Traumatic Victimization Among Adolescents in Substance Abuse Treatment: Time to Stop Ignoring the El

1
Traumatic Victimization Among Adolescents in
Substance Abuse TreatmentTime to Stop Ignoring
the Elephant

• Michael Dennis, Ph.D.
• Chestnut Health Systems,
• Bloomington, IL
• Presentation for the Society for Adolescent
  Substance Abuse Treatment Effectiveness (SASATE),
  San Juan, PR, June 18, 2004. Supported with
  funds from the Center for Substance Abuse
  Treatment (CSAT) contract no. 270-2003-00006 .
  This presentation builds on work by several
  colleagues (Titus, Stevens, Hawke, Funk and
  others). The opinions are those of the author do
  not reflect official positions of the consortium
  or government . Available on line at
  www.chestnut.org/li/posters.

2
Goals

• Review the prevalence of victimization among
  adolescents presenting for substance abuse
  treatment
• Demonstrate the feasibility and desirability of
  measuring victimization early with standardized
  protocols.
• Examine the correlates of victimization
• Examine the implications of victimization for
  treatment placement and outcomes

3
Introduction

• Victimization (including physical, sexual, and
  emotional abuse) are the norm for adolescents
  presenting to substance abuse treatment.
• Yet staff often express concerns that they do not
  have the tools for screening that screening
  might disrupt rapport (leading to early drop out
  or mandated reporting) and that they lack the
  resources to do anything about victimization.
• This is at odds with expert recommendations
  (CSAT, 1993, 1999, 2000 Dennis Stevens, 2003)
  that have consistently encouraged early
  systematic screening and intervention among
  adolescents entering substance abuse treatment.

4
Prevalence Rates of Victimization

• It is estimated that 826,000 to 3,000,000 (3-12)
  adolescents (age 12 to 17) have been victimized
  (DHHS, 2001 Sedlack Broadhurst, 1996).
• Among adolescents presenting for substance abuse
  treatment, the rates ranged from 40 to 80 -
  varying by gender, timing, definition, and level
  of care (Dennis Stevens, 2003) .
• 39 of male 59 of females acknowledged a
  lifetime history of physical or sexual
  victimization when interviewed a few questions in
  DATOS-A a month after intake (Grella Joshi,
  2003).
• 48 of the males and 80 of the females
  acknowledged a lifetime history of physical,
  sexual, or emotional victimization when
  interviewed with the GAIN at intake (Titus,
  Dennis, White, Scott Funk, 2003).

5
Multiple Types of Victimization
Sexual Physical,
Sexual, Physical,
Emotional
Emotional, 16
16
none
None
Sexual
43
43
Sexual 6
6
Physical
Physical
Emotional
Emotional, 6
6
Physical Only
Emotional
Emotional
Physical Only
23
6
6
23
Source Titus et al, 2003
6
Traumagenic Factors
Source Titus et al, 2003
All significant
at plt.05
7
Victimization is the Norm in Tx
100
84
90
82
80
73
71
69
70
62
56
60
52
45
50
37
40
25
30
19
20
10
0
OP/IOP (n560)
LTR (n390)
STR (n594)
Lifetime History of Victimization
Acute Victimization
Past Year Victimization
Past 90 Day Victimization
Source Dennis, 2004
8
Victimization is Related to Severity
Source Titus, Dennis, et al., 2003
9
Victimization is also consistentlycorrelated with

• Higher rates of problem recognition, substance
  use dependence, co-occurring psychiatric
  problems, and negative peer or family influence
  (Grella Joshi, 2003).
• HIV risk behaviors, health problems, and mental
  problems (Stevens, Murphy, McKnight, 2003).
• Traumatic Stress associated with further risks
  for HIV risk behaviors and health problems
  (Stevens, Murphy, McKnight, 2003).

10
Victimization and Gender Interact with Substance
Use Outcomes
Male
Female
60
50
40
Days of 90
30
20
10
0
Pre-Treatment
Post-Discharge
Pre-Treatment
Post-Discharge
Low
Clinical
Acute
Source Titus, Dennis, et al., 2003
11
Victimization Also Interacts with Level of Care
Outpatient
Residential
40
35
30
25
Marijuana Use (Days of 90)
20
15
10
5
0
Intake
6 Months
Intake
6 Months
OP -Acute
OP - Low/Cl.
Resid-Acute
Resid - Low/Cl.
Source Funk, et al., 2003
12
5 Year follow-up after TC treatment (Hawke et al,
2003)

• 40 victimized at intake to 9 TC (n446)
• 52 reported additional victimization following
  separation from TC treatment.
• 58 engaged in serious violent behaviors (e.g.,
  beatings, threatening or using weapons against
  other people, or violent crimes such as assaults,
  rapes, murders) toward others in the five years
  following their separation from TC treatment.
• Prior and on-going victimization were the best
  predictors of future violence.

