The Prevalence, Co-morbidity, and Treatment of Mental Health, Substance, and Crime Problems among Teenagers Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL Presentation at “Pediatric Mental Health Primer V: The Complex Needs of Children with Dual Diagnosis (Mental Illness and Substance Abuse)”, September 18, 2007, InPlay’s Forté Conference Center, Peoria, IL. 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 and 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 1.To examine the prevalence, course, and consequences of adolescent substance use and co-occurring disorders and the unmet need for treatment 2.To summarize major trends, variability and problems in the adolescent treatment system 3.To present the findings from several recent treatment outcome studies on substance abuse treatment research, trauma and violence/crime. Goals of this Presentation

3 Severity of Past Year Substance Use/Disorders by Age Source: 2002 NSDUH and Dennis & Scott in press No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence NSDUH Age Groups Severity Category Adolescent Onset Remission Increasing rate of non- users 2002 U.S. Household Population age 12+ = 235,143,246

4 Higher Severity is Associated with Higher Annual Cost to Society Per Person Source: 2002 NSDUH $0 $231 $725 $406 $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence Median (50 th percentile) $948 $1,613 $1,078 $1,309 $1,528 $3,058 Mean (95% CI) This includes people who are in recovery, elderly, or do not use because of health problems Higher Costs

5 Substance Use Careers Last for Decades Cumulative Survival Years from first use to 1+ years abstinence Median of 27 years from first use to 1+ years abstinence Source: Dennis et al., 2005

6 Substance Use Careers are Longer the Younger the Age of First Use Cumulative Survival Years from first use to 1+ years abstinence under 15* * Age of 1 st Use Groups * p<.05 (different from 21+) Source: Dennis et al., 2005

7 Substance Use Careers are Shorter the Sooner People Get to Treatment Cumulative Survival * 10-19* Year to 1 st Tx Groups * p<.05 (different from 20+) Source: Dennis et al., 2005 Years from first use to 1+ years abstinence

8 Treatment Careers Last for Years Cumulative Survival Years from first Tx to 1+ years abstinence Median of 3 to 4 episodes of treatment over 9 years Source: Dennis et al., 2005

9 Need for Treatment (% of 24,753,586 Adolescents in the U.S. Household Population) Source: NSDUH and TEDS (see state level estimates in appendix) 8.9% 0.7% 0.6% 5.7% 8.1% 11.5% 10.7% 14.9% 17.8% 0%5%10%15%20%25% Tobacco Alcohol Alcohol Binge Any Drug Use Marijuana Use Any Non-Marijuana Drug Use Past Year AOD Dependence or Abuse Any Treatment (From NHSDA) Public Treatment (From TEDS)  Past Month Use  Less than 1 in 10 getting treatment 88% of adolescents are treated in the public system

10 Unmet Treatment Need Adolescent (% of AOD Dependence/Abuse without any private/public treatment) Prevalence 82.4 to 90.1% 90.2 to 92.3% 92.4 to 94.2% 94.3 to 98.0% U.S.Avg.=92.2% IL=92.5% Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA , NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from ) 9 in 10 Untreated

11 Adolescent Treatment Admissions have increased by 61% over the past decade Source: Office of Applied Studies Treatment Episode Data Set (TEDS) 64% increase from 95,271 in 1993 to 158,723 in 2005

12 Severity Goes up with Level of Care Source: Treatment Episode Data Set (TEDS) % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Weekly use at intake First used under age 15 Dependence Prior Treatment Case Mix Index (Avg) OutpatientIntensive OutpatientDetoxification Long-term ResidentialShort-term Residential STR: Higher on Dependence Baseline Severity Goes up with Level of Care Detox: Higher on Use Detox: Higher on Use, but lower on prior tx

13 Median Length of Stay is only 50 days Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) , Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from Outpatient (37,048 discharges) IOP (10,292 discharges) Detox (3,185 discharges) STR (5,152 discharges) LTR (5,476 discharges) Total (61,153 discharges) Level of Care Median Length of Stay 50 days 49 days 46 days 59 days 21 days 3 days Less than 25% stay the 90 days or longer time recommended by NIDA Researchers

14 53% Have Unfavorable Discharges Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) , Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from Despite being widely recommended, only 10% step down after intensive treatment 0%20%40%60%80%100% Outpatient (37,048 discharges) IOP (10,292 discharges) Detox (3,185 discharges) STR (5,152 discharges) LTR (5,476 discharges) Total (61,153 discharges) CompletedTransferredASA/ Drop outAD/Terminated

