Adolescent Addiction: Research and Treatment Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL Presentation on October 30, 2008 at a conference sponsored by the Council on Chemical Abuse in cooperation with Community Care Behavioral Health Organization (CCBH), the Berks County Mental Health/Mental Retardation Program, Berks County Children and Youth Services, the Substance Abuse Service Providers Association of Berks County, and the PA Department of Health/Bureau of Drug and Alcohol Program, Sheraton Reading Hotel, Wyomissing, PA. This presentation reports on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contracts and , as well as several individual CSAT, NIAAA, NIDA and private foundation 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 448 Wylie Drive, Normal, IL 61761, phone: (309) , Fax: (309) ,

2 1.The Cannabis Youth Treatment (CYT) Experiments and its Replications 2.The Adolescent Treatment Model (ATM) studies 3.CSAT Actuarial Estimates of NOMS outcomes to improve placement 4.The Assertive Continuing Care (ACC) experiment This Presentation Will Examine

CYT Cannabis Youth Treatment Randomized Field Trial Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services Coordinating Center: Chestnut Health Systems, Bloomington, IL, and Chicago, IL University of Miami, Miami, FL University of Conn. Health Center, Farmington, CT Sites: Univ. of Conn. Health Center, Farmington, CT Operation PAR, St. Petersburg, FL Chestnut Health Systems, Madison County, IL Children’s Hosp. of Philadelphia, Phil.,PA

4 Context Circa 1997 Cannabis had become more potent, was associated with a wide of problems (particularly when combined with alcohol), and had become the leading substances mentioned in arrests, emergency room admissions, autopsies, and treatment admissions (doubling in in 5 years) Over 80% of adolescents with Cannabis problems were being seen in outpatient setting The median length of stay was 6 weeks, with only 25% making it 3 months There were no published manuals targeting adolescent marijuana users in outpatient treatment The purpose of CYT was to manualize five promising protocols, field test their relative effectiveness, cost, and benefit-cost and provide them to the field Source: Dennis et al, 2002

5 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 Two Effectiveness 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

6 Contrast of the Treatment Structures Individual Adolescent Sessions CBT Group Sessions Individual Parent Sessions Family Sessions/Home Visits Parent Education Sessions Total Formal Sessions Type of Service MET/ CBT5 MET/ CBT12 FSNACRAMDFT Case management/ Other Contacts As needed Total Expected Contacts Total Expected Hours Total Expected Weeks Source: Diamond et al, 2002

7 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

8 $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

9 Implementation of Evaluation Over 85% of eligible families agreed to participate Quarterly follow-up of 94 to 98% of the adolescents from 3- to 12-months (88% all five interviews) Collateral interviews were obtained at intake, 3- and 6- months on over % of the adolescents interviewed Urine test data were obtained at intake, 3, 6, 30 and 42 months % of the adolescents who were not incarcerated or interviewed by phone (85% or more of all adolescents). Long term follow-up completed on 90% at 30-months Self reported marijuana use largely in agreement with urine test at 30 months (13.8% false negative, kappa=.63) Good reliability (alphas over.85 on main scales) and correlations with collateral reports (r=.4 to.7) Source: Dennis et al, 2002, 2004

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

11 Demographic Characteristics Source: Tims et al, 2002

12 Institutional Involvement 25% 87% 47% 62% 0% 20% 40% 60% 80% 100% In schoolEmployedCurrent JJ Involvement Coming from Controlled Environment Source: Tims et al, 2002

13 Patterns of Substance Use 9% 17% 71% 73% 0% 20% 40% 60% 80% 100% Weekly Tobacco Use Weekly Cannabis Use Weekly Alcohol Use Significant Time in Controlled Environment Source: Tims et al, 2002

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

15 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)

16 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

17 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)

18 Moderate to large differences in Cost-Effectiveness by Condition Source: Dennis et al., 2004 $0 $4 $8 $12 $16 $20 Cost per day of abstinence over 12 months $0 $4,000 $8,000 $12,000 $16,000 $20,000 Cost per person in recovery at month 12 CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38 CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 MET/ CBT5 MET/ CBT12 FSN MET/ CBT5 ACRA MDFT * p<.05 effect size f=0.48 ** p<.05, effect size f=0.72 Trial 1 Trial 2 * p<.05 effect size f=0.22 ** p<.05, effect size f=0.78 MET/CBT5 and 12 did better than FSN ACRA did better than MET/CBT5, and both did better than MDFT

