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Screening and Assessment: Lessons from RWJF’ s Reclaiming Futures Projects
Michael Dennis, Ph.D.Chestnut Health Systems, Bloomington, IL
On line webinar Presentation for Reclaiming Futures, March 28, 2009. This presentation was supported by a Grant from the Robert Woods Johnson Foundation (RWJF) and reports on treatment & research funded by them as well as Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contracts 270-2003-00006 and 270-07-0191, as well as several individual CSAT, NIAAA, NIDA and private foundation 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 Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761, phone 309-451-7801, fax 309-451-7765, e-Mail: [email protected] Questions about the GAIN can also be sent to [email protected]
2
1. Summarize the physical and chronic nature of substance use disorders, why the justice system cares and why adolescence is just a critical time period
2. Describe the need for standardizing how we identify juveniles with behavioral health issues
3. Explaining how to decide what is needed on the continuum of screening to assessment
4. Illustrate how the differences in what this looks like in terms what you receive at client and program level using data from 5 of the original Reclaiming Futures Sites
5. Discuss implications for program planing and policy
Goals of this Presentation are to
3
Short Term Impact of Substance Use on the BrainShort Term Impact of Substance Use on the Brain(PET Scan Minutes After Using Cocaine)(PET Scan Minutes After Using Cocaine)
Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377.
Rapid rise in brain activity after taking
cocaine
Actually ends up lower than they started
4
Normal
Cocaine Abuser (10 days)
Cocaine Abuser (100 days)Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain
metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.
Recovery from cumulative use takes more time Recovery from cumulative use takes more time (PET Scan Activity Days After Using Cocaine)(PET Scan Activity Days After Using Cocaine)
With repeated use, there is a cumulative
effect of reduced brain activity which
requires increasingly more stimulation (i.e.,
tolerance)
Even after 100 days of abstinence
activity is still low
5Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine
The effects on the brain can be long lasting(Serotonin Present in Cerebral Cortex Neurons )
Reduced in response to excessive use Still not back to normal after 7 years
6
The Costs of Substance Use
Drug use costs the U.S. over $181 billion a year, primarily due to productivity loss, and health care and crime costs (Harwood, 2000)
Abuse of alcohol, tobacco, and other drugs, kills more Americans than any other class of health behavior (Mokdad et al 2004)
Of the 20,196 deaths from overdose in 2004, 358 (2%) were from alcohol and 19,838 (98%) were from other drugs, with 9798 (49%) from opioids. (MMWR, 2007)
Of the 23.2 million people (9.5% of the U.S. population) who had substance disorders in 2005, only 2.2 million (0.9%) received any treatment (OAS, 2006)
7
Committing property crime, drug related crimes, gang related crimes, prostitution, and gambling to trade or get the money for alcohol or other drugs
Committing more impulsive and/or violent acts while under the influence of alcohol and other drugs
Crime levels peak between ages of 15-20 (periods or increased stimulation and low impulse control in the brain)
Adolescent crime is still the main predictor of adult crime Parent substance use is intertwined with child maltreatment and neglect – which in
turn is associated with more use, mental health problems and perpetration of violence on others
Overlap with Crime and Civil Issues
8
Potential Cost Savings of Expanding Diversion to Treatment Programs in Justice Settings
Currently treating about 55,000 people in these diversion programs and drug courts at a cost of $515 million with an average return on investment (ROI) of $2.14 per dollar
The ROI is higher (2.71) for those with more crime
It is estimated that there are at least twice as many people in need of drug court as getting it
Investing the $1 billion to treat them would likely produce a ROI of $2.17 billion to society
Source: Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban Institute.