15 Most Lack of Standardized Assessment for… Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidality) Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime) HIV risk behaviors (needle use, sexual risk, victimization) Child maltreatment (physical, sexual, emotional)

16 GAIN Clinical Collaborators Adolescent and Adult Treatment Program 7/07 DC One or more state or county wide systems uses the GAIN

17 CSAT Adolescent Treatment (AT) Outcome Data Set Recruitment: (updated annually) Sample: The 2006 CSAT adolescent treatment data set included data with 1 to 4 follow-ups on 12,690 adolescents from 96 local evaluations Levels of Care: Early Intervention, Outpatient, Intensive Outpatient, Short, Moderate & Long term Residential, Corrections Based and Post Residential Outpatient Continuing Care Instrument:Global Appraisal of Individual Needs (GAIN) (see Follow-up:Over 80% follow-up 3, 6, 9 & 12 months post intake Funding: CSAT contract and 72 individual grants

18 Level of Care (n=12,601) Source: CSAT 2006 AT Outcome Data Set (n=12,601)

19 Type of Treatment (n=12,601) Source: CSAT 2006 AT Outcome Data Set (n=12,601) * Data Prior to current AAFT program replicating A-CRA

20 Demographics Source: CSAT 2006 AT Outcome Data Set (n=12,601)

21 Recovery Environment Source: CSAT 2006 AT Outcome Data Set (n=12,601)

22 Past 90 day HIV Risk Behaviors Source: CSAT 2006 AT Outcome Data Set (n=12,601)

23 Weekly or More Often Use in the Past 90 Days Source: CSAT 2006 AT Outcome Data Set (n=12,601)

24 Substance Use Problems Source: CSAT 2006 AT Outcome Data Set (n=12,601)

25 Prevalence of Past Year Substance Use Disorder by Age Source: Chan, Dennis & Funk in press

26 Co-Occurring Psychiatric Problems Source: CSAT 2006 AT Outcome Data Set (n=12,601)

27 Prevalence of Substance, Internalizing and Externalizing Disorders by Age Source: Chan, Dennis & Funk in press

28 Past Year Violence & Crime *Dealing, manufacturing, prostitution, gambling (does not include simple possession or use) Source: CSAT 2006 AT Outcome Data Set (n=12,601)

29 Intensity of Juvenile Justice System Involvement Source: CSAT 2006 AT Outcome Data Set (n=12,601)

30 Relationship of Level of Care to the Number of Major Clinical Problems Source: CSAT 2006 AT Outcome Data Set (n=12,601); Odds Ratio (OR) of having 5+ of 12 problems (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

31 Relationship of Victimization to the Number of Major Clinical Problems Source: CSAT 2006 AT Outcome Data Set (n=12,601); Odds Ratio (OR) of having 5+ of 12 problems (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

32 Treatment Outcomes by Level of Care: Days of AOD Abstinence* * Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT 2006 AT Outcome Data Set (n=12,601)

33 Treatment Outcomes by Level of Care: Recovery* * Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT 2006 AT Outcome Data Set (n=12,601)

34 Change in Substance Frequency Scale by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect. Residential programs start more severe, go down sharply, but then come back over time Note the sharp “hinge” in outcomes during the active phase of AOD treatment Short- Term Resid. \t,s,ts Long- Term Resid \t,ts Outpatient \t,s

35 Pattern of SA Outcomes is Related to the Pattern of Psychiatric Multi-morbidity Source: Shane et al 2003, PETSA data Months Post Intake (Residential only) Number of Past Month Substance Problems 2+ Co-occurring 1 Co-occurring No Co-occurring Multi-morbid Adolescents start the highest, change the most, and relapse the most

36 Change in Emotional Problem Scale by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect. Short- Term Resid. \t,s,ts Long- Term Resid \t,ts Outpatient \t,s Note the lack of a hinge; Effect is generally indirect (via reduced use) not specific

37 Victimization and Level of Care Interact to Predict Outcomes 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

38 Are there other more effective OP programs? Source: CYT and ATM Outpatient Data Set Dennis IntakeMon 1-3Mon 4-6Mon 7-9Mon Z-Score on Substance Frequency Scale (SFS) CYT Total (n=217; d=0.51) CHSOP (n=57; d=0.18) And on average the CYT 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

39 Change in Illegal Activity Scale by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect. Short- Term Resid. \t,s,ts Long- Term Resid \t,ts Outpatient \t,s Residential Treatments have a specific effect Outpatient Treatments has an indirect effect

