1. Understanding the Role of Residential Addiction Treatment for Adolescent: An Overview of Characteristics, Services and Outcomes Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL January 10 th, 2008 presentation at the Symposium on Adolescent Residential Alcohol and Drug Treatment, Cromwell, CT. This presentation reports on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270- 2003-00006 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 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.national trends in residential treatment for adolescents 2.how the clinical severity of adolescents varies by level of care 3.how the source of referral, length of stay, type of discharge, outcomes, and type of evidenced based practice varies by level of care 4.observational and experimental evidence on the impact of continuing care 5.the interaction of level of care and victimization This presentation will examine..

3. 3 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 50% increase from 95,017 in 1992 to 142,646 in 2005 10% drop off from 2004 to 2005

4. 4 Trends in Adolescent (Age 12-17) Level of Care Placement in the U.S. Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm Average 17% residential Size increasing over time % decreasing over time

5. 5 Variation by State in the Percentage of Adolescent Residential Treatment: 1995 to 2005 10/07 Virgin Islands 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%

6. 6 Severity Goes up with Level of Care Source: Treatment Episode Data Set (TEDS) 1993-2003. 0% 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

7. 7 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

8. 8 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

9. 9 So what does it mean to move the field towards Evidence Based Practice (EBP)? 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, and long term program planning 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

10. 10 Key Issues that we try to address with the Global Appraisal of Individual Needs (GAIN) High turnover workforce with variable education background related to diagnosis, placement and treatment planning. Heterogeneous needs and severity characterized by multiple problems, chronic relapse, and multiple episodes of care Lack of access to or use of data at the program level to guide immediate clinical decisions, billing and program planning Missing or misrepresented data that needs to be minimized and incorporated into interpretations

11. 11 GAIN Logic Model IssueInstrument FeatureProtocol FeatureOutcome High Turnover Workforce with Variable Education Standardized approach to asking questions across domains Questions spelled out and simple question format Lay wording mapped onto expert standards for given area Built in transition statements, prompts, and checks for inconsistent and missing information. Responses to frequently asked questions Multiple training resources Formal training and certification protocols on administration, clinical interpretation, data management, project coordination, local, regional, and national “trainers” Above focuses on consistency across populations, level of care, staff and time On-going quality assurance and data monitoring for the reoccurrence or problems at the staff (site or item) level Availability of technical assistance Improved Reliability and Efficiency Heterogeneous Needs and Severity Multiple domains Focus on most common problems Participant self description of characteristics, problems, needs, personal strengths and resources Behavior recency, breadth, frequency Utilization lifetime, recency and frequency Dimensional measures Interpretative cut points Items and cut points mapped onto DSM for diagnosis, ASAM for placement, and to multiple standards and evidence- based practices for treatment planning Computer generated scoring and reports Treatment planning recommendations and links to evidence-based practice Basic and advanced clinical interpretation training and certification Comprehensive Assessment

12. 12 GAIN Logic Model (continued) IssueInstrument FeatureProtocol FeatureOutcome Missing or Misrepresented Data Assurances, time anchoring, definitions, transition, and question order to reduce confusion and increase valid responses Cognitive impairment check Validity checks on missing, bad, inconsistency and unlikely responses Validity checks for atypical and overly random symptom presentations Validity ratings by staff Training on optimizing clinical rapport Training on time anchoring Training answering questions, resolving vague or inconsistent responses, following assessment protocol and accurate documentation. Utilization and documentation of other sources of information Post hoc checks for on-going site, staff or item problems Improved Validity Lack of Access to or use of Data at the Program Level Data immediately available to support clinical decision making for a case Data can be transferred to other clinical information system to support billing, progress reports, treatment planning and on-going monitoring Data can be exported and cleaned to support further analyses Data can be pooled with other sites to facilitate comparison and evaluation PC and (soon) web based software applications and support Formal training and certification on using data at the individual level and data management at the program level Data routine pooled to support comparisons across programs and secondary analysis Over two dozen scientists working with data to link to evidence-based practice Improved Program Planning and Outcomes