9
Severity of Past Year Substance Use/Disorders by age
0
10
20
30
40
50
60
70
80
90
100
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
65+
No Alcohol or Drug Use
Light Alcohol Use Only
Any Infrequent Drug Use
Regular AOD Use
Abuse
Dependence
NSDUH Age Groups
Severity CategoryAdolescent
OnsetRemission
Increasing rate of non-
users
Source: 2002 NSDUH; Dennis & Scott 2007
(2002 U.S. Household Population age 12+= 235,143,246)
10
Crime & Violence by Substance Severity
0%
10%
20%
30%
40%
50%
60%
Serious FightAt School
Fighting withGroup
Sold Drugs Attacked withintent to harm
Stole (>$50) CarriedHandgun
Dependence (3.9%) Abuse (4.2%)
Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)
Light Alc Use (12.4%) No PY AOD Use (64.3%)
Source: NSDUH 2006
Age 12-17
Severity is related to other violence/crime
problems
11
Family, Vocational & MH by Substance Severity
Source: NSDUH 2006
0%
10%
20%
30%
40%
50%
60%
10 or MoreArguments with
Parents
Disliked School GPA = D orlower
MajorDepression
Any MHTreatment
Dependence (3.9%) Abuse (4.2%)
Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)
Light Alc Use (12.4%) No PY AOD Use (64.3%)
Age 12-17
As well as other School and Mental Health Problems
12
Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.t
pain
Adolescent Brain Development Occurs from the
Inside to Out and from Back to Front
Main reasons for using are to get pleasure or
dull pain
13
Substance Use Careers Last for Decades C
um
ula
tive
Su
rviv
al
Years from first use to 1+ years abstinence302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median of 27 years from
first use to 1+ years
abstinence
Source: Dennis et al., 2005
14
Substance Use Careers are Longer the Younger the Age of First Use
Cu
mu
lati
ve S
urv
ival
Years from first use to 1+ years abstinence
under 15*
21+
15-20*
Age of 1st UseGroups
* p<.05 (different from 21+)
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Source: Dennis et al., 2005
15
Substance Use Careers are Shorter the Sooner People Get to Treatment
Cu
mu
lati
ve S
urv
ival
20+
0-9*
10-19*
Year to 1st TxGroups
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
* p<.05 (different from 20+)Source: Dennis et al., 2005
Years from first use to 1+ years abstinence
Reducing the years of use and its
associated problems by over a decade
16
Treatment Careers Last for Years C
um
ula
tive
Su
rviv
al
Years from first Tx to 1+ years abstinence2520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Over 2/3rds eventually get better(which is
better than most major
DSM disorders)
Source: Dennis et al., 2005
Median of 3 to 4 episodes of treatment
over 9 years
Several Recent Reviews and over 22 Experiments and Quasi-Experiments Have Demonstrated That
A growing range of drug treatment courts are being found effective and cost effective
More assertive continuing care can increase adherence with continuing care expectations
Recovery management checkups can identify people who have relapsed and get them back to treatment faster
That doing each improves short and long term outcomes
That the rate of improve effects went up as interventions when from less than 3 months (38%) to 3 to 12 months (44%) to more than 12 months (100%)
Source: Bhati et al 2008; Dennis et al 2003, 2007, Godley et al 2002, 2007; Marlowe, 2008; McKay, in press; Scott et al 2005, in press
18
The Movement to Increase Screening Screening, Brief Intervention and Referral to Treatment (SBIRT) has
been shown to be effective in identifying people not currently in treatment, initiating treatment/change and improving outcomes (see http://sbirt.samhsa.gov/ )
The US Preventive Services Task Force (USPSTF, 2004; 2007), National Quality Forum (NQF, 2007), and Healthy People 2010 have each recommended regular screening, brief intervention, and referral to treatment (SBIRT) for tobacco and alcohol abuse in general medical settings for everyone
The latter two also recommend SBIRT for drug use in high risk populations (e.g., adolescents, pregnant and post partum women, people with HIV, and people with co-occurring psychiatric conditions)
RWJF, OJJDP, CSAT and NIDA are each funding several projects to develop and evaluate models for doing this
19
Places vary in the rate of problems (Past Year Substance Abuse or Dependence)
Source: OAS, 2006
There is even
variation within DC
(an area less than 10 square
miles) and of course within
individuals
20
Crime/Violence and Substance Problems Interact to Predict Any Recidivism
Low
Mod.
High
LowMod
.High0%
20%
40%
60%
80%
100%
Source: CYT & ATM Data
12 m
onth
rec
idiv
ism
Crime/ Violence predicted recidivism
Substance Problem Severity predicted
recidivismKnowing both was the
best predictor
Substance Problem
Scale
Crime and Violence
Scale
21
Crime/Violence and Substance Problems Interact Differently to Predict Recidivism to Violent Crime
Low
Mod.
