Moving Adolescent Treatment to EvidencedBased Practice

1
Moving Adolescent Treatment to Evidenced-Based
Practice

• Michael Dennis, Ph.D.,
• Chestnut Health Systems,
• Bloomington, IL
• Part of the continuing education workshop,
  Advancing the Field of Adolescent Substance
  Abuse Treatment, Hamden, CT, April 22, 2005.
  Sponsored by the Department of Children and
  Families Substance Abuse Division. 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 270-2003-00006 using data provided by
  the following grantees (TI11320, TI11324,
  TI11317, TI11321, TI11323, TI11874, TI11424,
  TI11894, TI11871, TI11433, TI11423, TI11432,
  TI11422, TI11892, TI11888, TI013313, TI013309,
  TI013344, TI013354, TI013356, TI013305, TI013340,
  TI130022, TI03345, TI012208, TI013323, TI14376,
  TI14261, TI14189,TI14252, TI14315, TI14283,
  TI14267, TI14188, TI14103, TI14272, TI14090,
  TI14271, TI14355, TI14196, TI14214, TI14254,
  TI14311, TI15678, TI15670, TI15486, TI15511,
  TI15433, TI15479, TI15682, TI15483, TI15674,
  TI15467, TI15686, TI15481, TI15461, TI15475,
  TI15413, TI15562, TI15514, TI15672, TI15478,
  TI15447, TI15545, TI15671)). 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 [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org

2
Goals of this Presentation

• Provide a brief introduction on the move to
  evidenced based practice (ECP)
• Summarize the recent growth in adolescent
  substance abuse treatment and research
• Introduce a common data set of adolescent
  treatment programs using the Global Appraisal of
  Individual Needs (GAIN) that is being used by
  CSATs adolescent grantees and which has provided
  data to support the planning of many of recent
  papers and presentations

3
Context

• The field is increasingly facing demands from
  payers, policymakers, and the public at large for
  evidence-based practices (EBP) which can
  reliably produce practical and cost-effective
  interventions, therapies and medications that
  will
• reduce substance use and its negative
  consequences among those who are abusing or
  dependent,
• reduce the likelihood of relapse for those who
  are recovering, and
• reduce risks for initiating drug use among those
  not yet using,
• NIDA Blue Ribbon Panel on Health Services
  Research
• (see www.nida.nih.gov )

4
General Behavioral Health Practice

• Accumulating evidence indicates that most of the
  theories and approaches that are used within the
  community of practitioners are unsupported by
  empirical evidence of effects
• Various lists of 70 or so proven "empirically
  supported therapies (ESTs) have proven to be
  relatively infeasible because they have rarely
  been compared and generally have not been tested
  with the clinically diverse samples found in
  community based settings
• Need for a new method of integrating scientific
  evidence and the realities of practice is called
  for.
• Source Beutler, 2000

5
Problems and Barriers in SA Tx

• People with multiple substance use and multiple
  co-occurring problems are the norm of severity in
  practice, but are often excluded from research
• Individualization of treatment content/duration
  is the norm in practice, but research based
  protocols typically involves fixed
  components/length that are not as appropriate for
  heterogeneous problems
• No treatment is not considered a ethical or
  significant option, practitioners are more
  interested in identifying which of several
  treatments to use for a given type of patient
  but few such studies have been done
• When research practices have been identified,
  they are often not adopted because practitioners
  often lack the appropriate materials, training
  and resources to know when or how to implement
  best practices

6
Randomized Clinical Trials (RCT) are to Evidence
Based Practice (EBP) like Self-reports are to
Diagnosis

• They are only as good as the questions asked (and
  then only if done in a reliable/valid way)
• They are an efficient and logical place to start
• But they can be limited or biased and need to be
  combined with other information
• Just because the person does not know something
  (or the RCT has not be done), does not mean it is
  not so
• Synthesizing them with other information usually
  makes them better

7
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

8
What are the pitfalls of EBP?

• EBP generally causes some staff turnover
• EBP often shines a light on staff or work place
  problems that would otherwise be ignored
• EBP often impact a wide range of existing
  procedures and policies requiring modification
  and provoking resistance
• EBP (and most organizational changes) will fail
  without good senior staff leadership
• EBP typically require going for more funds from
  grant or other funders
• On-going needs assessment will create demand for
  more change and more EBP

