serving adolescents in family treatment drug court: identifying … servingadolescentsinftdc.pdf ·...

1

Serving Adolescents in Family Treatment Drug Court:

Identifying and providing youth with services for substance use, mental health

d lti l i dand multiple co-occurring needs

Randolph D. Muck, M.Ed.

Advocates for Youth and Family Behavioral Health

Treatment, LLC

Family Drug Courts: A National Symposium to

Improve Family Recovery, Safety and Stability

September 6, 2012

Family Drug CourtsFamily dependency treatment court is a juvenile or family court docket of which selected abuse, neglect, and dependency cases are identified where parental substance abuse is a primary factor. Judges, attorneys, child protection services, and treatment personnel unite with the goal of providing safe, nurturing, and permanent homes for children while simultaneously providing parents the necessary support and services to become drug and alcohol abstinent. Family dependency g y p ytreatment courts aid parents in regaining control of their lives and promote long-term stabilized recovery to enhance the possibility of family reunification within mandatory legal timeframes (Wheeler & Siegerist, 2003).

2

Marriage counseling movement begins before family therapy

35000

40000

45000

Age of Children in Foster Care as of September 30, 2005

15000

20000

25000

30000

0

5000

10000

Under1

2 4 6 8 10 12 14 16 18 20

Age

3

Substance Abuse Treatment and Foster Care Status

CSAT d 8 3% i• CSAT data set – 8.3% in treatment currently in foster care

• NSDUH (2005) – 0.6% of youth 12 – 17 ever in foster careever in foster care

• Odds ratio of 15:1 (but an underestimate)

We know the parents are really the problem!

4

Multiple Clinical Problems are the NORM!

20%

33%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Alcohol

Cannabis

41%

24%

14%

34%

27%Other drug disorder

Depression

Anxiety

Trauma

ADHD

7

80%

48%

63%

11%

CD

Suicide

Victimization

Violence/ illegal activity

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

Youth are involved in multiple systems placing competing demands on them and potentially in conflict with each other

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

9%

22%

33%

40%

Employed

Controlled environment

Prior Substance Abuse Treatment

Prior Mental Health Treatment

8

40%

68%

73%

Prior Mental Health Treatment

Current justice system involvement

In School

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

5

90%

100%None

The Number of Major Clinical Problems is highly related to Victimization

71%30%

40%

50%

60%

70%

80% One

Two

Three

Four

i

9

46%

15%0%

10%

20%

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

Five to Twelve


Significantly more likely to

have 5+ problems

(OR=13.9)

No. of Problems* by Severity of Victimization

80%

90%

100%Those with high lifetime levels of

victimization have 117 times higher

30%

40%

50%

60%

70%

Five or More

Four

Three

Two

117 times higher odds of having 5+ major problems*

Source: CSAT AT Common GAIN Data set (odds for High over odds for Low)

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

0%

10%

20%

Low (31%) Moderate (17%) High (51%)

One

None

GAIN General Victimization Scale Score (Row %)

6

Substance Use Careers Last for Decades

1.0

.9 Median of 27 f

ve S

urv

ival

.8

.7

.6

.5

.4

3

years from first use to 1+

years abstinence

Cu

mu

lati

v

Years from first use to 1+ years abstinence302520151050

.3

.2

.10.0

Source: Dennis et al., 2005

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

Age of 1st Use

1.0

.9

e S

urv

ival

under 15*

15-20*

Groups.8

.7

.6

.5

.4

3

Cu

mu

lati

ve

Years from first use to 1+ years abstinence

21+

15 20

* p<.05 (different from 21+)

302520151050

.3

.2

.10.0

Source: Dennis et al., 2005

7

Substance Use Careers are Shorter the Sooner Treatment Occurs

Year to 1st Tx

1.0

.9

ve S

urv

ival

20+

Groups.8

.7

.6

.5

.4

3

Cu

mu

lati

v

0-9*

10-19*

302520151050

.3

.2

.10.0

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

Years from first use to 1+ years abstinence

The Number of Clinical Problems is Related to Level of Care

90%

100%None

53%65%

80%

30%

40%

50%

60%

70%

80% One

Two

Three

Four

14

41% 45%53%

0%

10%

20%

Outpatient IntensiveOutpatient

OP Cont.Care

Long TermResid.

