understanding the role of residential addiction treatment for adolescent: an overview of...

Understanding the Role of Residential Addiction Treatment for Adolescent: An Overview of Characteristics, Services and Outcomes

Michael Dennis, Ph.D.Chestnut Health Systems, Bloomington, IL

January 10th, 2008 presentation at the Symposium on Adolescent Residential Alcohol and Drug Treatment, Cromwell, CT. This presentation reports on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270-2003-00006 and several individual grants. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: [email protected]

2

1. national trends in residential treatment for adolescents

2. how the clinical severity of adolescents varies by level of care

3. how the source of referral, length of stay, type of discharge, outcomes, and type of evidenced based practice varies by level of care

4. observational and experimental evidence on the impact of continuing care

5. the interaction of level of care and victimization

This presentation will examine..

3

Trends in Adolescent (Age 12-17) Treatment Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S.Admissions in the U.S.

Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

1992 1994 1996 1998 2000 2002 2004

Year of Admission

Num

ber

of A

dmis

sion

s A

ge 1

2-17

.

50% increase from95,017 in 1992

to 142,646 in 2005

10% drop off from 2004 to

2005

4

Trends in Adolescent (Age 12-17) Trends in Adolescent (Age 12-17) Level of Care Placement in the U.S.Level of Care Placement in the U.S.

Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,00019

92

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Detoxcification

Short Term Residential

Long Term Residential

Intensive Outpatient

Outpatient

•Average 17% residential •Size increasing over time•% decreasing over time

5

Variation by State in the Percentage of Adolescent Residential Treatment: 1995 to 2005

10/07

Virgin Islands

1.6 to 5.9%

Indiana

Kansas

MaineMontana

NebraskaNevada

North Dakota

Puerto Rico

Hawaii

New Mexico

South Dakota

Alabama

Arkansas

Iowa

Oklahoma

Rhode Island

South CarolinaDistrict Of ColumbiaTennessee

Utah

Louisiana

W. Virginia

Minnesota

Wisconsin

New Jersey

North Carolina

Alaska

Delaware

Maryland

Pennsylvania

Georgia

KentuckyVirginia

MichiganNew York

Oregon

Colorado

Texas

New Hampshire

Connecticut

Illinois

Missouri

Arizona

Florida

Ohio

Vermont

Idaho

Massachusetts

California

Washington

Wyoming

% ResidentialMississippi

6.0 to 10.5%

10.6 to 18.7%

18.8 to 29.9%30.0 to 52.3%

6

Severity Goes up with Level of Care

Source: Treatment Episode Data Set (TEDS) 1993-2003.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Weekly useat intake

First usedunder age 15

Dependence Prior Treatment

Case Mix Index (Avg)

Outpatient Intensive Outpatient DetoxificationLong-term Residential Short-term Residential

STR: Higher on

Dependence

Baseline Severity Goes up with Level

of CareDetox: Higher on Use

Detox: Higher on Use, but lower on prior tx

7

Median Length of Stay is only 50 days

Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

0 30 60 90

Outpatient(37,048 discharges)

IOP(10,292 discharges)

Detox(3,185 discharges)

STR(5,152 discharges)

LTR(5,476 discharges)

Total(61,153 discharges)

Lev

el o

f C

are

Median Length of Stay

50 days

49 days

46 days

59 days

21 days

3 days

Less than 25% stay the

90 days or longer time

recommended by NIDA

Researchers

8

53% Have Unfavorable Discharges

Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

0% 20% 40% 60% 80% 100%

Outpatient(37,048 discharges)

IOP(10,292 discharges)

Detox(3,185 discharges)

STR(5,152 discharges)

LTR(5,476 discharges)

Total(61,153 discharges)

Completed Transferred ASA/ Drop out AD/Terminated

Despite being widely recommended, only 10% step down after intensive treatment

9

So what does it mean to move the field towards Evidence Based Practice (EBP)?

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, and long term program planning

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

Having the ability to evaluate performance and outcomes – For the same program over time, – Relative to other interventions

10

Key Issues that we try to address with the Global Appraisal of Individual Needs (GAIN)

High turnover workforce with variable education background related to diagnosis, placement and treatment planning.