9
Growing Infrastructure

• Increasing availability and use of standardized
  assessment to help focus and improve clinical
  practice
• Growing number of manualized protocols designed
  for replication and use in practice
• CSAT increasingly encouraging and/or requiring
  the use of standardized assessment, manuals,
  training, and quality assurance practices to
  ensure adherence
• ATTCs collaborating with CSAT, NIDA and NIAAA to
  train individual staff
• Growing Literature
• GAIN/ JMATE workgroups (Gender, Spanish, African
  American, Asian, LGBT, Juvenile Justice,
  Comorbidity, Strength Based, Substance-specific,
  Intervention-specific, Trainers, Data Managers,
  MIS, Evaluators )

There is a list of above resources at the end of
these handouts
10
How we are building a common knowledge base about
what is working for whom through

• Pooling data across multiple evaluations and
  programs
• Identifying common factors and principals that
  appear to hold across interventions
• Having peer reviewed panels review and rate the
  strength of evidence on the effectiveness and
  generalizability of specific interventions
• Conducting formal meta analysis of a groups of
  similar interventions that have been replicated
  and evaluated several times

11
Reoccurring Themes

• Severity and specificity of problem subgroup
• Manualized and replicable protocols
• Relative strength of intervention for a specific
  problem
• Adherence and implementation of intervention
• Evaluation of outcomes targeted by the
  intervention (a.k.a., logic modeling)

12
Global Appraisal of Individual Needs (GAIN)

• The GAIN family of instruments were developed
  through a 10 year collaboration of researchers,
  clinicians, policy makers, and IT specialists
• They provide a standardized approach to
  measuring
• Eligibility/need (i.e., screening),
• DSM/ICD Diagnosis,
• ASAM level of care Placement,
• Study/State/Federal Reporting,
• Treatment Planning,
• Severity/Case Mix,
• Change in Functioning, Service Utilization, and
  other Outcomes, and
• Economic Cost and Benefits of treatment
• Includes 103 scales and over 2000 created
  variables, had good reliability/validity, 174
  agencies and over four dozen scientists working
  with it
• More information is available at
  www.chestnut.org/li/gain

13
Adolescent and Adult Treatment Program GAIN
Clinical Collaborators
CSAT
Other Collaborators
Co-occurring Disorder (CD) Studies
Cannabis Youth Treatment (CYT)
RWJF Reclaiming Futures Program
Other RWJF Grantees
Adolescent Treatment Model (ATM)
NIAAA/NIDA Other Grantees
Strengthening Communities for Youth (SCY)
Other Grants/Contracts
Adolescent Residential Treatment (ART)
State, county, or agency systems Other states,
counties, or agencies proposing or considering it
Effective Adolescent Treatment (EAT)
Young Offender Re-Entry Program (YORP)
Targeted Capacity Expansion (TCE) grants
14
Studies with Publications Currently Coming Out

• 1994-2000 NIDAs Drug Abuse Treatment Outcome
  Study of
• Adolescents (DATOS-A)
• 1995-1997 Drug Abuse Treatment Outcome Study
  (DOMS)
• 1997-2000 CSATs Cannabis Youth Treatment (CYT)
  experiments
• 1998-2003 NIAAA/CSATs 15 individual research
  grants
• 1998-2003 CSATs 10 Adolescent Treatment Models
  (ATM)
• 2000-2003 CSATs Persistent Effects of Treatment
  Study (PETS-A)
• 2002-2007 CSATs 12 Strengthening Communities for
  Youth (SCY)
• 2002-2007 RWJFs 10 Reclaiming Futures (RF)
  diversion projects
• 2002-2007 CSATs 12 Targeted Capacity Expansion
  TCE/HIV
• 2003-2009 NIDAs 14 individual research grants
  and CTN studies
• 2003-2006 CSATs 17 Adolescent Residential
  Treatment (ART)
• 2003-2008 NIDAs Criminal Justice Drug Abuse
  Treatment Study
• (CJ-DATS)
• 2003-2007 CSATs 36 Effective Adolescent
  Treatment (EAT)
• 2004-2007 NIAAA/CSATs study of diffusion of
  innovation