Short TermResid.

Five Plus


Significantly more likely to

have 5+ problems (OR=5.8)

8

The Cost of Treatment is Small Relative to Reductions in other Costs

$0 $10,

000

$20,

000

$30,

000

$40,

000

$50,

000

$60,

000

$70,

000

$407$1,249$1,132$1,384$2,486

$2,907$4 277

Screening & Brief Inter.(1-2 days)

In-prison Therap. Com. (28 weeks) Outpatient (18 weeks)

Intensive Outpatient (12 weeks)Treatment Drug Court (46 weeks)

Residential (13 weeks)M h d M i (87 k )

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

• $27,000 per robbery• $67,000 per assault

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

$4,277

$14,818Methadone Maintenance (87 weeks)Therapeutic Community (33 weeks)

$22,000 / year to incarcerate

an adult

$30,000/ child-year in foster care

$70,000/year to keep a child in

detention

Major limits through 1997

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

f h t dof what was done• Participation, treatment completion, and follow-

up rates were often low limiting the validity of what could be learned

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

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

9

Early Adolescent Treatment Work Worth Street Narcotic Clinic in NY – 743 youth

Federal Narcotic Farms in Lexington, KY & Fort Worth, TX 22-440/yr

Riverside Hospital in NYC – 250 youth

1910

1920

1930

Teen Addiction Hospital Wards in several cities

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

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

Services Research Outcome Study (SROS) - 156 youth

1940

1950

1960

1970

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

1980

1990

1996

National Treatment Improvement Evaluation Study (NTIES) - 236 youth Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A) -3,382 youth (1,785 followed)

What These Early Studies Taught Us

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

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

• Need for assessment and treatment for a wider range of problems including victimization, co-occurring mental health and education needsoccurring mental health and education needs

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

10

The Current Renaissance of Adolescent Treatment Research

Feature 1930-1997 1997-2005

Tx Studies* 17 Over 200

Random/Quasi 9 44

Tx Manuals* 0 30+

QA/Adherence Rare Common

Std Assessment* Rare Common

Participation Rates Under 50% Over 80%Participation Rates Under 50% Over 80%

Follow-up Rates 40-50% 85-95%

Methods Descriptive/Simple More Advanced

Economic Some Cost Cost, CEA, BCA

* Published and publicly available

• 1997-2001, Cannabis Youth Treatment (CYT) – 600 youth

1998 2001 Ad l t T t t M d l (ATM) 1334

15+ Year Investment in ImprovingAdolescent Treatment Effectiveness

• 1998-2001, Adolescent Treatment Models (ATM) -1334 youth

• 1998-2004, CSAT/NIAAA experiments – several hundred youth

• 2000-2002, Persistent Effects of Treatment Study of AdolescentsAdolescents

(PETS-A) - 1200 youth

• 2001-2003, CSAT/RWJF Reclaiming Futures, 445 youth

11

• 2002-2007, Strengthening Communities for Youth (SCY) – 2,249 youth




• 2003-2012, Targeted Capacity Expansion (TCE) –, g p y p ( )1,417 youth

• 2003-2006, Adolescent Residential Treatment (ART) – 1,458 youth


• 2003-2007, Effective Adolescent Treatment (EAT) –5,854 youth

• 2002-2012, Targeted Capacity Expansion (TCE) –1,417 youth

• 2003-2006, Adolescent Residential Treatment (ART) –1,458 youth

• 2003-2007, Effective Adolescent Treatment (EAT) –

22

2003 2007, Effective Adolescent Treatment (EAT) 5,854 youth

• 2004-2009, Co-occurring State Infrastructure Grants (COSIG) –systems project w/CMHS

