Assessment and Treatment of Adolescents

1. Assessment and Treatment of Adolescents Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation at the Pacific Asia Judges Science and Technology Seminar, November 10-12, 2010, Hyatt Regency Hotel, Tumon, Guam.This presentation was supported by funds from and data from NIDA grants no. R01 DA15523, R37-DA11323, R01 DA021174, and CSAT contract no. 270-07-0191. It is available electronically at www.chestnut.org/li/posters . The opinions are those of the author do not reflect official positions of the government. Please address comments or questions to the author at Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761 mdennis@chestnut.org or 309-451-7801.

2. Goals of this Presentation are to • Examine the prevalence, course, and consequences of adolescent substance use • Highlight what it takes to move the field towards evidenced-based practice • Present the findings from several recent treatment needs assessment and outcome studies on adolescent substance abuse treatment

3. Severity of Past Year Substance Use/Disorders(2002 U.S. Household Population age 12+= 235,143,246) Dependence 5% Abuse 4% No Alcohol or Regular AOD Drug Use 32% Use 8% Any Infrequent Drug Use 4% Light Alcohol Use Only 47% Source: 2002 NSDUH, Dennis & Scott 2007

4. Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Problems Vary by Age NSDUH Age Groups 100 People with drug dependence die an average of 22.5 years sooner than those without a diagnosis 90 80 70 60 Severity Category 50 No Alcohol or Drug Use Light Alcohol Use Only 40 Any Infrequent Drug Use 30 Regular AOD Use 20 Abuse 10 Dependence 0 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Source: 2002 NSDUH and Dennis & Scott 2007

5. Mean (95% CI) $3,058 This includes people who are in recovery, elderly, or do not use because of health problems Higher Costs $1,613 $1,528 $1,309 $1,078 $948 Higher Severity is Associated with Higher Annual Cost to Society Per Person $4,000 Median (50th percentile) $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $725 $406 $500 $231 $231 $0 $0 $0 No Alcohol or Light Alcohol Regular AOD Any Dependence Abuse Infrequent Drug Use Use Only Drug Use Use Source: 2002 NSDUH

6. Substance use severity is related to crime and violence Crime & Violence by Substance Severity Adolescents 12-17 Source: NSDUH 2006

7. ..as well as family, school and mental health problems Family, Vocational & MH by Substance Severity Adolescents 12-17 Source: NSDUH 2006

8. Few Get Treatment: 1 in 19 adolescents, 1 in 21 young adults, 1 in 12 adults Substance Use Disorders are Common,But Treatment Participation Rates Are Low Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Much of the private funding is limited to 30 days or less and authorized day by day or week by week Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH

9. The Movement to Increase Screening Screening, Brief Intervention and Referral to Treatment (SBIRT) has been shown to be effective in identifying people not currently in treatment, initiating treatment/change and improving outcomes (see http://sbirt.samhsa.gov/ ) The US Preventive Services Task Force (USPSTF, 2004; 2007), National Quality Forum (NQF, 2007), and Healthy People 2010 have each recommended SBIRT for tobacco, alcohol and increasingly drugs CSAT and NIDA are both funding several demonstration and research projects to develop and evaluate models for doing this Washington State mandated screening in all adolescent and adult substance abuse treatment, mental health, justice, and child welfare programs with the 5 minute Global Appraisal of Individual Needs (GAIN) short screener

10. Overview of the GAIN-Short Screener (GSS) • A 3- to 5-minute screener • Used in general populations to identify or rule-out clients who will be identified as having a behavioral health disorders on the 60-120 min versions of the GAIN • Easy for use by staff with minimal training or direct supervision • Provides a measure of change • Designed for self- or staff-administration, with paper and pen, computer, or on the web • Translated by collaborators into several languages including French, Japanese, Portuguese, and Spanish so far

11. Factor Structure of GAIN Measures of Psychopathology and Behavior Source: Dennis, Chan, and Funk (2006)

12. Washington State Results with GAIN Short Screener: Adolescent Problems could be easily identified & Comorbidity common Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

13. Adolescent Client Validation of Hi Co-occurring from GAIN Short Screener vs Clinical Records by Setting in Washington State Two page measure closely approximated all found in the clinical record after the next two years Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

14. Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-occurring? School Assistance Programs (SAP) largest part of BH/MH system; 2nd largest of SA & Co-occurring systems SAP+ SA Treatment Over half of system Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

15. Construct Validity of GSS Internalizing Disorder Screener Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)

16. Construct Validity of GSS Externalizing Disorder Screener Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)

17. Construct Validity of GSS Substance Disorder Screener Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)

18. Construct Validity of GSS Crime/Violence Screener Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)

19. Total Disorder Screener Severity by Level of Care: Adolescents Outpatient Median=6.0 (30% at 10+) Residential Median= 10.5 (59% at 10+) Few missed (1/2-3%) Source: SAPISP 2009 Data and Dennis et al 2006 19

20. Track Gap Between Prior and current Lifetime Problems to identify “under reporting” Track progress in reducing current (past month) symptoms) GAIN SS Can Also be Used for Monitoring 20 12+ Mon.s ago (#1s) 2-12 Mon.s ago (#2s) 16 Past Month (#3s) Lifetime (#1,2,or 3) 11 12 10 10 9 9 8 8 3 4 2 2 0 Intake 3 6 9 12 15 18 21 24 Mon Mon Mon Mon Mon Mon Mon Mon Total Disorder Screener (TDScr) Monitor for Relapse

21. Use of a short common screener can • Provide immediate clinical feedback that is a good approximation of diagnosis and be used to guide placement and treatment planning • Can be used repeatedly to track change • Support evaluation and planning at program or state level (e.g., needs, case mix, services needed) • Provide practice based evidence to guide future clinical decision • Be incorporated into health risk/ wellness assessments and/or school surveys

22. In practice we need a Continuum of Measurement (Common Measures) More Extensive / Longer/ Expensive Screener Quick Comprehensive Special • Screening to Identify Who Needs to be “Assessed” (5-10 min) • Focus on brevity, simplicity for administration & scoring • Needs to be adequate for triage and referral • GAIN Short Screener for SUD, MH & Crime • ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD • SCL, HSCL, BSI, CANS for Mental Health • LSI, MAYSI, YLS for Crime • Quick Assessment for Targeted Referral (20-30 min) • Assessment of who needs a feedback, brief intervention or referral for more specialized assessment or treatment • Needs to be adequate for brief intervention • GAIN Quick • ADI, ASI, SASSI, T-ASI, MINI • Comprehensive Biopsychosocial (1-2 hours) • Used to identify common problems and how they are interrelated • Needs to be adequate for diagnosis, treatment planning and placement of common problems • GAIN Initial (Clinical Core and Full) • CASI, A-CASI, MATE • Specialized Assessment (additional time per area) • Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan • CIDI, DISC, KSADS, PDI, SCAN

23. Longer assessments identify more areas to address in treatment planning Most substance users have multiple problems 5 min. 20 min 30 min 1-2 hr Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192) 23

24. Major Predictors of Bigger Effects Found in Multiple Meta Analyses • A strong intervention protocol based on prior evidence • Quality assurance to ensure protocol adherence and project implementation • Proactive case supervision of individual • Triage to focus on the highest severity subgroup

25. Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis The more features, the lower the recidivism Average Practice Source: Adapted from Lipsey, 1997, 2005

26. Evidenced Based Treatment (EBT) that Typically do Better than Usual Practice in Reducing Juvenile Recidivism (29% vs. 40%) • Aggression Replacement Training • Reasoning & Rehabilitation • Moral Reconation Therapy • Thinking for a Change • Interpersonal Social Problem Solving • MET/CBT combinations and Other manualized CBT • Multisystemic Therapy (MST) • Functional Family Therapy (FFT) • Multidimensional Family Therapy (MDFT) • Adolescent Community Reinforcement Approach (ACRA) • Assertive Continuing Care NOTE: There is 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

27. On-site proactive urine testing can be used to reduce false negatives by more than half

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

29. Percentage Change in Abstinence (6 mo-Intake) by level of Adolescent Community Reinforcement Approach (A-CRA) Quality Assurance Effects associated with intensity of quality assurance and monitoring (OR=13.5) Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961) 29

