1. The Current Renaissance of Adolescent Treatment Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL Presentation for National Conference onBoys & Girls at Risk:The Emerging Science of Gender Differences, Madison, WI July 21-22, 2008. 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 270-2003-00006 and 270-07-0191, 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 www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: junsicker@Chestnut.Org

2. 2 1.Examine the prevalence, course, and consequences of adolescent substance use, co- occurring disorders and the unmet need for treatment overall and by gender 2.Summarize major trends in the adolescent treatment system and Wisconsin 3.Highlight what it takes to move the field towards evidenced-based practice related to assessment, treatment, program evaluation and planning 4.Present the findings from several recent treatment outcome studies on substance abuse treatment research, trauma and violence/crime Goals of this Presentation are to

3. 3 Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246) Dependence 5% Abuse 4% Regular AOD Use 8% Any Infrequent Drug Use 4% Light Alcohol Use Only 47% No Alcohol or Drug Use 32% Source: 2002 NSDUH

4. 4 Problems Vary by Age Source: 2002 NSDUH and Dennis et al forthcoming 0 10 20 30 40 50 60 70 80 90 100 12-1314-1516-1718-2021-2930-3435-4950-64 65+ 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

5. 5 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

6. 6 Past Year Alcohol or Drug Abuse or Dependence Source: OAS, 2006 10.8% Wisc vs. 9.3% National

7. 7 Past Year Alcohol Abuse or Dependence Source: OAS, 2006 10.6% Wisc vs. 7.7% National

8. 8 Pattern of Teen Substance Use in WI by Gender\a 18% 3% 23% 24% 15% 14% 10% 9% 19% 21% 30% 27% 45% 42% 19% 20% 19% 20% 2% 20% 0%10%20%30%40%50%60%70%80%90%100% Female Male Female Male More than Marijuana use Alcohol Intoxication Alcohol or Tobacco Use No Use \a Each severity level includes any substance to the right \b More than marijuana is only Cocaine for Past month Lifetime. Past Month\b Source: Wisconsin 2005 YRBS Most drug users also drink to intoxication

9. 9 Behavior Problems by Substance Severity in WI\a More than Marijuana use Alcohol Intoxication Alcohol or Tobacco Use No Use \a Each lifetime severity level includes any substance to the right Source: Wisconsin 2005 YRBS * p<.05 Behavior problems increase with substance use severity

10. 10 Victimization by Substance Severity in WI\a More than Marijuana use Alcohol Intoxication Alcohol or Tobacco Use No Use Source: Wisconsin 2005 YRBS * p<.05 \a Each lifetime severity level includes any substance to the right Victimization also goes up with substance use severity

11. 11 Mental Health by Substance Severity in WI\a More than Marijuana use Alcohol Intoxication Alcohol or Tobacco Use No Use Source: Wisconsin 2005 YRBS * p<.05 \a Each lifetime severity level includes any substance to the right As does mental health…

12. 12 Other Problems by Substance Severity in WI\a More than Marijuana use Alcohol Intoxication Alcohol or Tobacco Use No Use Source: Wisconsin 2005 YRBS * p<.05 \a Each lifetime severity level includes any substance to the right..and other problems

13. 13 Count of Problems by Substance Severity in WI\a More than Marijuana use Alcohol Intoxication Alcohol or Tobacco Use No Use Source: Wisconsin 2005 YRBS * p<.05 \a Each severity level includes any substance to the right The number of different types of problems also up with severity The relationship between the number of problems and substance use severity is even greater if we focus on past month use

14. 14 Brain Activity on PET Scan After Using Cocaine 1-2 Min3-45-6 6-77-88-9 9-1010-2020-30 Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377. Rapid rise in brain activity after taking cocaine Actually ends up lower than they started

15. 15 Normal Cocaine Abuser (10 days) Cocaine Abuser (100 days) Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993. Brain Activity on PET Scan After Using Cocaine With repeated use, there is a cumulative effect of reduced brain activity which requires increasingly more stimulation (i.e., tolerance) Even after 100 days of abstinence activity is still low

16. 16 Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

17. 17 Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front

18. 18 Substance Use Careers Last for Decades Cumulative Survival Years from first use to 1+ years abstinence 302520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 Median of 27 years from first use to 1+ years abstinence Source: Dennis et al., 2005

19. 19 Substance Use Careers are Longer the Younger the Age of First Use Cumulative Survival Years from first use to 1+ years abstinence under 15* 21+ 15-20* Age of 1 st Use Groups * p<.05 (different from 21+) 302520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 Source: Dennis et al., 2005

