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EFFECTIVENESS STANDARDS FOR THE TREATMENT OF CHEMICAL DEPENDENCY IN JUVENILE OFFENDERS:
A REVIEW OF THE LITERATURE
House Bill 3900 (Sec 26-28) requires the development, implementation, and evaluation of the Chemical Dependency Disposition Alternative (CDDA) program, which provides local juvenile courts with a sentencing alternative for chemically dependent youth. Following an assessment to determine that the juvenile is chemically dependent,
"... the court shall then consider whether the offender and the community will benefit from use of this chemical dependency disposition alternative. If the court determines that this chemical dependency disposition alternative is appropriate, then the court shall impose the standard range for the offense, suspend execution of the disposition, and place the offender on community supervision for up to one year. As a condition of the suspended disposition, the court shall require the offender to undergo available outpatient drug/alcohol treatment and/or inpatient drug/alcohol treatment." (RCW 13.40.165 5a, 5b)
The University of Washington was mandated by this statute to develop standards for measuring the effectiveness of chemical dependency treatment programs for CDDA youth. These standards must include methods for measuring success following treatment of CDDA youth. The following report responds to the statute and describes the scientific basis for the chemical dependency programs for CDDA youth.
The CDDA legislation provides an opportunity for the Juvenile Rehabilitation Administration (JRA), in conjunction with the Division of Alcohol and Substance Abuse (DASA) and local juvenile courts, to strengthen existing chemical dependency programs for youth involved with the juvenile justice system. This will be accomplished by providing CDDA youth with additional elements of treatment that research has demonstrated to be effective in reducing substance use. Treatment of CDDA youth will emphasize enhancing linkages with community based services in order to provide a comprehensive continuum of care. Effectiveness of CDDA treatment programs can be assessed using changes in variables which research has demonstrated to be critical in the development and maintenance of adolescent substance use problems (such as school performance and emotional distress).
II. EFFECTIVENESS STANDARDS
Effectiveness standards for treatment programs should address three factors: Changes in adolescent behaviors with regards to substance use, criminal activity, and overall adjustment; Program implementation and integrity; and, Compliance with reporting requirements of the Juvenile Rehabilitation Administration, as well as the Division of Alcohol and Substance Abuse assessments and treatment standards for State-approved programs under WAC 440-22, and other involved agencies.
A. Changes in Adolescent Behavior
It is impossible to require that chemical dependency programs reduce substance use or criminal activity by a specific amount as each individual will have varying degrees of substance use, criminal involvement, and other problems at entry to treatment. Although an adolescent may not demonstrate a substantial decrease in substance use after treatment he may show improvement in other areas such as family and school functioning. It is important, therefore, to look at overall improvements in functioning after treatment and not solely at substance use or recidivism. Ideally, an effective treatment program will reduce an adolescent's involvement in substance use and or criminal activity, effectively treat psychopathology (if present), and will increase the level of family and social adjustment, and school/vocational performance. Some effective programs may not, however, be successful in modifying all problematic behavior in every individual treated.
1. Reductions in substance use will be assessed by:
- The frequency of substance use; the primary measure will be a reduction in the total number of days of use over the intervening period;
- The intensity of substance use; the primary measure will be a reduction in the number of times a day a drug is used;
- The number of substances an individual currently uses;
- The proportion of positive urinalyses collected over the intervening period;
- The number of re-convictions for alcohol or drug related offenses in the intervening period;
- Re-admission to a chemical dependency treatment program (detox, inpatient, or outpatient) over the intervening period;
- The number of emergency room visits;
- The number of inpatient medical hospitalizations.
2. Reductions in recidivism will be assessed by:
- The number of subsequent convictions incurred over the intervening period;
- A subsequent conviction is any court legal action including a conviction, deferred disposition or diversion agreement in a Washington State court for an offense committed following the initial action that made the youth eligible for the CDDA program;
- Felonies and misdemeanors, including gross misdemeanors, will be reported separately;
- The number of violations of the terms of community supervision;
- Violations are usually not criminal actions;
- Probation officers vary greatly in their reporting of violations;
- This is a difficult area to measure as violations typically increase as the level of supervision becomes more intense resulting in a potentially ambiguous and misleading measure of program effectiveness;
- Completion of any restitution to victims ordered by the court;
- The amount of the restitution will vary;
- Measures will include whether a youth is failing, successfully completing, or has fully completed restitution.
