Implementing an Evidence-Based Program with Latino Families

1. Implementing an Evidence-Based Program with Latino Families Joint Meeting on Adolescent Treatment Effectiveness December 14–16, 2010 Southern California Alcohol & Drug Programs Youth Family Services Division Lisa Markell, SCADP, Director of Public Relations and Fund Development Martha Varela, SCADP, Project Director Sara Millán, SCADP, Clinical Supervisor Guillermo Ayala, MBA, SCADP, Clinical Supervisor Carrie Petrucci, MSW, Ph.D., EMT, Project Evaluator

2. Southern California Alcohol and Drug Program • Started in 1972 • Non-profit services Los Angeles and Orange County • Headquarters in Downey, California • Inpatient and outpatient substance abuse treatment programs serving… • Youth and teens • Men and women • Parents • Families

3. Youth and Family Services Division • Initially provided outpatient group treatment as primary modality of treatment for youth • Served Latino youth and their families • Paid through Med-i-Cal services • Saw need for individual services but no funding source

4. Overview of Today’s Presentation • Recruitment, Follow-up and Fidelity: Consideration of Latino culture in recruitment and follow-up, including understanding how drug and alcohol use is perceived, how treatment is perceived, and development of a parenting group to further support families; brief presentation of fidelity and outcomes from our AAFT1 project • Engaging our Families: Engaging and retaining Latino youth and families in treatment using culturally appropriate strategies and program enhancements • Implementation Issues and Solutions for A-CRA: Implementation barriers to substance abuse treatment for Latino families and how to overcome them

5. Recruitment: Alcohol vs. Drugs • How substance use and abuse and substance treatment is viewed and understood by Latino (primarily Mexican) families • Seen separately as alcohol or drugs (not “substance use”) • Greater stigma in drug use than alcohol use • 1st generation perspective on marijuana use • Any use of drugs is problematic

6. Recruitment: Cultural Understanding • We are sensitive to needs of the families • Latino culture varies by… • Country-of-origin • How many generations in the U.S. • Reasons for leaving the home country • Connections to relatives in the U.S. and in country-of-origin • Other factors • ¡Si Se Puede! serves families primarily from Mexico • We also serve families from Central America and South America

7. Recruitment: Cultural Understanding • Important background considerations for understanding culture of families • Families are proud to be Mexicans (or their country-of-origin) • Spanish spoken in 70-80% of the homes • Most youth are bilingual • Acculturation among youth not high • Youth have to balance both cultures • Most families still maintain significant contact with their families in Mexico (or their country-of-origin)

8. Parent Perceptions of Alcohol Use • Alcohol is viewed differently • Seen as more common • Expected that everyone will drink some • Okay for teens to drink at home with family • 1 or 2 beers with family on special occasions • “Not to the point of getting drunk” • Parents prefer use of alcohol (but not drugs) in the home so at least the youth are safe • Alcohol abuse more acceptable if… • No violence attached • Perceived as “normal” • Until they get sick

9. Parent Perceptions of Alcohol Use • Alcoholism not seen as a disease • Alcoholics are those people on the streets, who are homeless and drunk • Use alcohol to reduce stress • People who are alcoholic are “weak” • People who receive mental health services are “crazy”

10. Parent Perceptions of Drug Use • Parents assume that school is teaching youth about drugs, how to avoid them, and what to do about them so parents don’t think they need to learn this • Parents see drug use symptoms as their youth being lazy, not following directions • For this generation of Latinos, this is the first time that both caregivers have had to go out to work • We explain to parents… • What substance use and abuse is • What treatment is and what it does

11. Youth Perceptions of AOD Use • Marijuana used to reduce stress in the same way that alcohol is used by adults to reduce stress • Marijuana use not seen as unhealthy; “it’s organic” • Alcohol/marijuana may be viewed similarly, not as a problem • Use may be hidden from parents/caregivers • For Latina girls, ecstasy is seen as okay to have fun • Girls using gateway drugs more • Marijuana use has had a lot of publicity around “don’t use” but ecstasy has not gotten this type of attention • Girls say “but I’m not using marijuana” – they ARE using ecstasy

12. Youth Perceptions of AOD Use • Youth say they will not use marijuana because it stays in their system, but they will drink a bit more because they can’t be tested for that • Youth use strategies to avoid testing positive – switch drug use • Siblings will use together at home to keep each other safe • Youth may substitute with tobacco use for marijuana

13. Youth Motivators to Use • What motivates youth to use? • Boredom • Limited family interaction due to parents working a lot • Want to have fun • Lack of problem-solving skills • Lack of self-esteem • “Everybody’s doing it” • Necessity to fit in • Easy to get alcohol or marijuana for free from friends

