the prevalence, co-morbidity, and treatment of mental health, substance, and crime problems among...

The Prevalence, Co-morbidity, and Treatment of Mental Health, Substance, and Crime Problems among Teenagers

Michael Dennis, Ph.D.Chestnut Health Systems, Bloomington, ILPresentation at “Pediatric Mental Health Primer V: The Complex Needs of Children with Dual Diagnosis (Mental Illness and Substance Abuse)”, September 18, 2007, InPlay’s Forté Conference Center, Peoria, IL. The content of this presentations are based on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270-2003-00006 and several individual grants. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: [email protected]

2

1. To examine the prevalence, course, and consequences of adolescent substance use and co-occurring disorders and the unmet need for treatment

2. To summarize major trends, variability and problems in the adolescent treatment system

3. To present the findings from several recent treatment outcome studies on substance abuse treatment research, trauma and violence/crime.

Goals of this Presentation

3

Severity of Past Year Substance Use/Disorders by Age

Source: 2002 NSDUH and Dennis & Scott in press

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 CategoryAdolescent

OnsetRemission

Increasing rate of non-

users

2002 U.S. Household Population age 12+ = 235,143,246

4

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

5

Substance Use Careers Last for Decades C

um

ula

tive

Su

rviv

al

Years from first use to 1+ years abstinence302520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

Median of 27 years from

first use to 1+ years

abstinence

Source: Dennis et al., 2005

6

Substance Use Careers are Longer the Younger the Age of First Use

Cu

mu

lati

ve S

urv

ival

Years from first use to 1+ years abstinence

under 15*

21+

15-20*

Age of 1st UseGroups

* p<.05 (different from 21+)

302520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0


7

Substance Use Careers are Shorter the Sooner People Get to Treatment

Cu

mu

lati

ve S

urv

ival

20+

0-9*

10-19*

Year to 1st TxGroups

302520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

* p<.05 (different from 20+)Source: Dennis et al., 2005

Years from first use to 1+ years abstinence

8

Treatment Careers Last for Years C

um

ula

tive

Su

rviv

al

Years from first Tx to 1+ years abstinence2520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

Median of 3 to 4 episodes of treatment over 9 years


9

Need for Treatment (% of 24,753,586 Adolescents in the U.S. Household Population)

Source: NSDUH and TEDS (see state level estimates in appendix)

8.9%

0.7%

0.6%

5.7%

8.1%

11.5%

10.7%

14.9%

17.8%

0% 5% 10%

15%

20%

25%

Tobacco

Alcohol

Alcohol Binge

Any Drug Use

Marijuana Use

Any Non-Marijuana Drug Use

Past Year AOD Dependence or Abuse

Any Treatment (From NHSDA)

Public Treatment (From TEDS)

--

----

--P

ast M

onth

Use

----

--

Less than 1 in 10 getting treatment

88% of adolescents are treated in the

public system

10

Unmet Treatment Need Adolescent (% of AOD Dependence/Abuse without any private/public treatment)

Prevalence82.4 to 90.1%90.2 to 92.3%92.4 to 94.2%94.3 to 98.0%U.S.Avg.=92.2%IL=92.5%

Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf )

9 in 10 Untreated

11

Adolescent Treatment Admissions have increased by 61% over the past decade

Source: Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS)http://www.samhsa.gov/oas/dasis.htm

64% increase from95,271 in 1993

to 158,723 in 2005

12

Severity Goes up with Level of Care

Source: Treatment Episode Data Set (TEDS) 1993-2003.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Weekly useat intake

First usedunder age 15

Dependence Prior Treatment

Case Mix Index (Avg)

Outpatient Intensive Outpatient DetoxificationLong-term Residential Short-term Residential

STR: Higher on

Dependence

Baseline Severity Goes up with Level

of CareDetox: Higher on Use

Detox: Higher on Use, but lower on prior tx

13

Median Length of Stay is only 50 days

Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

0 30 60 90

Outpatient(37,048 discharges)

IOP(10,292 discharges)

Detox(3,185 discharges)

STR(5,152 discharges)

LTR(5,476 discharges)

Total(61,153 discharges)

