1. Crime, Violence, and Managing Client and Public Safety Michael L. Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL Presentation at NEW DIRECTIONS TO HEALTHIER COMMUNITIES & METH SUMMIT, September 28-30, 2005, Savannah Marriott Riverfront, Savannah, GA. Sponsored by the Georgia Council on Substance Abuse and the Georgia Department of Juvenile Justice, Office of Behavioral Health Services. 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 CYT and AMT grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888). The meta analysis of juvenile offender intervention data was adapted from an earlier presentation by Mark Lipsey with his permission. 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: (309) 827-6026, fax: (309) 829-4661, e-Mail: junsicker@Chestnut.Org

2. To summarize the need for measuring substance use, crime and violence and its correlates To examine the utility of the GAINs Substance Problem for assessing the risk of relapse and recidivism To summarize the results of meta analyses of effective programs for juvenile offenders by Lipsey and colleagues Goals of this Presentation

3. Adolescent Present with a Broad Range of Past Year Illegal Activity and Violence Source: Adolescent Treatment Model (ATM) data 74 78 82 69 71 68 86 65 85 80 81 93 95 0 10 20 30 40 50 60 70 80 90 100 OP/IOP (n=560)LTR (n=390)STR (n=594) Any illegal activityProperty crimesInterpersonal crimes Drug related crimesActs of physical violence

4. Substance Abuse Treatment (particularly residential) Reduces Illegal Activity 40 50 60 Intake 3 6 9 12 Months from Intake STR\t,s,ts LTR\t,ts OP\s \a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

5. Background Substance use and crime are inter-related. Self-report method is valid and useful for predicting treatment placement, relapse and recidivism. Typically, substance use measures have been used to predict placement and relapse, while criminological measures have been used to predict recidivism. This is one of the first adolescent studies to look at the ability of substance use and criminological measures combined to predict placement, relapse, and recidivism in the same population or study.

6. 1 2 3 4 56 7 8 9 10 a b c d Location of CYT/ATM Treatment Sites Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services Adolescent Treatment Model (ATM) Sites: 1.Chestnut Health Systems, Bloomington, IL 2.Dynamite Youth, New York, NY 3.Four Corners Regional Adolescent Center/ University of Oklahoma Shiprock, NM 4.Friends Institute/Epoch Counseling, Catonsville, MD 5.Mountain Manor, Baltimore, MD 6.Public Health Institute/Thunder Road, Oakland, CA 7.Rand Corp./Phoenix Academy/Group Homes, Santa Monica, CA 8.University. of Arizona/IMPACT, Phoenix, AZ 9.University of Arizona/La Cañada/7-Challenges/Drug Court, Tucson, Az 10.University of Miami/MDFT/The Village, Miami, FL Cannabis Youth Treatment (CYT) Sites: a.Chestnut Health Systems, Madison County, IL b.Childrens Hospital of Phil., Philadelphia, PA c.Operation PAR, St. Petersburg, FL d.Univ. of Conn. Health Center, Farmington, CT

7. Evaluation Target Population: Adolescents entering substance abuse treatment. Inclusion Criteria: 12 to 22 year old adolescents who present for substance abuse treatment and received at least 2 outpatient sessions or 1 week of residential treatment. Data Sources: Self-report measures of diagnosis and outcome collected with the Global Appraisal of Individual Needs (GAIN). Participants: 2007 adolescents recruited from 14 sites around the U.S. and interviewed at 3, 6, 9 and 12 months later (98% completed 1 plus interview; 92% completed 12 month interview).

8. Intensity of Juvenile Justice System Involvement 0%10%20%30%40%50%60%70%80%90% 100% Severity Detention 14+ days (n=433) Probation/parole and urine monitoring 14+ days (n=472) Other current arrest or JJ status (n=303) Other detention, parole, or probation (n=374) Past arrest or JJ status (n=170) Past year illegal activity (n=298) Source: CYT & ATM Data Low Hi Row %

9. Intensity by Level of Care 0%10%20%30%40%50%60%70%80%90%100% Short Term Residential Long Term Residential Outpatient/IOP Step Down OP Total Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data Row %

10. Demographic Characteristics Source: CYT & ATM Data Row %

11. Demographics by Intensity Detention 14+ days (n=433)Probation/parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Female Caucasian African American Hispanic Native American Other Females and Caucasians more likely in lower intensity Minorities More Likely to be in higher intensity Col %

12. Demographics by Intensity (continued) Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data High Severity More likely to be 15-17 years olds and from Single Parent Families Youngest least likely to be in the system Col %

13. Substance Use Characteristics Source: CYT & ATM Data Row %

14. Substance Use Disorder Diagnosis by Intensity Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data; a\ Self report for past year Current Intensity Inversely related to Substance Use Severity Past Involvement a Mix of Severity Col %