30. So what does it mean to move towards Evidence Based Practice (EBP)? • 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 • 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, performance monitoring and long term program planning • Having the ability to evaluate client and program outcomes • For the same person or program over time, • Relative to other people or interventions

31. Key Challenges to Delivery of Quality Care in Behavioral Health Systems • High turnover workforce with variable educationbackground related to diagnosis, placement, treatment planning and referral to other services • Heterogeneous needs and severitycharacterized by multiple problems, chronic relapse, and multiple episodes of care over several years • Lack of access to or use of data at the program levelto guide immediate clinical decisions, billing and program planning • Missing, bad or misrepresented datathat needs to be minimized and incorporated into interpretations • Lack of Infrastructure that is needed to support implementation and fidelity

32. Questions spelled out and simple question format Lay wording mapped onto expert standards for given area Built in definitions, transition statements, prompts, and checks for inconsistent and missing information. Standardized approach to asking questions across domains Range checks and skip logic built into electronic applications Formal training and certification protocols on administration, clinical interpretation, data management, coordination, local, regional, and national “trainers” Above focuses on consistency across populations, level of care, staff and time On-going quality assurance and data monitoring for the reoccurrence or problems at the staff (site or item) level Availability of training resources, responses to frequently asked questions, and technical assistance 1. High Turnover Workforce with Variable Education Outcome: Improved Reliability and Efficiency

33. Multiple domains Focus on most common problems Participant self description of characteristics, problems, needs, personal strengths and resources Behavior problem recency, breadth , and frequency Utilization lifetime, recency and frequency Dimensional measures to measure change with interpretative cut points to facilitate decisions Items and cut points mapped onto DSM for diagnosis, ASAM for placement, and to multiple standards and evidence- based practices for treatment planning Computer generated scoring and reports to guide decisions Treatment planning recommendations and links to evidence-based practice Basic and advanced clinical interpretation training and certification 2. Heterogeneous Needs and Severity Outcome: Comprehensive Assessment

34. Data immediately available to support clinical decision making for a case Data can be transferred to other clinical information system to support billing, progress reports, treatment planning and on-going monitoring Data can be exported and cleaned to support further analyses Data can be pooled with other sites to facilitate comparison and evaluation PC and web based software applications and support Formal training and certification on using data at the individual level and data management at the program level Data routinely pooled to support comparisons across programs and secondary analysis Over three dozen scientists already working with data to link to evidence-based practice 3. Lack of Access to or use of Data at the Program Level Outcome: Improved Program Planning and Outcomes

35. Assurances, time anchoring, definitions, transition, and question order to reduce confusion and increase valid responses Cognitive impairment check Validity checks on missing, bad, inconsistency and unlikely responses Validity checks for atypical and overly random symptom presentations Validity ratings by staff Training on optimizing clinical rapport Training on time anchoring Training answering questions, resolving vague or inconsistent responses, following assessment protocol and accurate documentation. Utilization and documentation of other sources of information Post hoc checks for on-going site, staff or item problems 4. Missing, Bad or Misrepresented Data Outcome: Improved Validity

36. Direct Services Training and quality assurance on administration, clinical interpretation, data management, follow-up and project coordination Data management Evaluation and data available for secondary analysis Software support Technical assistance and back up to local trainer/expert Development Clinical Product Development Software Development Collaboration with IT vendors (e.g., WITS) Over 36 internal & external scientists and students Workgroups focused on specific subgroup, problem, or treatment approach Labor supply (e.g., consultant pool, college courses) 5. Lack of Infrastructure Outcome: Implementation with Fidelity

37. Some Common Record Based Performance Measures * NQF: National Quality Forum; WCG: Washington Circle Group; CSAT: Center for Substance Abuse Treatment evaluations; NOMS: National Outcome Monitoring System; NIATX: Network for the Improvement of Addiction Treatment; PFP: Pay for Performance evaluations