Lev

el o

f C

are

Median Length of Stay

50 days

49 days

46 days

59 days

21 days

3 days

Less than 25% stay the

90 days or longer time

recommended by NIDA

Researchers

14

53% Have Unfavorable Discharges

Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

Despite being widely recommended, only 10% step down after intensive treatment

0% 20% 40% 60% 80% 100%

Outpatient(37,048 discharges)

IOP(10,292 discharges)

Detox(3,185 discharges)

STR(5,152 discharges)

LTR(5,476 discharges)

Total(61,153 discharges)

Completed Transferred ASA/ Drop out AD/Terminated

15

Most Lack of Standardized Assessment for…

Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment

Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidality)

Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime)

HIV risk behaviors (needle use, sexual risk, victimization)

Child maltreatment (physical, sexual, emotional)

16

GAIN Clinical CollaboratorsAdolescent and Adult Treatment Program

7/07

VI

01 to 1011 to 2526 to 100

DE

HI

ID

IN

KS

LA

MS

MT ND

PR

SDWY

ME

NH

AK

AR

IA

MO

OK

WV

AL

CO

NM

NV

MI

NJ

VT

NE

WA

WI NY

PARI

SC

OR

FL

UTVA

NCTN

MN

KY

TX

GA

MD

AZ

CT

IL

MA

CA

OH

DC

One or more state or county wide systems uses the GAIN

17

CSAT Adolescent Treatment (AT)Outcome Data SetRecruitment: 1998-2006 (updated annually)

Sample: The 2006 CSAT adolescent treatment data set included data with 1 to 4 follow-ups on 12,690 adolescents from 96 local evaluations

Levels of Care: Early Intervention, Outpatient, Intensive Outpatient, Short, Moderate & Long term Residential, Corrections Based and Post Residential Outpatient Continuing Care

Instrument: Global Appraisal of Individual Needs (GAIN) (see www.chestnut.org/li/gain)

Follow-up: Over 80% follow-up 3, 6, 9 & 12 months post intake

Funding: CSAT contract 270-2003-00006 and 72 individual grants

18

Level of Care (n=12,601)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Cont. Care (5%)

Detention (1%)

Long Term Resid. (7%)

Mod. Term Resid. (10%)

Short Term Resid. (3%)

Intensive OP (8%)

Outpatient (60%)

Early Intervention (6%)

Source: CSAT 2006 AT Outcome Data Set (n=12,601)

19

Type of Treatment (n=12,601)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Other (22%)

Other ManualizedPrograms (15%)

Other Evidenced BasedTx (3%)

Adolescent CRA (3%)*

MET/CBT (51%)


* Data Prior to current AAFT program replicating A-CRA

20

Demographics


27%

19%

17%

4%

14%

19%

73%

8%

49%

31%

88%

31%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Female

Hispanic

African American

Native American

Mixed

Age <15

Age 15-17

Age >17

Single Parent

Employed

In School

Ever Homeless or Runaway

21

Recovery Environment

55%

49%

27%

73%

65%

13%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Social Peers Getting Drunk Weekly+

School/Work Peers Getting Drunk Weekly+

Others at Home Getting Drunk Weekly+

Social Peers Using Drugs

School/Work Peers Using Drugs

Others at Home Using Drugs


22

Past 90 day HIV Risk Behaviors

67%

37%

30%

26%

21%

2%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sexually active

Sex Under the Influence of AOD

Multiple Sex partners

Any Unprotected Sex

Victimized Physically, Sexually, orEmotionally

Any Needle use


23

Weekly or More Often Use in the Past 90 Days

59%

46%

16%

4%

2%

6%

53%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Substance

Marijuana

Alcohol

Crack/Other Cocaine

Heroin/Opioids

All Other Drugs

Tobacco


24

Substance Use Problems

83%

50%

29%

7%

34%

29%

26%

94%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Past Year Substance Diagnosis

