Michael L. Dennis, Melissa Ives , Chestnut Health Systems (CHS), Normal, IL

1. Characteristics, Needs and Strengths of Substance Using Youth by Level of Involvement in the Juvenile Justice System Michael L. Dennis, Melissa Ives, Chestnut Health Systems (CHS), Normal, IL Randy Muck, Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), Rockville, MD Laura Nissen, Ph.D. Reclaiming Futures National Program Office, Regional Research Institute, Portland State University (PSU), Portland, OR Presentation at the Reclaiming Futures Leadership Institute, May 18 – 19, 2011, Miami, FL

2. Acknowledgement and Contact Information • This paper was supported by the Reclaiming Futures National Program Office, Regional Research Institute, Portland State University, and Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) contract 270-07-0191 using data from the 2009 CSAT Adolescent Treatment data set (for a fullest of 128 grantees, see www.chestnut.org/li/gain/#Data_Summaries_and_Reports ). • Opinions are those of the author and not official positions of the government • Available from www.chestnut.org/li/posters • Please direct comments to Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761, 309-451-7801, mdennis@chestnut.org .

3. Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20 100 People with drug dependence die an average of 22.5 years sooner than those without a diagnosis 90 Percentage 80 70 60 Severity Category 50 Other drug or heavy alcohol use in the past year 40 30 Alcohol or Drug Use (AOD) Abuse or Dependence in the past year 20 10 0 65+ Age 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000

4. Adolescents who use weekly or more often are more likely during the past year to have .. Source: Dennis, White & Ives, 2009

5. 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 in U.S. 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

6. The Need for Systematic Behavioral Screening • About half of the youth in the juvenile justice system have substance use problems • the juvenile justice systems is the leading source of referral among adolescents entering treatment for substance use problems • Recent studies have generally suggested that 67-70% of the youth in juvenile justice settings have one or more substance or mental disorders (79% with 2 or more, 61% 3 or more) • This has led to multiple calls for systematic screening of youth in the justice system for substance use and other psychiatric disorders

7. Goals • Describe the characteristics, treatment planning needs, and strengths of youth by their level of involvement in the juvenile justice system • Illustrate how victimization is related to other problems • Demonstrate how juvenile justice based treatment can replicate the outcomes of adolescent outpatient treatment • Draw out the policy implications for improving the juvenile justice system and reclaiming futures grantees

8. Global Appraisal of Individual Needs (GAIN) • The GAIN is one of the assessment tools used for screening juveniles (and adults) in the justice, substance abuse, and mental health treatment systems • The GAIN is explicitly designed to generate information to support clinical decision making at the individual level and program planning at the agency level • It is actually a family of evidence-based assessment instruments (ranging from 5 minutes to 2 hours in length), web-based software applications, training, coaching, and monitoring protocols that are in use in over 1500 agencies in 48 states and half a dozen other countries and have generated over 200 peer reports and publications

9. Methods • The GAIN data were collected between 2002 and 2009 by 128 SAMHSA/CSAT grantees in 90 locations • All sites collected at least the data in the CSAT Core version (n=17,335) and a subset went on to collect optional items on things like strengths (n=6,681) • All data were collected as part of general, clinical practice or specific research studies under each treatment site’s respective voluntary consent procedures. • All sites received standardized training and quality assurance on their GAIN data collection to facilitate comparison with other grantees collecting GAIN data. • Data pooled for secondary analysis are under the terms of data sharing agreements and the supervision of Chestnut Health System’s Institutional Review Board.

10. Data from 128 Grantees in 90 Locations Around the U.S. NH WA WA VT VT MT MT ND ND ME ME OR OR MN MN MA MA ID ID WI WI NY NY SD SD MI WY WY MI RI RI PA PA IA IA CT CT NE NE OH OH NJ NJ NV NV DC DC IN IN UT UT IL CA CA IL WV WV VA DE DE CO CO VA KS KS MO KY KY MO NC NC MD TN TN OK OK AZ AZ AR NM NM AR SC SC AL AL MS MS GA GA TX TX LA LA AK AK FL FL HI HI

11. Intensity of Justice System Involvement (n=17,335) Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

12. Males more likely to have higher intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

13. Hispanic, Mixed, & AA more likely to have higher intensity Being Caucasian associated with lower intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

14. Older Youth have higher intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

15. Being from a Single Parent Family and Runaway associated with higher intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

16. Being in School or Employedassociated with lower intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

17. Any and Each Type of Crime associated with higher intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

18. Regular Alcohol Use at Home associated with lower intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

19. Drug Use by Peers at School/Work associated with lower intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

20. Regular Alcohol Use by Social Peers associated with higher intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

21. Any and Severity of Lifetime Victimizationassociated with higher intensity Recent victimization related to lower intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

22. Early Use, Dependence and Tx History associated with higher intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

23. Recent Weekly Use and Withdraw associated with lower intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

24. Weekly Use of Tobacco, Marijuana and Alcohol the most common across intensity Specific Geographic locations have high rates of opioid, methamphetamine and/or cocaine use Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

25. Mental Health Disorders associated with more extreme high & low intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

26. Mental Health Disorders associated with more extreme high & low intensity (cont.) Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

27. HIV Risk Behaviors associated with higher intensity Risk Primarily Coming from Sex, Not Needle Use Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

28. Having 3 or more clinical problems is associated with higher intensity But even at the lowest intensity, most have 3 or more major clinical problems Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

29. Quarterly Costs to Society* Prior to Intakeassociated with higher intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335) in 2009 dollars