15
Since 1997, the data has been pooled to create
one of the largest benchmark data sets in the
field
90,000
80,000
70,000
57,360
60,000
Cumulative GAIN Interviews (observations)
50,000
32,054
40,000
30,000
17,464
20,000
10,000
0
Prior to FY2003
FY2004
FY2005
FY2006
Half of all Adolescent Treatment Data
One of the Largest Data Sets in the Field with
1 year follow-up (2nd only to ASI)
Largest Combined Adolescent Data Set
16
CSAT AT Program Common Data Set

• The working CSAT adolescent treatment data set
  including data on 5,468 adolescents from 67 local
  evaluations (current through quarterly data
  submission cycle ending in December 2004)
• All data collected with the Global Appraisal of
  Individual Needs (GAIN) using centrally trained
  and certified staff
• Outcome data through 12 months available on over
  90 of CYT and ATM clients and over 80 of others
  due in on-going programs
• Programs include several standardized protocols
  based on both research and practice (ACC, ACRA,
  ATM, FFT, FSN, Matrix, MET/CBT, MDFT, MST)
• Local evaluations include several experiments and
  quasi experiments
• Several workgroups working on common themes
  across programs (African American, Co-morbidity,
  Family, Native American/Indian, Spanish
  translation/workforce)
• Data being shared with several secondary analysis
  grantees and panel presentations for this week

17
CSAT Adolescent Treatment (AT) Programs
Reordered by Level of Care and Severity

• EAT Effective Adolescent Treatment (2003-2007
  n975) replicating the CYT MET/CBT intervention
  in early intervention, school and outpatient
  settings(22 of 36 grants Bradley, Brown,
  Clayton,Curry, Davis, Dillon, Dodge, Kressler,
  Kincaid, Levine, Levy, Locario, Mason, Moore,
  Rajaee-Moore, Paull, Payton, Rezende, Taylor,
  Tims, Turner, Vincent)
• CYT Cannabis Youth Treatment (1997-2001 n600)
  Experiments with adolescent outpatient/intensive
  outpatient (5 grants Babor, Dennis, Diamond,
  Godley, Tims)
• TCE Targeted Capacity Expansion (2002-2007
  n189) evaluation of intensive outpatient
  programs and some residential treatment (2 of 12
  grants Tims, Lloyd)
• SCY Strengthening Communities-Youth (2002-2007
  n1120) evaluations of early intervention,
  outpatient, intensive outpatient and some
  residential (11 of 12 grants Beach, Bolland,
  Dahl, Gerstel, Godley, Hall, Hutchinson, Keehn,
  Murphy, Noonan, Panzarella)
• ATM Adolescent Treatment Model (1998-2002
  n1468) evaluations of outpatient, short and long
  term residential (10 grants Batttjes, Fishman,
  Godley, Liddle, Morral, Perry, Sabin, Shane,
  Stevens-2)
• ART Adolescent Residential Treatment (2003-2006
  n1179) evaluations of residential treatment
  enhancements and continuing care (17 grants
  Beach, Fishman, Flores, Gay, Gnazzo, Hatch,
  Hurtig, Lane, Law, Manov, May, Miley, Nordquist,
  Snipes, Urquahart, Whitmore, Zammarelli)