High
LowMod
.High
Source: CYT & ATM Data
12 m
onth
rec
idiv
ism
T
o vi
olen
t cri
me
or a
rres
t
Substance Problem
Scale
Crime and Violence
Scale
0%
20%
40%
60%
80%
100%
Crime/ Violence predicted
violent recidivism
(Intake) Substance Problem Severity did
not predict violent recidivism
Knowing both was the best predictor
22
Mental Health Comorbidity Among Girls in Detention
Source: Teplin, LA, Abram, KM, McCelland, GM, Mericle, AA, Dulcan, MK, and Washburn, JJ (2006) Psychiatric Disorders of Youth in Detention. Washington, DC: OJJDP. Retrieved from http://www.ncjrs.gov/pdffiles1/ojjdp/210331.pdf
Multiple Problems
are the norm
23
Mental Health Comorbidity Among Boys in Detention
Source: Teplin, LA, Abram, KM, McCelland, GM, Mericle, AA, Dulcan, MK, and Washburn, JJ (2006) Psychiatric Disorders of Youth in Detention. Washington, DC: OJJDP. Retrieved from http://www.ncjrs.gov/pdffiles1/ojjdp/210331.pdf
While there are gender differences,
the differences are often
degrees of variation
24
Number of Major Clinical Problems by System of Care
45% 44% 46%56%
46%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total In School In workforce In ChildWelfare
In Juv.Justice
0 to 1
2 to 4
5 or more
Source: Dennis et al in 2008; CSAT 2007 AT Outcome Data Set (n=12,824)
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
25
Number of Problems is Related to Level of Care
39%50% 55%
67%78%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Outpatient(OR=1)
IntensiveOutpatient(OR=1.6)
Long TermResidential(OR=1.9)
Med. TermResidential(OR=3.2)
Short TermResidential(OR=5.5)
0 to 1
2 to 4
5 or more
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824)
Clients entering Short Term Residential
(usually dual diagnosis) have 5.5 times higher
odds of having 5+ major problems*
26
15%
45%
70%
0%10%20%30%40%50%60%70%80%90%
100%
Low (OR 1.0)
Mod.(OR=4.6)
High(OR=13.2)
NoneOneTwoThreeFourFive+
No. of Prob. is related to the Severity of Victimization
Severity of Victimization
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824)
Those with high lifetime levels of
victimization have 13 times higher odds of
having 5+ major problems*
27
Continuum of Measurement (Common Measures)
Screening to Identify Who Needs to be “Assessed” (5-10 min)– Focus on brevity, simplicity for administration & scoring– Needs to be adequate for triage and referral– GAIN Short Screener for SUD, MH & Crime– ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD– SCL, HSCL, BSI, CANS for Mental Health– LSI, MAYSI, YLS for Crime
Quick Assessment for Targeted Referral (20-30 min)– Assessment of who needs a feedback, brief intervention or referral for
more specialized assessment or treatment– Needs to be adequate for brief intervention– GAIN Quick – ADI, ASI, SASSI, T-ASI, MINI
Comprehensive Biopsychosocial (1-2 hours) – Used to identify common problems and how they are interrelated– Needs to be adequate for diagnosis, treatment planning and placement
of common problems– GAIN Initial (Clinical Core and Full)– CASI, A-CASI
Specialized Assessment– Additional assessment by a specialist (e.g., psychiatrist, MD, nurse,
spec ed) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan
– CIDI, DISC, KSADS, PDI, SCAN
Screener Quick C
omprehensive S
pecial
More E
xtensive / Longer/ E
xpensive
28
Key Work Force / System Issues to Consider When Selecting Assessment
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
29
Global Appraisal of Individual Needs (GAIN) Logic Model as an Example
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
Issue 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
30
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
Global Appraisal of Individual Needs (GAIN) Logic Model as an Example
31
Questions So Far?
