1. Assertive Continuing Care for Adolescents Mark D. Godley, Ph.D., Susan H. Godley, Rh.D., Michael L. Dennis, Ph.D., Rod Funk, B.S., and Lora L. Passetti, M.A. Chestnut Health Systems Bloomington, IL This work is supported by grants from the National Institute on Alcoholism & Alcohol Abuse, the SAMHSA Center for Substance Abuse Treatment, and the Illinois Division 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, Tracy Karvinen, Matt Orndorff, Lora Passetti, Laura Sloan, Ben Wells, Jen White, and Kelli Wright And… Drs. H. Perl & J. Hough, NIAAA; R. Muck & J. Buttler, CSAT; and M. Whitter, Illinois OASA

3. Questions  Why is continuing care important?  What have we learned about continuing care in treatment programs?  What is an “assertive” approach to continuing care?  What is the critical roll of supervision in Assertive Continuing Care (ACC)?  How does ACC compare to standard practice in terms of implementation and outcome?

4. Why is Continuing Care Important?  Like many other illnesses, addiction is a chronic, relapsing condition.  Brown et al., 1989: 60% of youth relapsed in first 90 days after res. tx.  Dennis reports that most youth treated in the CYT outpatient study moved in and out of recovery.

5. Most Patients Alternate Between Relapse & Recovery (30 mo. follow up) Source: Dennis et al, forthcoming 37% Sustained Problems 5% Sustained Recovery 19% Intermittent, currently in recovery 39% Intermittent, currently not in recovery

6. 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)

7. 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)

8. Asthma  Adherence to medication is less than 30%  Re-treated in 12 months: 60-80% (McLellan, 2003; Treatment Research Institute)

9. What Predicts Relapse in these Illnesses? 1.Poor adherence to behavior change requirements (diet, exercise, medication compliance) 2.Low Socioeconomic Status 3.Low Family Support 4.Psychiatric Co-Morbidity (McLellan, 2003; Treatment Research Institute)

10. Why is Continuing Care Research in Addiction Treatment Important?  Existing studies reveal high levels of relapse after treatment  The evidence for continuing care is not yet clearly established (McKay, 2001)  Almost no continuing care studies of adolescents in the scientific literature

11. Time to Enter Continuing Care and Relapse after Residential Treatment (Adults) Source: 1999 & 2000 Statewide TEDS and Godley et al 2004 1999 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0102030405060708090 Days from Discharge Percent of Clients 2000 Relapse

12. Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17) Source: 1999 & 2000 Statewide TEDS and Godley et al., 2004 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0102030405060708090 Days after Residential (capped at 90) Percent of Clients 1999 2000 Relapse

13. Linkage to Continuing Care After Residential Treatment (Adolescents) Source: 1999 & 2000 Statewide TEDS 1999 2000

14. What does Continuing Care look like in actual practice? 0% 10% 20% 30%40%50%60%70%80%90%100% Expected 0% 10% 20% 30%40%50%60%70%80%90%100% Expected UCC WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/ probation/school Follow up on referrals Relapse prevention Communication skills training Problem solving component Meet with parents 1-2x month Weekly telephone contact Referrals to other services Discuss probation/school compliance Adherence: Meets 8/12 criteria Actual UCC

15. Barriers to Continuing Care  Typical referral process is passive, emulating medical clinics, and presumes the patient is motivated  Treatment Fatigue  Reimbursement methods do little to encourage continuing care  Assertive approaches shift the responsibility for linkage 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

20. Research Questions  To determine the effectiveness of usual vs. assertive continuing care following residential treatment in:  engaging and retaining youth in continuing care services  linking youth to additional services  reducing AOD use and problems

21. Who was eligible to participate in 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. ACC Study Research Design Intervention NIntake Residential Treatment Plus Aftercare 3mo after discharge from RT 6mo after discharge from RT 9mo after discharge from RT Assertive Continuing Care 102 O 0 T UCC+ACC O 3 O 6 O 9 Usual Continuing Care 81 O 0 T UCC O 3 O 6 O 9 Note O = participant interview T = treatment No line between rows means randomization

23. Core Measures  GAIN-I and GAIN M90  Form 90 TLFB  BAC and Urine tests  Collateral Assessment Form

24. 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

25. Demographic Characteristics

26. Baseline Substance Use Characteristics

27. 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

29. 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)

30. Monitoring ACC Implementation  Weekly Case Review Tracking Form  Therapist Skillfulness Rating Form  Procedure checklists completed independently by therapist and supervisor  100% of sessions taped until certification

31. Monitoring Implementation  Simple monitoring systems work best  Monitor client contact and intervention procedures  Monitor total caseload weekly  Weekly feedback on caseload

32. ACC Weekly Case Review

33. 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

34. Results: Improved Adherence ACC * p<.05 0% 10% 20% 30% 40%50%60%70%80%90% 100% WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/ probation/school Follow up on referrals* 0% 10% 20% 30% 40%50%60%70%80%90% 100% Relapse prevention* Communication skills training* Problem solving component* Meet with parents 1-2x month* Weekly telephone contact* Referrals to other services* Discuss probation/school compliance* Adherence: Meets 8/12 criteria* UCC

35. Reduced Relapse: Marijuana Days to First Marijuana Use p<.05 2702402101801501209060300 Proportion Remaining Abstinent 1.0.9.8.7.6.5.4.3.2.1 0.0 ACC UCC

36. Reduced Relapse: Alcohol Days to First Alcohol Use (p<.05) 2702402101801501209060300 Proportion Remaining Abstinent 1.0.9.8.7.6.5.4.3.2.1 0.0 ACC UCC

37. 0 5 10 15 20 25 30 35 40 45 Pre-treatmentACC PhasePost ACC Days ACC (N=93) UCC (N=76) Days of Alcohol Use (out of 90)

38. Days of Marijuana Use (out of 90) 0 5 10 15 20 25 30 35 40 45 Pre-treatmentACC PhasePost ACC Days ACC UCC

39. Proportion Remaining Abstinent 0306090120150180210240270 Days Since Residential Discharge 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Usual Continuing Care: Did not attend CC (n=36) “Unmotivated” Attended CC (n=42) Assertive Continuing Care (n=96; 94% Attended CC) Patients Remaining Abstinent Can Assertive Continuing Care (ACC) Help “Unmotivated” Patients? Godley et al., 2004

40. Conclusions  Failure to link to CC is the norm in actual practice  For those who do link retention beyond 4 hours of service is less than 50%  ACC is clearly superior to UCC in linking and retaining youth in continuing care  ACC clients receive more referrals to ancillary services than UCC clients  ACC was significantly better in preventing relapse than UCC

41. Next Steps for Research  Additional research is necessary to further improve relapse prevention effectiveness  We need to test models of continuing care following outpatient treatment  We need to test ways of improving 12 step attendance among adolescents  We need to better address the co-occurring problems of adolescents  Research is needed to test longer term models of CC with adolescents-particularly decreasing levels of contact for monitoring, support, and re-intervention

42. Contact Information Mark D. Godley, Ph.D. Chestnut Health Systems 720 W. Chestnut St. Bloomington, IL 61704 309.827.6026 ext.3401 mgodley@chestnut.org www.chestnut.org

43. Introduction  Our Background  Experience with adolescents involved in residential and outpatient treatment  Is it Aftercare or Continuing Care?