Consq of drug-related illegal acts

Discuss lifetime arrest history

Consq of other illegal acts

Civil court proceedings


5858

B4.Readiness Treatment Plan Needs

81%

16%

9%

3%

79%

73%

63%

0%

10

%

20

%

30

%

40

%

50

%

60

%

70

%

80

%

90

%

10

0%

Any Treatment Readiness Issues

Wrap-around or casemanagement services

Any pressure to be in treatment

Required to go to treatment

Reviw expectations for length oftreatment

Review dissatisfaction w/treatment

Partner to understandtreatment process


5959

B5. Relapse Potential Treatment Plan Needs

67%

2%

84%

30%

28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

High Relapse Potential

Recovery coach or mentor

Continuing Care aftercontrolled environment

Significant time in controlledenvironment

Discuss substance abusetreatment history


6060

B6. Environment Treatment Plan Needs

63%

32%

29%

26%

32%

47%

54%

56%

70%

85%

0%

10

%

20

%

30

%

40

%

50

%

60

%

70

%

80

%

90

%

10

0%

Attended school in past 90 days

Coping with psycho-socialstressors

Child maltreatment

Recent school problems

Dissatisfaction withenvironment

Family fighting in the home

Vocational or governmentassistance

Substance use in the home

Employed in past 90 days

Housing situation


6161

NOMS: Early Treatment Outcomes

56%

66%

76%

84%

72%

58%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Initiation within 14 days

Evidenced Based Practice

Engagement for at least 6weeks

Any Continuing Care (91-180 days)

Substance Use-Abstinent/Reduced 50% at 3 Months

12 month cost within bandsfor initial type of treatment

Source: CSAT 2009 SA Data Set subset to 1+ Follow ups (n=11,668)

6262

NOMS: Post Treatment Outcome (6-12 mo)

Source: CSAT 2009 SA Data Set subset to 1+ Follow ups

41%

90%

71%

12%

89%

80%

66%

17%

44%

99%

76%

68%

47%

44%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Use

Abuse/Dependence Sx*

Physical Health

Mental Health

Nights of Psychiatric Inpatient

Illegal Activity

Arrests

Housed in Community**

Family/Home Problems

Vocational Problems

Social Support/Engagement

Recovery Environment Risk

Quarterly Cost to Society

In Work/School**

Reduced 50%or NoProblemNo Problem

*This variable measures the last 30 days. All others measure the past 90 days

**The blue bar represents an increase of 50% or no problem

6363

But Need to Control for the lack of Problems at Intake

Source: CSAT 2009 SA Data Set subset to 1+ Follow ups

98%

79%

13%

33%37%

52%

78%

61%

11%37%

42%19%

5%

2%

0%

10

%

20

%

30

%

40

%

50

%

60

%

70

%

80

%

90

%

10

0%

Use

Abuse/Dependence Sx*

Physical Health

Mental Health

Nights of Psychiatric Inpatient

Illegal Activity

Arrests

Housed in Community

Family/Home Problems

Vocational Problems

Social Support/Engagement

Recovery Environment Risk

Quarterly Cost to Society

In Work/School

* Variable measures the last 30 days. All others measure the past 90 days.

6464

Change in Number of Positive NOMS Outcomes (Last Follow up – Intake)

Source: CSAT 2009 SA Data Set subset to 1+ Follow ups (n=18,770)

8%6%8%

14%

12%

29%

11%

13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total

Five or More

Four

Three

Two

One

None

Negative one

Less than negative one

78% Improved in 1 or more areas (29% in 5 or more)

65

Any Illegal Activity can be better predicted by using Intake Severity on Crime/Violence and Substance Problem Scales

58%46%

36%53%

33%26%44%

27%20%

0%

20%

40%

60%

An

y I

leg

al

Ac

tiv

ity

(mo

nth

s1

-6)

High Mod Low LowMod

High

Crime/Violence Scale (Intake)

Substance Problem Scale

(Intake)

Source: CSAT 2008 V5 dataset Adolescents aged 12-17 with 3 and/or 6 month follow-up (N=9006)

Intake Crime/ Violence Severity

Predicts Recidivism

Intake Substance Problem Severity

Predicts Recidivism

Knowing both is a better predictor(high –high group is 5.5 times more

likely than low low)

