Challenges and Strategies for Implementing

Evidence-based Family Treatments in Complex

Settings: Working within the Juvenile Justice System

Cynthia L. Rowe, Ph.D., Howard A. Liddle, Ed.D., and Gayle A. Dakof, Ph.D.

Center for Treatment Research on Adolescent Drug Abuse

University of Miami Miller School of Medicine

Presented at the American Family Therapy Association (AFTA) 8th Clinical Research Conference, “Evidence-based Family Treatments: Improving Family Therapy and Research by Advancing Clinician and Researcher

Collaborations;” Miami Lakes, FL; February 23rd, 2007

Overview What are the specific challenges of our

work within the juvenile justice system? How have we addressed these

challenges to successfully implement evidence-based family treatments within complex systems?

Is there any evidence that implementing evidence-based family treatments in real-world settings improves youths’ outcomes?

What are the current pressing questions?

“ Instead of helping, we are writing off these young Americans, we are releasing them

without attending to their needs for substance abuse treatment and other

services, punishing them without providing help to get back on track.”

-- Joseph A. Califano, CASA, 2004

Four of every five children and teen arrestees in state juvenile

justice systems have some involvement with drugs and

alcohol

Only 3.6 percent of these juvenile justice involved

youth receive any type of treatmentCASA 2004

“I have been there. I have witnessed the deplorable conditions forced upon these young people. The system must be changed to address the needs of these juveniles and prevent them from living a life crime and drug addiction.”

- Charles W. Colson, Founder and Chairman of the Board, Prison Fellowship, the world's largest outreach to prisoners, ex-prisoners, crime victims and their families.

“The juvenile courts of our country have become the leading service delivery system for children and youth with substance abuse problems, not by choice, but by necessity.”

- Reclaiming Futures: A model for judicial leadership (2006).

Multiple Interacting Problems of Juvenile

Offenders Serious substance abuse: 60 - 80% of

incarcerated samples Violent offenses: 70% of repeat

offenders Co-occurring mental health problems:

75% have a DSM disorder + CD and SUD Family disruption, conflict, and chaos School problems: 85% suspended/80%

LD Negative peers/ gang involvement High-risk sexual behavior

Antisocial Behavior Over Time

Early childhood risk factors and family problems set the stage Antisocial behavior compromises emotional and social development Long-term deficits across domains Family-based intervention during adolescence may halt the progression of drug abuse and antisocial behavior

Assessment and Intervention in the Juvenile

Justice System Youth screened at intake centers Screening conducted to determine level of risk Youth at lowest risk placed in diversion programs – few are empirically supported Comprehensive assessments conducted with moderate and high risk youth Highest risk youth stay in detention 3-21 days Disposition may involve court-ordered

treatment as part of probation or drug court

DJJ System Challenges JACs and facilities overcrowded/understaffed Assessments not conducted with all teens at risk due to limited resources Services for youth in JJ settings are limited and few have any empirical basis Families rarely involved in treatment Little coordination/follow-through between JJ facilities and treatment programs Bottom line: Most juvenile offenders don’t receive services at all – positive outcomes in the DJJ system are truly “against all odds”

Barriers to Implementing Effective Family Treatments

Focus is on punishment – not treatment

“Too many cooks” (DA/SA, PD, judge, PO)

Deep and pervasive pessimism about families

– belief that “boot camp” is helpful

Disconnect between research, clinical, and

DJJ systems – different theories of change,

different agendas, and different masters

Treatment models not seen as credible/

seen

as too complex to integrate within system

Lack of resources to fully implement the

models and sustain them over time

 

Evidence-based Family Treatments for Young

Offenders Multifaceted problems require multicomponent assessment and intervention strategy Families and other systems are primary contexts for development and change Effective interventions go beyond a uni- dimensional theory of change Multidimensional approaches address risk and protective factors within the individual teen, the parent, family system, and school, court, and other systems

“Today, we have solid evidence showing that rehabilitation works and is cost-effective.  Studies by the Washington State Institute for Public Policy found proven treatment programs are a good investment.  For example, Functional Family Therapy reduced recidivism by 38 percent, saving the tax-payers $10 for every dollar spent.”