18
Level of Care
100
Other
Resid. Continuing Care
80
Long Term Residential
60
Med. Term Residential
Short Term Residential
40
Intensive Outpatient
20
Outpatient
Early Intervention
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
19
Gender
100
90
80
Male
70
60
50
40
30
Female
20
10
While few individual studies can break out
females, this data set has 1497 (so far)
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
20
Race
100
Other
90
Mixed
80
Native American/
70
Alaskan
60
Hispanic
50
Caucasian/White
40
Asian/Pacific Islander
30
20
African American
10
0
Across sites there are 300 or more for all
subgroups but Asian (so far)
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
21
Age
100
21-25
90
80
70
18-20
60
50
40
15-17
30
20
0-14
10
921 Under 14 and 377 young adults
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
22
Other Characteristics
100
10
20
30
40
50
60
70
80
90
0
50
Single Parent
Homeless or
39
Runaway
34
Employed
86
In School
Juvenile Justice Involvement
70
Recently in a Controlled Environment
45
Source CSAT AT Common GAIN Data set
23
Years of Use
100
5 Years
90
80
70
3-4 Years
60
50
40
1-2 Years
30
20
10
Less than 1
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
24
Substance Use Severity (based on self-report)
100
90
Dependence
80
70
60
50
Abuse
40
30
20
Subclinical use/problems
10
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
25
Weekly/Daily Substance Use Pattern
100
10
20
30
40
50
60
70
80
90
0
65
Any AOD Use
52
Marijuana
20
Alcohol
In our data and in TEDS, 1 in 5 did not use in
the month before intake hence the use of 90 day
window and measures of pre-CE use
5
Cocaine/Crack
3
Heroin/Opioids
8
Other Drugs
14 or more days in Controlled Environment
30
Source CSAT AT Common GAIN Data set
26
Prior Substance Abuse Treatment
100
90
Two or more
80
70
60
50
One
40
30
20
None
10
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
27
Mixed Problem Recognition
100
10
20
30
40
50
60
70
80
90
0
Acknowledges AOD problem
35
Believes treatment needed
81
Self reports meets
abuse/dependence
92
criteria
Gives one or more
99
reasons to quit
Source CSAT AT Common GAIN Data set
28
High Risk Recovery Environments
100
10
20
30
40
50
60
70
80
90
0
29
In home
among work/ school peers
52
Regular alcohol use
among social peers
61
17
In home
among work/ school peers
67
Regular drug use
among social peers
79
Source CSAT AT Common GAIN Data set
29
Patterns of Co-Occurring Disorders
100
Both Internal
External
90
Disorders
80
70
External
Disorder(s)
60
Only
50
Internal
40
Disorder(s)
30
only
20
Neither
10
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
30
Interventions need to be more specific
100
10
20
30
40
50
60
70
80
90
0
49
Any Internal Disorder
Depressive Disorder
38
21
Anxiety Disorder
28
Trauma Related Disorder
32
Any Self Mutilation
Any homicidal/ suicidal thoughts
28
67
Any External Disorder
59
Conduct Disorder
Attention Deficit-Hyperactivity Disorder (ADHD)
Within a diagnosis there are also mild to severe
subgroups
48
Source CSAT AT Common GAIN Data set
31
Also High Rates of HIV/STI risk behaviors
100
10
20
30
40
50
60
70
80
90
0
81
Sexual Activity
57
Victimization
Lifetime
16
Needle Use
61
Sexual Activity
Sex Under AOD Influence
51
Multiple Sex Partners
35
Past 90 Days
Unprotected Sex
29
23
Victimization
4
Needle Use
Source CSAT AT Common GAIN Data set
32
Severity of Victimization History
100
High (4-15 on General Victimization Scale GVS )
90
80
70
Moderate (Any Lifetime, 1-3 on GVS)
60
50
Low (No History)
40
30
Based on lifetime history and current fear of 4
types of victimization (attached with a weapon,
beaten, sexually assaulted, emotionally abused),
and 8 trauma factors (under 18, someone trusted,
multiple people, multiple times, sexual
penetration, fear for life, no one believed when
reported)
20
10
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
33
Victimization interacts with MH problems
100
Both Internal
External
90
Disorders
80
70
External
Disorder(s)
60
Only
50
Internal
40
Disorder(s)
30
only
20
Neither
10
0
Low
Moderate
High
Total
?Severity of Victimization?
Source CSAT AT Common GAIN Data set
34
Intensity of Juvenile Justice System Involvement
100
In detention/ jail 14 days
90
On prob./ parole 14 days w/ 1 drug screens
80
70
60
Other probation, parole, detention
50
Other JJ status
40
30
Past arrest/ JJ status
20
Past year illegal
10
activity/SA use
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
35
It is NOT just about possession
100
10
20
30
40
50
60
70
80
90
0
Past Year
Any violence or
86
illegal activity
72
Physical Violence
58
Property Crimes
57
Drug Related Crime
Interpersonal
51
Crimes
Source CSAT AT Common GAIN Data set
36
Need to focus on multiple problems clients
100
Number of 12 Major Clinical Problems
90
80
5 or more
70
Problems
60
4 Problems
50
3 Problems
40
2 Problems
30
1 Problem
20
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
10
0
EAT
CYT
TCE
SCY
ATM
ART
Total
Source CSAT AT Common GAIN Data set
37
Areas where staff wanted more specific knowledge
and interventions

