Chapter 4 Overview of Justice Program Treatment Sites GAIN Coordinating Center (11/21/2012). Normal, IL: Chestnut Health Systems. November Available from Created for: Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT) under contract number

2 SAMHSA/CSAT Full GAIN Outcome Data Set Sample: The 2011 SAMHSA/CSAT data set includes data on 29,782 clients from 230 local evaluations, recruited between who were due for at least one follow-up and available in the last quarterly data set of Levels of Care: Outpatient, Intensive Outpatient, Short-term & Moderate/Long-term Residential, Corrections-Based Treatment and Post-Treatment Continuing Care Instrument:Global Appraisal of Individual Needs (GAIN) (see Versions 3 (CYT & ATM) and 5.1 through Follow-up:89% with one or more follow-ups at 3, 6, 9 & 12 months post intake, and 66% with two or more Funding: SAMHSA/CSAT contracts and and 230 individual grants (see Detailed Acknowledgement)

3 Risk and Protective Factors  The following slides present information on demographics, and risk and protective factors for clients at intake, including:  Demographics  Substance use  Risk behaviors  Victimization  Mental health disorders  Physical health problems  Crime and violence  Sources of stress and strengths  Costs  Summary indices (problem prevalence, quality of life, general satisfaction)  Non-client characteristics (program, level of care, and type of treatment)

4 Age Years 21.7% (n=1,719) Under 15 Years (<15) 6.7% (n=532) Years 42.3% (n=3,343) 26+ Years 29.2% (n=2,312) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,906)

5 Gender Males 70.6% (n=5,582) Females 29.4% (n= 2,322) Other 0.01% (n=1) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,905)

6 Race Multi-racial 11.6% (n=918) African American 17.3% (n=1,371) Hispanic 33.7% (n=2,660) White 34.7% (n=2,744) Other 2.7% (n=211) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,904)

7 Demographic Characteristics *Any Hispanic ethnicity separate from race group CSAT data dominated by male, minority, age 18+ Source: CSAT 2011 JP Summary Analytic Data Set (n=7,843)

8 Environment *n = 5,442 Source: CSAT 2011 JP Summary Analytic Data Set (n=7,860)

9 Current Risk of Homelessness At Risk 14.9% (n=1,163) Housed 58.5% (n=4,578) Group or Institution 20.1% (n=1,575) Currently Homeless 6.4% (n=503)

10 Substance Problem Recognition * n=5,252 Source: CSAT 2011 JP Summary Analytic Data Set (n=7,895)

11 Substance Severity by Time Period Source: CSAT 2011 Summary Analytic Data Set (n=7,821)

12 Past 90 Day Primary Substance Cocaine 9.7% (n=766) Alcohol 26.9% (n=2,130) Amphetamines 11.5% (n=912) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,904) Other Drugs 2.3% (n=179) Opioids 10.0% (n=792)

13 Substance Use Problems *Count of 8 items Source: CSAT 2011 JP Summary Analytic Data Set (n=7,820)

14 Pattern of Weekly Use (13+/90 days) *Not a weekly measure; any in past 90 days Source: CSAT 2011 JP Summary Analytic Data Set (n=7,885)

15 Substance Use Disorders in Past Year by Major Substances *n=4,074 **Not counted in Any SUD Diagnosis. Abuse is not an option for Tobacco. Source: CSAT 2011 JP Summary Analytic Data Set (n=6,915)

16 Tobacco Diagnosis Source: CSAT 2011 JP Summary Analytic Data Set (n=7,803)

17 Recovery Environment - Peers Source: CSAT 2011 JP Summary Analytic Data Set (n=7,780)

18 Recovery Environment - Home Source: CSAT 2011 JP Summary Analytic Data Set (n=7,799) *Past 90 days

19 HIV Risk Scale* Past Year at Intake: Needle Use * Mean of 36 items from the next four slides. Intake only. Source: CSAT 2011 JP Summary Analytic Data Set (n=7,896)

20 HIV Risk Scale* Past Year at Intake: Sex * Mean of 36 items. Intake only. Source: CSAT 2011 JP Summary Analytic Data Set (n=7,294) **n=8,246

21 HIV Risk Scale* Past Year at Intake: Victimization * Mean of 36 items. Intake only. Source: CSAT 2011 JP Summary Analytic Data Set (n=7,622) **n=18,224

22 HIV Risk Scale* Past Year at Intake: Trauma *Mean of 36 items. Available at intake only. Source: CSAT 2011 JP Summary Analytic Data Set (n=7,864)