The number of arrests incurred over the follow-up periods will not be used as a measure of criminal recidivism in evaluation of the CDDA programs. Arrest data are difficult and costly to reliably obtain because there is no statewide database for arrests. Therefore, until there is a statewide database for arrests, arrests will not be used in determining effectiveness of chemical dependency treatment programs for CDDA youth.
3. Improvements in other areas:
Improved school performance over the intervening period as evidenced by:
- An improvement in grades;
- A decrease in truancy or drop-out;
- A decrease in the number of disciplinary actions.
Improved family functioning over the intervening period as evidenced by:
- Fewer conflicts with family members;
- Greater parental satisfaction with adolescent's behavior;
- Decreased runaway episodes.
Improved social functioning over the intervening period as evidenced by:
- Less time spent with substance-using and/or delinquent peers;
- Increased friendships with prosocial peers;
- Decreased feelings of alienation;
- Fewer incidences of unprotected sexual activity.
Improved psychological functioning over the intervening period as evidenced by:
Improved vocational functioning (if applicable) over the intervening period as evidenced by:
- Fewer days of self reported mood disorders;
- Fewer days of aggressive or hostile acts towards family, peers or others;
- Fewer days of antisocial behaviors;
- Greater ability to concentrate on tasks;
- Fewer admissions for psychiatric treatment, either inpatient or outpatient;
- Decreased use of psychiatric medications.
- Fewer absences from work;
- Fewer days of late attendance or leaving early;
- Fewer disciplinary actions;
- More positive relationship with co-workers.
B. Program Implementation and Integrity
If a program is not actually delivering the services contracted for by CDDA, it may be wrongfully evaluated as being ineffective. If the proposed services actually were provided by the treatment program, the program may have been effective in treating adolescent chemical dependency problems. For example, family involvement in treatment has been shown to be related to positive treatment outcomes. If a treatment program for CDDA youth does not actually provide family therapy as recommended, adolescents in that program may not reduce their substance use to the same degree as adolescents treated in a program that did include family therapy. Therefore, in order to determine program effectiveness and success in delivering proposed services the following factors will be assessed:
- The level of service adherence to treatment guidelines for chemical dependency treatment programs for CDDA youth;
- The number of direct treatment hours provided;
- The overall program completion and drop-out rates;
- The degree to which adolescents and their families are satisfied with the treatment program;
- The degree to which the CDDA programs are successful in linking JRA supervision services, community-based services, and families (or family substitute) in treatment of the youth.
C. Reporting Compliance
The agency's ability to meet regular deadlines will have a bearing on the evaluation of its effectiveness. Regular reporting to the Juvenile Rehabilitation Association, the Division of Alcohol and Substance Abuse, and the University of Washington research team will be considered an essential element of a successful treatment program.
III. CHEMICAL DEPENDENCY TREATMENT FOR ADOLESCENTS
Based on a review of the literature provided in the report, the ideal chemical dependency treatment program for CDDA youth would include the following:
- A structured clinical interview to determine DSM-IV diagnoses of substance dependence, abuse or use;
- A comprehensive evaluation addressing the following areas:
Treatment placement decisions should be made based on the findings from these clinical evaluations.
B. Elements of Effective Treatment
Based on a review of the literature it is recommended that all CDDA treatment programs, regardless of modality, should, ideally, include the following elements:
- Treatment should be delivered in the least restrictive setting, while considering issues of community safety;
- Treatment should be comprehensive and address the problems identified by the evaluation process (e.g., psychiatric disturbance, sexual abuse);
- Treatment must involve the family, or a family substitute, in all aspects of treatment planing, discharge recommendations, and continuing care;
- Family therapy and cognitive-behavioral therapy should be primary therapeutic techniques;
- General life skills, decision making, and coping skills education and training should be provided;
- Relapse prevention should be stressed;
- Treatment should be a continuum of care, meaning upon discharge from a program additional services are provided, in decreasing frequency, so that each adolescent will have services available for at least 12 months.
It is recommended that the treatment fidelity of the chemical dependency programs for CDDA youth be evaluated at six month intervals, at least initially, to determine whether similar services are being delivered by different chemical dependency treatment programs (e.g., all outpatient programs all provide the same type and intensity of services).