• Victimization, trauma and helplessness
• Self mutilation, para-suicidal and suicidal
  behaviors
• Anger management, violence and crime
• How to help their kids access mental health
  services (typically for internal disorders) when
  availability is limited
• Managing ADHD and impulsivity
• How to get parents involved in treatment and
  continuing care
• Tobacco, opioids, and methamphetamine use,
• Working with schools, probation, families
• Females, Males, African Americans, Native
  Americans, Spanish Speaking adolescents and their
  families
• HIV, STI, and Liver risk
• How to make interventions more assertive and
  strength based
• Evaluation issues like follow-up, data
  management, analysis
• Workforce development, including peer-to-peer on
  specific treatment approaches and other job
  functions like MIS

38
Common Strategies you can do NOW

• Standardize assessment and identify most common
  problems
• Pool knowledge about what staff have done in the
  past, whether it worked, and what the barriers
  were
• Identify system barriers (e.g., criteria to local
  access case management, mental health) that could
  be avoided if thought of in advance
• Identify existing materials that could help and
  make sure they are readily available on site
• Identify promising strategies for working with
  the adolescent, parents, or other providers
• Develop a 1-2 page checklist of things to do when
  this problem comes up
• Identify a more detailed protocol and trainer to
  address the problem, then go for a grant to
  support implementation

39
Resources

• Assessment Instruments
• CSAT TIP 3 at http//www.athealth.com/practitioner
  /ceduc/health_tip31k.html
• NIAAA Assessment Handbook,http//www.niaaa.nih.gov
  /publications/instable.htm
• GAIN Coordinating Center www.chestnut.org/li/gain
  
• Treatment Programs
• CSAT CYT, ATM, ACC and other treatment manuals at
  www.chestnut.org/li/apss/csat/protocols or
  www.chestnut.org/li/bookstore
• SAMHSA at http//kap.samhsa.gov/products/manuals/c
  yt/index.htm or NCADI at www.health.org
• National Registry of Effective Prevention
  ProgramsSubstance Abuse and Mental Health
  Services Administration (SAMHSA), Department of
  Health and Human Services http//www.modelprogra
  ms.samhsa.gov

40
Resources

• Implementing Evidenced based practice
• Central East ATTC Evidence Based Practice
  Resource Page http//www.ceattc.org/nidacsat_bpr.a
  sp?idLGBT
• Northwest Frontier ATTC Best Practices in
  Addiction Treatment A Workshop Facilitator's
  Guide http//www.nattc.org/resPubs/bpat/index.html
  
• Turning Knowledge into Practice A Manual for
  Behavioral Health Administrators and
  Practitioners About Understanding and
  Implementing Evidence-Based Practices
  http//www.tacinc.org/index/viewPage.cfm?pageId11
  4
• Evidence-Based Practices An Implementation Guide
  for Community-Based Substance Abuse Treatment
  Agencies http//www.uiowa.edu/iowapic/files/EBP2
  0Guide20-20Revised205-03.pdf
• National Center for Mental Health and Juvenile
  Justice Evidence Based Practice resource list at
  http//www.ncmhjj.com/EBP/default.asp
• 2005 Joint Meeting on Adolescent Substance Abuse
  Treatment Effectiveness http//www.mayatech.com/ct
  i/csatsasatepost/
• Society for Adolescent Substance Abuse Treatment
  Effectiveness (SASATE) www.chestnut.org/li/apss/s
  asate

41
References Cited Here

• Beutler, L. E. (2000). David and Goliath When
  empirical and clinical standards of practice
  meet. American Psychologist, 55, 997-1007.
• 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., White, M.K. (2003). The
  effectiveness of adolescent substance abuse
  treatment a brief summary of studies through
  2001, (prepared for Drug Strategies adolescent
  treatment handbook). Bloomington, IL Chestnut
  Health Systems. On line Available at
  http//www.drugstrategies.org
• Dennis, M. L. and White, M. K. (2004).
  Predicting residential placement, relapse, and
  recidivism among adolescents with the GAIN.
  Poster presentation for SAMHSA's Center for
  Substance Abuse Treatment (CSAT) Adolescent
  Treatment Grantee Meeting Feb 24 Baltimore,
  MD. 2004 Feb.
• 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), 67-69.
• White, M. K., White, W. L., Dennis, M. L.
  (2004). Emerging models of effective adolescent
  substance abuse treatment. Counselor, 5(2), 24-28.