While there is risk, most (42-80%) actually do not commit

additional crime

66

Outcomes May be Hidden by Subgroups: Example of HIV Risk Outcomes

-0.0

3

-0.1

0 -0.0

2

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

A. Low Risk

B. Mod. RiskW/O Trauma

C. Mod. RiskWith Trauma

D. High Risk

Total

Coh

en's

Eff

ect S

ize

d

Unprotected Sex Acts (f=.14)

Days of Victimization (f=.22)

Days of Needle Use (f=1.19)

-0.3

9

0.20

-0.0

4

-0.0

8

0.00

0.15

-0.2

9

0.01

0.10

0.27

0.00

-0.6

9

Source: Lloyd et al 2007

CYT Cannabis Youth Treatment Randomized Field Trial

Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services

Coordinating Center:Chestnut Health Systems, Bloomington, IL, and Chicago, ILUniversity of Miami, Miami, FLUniversity of Conn. Health Center, Farmington, CT

Sites:Univ. of Conn. Health Center, Farmington, CTOperation PAR, St. Petersburg, FLChestnut Health Systems, Madison County, ILChildren’s Hosp. of Philadelphia, Phil. ,PA

68

Randomly Assigns to:

MET/CBT5Motivational Enhancement Therapy/

Cognitive Behavioral Therapy (5 weeks)



FSN

Family Support Network

Plus MET/CBT12 (12 weeks)

Trial 2Trial 1Incremental Arm Alternative Arm

Cannabis Youth Treatment (CYT) Experiments

ACRAAdolescent Community

Reinforcement Approach(12 weeks)

MDFTMultidimensional Family Therapy

Randomly Assigns to:



(12 weeks)

Source: Dennis et al, 2002

69

5

10

5

11

14

23

0

5

10

15

20

25

MET/CBT5

MET/CBT12

MET/CBT12 +

FSN

MET/CBT5

ACRA MDFT

Hou

rs

Day

s

CaseManagement

FamilyCounseling

Collateral only

Multi-Familygroup

Multi-ParticipantGroup

Participant only

Incremental Arm Alternative Arm

Actual Treatment Received by Condition

Source: Dennis et al, 2004

MET/CBT12 adds 7 more sessions of

group

FSN adds multi family group,

family home visits and more case management

ACRA and MDFT both rely on

individual, family and case management instead of group

With ACRA using more individual therapy

And MDFT using more

family therapy

70

$1,559$1,413

$1,984

$3,322

$1,197$1,126

$-

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

MET/C

BT5 (6.8

wee

ks)

MET/C

BT12 (1

3.4 w

eeks

)

FSN (14.2

wee

ks w

/family

)

MET/C

BT5 (6.5

wee

ks)

ACRA (12.8

wee

ks)

MDFT(1

3.2 w

eeks

w/fa

mily)

$1,776

$3,495

NTIES E

st (6

.7 wee

ks)

NTIES E

st.(1

3.1 w

eeks

)

Ave

rage

Cos

t P

er C

lien

t-E

pis

ode

of C

are

|--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----|

Average Episode Cost ($US) of Treatment

Source: French et al., 2002

Less than average

for 6 weeks

Less than average

for 12 weeks

Integrating family therapy

was less expensive

than adding it

71

CYT Increased Days Abstinent and Percent in Recovery*

Source: Dennis et al., 2004

0

10

20

30

40

50

60

70

80

90

Intake 3 6 9 12

Day

s A

bsti

nent

Per

Qua

rter

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% in

Rec

over

y at

the

End

of

the

Qua

rter

Days Abstinent

Percent in Recovery

*no use, abuse or dependence problems in the past month while in living in the community

72

Similarity of Clinical Outcomes by Conditions


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)

73

Moderate to large differences in Cost-Effectiveness by Condition


$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/ CBT5MET/

CBT12FSN 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

74

Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition

Source: Dennis et al., 2003; forthcoming

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

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

MET/ CBT5 MET/ CBT12 FSNM MET/ CBT5 ACRA MDFT

Trial 1 (n=299) Trial 2 (n=297)

Cos

t P

er P

erso

n in

Rec

over

y (C

PP

R)

* 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

Stability of MET/CBT-5

findings mixed at 30 months

MET/CBT-5, -12 and ACRA more cost effective at

12 months

Integrated family therapy (MDFT) was more cost effective than

adding it on top of treatment (FSN) at 30 months

ACRA Effect Largely Sustained

75

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 Re-entry Grant from CSAT to use A-CRA, ACC & GAIN last month

75

76

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

77

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

78

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

79

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

80

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

assessment and treatment of adolescents michael l. dennis, ph.d. chestnut health systems normal, il...

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