40 Randomly Assigns to: MET/CBT5 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) MET/CBT12 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (12 weeks) FSN Family Support Network Plus MET/CBT12 (12 weeks) Trial 2Trial 1 Incremental ArmAlternative Arm Cannabis Youth Treatment (CYT) Experiments ACRA Adolescent Community Reinforcement Approach(12 weeks) MDFT Multidimensional Family Therapy Randomly Assigns to: MET/CBT5 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) (12 weeks) Source: Dennis et al, 2002

41 Actual Treatment Received by Condition Source: Dennis et al, 2004 MET/CBT12 adds 7 more sessions of group FSN adds multi family group, family home visits and more case management ACRA and MDFT both rely on individual, family and case management instead of group With ACRA using more individual therapy And MDFT using more family therapy

42 $1,559 $1,413 $1,984 $3,322 $1,197 $1,126 $- $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 MET/CBT5 (6.8 weeks) MET/CBT12 (13.4 weeks) FSN (14.2 weeks w/family) MET/CBT5 (6.5 weeks) ACRA (12.8 weeks) MDFT(13.2 weeks w/family) $1,776 $3,495 NTIES Est (6.7 weeks) NTIES Est.(13.1 weeks) Average Cost Per Client-Episode of Care | Economic Cost | Director Estimate-----| Average Episode Cost ($US) of Treatment Source: French et al., 2002 Less than average for 6 weeks Less than average for 12 weeks Integrating family therapy was less expensive than adding it

43 Adolescent Cannabis Users in CYT were as or More Severe Than Those in TEDS* Source: Tims et al, 2002

44 Multiple Problems were the NORM Self-Reported in Past Year Source: Dennis et al, 2004

45 Substance Use Severity was Related to Other Problems * p<.05 Source: Tims et al % 57% 25% 42% 30% 37% 22% 5% 13% 22% 0% 20% 40% 60% 80% 100% Health Problem Distress* Acute Mental Distress* Acute Traumatic Distress* Attention Deficit Hyperactivity Disorder* Conduct Disorder* Past Year Dependence (n=278)Other (n=322)

46 CYT Increased Days Abstinent and Percent in Recovery* Source: Dennis et al., Intake36912 Days Abstinent Per Quarter 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% % in Recovery at the End of the Quarter Days Abstinent Percent in Recovery *no use, abuse or dependence problems in the past month while in living in the community

47 Similarity of Clinical Outcomes by Conditions Source: Dennis et al., Total days abstinent. over 12 months 0% 10% 20% 30% 40% 50% Percent in Recovery. at Month 12 Total Days Abstinent* Percent in Recovery** MET/ CBT5 (n=102) MET/ CBT12 FSN (n=102) MET/ CBT5 (n=99) ACRA (n=100) MDFT (n=99) Trial 1 Trial 2 * n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.12 * n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16 Not significantly different by condition. But better than the average for OP in ATM (200 days of abstinence)

48 Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition Source: Dennis et al., 2003; forthcoming $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 CPPR at 30 months** $6,437 $10,405 $24,725 $27,109 $8,257 $14,222 CPPR at 12 months* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 MET/ CBT5MET/ CBT12FSNMMET/ CBT5ACRAMDFT Trial 1 (n=299)Trial 2 (n=297) Cost Per Person in Recovery (CPPR) * P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months ** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months Stability of MET/CBT-5 findings mixed at 30 months MET/CBT-5, -12 and ACRA more cost effective at 12 months Integrated family therapy (MDFT) was more cost effective than adding it on top of treatment (FSN) at 30 months ACRA Effect Largely Sustained

49 Cumulative Recovery Pattern at 30 months Source: Dennis et al, forthcoming 37% Sustained Problems 5% Sustained Recovery 19% Intermittent, currently in recovery 39% Intermittent, currently not in recovery The Majority of Adolescents Cycle in and out of Recovery

50 Post Script on CYT The CYT interventions provide replicable models of brief (1.5 to 3 month) treatments that can be used to help the field maintain quality while expanding capacity. While a good start, the CYT interventions were still not an adequate dose of treatment for the majority of adolescents – including many who continued to vacillate in and out of recovery after discharge from CYT. Descriptive, outcome and economic analyses have been published All five interventions are currently being used in subsequent experiments The MET/CBT5 intervention has just been replicated in a 38 site study and ACRA is currently being replicated in a 33 site study. Over 60,000 copies of the CYT manuals have been distributed by NCADI and as many electronic copies have been distributed by CD or the website

