Victimization, Trauma, and Suicidality Among Adolescents Presenting for Substance Abuse Treatment

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

Part of the continuing education workshop, “Advancing the Field of Adolescent Substance Abuse Treatment”, Hamden, CT, April 22, 2005. Sponsored by the Department of Children and Families Substance Abuse Division. 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 using data provided by the following grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888, TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340, TI130022, TI03345, TI012208, TI013323, TI14376, TI14261, TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272, TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678, TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674, TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514, TI15672, TI15478, TI15447, TI15545, TI15671)). 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: junsicker@Chestnut.Org

Demonstrate the feasibility and desirability of measuring victimization at intake with the GAIN’s General Victimization Scale (GVS)

Show that victimization is common and varies in severity

Examine the how the severity of victimization (measured with GVS) is correlated with with level of care, demographic characteristics, substance use severity, relapse potential, HIV risk, mental health, and crime/violence

Examine the implications of traumatic victimization for treatment outcome and matching

Goals of this Presentation

Victimization (including physical, sexual, and emotional abuse) are the norm for adolescents presenting to substance abuse treatment.

Yet staff often express concerns that they do not have the tools for screening; that screening might disrupt rapport (leading to early drop out or mandated reporting); and that they lack the resources to do anything about victimization.

This is at odds with expert recommendations (CSAT, 1993, 1999, 2000; Dennis & Stevens, 2003; Dennis, 2004) that have consistently encouraged early systematic screening and intervention among adolescents entering substance abuse treatment.

Introduction

Prevalence Rates of Victimization It is estimated that 826,000 to 3,000,000 (3-12%)

adolescents (age 12 to 17) have been victimized (DHHS, 2001; Sedlack & Broadhurst, 1996).

Among adolescents presenting for substance abuse treatment, the rates ranged from 40 to 80% - varying by gender, timing, definition, and level of care (Dennis & Stevens, 2003) .

– 39% of male & 59% of females acknowledged a lifetime history of physical or sexual victimization when interviewed a few questions in DATOS-A a month after intake (Grella & Joshi, 2003).

– 48% of the males and 80% of the females acknowledged a lifetime history of physical, sexual, or emotional victimization when interviewed with the GAIN at intake (Titus, Dennis, White, Scott & Funk, 2003).

Multiple Types of Victimization Measured by the GAIN’s General Victimization Scale (GVS)

Source: Titus et al, 2003

Emotional6%

none43%

Physical Only23%

Sexual Physical, & Emotional16%Sexual6%

Physical & Emotional6%

Emotional6%

None43%

Physical Only23%

Sexual, Physical, && Emotional, 16%

Sexual 6%

Physical & Emotional, 6%

Additional Traumagenic Factors Measured by GVS

Source: Titus et al, 2003 *All significant at p<.05

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

Abused before 18

Repeated abuse

Multiple abusers

Abused by trusted person

Afraid for life

Abuse resulted in sex

No one believed the abuse

Worried about weapon attack

Worried about physical abuse

Worried about sexual abuse

Worried about emotional abuse

Boys

Girls

CSAT Adolescent Treatment (AT) Programs Reordered by Level of Care and Severity

EAT: Effective Adolescent Treatment (2003-2007; n=975) replicating the CYT MET/CBT intervention in early intervention, school and outpatient settings(22 of 36 grants: Bradley, Brown, Clayton,Curry, Davis, Dillon, Dodge, Kressler, Kincaid, Levine, Levy, Locario, Mason, Moore, Rajaee-Moore, Paull, Payton, Rezende, Taylor, Tims, Turner, Vincent)

CYT: Cannabis Youth Treatment (1997-2001; n=600) Experiments with adolescent outpatient/intensive outpatient (5 grants: Babor, Dennis, Diamond, Godley, Tims)

TCE: Targeted Capacity Expansion (2002-2007; n=189) evaluation of intensive outpatient programs and some residential treatment (2 of 12 grants: Tims, Lloyd)

SCY: Strengthening Communities-Youth (2002-2007; n=1120) evaluations of early intervention, outpatient, intensive outpatient and some residential (11 of 12 grants: Beach, Bolland, Dahl, Gerstel, Godley, Hall, Hutchinson, Keehn, Murphy, Noonan, Panzarella)

ATM: Adolescent Treatment Model (1998-2002; n=1468) evaluations of outpatient, short and long term residential (10 grants: Batttjes, Fishman, Godley, Liddle, Morral, Perry, Sabin, Shane, Stevens-2)

ART: Adolescent Residential Treatment (2003-2006; n=1179) evaluations of residential treatment enhancements and continuing care (17 grants: Beach, Fishman, Flores, Gay, Gnazzo, Hatch, Hurtig, Lane, Law, Manov, May, Miley, Nordquist, Snipes, Urquahart, Whitmore, Zammarelli)

