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Victimization, Trauma, and Suicidality Among Adolescents Presenting for Substance Abuse Treatment Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington,

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Presentation on theme: "Victimization, Trauma, and Suicidality Among Adolescents Presenting for Substance Abuse Treatment Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington,"— Presentation transcript:

1 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, 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 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 or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) , fax: (309) ,

2 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

3 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

4 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).

5 Multiple Types of Victimization Measured by the GAIN’s General Victimization Scale (GVS) Source: Titus et al, 2003 Emotional 6% none 43% Physical Only 23% Sexual Physical, & Emotional 16% Sexual 6% Physical & Emotional 6% Emotional 6% None 43% Physical Only 23% Sexual, Physical, & & Emotional, 16% Sexual 6% Physical & Emotional, 6%

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

7 CSAT Adolescent Treatment (AT) Programs Reordered by Level of Care and Severity EAT: Effective Adolescent Treatment ( ; 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 ( ; n=600) Experiments with adolescent outpatient/intensive outpatient (5 grants: Babor, Dennis, Diamond, Godley, Tims) TCE: Targeted Capacity Expansion ( ; n=189) evaluation of intensive outpatient programs and some residential treatment (2 of 12 grants: Tims, Lloyd) SCY: Strengthening Communities-Youth ( ; 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 ( ; 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 ( ; 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)

8 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

9 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 LowMod.High

10 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 Controlled Environment Mixed Race Homeless/ Runaway Year Olds LowMod.High

11 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) st Use under 10 (3.6) 5+ Years of Use (3.3) Weekly Use of AOD (1.7) AOD Dependence (4.1) Prior Treatment (2.2) Severe Withdrawal (3.9) LowMod.High

12 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) Acknowledges AOD problem (3.1) Believes treatment needed (2.0) in home (1.9) among work/school peers (1.8) among social peers (2.3) in Home (2.6) among work/school peers (1.4) among social peers (1.8) LowMod.High Regular Alcohol Use Regular Drug Use Readiness

13 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) Sexual Activity (0.8) Multiple Sex Partners (2.0) Unprotected Sex (2.7) Victimization* (2.1) Worries about victimization* (4.8) Needle Use (2.5) LowMod.High * Relative to Mod.

14 GVS has its strongest relationship with internal disorders Source: CSAT AT Common GAIN Data set (Odds Ratios: odds for High over odds for Low) Any Internal Disorder (6.1) Depressive Disorder (5.2) Anxiety Disorder (6.5) Trauma Related Disorder (9.6) Any Self Mutilation (3.5) Any homicidal/ suicidal thoughts (5.2) LowMod.High

15 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) Any External Disorder (4.7) Conduct Disorder (4.7) ADHD (3.7) External And Internal (6.7) LowMod.High

16 GVS is also related to Crime and Violence Source: CSAT AT Common GAIN Data set (Odds Ratios: odds for High over odds for Low) Any violence or illegal activity (3.6) Physical Violence (4.4) Any Illegal Activity-past year (2.8) Property Crimes (3.0) Interpersonal Crimes (3.1) Drug Related Crime (4.6) LowMod.High

17 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 Problems3 Problems 4 Problems5 or more Problems (117.2) LowMod.High * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

18 Victimization and Gender Interact with Substance Use Outcomes Source: Titus, Dennis, et al., Pre-TreatmentPost-DischargePre-TreatmentPost-Discharge Days of 90 LowClinicalAcute MaleFemale

19 Victimization Also Interacts with Level of Care Source: Funk, et al., Intake6 MonthsIntake6 Months Marijuana Use (Days of 90) OP -HighOP - Low/ModResid-HighResid - 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

20 How do CHS OP’s high GVS outcomes compare with other OP programs on average? Source: CYT and ATM Outpatient Data Set IntakeMon 1-3Mon 4-6Mon 7-9Mon Z-Score on Substance Frequency Scale (SFS) 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

21 Which 5 OP Programs Did the Best with High GVS adolescents? Source: CYT and ATM Outpatient Data Set IntakeMon 1-3Mon 4-6Mon 7-9Mon Z-Score on Substance Frequency Scale (SFS) 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

22 IntakeMon 1-3Mon 4-6Mon 7-9Mon Z-Score on Substance Frequency Scale (SFS) 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

23 Other approaches specifically targeting trauma Cognitive Behavioral Intervention for Trauma in Schools (CBITS)® Manual (Lisa H. Jaycox Ph.D., 2004) or Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (Najavits, 2002) or from Guilford Press ( )www.seekingsafety.org Trauma Adaptive Recovery Group Education & Therapy Model for Adolescents (TARGET-A; Ford et al., 2000, Ford, Mahoney & Russo, 2004) from or 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

24 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

25 Resources and References Copy of these slides and handouts are at see also Information on the GAIN is at Information on the adolescent treatment manuals discussed are at 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, 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 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, 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): 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):

26 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), Najavits, L. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York, NY: Guilford Press. Aavailalbe from or www.seekingsafety.org Schwebel, R. (2004) The Seven Challenges® Manual. Available from or 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), 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), U.S. Department of Health and Human Services. (2001). Child Maltreatment Washington, DC: U.S. Government Printing Office.


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