University of Miami Center for Treatment Research on Adolescent Drug Abuse Detention to Community Projects Scientific Team Howard Liddle Gayle Dakof Cindy Rowe Craig Henderson Paul Greenbaum Wei Wang Paul Roman Linda Alberga Rocio Ungaro Community Partners FL Dept of Justice Probation FL Dept of Juv Justice Detention FL Judiciary Miami Public Defender Miami SAO Operation PAR UM Adolescent & Families Clinic UM Adolescent Medicine Clinic

Detention to Community Implementation (DTC-I) Implementing & Sustaining a Family-Based Substance Abuse & Delinquency Treatment and HIV Prevention Intervention for Young Offenders. Center for Treatment Research on Adolescent Drug Abuse University of Miami Miller School of Medicine H. Liddle, G. Dakof, L. Alberga, C.Rowe, C. Henderson

Multidimensional Family Therapy Detention to Community Program (MDFT-DTC): A Cross-System & Family-Based Substance Abuse, Delinquency Treatment and HIV Prevention Intervention for Juvenile Offenders Lead Center - Florida Research Center at the University of Miami; Miller School of Medicine - H. Liddle, C. Rowe, G. Dakof, L. Alberga, C. Henderson, P. Greenbaum, R. DiClemente, & K. McCollister Collaborating Center - NDRI Midwest - N. Jainchill, R. Dembo, S. Farkas, and R. Ungaro NIDA – Redonna Chandler, Bennett Fletcher, and Akiva Liberman CJ-DATS is funded by NIDA in collaboration with: SAMHSA, CDC, NIAAA, and BJA

Why MDFT-DTC? Substance abuse & mental health disorders & high STD & HIV risk among youthful offenders Juvenile Justice is where substance abuse and other problems come to the attention of treatment system Little coordination or integration of services between JJ and provider systems

Hypothesized that this bridge would enhance: MDFT-DTC: A Bridge Between Juvenile Justice and Substance Abuse Treatment Hypothesized that this bridge would enhance: Youth and family participation in substance abuse treatment & HIV/STD prevention services Youth outcomes (substance use, delinquency, re-arrest, HIV risk, school problems, mental health symptoms/co-morbidity, family problems)

MDFT-DTC: A Bridge Between Juvenile Justice and Substance Abuse Treatment MDFT-DTC was developed to address lack of coordination and integration between Juvenile Justice and Substance Abuse Treatment Provider Systems In MDFT-DTC, Substance Abuse Treatment & HIV Prevention begins in the short-term detention facility, pre-adjudication, and continues on an outpatient basis with the same therapist once the youth is released. Multidimensional Family Therapy is a family based treatment that specializes in adolescent drug abuse and delinquency. It is a treatment system, which means that it has been developed and tested in various forms or versions. This study is one of seven controlled trails of the MDFT system. As examples: We have tested the approach in juvenile drug court, with young adolescents in an early intervention study, in a prevention study with non clinically referred kids, in an intensive version where we compared an intensive version of MDFT as an alternative to residential treatment. MDFT has been compared to active treatments, including manualized individual CBT, CBT group counseling, and multifamily groups. NIDA’s support, first through the Treatment Research Branch, began in 1985. This support continued in the Behavioral Therapies Development initiative, and continues to the present day in the Services Research Branch, as our work expands to include implementation and dissemination of the approach across diverse settings. In the DTC intervention - therapists meets with the teen while in detention, they meet with the parents in the home, and when possible, with the parent and teen together in detention. We also reach out to the jpo and other juvenile justice professionals, working closely with them first to understand the nature of the changes and potential consequences of the youth’s offense. The objective of the first phase is information gathering, building working relationships, facilitating motivation to participate in treatment. The treatment includes a drugs focus, a family focus, a focus on jj and getting out from under the legal situation, it focuses on the teen’s day to day life including involvement with drug using and antisocial peers, and school connection and performance. In the second stage, which may last up to 4 months of weekly or more than once a week meetings in the clinic or in the home, there are individual sessions with the parent, teen, family sessions, and sessions with those who have current influence in the teen’s life – jj professionals and school personnel.