12


• 2004-2009, Young Offender Re-entry Program (YORP) – 1,597 youth

• 2005-2008, State Adolescent Coordinator (SAC) –system

• 2005-2010, Juvenile Treatment Drug Court (JTDC) –1,678 youth

• 2006-2013, Adolescent Assertive Family Tx (AAFT)-2006 2013, Adolescent Assertive Family Tx (AAFT)4,769 youth

• 2007-2011, Brief Interventions and Referrals to Treatment (BIRT)-427 youth, Joint Funding (CSAT/OJJDP)


• 2009-2011. Reintegration of Youth and Families (Research Contract to randomly assign youth to one of three conditions of supportive services followingof three conditions of supportive services following residential treatment.

• 2009-2016, Reclaiming Futures structure joined with juvenile drug courts and their 16 Strategies (joint funding – OJJDP/RWJF/CSAT)

• 2012-2015 SA-TED – Grants to be awarded in FY 12• 2012-2015, SA-TED – Grants to be awarded in FY 12 for up to 10 states/tribes/territories for developing their infrastructure to field and monitor EBPs for youth treatment

13

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

Rapid Screening & Assessment

26

14

Developing and Engaging a Community Network

27

The Importance of Teams

• Engage all stakeholders in creating an interdisciplinary, coordinated, and systemic approach to working with youth and familiesapproach to working with youth and families

• Develop and maintain an interdisciplinary, non-adversarial work team

S h d l f t i t di i li i d b• Schedule frequent interdisciplinary reviews and be sensitive to the effect that juvenile justice and treatment actions can have on youth and families, for both good and inadvertent harm when working at cross purposes.

15

Environmental Factors as Major Mediators/Moderators and Predictors of Use and Need for Early Reengagement in

TreatmentAOD use in the home, family problems, homelessness, fighting,

victimization, self help group participation, structure activities

The effects of adolescent treatment are mediated by the

RecoveryEnvironment

Risk

FamilyConflict

FamilyCohesion Substance

Use

Substance-RelatedProblems

Baseline

.32.18

-.13

.32 .22

.32

.17

.43

.77

.82

.74 .58

-.54

-.09

.19

treatment are mediated by the extent to which they lead to actual changes in the recovery environment or peer group

SocialRisk

SocialSupport

Baseline

Baseline Baseline

.21

-.08 .19 .22.11

Source: Godley et al (2005)

Model FitCFI=.97 to .99 RMSEA=.04 to .06

Peer AOD use, fighting, illegal activity,

treatment, recovery, vocational activity

Most Programs Lack Standardized Assessment for…

• Substance use disorders (e.g., abuse, dependence, ithd l) di f h l t ti lwithdrawal), readiness for change, relapse potential

and recovery environment

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

16

Assessment for ALL disorders

is needed because. . .

• Having one disorder increases the risk of developingHaving one disorder increases the risk of developing another disorder;

• The presence of a second disorder makes treatment of the first more complicated;

• Treating one disorder does NOT lead to effective management of the other(s);

• Treatment outcomes are poorer when co occurring• Treatment outcomes are poorer when co-occurring disorders are present.

Psychometric Properties GAIN-SS

80

90%

100%

Prevalence (% 1+ disorder)

Sensitivity (% w disorder b )

Low Mod. High

30%

40%

50%

60%

70%

80%

above)Specificity (% w/o disorder below)

99% prevalence, 91% sensitivity &

Using a higher cut point increases prevalence and specificity, but decreases sensitivity

Total Disorder Screener (TDScr)

0%

10%

20%

%

0 1 2 3 4 5 6 7 8 9 10

11 12

13

14

15

16

17

18

19

20

(n=6194 adolescents)