For the rest of the session we will focus on doing two things simultaneously
Demonstrating the difference in the depth and and breadth of information you get with different levels of assessment
Doing this by using findings from the first cohort of RWJF Reclaiming Future sites to also review what they learned
32
GAIN Clinical CollaboratorsAdolescent and Adult Treatment Program
10/08
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
33
Across measures, the GAIN has a Common Factor Structure of Psychopathology
Source: Dennis, Chan, and Funk (2006)
34
GAIN-Short Screener (GSS): Overview
Administration Time: A 3- to 5-minute screener Purpose: Used in general populations to
– identify or rule-out clients who will be identified as having any behavioral health disorders on the 60-120 min versions of the GAIN
– triage area of problem– serve as a simple measure of change– Easy for administration and interpretation by staff with minimal training
or direct supervision Mode: Designed for self- or staff-administration, with paper and pen,
computer, or on the web Translations: English, with translations with us into Spanish and by
collaborators into several languages including French, Hmong, Japanese, Mandarin, Pilipino, Portuguese, and Vietnamese so far
35
Scales: Four screeners for Internalizing Disorders, Externalizing Disorders, Substance Disorders, Crime/Violence, and a Total
Response Set: Recency of 20 problems rated past month (3), 2-12 months ago (2), more than a year ago (1), never (0)
Interpretation: Combined by cumulative time period as: – Past month count (3s) to measure of change– Past year count (2s or 3s) to predict diagnosis– Lifetime count (1s, 2s or 3s) as a measure of peak severity– Can be classified within time period low (0), moderate (1-2) or high (3)– Can also be used to classify remission as – Early (lifetime but not past month)– Sustained (lifetime but not past year)
Reports: Narrative, tabular, and graphical reports built into web based GAIN ABS and/or ASP application for local hosting
GAIN-Short Screener (GSS): Overview (continued)
36
Internalizing Disorder Screening (IDScr)
Externalizing Disorder Screening (EDScr)
37
Substance Disorder Screening (SDScr)
Crime/violence Disorder Screening (CVScr)
38
GAIN Short Screener Profile of 2 Recl. Futures Sites(Range based on 0/1-2/3+ Symptoms)
33% 37%48%
38%
81%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
InternalizingDisorderScreener
ExternalizingDisorderScreener
SubstanceDisorderScreener
Crime/ViolenceScreener
TotalDisorderScreener
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
39
GAIN Short Screener Number of Problems Mod/Hi
40%
22%
22%
9%7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No. ofProblems
No SR prob
1 Prob.
2 Probs.
3 Probs.
4 Probs.
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
93% endorsed one or more problems
(40% 4 or more)
40
GAIN SS Psychometric Properties
Total Disorder Screener (TDScr)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Prevalence (% 1+ disorder)
Sensitivity (% w disorder above)
Specificity (% w/o disorder below)
(n=6194 adolescents)
Low Mod. High
At 3 or more symptoms we get 99% prevalence, 91% sensitivity, & 89% specificity
Using a lower cut point increases prevalence and specificity, but
decreases sensitivity
Total score has alpha of .85 and is
correlated .94 with full GAIN version
Source: Dennis et al 2006
41
GSS Performance by Subscale and Disorders
Prevalence Sensitivity Specificity Screener/Disorder 1+ 3+ 1+ 3+ 1+ 3+ Internal Disorder Screener (0-5) Any Internal Disorder 81% 99% 94% 55% 71% 99% Major Depression 56% 87% 98% 72% 54% 94% Generalized Anxiety 32% 56% 100% 83% 44% 83% Suicide Ideation 24% 43% 100% 84% 41% 79% Mod/High Traumatic Stress 60% 82% 94% 60% 55% 90%
External Disorder Screener (0-5) Any External Disorder 88% 97% 98% 67% 75% 96% AD, HD or Both 65% 82% 99% 78% 51% 85% Conduct Disorder 78% 91% 98% 70% 62% 90%
Substance Use Disorder Screener (0-5) Any Substance Disorder 96% 100% 96% 68% 73% 100% Dependence 65% 87% 100% 91% 30% 82% Abuse 30% 13% 89% 25% 14% 28%