23 HIV Risk Change Index* in Past 90 Days at Intake *Count of 7 items listed. Can be used to measure change. Source: CSAT 2011 JP Summary Analytic Data Set (n=7,736)

24 Number of Sex Partners* Source: CSAT 2011 JP Summary Analytic Data Set (n=7,507) *In the past 90 days

25 Severity of Victimization Scale **Mean of 15 items Source: CSAT 2011 JP Summary Analytic Data Set (n=7,862) *n=5,235

26 Past Year Mental Health Disorders Internalizing Disorders Only 13.8% (n=1,087) Externalizing Disorders Only 15.5% (n=1,222) Both 27.8% (n=2,192) Neither 42.8% (n=3,371) Source: CSAT 2011 Summary Analytic Data Set (n=7,872)

27 Co-Occurring Psychiatric Problems *(n=7,704) ** Count of Conduct Disorder, ADHD/ADD Major Depressive Disorder, Traumatic Stress Disorder, and Generalized Anxiety Disorder Source: CSAT 2011 JP Summary Analytic Data Set (n=7,875)

28 Homicidal/Suicidal Thoughts *Mean of 5 items Source: CSAT 2011 JP Summary Analytic Data Set (n=7,890)

29 Para-suicidal Index *Sum of 4 items Source: CSAT 2011 JP Summary Analytic Data Set (n=7,701)

30 Family History of Health Problems Source: CSAT 2011 JP Summary Analytic Data Set (n=7,690)

31 Past 90 Day Health Problems High Problems 10.0% (n=781) Low Problems 59.2% (n=4,625) Moderate Problems 30.8% (n=2,410) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,816)

32 Quarterly Cost of Health Care Utilization  Using the GAIN, we are able estimate the quarterly cost to society of tangible services (e.g., hospital visits, emergency room visits, etc.) in 2011 dollars for the 90 days before intake.  For the 7,598 clients served in 58 sites between , the average Quarterly Cost of Health Care Utilization (HCU) per client: –in the quarter before they entered treatment, was $2,323 and totaled $17,648,250 across clients. –in the year before they entered treatment, was $9,292 per client and totaled $70,593,000 across clients.

33 HCU Cost to Society – 2011 Dollars * Quarterly Health Care Utilization 2011 dollars w/ SA TX based on French, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and reimbursement. Journal of Substance Abuse Treatment, 35, DescriptionUnitCost 2011 dollars Inpatient hospital dayDays $ 2, Emergency room visitVisits $ 6, Outpatient clinic/doctor’s office visitVisits $ Nights spent in hospitalNights $ 2, Times gone to emergency roomTimes $ 6, Times seen MD in office or clinicTimes $ How many days in detoxDays $ Times in ER for AOD useTimes $ Nights in residential for AOD useNights $ Days in Intensive outpatient program for AOD useDays $ Times did you go to regular outpatient programTimes $ 32.50

34 Health Care Utilization Cost Source: CSAT 2011 JP Summary Analytic Data Set (n=7,598)

35 Past Year Crime and Violence High 30.4% (n=2,396) Low 49.6% (n=3,910) Moderate 20.0% (n=1,581) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,887)

36 Past Year Crime & Justice Involvement *Dealing, manufacturing, prostitution, gambling (does not include simple possession or use) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,893)

37 Type of Crime * Violent crime includes assault, rape, murder, and arson. ** Other crime includes vandalism, possession of stolen goods, forgery, and theft. Source: CSAT 2011 JP Summary Analytic Data Set (n=7,754)

38 Cost of Crime in the Past Year  Using the GAIN we are able estimate the cost to society associated with economic losses due to criminal activity (e.g., vandalism, forgery, theft, assault, arson, rape, murder) in 2011 dollars for the year prior to intake  Of the 7,906 clients served in 58 CJ sites between , the average Cost of Crime per client, in the year before they entered treatment, was $264,685 and totaled $2,058,982,855 across clients.

39 Cost of Crime – 2011 Dollars* *Cost of Crime 2011 dollars w/ SA TX based on McCollister, K. E., French, M. T., & Fang, H. (2010). The cost of crime to society: New crime-specific estimates for policy and program evaluation. Drug and Alcohol Dependence, 108(2)(1-2), DescriptionUnit Cost 2011 dollars Purposely damaged or destroyed propertyTimes$5, Passed bad checks/forged a prescription/took money from employerTimes$5, Taken money/property (not from a store)Times$8, Broken into a house/building to stealTimes$6, Taken a car that didn't belong to youTimes$11, Used a weapon, force, or strong-arm methods to get money or things from a personTimes$44, Hurt someone badly enough they needed bandages or a doctorTimes$112, Made someone have sex with you by forceTimes$252, Been involved in the death or murder of another person (including accidents)Times$9,418, Intentionally set a building, car, or other property on fireTimes$22,126.20