Any Past Year Dependence

Any withdrawal symptoms in the past week

Severe withdrawal (11+ symptoms) in past week

Can Give 1+ Reasons to Quit

Any prior substance abuse treatment

Acknowledges having an AOD problem

Client believes Need ANY Treatment


25

Prevalence of Past Year Substance Use Disorder by Age

Source: Chan, Dennis & Funk in press

26

Co-Occurring Psychiatric Problems

52%

44%

36%

25%

15%

64%

46%

31%

24%

11%

67%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Co-occurring Psychiatric

Conduct Disorder

Attention Deficit/Hyperactivity Disorder

Major Depressive Disorder

Traumatic Stress Disorder

General Anxiety Disorder

Ever Physical, Sexual or Emotional Victimization

High severity victimization (GVS>3)

Ever Homeless or Runaway

Any homicidal/suicidal thoughts past year

Any Self Mutilation


27

Prevalence of Substance, Internalizing and Externalizing Disorders by Age

Source: Chan, Dennis & Funk in press

0

20

40

60

80

100

<15 15-17 18-25 25-39 40+

Age groups

Pre

va

len

ce

(%

)

Substance

Internalizing

Externalizing

Both internaland external

28

Past Year Violence & Crime

*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)


81%

68%

65%

49%

47%

44%

84%

69%

38%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any violence or illegal activity

Physical Violence

Any Illegal Activity

Any Property Crimes

Other Drug Related Crimes*

Any Interpersonal/ Violent Crime

Lifetime Juvenile Justice Involvement

Current Juvenile Justice involvement

1+/90 days In Controlled Environment

29

Intensity of Juvenile Justice System Involvement


Other prob/ parole/

detention, 16%

Other JJ status, 17%

Past arrest/JJ

status, 7%

Past year illegal

activity/SA use, 20%

Probation/ Parole with

urine monitoring,

24%

Detention 14+ Days,

16%

30

Relationship of Level of Care to theNumber of Major Clinical Problems

Source: CSAT 2006 AT Outcome Data Set (n=12,601); Odds Ratio (OR) of having 5+ of 12 problems (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

31

Relationship of Victimization to theNumber of Major Clinical Problems

Source: CSAT 2006 AT Outcome Data Set (n=12,601); Odds Ratio (OR) of having 5+ of 12 problems (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

32

Treatment Outcomes by Level of Care: Days of AOD Abstinence*

* Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change)


0

30

60

90

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

Day

s of

Ab

stin

ence

(of

90)

Outpatient (+21%, -1%)

Residential (+83%, -10%)

Cont. care (+17%, -11%)

33

Treatment Outcomes by Level of Care: Recovery*

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

cen

t in

Pas

t M

onth

Rec

over

y*

Outpatient (+97%, +2%)

Residential (+115%, +9%)

Cont. care (+165%, +27%)

* 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)


34

Change in Substance Frequency Scaleby Level of Care\a

\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\t,s,ts

Residential programs start more severe, go down sharply,

but then come back over time

Note the sharp “hinge” in outcomes

during the active phase of AOD

treatment

Short- Term Resid. \t,s,ts

Long- Term Resid\t,ts

Outpatient\t,s

35

Pattern of SA Outcomes is Related to the Pattern of Psychiatric Multi-morbidity

Source: Shane et al 2003, PETSA data

Months Post Intake (Residential only)0 3 6 12

Nu

mb

er o

f P

ast

Mon

th S

ub

stan

ce P

rob

lem

s

2+ Co-occurring 1 Co-occurring No Co-occurring

Multi-morbid Adolescents start the highest, change the most, and relapse the most

36

Change in Emotional Problem Scale by Level of Care\a


40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,s,ts

OP\t,s



Outpatient\t,s

Note the lack of a hinge; Effect is generally indirect (via

reduced use) not specific

37

Victimization and Level of Care Interact to Predict Outcomes

Source: Funk, et al., 2003

0

5

10

15

20

25

30

35

40

Intake 6 Months Intake 6 Months

Mar

ijua

na U

se (

Day

s of

90)

OP -High OP - Low/Mod Resid-High Resid - Low/Mod.

CHS Outpatient CHS Residential Traumatized groups have higher severity

High trauma group does not respond to OP

Both groups respond to residential treatment

38

Are there other more effective OP programs?

