Presentation at the SAMHSA/OJJDP Expert Panel on Juvenile Justice and Adolescent Substance Abuse Treatment, December 7, 2006, Rockville, MD. This presentations was developed with support from the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract and uses data from 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) , Part 2. Institution-Based Treatment for Adolescents With Substance Use/Co-Occurring Disorders Facilitator Michael L. Dennis, Ph.D. Chestnut Health Systems Bloomington, IL

The literature In Lipsey’s (1997, 2001) meta analyses of juvenile delinquency literature and updated literature searches revealed no major randomized trials of adolescent substance abuse treatment in detention or other institutionalized juvenile justice settings Lipsey’s meta analysis of juvenile justice institutional programs found that: –On average they had 5.6 distinguishable components –While the average program had little to no effect, the best quartile of programs reduced recidivism by 30% or more, Could be predicted based on whether the program –Chose a strong intervention protocol based on prior evidence –Used quality assurance to ensure protocol adherence and project implementation –Used proactive case supervision of individual –Used triage to focus on the highest severity subgroup

Program components associated with average or better effects on recidivism BETTER/BEST Behavior management Group counseling Individual counseling Interpersonal skills training AVERAGE OR BETTER Family counseling Cognitive-behavioral therapy Employment/job training AVERAGE OR WORSE “Scared Straight” and similar shock incarceration program Boot camps mixed – had bad to no effect Routine practice – had no or little (d=.07 or 6% reduction in recidivism) No differences by race No “iatrogenic” or “peer contagion” effect of group treatment Source: Adapted from Lipsey et al 2001

Specific Evidenced Based Interventions that Typically do Better than Practice in Reducing Recidivism (29% vs. 40%) Aggression Replacement Training (ART) Reasoning & Rehabilitation (RR) Moral Reconation Therapy (MRT) Thinking for a Change (TC) Interpersonal Social Problem Solving (ISPS) Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ARCA) Motivational Enhancement Therapy/ Cognitive Behavior Therapy (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

Implementation is Essential ( Reduction in Recidivism from.50 Control Group Rate) The effect of a well implemented weak program is as big as a strong program implemented poorly The best is to have a strong program implemented well Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2001

Data from 14 CSAT Young Offender Re- Entry Program (YORP) grants (N=1066) 85% Male 84% Minority (45% Hispanic, 20% African American, 15% Mixed) 92% Age 15 or older (27% 18 or older) 70% Below the poverty line (54% below half the poverty line) 64% From Single Parent Households 42% With a history of being homeless or running away 73% With 3 or more years of use (40% with 5 or more) 90% Self reporting criteria for substance disorders (40% past year dependence; 38% with prior SA treatment) 58% Self reporting criteria for co-occurring mental health disorders (32% with prior MH treatment)

Co-occurring Psychiatric Conditions \2 Post traumatic distress, acute traumatic distress or disorders of extreme stress not otherwise specified 41% 34% 9% 21% 22% 58% 49% 41% 37% 31% 9% 17% 19% 49% 41% 31% 0%10%20%30%40%50%60%70%80%90%100% Any Past Year Internal Disorder Major Depression Disorder Generalized Anxiety Disorder Suicidal Thoughts or Actions Traumatic Distress Disorder\2 Any Past Year External Disorder Conduct Disorder Attention Deficit-Hyperactivity Disorder 1 DC Total2 YORP Total Compared to 246 adolescent entering juvenile drug courts in 6 CSAT sites

Pattern of Maltreatment/Victimization \3 Reporting 4 or more of the following: types of victimization, traumagenic factors (e.g., multiple people, someone they trusted, fearing for life, sexual penetration, people didn't believe them) or continuing fear it will reoccur 62% 60% 43% 36% 19% 20% 75% 74% 57% 37% 12% 20% 0%10%20%30%40%50%60%70%80%90%100% Any history of victim. or current worries Lifetime History of Victimization High Levels of Victimization\3 Past Year Past 90 Days Current worry about victimization 1 DC Total2 YORP Total

Pattern of Crime & Violence (towards others) \4 Physical assault of another person within the past year. \5 Self report of or arrests related to vandalism, forgery, bad checks, shop lifting, theft, robbery, auto theft. \6 Self report of or arrests related to assault, aggravated assault with a weapon, rape, murder, and arson \7 Self report of or arrests related to driving under the influence, manufacture or distribution, prostitution, gang involvement 82% 74% 67% 48% 51% 52% 85% 81% 65% 53% 50% 0%10%20%30%40%50%60%70%80%90%100% Any Violence or Illegal Activity Acts of Physical Violence\4 Any Illegal Activity Property crimes\5 Interpersonal crimes\6 Drug related crimes\7 1 DC Total2 YORP Total