CSAT AT Program Common Data Set The working CSAT adolescent treatment data set including data on 5,468

adolescents from 67 local evaluations (current through quarterly data submission cycle ending in December 2004)

All data collected with the Global Appraisal of Individual Needs (GAIN) using centrally trained and certified staff

Outcome data through 12 months available on over 90% of CYT and ATM clients and over 80% of others “due” in on-going programs

Programs include several standardized protocols based on both research and practice (ACC, ACRA, ATM, FFT, FSN, Matrix, MET/CBT, MDFT, MST)

Local evaluations include several experiments and quasi experiments Several workgroups working on common themes across programs (African

American, Co-morbidity, Family, Native American/Indian, Spanish translation/workforce)

Data being shared with several secondary analysis grantees and panel presentations for this week

GVS Goes up With Level of Care

Source: CSAT AT Common GAIN Data set

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Early Intervention

Outpatient

Other

Intensive Outpatient

Medium Term Residential

Resid. Continuing Care

Long Term Residential

Short Term Residential

Low Mod. High

GVS Goes up With Several Characteristics

Source: CSAT AT Common GAIN Data set

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total

Female

In ControlledEnvironment

Mixed Race

Homeless/Runaway

21-25 Year Olds

Low Mod. High

GVS predicts higher substance use severity in multiple measures

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

0102030405060708090

100

1st U

se

unde

r 10

(3.6

)

5+ Y

ears

of

Use

(3

.3)

Wee

kly

Use

of A

OD

(1

.7)

AO

D

Dep

ende

nce

(4.1

)

Prio

rT

reat

men

t

(2.2

)

Seve

re

Wit

hdra

wal

(3.9

)

Low Mod. High

GVS predicts greater readiness to change, but higher relapse risks

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

010

2030

4050

6070

8090

100

Ack

now

ledg

esA

OD

pro

blem

(3.1

)

Bel

ieve

str

eatm

ent

need

ed (

2.0)

in h

ome

(1.9

)

amon

gw

ork/

scho

olpe

ers

(1.8

)

amon

g so

cial

peer

s (2

.3)

in H

ome

(2.

6)

amon

gw

ork/

scho

olpe

ers

(1.4

)

amon

g so

cial

peer

s (1

.8)

Low Mod. High

Regular Alcohol Use Regular Drug UseReadiness

GVS predicts higher HIV/STI risk in the 90 days before intake

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

0102030405060708090

100Se

xual

Act

ivit

y (0

.8)

Mul

tipl

e Se

x

Part

ners

(2.

0)

Unp

rote

cted

Sex

(2.7

)

Vic

tim

izat

ion*

(2.1

)

Wor

ries

abo

ut

vict

imiz

atio

n*

(4.8

)

Nee

dle

Use

(2.5

)

Low Mod. High* Relative to Mod.

GVS has its strongest relationship with internal disorders

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

0102030405060708090

100

Any

Int

erna

l

Dis

orde

r(6

.1)

Dep

ress

ive

Dis

orde

r (

5.2)

Anx

iety

Dis

orde

r

(6.5

)

Tra

uma

Rel

ated

Dis

orde

r (

9.6)

Any

Sel

f

Mut

ilat

ion

(3.

5)

Any

hom

icid

al/

suic

idal

thou

ghts

(5.

2)

Low Mod. High

GVS is also related to external/impulse control disorders

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

0

10

20

30

40

50

60

70

80

90

100A

ny E

xter

nal

Dis

orde

r

(4.7

)

Con

duct

Dis

orde

r

(4.7

)

AD

HD

(3.

7)

Ext

erna

l

And

Int

erna

l

(6.7

)

Low Mod. High

GVS is also related to Crime and Violence

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

0102030405060708090

100

Any

vio

lenc

e

or il

lega

l

acti

vity

(3.

6)

Phys

ical

Vio

lenc

e

(4.4

)

Any

Ill

egal

Act

ivit

y-pa

st

year

(2.

8)

Prop

erty

Cri

mes

(3.

0)

Inte

rper

sona

l

Cri

mes

(3

.1)

Dru

g R

elat

ed

Cri

me

(4.6

)

Low Mod. High

GVS is consequently related to the total number of major problems*

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

0%

10%

20%30%

40%

50%60%

70%

80%90%

100%

1 Problem 2 Problems 3 Problems 4 Problems 5 or moreProblems(117.2)Low Mod. High

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

Victimization and Gender Interact with Substance Use Outcomes

Source: Titus, Dennis, et al., 2003

0

10

20

30

40

50

60

Pre-Treatment Post-Discharge Pre-Treatment Post-Discharge

Day

s of

90

Low Clinical Acute

Male Female

Victimization Also Interacts with Level of Care

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

How do CHS OP’s high GVS outcomes compare with other OP programs on average?

