Assertive Continuing Care for Adolescents

1
Assertive Continuing Care for Adolescents

• Mark D. Godley, Ph.D.
• Chestnut Health Systems
• Bloomington, IL
• Presented at the Robert Wood Johnson Foundations
• Treatment Fellowship Meeting.
• Denver, Co
• November 11, 2003
• This work is supported by grants from the
  National Institute on Alcoholism Alcohol Abuse,
  the SAMHSA Center for Substance Abuse Treatment,
  and the Illinois Office of Alcoholism Substance
  Abuse. The opinions are those of the author and
  do not reflect official positions of the
  government.

2
Collaborators

• Several colleagues at Chestnut served as
  co-investigators or collaborators on this study.
  Their contributions made this work possible
  Loree Adams, Becky Buddemeyer, Michael Dennis,
  Rod Funk, Susan Godley, Jen Hammond, Matt
  Orndorff, Lora Passetti, Laura Sloan, Ben Wells,
  and Jen White
• And
• Drs. H. Perl J. Hough, NIAAA R. Muck, CSAT
  and M. Whitter, Illinois OASA

3
Introduction

• Our Background
• Experience with adolescents involved in
  residential and outpatient treatment
• Is it Aftercare or Continuing Care?

4
(No Transcript)
5
(No Transcript)
6
Workshop Goals

• Discuss Continuing Care (CC) in current practice
• Describe the ACC approach to engaging and serving
  adolescents in continuing care
• Briefly describe the ACC model
• Review ACC supervision model
• Present research findings and implications of the
  ACC model
• Discuss application to your projects

7
Why is Continuing Care Important?

• Is Addiction a Chronic Relapsing Condition?
• McLellan et al. (2000) JAMA article compared
  addictions to other chronic illnesses.

8
Hypertension

• Adherence to medication is less than 60
• Adherence to diet exercise is less than 30
• Re-treated in 12 months 50-60
• (McLellan, 2003 Treatment Research Institute)

9
Diabetes

• Adherence to medication is less than 50
• Adherence to diet exercise is less than 30
• Re-treated in 12 months 30-50
• (McLellan, 2003 Treatment Research Institute)

10
Asthma

• Adherence to medication is less than 30
• Re-treated in 12 months 60-80
• (McLellan, 2003 Treatment Research Institute)

11
What Predicts Relapse in these Illnesses?

• Poor adherence to behavior change requirements
  (diet, exercise, medication compliance)
• Low Socioeconomic Status
• Low Family Support
• Psychiatric Co-Morbidity
• (McLellan, 2003 Treatment Research Institute)

12
Why is Continuing Care Research in Addiction
Treatment Important?

• Existing studies reveal high levels of relapse
  for after treatment
• Adult continuing care trials have shown mixed
  effects (McKay, 2001)
• Almost no continuing care studies of adolescents

13
Time to Enter Continuing Care and Relapse after
Residential Treatment (Age 12-17)
1.00
.90
CC
.80
.70
.60
.50
.40
.30
Proportion of Clients
.20
.10
.00
90
80
70
60
50
40
30
20
10
0
Days after Residential Treatment (capped at 90)
Source DARTS 2000 and Godley et al 2002
14
What does Continuing Care look like in actual
practice?
100
100
20
20
10
30
40
50
60
70
80
90
10
30
40
50
60
70
80
90
0
0
Weekly
Tx
Weekly 12 step meetings
Relapse prevention
Communication skills training
Problem solving component
Regular urine tests
Meet with parents 1-2x month
Weekly telephone contact
Contact w/ probation/school
Referrals to other services
Follow up on referrals
Discuss probation/school compliance
Adherence Meets 8/12 criteria
Expected
Expected UCC
15
How do we engage and retain youth in aftercare?