40 Cost of Crime Source: CSAT 2011 JP Summary Analytic Data Set (n=7,779)

41 Intensity of Justice System Involvement Source: CSAT 2011 JP Summary Analytic Data Set (n=7,891)

42 Recency of System Involvement Source: CSAT 2011 JP Summary Analytic Data Set (n=7,852)

43 Count of Major Clinical Problems at Intake *Based on count of self reporting criteria to suggest alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity Source: CSAT 2011 JP Summary Analytic Data Set (n=7,631)

44 GAIN-Initial Profile: Behavior Change Scales at Intake * n =5,325 Source: CSAT 2011 JP Summary Analytic Data Set (n=7,777)

45 Sources of Stress: Personal Source: CSAT 2011 JP Summary Analytic Data Set (n=5,333)

46 Sources of Stress: Other *Sum of 15 items Source: CSAT 2011 JP Summary Analytic Data Set (n=5,300)

47 Treatment Readiness *Sum of 9 items Source: CSAT 2011 JP Summary Analytic Data Set (n=7,845)

48 Self-Help Activities Scale *Mean of 19 items Source: CSAT 2011 JP Summary Analytic Data Set (n=3,769)

49 Individual Strengths *Sum of 10 items Source: CSAT 2011 JP Summary Analytic Data Set (n=5,315)

50 General Social Support Strengths *Sum of 9 items Source: CSAT 2011 JP Summary Analytic Data Set (n=5,337)

51 Spiritual Social Support Index * Sum of 7 items Source: CSAT 2011 JP Summary Analytic Data Set (n=5,287)

52 Potential Mentors in the Recovery Environment Home School or Work Social Peers *Sum of 12 items Critical gap in connection to recovery community Source: CSAT 2011 JP Summary Analytic Data Set (n=7,793)

53 Quarterly Cost to Society  Using the GAIN we are able estimate the cost to society of tangible services (e.g., health care utilization, days in detention, probation, parole, days of missed school) in 2011 dollars for the 90 days before intake  Of the 7,092 clients served in 58 sites between , the average Quarterly Cost to Society (QCS) per client: – in the quarter before they entered treatment, was $6,445 and totaled $45,707,064 across clients. –in the year before they entered treatment, was $25,780 per client and a total of $182,828,256 across clients.

54 Quarterly Cost to Society – 2011 Dollars* * Quarterly cost to society 2011 dollars w/ SA TX based on Dennis, M. L., French, M. T., McCollister, K. E., & Scott, C. K. (2011). The economic costs of quarterly monitoring and recovery management checkups for adults with chronic substance use disorders. Journal of Substance Abuse Treatment, 41, DescriptionUnitCost 2011 dollars Inpatient hospital dayDays $ 2, Emergency room visitVisits $ 6, Outpatient clinic/doctor’s office visitVisits $ Nights spent in hospitalNights $ 2, Times gone to emergency roomTimes $ 6, Times seen MD in office or clinicTimes $ Days bothered by any health problemDays $ Days bothered by psych problemsDays $ How many days in detoxDays $ Times in ER for AOD useTimes $ Nights in residential for AOD useNights $ Days in Intensive outpatient program for AOD useDays $ Times did you go to regular outpatient programTimes $ Days missed school or training for any reasonDays $ How many times arrestedTimes $ 2, Days on probationDays $ 5.94 Days on paroleDays $ Days in jail/prison/detentionDays $ 84.15

55 Quarterly Cost to Society Source: CSAT 2011 JP Summary Analytic Data Set (n=7,092)

56 Problem Prevalence Index  Summarizes days of problems across domains: substance use, internalizing disorders, externalizing disorders, physical health risk behaviors, criminal involvement, vocational problems, and environmental concerns.  Calculation: the average of the percent of days with problems (of past 90) on each of 23 items across 8 areas. The resulting score is multiplied by 100 to get an index score from 0 to 100.  Interpretation: continuous; where higher values represent more problems across multiple domains.  Triage groups: Low (0-5), Moderate (6-24) or High ( ) based on roughly 50%, 40% and 10% of the clinical population.

57 Quality of Life  Summarizes quality of life represented by fewer reported problems during the past year in school problems, work problems, health problems, sources of stress, risk behavior, internal disorders, external disorders, substance disorders, and crime/violence.  Calculation: the sum of 9 screeners from the GAIN-Q version 3 (reversed to Low=2, Moderate=1, and High=0) divided by the range (18), and multiplied by 100 to get a score from 0 to 100.  Interpretation: continuous; where higher values represent greater quality of life.  Triage groups: Low (0-36), Moderate (37-69) or High ( ) groups.

