Brooke Hunter & Susan H. Godley – Chestnut Health Systems

1. Exposure to the Adolescent Community Reinforcement Approach (A-CRA) and Mechanisms of Change for Substance Use and Illegal Activity Brooke Hunter & Susan H. Godley – Chestnut Health Systems Matthew Hesson-McInnis – Illinois State University Hendrik Roozen – Erasmus University Medical Centre, the Netherlands Joint Meeting on Adolescent Treatment Effectiveness Washington, D.C. Tuesday April 10, 2012

2. Acknowledgements • Special thanks to Drs. Susan Godley, Matthew Hesson-McInnis and Hendrik Roozen for their collaboration on this study. • Funding for this work has been provided by SAMSHA/CSAT (HHSS270200700004C) • The opinions expressed are those of the authors and do not reflect official positions of the contributing grantees’ project directors or the federal government.

3. Learning Objectives • Do adolescents who receive A-CRA experience reductions in illegal activity and juvenile justice system involvement? • What are the mechanisms of change for substance use and illegal activity within the treatment context? • Does exposure to A-CRA indirectly impact juvenile justice system involvement through reductions in substance use and illegal activity?

4. Co-Occurrence of Substance Use and Illegal Activity • There is a well established correlation between substance use and illegal activity • e.g., Donovan & Jessor, 1985; Elliot, Huizinga, & Menard, 1989; Loeber, Stouthamer-Loeber, & White, 1999 • ~ 49% - 70% of adolescents in substance use treatment were involved with the justice system • TEDS, 2008; Godley, Garner, Smith, Meyers, & Godley, 2011 • 2.4 million adolescents were arrested in 2000 • 38% self-reported substance use • 54% tested positive for an illicit substance • Only 13.5% were arrested for a drug or alcohol violation • National Center on Addiction and Substance Abuse at Columbia University, 2004

5. Increased Risk • Adolescents who use: • Alcohol are 2 times more likely to be arrested • Marijuana are 3.5 times more likely to be arrested • Cocaine are 9 times more likely to be arrested • Heroin are 20 times more likely to be arrested • Horowitz et al., 2006 • Each conviction of a criminal charge increases the likelihood that an adolescent will become an adult felon

6. Theories of Causation: What mechanisms underlie the relationship between substance use and illegal activity?

7. Substance Use Leads to Illegal Activity

8. Illegal Activity Leads to Substance Use

9. Common Antecedent Hypothesis

10. Reciprocal Causation

11. Treatment of Co-occurring Substance Use and Illegal Activity • Experts have identified key Elements of adolescent substance use treatment • Brannigan et al., 2004 • Drug Strategies: Bridging the Gap, 2005 – substance use treatment in the juvenile justice system • e.g., thorough assessments, developmentally appropriate, qualified therapists, family involvement, continuing care, etc. • A-CRA treatment protocol exhibits best practices

12. Aims of Current Study • Does A-CRA directly reduce illegal activity? • Does A-CRA indirectly reduce illegal activity through reductions in substance use? • Does A-CRA indirectly reduce substance use through reductions in illegal activity? • Does A-CRA reduce involvement with the juvenile justice system through reductions in substance use or illegal activity?

13. Baseline 6 month 12 month A-CRA Exposure Scale Alcohol & Other Drug Use Alcohol & Other Drug Use Alcohol & Other Drug Use Illegal Activity Scale Illegal Activity Scale Illegal Activity Scale Criminal Justice System Index Criminal Justice System Index Hypothesized Model

14. Participants • Adolescents who presented to substance use treatment and reported involvement in illegal activities during past year • 44 organizations located across the nation receiving federal funding to implement the Adolescent Community Reinforcement Approach • 1,467 adolescents

15. Sample Characteristics

16. Treatment Plan • Adolescent Community Reinforcement Approach – 3 months of treatment • 10 adolescent sessions • 2 caregiver sessions • 2 family sessions • Assertive Continuing Care – 3 months of home based A-CRA plus enhance case management • A-CRA includes 18 possible procedures, which can be repeated multiple times