Source: CYT and ATM Outpatient Data Set Dennis 2005

-1.00

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

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

Z-S

core

on

Sub

stan

ce F

requ

ency

Sca

le (

SF

S) CYT Total (n=217; d=0.51)

CHSOP (n=57; d=0.18)

And on average the CYT have moderate effect sizes

even with high GVS

Green line is CHS OP’s High GVS adolescents; they have some initial gains but substantial relapse

39

Change in Illegal Activity Scaleby Level of Care\a


40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\s



Outpatient\t,s

Residential Treatments have a specific effect

Outpatient Treatments has an indirect effect

40

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

41

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


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

42

$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

43

Adolescent Cannabis Users in CYT were as or More Severe Than Those in TEDS*

Source: Tims et al, 2002

85%

46%

26%

78%

26%

47%

26%

71%

0%

20%

40%

60%

80%

100%

First usedunder age

15

Dependence Weekly ormore use at

intake

PriorTreatment

% o

f A

dm

issi

on

s

.

CYT Outpatient(n=600) TEDS Outpatient (n=16,480)* Adolescents with marijuana problems admitted to outpatient treatment

44

Multiple Problems were the NORM

86%

37%

12%

25%

61%

60%

66%

83%

83%

0% 20% 40% 60% 80% 100%

Any Marijuana Use Disorder

Any Alcohol Use Disorder

Other Substance Use Disorders

Any Internal Disorder

Any External Disorder

Lifetime History of Victimization

Acts of Physical Violence

Any (other) Illegal Activity

Three to Twelve Problems

Self-Reported in Past Year


45

Substance Use Severity was Related to Other Problems

* p<.05

Source: Tims et al 2002

71%

57%

25%

42%

30%37%

22%

5%

13%

22%

0%

20%

40%

60%

80%

100%

Health ProblemDistress*

Acute MentalDistress*

AcuteTraumaticDistress*

AttentionDeficit

HyperactivityDisorder*

ConductDisorder*

Past Year Dependence (n=278) Other (n=322)

46

CYT Increased Days Abstinent and Percent in Recovery*


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

47

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)

48

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

49

Cumulative Recovery Pattern at 30 months

Source: Dennis et al, forthcoming

37% Sustained Problems

5% Sustained Recovery

19% Intermittent, currently in

recovery

39% Intermittent, currently not in

recovery

The Majority of Adolescents Cycle in and out of Recovery

50

Post Script on CYT

The CYT interventions provide replicable models of brief (1.5 to 3 month) treatments that can be used to help the field maintain quality while expanding capacity.

While a good start, the CYT interventions were still not an adequate dose of treatment for the majority of adolescents – including many who continued to vacillate in and out of recovery after discharge from CYT.

Descriptive, outcome and economic analyses have been published All five interventions are currently being used in subsequent

experiments The MET/CBT5 intervention has just been replicated in a 38 site study

and ACRA is currently being replicated in a 33 site study. Over 60,000 copies of the CYT manuals have been distributed by

NCADI and as many electronic copies have been distributed by CD or the website

Findings from the Assertive Continuing Care (ACC)

Experiment

183 adolescents admitted to residential substance abuse treatment

Treated for 30-90 days inpatient, then discharged to outpatient treatment

Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC)

Over 90% follow-up 3, 6, & 9 months post discharge

Source: Godley et al 2002, forth coming

52

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

53

ACC Enhancements

Continue to participate in UCC

Home Visits

Sessions for adolescent, parents, and together

Sessions based on ACRA manual (Godley, Meyers et al., 2001)

Case Management based on ACC manual (Godley et al, 2001) to assist with other issues (e.g., job finding, medication evaluation)

54

Assertive Continuing Care (ACC)Hypotheses

Assertive Continuin

g Care

General Continuin

g Care Adherence

Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA)

Early Abstinence

GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence

Sustained Abstinence

Early abstinence will be associated with higher rates of long term abstinence.

55

ACC Improved Adherence

Source: Godley et al 2002, forthcoming

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

56

GCCA Improved Early (0-3 mon.) Abstinence


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

57

Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence


19% 22% 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*)

Early(0-3 mon.) Relapse

69%

59%

73%

Early (0-3 mon.) Abstainer * p<.05

58

Post script on ACC

The ACC intervention improved adolescent adherence to the continuing care expectations of both residential and outpatient staff; doing so improved the rates of short term abstinence and, consequently, long term abstinence.