91% sensitivity, & 89% specificity at 3 or more symptoms

sensitivity

Total score has alpha of .85 and is correlated .94 with full GAIN versionSource: Dennis et al 2006

17

Rapidly Spreading

• State or Provincial wide implementation in multiple states (ID, CT, LA, MD, NH, NV, OR, SC, WA, WI) and provinces (BC, ON, QU) in one or more large systems (adolescent or adult addiction treatment, mental health, welfare, juvenile or criminal justice , Student or Employee Assistance Programs),

• Used by SAP or EAP in Brazil, Canada, Japan, M i U it d St t d b i t l t d fMexico, United States and being translated for use in China.

• In our GAIN ABS software, from other commercial vendors (e.g., Assessments.com ) and local IT systems (e.g., ID, WA)

Assessing the true needs and resources: what is appropriate in a

treatment setting?

• Conduct a strengths based assessment: (NPC g (Research Youth Competency Assessment ) http://www.npcresearch.com/materials/_yca_tools.php

• Individualize responses and direct toward pro-social and strengths/needs of youth (picking up trash is not a treatment intervention, though it may be a logical and

t l f th t)natural consequence from the court)

• “Build partnerships with community organizations to expand the range of opportunities available to youth and their families.”

18

Crime/Violence and Substance Problems Interact to Predict Recidivism

80%

100%

vism

Crime/ Violence

0%

20%

40%

60%

12 m

onth

rec

idivViolence

predicted recidivism

Substance Crime and Violence

Source: CYT & ATM Data

Substance Problem Severity predicted

recidivismKnowing both was the

best predictor

Problem Scale

ViolenceScale

Crime/Violence and Substance Problems Interact to Predict Violent Crime or Arrest

vism

r

arre

st

80%

100%

Crime/

12 m

onth

rec

idiv

To v

iole

nt c

rim

e or

SubstanceCrime and Violence 0%

20%

40%

60%

Crime/ Violence predicted

violent recidivism

Source: CYT & ATM Data

Substance Problem

Scale

ViolenceScale

(Intake) Substance Problem Severity did

not predict violent recidivism

Knowing both was the best predictor

19

Common Substance Use Disorder Screening Instrument Across Agencies

14

16

2

4

6

8

10

12 Began During Grant Period

Existed Prior to Grant Period

N=16

0

2

Substance Abuse

Mental Health

Juvenile Justice

Child Welfare

Education

Common Substance Use Disorder Assessment Instrument

Across Agencies16

B

4

6

8

10

12

14 Began During Grant Period


N=16

0

2

4

Substance Abuse

Mental Health

Juvenile Justice

Child Welfare

Education

20

Change and Opportunity

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

• Have pooled data from 19,229 youth assessed with the Global Appraisal of Individual Needs (GAIN), including 88% with one or more follow-ups, made available for program evaluation and secondary analysis, and helped to generate over 200 publicationsover 200 publications

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

• Several System level grants

Treating Teens:

A Guide to Adolescent Drug Programs

http://drugstrategies.com/treatingteens.html

21

Key Elements of Effectiveness

• Screening/Assessment and Treatment Matching

• Engage and Retain Teens in Treatmentg

• Comprehensive, Integrated Treatment Approach

• Family Involvement in Treatment

• Qualified Staff

• Gender and Cultural Competence

• Developmentally Appropriate Treatment

• Continuing Care

• Treatment Outcomes

*Continued supports/services *added post-hoc by presenter

Evidence-Based Practices

12

14

16

2

4

6

8

10

12

Began During Grant Period


N=16

0

2

Revised Policies to Support EBPs

Sequenced EBP Implementation

Plans

Developed contracts requiring EBPs

22

Victimization and Level of Care Interact to Predict Outcomes

35

4090

)CHS Outpatient CHS Residential

Traumatized groups have higher severity

10

15

20

25

30

ariju

ana

Use

(D

ays

of 9

Source: Funk, et al., 2003

0

5

10

Intake 6 Months Intake 6 Months

Ma

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

High trauma group does not respond to OP

Both groups respond to residential treatment

Interventions Associated With No or Minimal Change in Substance Use or Symptoms• Passive referrals