13
Concluding Comments

• Victimization can and should be comprehensively
  at intake and can be conceptualized as a
  dimensional continuum of severity
• Victimization is the norm among adolescents
  presenting for substance abuse treatment
• Higher levels of victimization are correlated
  with a wide range of health, mental health and
  HIV related problems
• Higher levels of victimization interact with
  treatment effectiveness
• Each of these areas varies by gender

14
Resources

• Copy of these slides and handouts
• http//www.chestnut.org/LI/Posters/
• Assessment Instruments
• GAIN at www.chestnut.org/li/gain
• CSAT TIP 3 at http//www.athealth.com/practitioner
  /ceduc/health_tip31k.html
• NIAAA Assessment Handbook,http//www.niaaa.nih.gov
  /publications/instable.htm
• Adolescent Treatment Manuals
• NCADI at www.health.org or www.chestnut.org/li/boo
  kstore
• CSAT CYT, ATM and other manuals at
  www.chestnut.org/li/apss/csat/protocols
• Adolescent Treatment Programs and Studies
• List of programs by state and summary of pre-2002
  studies at www.drugstrategies.com
• Cannabis Youth Treatment (CYT)
  www.chestnut.org/li/cyt
• Persistent Effects of Treatment Study of
  Adolescents (PETSA) www.samhsa.gov/centers/csat/
  csat.html (then select PETS from program
  resources)
• Adolescent Program Support Site (APSS)
  www.chestnut.org/li/apss
• Society for Adolescent Substance Abuse Treatment
  Effectiveness (SASATE)
• Website at www.chestnut.org/li/apss/sasate with
  bibliography
• E-mail Darren Fulmore ltdfulmore_at_mayatech.comgt to
  be added to list server
• Next conference is June 18, 2004, See website or
  E-mail Joan Unsicker ltjunsicker_at_chestnut.orggt for
  information about about meeting

15
References

• Dennis, M.L. (2004). Traumatic victimization
  among adolescents in substance abuse treatment
  Time to stop ignoring the elephant in our
  counseling rooms. Counselor, April, 36-40.
• Dennis, M. L., Titus, J. C., White, M., Unsicker,
  J., Hodgkins, D. (2003). Global Appraisal of
  Individual Needs (GAIN) Administration guide for
  the GAIN and related measures. (Version 5 ed.).
  Bloomington, IL Chestnut Health Systems. Retrieve
  from http//www.chestnut.org/li/gain
• Funk, R. R., McDermeit, M., Godley, S. H.,
  Adams, L. (2003). Maltreatment issues by level of
  adolescent substance abuse treatment The extent
  of the problem at intake and relationship to
  early outcomes. Journal of Child Maltreatment, 8,
  36-45.
• Dennis, M. L., Stevens, S. J., (Eds.). (2003).
  Maltreatment issues and outcomes of adolescents
  enrolled in substance abuse treatment special
  issue. Journal of Child Maltreatment, 8(1) 3-6.
  See http//www.sagepub.com/journalIssue.aspx?pid
  15jiid6072
• Dennis, M. L., Titus, J. C., White, M., Hodgkins,
  D., Unsicker, J. (2003). Global Appraisal of
  Individual Needs (GAIN) Trainers Training
  Manual and Resources. Bloomington, IL Chestnut
  Health Systems. Retrieved from
  http//www.chestnut.org/li/gain
• Funk, R., McDermeit, M., Godley, S. H., Adams,
  L. (2003). Maltreatment issues by level of
  adolescent substance abuse treatment The extent
  of the problem at intake and relationship to
  early outcomes. Journal of Child Maltreatment,
  8(1) 36-45.
• Grella, C. E., Joshi, V. (2003). Treatment
  processes and outcomes among adolescents with a
  history of abuse who are in drug treatment.
  Journal of Child Maltreatment, 8(1) 7-18.
• Hawke, J. M., Jainchill, N., De Leon, G.
  (2003). Post-treatment victimization violence
  among high risk adolescents following residential
  drug treatment. Journal of Child Maltreatment,
  8(1) 58-71.
• Stevens, S. J., Murphy, B. S., McKnight, K.
  (2003). Traumatic stress and gender differences
  in relationship to substance use, mental health,
  physical health, and HIV risk behavior in a
  sample of adolescents enrolled in drug treatment.
  Journal of Child Maltreatment, 8(1) 46-57.
• Titus, J.C., Dennis, M.L., White, W.L., Scott,
  C.K., Funk, R.R. (2003). Gender Differences in
  Victimization Severity and Outcomes Among
  Adolescents Treated for Substance Abuse. Journal
  of Child Maltreatment, 8(1), 19-35.
• U.S. Department of Health and Human Services.
  (2001). Child Maltreatment 1999. Washington, DC
  U.S. Government Printing Office.

16
Contact Information

• Michael L. Dennis, Ph.D., Senior Research
  Psychologist
• Lighthouse Institute, Chestnut Health Systems
• 720 West Chestnut, Bloomington, IL 61701
• Phone [phone], Fax [phone]
• E-Mail Mdennis_at_Chestnut.Org