Challenges and Strategies for Implementing Evidence-based Family Treatments in Complex Settings: Working within the Juve

1. Challenges and Strategies for Implementing Evidence-based Family Treatments in Complex Settings: Working within the Juvenile Justice System Cynthia L. Rowe, Ph.D., Howard A. Liddle, Ed.D., and Gayle A. Dakof, Ph.D. Center for Treatment Research on Adolescent Drug Abuse University of Miami Miller School of Medicine Presented at the American Family Therapy Association (AFTA) 8th Clinical Research Conference, “Evidence-based Family Treatments: Improving Family Therapy and Research by Advancing Clinician and Researcher Collaborations;” Miami Lakes, FL; February 23rd, 2007

2. Overview • What are the specific challenges of our work within the juvenile justice system? • How have we addressed these challenges to successfully implement evidence-based family treatments within complex systems? • Is there any evidence that implementing evidence-based family treatments in real- world settings improves youths’ outcomes? • What are the current pressing questions?

3. “ Instead of helping, we are writing off these young Americans, we are releasing them without attending to their needs for substance abuse treatment and other services, punishing them without providing help to get back on track.”-- Joseph A. Califano, CASA, 2004

4. Four of every five children and teen arrestees in state juvenile justice systems have some involvement with drugs and alcohol Only 3.6 percent of these juvenile justice involved youth receive any type of treatment CASA 2004

5. “I have been there. I have witnessed the deplorable conditions forced upon these young people. The system must be changed to address the needs of these juveniles and prevent them from living a life crime and drug addiction.” - Charles W. Colson, Founder and Chairman of the Board, Prison Fellowship, the world's largest outreach to prisoners, ex-prisoners, crime victims and their families.

6. “The juvenile courts of our country have become the leading service delivery system for children and youth with substance abuse problems, not by choice, but by necessity.” - Reclaiming Futures: A model for judicial leadership (2006).

7. Multiple Interacting Problems of Juvenile Offenders • Serious substance abuse: 60 - 80% of incarcerated samples • Violent offenses: 70% of repeat offenders • Co-occurring mental health problems: 75% have a DSM disorder + CD and SUD • Family disruption, conflict, and chaos • School problems: 85% suspended/80% LD • Negative peers/ gang involvement • High-risk sexual behavior

8. Antisocial Behavior Over Time • Early childhood risk factors and family problems set the stage • Antisocial behavior compromises emotional and social development • Long-term deficits across domains • Family-based intervention during adolescence may halt the progression of drug abuse and antisocial behavior

9. Assessment and Intervention in the Juvenile Justice System • Youth screened at intake centers • Screening conducted to determine level of risk • Youth at lowest risk placed in diversion programs – few are empirically supported • Comprehensive assessments conducted with moderate and high risk youth • Highest risk youth stay in detention 3-21 days • Disposition may involve court-ordered treatment as part of probation or drug court

10. DJJ System Challenges • JACs and facilities overcrowded/understaffed • Assessments not conducted with all teens at risk due to limited resources • Services for youth in JJ settings are limited and few have any empirical basis • Families rarely involved in treatment • Little coordination/follow-through between JJ facilities and treatment programs • Bottom line: Most juvenile offenders don’t receive services at all – positive outcomes in the DJJ system are truly “against all odds”

11. Barriers to Implementing Effective Family Treatments • Focus is on punishment – not treatment • “Too many cooks” (DA/SA, PD, judge, PO) • Deep and pervasive pessimism about families – belief that “boot camp” is helpful • Disconnect between research, clinical, and DJJ systems – different theories of change, different agendas, and different masters • Treatment models not seen as credible/ seen as too complex to integrate within system • Lack of resources to fully implement the models and sustain them over time

12. Evidence-based Family Treatments for Young Offenders • Multifaceted problems require multicomponent assessment and intervention strategy • Families and other systems are primary contexts for development and change • Effective interventions go beyond a uni- dimensional theory of change • Multidimensional approaches address risk and protective factors within the individual teen, the parent, family system, and school, court, and other systems

13. “Today, we have solid evidence showing that rehabilitation works and is cost-effective.  Studies by the Washington State Institute for Public Policy found proven treatment programs are a good investment.  For example, Functional Family Therapy reduced recidivism by 38 percent, saving the tax-payers $10 for every dollar spent.”-- Jonathon Fanton, President, MacArthur Foundation

14. Multisystemic Therapy for Youth in Juvenile Drug Court • Henggeler et al (2006) reported successful implementation of MST within the juvenile drug court program • Family Court + TAU and Drug Court + TAU performed poorly in comparison to combined effects of the 2 MST conditions (MST + Drug Court; MST + CM + Drug Court)