14. Parent Treatment Perceptions • Problems with drugs or alcohol seen as… • A problem that an individual has and… • Not a family problem • Most parents feel like treatment is… • A “clinic” or a “school” • Concept of treatment is not known • Expectations are that treatment is used to punish the youth and that the therapist should tell the youth when they did something wrong • Parents ask therapist to punish the youth based on a recent act

15. Parent Treatment Perceptions • Most parents feel that treatment is going to “cure” their youth; you’re going to “fix” them • Parents don’t understand that part of treatment is for youth to feel understood • Youth stop going to school or get into fights but parents wait until youth are sent by court to look for help • Most parents deny the behavior • Parents react when it’s an emergency • No concept or use of prevention related to risk behaviors • Most parents didn’t know “these kind of programs” existed and have no information about drugs or alcohol

16. Parent Treatment Perceptions • Parents feel similar to youth… • Why am I involved in my child’s treatment? It’s up to him/her. How much more do I need to do? • Parents are busy and don’t understand the importance of talking to their youth… • Regularly about what’s going on with them, or about school • Or role modeling non-drinking behaviors • Parents come to understand… • What substance treatment is • Importance of addressing their youth’s substance use • Youth come to appreciate parent involvement

17. Youth Treatment Perceptions • How do youth perceive treatment? • Initially, as punishment • At beginning, very timid, shy, quiet, angry at the world, at us, mostly at their parent • As weeks go by, youth open up more • Eventually they see it as a way of someone understanding them; at 2 months they’re able to talk to the counselor or therapist about relapse or their use-related activities • Youth begin to get the language of recovery and the reason for what is happening in treatment • They begin to refuse to use with their friends • Youth begin to understand how positive reinforcers help them stop using

18. Youth Treatment Perceptions • Youth think we’re going to get mad at them • Youth feel shameful in the beginning • Youth feel shameful if they relapse and are unwilling to share • Clinicians address this shame so that youth feel comfortable talking about relapse • Hard for youth to understand why parents are brought into treatment • Youth don’t want their parents involved • See it as their own issue • Youth don’t see parent involvement as needed

19. Parenting Class • Helps the parent to understand how to communicate better with their youth • Instead of attacking the youth, they’re able to take the youth out for a burger or ice cream and take time to talk to them • When parents get information about effects of drugs or alcohol, they understand that the behavior was due to that • Parents learn to forgive their youth • Parents learn how to manage the aggressive behavior of their youth if it occurs due to substance use • Parents use different problem solving and communication skills • Made changes for parenting classes weekly

20. Parenting Class • Strictness in parenting • Parents very co-dependent so go along with what the adolescent wants or needs • In parenting, parents become more assertive • Parents learn how to set boundaries • Many parents experienced abusive parents themselves and don’t want to repeat this with their own children • Parents might be working a lot so they let their children do more • Parents didn’t realize they were losing control

21. Parenting Class • High resilience among parents – good survival skills • When they come here, parents don’t have skills in: • Talking to kids • Controlling their own emotions • They learn how to say whatever they want to say in more positive ways • They learn how to be supportive of their youth • Very family oriented – can talk to a cousin or someone else in the family to help bring them into treatment • We ask parents to come and help cook something, they like to feel involved, needed, with specific roles

22. Youth and Family Services Division • In 2006… • Awarded Federal SAMHSA grant • Supported individualized treatment in addition to existing group services • AAFT1 – 3 year project (Oct. 2006 – Sept. 2009) • Incorporated A-CRA and ACC in 6 month intervention • October 2006 to September 2009: 167 youth ages 13 to 18 and their families were provided services

23. Youth Program Description • The ¡Si Se Puede! program… • Serves Latino families • …seeks to ensure that high-risk Latino youth will gain skills to lead healthy, substance-free lives, and positively contribute to their own well-being, and the well-being of their families and their communities • …provides intensive culturally appropriate family centered outpatient substance abuse services to 14 to 18 year old first generation Latino youth with substance abuse issues and their families in Southeast Los Angeles

24. Drug/Alcohol Use 30 Days Prior to Intake Here we see drug and alcohol use 30 days prior to intake. More than half of youth self-reported illegal drug use. Marijuana and alcohol were the top two drugs of choice. About one quarter of youth reported use of 5 or ore drinks. Smaller percentages of youth used alcohol and drugs in the same day (17%), or reported using methamphetamine (6%), cocaine (4%) or hallucinogens (2%).

25. History of Substance Use Here we see the history of substance use among 149 youth at intake. Just under half had been using for 1 to 2 years (49%). Just under a quarter (21%) had been using for 3 to 4 years, and 11% reported using for 5 or more years. The remaining 18% had been using for less than a year.

