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Exposure to the Adolescent Community Reinforcement Approach (A-CRA) and Mechanisms of Change for Substance Use and Illegal Activity. Brooke Hunter & Susan H. Godley – Chestnut Health Systems Matthew Hesson-McInnis – Illinois State University

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slide1

Exposure to the Adolescent Community Reinforcement Approach (A-CRA) and Mechanisms of Change for Substance Use and Illegal Activity

Brooke Hunter & Susan H. Godley – Chestnut Health Systems

Matthew Hesson-McInnis – Illinois State University

Hendrik Roozen – Erasmus University Medical Centre, the Netherlands

Joint Meeting on Adolescent Treatment Effectiveness

Washington, D.C.

Tuesday April 10, 2012

acknowledgements
Acknowledgements
  • Special thanks to Drs. Susan Godley, Matthew Hesson-McInnis and Hendrik Roozen for their collaboration on this study.
  • Funding for this work has been provided by SAMSHA/CSAT (HHSS270200700004C)
  • The opinions expressed are those of the authors and do not reflect official positions of the contributing grantees’ project directors or the federal government.
learning objectives
Learning Objectives
  • Do adolescents who receive A-CRA experience reductions in illegal activity and juvenile justice system involvement?
  • What are the mechanisms of change for substance use and illegal activity within the treatment context?
  • Does exposure to A-CRA indirectly impact juvenile justice system involvement through reductions in substance use and illegal activity?
co occurrence of substance use and illegal activity
Co-Occurrence of Substance Use and Illegal Activity
  • There is a well established correlation between substance use and illegal activity
      • e.g., Donovan & Jessor, 1985; Elliot, Huizinga, & Menard, 1989; Loeber, Stouthamer-Loeber, & White, 1999
  • ~ 49% - 70% of adolescents in substance use treatment were involved with the justice system
      • TEDS, 2008; Godley, Garner, Smith, Meyers, & Godley, 2011
  • 2.4 million adolescents were arrested in 2000
    • 38% self-reported substance use
    • 54% tested positive for an illicit substance
    • Only 13.5% were arrested for a drug or alcohol violation
      • National Center on Addiction and Substance Abuse at Columbia University, 2004
increased risk
Increased Risk
  • Adolescents who use:
    • Alcohol are 2 times more likely to be arrested
    • Marijuana are 3.5 times more likely to be arrested
    • Cocaine are 9 times more likely to be arrested
    • Heroin are 20 times more likely to be arrested
      • Horowitz et al., 2006
  • Each conviction of a criminal charge increases the likelihood that an adolescent will become an adult felon
theories of causation

Theories of Causation:

What mechanisms underlie the relationship between substance use and illegal activity?

treatment of co occurring substance use and illegal activity
Treatment of Co-occurring Substance Use and Illegal Activity
  • Experts have identified key Elements of adolescent substance use treatment
    • Brannigan et al., 2004
  • Drug Strategies: Bridging the Gap, 2005 – substance use treatment in the juvenile justice system
    • e.g., thorough assessments, developmentally appropriate, qualified therapists, family involvement, continuing care, etc.
  • A-CRA treatment protocol exhibits best practices
aims of current study
Aims of Current Study
  • Does A-CRA directly reduce illegal activity?
  • Does A-CRA indirectly reduce illegal activity through reductions in substance use?
  • Does A-CRA indirectly reduce substance use through reductions in illegal activity?
  • Does A-CRA reduce involvement with the juvenile justice system through reductions in substance use or illegal activity?
hypothesized model

Baseline

6 month

12 month

A-CRA Exposure Scale

Alcohol & Other Drug Use

Alcohol & Other Drug Use

Alcohol & Other Drug Use

Illegal Activity Scale

Illegal Activity Scale

Illegal Activity Scale

Criminal Justice System Index

Criminal Justice System Index

Hypothesized Model
participants
Participants
  • Adolescents who presented to substance use treatment and reported involvement in illegal activities during past year
  • 44 organizations located across the nation receiving federal funding to implement the Adolescent Community Reinforcement Approach
  • 1,467 adolescents
treatment plan
Treatment Plan
  • Adolescent Community Reinforcement Approach – 3 months of treatment
      • 10 adolescent sessions
      • 2 caregiver sessions
      • 2 family sessions
  • Assertive Continuing Care – 3 months of home based A-CRA plus enhance case management
  • A-CRA includes 18 possible procedures, which can be repeated multiple times
analytic plan
Analytic Plan
  • Sample was split into two sub-samples
    • Model development sample
    • Model validation sample
  • Multiple groups analysis was used to cross-validate the final model
  • Mediation analysis with a bootstrapping procedure was conducted to further examine the relationship between A-CRA exposure and illegal activity
results