Youth Screened on Substance Abuse & Placement Risk Study Design Youth Screened on Substance Abuse & Placement Risk T1-Baseline Assessment & Randomization MDFT-DTC 76 43 Miami 33 Pinellas ESAU 78 42 Miami 36 Pinellas N = 154 (Miami = 85) (Pinellas = 69) MDFT-DTC MDFT engagement and preparation for release CDC HIV Prevention Intervention ESAU Usual Detention Services CDC HIV Prevention Intervention In-Detention PHASE 1: MDFT-DTC Outpatient MDFT Family Adolescent Parent Extrafamilal (Court, JPO, School) Social Systems MDFT Family Based HIV Prevention ESAU Community Treatment Services as Usual Twice weekly substance abuse counseling groups Individual sessions as needed HIV Prevention as usual Incorporated into groups Let’s walk through the study design. The sample consisted of 154 youths across two study sites - in Pinellas County and Miami-Dade Counties, Florida. Participants were assigned at random to one of two intervention conditions – the family based treatment and an enhanced services as usual condition. Both interventions had two stages, and participants began both interventions, by design, while they were in juvenile detention. During the In Detention phase, ESAU youths participated in the usual detention services as well as a CDC standard HIV Prevention Intervention. During the In Detention phase, MDFT youths participated in the same CDC HIV Prevention Intervention, and also received MDFT engagement and motivation interventions in the detention center. The MDFT youths parents and families were also involved at this point - sessions were held at the home, and sometimes in the detention center itself. During the Post-Detention phase, ESAU teens received the services detention youth participate in post release – weekly substance abuse counseling groups, and HIV prevention intervention offered in a group format at local youth focused agencies who treat juvenile justice involved drug using teens. During the Post-Detention phase, MDFT teens participated in a new version of outpatient MDFT. This included individual sessions with the parent and teen, family therapy sessions, and a multi-family group intervention to focus on reducing the high risk sexual behaviors of the youths. Measures were administered at baseline - the youth was in detention - and then again at 3 months, 6 months, and 9 months post intake. We will be following up the youth at longer follow points as well, at 18 and 24 months post intake. Post-Detention PHASE 2: T6 24 mo. T2 3 mo. T3 6 mo. T4 9 mo. T5 18 mo.

Engagement and Retention Outcomes Percentage of Clients Retained for 3 Months of Treatment Engagement & Retention Rates in Context Kazdin et al (1997) adolescent therapy studies: 40-60% drop out rate DATOS-A 3 mo. retention 27% (Grella et al 2001) CSAT data base (Dennis, 2008) All levels of care 3 mo. retention 25% IOP 3 mo. retention 36% OP 3 mo. retention 35% MDFT-DTC 3 mo. retention 91% Previous studies - MDFT retention MDFT IOP 3 mo. retention 95% MDFT IOP 6 mo. retention 88% MDFT OP 4 mo. retention 96% First lets look at retention outcomes. Engagement and retention are important since we all can agree that enrollment and retention in substance abuse treatment, especially for adolescents, is not something we can take for granted. It is a necessary first step. The data here show that 91% of youth randomized to MDFT were enrolled and remained in treatment for at least 90 days, in comparison to only a 13% 90 day retention rate for youth randomized to ESAU. Obviously, this is a huge and meaningful difference. On the right side of this slide I included some retention data for relevant studies and you can see that the 91% for MDFT is high in comparison to these studies and that the 13% for ESAU is arguably a bit lower than the 27% in DATOS and the 25% in the more recent analysis of the CSAT database. There are a couple points I want to make about this. I think the 13% in this study compared to the 25% in CSAT for example, reflects the innovative, system influencing nature of the DTC - Detention to Community Program. Youth in this program were not ordered to drug abuse treatment by the juvenile justice system, instead they were screened for substance use and then offered treatment. This is because in the DTC we contact the youth before their disposition and before a judicial outcome. This is in distinction to a probation situation where treatment participation might be part of the probation order.   Also, it should be recognized that the comparison condition is ESAU and one of the key enhancements was follow up phone calls to youth and family to encourage participation in the first few therapy sessions, and reduction of potential barriers to treatment such as transportation. So, even with those supports, only 13% received 90 days of treatment. So clearly, MDFT is very effective in retaining post detention youth in substance abuse treatment; even juvenile justice involved youth who are not ordered to treatment.   *** ***p<.001 MDFT ESAU MDFT-DTC (91%) & ESAU (13%) comparative engagement and retention rates

Drug Use & Delinquency:9 Months Drug use decreased more in MDFT than ESAU in Pinellas (d=.75) but not in Miami (d=.14) Self-reported delinquency decreased more in MDFT than ESAU in Pinellas (d =.63) and Miami (d = .69) Days detained fewer for MDFT than ESAU in Pinellas (d = 2.79) but not in Miami (d = .28) Now lets consider drug use and delinquency. We used the Timeline Follow Back method to collect days used drugs over a 90 day period, and total delinquency from the national youth survey to capture delinquency. Once again, we see promising results for MDFT in comparison to the control condition with youth in MDFT reporting a greater decrease in drug use, and delinquency.