26. Mental Health Risk Factors at Intake Here we see mental health risk factors at intake among 167 youth. Two thirds of youth displayed symptoms for Impulsive Personality Index (69%), and emotional problems (60%). Under half showed symptoms of a worrying personality (44%). One third or less exhibited depressive symptoms (37%), general mental distress (37%), somatic symptoms (32%), anxiety/fear (29%), traumatic stress (29%), and internal mental distress (26%).

27. Behavior Problems at Intake Here we see the percent of youth with moderate to high behavior problems at intake on several scales including: behavior complexity scale (66%), general conflict tactic scale (53%), ADHD disorder (52%), conduct disorder scale (48%), physical conflict scale (47%), inattentive disorder scale (43%), verbal conflict scale (39%), and hyperactivity-impulsivity scale (12%).

28. Crime Involvement at Intake Here we see the percentage of youth that scored moderate to high on crime involvement at intake among 167 youth on several scales including: crime/violence scale (58%), general crime scale (48%), property crime scale (35%), interpersonal crime scale (27%), illegal activity scale (26%), and drug crime scale (21%).

29. Fidelity to A-CRA Model This chart displays three different fidelity measures we tracked. Staff determined which of the A-CRA procedures they expected to provide to each youth and within what time frames. These were considered “required” procedures. Staff also identified optional A-CRA procedures. Adolescent fidelity scores tracked procedures provided to adolescents, and caregiver procedures were also tracked. The two were combined for a total fidelity score. Scores closer to one indicate greater fidelity. These scores show greater fidelity to adolescent procedures than caregiver procedures. This was a challenge in this grant that has been addressed in subsequent projects. Fidelity was up and then down in Years 1 and 2, typical of a new program, then stabilized by Year 3.

30. Statistically significant improvements occurred at 3 and 6 month follow-up compared to intake Improvement in Substance Problems Here we see a statistically significant improvement in the GAIN Substance Problem Scale at 3 months and 6 months among 104 youth with data at all three time points.

31. Statistically significant improvements occurred at each time point. Improvement in Abstinence Here we see a statistically significant improvement in abstinence at 3 and 6 month follow-up among 104 youth with data at all three time points. Abstinence increased by 25% from intake to 6 months.

32. Additional Outcomes at 3 & 6 Months Table 1. Repeated Measures General Linear Models at Intake, 3 months, and 6 months Examining Substance Abuse Consequences (N varies). Using a repeated measures general linear model among youth with data at intake, 3 and 6 months, here we see significant improvement on the GAIN Interpersonal Crime Scale and the Property Crime Scale, but no change in Vocational and Social Environmental Risk Indices.

33. Additional Outcomes at 3 & 6 Months Table 2. Friedman Tests at Intake, 3 months, and 6 months Examining Substance Abuse Consequences (N varies). Using Friedman Tests among youth with data at intake, 3 and 6 months, here we see significant improvement on the GAIN General Crime Scale, Drug Crime Scale, and Emotional Problems Scale.

34. Summary of AAFT1 Evaluation • Selected Outcomes for AAFT1 project: • Program implemented with good fidelity to A-CRA model, especially given that it was newly implemented • 85% (142/167) successfully completed A-CRA/ACC • Substance use significantly decreased from intake to 6 months • Substance use consequences significantly decreased from intake to 6 months

35. Engaging our Families • How can treatment professionals successfully engage and retain Latino youth and their families in substance abuse treatment using culturally appropriate strategies? • Welcome the entire family • Use positive, strengths-based, non-judgmental approach • Invite parents to parenting class • Use A-CRA procedures in one-on-one sessions with youth and in parenting class to establish trusting relationship • Be culturally sensitive to the needs of families

36. Engaging our Families • We establish rapport several ways including… • Initial meeting with the entire family and all staff • Creating a more welcoming environment from the start • Building trust with families • Showing families we understand different cultures • Accepting differences • Using humor to engage parents • Weekly Saturday activities for youth • Monthly family get-togethers

37. Engaging our Families • By 2nd or 3rd week of treatment, we are… • Looking at reinforcers for why youth use • Exploring why they have to smoke with friends or alone • Identifying triggers for cycle of use (people, places, things) • Youth look forward to positive reinforcers to stop using • Examples: completing probation, getting a job, regaining trust of parent and family • Youth become more comfortable with use and with the program

38. Engaging our Families • Often by the 2nd month, parents and youth come to accept family involvement • Youth see change in their mom or dad; see that they are more positive • Youth see that they can talk to their mom or dad • Youth spending more time together with their mom or dad • Youth don’t feel like they have to go out all the time because they can spend time with their parent