Heterogeneous needs and severity characterized by multiple problems, chronic relapse, and multiple episodes of care

Lack of access to or use of data at the program level to guide immediate clinical decisions, billing and program planning

Missing or misrepresented data that needs to be minimized and incorporated into interpretations

11

GAIN Logic ModelIssue Instrument Feature Protocol Feature Outcome

Hig

h T

urno

ver

Wor

kfor

cew

ith

Var

iabl

e E

duca

tion

• Standardized approach to asking questions across domains

• Questions spelled out and simple question format

• Lay wording mapped onto expert standards for given area

• Built in transition statements, prompts, and checks for inconsistent and missing information.

• Responses to frequently asked questions• Multiple training resources

• Formal training and certification protocols on administration, clinical interpretation, data management, project 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 technical assistance

Impr

oved

Rel

iabi

lity

and

E

ffic

ienc

y

Het

erog

eneo

us N

eeds

an

d S

ever

ity

• Multiple domains• Focus on most common problems• Participant self description of

characteristics, problems, needs, personal strengths and resources

• Behavior recency, breadth, frequency• Utilization lifetime, recency and

frequency• Dimensional measures• Interpretative cut points

• 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• Treatment planning recommendations

and links to evidence-based practice• Basic and advanced clinical

interpretation training and certification

Com

preh

ensi

ve A

sses

smen

t

12

GAIN Logic Model (continued)Issue Instrument Feature Protocol Feature Outcome

Mis

sing

or

Mis

repr

esen

ted

Dat

a

• 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

Impr

oved

Val

idit

y

Lac

k of

Acc

ess

to o

r us

e of

D

ata

at th

e P

rogr

am L

evel • 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 (soon) 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 routine pooled to support comparisons across programs and secondary analysis

• Over two dozen scientists working with data to link to evidence-based practice Im

prov

ed P

rogr

am P

lann

ing

and

Out

com

es

13

GAIN Clinical CollaboratorsAdolescent and Adult Treatment Program

10/07

GAIN State System

Virgin Islands

01 to 1011 to 25

26 to 130

Indiana

Kansas

MaineMontana

NebraskaNevada

North Dakota

Puerto Rico

Hawaii

New Mexico

South Dakota

Alabama

Arkansas

Iowa

Oklahoma

Rhode Island

South CarolinaDistrict Of ColumbiaTennessee

Utah

Louisiana

W. Virginia

Minnesota

Wisconsin

New Jersey

North Carolina

Alaska

Delaware

Maryland

Pennsylvania

Georgia

KentuckyVirginia

MichiganNew York

Oregon

Colorado

Texas

New Hampshire

Connecticut

Illinois

Missouri

Arizona

Florida

Ohio

Vermont

Idaho

Massachusetts

California

Washington

Wyoming

GAIN-SS State or County System

Number of GAIN SitesMississippi

14

TEDS vs. CSAT GAIN Data: Demographics

*Any Hispanic ethnicity separate from race group.

Sources: TEDS 1992 to 2005 Concatenated file subsetted to 1998 to 2005, age 12-17. and CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).

79

19

28

32

42

27

82

18

16

11

65

30

1618

0 20 40 60 80 100

15 to 17 years old

12 to 14 years old

Hispanic*

Mixed/Other

Caucasian

African American

Female TEDS (n=1,188,223)

CSAT (n=15,254)

CSAT less likely to be Caucasian

Admin

15

TEDS vs. CSAT GAIN Data: Level of Care

* Excluding Detoxification ** Excluding Early Intervention, Corrections and Continuing Care

Sources: TEDS 1992 to 2005 Concatenated file subsetted to 1998 to 2005, age 12-17. and CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).