-- Jonathon Fanton, President, MacArthur Foundation

Multisystemic Therapy for Youth in Juvenile Drug Court

Henggeler et al (2006) reported successful implementation of MST within the juvenile drug court program

Family Court + TAU and Drug Court + TAU performed poorly in comparison to combined effects of the 2 MST conditions (MST + Drug Court; MST + CM + Drug Court)

Multidimensional Family Therapy with Drug Abusing

Juveniles in Detention Assess youth immediately in detention

MDFT therapist intervenes with youth in detention and parents in their home

Continue MDFT after release, building upon foundation established in detention

Incorporates HIV/STD prevention

Targets multiple domains of functioning

Collaboration with PO, judge, PD

Multidimensional Family Therapy in Juvenile Drug

Court MDFT is currently being tested within Miami-Dade’s Juvenile Drug Court program

MDFT therapists work collaboratively with the court and probation officers to ensure compliance with the program

Outcomes expected to be better than drug court + standard group treatment

Incorporates HIV/STD prevention

Outcomes targeted across domains (e.g., individual, family, school functioning)

Implementing Evidence-based Family Treatments: “Are we

doing our own model?” Multi-level assessment/intervention strategy Negotiating multiple alliances Collaborative approach Assessing and reading feedback   Planning and flexibility are complementary Accept “rough around the edges” outcomes Actively shaping and directing the process Maintaining intensity and focus

Addressing Barriers to Implementation

Start with what juvenile justice authorities feel needs to change Multisystemic assessment of context Identify multiple levels of system/ subsystem units Assess by joining system

Involve jj folks and the providers at all levels in assessing, planning, and implementing EBP

Work as a team with jj system and providers

  Emphasize the efficacy of the approach in ways that are concrete and meaningful

SIMPLIFY and protocolize the approach

Addressing Barriers (cont.)

Communicate clearly about the intervention and the outcomes being achieved

Discuss how new treatment fits in/augments existing system and practices

Be creative in providing incentives for change   Discuss and address obstacles to change in a

realistic, non-defensive way Reinforce knowledge gained with providers Create opportunities for providers to practice

skills, give feedback, and get feedback from them about intervention’s fit and any

obstacles

Transporting MDFT into an Adolescent Day Treatment

Program NIDA-funded project attempting to implement MDFT within an existing day treatment program for drug abusing young offenders

Day treatment program set in a large, complex public hospital system

Interrupted time-series design with 4 phases: Baseline, Training, Implementation, and Durability

First systematic study of the integration of MDFT in an existing drug treatment

program

Study Aims

Clinical Practices: Determine whether providers could implement MDFT with adequate fidelity within the day treatment program

Program Changes: Determine whether the program could be transformed based on MDFT principles and interventions

Client Changes: Determine whether MDFT implementation would positively impact youths’ outcomes across domains of functioning

Durability: Determine whether changes could be sustained without MDFT trainers

Study Phases

Phase I. Baseline: Assessment of provider practices, program environment, and clientoutcomes

Phase II. Training: Work with all staff in day treatment program and larger system

Phase III. Implementation: Continue expert supervision and booster trainings as

needed;Assess impact of training

Phase IV. Durability: MDFT experts withdraw;

Assess sustainability of approach

Adolescent Day Treatment Program

Multicomponent program/multidisciplinary staff

Behaviorally oriented “levels approach”

School through alternative education program

Group therapy daily and recreational activities

Psychiatric evaluation and intervention

Individual therapy weekly

Family therapy “as needed”

Implementation Approach

Guiding principle: Isomorphism between training approach and therapy model

Collaboration/ Consultation

Empowering clinical staff and redefining roles

Conceptualizing change at different levels of system and in different domains

Modeling interventions, practice, and feedback

Increasing staff accountability

Outcomes

Clinical Practices (Adherence to MDFT): Changes in sessions and contacts (parameters) Changes within sessions (interventions)

Program Changes: Changes in adolescents’ perceptions of program environment

Client Changes: Drug use, externalizing/internalizing symptoms Arrests and placements in controlled settings Involvement with delinquent peers

Increases in Sessions over Study Phases

0

0.05

0.1

0.15

0.2

0.25

0.3

Individual Sessions Family Sessions

Baseline

Implementation

Durability

More individual sessions on

days attended in Implementation and Durability

More family sessions on days

attended in Implementation and Durability

Increases in Contacts over Study Phases

0

0.2

0.4

0.6

0.8

Ave

rage N

um

ber

of W

eekly

Conta

cts

DJ J Contacts School Contacts

Baseline

Implementation

Durability

More contacts with schools in

Implementation and Durability

More DJJ contacts in Implementation than

Baseline

Slight decrease in DJJ contacts in

Durability

Adherence to MDFT Interventions

Coding of therapists’ charts revealed more focus on drugs during sessions in the Baseline phase (p<.05)

Therapists focused on school issues and adolescents’ thoughts and feelings about themselves more in the Implementation and Durability phases (p’s<.01)

Therapists in Implementation and Durability addressed more core MDFT content themes per session than sessions in Baseline (p<.05)

Ratings of sessions revealed significant increases in adherence to MDFT interventions over phases (adolescent-focused, family-focused, and engagement/reconnection interventions all p < .05)