15. External Diagnoses by Intensity Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data Col % Multiple Co-Occurring Disorders are Common in all levels of JJ involvement

16. Internal Diagnoses/Problems by Intensity Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data \b n=1838 because some sites did not ask trauma questions Curvilinear Relationship between Intensity and Internal Distress Col %

17. Pattern of Co-occurring Disorders by Intensity Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data Most Internal Distress is Multi- morbid with External (and Substance Use) Disorders Col %

18. Legal Characteristics Source: CYT & ATM Data Row %

19. Crime/Other Problems by Intensity Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any Victimization High levels of Victimization Any crime High Crime/ Violence Homeless or Runaway High Health Problems Focus of JJ Detention Often Both Perpetrator and Victim Stress Can lead to higher rates of health problems Also higher incidents of Running away Col %

20. Substance Problem Scale (SPS) The SPS (alpha=.88) is a count of 16 past year symptoms based on three common screening questions (S9c-e), two questions related to substance induced psychological or health disorders (S9f-g), lay versions of the DSM-IV/ICD-9 criteria for substance abuse (S9h-m), Lay versions of the DSM-IV/ICD-9 criteria for substance dependence (S9n-u). The latter also forms the Substance Dependence Subscale (SDS; alpha=.82). The SPS symptom count severity is triaged as Low (0 past year symptoms), Moderate (1 to 9 symptoms) or High (10 to 16 symptoms) severity.

21. S9.When was the last time that... (code 1 if past year, 0 if before or never) … c. you tried to hide that you were using alcohol or drugs? d. your parents, family, partner, co-workers, classmates or friends complained about your alcohol or drug use? e. you used alcohol or drugs weekly? f. your alcohol or drug use caused you to feel depressed, nervous, suspicious, uninterested in things, reduced your sexual desire or caused other psychological problems? g. your alcohol or drug use caused you to have numbness, tingling, shakes, blackouts, hepatitis, TB, sexually transmitted disease or any other health problems? h. you kept using alcohol or drugs even though you knew it was keeping you from meeting your responsibilities at work, school, or home? j. you used alcohol or drugs where it made the situation unsafe or dangerous for you, such as when you were driving a car, using a machine, or where you might have been forced into sex or hurt? k.your alcohol or drug use caused you to have repeated problems with the law? m. you kept using alcohol or drugs even after you knew it could get you into fights or other kinds of legal trouble?

22. Substance Dependence Scale (SDS; alpha=82) based on DSM-IV/ICD-9 S9.When was the last time that (code 1 if past year, 0 if prior to past year or never) n. you needed more alcohol or drugs to get the same high or found that the same amount did not get you as high as it used to? p. you had withdrawal problems from alcohol or drugs like shaking hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or drugs to stop being sick or avoid withdrawal problems? q. you used alcohol or drugs in larger amounts, more often or for a longer time than you meant to? r. you were unable to cut down or stop using alcohol or drugs? s. you spent a lot of time either getting alcohol or drugs, using alcohol or drugs, or feeling the effects of alcohol or drugs (high, sick)? t. your use of alcohol or drugs caused you to give up, reduce or have problems at important activities at work, school, home or social events? u. you kept using alcohol or drugs even after you knew it was causing or adding to medical, psychological or emotional problems you were having?

23. Crime and Violence Scale (CVS) The CVS (alpha=.90) is a count of 29 past year symptoms from two subscales: – The General Conflict Tactic Subscale (GCTS; alpha =.88) - based on the National Family Violence Survey and work by Murray Strauss. –The General Crime Subscale (GCS; alpha =.86) - based on the National Household Survey on Drug Abuse lay terms for the Uniform Crime Report categories. CVS symptom count severity is triaged as: –Low (0 to 2 past year symptoms), –Moderate (3 to 6 symptoms), or –High (7 to 29 symptoms) severity.

24. The General Conflict Tactic Subscale (GCTS; alpha=.88) based on the National Family Violence Survey and work by Murray Strauss. E8.During the past 12 months, have you had a disagreement in which you did the following things? a. Discussed it calmly and settled the disagreement? b. Left the room or area rather than argue? c. Insulted, swore or cursed at someone? d. Threatened to hit or throw something at another person e. Actually threw something at someone? g. Slapped another person? h. Kicked, bit, or hit someone? j. Hit or tried to hit anyone with something (an object)? k. Beat up someone? m.Threatened anyone with a knife or gun? n. Actually used a knife or gun on another person?