19 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

20 Change in Quarterly Costs to Society (12 months minus Intake) Source: Dennis et al., 2004 $(25,000) $(20,000) $(15,000) $(10,000) $(5,000) $- $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 MET/ CBT5 MET/ CBT12 FSNMET/ CBT5 ACRAMDFTAverage $(25,000) $(20,000) $(15,000) $(10,000) $(5,000) $- $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Significant Reduction in Cost to Society Overall Three sites went down significantly, one went up significantly No Significant Difference by Condition Cond x Site: 4 sig reduction, 2 sig Incr, 6 no sig dif (low power)

21 Environmental Factors are also the Major Predictors of Relapse Recovery Environment Risk Social Risk Family Conflict Family Cohesion Social Support Substance Use Substance- Related Problems Baseline Source: Godley et al (2005) Model Fit CFI=.97 to.99 RMSEA=.04 to.06 AOD use in the home, family problems, homelessness, fighting, victimization, self help group participation, structure activities Peer AOD use, fighting, illegal activity, treatment, recovery, vocational activity The effects of adolescent treatment are mediated by the extent to which they lead to actual changes in the recovery environment or peer group

22 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

23 36 Site Replication on MET/CBT5 AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY CYT: 4 Sites EAT: 36 Sites Source: Dennis, Ives, & Muck, 2008

24 Range of Effect Sizes (d) for Change in Days of Abstinence (intake to 12 months) by Site CYT Sites (f=0.39) (median within site d=0.29) 36 EAT Sites (f=0.21) (median within site d=0.49) Cohen’s d Source: Dennis, Ives, & Muck, 2008

25 Source: Morral and Stevens 2003al 2006

26 Context Circa Few research studies of existing treatment programs and no published manuals to support replication for the few studies that were done Not clear whether research based treatment protocols were any better than what the better programs were already doing The purpose of ATM was to manualize existing programs that appeared promising, then to evaluate them using the same measures and methods as CYT (allowing quasi-experimental comparisons)

27 Normal Adolescent Development Biological changes in the body, brain, and hormonal systems that continue into mid-to-late 20s. Shift from concrete to abstract thinking. Improvements in the ability to link causes and consequences (particularly strings of events over time). Separation from a family-based identity and the development of peer- and individual-based identities. Increased focus on how one is perceived by peers. Increasing rates of sensation seeking/trying new things. Development of impulse control and coping skills. Concerns about avoiding emotional or physical violence.

28 Key Adaptation for Adolescents Examples need to be altered to relevant substances, situations, and triggers Consequences have to be altered to things of concern to adolescents Most adolescents do not recognize their substance use as a problem and are being mandated to treatment All materials need to be converted from abstract to concrete concepts Co-morbid problems (mental, trauma, legal) are the norm and often predate substance use Treatment has to take into account the multiple systems (family, school, welfare, criminal justice) Less control of life and recovery environment Less aftercare and social support Complicated staffing needs

29 Program Evaluation Data Level of CareClinicsAdolescents1+ FU* Outpatient/ Intensive Outpatient (OP/IOP) % Long Term Residential (LTR)**439098% Short Term Residential (STR)** % Total % * Completed follow-up calculated as 1+ interviews over those due-done, with site varying between 2-4 planned follow-up interviews. Of those due and alive, 89% completed with 2+ follow-ups, 88% completed 3+ and 78% completed 4. ** Both LTR and STR include programs using CD and therapeutic community models

30 Length of Stay Varies by Level of Care Source: Adolescent Treatment Model (ATM) Data 0% 50% 100% Length of Stay Percent Still in Treatment Long Term Residential (median=154 days; n=222) Short Term Residential (median=31 days; n=589) Outpatient (median= 88 days; n=554) About half of those in OP stay 90 or more days Over half the STR say more than 30 days

31 Adolescents more likely to transfer Source: Adolescent Treatment Model (ATM) Data Length of Stay Across Episodes of care is about 50% longer

32 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

33 Change in Substance 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. LTR more like OP on symptoms count Short- Term Resid. \t,s,ts Long- Term Resid \t,ts Outpatient \t,s

34 Percent in Recovery (no past month use or problems while living in the community) \a Source: Adolescent Treatment Model (ATM) data; Levels of cares 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 Longer term outcomes are similar on substance use

35 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

36 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

37 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

38 CSAT Adolescent Treatment GAIN Data from 203 level of care x site combinations Outpatient General Group Home Short-Term Residential Outpatient Continuing Care Intensive Outpatient Long-term Residential Moderate-Term Residential Early Intervention Other Corrections Levels of Care Source: Dennis, Funk & Hanes-Stevens, 2008