Changes in Session Content over Study

Phases

0

20

40

60

80

100

Pro

port

ion o

f Sess

ions

Drugs Self School

Baseline

Implementation

Durability

More focus on drugs

in Baseline

More focus on self in

Implementation and Durability

More focus on school in

Implementation and Durability

Changes in Program Environment

0

1

2

3

4

5

6

7

8

Baseline

Implementation

Durability

Adolescents felt the program was more

organized in Implementation than

Baseline

Adolescents felt the program had a more

practical orientation in Implementation and

Durability

Adolescents felt staff were more

clear about rules/expectations in Implementation

and Durability

Results: Client Outcomes LGM used to compare drug use, externalizing, and

internalizing trajectories between intake and 9 months for youth in the 3 study phases

Youth decreased drug use more rapidly in Implementation and Durability phases than youth in Baseline (p’s<.05)

Youth in Implementation and Durability decreased their externalizing and internalizing symptoms more rapidly than youth in Baseline (p<.05) according to self-report

Youth improved more rapidly in internalizing (p<.05) and externalizing symptoms (p=.01) in Durability relative to Baseline according to parent reports

Change in Self-Reported Externalizing Problems

50

60

70

80

Intake 1 Month Discharge 9 Months

Baseline

Implementation

Durability

Youth in Implementation and Durability improved more rapidly than youth in Baseline

Change in Self-Reported Internalizing Problems

40

50

60

Intake 1 Month Discharge 9 Months

Baseline

Implementation

Durability

Youth in Implementation and Durability improved more rapidly than youth in Baseline

Percent in Controlled Environment

at Follow-up over Study Phases39

8

00

5

10

15

20

25

30

35

40

Baseline

Implementation

Durability

Summary of Findings

Clinical Practices: Therapists implemented MDFT in accordance with treatment parameters and interventions

Program Environment: Program was more practical, individually focused, organized, and clear following training in MDFT

Client Outcomes: Youths’ drug use, internalizing and externalizing symptoms, peer delinquency, and placements were reduced following MDFT training

Durability: Staff continued to use MDFT and to demonstrate outcomes with youth a year after MDFT experts withdrew

Implications of Findings

Evidence-based family treatment was successfully implemented within a complex hospital system, overcoming many obstacles

Implementation was successful in impacting all three levels of outcomes (provider, program, client)

Implementation successfully created lasting change in fundamental areas of provider and program functioning that impacted client outcomes

Current Pressing Questions How can evidence-based family treatments

be integrated within residential settings? Can protocols and training components be

simplified to help juvenile justice workers at different levels implement key interventions?

What can these approaches offer to make progress on challenges of workforce development/retention?

How can methods be improved to measure whether we’re “doing our model?”

Resources for Working with Drug Abusing Juvenile Offenders

Barnoski, R. (2002). Monitoring vital signs: Integrating a standardized assessment into Washington State’s Juvenile Justice System. In R. Corrado et al. (Eds.), Multi-problem violent youth. IOS Press.

Brown, D., Maxwell, S., DeJesus, E., & Schiraldi, V. (2002). Barriers and promising approaches to workforce and youth development for young offenders. The Annie E. Casey Foundation, Baltimore, MD.

CASA (2004). Criminal neglect: Substance abuse, juvenile justice and the children left behind.

Grisso, T. (1998). Forensic evaluation of juvenile offenders: A manual for practice. Sarasota, FL. Professional Resource Press.

Hoge, R., & Andrews, D. (1996). Assessing the youthful offender: Issues and techniques. New York: Plenum Press.

Liddle, H. (2002). Multidimensional Family Therapy Treatment (MDFT) for adolescent cannabis users. Volume 5 of the Cannabis Youth Treatment (CYT) manual series. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services.

NIDA (1999). Principles of Drug Addiction Treatment: A research-based guide. (NIH publication 99-4180). Rockville, MD.

NIDA (2006). Principles of Drug Abuse Treatment for Criminal Populations: A research-based guide. (NIH publication 06-5316). Rockville, MD.

OJJDP (1995). Guide for implementing the comprehensive strategy for serious, violent, and chronic juvenile offenders. Washington, DC: OJJDP.

Reclaiming Futures Fellowship Report (2006). A model for judicial leadership: Community responses to juvenile substance abuse. Reclaiming Futures.

Acknowledgements

We gratefully acknowledge the National Institute on Drug Abuse for supporting this work through many grants, including the Criminal Justice Drug Abuse Treatment Studies (CJDATS: Grant No. 5 U01 DA16193; P50 DA; H. Liddle, PI), “Family-based Juvenile Drug Court Services” (Grant no. 1 R01 DA17478; G. Dakof, PI), and our “Bridging” study (Grant No. R01 DA3089, H. Liddle, P.I.).

We are also indebted to the many therapists and the teens and families who have participated in these studies to develop and test MDFT over more than 20 years.

Please see our website for more information on the Center’s program of research: www.miami.edu/ctrada or contact me at crowe@med.miami.edu for more details.