30. Cost of Substance Abuse Treatment Episode Many SBIRT, School, Workplace and other early intervention programs focus on brief intervention • $750 per night in Detox • $1,115 per night in hospital • $13,000 per week in intensive • care for premature baby • $27,000 per robbery • $67,000 per assault $70,000/year to keep a child in detention $22,000 / year to incarcerate an adult $30,000/ child-year in foster care Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004

31. Investing in Treatment has a Positive Annual Return on Investment (ROI) • Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested • Treatment drug courts have an average ROI of $2.14 to $2.71 per dollar invested This also means that for every dollar treatment is cut, we lose more money than we saved. Source: Bhati et al., (2008); Ettner et al., (2006)

32. SAMHSA/CSAT’s Adolescent Clients • As part of SAMHSA/CSAT contract 270-07-0191, data were pooled on clients from 148 local evaluations, recruited between 1997 to 2009 and followed quarterly for 6 to 12 months (over 80% completion). • In 2009 dollars, the 16,915 adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake). • This would be $3.9 Million per 1,000 adolescents served. • Within 12 months, the cost of treatment provided by CSAT grantees was offset by reductions in other costs producing a net benefit to taxpayers of $4,592 per adolescent.

33. SAMHSA/CSAT’s Adolescents Clients Economic Benefit by Level of Care \a Includes the cost of treatment \b Year after intake (including treatment) - year before treatment

34. Treatment Planning Needs that increase with intensity Residential treatment referral Child maltreatment Dissatisfaction with environment Vocational assistance Housing situation Recent victimization Worried about being victimized Coordinating care w DCFS/CPS Substance use in public housing School or GED program Vocational counseling or placement Recent work problems Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

35. Treatment Planning Needs that decrease with intensity Attended school in the past 90 days Coping with psycho-social stressors Recent school problems Family fighting in the home Substance use in the home Attended work in the past 90 days Financial counseling Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335)

36. Individual Strengths Doing well at close friends Listening, caring or comm. w/ others Sports, exercise, physical activity Doing well at with your family Problem solving and figuring things out Doing well at school or training Working or playing with computers Music, dancing, acting, other perf. art Drawing, painting,  design or other art Doing well at work Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)

37. Variation in Strengths by Intensity • Those that tend increase with intensity include • Doing well at sports, exercise, physical activity • Doing well at with your family • Doing well at school or training • Doing well at music, dancing, acting, other performing art • Drawing, painting, design or other art activities • That tend to decrease with intensity include • Doing well at close friends • Listening, caring or communicating with others • Problem solving and figuring things out • Working or playing with computers • Doing well at work

38. Sources of Social Support Doing well at close friends Listening, caring or comm. w/ others Sports, exercise, physical activity Doing well at with your family Problem solving and figuring things out Doing well at school or training Working or playing with computers Music, dancing, acting, other perf. art Drawing, painting,  design or other art Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)

39. Variation in Social Support by Intensity • Those that tend increase with intensity include • Family members/close partners • Professional counselor/health provider • That tend to decrease with intensity include • Friends to hang out with • Someone to talk with to about emotions • Someone to help cope with problems • Legal hobby or activity • People at work/school to help get assignments done • People at work/school to help with day to day things • Friends/colleagues from other schools or companies

40. Potential Mentors in the Recovery Environment Home School or Work Social Peers Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681) 40

41. Variation in Potential Mentors by Intensity • Those that tend increase with intensity include • Home Peers: Know any in recovery • School/Work Peers: Know any in recovery • Home Peers: Know any in treatment • Home Peers: None involved in shouting, arguing or fighting most weeks • That tend to decrease with intensity include • Social Peers: Know any in recovery • Social Peers: Know any in treatment • School/Work Peers: Know any in treatment • Social Peers: None involved in shouting, arguing or fighting most weeks • School Work Peers: None involved in shouting, arguing or fighting most weeks

42. Environment with No One Involved Illegal activity most common in the middle of intensity Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)

43. General Victimization Scale: Example from Offender Re-entry Program (ORP) Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)

44. Psychiatric Disorders by Severity of Victimization Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)

45. Type of Crime By Severity of Victimization High victimization group more likely (OR=1.9) to report violent crime than low group Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)

46. GAIN-I Main Scale Problem Profile Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)

47. GAIN-I Main Scales Problem Count By Severity of Victimization High victimization group more likely (OR=6.6) to have 7 to 13 problems than low group Source: CSAT 2010 YORP and ORP studies only (N = 2,966) 47

48. Traumatized groups have higher severity High trauma group does not respond to OP Both groups respond to residential treatment Victimization and Level of Care Interact to Predict Outcomes CHS Outpatient CHS Residential 40 35 30 25 Marijuana Use (Days of 90) 20 15 10 5 0 Intake 6 Months Intake 6 Months OP -High OP - Low/Mod Resid-High Resid - Low/Mod. Source: Funk, et al., 2003

49. JTDC Reduced Use More than AOP (d between= -0.24) Comparison of Treatment Outcomes: Adolescent Outpatient (AOP) vs. Juvenile Treatment Drug Court (JTDC) Others Outcomes Not Significantly Different Post-Pre d (AOP, JTDC) Illegal Activity (d=-0.11, -0.02) Substance Use* ( d=-0.45, -0.57) Emotional Problems (d=-0.32, -0.22) Trouble w/ Family (d= -0.23, -0.18) In Controlled Environment (d=-0.02, -0.08) Source: Ives et al., in press *p<.05 change greater for JTDC vs AOP (d=-0.24)

50. 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