• Educational units alone

• Probation services as usual

• Unstandardized outpatient services as usual

Interventions associated with

deterioration• Treatment of adolescents with/in adult units

23

Cumulative Recovery Pattern at 30 Months Post Intake

5% Sustained Recovery

37% Sustained Problems 19% Intermittent,

currently in recovery

Source: Dennis et al, forthcoming

39% Intermittent, currently not in

recovery

The Majority of Adolescents Cycle in and out of Recovery

THE VOICES OF YOUTH

Substance Abuse & Mental Health Services Administration

Center for Substance Abuse Treatment

46

National Summit on Recovery

Randolph Muck, M.Ed.Team Leader/Adolescent ProgramsDivision of Services Improvement

24

Barriers to Recovery

• Staff uninterested in listening to youth

• Continuing care is optional or not offered

• No opportunity to practice skills in real life settingslife settings

• No linkages with mentors or sponsors before treatment ends

Evidence Based Practice

Tested with good outcomes

Manual exists so it can be replicated/trained

A training program exists

Supervision leading to certification

Ongoing monitoring

Outcomes measurement

25

Observable and Significant Differential Outcomes

A Comparison of Nine Treatment Approaches • The Seven Challenges

• Chestnut Health Systems Intensive Outpatient

• Adolescent Community Reinforcement Approach

• Multi-Systemic Therapy

M lti Di i l F il Th• Multi-Dimensional Family Therapy

• Motivational Enhancement Therapy-Cognitive Behavioral Therapy 5 sessions

• Family Support Network

*Focus on Co-occurring Disorders and Trauma

• Emotional Problems Scale

• Days of Victimization

• Days of Traumatic• Days of Traumatic Memories

*Scales, scores and norms derived from the Global Appraisal of individual Needs, author: Michael Dennis, Ph.D.

26

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

Treatment Seven

Challenges(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)

39 .37

.37

-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

-0.40

-0.20

0.00

0.20

hang

e E

ffec

t Siz

e d

p -

mea

n in

take

)/ s

td d

ev. i

ntak

e)

-0.5

4

-0.4

3

-0.4

5 -0. 3 -0 -0. -

-0.80

-0.60

Ch

((m

ean

foll

ow-u

p

Emotional Problem Scale Days of traumatic memories Days of victimization

Four best on mental health outcomes include 7 challenges,

CHS, A-CRA, & MST

Workforce Implications

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

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

• Seven Challenges, with a mix of para-professional (non-degreed), BA/MA therapists did as well as A-CRA and MST

27

Proliferation of EBPs

% Change: Abstinence at 6-months post-initial assessment

*MET/ *ACRA/ **TARGET **SEE

CBT 5 ACC YOUTH YOUTH

60.6 69.3 12.6 21.1

* GAIN Mandated

** GAIN Optional

Source: SAIS System (GPRA)

28

Interventions that Typically do Better than Practice As Usual in Reducing

Recidivism (29% vs. 40%)• Aggression Replacement Training

Th S Ch ll• The Seven Challenges• Reasoning & Rehabilitation• Moral Reconation Therapy• Thinking for a Change• Interpersonal Social Problem Solving• Multisystemic Therapy• Functional Family Therapy• Functional Family Therapy• Multidimensional Family Therapy• Adolescent Community Reinforcement Approach• MET/CBT combinations and Other manualized CBT

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

Tanner-Smith, E.E., Wilson, S.J, & Lipsey, M.W. ( ).

The comparative effectiveness ofThe comparative effectiveness of outpatient treatment for

adolescent substance abuse: A meta-analysis. Journal of

S b t Ab T t t iSubstance Abuse Treatment , in press.