Crime Violence Screener (0-5) Any Crime/Violence 88% 99% 94% 49% 76% 99% High Physical Conflict 31% 46% 100% 70% 38% 77% Mod/High General Crime 85% 100% 94% 51% 71% 100%
Total Disorder Screener (0-5)Any Disorder 97% 99% 99% 91% 47% 89% Any Internal Disorder 58% 63% 100% 98% 8% 28% Any External Disorder 68% 75% 100% 99% 10% 37% Any Substance Disorder 89% 92% 99% 92% 20% 51% Any Crime/Violence 68% 73% 100% 96% 10% 32%
Low (0), Moderate (1-2), and High (3+) cut points can
be used to identify the need
for specific types of
interventions
Moderate can be targeted where resources allow or where a more
assertive approach is
desired
Mod/Hi can be used to evaluate
program delivery/referral
42
GAIN SS Total Score is Correlated With Level Of Care Placement
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
TDScr Score
% w
ithi
n L
evel
of
Car
e an
d A
ge G
roup OP/IOP (n=2499)
Residential (n=1965)
Low
Mod High ->OP/IOP
Median=6.0Residential
Median=10.5
43
GAIN SS Can Also be Used for Monitoring
109
11
910
8
32 2
0
4
8
12
16
20
Intake 3Mon
6Mon
9Mon
12Mon
15Mon
18Mon
21Mon
24Mon
Total Disorder Screener (TDScr)
12+ mon.s ago (#1s)
2-12 Mon.s ago (#2s)
Past Month (#3s)
Lifetime (#1,2,or 3)
Track Gap Between Prior and current
Lifetime Problems to identify “under
reporting”
Track progress in reducing current
(past month) symptoms)
Monitor for Relapse
44
GAIN Quick (GQ) : Overview
Administration Time: 20-30 minutes (depending on severity and wether reasons for quiting module used)
Training Requirements: 1 day (train the trainer) plus certification within 1-2 months
Mode: Generally Staff Administered on Computer (can be done on paper or self administered with proctor)
Purpose: Designed for use in targeted populations to support brief intervention or referral for further assessment or behavioral intervention
Translation: English, with translations with us into Spanish by Chestnut and by collaborators being translated into French and Portuguese so far
45
GAIN Quick (GQ): Overview (Continued)
Scales: The GQ has total scale (99-symptoms) and 15 subscales (including more detailed versions of the GSS scales and subscales plus scales for service utilization, sources of psychosocial stress, and health problems). All scales focus on the past year only and it is primarily used to support motivational interviewing or for a one time assessment (though there is a shorter follow-up version). Lifeimt
Response Set: Breadth (past year symptom counts for behavior and lifetime for utilization) and Prevalence (past 90 days)
Interpretation: – Items can be used individually or to create specific diagnostic or
treatment planning statements– Items can be summed into scales or indices for each behavior
problem or and for recent service utilization overall– All scales, indices and selected individual items have interpretative
cut-points to facilitate clinical interpretation and decision making Reports: Narrative, tabular, graphical, validity and motivational
interviewing reports built into web based GAIN ABS; Program level reports available in SPSS/Excel
46
GAIN Quick Profile of 4 Reclaiming Futures Sites (Range based on 0-24% / 25-74% / 75-100% of Symptoms)
18% 24%
26%
29%
22% 29
%
25%
28%
5%24%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%G
ener
al F
acto
rs
Sour
ces
of S
tres
s
Hea
lth
Dis
tres
s
*Gen
eral
Lif
e P
rob
Dep
ress
ion
Suic
ide
Ris
k
Anx
iety
-Tra
uma
Sx
*Int
erna
lizi
ng
Hyp
er-I
natt
enti
on
Con
duct
Dis
orde
r
Gen
eral
Cri
me
*Ext
erna
lizi
ng
AO
D U
se &
Abu
se
AO
D D
epen
denc
e
Subs
tanc
e P
robl
em
*Tot
al S
core
Low (0-24%)
Mod (25-75%)
High (76-100%)
Source: Reclaiming Futures Chicago, IL, Dayton, OH, Portland, OR and Santa Cruz, CA sites (n=475). * Summary Measure
RiskStressHealth
More detail within
each area
47
GAIN Quick Number of Problems Mod/Hi
69%
13%
8%8%3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No. ofProblems
No SR prob
1 Prob.
2 Probs.
3 Probs.
4 Probs.
97% endorsed one or more problems(69% 4 or more
problems)
Source: Reclaiming Futures Chicago, IL, Dayton, OH, Portland, OR and Santa Cruz, CA sites (n=475).