39. Youth Program Enhancements • ¡Si Se Puede! also incorporates the following enhancements to A-CRA/ACC: • Weekly Saturday sessions to enhance pro-social activities for youth and families • Weekly parenting classes to help parents recognize substance abuse in their children • Services provided at a community-based agency setting

40. Youth Program Enhancements • For youth, family get-togethers… • Help youth see they can do something fun with their parent • Help youth be more willing to do something fun with their family • Youth found they could talk to their Mom or “party” with their mom in a socially acceptable way and still have a good time • This was a key pro-social activity emphasized in A-CRA/ACC • Youth like seeing project staff in these sessions to see them in a different environment; everyone is relaxed

41. Youth Program Enhancements • For parents, family get-togethers… • Expose parents who didn’t come to the parenting group to what it was and what other parents were saying about it • Help parents see they aren’t the only ones who have a youth with substance use problems • Reduce shame among parents • Are fun, relaxing and not stressful • Occasionally get recognition for a dish they made • Help parents feel validated, supported, and less isolated • Help parents move to a more positive perception of their youth

42. Youth Program Enhancements • Monthly family get-togethers • Celebrate cultural and standard holidays • Allow parents and youth to meet project staff and see staff as more accessible • Help parents and youth feel comfortable talking about any problems with staff • Include potlucks to share homemade cooked meals • Or catering Mexican food • Emphasize family involvement, which is essential in these activities

43. Youth Program Enhancements • Gains made from the weekly and monthly family get-togethers… • Opens up the line of communication between youth and parents • Without shame or fear • Changes how families view the facility to a more positive view (get-togethers occur in back parking lot of treatment facility) • Festive atmosphere helps youth and parents move toward trusting relationships • Success story

44. Implementation Issues and Solutions for A-CRA • Common barriers to implementation of substance abuse treatment with Latino youth and how we overcame these • Transportation • Poor public transportation available • Low-income families have limited transportation options • Solution… • ¡Si Se Puede! offered weekly van pick-up and drop-off • Adapted afternoon schedule of counseling sessions to accommodate van pick-up and drop-off

45. Implementation Issues and Solutions • Child care • ¡Si Se Puede! does not offer child care • Culturally acceptable for youth to be accompanied by entire family • Limited resources limit availability of paying for a babysitter for younger siblings • Solution… • ¡Si Se Puede! accommodated younger siblings with a waiting room appropriate for youth children • Crayons, books, toys, and snacks available for siblings during youth and parent sessions • If really needed, program staff supervised young children while counselor met with youth or family member for one-on-one sessions

46. Implementation Issues and Solutions • Need for mental health treatment • Some youth diagnosed with mental health issues • ¡Si Se Puede! does not provide onsite mental health services by a licensed clinician • Some were already receiving mental health services prior to coming to the program • Solution… • ¡Si Se Puede! clinician referred to other community-based agencies for mental health services • Systematic encouragement to assure appointments for mental health services were made

47. Implementation Issues and Solutions • Neighborhood safety • Immediate vicinity of ¡Si Se Puede! agency location (Downey, CA) is a reasonably safe location • Police station one mile from office • Some youth were involved in gangs • Concern that gang issues would be brought to the office • Solution… • We asked youth to respect the program by signing a dress code agreement • No gang identifying clothing or paraphernalia is permitted • Never had any violent or negative incidents • The facility served as a neutral zone. No one was going to claim Downey. It helped that counselors were providing one-on-one sessions.

48. Implementation Issues and Solutions • Clinical/Administrative issues • Not all staff comfortable or open to working with an evidence based model and this lead to initial high turnover • The constant feedback given to counselors from various sources not always welcomed • Had the potential to affect treatment outcome of Latino youth and cooperation by family members • Solution… • Ensure commitment of new counselors to work with an evidence based model that incorporates harm reduction • Express importance of fidelity checks, taping sessions, certification process, and role of clinical supervisor

49. Implementation Issues and Solutions • Clinical / administrative schedule had to be changed • Initially, staff weren’t available enough during non-school hours • Solution… • Changed office hours so staff were available in late afternoon and evening (12pm – 8pm) • Hours of operation… • Staff initially had difficulty adjusting to these later hours • Solution… • Staff adjusted to later schedule • One of the clinicians is now in the role of Clinical Supervisor instead of the Program Director

50. Youth and Family Services Division • Success of AAFT1 contributed to youth program expansion, utilizing A-CRA/ACC • AAFT3 in 2009—3-year project • October 2009 to September 2012: 105 youth ages 18-24 and their families will be provided services • ORP1 in 2009—3-year project • October 2009 to September 2012: 180 probation-involved youth ages 14-18 and their families will be provided services • AAFT4 in 2010—3-year project • October 2010 to September 2013: 105 youth ages 12–13 and their families will be provided services