29

Meta Analysis of the Effectiveness of Programs for Juvenile Offenders

N ofOffender Sample Studies

Preadjudication (prevention) 178Probation 216Institutionalized 90Aftercare 25

Total 509

Source: Adapted from Lipsey, 1997, 2005

Most Programs are actually a mix of components

Average of 5.6 components distinguishable in d i ti f h tprogram descriptions from research reports

Intensive supervisionPrison visitRestitutionCommunity serviceWilderness/Boot campTutoringIndividual counseling

Anger managementMentoringCognitive behavioralBehavior modificationEmployment trainingVocational counselingLife skillsIndividual counseling

Group counselingFamily counselingParent counselingRecreation/sportsInterpersonal skills

Life skillsProvider trainingCaseworkDrug/alcohol therapyMultimodal/individualMediation


30

Major Predictors of Bigger Effects

1. A strong intervention protocol based on prior evidenceon prior evidence

2. Quality assurance to ensure protocol adherence and project implementation

3. Proactive case supervision of individual

4 T i t f th hi h t it4. Triage to focus on the highest severity subgroup

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

Analysis

The more features, the lower

the recidivism


Average Practice

recidivism

31

Implementation is Essential (Reduction in Recidivism)

The best is tohave a strongprogram implemented well

61

The effect of a well implemented weak program is as big as a strong program implemented poorly

Thus one should optimally pick the strongest intervention that one can implement well


Range of Effect Sizes (d) for Change in Days of Abstinence (intake to 12 months) by site: First evidence of rapid movement of a clinical trial to an effectiveness study with promising outcomes and quick adoption. More to come from the CSAT AAFT program and is showing promising preliminary results

1.20

1.40

1.20

1.40EAT Programs did Better than

6 programs completely b CYT

0.40

0.60

0.80

1.00

0.40

0.60

0.80

1.00

Coh

en’s

d

CYT on average above CYT

0.00

0.20

0.40

4 CYT Sites (f=0.39)(median within site d=0.29)

36 EAT Sites (f=0.21)(median within site d=0.49)

0.00

0.20

0.40

Source: Dennis, Ives, & Muck, 2008 Results of a community based Type IV Clinical Trail for Effectiveness

75% above CYT median

32

Other Common Findings

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

Wilderness programs have mixed effects

Treating adolescents like adults (or with adults), and in boot camp causes harm on averageg

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

Continuing Care

• The continuation of services in a seamless fl i i ti f f l li tflow is imperative for successful client outcomes

• All too often, they fall through the cracks in the systemthe system

= 14 days

33

Time to Enter Continuing Care and First Use after Residential Treatment

80%

90%

100%

30%

40%

50%

60%

70%

Per

cent

of A

dole

scen

ts

Entered

CC

First Use

Source: DARTS 2000 and Godley et al 2002

0%

10%

20%

0 10 20 30 40 50 60 70 80 90

Days after Residential (capped at 90)

P CC

Do adolescents attend 12 step meetings after residential discharge?

85%90%

100%

9

10

42%

4.5

40%

50%

60%

70%

80%

4

5

6

7

8

00%

10%

20%

30%

Attended One or More Meetings Median No. Meetings Attended0

1

2

3

Adults Adolescents

34

High Risk Recovery Environments

29%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

use

In home

52%

61%

17%

Reg

ular

alc

ohol

among work/school peers

among social peers

use In home

67%

79%Reg

ular

dru

g

among work/school peers

among social peers

Source: CSAT AT Common GAIN Data set

Assertive Continuing Care

• The Assertive Continuing Care Protocol (ACC) is a continuing care intervention specifically designedcontinuing care intervention specifically designed for adolescents following a period of residential treatment.

• ACC is delivered primarily through home visits.

• ACC case managers are assertive in their attempts to engage participantsto engage participants.