C. Continuum of Care
Reported relapse rates as high as 71% for adolescents 3-6 months following treatment indicate the need to provide additional support if abstinence is to be maintained. Although results regarding aftercare are inconsistent, the most promising treatment approaches for substance abuse treatment of juvenile offenders include a continuum of care for 12 months. Therefore, it is recommended that all CDDA youth be provided a continuum of care, ideally over a 12 month period. The intensity of treatment should vary over the 12 months based on the adolescent's needs and treatment plan. A 12 month continuum of care would enable practice and monitoring of new prosocial skills acquired in the primary treatment assignment. It is recommended that treatment services provided in the continuum of care utilize familial and community resources. Ideally, this would mean that:
- A team of individuals, including substance abuse treatment specialists, teachers, parents, probation officers and social service agency case managers, work in cooperation to provide a continuum of care;
- A proportion of the services be delivered in the home at the convenience of the family;
- Strengths of the family and adolescent are stressed;
- A flexible approach involving numerous therapy techniques is taken in treating the family and adolescent;
- Prosocial behaviors are reinforced;
- Relapse prevention is stressed;
- Formation of a pro-social peer group is strongly encouraged;
- Urine drug screens are randomly taken on adolescents. If results are positive, the frequency of treatment is increased.
- Frequency of therapy slowly decreases over time, allowing for practice and monitoring of treatment gains and the success to which those gains are integrated into daily community life.
IV. EVALUATION OF CDDA TREATMENT PROGRAMS
The CDDA legislation provides an opportunity for the Juvenile Rehabilitation Administration (JRA), in conjunction with the Division of Alcohol and Substance Abuse (DASA) and local juvenile courts, to strengthen existing chemical dependency programs for youth involved with the juvenile justice system. This will be accomplished by providing CDDA youth with additional elements of treatment that research has demonstrated to be effective in reducing substance use. Enhanced linkages with community based services in order to provide a comprehensive continuum of care will be emphasized. The CDDA program provides an opportunity to evaluate the process, and any difficulties that may arise, in implementation of the CDDA legislation. Effectiveness of these treatment programs can be assessed using changes in variables which research has demonstrated to be critical in the development and maintenance of adolescent substance use problems (such as school performance and emotional distress). Furthermore, the CDDA program provides the opportunity to evaluate the short term (6 month) and long term (18 month) effectiveness of this sentencing alternative in reducing substance use and recidivism in juvenile justice involved youth.
To determine whether the chemical dependency programs for CDDA youth are successful in decreasing substance use and delinquency, it is recommended that evaluations of outcome measures for CDDA treated adolescents, and the comparison groups be performed at several time points including:
- At baseline, the date of the court-ordered CDDA disposition;
- Upon discharge from the initial treatment placement (e.g., detention based treatment, inpatient treatment); this evaluation will provide data on the decrease in substance use achieved during the initial treatment and act as a baseline measure of substance use and general functioning for the continuing care component of CDDA treatment;
- At 6,12, and 18 months following the date of the court-ordered CDDA disposition.
Data regarding substance use and criminal activity will be corroborated at each evaluation through the use of urinalysis, criminal histories, and whenever possible by interviews with parents, probation officers and other individuals involved in the adolescent's treatment .
A. Measurement Timeframe
Several time frames will be utilized in measuring substance use, criminal activity, and other problem area outcomes:
- Measures will focus on the 30 days prior to each evaluation;
- Measures will focus on the six month follow-up periods (i.e. 6, 12 and 18 months);
- Measures will focus on the entire 18 month follow-up period.
At least initially, a few treatment programs with a large census should be utilized. This procedure will provide large enough sample sizes that statistically significant differences are more likely to be revealed by data analyses if they exist. By utilizing fewer programs and appropriate comparison groups, one can be more confident in concluding that any outcome differences are truly an effect of the program intervention and not due to some other factor.
Full report: Rutherford, M, Banta-Green C. Effectiveness Standards for the Treatment of Chemical Dependency in Juvenile Offenders: A Review of the Literature. Seattle: University of Washington. Alcohol and Drug Abuse Institute, January 1998. (ADAI Technical Report 98-01). Download full report (.pdf)
Page updated 8/17/00