58 General Satisfaction Index  Summarizes life satisfaction in 6 areas (sexual relationship, living situation, family relationships, school/work, free time, and getting help with problems). This index is optional.  Calculation: sum of these dichotomous items  Interpretation: continuous; where higher values represent greater satisfaction with life situations.  Triage groups: Low problems (5-6), Moderate problems (3- 4) or High problems (0-2) groups. High satisfaction corresponds to low problems. –However, for the purposes of this presentation, the groups are not reversed, so in the following slides, low satisfaction scores (0-2) are in the low group, and high satisfaction scores (5-6) are in the high group.

59 Cross Validation of Four Summary Indices Problematic Beneficial *GSI groups are usually reversed (low satisfaction scores (0-2) are in the high problem group); here low satisfaction scores are in the low group, and high satisfaction scores are in the high group (n=5,225) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,344)

60 General Satisfaction Index by Problem Prevalence Index Problems are subjectively unpleasant and are associated with lower satisfaction Source: CSAT 2011 JP Summary Analytic Data Set (n=5,223)

61 General Satisfaction Index by Quarterly Cost to Society Higher costs are subjectively unpleasant and are associated with lower satisfaction Source: CSAT 2011 JP Summary Analytic Data Set (n=4,676)

62 General Satisfaction Index by Quality of Life Quality of life is subjectively pleasant and is associated with higher satisfaction Source: CSAT 2011 JP Summary Analytic Data Set (n=5,225)

63 Funder CSAT Criminal Justice (CJ) Adolescent: 59.7% (n=4,720; 32 grants) CSAT CJ Adult:40.3% (n=3,186; 26 grants) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,906)

64 Grant Program in Chronological Order of first grant cohort , Young Offender Reentry Program (YORP) , Juvenile Treatment Drug Court (DC) , Family Drug Court (FDC) , Adult Treatment Drug Court (ATDC) , Offender Re-entry Program (ORP) , Juvenile Treatment Drug Court (JTDC)

65 Grant Program DC: Drug Court (n=1,768; 11 grants) YORP: Young Offender Re-entry Program (n=2,278; 10 grants) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,906) ATDC: Adult Treatment Drug Court (n=1,147; 11 grants) ORP: Offender Re- entry Program (n=2,449; 21 grants) FDC: Family Drug Court (n=193; 2 grants) JTDC: Juvenile Treatment Drug Court (n=71; 3 grants)

66 Level of Care M-LTR: Mid to Long Term Residential 1.6% (n=124) STR: Short Term Residential.03% (n=2) OP: Outpatient 59.1% (n=4,465) CC-OP: Continuing Care – Outpatient 13.0% (n=979) IOP: Intensive Outpatient 26.2% (n=1,980) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,550)

67 Type of Treatment Local Tx Manual: Specific Manualized Treatment 2.1% (n=163) MET/CBT: Motivational Enhancement Therapy/Cognitive- Behavioral Therapy 22.1% (n=1,748) Other: Non-manualized Treatment 33.0% (n=2,609) Other EBTx: Evidence Based Treatment 18.1% (n=1,403) A-CRA/ACC: Adolescent Community Reinforcement Approach/ Assertive Continuing Care 24.7% (n=1,956) Source: CSAT 2011 JP Summary Analytic Data Set (n=7,906)

68 Outcomes  The following slides present information on the outcomes of substance abuse treatment, including:  Abstinence  Recovery  GAIN change scales over time (SPSm, CWS, HPS, EPS, EmPS, TPSl, IAS, TRI, SES, SATI, MHTI, PHTI, CJSI)  GPRA outcomes (vocationally engaged, housed, no justice system involvement, social consequences, abstinence, and social connectedness) and  NOMS outcomes (treatment initiation, engagement and continuing care; no problems with: health, mental health, family, illegal activity; abstinent, vocationally engaged and housed).  Data on follow up rates, months to last follow up, and number of follow ups per client are provided in the Methods Appendix Methods Appendix

69 Days of Use in the Past 90 Days by Substance Source: CSAT 2011 SA Data Set subset to those with 1+ Follow ups Days Used in Past 90 –solid line *There is no pre-ce information available for tobacco Days Used in Past 90 – dashed line

70 Percent Change in 6 Month Abstinence Source: CSAT 2011 SA Data Set subset to those with 6-Month Follow up (n=14,290) Percent change in 6 month abstinence is calculated as % abstinent at 6 month minus % abstinent at intake Abstinence increased 22% from 36% at intake to 58% at 6-months.