• Most S.A. treatment referral and service delivery
  systems are passive
• Assertive referral and service delivery
  approaches shift the responsibility from the
  client to the provider

16
Examples of Assertive Approaches

• Recovery Management Check-ups (Dennis, Scott,
  Funk, 2003)
• Multisystemic Therapy (Henggeler, 1999)
• Tarrant Co. Juvenile Services-TCAP Family
  Preservation (Woods Haene, 2002)
• Case Monitoring and Telephone Support (Foote
  Erfurt, 1991 Stout et al., 1999)
• Assertive Continuing Care Study (Godley et al.,
  2002)

17
Suggested Goals of CC

• Encouraging and Priming Prosocial activities
• Reduce Social Risk
• Social Skill Development
• Monitoring to Prevent Relapse
• Support
• Linkage to Other Services
• Re-Intervention for Major Relapse
• Essential CC Functions

18
A Controlled Study of the Effectiveness of
Assertive Continuing Care
19
Research Questions

• To determine the effectiveness of
  post-residential ACC in
• engaging and retaining youth in continuing care
• linking youth to additional services
• reducing AOD use and problems

20
ACC Study Research Design
Intervention
N
Intake
Residential
3
mo after
6
mo after
9
mo after
Treatment
discharge
discharge
discharge
Plus
from RT
from RT
from RT
Aftercare
Assertive
102
O
T
O
O
O
0
UCCACC
3
6
9
Continuing
Care
Usual
81
O
T
O
O
O
0
UCC
3
6
9
Continuing
Care
Note O participant interview
T treatment
No line between rows means randomization
21
Who was eligible for the study?

• Adolescents admitted to residential treatment
  (ASAM Level 3 care)
• Length of stay of 7 days or longer (not required
  to have a successful discharge)
• Reside in one of our aftercare target counties

22
Baseline Characteristics of ASAM Level 3 vs.
Level 1 Clients
100
Outpatient
76
Residential
75
61
58
44
47
47
48
45
50
35
28
26
24
25
0
Self-Reported
Past-Year
General
Acute Stress
ADHD
Conduct
Criteria for
Health
Mental
Symptoms
Symptoms
Disorder
Dependence
Problems
Distress
Symptoms
23
Recruitment and Follow-up

• 81 of eligible clients agreed to participate
• 93 of all participants were interviewed at
  baseline, 3, 6, and 9 months
• 96 of all follow-up interviews were completed
  within two weeks of due date

24
Residential Treatment

• Approach
• Length of Stay
• Average LOS - 49 days for both groups
• 1- 3 weeks 25 ACC - 28 UCC
• 4-12 weeks 68 ACC - 71 UCC
• 13 weeks 6 ACC - 2 UCC
• Rate of Successful Completion
• 50 ACC - 53 UCC

25
(No Transcript)
26
Components of ACC

• Adolescent Community Reinforcement Approach
  (ACRA) Manual
• ACC Case Managers Manual
• Approach to Clinical Supervision

27
Features of the Assertive Continuing Care
Intervention

• Home Visits
• Sessions for patient, 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)

28
Monitoring ACC Implementation

• Weekly Case Review Tracking Form
• Therapist Skillfulness Rating Form
• Procedure checklists completed independently by
  therapist and supervisor
• 100 of taped sessions reviewed until
  certification

29
Monitoring Implementation

• Simple tracking systems work best
• Low tech/low cost systems work fine
• Tracking system must provide summary data on
  intervention procedures
• Tracking system should result in rapid feedback
  to staff who can make changes to improve
  performance if need be

30
ACC Case Review Tracking Form
31
Core Measures

• GAIN-I and GAIN M90
• Form 90 TLFB
• BAC and Urine tests
• Collateral Assessment Form

32
Demographic Characteristics
33
Baseline Substance Use Characteristics
34
Engagement Retention

• 94 of ACC vs. 54 of UCC group enrolled
• ACC averaged 14.1 aftercare sessions vs. 6.3
  sessions for the UCC group
• ACC median sessions 10 compared to 2 for UCC
  group
• No difference in average UCC sessions between
  groups
• ACC significantly more likely to receive
  referrals to other human service providers