13. 13 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

14. 14 TEDS vs. CSAT GAIN Data: Demographics *Any Hispanic ethnicity separate from race group. Sources: TEDS 1992 to 2005 Concatenated file subsetted to 1998 to 2005, age 12-17. and CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older). CSAT less likely to be Caucasian

15. 15 TEDS vs. CSAT GAIN Data: Level of Care * Excluding Detoxification ** Excluding Early Intervention, Corrections and Continuing Care Sources: TEDS 1992 to 2005 Concatenated file subsetted to 1998 to 2005, age 12-17. and CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older). CSAT more likely to be long term residential CSAT breaks out Moderate Term Residential (MTR; 30-90 days expected length of stay)

16. 16 Substance Use Problems Source: CSAT 2007 AT Outcome Data Set (n=12,601)

17. 17 Past Year Substance Severity by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

18. 18 Past 90 day HIV Risk Behaviors Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

19. 19 Sexual Partners by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

20. 20 Co-Occurring Psychiatric Problems Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

21. 21 Co-Occurring Psychiatric Diagnoses by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

22. 22 Severity of Victimization by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

23. 23 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)

24. 24 Type of Crime by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

25. 25 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)

26. 26 Number of Problems by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

27. 27 Adolescent Residential Treatment Sites (N=1,997 adolescents from 30 sites) 10/07 AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY PR VI Baltimore Dallas Eugene Fairbanks Ft. Collins Houston Iowa City Laredo Los Angeles Louisville Medford New York Oakland Orlando Paia Philadelphia Phoenix Richmond San Diego San Jose Shiprock St Louis Tucson ART SCY TCE-HIV ATM DC YORP TCE AAFT Washington Cnty.

28. 28 Sources of Referral by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=1689)

29. 29 Length of Stay by Level of Care Source: CSAT AT 2007 dataset subset to adolescent studies (N=1,997) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0306090120150180210240270300330360 Length of Stay (Days) Percent Still in Treatment STR (Median= 30 days) MTR (Median=60 days) LTR (Median=145 days) Length of Stay Varies Both by level of care and within level of care All better than the National average

30. 30 Type of Discharge by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=1689) All levels significantly better than the 10% national average

31. 31 Selected Outcomes by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=1,997) Longer lengths of stay doing better Shorter lengths of stay doing better MTR doing better

32. 32 Types of Treatment by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=2677)

33. 33 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 2006 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

34. 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, forth coming

35. 35 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)

36. 36 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.

37. 37 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

38. 38 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

39. 39 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

40. 40 Some Concluding Thoughts… Residential Treatment continues to play a critical role by targeting higher severity clients Evidenced based practices are not panacea, but they pull up the bottom and improve average outcomes Implementing continuing care improves average outcomes More work is need on the use of schools and recovery schools as a location for continuing care after residential treatment.

41. 41 Other Assessment and Treatment Resources Assessment Instruments – GAIN Coordinating Center at www.chestnut.org/li/gainwww.chestnut.org/li/gain – CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html http://www.athealth.com/practitioner/ceduc/health_tip31k.html – NIAAA Assessment Handbook at http://www.niaaa.nih.gov/publications/instable.htm http://www.niaaa.nih.gov/publications/instable.htm Treatment Programs – CSAT CYT, ATM, ACC and other treatment manuals at www.chestnut.org/li/apss/csat/protocols and on CDs provided www.chestnut.org/li/apss/csat/protocols – SAMHSA Knowledge Application Program (KAP) at http://kap.samhsa.gov/products/manuals http://kap.samhsa.gov/products/manuals – NCADI at www.health.orgwww.health.org – National Registry of Effective Prevention Programs Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov http://www.modelprograms.samhsa.gov Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) www.chestnut.org/li/apss/sasate www.chestnut.org/li/apss/sasate Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/jmate/ http://www.mayatech.com/cti/jmate/ – next meeting March 30-April 2, 2008, Washington, DC