Adolescence and Substance Use by Rick Sampson, American Institutes for Research (03-15-07) An Overview

Adolescence and Substance Use How does substance use impact adolescents? What is the scope of the issue? Challenges to responding effectively Yielding results: promising practices

Adolescence and Substance Use How does substance use impact adolescents? Societal messages Family involvement Experimentation/use/abuse/ dependence The promise of recovery

Adolescence and Substance Use Societal Messages Beyond perception of risk to perception of self Better living through chemistry The double bind

Adolescence and Substance Use Family Involvement Parental use/abuse Sibling use/abuse Losing the childhood you never had

Adolescence and Substance Use Experimentation/Use/Abuse/ Dependence Developmental denial Motivational focus Who am I?

Adolescence and Substance Use The Promise of Recovery Going away so we can go home

Adolescence and Substance Use What is the Scope of the Issue? 1.5 m (6.1% youth aged 12 to 17) needed alcohol treatment in the past year and only about 111,000 youth (7.2% of those needing alcohol treatment) received specialty treatment for alcohol in the past year. 1.4 m youth (5.4%) needed illicit drug use treatment in the past year and only about 124,000 (9.1% of those needing illicit drug treatment) received specialty treatment for an illicit drug. Youth aged 12 to 17 who were in need of substance use treatment in the past year and did not receive treatment were not likely to perceive a need for substance use treatment.

Adolescence and Substance Use What is the Scope of the Issue?

Adolescent AOD Dependence/Abuse Dependence/ Abuse up 27% from 7.0% in 1995 to 8.9% in 2003 Prevalence 6.0 to 8.4% 8.5 to 9.0% 9.1 to 9.9% 10.0 to 14.6% U.S.Avg.=8.9% Approximately 8.9% of the adolescents (age 12 to 17) in the U.S. meet past year criteria for abuse or dependence. As shown here, the rates vary by more than two fold by state. From 1995 to 2003, the rate of Dependence or Abuse has risen 27% (from 7.0% to 8.9%). Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf ) and Kilpatrick et al, 2000.

Adolescence and Substance Use Challenges to Responding Effectively Retention and engagement Family involvement Availability Cost

Unmet Treatment Need Adolescent (% of AOD Dependence/Abuse without any private/public treatment) 9 in 10 Untreated Prevalence 82.4 to 90.1% 90.2 to 92.3% 92.4 to 94.2% 94.3 to 98.0% U.S.Avg.=92.2% Of the adolescents with abuse or dependence, 92.2% have not received any kind of treatment in the past year. The rate of adolescents with unmet treatment need ranged from 82 to 98% by state. Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf )

Adolescence and Substance Use Yielding results: promising practices Data Review Review of two promising practices

CSAT is helping the field move towards evidence-based practice (EBP) by: 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

CSAT Adolescent Treatment (AT) Outcome Data Set Recruitment: 1998-2006 (updated annually) Sample: The 2006 CSAT adolescent treatment data set included data with 1 to 4 follow-ups on 12,690 adolescents from 96 local evaluations Levels of Care: Early Intervention, Outpatient, Intensive Outpatient, Short, Moderate & Long term Residential, Corrections Based and Post Residential Outpatient Continuing Care Instrument: Global Appraisal of Individual Needs (GAIN) (see www.chestnut.org/li/gain) Follow-up: Over 80% follow-up 3, 6, 9 & 12 months post intake Funding: CSAT contract 270-2003-00006 and 72 individual grants To help move the field towards evidenced based practice, CSAT has worked with its adolescent treatment grantees to combine the data into one larger outcome data set . By the end of 2005, data from 9,275 adolescents from 72 local evaluations had been pooled. The combined data set represents all of the major levels of care, and includes multiple efforts to replicate evidenced based practice in real programs. All of the sites used a standardized biopsychosocial called the GAIN. The data set here is limited to those individuals for whom follow-up was planned and whose site with one or more follow-up interviews on 80% or more of the clients.