35
Results Improved Adherence
100
100
20
20
10
30
40
50
60
70
80
90
10
30
40
50
60
70
80
90
0
0
Weekly
Tx
Weekly 12 step meetings
Relapse prevention
Communication skills training
Problem solving component
Regular urine tests
Meet with parents 1-2x month
Weekly telephone contact
Contact w/ probation/school
Referrals to other services
Follow up on referrals
Discuss probation/school compliance
Adherence Meets 8/12 criteria
UCC
36
Reduced Relapse Marijuana
1.0
.9
.8
.7
.6
.5
Proportion Remaining Abstinent
.4
ACC
.3
.2
UCC
.1
0.0
270
240
210
180
150
120
90
60
30
0
Days to First Marijuana Use plt.05
37
Reduced Relapse Alcohol
1.0
.9
.8
.7
.6
.5
Proportion Remaining Abstinent
.4
ACC
.3
.2
UCC
.1
0.0
270
240
210
180
150
120
90
60
30
0
Days to First Alcohol Use (plt.05)
38
Conclusions and Next Steps

• Relatively few youth enroll in usual continuing
  care following residential tx
• Retention beyond two sessions is quite low in
  typical continuing care programs
• CC programs that take on more responsibility for
  engaging youth do better
• ACC is clearly superior to UCC in linking and
  retaining youth in continuing care
• ACC clients receive more referrals to other
  services

39
Conclusions and Next Steps

• ACC appears to prevent relapse better than UCC
• Additional research is necessary to improve
  effectiveness durability
• We have no tested models of continuing care
  following outpatient treatment
• We need to address the co-occurring problems of
  adolescents
• We need to test longer term models of CC with
  adolescents-particularly decreasing levels of
  contact for monitoring, support, and
  re-intervention

40
Study 2 Telephone Support Continuing Care

• Recruitment 8/02 1/03
• Sample 100 adults admitted to Chestnut Health
  Systems Residential Program
• Diagnosis Dependence on one or more drugs
• Design Randomized Field Experiment
• Instrument Global Appraisal of Individual Needs
  (GAIN)
• Follow-up Quarterly follow-up assessments will
  be completed for 6 months post discharge

41
Hypotheses

• When compared to individuals in the standard
  continuing care group, individuals who receive
  the telephone support intervention will (a)
  receive continuing care services sooner,
• (b) receive more continuing care sessions,(c)
  remain abstinent longer, have fewer days of use,
  fewer SA problems.

42
Rationale

• Passive referrals to continuing care do not work
  well
• Less than 20 of clients connect to step down
  within the first 30 days
• Paradoxically, the highest percentage of clients
  relapsing is in the first 30 days after discharge
• Best practice guidelines call for continuing care
  following primary treatment
• McKay found that telephone counseling for
  continuing care was as effective as face-to-face.
• By using a well-timed assertive approach to
  telephone support calls, can we decrease relapse?

43
Telephone Support Counseling

• Weekly calls for the first month, followed by
  calls every two weeks for the next two months
• Telephone calls last from 5 20 minutes
• Telephone protocol
• Review of the previous week (or since last call)
• Review of Continuing Care goals/activities
• Review motivation for abstinence
• Review use and/or using thoughts
• Review ways they overcame using thoughts
• Refer to primary counselor if necessary
• Always praise recovery-oriented behaviors

44
Tracking Form for Telephone Support Study
45
Findings to Date

• Using client follow-up technology for research
  studies (Scott, 2001) we are able to reach most
• Reaching clients within the on-time window is the
  most challenging aspect of this study
• Training and implementation are easier than other
  behavioral interventions
• Supervision is easier because its not difficult
  to learn the protocol
• Findings to date are mixed

46
Next Steps

• Will adolescents benefit from this?
• May work best when combined with a
  re-intervention strategy for those in relapse.
• Need to determine which clients this may benefit
• Need to test different call frequency schedules
  depending on client recovery status

47
Contact Information

• Mark D. Godley, Ph.D.
• Chestnut Health Systems
• 720 W. Chestnut St.
• Bloomington, IL 61704
• 309.827.6026 ext.3401
• mgodley_at_chestnut.org
• www.chestnut.org