Baseline

6 month

12 month

A-CRA

Exposure

Scale

-.11

Alcohol &

Other Drug

Use

Alcohol &

Other Drug

Use

.42

Alcohol &

Other Drug

Use

.24

.14

.26

.25

.27

Illegal

Activity

Scale

.23

Illegal

Activity

Scale

Illegal

Activity

Scale

.29

-.08

.12

-.13

Criminal

Justice

System

Index

.22

Criminal

Justice

System

Index

Results
mediation

A-CRA

Exposure

path c

Illegal

Activity

p = .00

Alcohol &

Other Drug

Use

p = .00

p = .00

path b

path a

path c’

Illegal

Activity

A-CRA

Exposure

p = .04

Alcohol & Other Drug Use was a significant mediator according bootstrap 95% CI (-.0011, -.0003).

Mediation
main findings
Main Findings
  • A-CRA exposure directly reduced both substance use and illegal activity
  • A-CRA exposure indirectly reduced illegal activity through reductions in substance use (partial mediation)
  • A-CRA exposure reduced involvement with the juvenile justice system through reductions in substance use and illegal activity
implications
Implications
  • Substance use treatment is important for this population not only because it impacts substance use, but also because it impacts illegal activity and juvenile justice involvement
  • Reductions in juvenile justice involvement result in reduced costs to society
strengths
Strengths
  • Large sample size
  • Cross-validation of path model
  • Longitudinal design
  • Diverse multi-site sample of adolescents
limitations
Limitations
  • Self reported intake and follow up assessments
  • Lack of experimental design: cannot establish causal relationship of treatment on outcomes
future research
Future Research
  • Is the model developed in the current study invariant by sub-groups (e.g., gender, race, or type of crimes committed)?
  • Are specific A-CRA procedures (e.g., anger management, increasing pro-social behavior) more important for adolescent who are engaging in criminal behavior?
  • What additional mediators explain the relationship between A-CRA exposure and illegal activity?
references
References
  • Brannigan, R., Schackman, B. R., Falco, M., & Millman, R. B. (2004). The quality of highly regarded adolescent substance abuse treatment programs, results of an in-depth national survey. Archives Pediatric Adolescent Medicine, 158, 904-909.
  • Donovan, J. E. & Jessor, R. (1985). Structure of problem behavior in adolescence and young adulthood. Journal of Consulting and Clinical Psychology, 53(6), 890–904.
  • Elliott, D., Huizinga, D., & Menard, S. (1989). Multiple problem youth: Delinquency, substance use, and mental health problems. New York, NY: Springer-Verlag.
  • Drug Strategies. (2005). Bridging the Gap: A Guide to Drug Treatment in the Juvenile
  • Justice System. Washington: Drug Strategies.
  • Loeber, R., Stouthamer-Loeber, M., & White, H. R. (1999). Developmental aspects of delinquency and internalizing problems and their association with persistent juvenile substance use between ages 7 and 18. Journal of Clinical Child Psychology, 28(3), 322–332.
  • Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J., & Godley, M. D. (2011). A large-scale dissemination and implementation model for evidence-based treatment and continuing care. Clinical Psychology: Science and Practice,18(1), 67-83.
  • Horowitz, H., Sung, H.-E., & Foster, S. E. (2006). The role of substance abuse in U.S. juvenile justice systems and populations. Corrections Compendium, 31(1), 1-4, 24-26.
  • National Center on Addiction and Substance Use. (2004). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York: Columbia University.
  • United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Bibliographic Citation: Studies. Treatment Episode Data Set -- Admissions (TEDS-A), 2008 [Computer file]. ICPSR27241-v3. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2010-03-31.
thank you
Thank you!

If you have any questions regarding this presentation please contact:

Brooke Hunter, M.S.

Lighthouse Institute

Chestnut Health Systems

448 Wylie Drive

Normal, IL 61761

[email protected]

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