Findings from the Assertive Continuing Care (ACC) Experiment 183 adolescents admitted to residential substance abuse treatment Treated for days inpatient, then discharged to outpatient treatment Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC) Over 90% follow-up 3, 6, & 9 months post discharge Source: Godley et al 2002, forth coming

52 Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17) Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Days after Residential (capped at 90) Percent of Clients Cont. Care Admis. Relapse

53 ACC Enhancements Continue to participate in UCC Home Visits Sessions for adolescent, parents, and together Sessions based on ACRA manual (Godley, Meyers et al., 2001) Case Management based on ACC manual (Godley et al, 2001) to assist with other issues (e.g., job finding, medication evaluation)

54 Assertive Continuing Care (ACC) Hypotheses Assertive Continuin g Care General Continuin g Care Adherence Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA) Early Abstinence GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence Sustained Abstinence Early abstinence will be associated with higher rates of long term abstinence.

55 ACC Improved Adherence Source: Godley et al 2002, forthcoming 0% 10% 20% 30% 40%50%60%70%80% WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/probation/school Follow up on referrals* ACC * p<.05 90% 100% Relapse prevention* Communication skills training* Problem solving component* Meet with parents 1-2x month* Weekly telephone contact* Referrals to other services* Discuss probation/school compliance* Adherence: Meets 7/12 criteria* UCC

56 GCCA Improved Early (0-3 mon.) Abstinence Source: Godley et al 2002, forthcoming 24% 36% 38% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=2.16*)Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA 43% 55% High (7-12/12) GCCA * p<.05

57 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence Source: Godley et al 2002, forthcoming 19% 22% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=11.16*)Alcohol (OR=5.47*) Marijuana (OR=11.15*) Early(0-3 mon.) Relapse 69% 59% 73% Early (0-3 mon.) Abstainer * p<.05

58 Post script on ACC The ACC intervention improved adolescent adherence to the continuing care expectations of both residential and outpatient staff; doing so improved the rates of short term abstinence and, consequently, long term abstinence. Despite these GAINs, many adolescents in ACC (and more in UCC) did not adhere to continuing care plans. The ACC preliminary findings are published and the main findings are currently under review. Several CSAT grantees are also seeking to replicate ACC as part of the Adolescent Residential Treatment (ART) program. A second ACC experiment is currently under way to evaluate whether providing contingency management will further improve outcomes. The ACC manual is being distributed via the website and the CD you have been provided.

59 A Fearless Appraisal… We are entering a renaissance of new knowledge in this area, but are only reaching 1 of 10 in need Several interventions work, but the majority of the adolescents are still having problems 12 months later Effectiveness is related to severity, intervention strength, implementation/adherence, and how assertive we are in providing treatment As other therapies have caught up technologically, there is no longer the clear advantage of family therapy found in early literature reviews While there have been concerns about the potential iatrogenic effects of group therapy, the rates do not appear to be appreciably different from individual or family therapy if it is done well (important since group tx typically costs less) Effectiveness was not consistently associated with the amount of therapy over a short period of time (6-12 weeks) but was related to longer term continuing care

60 Recommendations for Further Developments… We need to target the latter phases of treatment to impact the post-treatment recovery environment and/or social risk groups that are the main predictors of long term relapse We need to move beyond focusing on acute episodes of care to focus on continuing care and a recovery management paradigm We need to better understand the impact of involvement in juvenile justice system and how it can be harnessed to help More work is need on the use of schools as a location for providing primary treatment (they have entrée to the population and appear to be the venue of choice) and recovery-schools to provide support for those coming out of residential treatment

61 Other Assessment and Treatment Resources Assessment Instruments – GAIN Coordinating Center at – CSAT TIP 3 at – NIAAA Assessment Handbook at Treatment Programs – CSAT CYT, ATM, ACC and other treatment manuals at and on CDs provided – SAMHSA Knowledge Application Program (KAP) at – NCADI at – National Registry of Effective Prevention Programs Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : – NCTSN trauma intervention tool kit – National Center for Mental Health and Juvenile Justice Evidence Based Practice resource list at Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness – next meeting March 30-April 2, 2008, Baltimore, MD