71 Relative Percent Change in 6 Month Abstinence Relative percent change in 6 month abstinence is calculated as: (% abstinent at 6 month minus % abstinent at intake) divided by % abstinent at intake Relative percent of change can be large (i.e., greater than 100%) if baseline abstinence is low. Abstinence increased by almost two-thirds (61%) against the intake value. (22% increase/ 36% at intake). Source: CSAT 2011 SA Data Set subset to those with 6-Month Follow up (n=14,290)

72 Past Month AOD Abstinence Over Time *Interpolated Source: CSAT 2011 AT SA Data Set subset to 1+ Follow ups

73 Recovery Over Time* * Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Source: CSAT 2011 AT SA Data Set subset to 1+ Follow ups **Interpolated

74 GPRA Outcomes Over Time *Interpolated Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

75 Change in GPRA Outcomes (Intake to Last Wave*) Vocationally Engaged HousingNo Justice System Involvement No Social Consequences Abstinence Socially Connected *Last wave is the last follow-up Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

76 NOMS Outcome: Number of Treatment Received Outcomes Met* Source: CSAT 2011 SA Data Set subset to 1+ Follow ups (n=5,906) *Based on a count of initiation within 14 days, evidence based practice, engagement for at least 6 weeks, and any continuing care.

77 NOMS Outcome: Estimated Treatment Episode Cost by Treatment Modality *Used in slides; ** Inter-quartile range of actual costs in 2006 dollars Source: French, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and reimbursement. Journal of Substance Abuse Treatment, 35, Modality SAMSHA Episode Cost (2004)* French’s Estimated Episode Cost (2008)** Adolescent Early Intervention$200-$1,200- Adult Outpatient-$1,132 - $2,099 Adolescent Outpatient$1,000 - $5,000$1,517 - $3,237 Intensive Outpatient/Continuing Care$1,000 - $7,000$1,384 - $5,780 Adult Drug Court-$2,486 - $4,888 Adult Methadone Maintenance-$4,277 - $13,395 Adult Residential$3,000 - $10,000$2,907 - $11,260 Adult Therapeutic Community/Residential$3,000 - $10,000$14,818 - $32,361 Adult Therapeutic Community/In-Prison-$1,249 - $2,112

78 SAMHSA Outcome: Treatment Cost Bands Source: CSAT 2011 SA Data Set subset to 1+ Follow ups (n=2,978)

79 Selected NOMS Outcomes Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups *Interpolated **Past month

80 Change in Selected NOMS Outcomes (Intake to Last Wave) Vocationally Engaged* No Health Problems No MH Problems Past Month Abstinent No Illegal Activity Housed No Family Problems *Past month Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

81 NOMS Outcomes: No Problems at Intake * Variable measures the last 30 days. All others measure the past 90 days. Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

82 NOMS Outcomes: Outcome Status at Last Wave *This variable measures the last 30 days. All others measure the past 90 days. **The blue bar represents an increase of 50% or no problem. Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

83 NOMS Outcomes: Count of Positive Outcomes* (Last FU– Intake) Source: CSAT 2011 SA Data Set subset to 1+ Follow ups (n=6,235) *Based on count of reductions or no problem in the following variables: Substance use frequency, Abuse/Dependence Sx (past 30d), Physical Health (past 90d), Mental Health (past 90d), Nights of Psychiatric Inpatient (past 90d), Illegal Activity (past 90d), Arrests (past 90d), Housed in Community (past 90d), Family/Home Problems (past 90d), Vocational Problems (past 30d), Social Support/Engagement (past 90d), Recovery Environment Risk (past 90d), Quarterly Cost to Society (past 90d), In Work/School (past 90d) at last wave Minus No problems at intake with these variables. 42% have one or more improved areas

84 Past Month Substance Problems Scale Groups Over Time Source: CSAT 2011 AT SA Data Set subset to 1+ Follow ups

85 Current Withdrawal Scale Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

86 Health Problems Scale Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

87 Emotional Problems Scale Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

88 Employment Problems Scale Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

89 Employment Problems Scale Groups Over Time – Subset to Those Employed Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

90 Training Problems Scale Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

91 Training Problems Scale Groups Over Time – Subset to Those in School/Training Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

92 Illegal Activities Scale Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

93 Treatment Resistance Index Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

94 Self-Efficacy Scale Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

95 Substance Abuse Treatment Index Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

96 Mental Health Treatment Index Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

97 Physical Health Treatment Index Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups

98 Criminal Justice System Index Groups Over Time Source: CSAT 2011 SA Data Set subset to 1+ Follow ups