No. of Problems* by Severity of Victimization 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% 30% 40% 50% 60% 70% 80% 90% 100% Low (31%)Moderate (17%)High (51%) Five or More Four Three Two One None Those with high lifetime levels of victimization have 117 times higher odds of having 5+ major problems* GAIN General Victimization Scale Score (Row %)

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 AT Outcome Data Set (n-9,276)

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 AT Outcome Data Set (n-9,276)

Questions 1.Given the dearth of research on evidenced based practices in juvenile institutions, which related practices are likely to be the most useful to try/study? 2.What are the key implementation issues that are likely to be essential in this setting? (e.g.., workforce, resources, length of detention) 3.Given the heterogeneity of clinical and behavioral problems, how do we identify and address the right issues for each adolescent? 4.Given the high rate of victimization and it association with co- occurring psychiatric, crime and violence problems – what can we do to provide interventions (e.g.., Anger Management, CBITS) to improve the adolescents sense of safety, teach coping skills and/or prepare them for re-entry? 5.How can we change policies and/ or train the workforce to better facilitate the above? 6.What strategies can help to provide continuity of care? (e.g., information sharing, joint staffing, transfer processes)

Appendix: Detailed Data on Needs Data from 20 CSAT JJ grantees –246 entering juvenile drug courts in 6 sites: Laredo, TX, San Antonio, TX, Belmont, CA, Tarzana, CA, Pontiac, MI, Birmingham, AL –1066 existing detention in 14 sites: San Jose, CA, Boston, MA, San Antonio, TX, Long Beach, CA, Racine, WI, San Diego, CA, Huntington, WV, Tucson, AZ, El Paso, TX, Pinellas Park, FL, Fort Collins, CO, Washington, DC, Cleveland, OH, Smyrna, GA Relative to those entering community substance abuse treatment, they are –Slightly lower on substance use severity –Similar on mental health severity –Slightly higher on crime, violence, and environmental problems

Demographics 22% 83% 1% 0% 8% 17% 57% 17% 0% 19% 80% 15% 84% 1% 3% 20% 16% 45% 15% 1% 8% 65% 27% 1% 0%10%20%30%40%50%60%70%80%90%100% Female Minority status American Indian/Alaska Native Asian African American\Black Caucasian\White Hispanic Mixed Other Less than 15 years years 18+ years 1 DC Total2 YORP Total

Living Situation 24% 20% 29% 22% 4% 52% 26% 10% 31% 54% 16% 23% 6% 2% 64% 11% 9% 42% 0%10%20%30%40%50%60%70%80%90%100% Very poor (0-49%) Poor (50-99%) Working class ( %) Upper middle class ( %) Upper class (1000%+) Single parent family Weekly Alcohol Use in Home Weekly Drug Use in Home Ever Homeless/Runaway 1 DC Total2 YORP Total

Peer Alcohol and Drug Use \1 Spent time in the past year with 1 or more people at work/school who got drunk weekly \2 Spent time in the past year with 1 or more people socially who got drunk weekly \3 Spent time in the past year with 1 or more people at work/school (or socially) who used drugs quarterly 39% 48% 44% 52% 0%10%20%30%40%50%60%70%80%90%100% Regular Peer Alcohol Use at Work/School\1 Regular Peer Alcohol Use\2 Regular Peer Drug Use at Work/School\3 Regular Peer Drug Use\3 1 DC Total2 YORP Total

Environment \4 During the past 90 days \5 Attacked with a weapon, beaten to the point of bruises or broken bones, sexually assaulted, or emotionally abused. '\6 Count of types of victimization and the number of traumagenic factors (GVS) is 4 or more. 88% 26% 99% 96% 51% 60% 43% 19% 85% 13% 100% 94% 92% 74% 57% 12% 0%20%40%60%80%100% In school \4 Employed\4 Any CJ Involvement Current CJ Involvement\4 Controlled Environment\4 Ever Been Victimized\5 High Levels of Victimization\6 Victimization (P90)\4 1 DC Total2 YORP Total

History of Substance Use 7% 82% 11% 0% 4% 42% 36% 18% 11% 76% 12% 1% 2% 25% 33% 40% 0%10%20%30%40%50%60%70%80%90%100% Under 10 Age Age Age 18 or older Less than years 3-4 years 5 or more years 1 DC Total2 YORP Total Age of First Use Years of Use