Source: CYT and ATM Outpatient Data Set

-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)

ATM Total (n=284; d=0.41)

CHSOP (n=57; d=0.18)

Other programs serve clients who have significantly

higher severity

And on average they 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

Which 5 OP Programs Did the Best with High GVS adolescents?

Source: CYT and ATM Outpatient Data Set

-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) 7 Challenges (n=42; d=1.21)

Tucson Drug Court (n=27; d=0.65)

MET/CBT5a (n=34; d=0.62)

MET/CBT5b (n=40; d=0.55)

FSN/MET/CBT12 (n=34; d=0.53)

CHSOP (n=57; d=0.18)

The two best were used with much higher severity adolescents and

TDC was not manualized

Next we can check to see if they are any more similar in severity

-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)

MET/CBT5a (n=34; d=0.62)

MET/CBT5b (n=40; d=0.55)

FSN/MET/CBT12 (n=34; d=0.53)Epoch (n=72; d=0.33)

TSAT (n=66; d=0.35)CHSOP (n=57; d=0.18)

Which 5 OP Programs Did the Best with High GVS adolescents?

Source: CYT and ATM Outpatient Data Set

Trying MET/CBT5 because it is

stronger, cheaper, and easier to

implement

Not much improvement and they do not work quite as well

Other approaches specifically targeting trauma Cognitive Behavioral Intervention for Trauma in Schools (CBITS)®

Manual (Lisa H. Jaycox Ph.D., 2004) www.sopriswest.com or jaycox@rand.org

Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (Najavits, 2002) www.seekingsafety.org or from Guilford Press (800-365-7006)

Trauma Adaptive Recovery Group Education & Therapy Model for Adolescents (TARGET-A; Ford et al., 2000, Ford, Mahoney & Russo, 2004) from www.ptsdfreedom.org or ford@psychiatry.uchc.edu

Dialectical Behavior Therapy for Adolescents (DBT-A; Rathus, Miller, & Linehan, in press) from

School-Based Trauma/Grief Group Psychotherapy Program (SPARCS; Layne, Saltzman, Pynoos, et al., 2000) from Ruth@bascom.com

Concluding Comments Victimization is the norm among adolescents presenting for

substance abuse treatment Victimization can and should be comprehensively assessed at intake The severity of traumatic victimization is highly correlated with a

wide range of substance use, HIV risk behaviors, mental health, and crime/violence problems.

Higher levels of victimization interact with treatment effectiveness Substance abuse treatment programs vary in their effectiveness at

dealing with trauma More interventions are need to specifically target victimization and

trauma It is Time to Stop Ignoring the Elephant in our Counseling Room

Resources and References Copy of these slides and handouts are at http://www.chestnut.org/LI/Posters/ , see also

www.mayatech

Information on the GAIN is at www.chestnut.org/li/gain

Information on the adolescent treatment manuals discussed are at www.chestnut.org/li/apss/csat/protocols

References cited: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., & Stevens, S. J., (Eds.). (2003). Maltreatment issues and outcomes of adolescents enrolled in substance

abuse treatment [special issue]. Journal of Child Maltreatment, 8(1): 3-6. See http://www.sagepub.com/journalIssue.aspx?pid=15&jiid=6072

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

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.

Grella, C. E., & Joshi, V. (2003). Treatment processes and outcomes among adolescents with a history of abuse who are in drug treatment. Journal of Child Maltreatment, 8(1): 7-18.

Jaycox, L.H., Stein, B., Kataoka, S., Wong, M., Fink, A., Escudera, P. & Zaragoza, C. (2002). Violence exposure, PTSD, and depressive symptoms among recent immigrant school children. Journal of the American Academy of Child and Adolescent Psychiatry, 41(9): 1104-1110.

References Continued

Kataoka, S., Stein, B. D., Jaycox, L. H., Wong, M., Escuerdo, P., Tu, W., Zaragosa, C., & Fink, A. (2003). A school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 311-318.

Najavits, L. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York, NY: Guilford Press. Aavailalbe from www.seekingsafety.org or 800-365-7006.

Schwebel, R. (2004) The Seven Challenges® Manual. Available from www.sevenchallenges.com or rschwebel@sevenchallenges.com

Stein, B.D., Jaycox, L.H., Kataoka, S.H., Wong, M., Tu, W., Eliot, M.N., & Fink, A. (2003). A mental health intervention for school children exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290(5), 603-611.

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(1), 19-35.

U.S. Department of Health and Human Services. (2001). Child Maltreatment 1999. Washington, DC: U.S. Government Printing Office.