20. 20 Substance Use Careers are Shorter the Sooner People Get to Treatment Cumulative Survival 20+ 0-9* 10-19* Year to 1 st Tx Groups 302520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 * p<.05 (different from 20+) Source: Dennis et al., 2005 Years from first use to 1+ years abstinence

21. 21 Treatment Careers Last for Years Cumulative Survival Years from first Tx to 1+ years abstinence 2520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 Median of 3 to 4 episodes of treatment over 9 years Source: Dennis et al., 2005

22. 22 Key Implications Adolescence is the peak period of risk for and actual on-set of substance use disorders Adolescent substance use can have short and long terms costs to society There are real and often lasting consequence of adolescent substance use on brain functioning and brain development Earlier Intervention during adolescence and young adult hood can reduce the duration of addiction careers

23. 23 Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S. Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm 69% increase from 95,017 in 1992 to 160,750 in 2002 15% drop off from 160,750 in 2002 to 136,660 in 2006

24. 24 Change in WI Public Treatment Admissions: Age at Admission from 1995 to 2005 11,004 13,491 15,558 14,606 16,472 17,596 17,322 16,840 20,354 20,154 20,506 23,845 22,818 25,559 - 5,000 10,000 15,000 20,000 25,000 30,000 199219931994199519961997199819992000200120022003 20042005 - 5,000 10,000 15,000 20,000 25,000 30,000 26+ 18-25 12-17 Total Little Change in Adolescent Admissions Has led to growing admissions in young and older adults

25. 25 Variation by State in the Percentage of Adolescent Residential Treatment: 1995 to 2005 10/07 1.6 to 5.9% Indiana Kansas Maine Montana Nebraska Nevada North Dakota Puerto Rico Hawaii New Mexico South Dakota Alabama Arkansas Iowa Oklahoma Rhode Island South Carolina District Of Columbia Tennessee Utah Louisiana W. Virginia Minnesota Wisconsin New Jersey North Carolina Alaska Delaware Maryland Pennsylvania Georgia Kentucky Virginia Michigan New York Oregon Colorado Texas New Hampshire Connecticut Illinois Missouri Arizona Florida Ohio Vermont Idaho Massachusetts California Washington Wyoming % Residential Mississippi 6.0 to 10.5% 10.6 to 18.7% 18.8 to 29.9% 30.0 to 52.3% Wisconsin significantly lower than the 16% 11 year average for U.S.

26. 26 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): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf. 0306090 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

27. 27 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): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf. Despite being widely recommended, only 10% step down after intensive treatment

28. 28 Key Problems Lack of standardized assessment for substance use disorders, mental health disorders, crime/violence, HIV risk and child maltreatment No or inconsistent use of placement criteria - knowing nothing about the person other than what door they walked through we can correctly predict 75% (kappa=.51) of the adolescent level of care placements (including ASAM systems) Virtually no link to actual data on the expected outcomes by level of care to inform decision making related to placement The lack of the full continuum of care to refer people due to availability or finance

29. 29 Summary of Problems in the Treatment System The public systems is changing size, referral source, and focus Less than 50% stay 50 days (~7 weeks) Less the 25% stay the 3 months recommended by NIDA researchers Less than half have positive discharges After intensive treatment, less than 10% step down to outpatient care Major problems are not reliably assessed (if at all) Difficult to link assessment data to placement or treatment planning decisions

30. 30 So what does it mean to move the field towards Evidence Based Practice (EBP)? Introducing explicit intervention protocols that are – Targeted at specific problems/subgroups and outcomes – Having explicit quality assurance procedures to cause adherence at the individual level and implementation at the program level Having the ability to evaluate performance and outcomes – For the same program over time, – Relative to other interventions Introducing reliable and valid assessment that can be used – At the individual level to immediately guide clinical judgments about diagnosis/severity, placement, treatment planning, and the response to treatment – At the program level to drive program evaluation, needs assessment, performance monitoring and long term program planning

31. 31 Major Predictors of Bigger Effects 1. Chose a strong intervention protocol based on prior evidence 2. Used quality assurance to ensure protocol adherence and project implementation 3. Used proactive case supervision of individual 4. Used triage to focus on the highest severity subgroup

32. 32 Impact of the numbers of Favorable features on Recidivism (509 JJ studies) Source: Adapted from Lipsey, 1997, 2005 Average Practice

33. 33 Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Recidivism (29% vs. 40%) Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving MET/CBT combinations and Other manualized CBT Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ACRA) Assertive Continuing Care 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