15. Multidimensional Family Therapy with Drug Abusing Juveniles in Detention • Assess youth immediately in detention • MDFT therapist intervenes with youth in detention and parents in their home • Continue MDFT after release, building upon foundation established in detention • Incorporates HIV/STD prevention • Targets multiple domains of functioning • Collaboration with PO, judge, PD

16. Multidimensional Family Therapy in Juvenile Drug Court • MDFT is currently being tested within Miami-Dade’s Juvenile Drug Court program • MDFT therapists work collaboratively with the court and probation officers to ensure compliance with the program • Outcomes expected to be better than drug court + standard group treatment • Incorporates HIV/STD prevention • Outcomes targeted across domains (e.g., individual, family, school functioning)

17. Implementing Evidence-based Family Treatments: “Are we doing our own model?” • Multi-level assessment/intervention strategy • Negotiating multiple alliances • Collaborative approach • Assessing and reading feedback •   Planning and flexibility are complementary • Accept “rough around the edges” outcomes • Actively shaping and directing the process • Maintaining intensity and focus

18. Addressing Barriers to Implementation • Start with what juvenile justice authorities feel needs to change • Multisystemic assessment of context • Identify multiple levels of system/ subsystem units • Assess by joining system • Involve jj folks and the providers at all levels in assessing, planning, and implementing EBP • Work as a team with jj system and providers •   Emphasize the efficacy of the approach in ways that are concrete and meaningful • SIMPLIFY and protocolize the approach

19. Addressing Barriers (cont.) • Communicate clearly about the intervention and the outcomes being achieved • Discuss how new treatment fits in/augments existing system and practices • Be creative in providing incentives for change •   Discuss and address obstacles to change in a realistic, non-defensive way • Reinforce knowledge gained with providers • Create opportunities for providers to practice skills, give feedback, and get feedback from them about intervention’s fit and any obstacles

20. Transporting MDFT into an Adolescent Day Treatment Program • NIDA-funded project attempting to implement MDFT within an existing day treatment program for drug abusing young offenders • Day treatment program set in a large, complex public hospital system • Interrupted time-series design with 4 phases: Baseline, Training, Implementation, and Durability • First systematic study of the integration of MDFT in an existing drug treatment program

21. Study Aims • Clinical Practices: Determine whether providers could implement MDFT with adequate fidelity within the day treatment program • Program Changes: Determine whether the program could be transformed based on MDFT principles and interventions • Client Changes: Determine whether MDFT implementation would positively impact youths’ outcomes across domains of functioning • Durability: Determine whether changes could be sustained without MDFT trainers

22. Study Phases • Phase I. Baseline: Assessment of provider practices, program environment, and client outcomes • Phase II. Training: Work with all staff in day treatment program and larger system • Phase III. Implementation: Continue expert supervision and booster trainings as needed; Assess impact of training • Phase IV. Durability: MDFT experts withdraw; Assess sustainability of approach

23. Adolescent Day Treatment Program • Multicomponent program/multidisciplinary staff • Behaviorally oriented “levels approach” • School through alternative education program • Group therapy daily and recreational activities • Psychiatric evaluation and intervention • Individual therapy weekly • Family therapy “as needed”

24. Implementation Approach • Guiding principle: Isomorphism between training approach and therapy model • Collaboration/ Consultation • Empowering clinical staff and redefining roles • Conceptualizing change at different levels of system and in different domains • Modeling interventions, practice, and feedback • Increasing staff accountability

25. Outcomes • Clinical Practices (Adherence to MDFT): • Changes in sessions and contacts (parameters) • Changes within sessions (interventions) • Program Changes: • Changes in adolescents’ perceptions of program environment • Client Changes: • Drug use, externalizing/internalizing symptoms • Arrests and placements in controlled settings • Involvement with delinquent peers

26. Increases in Sessions over Study Phases More individual sessions on days attended in Implementation and Durability More family sessions on days attended in Implementation and Durability

27. Increases in Contacts over Study Phases More DJJ contacts in Implementation than Baseline Slight decrease in DJJ contacts in Durability More contacts with schools in Implementation and Durability

28. Adherence to MDFT Interventions • Coding of therapists’ charts revealed more focus on drugs during sessions in the Baseline phase (p<.05) • Therapists focused on school issues and adolescents’ thoughts and feelings about themselves more in the Implementation and Durability phases (p’s<.01) • Therapists in Implementation and Durability addressed more core MDFT content themes per session than sessions in Baseline (p<.05) • Ratings of sessions revealed significant increases in adherence to MDFT interventions over phases (adolescent-focused, family-focused, and engagement/reconnection interventions all p < .05)