62 References Chan, Y.F., Dennis, M.L., & Funk, R. (in press). The prevalence of major co-occurring psychiatric and behavioral problems among adolescents and adults presenting to substance abuse treatment. Journal of Substance Abuse Treatment. 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., Babor, T., Roebuck, M. C., & Donaldson, J. (2002). Changing the focus The case for recognizing and treating marijuana use disorders. Addiction, 97 (Suppl. 1), S4-S15. Dennis, M.L., Chan, Y.F., & Funk, R.R. (2006). Development and Validation of the GAIN Short Screener (GSS) for Internalizing, Externalizing and Substance Use Disorders and Crime/Violence Problems Among Adolescents and Adults. American Journal on the Addictions, 15 (S1), Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003). The need for developing and evaluating adolescent treatment models. In S.J. Stevens & A.R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary Models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press and 1998 NHSDA. Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment, 27, Dennis, M. L., Godley, S. and Titus, J. (1999). Co-occurring psychiatric problems among adolescents: Variations by treatment, level of care and gender. TIE Communiqué (pp. 5-8 and 16). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Dennis, M.L., & Scott, C.K (in press). Managing Substance Use Disorders as a Chronic Condition. NIDA Addiction Science & Clinical Practice Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28 (2S), S49-S60. Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F., Webb, C., Kaminer, Y., Babor, T., Roebeck, M. C., Godley, M. D., Hamilton, N., Liddle, H., Scott, C., & CYT Steering Committee. (2002). The Cannabis Youth Treatment (CYT) experiment Rationale, study design, and analysis plans. Addiction, 97, 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//

63 References - continued French, M.T., Roebuck, M.C., Dennis, M.L., Diamond, G., Godley, S.H., Tims, F., Webb, C., & Herrell, J.M. (2002). The economic cost of outpatient marijuana treatment for adolescents: Findings from a multisite experiment. Addiction, 97, S84-S97. French, M. T., Roebuck, M. C., Dennis, M. L., Diamond, G., Godley, S. H., Liddle, H. A., and Tims, F. M. (2003). Outpatient marijuana treatment for adolescents Economic evaluation of a multisite field experiment. Evaluation Review,27(4) 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, Godley, S. H., Dennis, M. L., Godley, M. D., & Funk, R. R. (2004). Thirty-month relapse trajectory cluster groups among adolescents discharged from outpatient treatment. Addiction, 99 (s2), , Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. (2002). Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment, 23, Godley, S. H., Jones, N., Funk, R., Ives, M., and Passetti, L. L. (2004). Comparing Outcomes of Best-Practice and Research-Based Outpatient Treatment Protocols for Adolescents. Journal of Psychoactive Drugs, 36, Hser, Y., Grella, C. E., Hubbard, R. L., Hsieh, S. C., Fletcher, B. W., Brown, B. S., & Anglin, M. D. (2001). An evaluation of drug treatments for adolescents in four U.S. cities. Archives of General Psychiatry, 58, Lewinsohn, P.M., Hops, H., Roberts, R.E., Seeley, J.R., Andrews, J.A. (1993). Adolescent psychopathology, I: prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abn Psychol, 102, National Academy of Sciences (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press. Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved, from Office of Applied Studies (OAS) (1999). Treatment Episode Data Set (TEDS) : National admissions to substance abuse treatment services. Rockville, MD: Author. [Available online at.] Office of Applied Studies (OAS) (2000). Treatment Episode Data Set (TEDS) : National admissions to substance abuse treatment services. Rockville, MD: Author. [Available on line at.]

64 References - continued Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved, from Office of Applied Studies Treatment Episode Data Set (TEDS) retrived from Physician Leadership on National Drug Policy (PNLDP, 2002) Adolescent Substance Abuse: A Public Health Priority. Providence, RI: Brown University. Retrieved from Shane, P., Jasiukaitis, P., & Green, R. S. (2003). Treatment outcomes among adolescents with substance abuse problems: The relationship between comorbidities and post-treatment substance involvement. Evaluation and Program Planning, 26, Tims, F. M., Dennis, M. L., Hamilton, N., Buchan, B. J., Diamond, G. S., Funk, R., & Brantley, L. B. (2002). Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment. Addiction, 97, 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, White, M. K., Funk, R., White, W., & Dennis, M. (2003). Predicting violent behavior in adolescent cannabis users The GAIN-CVI. Offender Substance Abuse Report, 3(5), White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2), D. Wright & N. Sathe (2005). State Estimates of Substance Use from the National Survey on Drug Use and Health, Rockville, MD: OAS, SAMHSA (DHHS Publication No. SMA , NSDUH Series H-26).