38. Newer NQF Standards of Care • Annual screening for tobacco, alcohol and other drugs using systematic methods • Referral for further multidimensional assessment to guide patient-centered treatment planning • Brief intervention, referral to treatment and supportive services where needed • Pharmacotherapy to help manage withdrawal, tobacco, alcohol and opioid dependence • Provision of empirically validated psychosocial interventions • Monitoring and the provision of continuing care Source: www.tresearch.org/centers/nqf_docs/NQF_Crosswalk.pdf

39. Assessment combined with treatment records can make better performance measures 218/224=97% to targeted 553/771=72% unmet need 771/982=79% in need Size of the Problem Extent to which services are not reaching those in most need Extent to which services are currently being targeted Source: 2008 CSAT AAFT Summary Analytic Dataset

40. Mental Health Problem (at intake) vs. Any MH Treatment by 3 months Source: 2008 CSAT AAFT Summary Analytic Dataset

41. Why Do We Care About Unmet Need? • If we subset to those in need, getting mental health services predicts reduced mental health problems • Both psychosocial and medication interventions are associated with reduced problems • If we subset to those NOT in need, getting mental health services does NOT predict change in mental health problems Conversely, we also care about services being poorly targeted to those in need.

42. Residential Treatment need (at intake) vs. 7+ Residential days at 3 months Opportunity to redirect existing funds through better targeting Source: 2008 CSAT AAFT Summary Analytic Dataset

43. Will be using data from the Global Appraisal of Individual Needs (GAIN) Collaborators NH WA VT ME MT MN ND MA OR WI ID SD NY RI MI WY CT PA IA NV NE NJ OH UT IL IN CA DE CO WV MO VA MD KY KS DC NC TN OK NM State or Regional System GAIN-Short Screener GAIN-Quick GAIN-Full No of GAIN Sites AR AZ SC GA AL None (Yet) MS 1 to 14 TX LA 15 to 30 AK 31 to 165 FL HI More in BZ, CA, CN, JP, MX VI PR 3/10 43

44. Number of GAIN Sites None (Yet) 1 to 14 15 to 30 31 to 165 …as well as 6 provinces of Canada and 6 other countries Canada State or Regional System GAIN-Short Screener YT GAIN-Quick NU NT GAIN-Full NF BC AB MB QC SK PE ON NS NB

45. Some numbers as of June 2010 • 1,501 Licensed GAIN administrative units from 49 states (all by ND) and 7 countries • 3,270 users in 396 Agencies using GAIN ABS • 60,380 intake assessments (largest in field) • 22,045 (88% w 1+ follow-up) from 278 CSAT grantees • 22 states, 12 Federal, 6 Canadian provinces, 6 other countries, and 3 foundations mandate or strongly encourage its use • 4 dozen researchers have published 179 GAIN-related research publications to date 45

46. The GAIN is .. • A family of instruments ranging from screening, to quick assessment to a full Biopsychosocial and monitoring tools • Designed to integrate clinical and research assessment • Designed to support clinical decision making at the individual client level • Designed to support evaluation and planning at program level • Designed to support secondary analyses and comparisons across individuals and programs The GAIN is NOT an electronic health record (EHR), but a component that can interface with and support EHRs.

47. EHR can provide practice based evidence: Lessons from a Decade of GAIN data from CSAT Grants NH WA VT ME MT ND MN OR MA ID NY SD WI MI WY RI CT AAFT IA PA NE OH ART NJ IN NV DC UT ATDC CA IL DE WV VA CO BIRT MO KS MD JTDC KY EARMARK NC TN EAT AZ OK NM SC FDC AR JDC GA MS AL OJJDP ORP TX LA RCF FL AK SAC SCAN SCY HI TCE PR YORP VI 47

48. 2009 CSAT Data Set by Age 18 Years or Older (18+) 12.7%, (n=2,793) Under 15 Years Old (<15) 16.1%, (n=3,547) 15-17 Years Old 71.2%, (n=15,705) Source: CSAT 2009 Summary Analytic Data Set (n=22,045) 48

49. Diagnosis Time Period Matters Source: CSAT 2009 Summary Analytic Data Set (n=21,659) 49

50. Definition of Substance Use Severity Matters *(n=11,066) Source: CSAT 2009 Summary Analytic Data Set (n=21,816) 50