Past 90 Day Substance Use 65% 15% 46% 50% 3% 2% 9% 2% 32% 28% 7% 18% 2% 1% 2% 0% 84% 27% 0%10%20%30%40%50%60%70%80%90%100% Weekly use of anything Weekly Alcohol Use\2 Weekly Tobacco Use\2 Weekly Marijuana Use\2 Weekly Crack/Cocaine Use\2 Weekly Heroin/Opiod Use\2 Weekly Other Drug Use\2 Any past 90 day needle use 13+ Days in Controlled Environment\2 1 DC Total2 YORP Total \2 During the past 90 days

Substance Problem 26% 71% 33% 50% 91% 88% 32% 22% 79% 60% 35% 90% 70% 16% 0%10%20%30%40%50%60%70%80%90%100% Perceives AOD as a problem\3 Perceives need for ANY treatment Ready to remain abstinent (100%) Ready to quit (80% or more) Lifetime Abuse/Dependence Past Year Abuse/Dependence Past Month Abuse/Dependence 1 DC Total2 YORP Total \3 Do you currently feel that you have any problems related to alcohol or drug use?

Presenting Severity 1% 12% 39% 4% 45% 46% 31% 4% 1% 29% 27% 7% 36% 32% 13% 2% 0%10%20%30%40%50%60%70%80%90%100% No Use Use Abuse Dependence Physiological Dependence Any lifetime Any past week Acute past week 1 DC Total2 YORP Total Presenting (Past Year) Severity Withdrawal

Prior Treatment Episodes 68% 32% 17% 15% 62% 38% 24% 14% 0%10%20%30%40%50%60%70%80%90%100% None Any One Two or more 1 DC Total2 YORP Total

Co-occurring Psychiatric Conditions \2 Post traumatic distress, acute traumatic distress or disorders of extreme stress not otherwise specified 41% 34% 9% 21% 22% 58% 49% 41% 37% 31% 9% 17% 19% 49% 41% 31% 0%10%20%30%40%50%60%70%80%90%100% Any Past Year Internal Disorder Major Depression Disorder Generalized Anxiety Disorder Suicidal Thoughts or Actions Traumatic Distress Disorder\2 Any Past Year External Disorder Conduct Disorder Attention Deficit-Hyperactivity Disorder 1 DC Total2 YORP Total

Pattern and Tx of Psychiatric Conditions 32% 10% 32% 27% 33% 42% 9% 28% 21% 32% 0%10%20%30%40%50%60%70%80%90%100% Neither Internal only Both External only Any prior MH treatment 1 DC Total2 YORP Total

Pattern of Maltreatment/Victimization \3 Reporting 4 or more of the following: types of victimization, traumagenic factors (e.g., multiple people, someone they trusted, fearing for life, sexual penetration, people didn't believe them) or continuing fear it will reoccur 62% 60% 43% 36% 19% 20% 75% 74% 57% 37% 12% 20% 0%10%20%30%40%50%60%70%80%90%100% Any history of victim. or current worries Lifetime History of Victimization High Levels of Victimization\3 Past Year Past 90 Days Current worry about victimization 1 DC Total2 YORP Total

Other HIV Risks 2% 68% 33% 34% 0% 44% 17% 21% 0%10%20%30%40%50%60%70%80% Any past 90 day needle use Any past 90 day sexual experience Any past 90 day unprotected sex Multiple sexual partners in past 90 days 1 DC Total2 YORP Total

Pattern of Crime & Violence (towards others) \4 Physical assault of another person within the past year. \5 Self report of or arrests related to vandalism, forgery, bad checks, shop lifting, theft, robbery, auto theft. \6 Self report of or arrests related to assault, aggravated assault with a weapon, rape, murder, and arson \7 Self report of or arrests related to driving under the influence, manufacture or distribution, prostitution, gang involvement 82% 74% 67% 48% 51% 52% 85% 81% 65% 53% 50% 0%10%20%30%40%50%60%70%80%90%100% Any Violence or Illegal Activity Acts of Physical Violence\4 Any Illegal Activity Property crimes\5 Interpersonal crimes\6 Drug related crimes\7 1 DC Total2 YORP Total

Errata References Cited: 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, Lipsey, M. W. (1997). What can you build with thousands of bricks? Musings on the cumulation of knowledge in program evaluation. New Directions for Evaluation, 76, Lipsey, M. W., Chapman, G. L., & Landenberger, N. A. (2001). Cognitive-behavioral programs for offenders. The Annals of the American Academy of Political and Social Science, 578, Waldron, H. B., Slesnick, N., Brody, J. L., Turner, C. W., & Peterson, T. R. (2001). Treatment outcomes for adolescent substance abuse at four- and seven-month assessments. Journal of Consulting and Clinical Psychology, 69, 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 providedwww.chestnut.org/li/apss/csat/protocols –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 : Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness April 25-27, 2007, Washington< DC