71%

9%

17%

3%

68%

12%

9%

8%

0% 20% 40% 60% 80%

Outpatient

IntensiveOutpatient

Long TermResidential

Short TermResidential

TEDS (n=1,804,151)*

CSAT (n=12,824)**

CSAT more likely to be long term residential

CSAT breaks out Moderate Term Residential (MTR; 30-90 days expected length of stay)

Admin

16

Substance Use Problems

83%

50%

29%

7%

34%

29%

26%

94%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Past Year Substance Diagnosis

Any Past Year Dependence

Any withdrawal symptoms in the past week

Severe withdrawal (11+ symptoms) in past week

Can Give 1+ Reasons to Quit

Any prior substance abuse treatment

Acknowledges having an AOD problem

Client believes Need ANY Treatment

Source: CSAT 2007 AT Outcome Data Set (n=12,601)

17

Past Year Substance Severity by Level of Care

38%

57%

72% 75%86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Outpatient IOP LTR MTR STR

UseAbuseDependence


18

Past 90 day HIV Risk Behaviors

Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

64%

33%

29%

25%

20%

2%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sexually active

Sex Under the Influence of AOD

Multiple Sex partners

Any Unprotected Sex

Victimized Physically, Sexually, orEmotionally

Any Needle use

19

Sexual Partners by Level of Care

27%33%

39% 38%52%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

No SexualPartners

OneSexualPartner

MultipleSexualPartners


20

Co-Occurring Psychiatric Problems


66%

50%

42%

35%

24%

14%

63%

45%

31%

22%

9%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Co-occurring Psychiatric

Conduct Disorder

Attention Deficit/Hyperactivity Disorder

Major Depressive Disorder

Traumatic Stress Disorder

General Anxiety Disorder

Ever Physical, Sexual or Emotional Victimization

High severity victimization (GVS>3)

Ever Homeless or Runaway

Any homicidal/suicidal thoughts past year

Any Self Mutilation

21

Co-Occurring Psychiatric Diagnoses by Level of Care

29%42%

54% 52%68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

None

One

Multiple


22

Severity of Victimization by Level of Care

38%

53%64% 59%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

Low

Moderate

High


23

Past Year Violence & Crime

*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)


80%

68%

63%

48%

45%

43%

85%

71%

39%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any violence or illegal activity

Physical Violence

Any Illegal Activity

Any Property Crimes

Other Drug Related Crimes*

Any Interpersonal/ Violent Crime

Lifetime Juvenile Justice Involvement

Current Juvenile Justice involvement

1+/90 days In Controlled Environment

24

Type of Crime by Level of Care

36%

53%64%

54%67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

Drug Useonly

OtherCrime

ViolentCrime


25

Three

None

Five to Twelve

Four

Two

One

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Multiple Problems* are the Norm


Most acknowledge 1+ problems

Few present with just one problem (the

focus of traditional research)

In fact, 45%present acknowledging 5+

major problems

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

26

Number of Problems by Level of Care

39%50% 55%

67%78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

0 to 1

2 to 4

5 or more


27

Adolescent Residential Treatment Sites (N=1,997 adolescents from 30 sites)

10/07

AL

AK

AZ

AR

CACO

CT

DE

FL

GA

HI

ID

IL IN

IA

KSKY

LA

ME

MD

MA

MI

MN

MS

MO

MT

NENV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PARI

SC

SD

TN

TX

UT

VT

VA

WA

WV

WI

WY

PR

VI

Baltimore

Dallas

Eugene

Fairbanks

Ft. Collins

Houston

Iowa City

Laredo

Los AngelesLouisville

Medford

New York

Oakland

OrlandoPaia

Philadelphia

Phoenix

Richmond

San Diego

San Jose

Shiprock

St Louis

Tucson

ARTSCYTCE-HIVATMDCYORPTCEAAFT

Washington Cnty.

28

Sources of Referral by Level of Care

34%25%

14%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LTR MTR STR

Community

OtherSources

OtherTreatment

JuvenileJustice

Source: CSAT 2007 AT Outcome Data Set (n=1689)

29

Length of Stay by Level of Care


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 30 60 90 120 150 180 210 240 270 300 330 360

Length of Stay (Days)

Per

cent

Sti

ll in

Tre

atm

ent

STR (Median= 30 days)MTR (Median=60 days)LTR (Median=145 days)