CSAT Adolescent Treatment Program Grantees Using the GAIN (1997-2007) NH WA VT MT ME ND MN OR MA WI MI ID NY SD WY RI NE IA PA CT OH NJ NV CA UT IL IN CO WV DE KS VA MO KY MD TN NC OK Grant AZ NM SC AAFT AR ART GA MS AL ATM CYT TX LA Drug Court AK Drug Court 2 Earmark EAT FL RCF HI SCY TCE YORP SAC SAC expected

Current CSAT AT Outcome Data Set by Grant Program DC: Drug Court (2005-2009; 524 from 6 grants) CYT: Cannabis Youth Treatment (1997-2001; 600 from 4 grants) YORP: Young Offender Re-entry Project (2004-2008; 524 from 14 grants) ATM: Adolescent Treatment Model (1998-2002; 1,429 from 10 grants) SCY: Strengthening Communities-Youth (2002-2007; 2,292 from 11 grants) EAT: Effective Adolescent Treatment (2003-2007; 5,255 from 27 grants) The Cannabis Youth Treatment study is the oldest program in the data set and the source of the MET/CBT5 intervention being replicated in the more recent and largest program called Effective Adolescent Treatment. In the Strengthening Communities for Youth (SCY), Adolescent Residential Treatment (ART) and Young Offender Re-Entry Program (YORP), several grantees are also replicating NIH developed interventions. In the Adolescent Treatment Model (ATM) program grantees manualized several existing programs to make replication more efficient and reliable. This represents a relatively unparalleled sharing of what had previously be proprietary information. TCE: Other Targeted Capacity Expansion (2002-2009; 523 from 8 grant) ART: Adolescent Residential Treatment (2003-2006; 1,899 from 16 grants) Source: CSAT 2006 AT Outcome Data Set (n=12,601)

Demographics Source: CSAT 2006 AT Outcome Data Set (n=12,601) Consistent with the U.S. public treatment system, the sample is predominately male and white, but the sample size is large enough now that we have a 1000 or more in each of the subgroups show here, as well as 300 or more in subgroups like Asians, Mexicans, Employed, 12 to 14 year olds, and 18 to 20 year olds. Note – average age is 15.6 Source: CSAT 2006 AT Outcome Data Set (n=12,601)

Co-Occurring Psychiatric Problems Co-occurring psychiatric problems are the norm among adolescents presenting for substance abuse treatment. The most common are externalizing conditions like conduct disorder and ADHD. There are also significant rates of depression, trauma and anxiety disorders. The lower half of this panel shows that a wide range of other key psychiatric issues are also present including any victimization, high severity victimization (i.e., that occurred multiple times, multiple people, someone they trusted, involved sexual penetration or near death, that people did not believe when they sought help), running away, homicidal or suicidal thoughts, and self multilation. Source: CSAT 2006 AT Outcome Data Set (n=12,601)

Treatment Outcomes by Level of Care: Recovery* If we define recovery more as no past month use, abuse or dependence symptoms while living in the community (vs. a controlled environment like residential treatment or incarceration), about a third of the adolescents get better after treatment and the effects are largely sustained at the group level. However each month some relapse and some go into early remission. The best results come from further continuing care – where half to two thirds are in recovery. Hence the increasing focus of CSAT’s Adolescent Treatment program on continuing 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 AT Outcome Data Set (n=12,601)

Regular Outpatient vs. Evidenced-Based Practices from CYT: Percent in Recovery* If we look at the percent in recovery, the CYT interventions actually did better than regular outpatient in terms of achieving and sustaining their outcomes. Again, the EAT replications where not only able to replicate these advantage – they did better in part because they had better rates of continuing care than CYT. * 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 2007 AT Outcome Data Set (n=8,902 adolescents in outpatient)

Adolescence and Substance Use Yielding results: promising practices Seven Challenges Integrated Co-occurring Treatment (ICT)