25. General Crime Subscale (GCS; alpha=.86) based on the National Household Survey on Drug Abuse lay terms for the Uniform Crime Report categories. L3. During the past 12 months have you.. a. purposely damaged or destroyed property that did not belong to you? b. passed bad checks, forged (or altered) a prescription or took money from an employer? c. taken something from a store without paying for it? d. other than from a store, taken money or property that didnt belong to you? e. broken into a house or building to steal something or just to look around? f. taken a car that didnt belong to you? g. used a weapon, force, or strong-arm methods to get money or things from a person? h. hit someone or got into a physical fight? j. hurt someone badly enough they needed bandages or a doctor? k. used a knife or gun or some other thing (like a club) to get something from a person? m.made someone have sex with you by force when they did not want to have sex? n.been involved in the death or murder of another person (including accidents)? p. intentionally set a building, car or other property on fire? q.driven a vehicle while under the influence of alcohol or illegal drugs? r. sold, distributed or helped to make illegal drugs? s. traded sex for food, drugs, or money? t. been a member of a gang? u. gambled illegally?

26. Distribution of SPS by CVS Risk Groups Low Mod. High Low Mod. High 0% 20% 40% Percent of Total (n=2007) Substance Problem Scale Crime and Violence Scale Source: CYT & ATM Data Moderate to high severity substance use and crime/ violence problems are common

27. Validation of the SPS and CVS subgroups Endorsement of each items and subscales increased with the shift from low to moderate to high. For the Substance Problem Scale (SPS) severity subgroups: –Shifting from low to moderate was associated with sharp increases in the screener questions (c-e), continued use in spite of getting into fights or legal problems (m), and time spent on getting/using/recovering from substance use (s). –Shifting from moderate to high was associated with more of the above and greater increases in the substance dependence and substance induced disorder symptoms. For Crime/Violence Scale (CVS) severity subgroups: –Shifting from low to moderate was associated with increased oral violence, property crime, and drug related crime. –Shifting from moderate to high was associated with even more of these things, as well as more physical violence and interpersonal (aka violent) crimes. Next we looked at their predictive validity separately and together

28. Probability of Being Placed in Residential Treatment at Intake Low Mod. High Low Mod. High 0% 20% 40% 60% 80% 100% Source: CYT & ATM Data Substance Problem Scale Crime and Violence Scale Probability of Residential Placement Substance Problem Severity predicted residential placement Crime/ Violence did not predict residential placement

29. Probability of Using at Month 12 Low Mod. High Low Mod. High 0% 20% 40% 60% 80% 100% Probability of Using at Month 12 Source: CYT & ATM Data Substance Problem Scale Crime and Violence Scale Substance Problem Severity predicted Relapse However knowing both was the best predictor (Intake) Crime/ Violence did not predict relapse

30. Subsequent Violence, Victimization, and Illegal Activity (by self and others) is one of the Major Environmental Predictors of Relapse Recovery Environment Risk Social Risk Family Conflict Family Cohesion Social Support Substance Use Substance- Related Problems Baseline.32.18 -.13.21 -.08.32.19.22.32.22.17.11.43.77.82.74.58 -.54 -.09.19 Source: Godley et al (2005) Model Fit CFI=.97 to.99 RMSEA=.04 to.06 Recall that the effects of treatment are mediated by the extent to which they lead to actual changes in the recovery environment or peer group Includes days of aggression towards others and victimization by others Includes substance use, fighting, and illegal activity by peers

31. Crime/Violence and Substance Problems Interact to Predict Recidivism Low Mod. High Low Mod. High 0% 20% 40% 60% 80% 100% Source: CYT & ATM Data 12 month recidivism Crime/ Violence predicted recidivism Substance Problem Severity predicted recidivism Knowing both was the best predictor Substance Problem Scale Crime and Violence Scale

32. Crime/Violence and Substance Problems Interact to Predict Violent Crime or Arrest Low Mod. High Low Mod. High Source: CYT & ATM Data 12 month recidivism To violent crime or arrest Substance Problem Scale Crime and Violence Scale 0% 20% 40% 60% 80% 100% Crime/ Violence predicted violent recidivism (Intake) Substance Problem Severity did not predict violent recidivism Knowing both was the best predictor

33. Discussion of SPS and CVS The GAINs SPS and CVS scales appears to be face valid, internally consistent and to have good construct validity. While placement in residential treatment focuses on substance use severity, CVS helps to predict relapse. This suggests the need to consider crime and violence more closely in placement decisions. Conversely, SPS helps to predict recidivism. This suggests the potential benefits of screening for substance use problems in juvenile justice settings. The next step is to combine these variables with other factors in a multivariate model. We also need to replicate these findings, preferably with a sample not presenting for treatment and with urine and record checks.