HIV Risk & Mental Health Symptoms: 9 Months HIV Risk (unprotected sex acts) decreased more among MDFT youth than ESAU youth across both sites (d = 2.18). Internalizing symptoms decreased more among MDFT youth than ESAU youth Miami (d = 1.17), but not in Pinellas (d = .03) Finally, we look at sexual risk.   MDFT youth report more open conversations with their sexual partners about HIV and STD risk, a greater increase in protected sexual action, less overall risk for STDs, and greater decrease in STD incidence as measured by biologically analyses urine samples. And the effects for each of these variables, are in the moderate to large range. So obviously this is very promising. And let me show you a graph to highlight some of these results.

Summary of Treatment Outcomes Overall, MDFT more effective than ESAU The effects were often stronger in Pinellas than in Miami Results point to a pattern of MDFT being more effective with more seriously impaired youth Now lets consider drug use and delinquency. We used the Timeline Follow Back method to collect days used drugs over a 90 day period, and total delinquency from the national youth survey to capture delinquency. Once again, we see promising results for MDFT in comparison to the control condition with youth in MDFT reporting a greater decrease in drug use, and delinquency.

Possible Explanation of Site Effects Youth in Pinellas more severe than youth in Miami (substance use, jj record, mental health) Among MDFT youth, greater JPO and therapist collaboration in Pinellas in comparison to Miami at release from detention (d = 1.90) and a discharge from outpatient treatment (d = 2.83). Across both sites, greater collaboration during outpatient treatment was related to greater decrease in drug use (d = .23) Now lets consider drug use and delinquency. We used the Timeline Follow Back method to collect days used drugs over a 90 day period, and total delinquency from the national youth survey to capture delinquency. Once again, we see promising results for MDFT in comparison to the control condition with youth in MDFT reporting a greater decrease in drug use, and delinquency.

Implementation Limitations of Original DTC Once the study ended, so did the MDFT-DTC intervention. Sustaining the program was not an aim of the study. Both the successes and failures led to the development of the current project: MDFT-DTC-I (Implementation) Multidimensional Family Therapy is a family based treatment that specializes in adolescent drug abuse and delinquency. It is a treatment system, which means that it has been developed and tested in various forms or versions. This study is one of seven controlled trails of the MDFT system. As examples: We have tested the approach in juvenile drug court, with young adolescents in an early intervention study, in a prevention study with non clinically referred kids, in an intensive version where we compared an intensive version of MDFT as an alternative to residential treatment. MDFT has been compared to active treatments, including manualized individual CBT, CBT group counseling, and multifamily groups. NIDA’s support, first through the Treatment Research Branch, began in 1985. This support continued in the Behavioral Therapies Development initiative, and continues to the present day in the Services Research Branch, as our work expands to include implementation and dissemination of the approach across diverse settings. In the DTC intervention - therapists meets with the teen while in detention, they meet with the parents in the home, and when possible, with the parent and teen together in detention. We also reach out to the jpo and other juvenile justice professionals, working closely with them first to understand the nature of the changes and potential consequences of the youth’s offense. The objective of the first phase is information gathering, building working relationships, facilitating motivation to participate in treatment. The treatment includes a drugs focus, a family focus, a focus on jj and getting out from under the legal situation, it focuses on the teen’s day to day life including involvement with drug using and antisocial peers, and school connection and performance. In the second stage, which may last up to 4 months of weekly or more than once a week meetings in the clinic or in the home, there are individual sessions with the parent, teen, family sessions, and sessions with those who have current influence in the teen’s life – jj professionals and school personnel.

Overarching goal of MDFT-DTC-I Implement and sustain MDFT-DTC outside of our home turf of Florida and in systems that are not asking for this type of innovation As an implementation and not treatment study, we are focusing on system change and client outcome. Adherence to the MDFT-DTC will be obtained.