39 Ratings of Problem Severity (x-axis) by Treatment Utilization (y-axis) by Population Size (circle size) 12% 20% 14% 8% 14% 12% Average Current Problem Severity Average Current Treatment Utilization. A Low-Low B Low- Mod C Mod-Mod D Hi-Low E Hi- Mod F. Hi- Hi (CC) G. Hi-Mod (Env Sx/ PH Tx) 9% H. Hi-Hi (Intx Sx; PH/MH Tx) 12%

40 Variance Explained in NOMS Outcomes \1 Past month \2 Past 90 days *All statistically Significant

41 Predicted Count of Positive Outcomes by Level of Care: Cluster A Low - Low (n=1,025)

42 Best Level of Care*: Cluster A Low - Low (n=1,025)

43 Predicted Count of Positive Outcomes by Level of Care: Cluster C Mod-Mod (n=1209) OutpatientIntensive Outpatient Outpatient - Continuing Care Residential

44 Best Level of Care*: Cluster C Mod-Mod (n=1209)

45 Predicted Count of Positive Outcomes by Level of Care: Cluster F Hi-Hi (CC) (n=968) OutpatientIntensive Outpatient Outpatient - Continuing Care Residential

46 Best Level of Care*: Cluster F Hi-Hi (CC) (n=968)

47 Predicted Count of Positive Outcomes by Level of Care: Cluster G. Hi-Mod (Env/PH) (n=749)

48 Best Level of Care*: Cluster G Hi-Mod (Env/PH) (n=749)

49 The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents In the Community Using (75% stable) In Treatment (48% stable) In Recovery (62% stable) Incarcerated (46% stable) 5%5% 12% 7%7% 20% 24% 10% 26% 7 % 19% 7%7% 27% 3%3% Source: 2006 CSAT AT data set Avg of 39% change status each quarter P not the same in both directions Treatment is the most likely path to recovery More likely than adults to stay 90 days in treatment (OR=1.7) More likely than adults to be diverted to treatment (OR=4.0)

50 In the Community Using (75% stable) 12% 27% Probability of Going from Use to Early “Recovery” (+ good) -Age (0.8) + Female (1.7), - Frequency Of Use (0.23) + Non-White (1.6) + Self efficacy to resist relapse (1.4) + Substance Abuse Treatment Index (1.96) * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity. In Recovery (62% stable) Probability of from Recovery to “Using” (+ bad) + Freq. Of Use ( ) - Initial Weeks in Treatment (0.97) + Illegal Activity (1.42) - Treatment Received During Quarter (0.50) + Age (1.24) - Recovery Environment (r)* (0.69) - Positive Social Peers (r) (0.70) The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents

51 In the Community Using (75% stable) In Treatment (48 v 35% stable) 7%7% Source: 2006 CSAT AT data set Probability of Going from Use to “Treatment” (+ good) -Age (0.7) + Times urine Tested (1.7), + Treatment Motivation (1.6) + Weeks in a Controlled Environment (1.4) The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents

52 In the Community Using (75% stable) In Treatment (48 v 35% stable) In Recovery (62% stable) Source: 2006 CSAT AT data set 26% 19% The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents Probability of Going to Using vs. Early “Recovery” (+ good) -- Baseline Substance Use Severity (0.74) + Baseline Total Symptom Count (1.46) -- Past Month Substance Problems (0.48)+ Times Urine Screened (1.56) -- Substance Frequency (0.48)+ Recovery Environment (r)* (1.47) + Positive Social Peers (r)** (1.69) * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.

53 Recovery* by Level of Care: * 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 Adolescent Treatment Outcome Data Set (n-9,276) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pre-IntakeMon 1-3Mon 4-6Mon 7-9Mon Percent in Past Month Recovery* Outpatient (+79%, -1%) Residential(+143%, +17%) Post Corr/Res (+220%, +18%) OP & Resid Similar CC better

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, 2007

55 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

56 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)

57 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.

58 ACC Improved Adherence Source: Godley et al 2002, % 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

59 GCCA Improved Early (0-3 mon.) Abstinence Source: Godley et al 2002, % 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

60 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence Source: Godley et al 2002, % 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

61 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 ACC1 main findings are published and findings from two subsequent experiments are currently under review CSAT is currently replicating ACRA/ACC in 32 sites The ACC manual is being distributed via the website and the CD you have been provided.

62 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