34. The Effectiveness of Programs for Juvenile Offenders N of Offender Sample Studies Preadjudication (prevention) 178 Probation216 Institutionalized 90 Aftercare 25 Total 509 Source: Adapted from Lipsey, 1997, 2005

35. Most Programs are actually a mix of components Average of 5.6 components distinguishable in program descriptions from research reports Intensive supervision Prison visit Restitution Community service Wilderness/Boot camp Tutoring Individual counseling Group counseling Family counseling Parent counseling Recreation/sports Interpersonal skills Anger management Mentoring Cognitive behavioral Behavior modification Employment training Vocational counseling Life skills Provider training Casework Drug/alcohol therapy Multimodal/individual Mediation Source: Adapted from Lipsey, 1997, 2005

36. Most programs have small effects but those effects are not negligible The median effect size (.09) represents a reduction of the recidivism rate from.50 to.46 Above that median, most of the programs reduce recidivism by 10% or more One-fourth of the studies show recidivism reductions of 30% or more, that is, a recidivism rate of.35 or less for the treatment group compared to.50 for the control group The nothing works claim that rehabilitative programs for juvenile offenders are ineffective is false Source: Adapted from Lipsey, 1997, 2005

37. Major Predictors of Bigger Effects 1.Chose a strong intervention protocol based on prior evidence 2.Used quality assurance to ensure protocol adherence and project implementation 3.Used proactive case supervision of individual 4.Used triage to focus on the highest severity subgroup

38. Impact of the numbers of Favorable features on Recidivism (509 JJ studies) Source: Adapted from Lipsey, 1997, 2005 Usual Practice has little or no effect

39. Some Programs Have Negative or No Effects on recidivism Scared Straight and similar shock incarceration program Boot camps mixed – had bad to no effect Routine practice – had no or little (d=.07 or 6% reduction in recidivism) Similar effects for minority and white (not enough data to comment on males vs. females) The common belief that treating anti-social juveniles in groups would lead to more iatrogenic effects appears to be false on average (i.e., relapse, violence, recidivism for groups is no worse then individual or family therapy) Source: Adapted from Lipsey, 1997, 2005

40. Program types with average or better effects on recidivism AVERAGE OR BETTERBETTER/BEST Preadjudication Drug/alcohol therapyInterpersonal skills training Parent training Employment/job training Tutoring Group counseling Probation Drug/alcohol therapyCognitive-behavioral therapy Family counselingInterpersonal skills training MentoringParent training Tutoring Institutionalized Family counseling Behavior management Cognitive-behavioral therapy Group counseling Employment/job training Individual counseling Interpersonal skills training Source: Adapted from Lipsey, 1997, 2005

41. Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Practice in Reducing Recidivism (29% vs 40%) Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving Multisystemic Therapy Functional Family Therapy Multidimensional Family Therapy Adolescent Community Reinforcement Approach MET/CBT combinations and Other manualized CBT NOTE: Generally little or no differences in mean effect size between these brand names Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004

42. Implementation is Essential ( Reduction in Recidivism from.50 Control Group Rate) The effect of a well implemented weak program is as big as a strong program implemented poorly The best is to have a strong program implemented well Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

43. Conclusions Research shows that intervention programs can be very effective for reducing the recidivism of juvenile offenders, even in routine practice Program selection and strong implementation are critical; otherwise effects quickly slide to zero (or worse) What evidence we have about the effects of programs in routine practice indicates that most are not very effective– there is plenty of room for improvement

44. Next Steps Currently working on evaluating RWJF reclaiming futures diversion projects, CSAT young offender re-entry projects, drug court projects and several individual juvenile justice projects Doing more work on predicting risk of recidivism and how they related to substance use disorders, co-morbidity, and environmental factors

45. Resources and References Copy of these slides and handouts –http://www.chestnut.org/LI/Posters/http://www.chestnut.org/LI/Posters/ References cited Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment, 27, 197-213. 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 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. Godley, M. D., Kahn, J. H., Dennis, M. L., Godley, S. H., & Funk, R. R. (2005). The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment. Psychology of Addictive Behaviors. Lipsey, M. W. (1997). What can you build with thousands of bricks? Musings on the cumulation of knowledge in program evaluation. New Directions for Evaluation, 76, 7-24. Lipsey, M.W. (2005). What Works with Juvenile Offenders: Translating Research into Practice. Adolescent Treatment Issues Conference, February 28, Tampa, FL Lipsey, M.W., Chapman, G.L., & Landenberger, N.A. (2001). Cognitive-Behavioral Programs for Offenders. The ANNALS of the American Academy of Political and Social Science, 578(1), 144-157 Waldron, H. B., Slesnick, N., Brody, J. L., Turner, C. W., & Peterson, T. R. (2001). Treatment outcomes for adolescent substance abuse at four- and seven-month assessments. Journal of Consulting and Clinical Psychology, 69(5), 802-812. 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.