34. 34 Need for Short Protocols Targeted at Specific Issues: Detoxification services and medication, particularly related to opioid and methamphetamine use Tobacco cessation Adolescent psychiatric services related to depression, anxiety, ADHD, and conduct disorder Trauma, suicide ideation, & parasuicidal behavior Need for child maltreatment interventions (not just reporting protocols) HIV Intervention to reduce high risk pattern of sexual behavior Anger Management Problems with family, school, work, and probation Recovery coaches, recovery schools, recovery housing and other adolescent oriented self help groups / services

35. 35 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 10-12 Percent in Past Month Recovery* Outpatient (+79%, -1%) Residential(+143%, +17%) Post Corr/Res (+220%, +18%) OP & Resid Similar CC better

36. 36 Need for Tracks, Phases and Continuing Care Almost a third of the adolescents are “returning” to treatment, 23% for the second or more time We need to understand what did and did not work the last time and have alternative approaches We need tracks or phases that recognize that they may need something different or be frustrated by repeating the same material again and again We need to have better step down and continuing care protocols

37. 37 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, 2005

38. 38 On-site proactive urine testing can be used to reduce false negatives by more than half Reduction in false negative reports at no additional cost Effects grow when protocol is repeated

39. 39 Implications of Implementation Science Can identify complex and simple protocols that improve outcomes Interventions have to be reliably delivered in order to achieve reliable outcomes Simple targeted protocols can make a big difference Need for reliable assessment of need, implementation, and outcomes

40. 40 GAIN Clinical Collaborators Adolescent and Adult Treatment Program 10/07 GAIN State System Virgin Islands 0 1 to 10 11 to 25 26 to 130 Indiana Kansas Maine Montana Nebraska Nevada North Dakota Puerto Rico Hawaii New Mexico South Dakota Alabama Arkansas Iowa Oklahoma Rhode Island South Carolina District Of Columbia Tennessee Utah Louisiana W. Virginia Minnesota Wisconsin New Jersey North Carolina Alaska Delaware Maryland Pennsylvania Georgia Kentucky Virginia Michigan New York Oregon Colorado Texas New Hampshire Connecticut Illinois Missouri Arizona Florida Ohio Vermont Idaho Massachusetts California Washington Wyoming GAIN-SS State or County System Number of GAIN Sites Mississippi

41. 41 CSAT GAIN Data (n=15,254) *Any Hispanic ethnicity separate from race group. Sources: CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older). CSAT data dominated by Male, Caucasians, age 15 to 17 CSAT data dominated by Outpatient CSAT residential more likely to be over 30 days

42. 42 Substance Use Problems Source: CSAT 2007 AT Outcome Data Set (n=12,601)

43. 43 Past Year Substance Severity by Level of Care Note: OP=Outpatient, IOP=Intensive Outpatient; LTR= Long Term Residential (90+ days); MTR= Moderate Term Residential (30-90 days); STR=Short Term Residential (0-30 days) Source: CSAT 2007 AT Outcome Data Set (n=12,824)

44. 44 Past Year Substance Severity by Gender Source: CSAT 2007 AT Outcome Data Set (n=15,254)

45. 45 Past 90 day HIV Risk Behaviors Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

46. 46 Sexual Partners by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

47. 47 Sexual Partners by Gender Source: CSAT 2007 AT Outcome Data Set (n=15,254)

48. 48 Co-Occurring Psychiatric Problems Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

49. 49 Co-Occurring Psychiatric Diagnoses by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

50. 50 Severity of Victimization by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

51. 51 Co-Occurring Psychiatric Diagnoses by Gender Source: CSAT 2007 AT Outcome Data Set (n=15,254)

52. 52 Severity of Victimization by Gender Source: CSAT 2007 AT Outcome Data Set (n=15,254)

53. 53 Past Year Violence & Crime *Dealing, manufacturing, prostitution, gambling (does not include simple possession or use) Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

54. 54 Type of Crime by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

55. 55 Type of Crime by Gender Source: CSAT 2007 AT Outcome Data Set (n=15,254)

56. 56 Multiple Problems* are the Norm Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254) Most acknowledge 1+ problems Few present with just one problem (the focus of traditional research) In fact, 45%present acknowledging 5+ major problems * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

57. 57 Number of Problems by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

58. 58 Number of Problems by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=15,254)

59. 59 No. of Problems* by Severity of Victimization Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254) Those with high lifetime levels of victimization have 117 times higher odds of having 5+ major problems* * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Severity of Victimization