17. Analytic Plan • Sample was split into two sub-samples • Model development sample • Model validation sample • Multiple groups analysis was used to cross-validate the final model • Mediation analysis with a bootstrapping procedure was conducted to further examine the relationship between A-CRA exposure and illegal activity

18. Baseline 6 month 12 month A-CRA Exposure Scale -.11 Alcohol & Other Drug Use Alcohol & Other Drug Use .42 Alcohol & Other Drug Use .24 .14 .26 .25 .27 Illegal Activity Scale .23 Illegal Activity Scale Illegal Activity Scale .29 -.08 .12 -.13 Criminal Justice System Index .22 Criminal Justice System Index Results

19. A-CRA Exposure path c Illegal Activity p = .00 Alcohol & Other Drug Use p = .00 p = .00 path b path a path c’ Illegal Activity A-CRA Exposure p = .04 Alcohol & Other Drug Use was a significant mediator according bootstrap 95% CI (-.0011, -.0003). Mediation

20. Main Findings • A-CRA exposure directly reduced both substance use and illegal activity • A-CRA exposure indirectly reduced illegal activity through reductions in substance use (partial mediation) • A-CRA exposure reduced involvement with the juvenile justice system through reductions in substance use and illegal activity

21. Implications • Substance use treatment is important for this population not only because it impacts substance use, but also because it impacts illegal activity and juvenile justice involvement • Reductions in juvenile justice involvement result in reduced costs to society

22. Strengths • Large sample size • Cross-validation of path model • Longitudinal design • Diverse multi-site sample of adolescents

23. Limitations • Self reported intake and follow up assessments • Lack of experimental design: cannot establish causal relationship of treatment on outcomes

24. Future Research • Is the model developed in the current study invariant by sub-groups (e.g., gender, race, or type of crimes committed)? • Are specific A-CRA procedures (e.g., anger management, increasing pro-social behavior) more important for adolescent who are engaging in criminal behavior? • What additional mediators explain the relationship between A-CRA exposure and illegal activity?

25. References • Brannigan, R., Schackman, B. R., Falco, M., & Millman, R. B. (2004). The quality of highly regarded adolescent substance abuse treatment programs, results of an in-depth national survey. Archives Pediatric Adolescent Medicine, 158, 904-909. • Donovan, J. E. & Jessor, R. (1985). Structure of problem behavior in adolescence and young adulthood. Journal of Consulting and Clinical Psychology, 53(6), 890–904. • Elliott, D., Huizinga, D., & Menard, S. (1989). Multiple problem youth: Delinquency, substance use, and mental health problems. New York, NY: Springer-Verlag. • Drug Strategies. (2005). Bridging the Gap: A Guide to Drug Treatment in the Juvenile • Justice System. Washington: Drug Strategies. • Loeber, R., Stouthamer-Loeber, M., & White, H. R. (1999). Developmental aspects of delinquency and internalizing problems and their association with persistent juvenile substance use between ages 7 and 18. Journal of Clinical Child Psychology, 28(3), 322–332. • Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J., & Godley, M. D. (2011). A large-scale dissemination and implementation model for evidence-based treatment and continuing care. Clinical Psychology: Science and Practice,18(1), 67-83. • Horowitz, H., Sung, H.-E., & Foster, S. E. (2006). The role of substance abuse in U.S. juvenile justice systems and populations. Corrections Compendium, 31(1), 1-4, 24-26. • National Center on Addiction and Substance Use. (2004). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York: Columbia University. • United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Bibliographic Citation: Studies. Treatment Episode Data Set -- Admissions (TEDS-A), 2008 [Computer file]. ICPSR27241-v3. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2010-03-31.

26. Thank you! If you have any questions regarding this presentation please contact: Brooke Hunter, M.S. Lighthouse Institute Chestnut Health Systems 448 Wylie Drive Normal, IL 61761 bdhunter@chestnut.org