29. Changes in Session Content over Study Phases More focus on self in Implementation and Durability More focus on school in Implementation and Durability More focus on drugs in Baseline

30. Changes in Program Environment Adolescents felt the program was more organized in Implementation than Baseline Adolescents felt the program had a more practical orientation in Implementation and Durability Adolescents felt staff were more clear about rules/expectations in Implementation and Durability

31. Results: Client Outcomes • LGM used to compare drug use, externalizing, and internalizing trajectories between intake and 9 months for youth in the 3 study phases • Youth decreased drug use more rapidly in Implementation and Durability phases than youth in Baseline (p’s<.05) • Youth in Implementation and Durability decreased their externalizing and internalizing symptoms more rapidly than youth in Baseline (p<.05) according to self-report • Youth improved more rapidly in internalizing (p<.05) and externalizing symptoms (p=.01) in Durability relative to Baseline according to parent reports

32. Change in Self-Reported Externalizing Problems Youth in Implementation and Durability improved more rapidly than youth in Baseline

33. Change in Self-Reported Internalizing Problems Youth in Implementation and Durability improved more rapidly than youth in Baseline

34. Percent in Controlled Environment at Follow-up over Study Phases

35. Summary of Findings • Clinical Practices: Therapists implemented MDFT in accordance with treatment parameters and interventions • Program Environment: Program was more practical, individually focused, organized, and clear following training in MDFT • Client Outcomes: Youths’ drug use, internalizing and externalizing symptoms, peer delinquency, and placements were reduced following MDFT training • Durability: Staff continued to use MDFT and to demonstrate outcomes with youth a year after MDFT experts withdrew

36. Implications of Findings • Evidence-based family treatment was successfully implemented within a complex hospital system, overcoming many obstacles • Implementation was successful in impacting all three levels of outcomes (provider, program, client) • Implementation successfully created lasting change in fundamental areas of provider and program functioning that impacted client outcomes

37. Current Pressing Questions • How can evidence-based family treatments be integrated within residential settings? • Can protocols and training components be simplified to help juvenile justice workers at different levels implement key interventions? • What can these approaches offer to make progress on challenges of workforce development/retention? • How can methods be improved to measure whether we’re “doing our model?”

38. Resources for Working with Drug Abusing Juvenile Offenders Barnoski, R. (2002). Monitoring vital signs: Integrating a standardized assessment into Washington State’s Juvenile Justice System. In R. Corrado et al. (Eds.), Multi-problem violent youth. IOS Press. Brown, D., Maxwell, S., DeJesus, E., & Schiraldi, V. (2002). Barriers and promising approaches to workforce and youth development for young offenders. The Annie E. Casey Foundation, Baltimore, MD. CASA (2004). Criminal neglect: Substance abuse, juvenile justice and the children left behind. Grisso, T. (1998). Forensic evaluation of juvenile offenders: A manual for practice. Sarasota, FL. Professional Resource Press. Hoge, R., & Andrews, D. (1996). Assessing the youthful offender: Issues and techniques. New York: Plenum Press. Liddle, H. (2002). Multidimensional Family Therapy Treatment (MDFT) for adolescent cannabis users. Volume 5 of the Cannabis Youth Treatment (CYT) manual series. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services. NIDA (1999). Principles of Drug Addiction Treatment: A research-based guide. (NIH publication 99-4180). Rockville, MD. NIDA (2006). Principles of Drug Abuse Treatment for Criminal Populations: A research-based guide. (NIH publication 06-5316). Rockville, MD. OJJDP (1995). Guide for implementing the comprehensive strategy for serious, violent, and chronic juvenile offenders. Washington, DC: OJJDP. Reclaiming Futures Fellowship Report (2006). A model for judicial leadership: Community responses to juvenile substance abuse. Reclaiming Futures.

39. Acknowledgements We gratefully acknowledge the National Institute on Drug Abuse for supporting this work through many grants, including the Criminal Justice Drug Abuse Treatment Studies (CJDATS: Grant No. 5 U01 DA16193; P50 DA; H. Liddle, PI), “Family-based Juvenile Drug Court Services” (Grant no. 1 R01 DA17478; G. Dakof, PI), and our “Bridging” study (Grant No. R01 DA3089, H. Liddle, P.I.). We are also indebted to the many therapists and the teens and families who have participated in these studies to develop and test MDFT over more than 20 years. Please see our website for more information on the Center’s program of research: www.miami.edu/ctrada or contact me at crowe@med.miami.edu for more details.