60. 60 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

61. 61 Ratings of Problem Severity (x-axis) by Treatment Utilization (y-axis) by Population Size (circle size) 12% 20% 14% 8% 14% 12% -0.20 0.00 0.20 0.40 0.60 0.80 1.00 -0.200.000.200.400.600.801.00 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%

62. 62 Variance Explained in 10 NOMS Outcomes \1 Past month \2 Past 90 days *All statistically Significant

63. 63 Best Level of Care*: Cluster A Low - Low (n=1,025)

64. 64 Best Level of Care*: Cluster C Mod-Mod (n=1209)

65. 65 Best Level of Care*: Cluster F Hi-Hi (CC) (n=968)

66. 66 Best Level of Care*: Cluster G Hi-Mod (Env/PH) (n=749)

67. 67 NOMS Outcome: Treatment Received by Gender Source: CSAT 2007 AT Outcome Data Set (n=11,294)

68. 68 NOMS Outcome: 50% Reduction or None Source: CSAT 2007 AT Outcome Data Set (n=11,294)

69. 69 NOMS Outcome at 12 months post-intake Source: CSAT 2007 AT Outcome Data Set (n=11,013)

70. 70 Change in Days Abstinent (while in community) by Level of Care and Gender Source: CSAT 2007 AT Outcome Data Set (n=11,013)

71. 71 MALES: Change in Adjusted Days Abstinent by type of Outpatient Approach Source: CSAT 2007 AT Outcome Data Set (n=11,013) 0 10 20 30 40 50 60 70 80 90 IntakeLast Followup Days of abstinence FSN (d=0.48) Other (d=0.44) METCBT5 (d=0.33) Total (d=0.33) Other CBT (d=0.32) Seven Challenges (d=0.27) METCBT12 (d=0.2) EMPACT (d=0.18) CHS OP (d=0.15) MDFT (d=0.07) Manualized Practice Tx (d=0.03) METCBT7 (d=-0.03) MST (d=0.87) Motivational Interviewing (d=0.79) ACRA/ACC (d=0.53)

72. 72 FEMALES: Change in Adjusted Days Abstinent by type of Outpatient Approach Source: CSAT 2007 AT Outcome Data Set (n=11,013) = 0 10 20 30 40 50 60 70 80 90 IntakeLast Follow-up Days of abstinence Other (d=0.51) CHS OP (d=0.48) METCBT12 (d=0.48) Seven Challenges (d=0.44) Total (d=0.42) FSN (d=0.41) Other CBT (d=0.41) METCBT5 (d=0.4) METCBT7 (d=0.38) MDFT (d=0.36) ACRA/ACC (d=0.35) EMPACT (d=0.02) Manualized Practice Tx (d=0.94) Motivational Interviewing (d=0.87) MST (d=0.86)

73. 73 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

74. 74 Replication and Site Effects Treatment can vary by implementation within site/clinic We want to compare the range of implementation in practice with the clinical trials In order to compare sites, we will at both the central tendency (median) and distribution using a Tukey Box Plot like the one shown here. Criteria MedianMiddle 50% “Range” -2.00 -1.50 -0.50 0.00 0.50 1.00 1.50 2.00 2.50 3.00

75. 75 Range of Effect Sizes (d) for Change in Days of Abstinence (intake to 12 months) by Site 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 4 CYT Sites (f=0.39) (median within site d=0.29) 36 EAT Sites (f=0.21) (median within site d=0.49) 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 Cohen’s d Source: Dennis, Ives, & Muck, 2008 EAT Programs did Better than CYT on average 75% above CYT median 6 programs completely above CYT

76. Findings from the Assertive Continuing Care (ACC) Experiment 183 adolescents admitted to residential substance abuse treatment Treated for 30-90 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

77. 77 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% 0102030405060708090 Days after Residential (capped at 90) Percent of Clients Cont. Care Admis. Relapse

78. 78 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)

79. 79 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.

80. 80 ACC Improved Adherence Source: Godley et al 2002, 2007 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

81. 81 GCCA Improved Early (0-3 mon.) Abstinence Source: Godley et al 2002, 2007 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

82. 82 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence Source: Godley et al 2002, 2007 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

83. 83 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.

84. 84 Recommendations for Further Developments… Evidenced based interventions can come from both research and practice Evidence based interventions can improve implementation of treatment and treatment outcomes Practice based evidence can be used to improve outcomes Evidenced based interventions and their outcomes can be replicated in practice Continuing care and is a key determinant of long term outcomes