Length of Stay VariesBoth by level of care

and within level of care

All better than the National average

30

Type of Discharge by Level of Care

47%

19%11%

22%

54% 75%

23% 23%11%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LTR MTR STR

Completed

Transfer toTreatment

JuvenileJustice

AMA/ASA


All levels significantly

better than the 10% national

average

31

Selected Outcomes by Level of Care

0% 20%

40%

60%

80%

100%

Abstinent

Remission from SUD

Good Health

Crime Free

No Family Problems

Mental Health

No Juv. Just. Invovlement

In Community

Vocational Engaged

LTR

MTR

STR


Longer lengths of stay doing

better

Shorter lengths of stay doing better

MTR doing better

32

Types of Treatment by Level of Care

Thunder Road Thunder RoadThunder Road

Phoenix Academy

Other CBT

Dynamic YouthACRA

AR-Hazeldon

Mountain Manor

Walking in Beauty on the Red Road

7 Challenges

La Cañada

Other TCOther Ther. Community

Other 12-Step

Other CBTOther

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LTR (n=660) MTR (n=1,094) STR (n=243)


33

Recovery* by Level of Care:

* Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT 2006 Adolescent Treatment Outcome Data Set (n-9,276)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Per

cent

in P

ast

Mon

th R

ecov

ery* Outpatient (+79%, -1%)

Residential(+143%, +17%)

Post Corr/Res (+220%, +18%)

OP & Resid

Similar

CC better

Findings from the Assertive Continuing Care (ACC)

Experiment

183 adolescents admitted to residential substance abuse treatment

Treated for 30-90 days inpatient, then discharged to outpatient treatment

Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC)

Over 90% follow-up 3, 6, & 9 months post discharge

Source: Godley et al 2002, forth coming

35

ACC Enhancements

Continue to participate in UCC

Home Visits

Sessions for adolescent, 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)

36

Assertive Continuing Care (ACC)Hypotheses

Assertive Continuin

g Care

General Continuin

g Care Adherence

Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA)

Early Abstinence

GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence

Sustained Abstinence

Early abstinence will be associated with higher rates of long term abstinence.

37

ACC Improved Adherence

Source: Godley et al 2002, forthcoming

0% 10%

20%

30%

40%

50%

60%

70%

80%

Weekly Tx Weekly 12 step meetings

Regular urine tests

Contact w/probation/school

Follow up on referrals*

ACC * p<.05

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 7/12 criteria*

UCC

38

GCCA Improved Early (0-3 mon.) Abstinence


24%

36% 38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*)

Low (0-6/12) GCCA

43%

55% 55%

High (7-12/12) GCCA * p<.05

39

Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence


19% 22% 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*)

Early(0-3 mon.) Relapse

69%

59%

73%

Early (0-3 mon.) Abstainer * p<.05

40

Some Concluding Thoughts…

Residential Treatment continues to play a critical role by targeting higher severity clients

Evidenced based practices are not panacea, but they pull up the bottom and improve average outcomes

Implementing continuing care improves average outcomes

More work is need on the use of schools and recovery schools as a location for continuing care after residential treatment.

41

Other Assessment and Treatment Resources

Assessment Instruments – GAIN Coordinating Center at www.chestnut.org/li/gain – CSAT TIP 3 at

http://www.athealth.com/practitioner/ceduc/health_tip31k.html – NIAAA Assessment Handbook at

http://www.niaaa.nih.gov/publications/instable.htm Treatment Programs

– CSAT CYT, ATM, ACC and other treatment manuals at www.chestnut.org/li/apss/csat/protocols and on CDs provided

– SAMHSA Knowledge Application Program (KAP) at http://kap.samhsa.gov/products/manuals

– NCADI at www.health.org – National Registry of Effective Prevention Programs

Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov

Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) www.chestnut.org/li/apss/sasate

Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/jmate/

– next meeting March 30-April 2, 2008, Washington, DC

http://www.chestnut.org/li/gain

http://www.athealth.com/practitioner/ceduc/health_tip31k.html

http://www.niaaa.nih.gov/publications/instable.htm

http://www.chestnut.org/li/apss/csat/protocols

http://kap.samhsa.gov/products/manuals

http://www.health.org/

http://www.modelprograms.samhsa.gov/

http://www.chestnut.org/li/apss/sasate

http://www.mayatech.com/cti/jmate/



understanding the role of residential addiction treatment for adolescent: an overview of...

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