How will we attempt to achieve these goals? By using community organization and family systems principles and methods to motivate local stakeholders to champion cross-system change. System change coming from inside the systems, in contrast to the original study where the change (innovative, evidence-based program) came from outside the system (University of Miami).

Phase I We interviewed and administered questionnaires to stakeholders involved in the Florida study (judges, therapists, probation officers, detention superintendents, detention staff, attorneys) in order to obtain their views about the MDFT-DTC, its successes and strengths as well as weaknesses and failures.

Phase I: Initial Lessons learned from Miami & Pinellas Counties Keep stakeholders informed regularly and through a variety of methods Address sustainability from the start Accept that in the beginning, you are going to be the motivator and organizer Work in a sustained way to shift responsibility for change from the researcher to the stakeholder champions The process should be collaborative Don’t underestimate the importance of personal relationships in achieving your objectives. Develop trusting relationships with stakeholder champions and others involved in the process of change. Be patient: System change takes time. Setbacks and failure are the stepping stones to success

Phase II: Implementing MDFT-DTC in Connecticut Study Design Youth Outcomes of Interest: length of time in detention, length of time in substance abuse treatment, type of treatment received, STD/HIV prevention intervention received, hours of STD/HIV intervention, judicial outcome of charge(s) that led to target detainment, re-arrests. Baseline Phase: n=100 youth (what happens to them now) Implementation Phase: n=40 youth referred by JJ staff to the MDFT-DTC program System Outcomes: Qualitative analysis of implementation process; administrator and staff attitudes and view of implementation process and the MDFT DTC program

Phase II: Implementing MDFT-DTC in Connecticut: Progress to Date All key stakeholders on board and ready to implement the MDFT-DTC program: Dept of Children and Families, Juvenile Justice, Judiciary, Dept of Corrections, Wardens/Superintendents, Substance Abuse Treatment Providers, Public Defenders Office Procedures for how to integrate the MDFT – DTC into the correctional facility have been developed Protocols and procedures to train staff from both systems have been developed Funds to pay for the treatment have been obtained Study design has been finalized Waiting for IRB approval from DCF

Phase II: Implementing MDFT-DTC in Connecticut: Method Began by reaching out to one stakeholder with whom we had worked previously. Snowball effect: Soon had a group of 3 champions. The initial workgroup: 3 from the State; and 2 from UM This group has a shared mission (values) and a high level of collaboration This group, together and individually, has pitched the idea, got permissions, and persuaded other key stakeholders to join our effort (Public Defenders Office, Juvenile Justice, Detention Superintendents/Wardens, Department of Corrections, Treatment Providers)

Phase II: Implementing MDFT-DTC in Connecticut: Keys to our success (so far) MDFT implemented successfully in the substance abuse treatment provider system providing a foundation to build upon. The MDFT-DTC fills a need: Providing more high quality substance abuse treatment & STD/HIV prevention services to youthful offenders. Extremely careful to not be too over-bearing or too high and mighty as some University folks tend to be. Tremendous effort in being collaborative, to learn from the stakeholders, to listen carefully, to show respect, to be responsive to their needs and ideas. Developed and maintained personal relationships with the stakeholders: taking care to nurture those relationships by being trustworthy and honest; dependable; self-effacing; friendly and nice.

Phase II: What is next? Obtain DCF IRB approval of the study protocol (May 2010) Finalize data collection procedures, training detention staff, piloting the procedures Collect baseline data Train MDFT therapists in the MDFT- DTC protocol Implement modifications to detention center procedures, train staff. Begin implementation phase: Identify eligible youth, consent to study, contact MDFT provider to begin treatment while youth is still in detention, therapist continues MDFT upon release, collect data

Ultimate goal of the MDFT-DTC-I in Connecticut: Hoped for outcomes The cross-system MDFT DTC is fully implemented: Youth and families get high quality services Youth who received MDFT DTC, in comparison, to baseline youth have shorter stays in detention, receive more substance abuse treatment and STD/HIV prevention services, and are less likely to be re-arrested. Administrators, clinicians, and other staff in both systems are satisfied with the program The core champion group grows in membership, and are enthusiastic about the program MDFT-DTC becomes a standard part of care for youthful offenders in the State of Connecticut (sustainability)