• Case managers deliver the Adolescent Community Reinforcement Approach (ACRA) procedures

35

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

80%

90%

100%

73%

19% 22% 22%20%

30%

40%

50%

60%

70%69%

59%

73%

Source: Godley et al 2002, 2007

0%

10%

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

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

Ongoing Supportive Services(Ages 0 – 26) as defined by CMS

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Ongoing Support/Cost Effective Strategies

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Self-Management and Recovery Training: (SMART) Recovery

• Origins in Rational Emotive Therapy

• Portable, applicable in real world

• Group Modality – Led by trained facilitators

– Open enrollment

Uses common elements of CBT– Uses common elements of CBT

– Considered easy to learn and use

– http://www.smartrecovery.org/intro/

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Alternative Support Services

• Club House Model (several types, organized differently)

• The Seven Challenges Support Group

• SMART Recovery

• Alternative Peer Groups

• Mentoring

• Pima Prevention

• CRAFT• CRAFT

• Peer to Peer

• Technological Supports (very little in the scientific literature to support or disprove these approaches, with the exception of many promising studies in allied professions on the use of technological supports now emerging)

Evidence Based Practice

Tested with good outcomes

Manual exists so it can be replicated/trained

A training program exists

Supervision leading to certification

Ongoing monitoring

Outcomes measurement

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Technological Approaches For Ongoing Supports

– University of Arizona – pod casting, texting, geo-fencingfencing

• 90 – 95% Engagement, Utilization, Satisfaction

– Recovery Services for Adolescents and their Families (RSAF) CSAT Research Project (Cell phone, Texting, Web Site, CRAFT for Parent Groups)Groups)

– Dick Dillon , St. Louis – Second Life

• Continuing Care Participation Increased from 40% to 90% over 6 months

• Juvenile Justice involved youth increasing presence in the treatment system

Issues to Consider

• Youth who need treatment and not receiving it has swollen to 1:20

• Support for funding relies on ability to demonstrate effectiveness

• Treatment needs of the youth that we see and the need to incorporate appropriate andthe need to incorporate appropriate and effective interventions for these needs

• Continuing Care is as, or more important than the treatment delivered

• Ongoing Support Services Promising and potential for being a key ingredient

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ti l t t

– The resource center is continually updating its website with materials relevant to the reentry field.

– Sign up for the monthly NRRC newsletter to receive

b t i

www.nationalreentryresourcecenter.org

news about upcoming distance learning and funding opportunities.

Summary

• Achieving reliable outcomes requires reliable measurement, protocol delivery and on-going performance monitoring.

• The GAIN, CASI, and T-ASI (assessment tools) and MET/CBT 5, A-CRA, and Seven Challenges (treatment interventions) training is available through the National Council of Juvenile and Family Court Judges (OJJDP Grant) Contact: Jessica Pearce [email protected]

• Standardized and more specific screening/assessment helps to draw out treatment planning implications of readiness for change, recovery environment, relapse potential, psychopathology, crime/violence, and HIV risks.

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Summary

• Adolescents entering more intensive levels of care typically have higher severity.

• Multiple problems and child maltreatment and justice involvement are the norm and are closely related to each other.

• There are a growing number of standardized assessment tools, treatment protocols and other resources available to support evidenced based practices.

Summary, cont.

• Know what treatment services are provided (EBP? Appropriate for identified problems?(EBP?, Appropriate for identified problems?, Implemented with fidelity?)

• Choose EBPs that can be done well given limitations (staff experience/training, cost, belief in approach)

• Push for appropriate services and demandPush for appropriate services and demand outcome data

• DO NOT Ignore Continuing

Care/Supportive Services! =

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Contact Information

Randolph D. Muck, M.Ed.Senior Clinical Consultant

Advocates for Youth and Family Behavioral H lth T t t LLCHealth Treatment, LLC

e-mail: [email protected]

Website: www.ayftx.comy

Phone: 240-397-3918

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