Despite these GAINs, many adolescents in ACC (and more in UCC) did not adhere to continuing care plans.

The ACC preliminary findings are published and the main findings are currently under review.

Several CSAT grantees are also seeking to replicate ACC as part of the Adolescent Residential Treatment (ART) program.

A second ACC experiment is currently under way to evaluate whether providing contingency management will further improve outcomes.

The ACC manual is being distributed via the website and the CD you have been provided.

59

A Fearless Appraisal… We are entering a renaissance of new knowledge in this area, but are only

reaching 1 of 10 in need

Several interventions work, but the majority of the adolescents are still having problems 12 months later

Effectiveness is related to severity, intervention strength, implementation/adherence, and how assertive we are in providing treatment

As other therapies have caught up technologically, there is no longer the clear advantage of family therapy found in early literature reviews

While there have been concerns about the potential iatrogenic effects of group therapy, the rates do not appear to be appreciably different from individual or family therapy if it is done well (important since group tx typically costs less)

Effectiveness was not consistently associated with the amount of therapy over a short period of time (6-12 weeks) but was related to longer term continuing care

60

Recommendations for Further Developments…

We need to target the latter phases of treatment to impact the post-treatment recovery environment and/or social risk groups that are the main predictors of long term relapse

We need to move beyond focusing on acute episodes of care to focus on continuing care and a recovery management paradigm

We need to better understand the impact of involvement in juvenile justice system and how it can be harnessed to help

More work is need on the use of schools as a location for providing primary treatment (they have entrée to the population and appear to be the venue of choice) and recovery-schools to provide support for those coming out of residential treatment

61

Other Assessment and Treatment Resources

Assessment Instruments – GAIN Coordinating Center at www.chestnut.org/li/gain – CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html – NIAAA Assessment Handbook at

http://www.niaaa.nih.gov/publications/instable.htm Treatment Programs

– CSAT CYT, ATM, ACC and other treatment manuals at www.chestnut.org/li/apss/csat/protocols and on CDs provided

– SAMHSA Knowledge Application Program (KAP) at http://kap.samhsa.gov/products/manuals

– NCADI at www.health.org – National Registry of Effective Prevention Programs

Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov

– NCTSN trauma intervention tool kit http://www.nctsnet.org – National Center for Mental Health and Juvenile Justice Evidence Based Practice

resource list at http://www.ncmhjj.com/EBP/default.asp Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE)

www.chestnut.org/li/apss/sasate Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://

www.mayatech.com/cti/jmate/ – next meeting March 30-April 2, 2008, Baltimore, MD

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

http://www.athealth.com/practitioner/ceduc/health_tip31k.html

http://www.niaaa.nih.gov/publications/instable.htm

http://www.chestnut.org/li/apss/csat/protocols

http://kap.samhsa.gov/products/manuals

http://www.health.org/

http://www.modelprograms.samhsa.gov/

http://www.nctsnet.org/

http://www.ncmhjj.com/EBP/default.asp

http://www.ncmhjj.com/EBP/default.asp

http://www.chestnut.org/li/apss/sasate

http://www.mayatech.com/cti/jmate/



62

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among adolescents and adults presenting to substance abuse treatment. Journal of Substance Abuse Treatment.Dennis, M.L. (2004). Traumatic victimization among adolescents in substance abuse treatment: Time to stop ignoring the

elephant in our counseling rooms. Counselor, April, 36-40.Dennis, M. L., Babor, T., Roebuck, M. C., & Donaldson, J. (2002). Changing the focus The case for recognizing and treating

marijuana use disorders. Addiction, 97 (Suppl. 1), S4-S15.Dennis, M.L., Chan, Y.F., & Funk, R.R. (2006). Development and Validation of the GAIN Short Screener (GSS) for

Internalizing, Externalizing and Substance Use Disorders and Crime/Violence Problems Among Adolescents and Adults. American Journal on the Addictions, 15 (S1), 80 - 91

Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003). The need for developing and evaluating adolescent treatment models. In S.J. Stevens & A.R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary Models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press and 1998 NHSDA.

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Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28 (2S), S49-S60 .

Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F., Webb, C., Kaminer, Y., Babor, T., Roebeck, M. C., Godley, M. D., Hamilton, N., Liddle, H., Scott, C., & CYT Steering Committee. (2002). The Cannabis Youth Treatment (CYT) experiment Rationale, study design, and analysis plans. Addiction, 97, 16-34..

Dennis, M. L., Titus, J. C., White, M., Unsicker, J., & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN) Administration guide for the GAIN and related measures. (Version 5 ed.). Bloomington, IL Chestnut Health Systems. Retrieve from http//www.chestnut.org/li/gain

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References - continuedFrench, M.T., Roebuck, M.C., Dennis, M.L., Diamond, G., Godley, S.H., Tims, F., Webb, C., & Herrell, J.M. (2002). The

economic cost of outpatient marijuana treatment for adolescents: Findings from a multisite experiment. Addiction, 97, S84-S97.French, M. T., Roebuck, M. C., Dennis, M. L., Diamond, G., Godley, S. H., Liddle, H. A., and Tims, F. M. (2003). Outpatient

marijuana treatment for adolescents Economic evaluation of a multisite field experiment. Evaluation Review,27(4)421-459. Funk, R. R., McDermeit, M., Godley, S. H., & Adams, L. (2003). Maltreatment issues by level of adolescent substance abuse

treatment The extent of the problem at intake and relationship to early outcomes. Journal of Child Maltreatment, 8, 36-45.Godley, S. H., Dennis, M. L., Godley, M. D., & Funk, R. R. (2004). Thirty-month relapse trajectory cluster groups among

adolescents discharged from outpatient treatment. Addiction, 99 (s2), 129-139, Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. (2002). Preliminary outcomes from the assertive

continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment, 23, 21-32.

Godley, S. H., Jones, N., Funk, R., Ives, M., and Passetti, L. L. (2004). Comparing Outcomes of Best-Practice and Research-Based Outpatient Treatment Protocols for Adolescents. Journal of Psychoactive Drugs, 36, 35-48.

Hser, Y., Grella, C. E., Hubbard, R. L., Hsieh, S. C., Fletcher, B. W., Brown, B. S., & Anglin, M. D. (2001). An evaluation of drug treatments for adolescents in four U.S. cities. Archives of General Psychiatry, 58, 689-695.

Lewinsohn, P.M., Hops, H., Roberts, R.E., Seeley, J.R., Andrews, J.A. (1993). Adolescent psychopathology, I: prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abn Psychol, 102, 133-144.

National Academy of Sciences (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press.

Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics.

Office of Applied Studies (OAS) (1999). Treatment Episode Data Set (TEDS) 1992-1997: National admissions to substance abuse treatment services. Rockville, MD: Author. [Available online at <http://www.icpsr.umich.edu/SAMHDA>.]

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References - continuedOffice of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998.

Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics

Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS) retrived fromhttp://www.samhsa.gov/oas/dasis.htmPhysician Leadership on National Drug Policy (PNLDP, 2002) Adolescent Substance Abuse: A Public Health

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Shane, P., Jasiukaitis, P., & Green, R. S. (2003). Treatment outcomes among adolescents with substance abuse problems: The relationship between comorbidities and post-treatment substance involvement. Evaluation and Program Planning, 26, 393-402.

Tims, F. M., Dennis, M. L., Hamilton, N., Buchan, B. J., Diamond, G. S., Funk, R., & Brantley, L. B. (2002). Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment . Addiction, 97, 46-57.

Titus, J. C., Dennis, M. L., White, W. L., Scott, C. K., & Funk, R. R. (2003). Gender differences in victimization severity and outcomes among adolescents treated for substance abuse. Journal of Child Maltreatment, 8, 19-35.

White, M. K., Funk, R., White, W., & Dennis, M. (2003). Predicting violent behavior in adolescent cannabis users The GAIN-CVI. Offender Substance Abuse Report, 3(5), 67-69.

White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2), 24-28.

D. Wright & N. Sathe (2005). State Estimates of Substance Use from the 2002 - 2003 National Survey on Drug Use and Health, Rockville, MD: OAS, SAMHSA (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf

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