48
GAIN Quick (GQ): In Transition Strengths: Length, Range of topics, Efficiently Categorize, Narrative reports
to support screening, brief intervention, and referral to treatment Problems:
– Lacks scales to support analyses or outcomes related to change over time– Item response choices do not provide information about lifetime
problems or problems that have occurred in finer gradations of time within the past year
– Current Personal Feedback Report focuses only on substance use and does not address the other content areas of the GAIN-Q
– Only about 60% of the items can be directly imported into the GAIN-I– Cut points do not map onto GAIN I or clinical criteria well
Plans for Version 3:– Keep focus on screening, brief intervention and referral to treatment– Subsume GSS and add similar screeners in other GAIN Q areas with
recency response to address change and lifetime issues– Create a summary measure for days items to address change issues– Create reasons for change items in each area to support breif
intervention, reducing number of items in substance use– Make all questions importable into full GAIN
Plans for Version 4: Add computer adaptive testing (CAT) component to get at more detailed diagnosis
49
GAIN Initial (GAIN-I): Overview Administration Time: Core version 60-90 minutes/Full version 110-140 minutes
(depending on severity and inclusion of GPRA module) Training Requirements: 3.5 days (train the trainer) plus recommend formal
certification program (administration certification within 3 months of training; local trainer certification within 6 months of training); Advanced clinical interpretation recommended for clinical supervisors
Mode: Generally Staff Administered on Computer (can be done on paper or self administered with proctor)
Purpose: Designed to provide a standardized biopsychosocial for people presenting to a substance abuse treatment using DSM-IV for diagnosis, ASAM for placement, and needing to meet common (CARF, COA, JCAHO, insurance, CDS/TEDS, Medicaid, CSAT, NIDA) requirements for assessment, diagnosis, placement, treatment planning, accreditation, performance/outcome monitoring, economic analysis, program planning and to support referral/communications with other systems
Translation: English, with translations with us into Spanish by Chestnut and by collaborators being translated into French and Portuguese so far
50
GAIN Initial (GAIN-I): Overview (Continued) Scales: The GI has 9 sections (access to care, substance use, physical
health, risk and protective behaviors, mental health, recovery environment, legal, vocational, and staff ratings) that include 103 long (alpha over .9) and short (alpha over .7) scales, summative indices, and over 3000 created variables to support clinical decision making and evaluation. It is also modularized to support customization
Response Set: Breadth (past year symptom counts for behavior and lifetime for utilization), Recency (48 hours, 3-7 days, 1-4 weeks, 2-3 months, 4-12 months, 1+ years, never) and Prevalence (past 90 days), patient and staff ratings
Interpretation: – Items can be used individually or to create specific diagnostic or
treatment planning statements– Items can be summed into scales or indices for each behavior problem or
type of service utilization– All scales, indices and selected individual items have interpretative cut-
points to facilitate clinical interpretation and decision making Reports: Narrative, tabular, validity and motivational interviewing
reports built into web based GAIN ABS; New Narrative report include placement and treatment planning statements; Program level reports available in SPSS/Excel
51
GAIN Initial Profile: Substance Problems Past Year(Range based range of clinical/logical/statistical rules)
31%19%15%
7%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sub.
Use
/In
duce
dP
rob.
Abu
se
Dep
ende
nce
Sub.
Pro
b.P
ast
Yea
r
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
52
GAIN Initial Profile: Substance Problems by Time(Range based range of clinical/logical/statistical rules)
39%31%
13%2%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sub.
Pro
b.L
ifet
ime
Sub.
Pro
b.P
ast
Yea
r
Sub.
Pro
b.P
ast
Mon
th
Wit
hdra
wal
Sx P
ast
Wee
k
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
53
GAIN Initial Profile: Motivation and Readiness(Range based range of clinical/logical/statistical rules)
0% 7%19%
32%
76%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Self
-E
ffic
acy
Tre
atm
ent
Res
ista
nce
Tre
atm
ent
Pre
ssur
e
Tre
atm
ent
Mot
ivat
ion
Pro
blem
Ori
enta
tion
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
54
GAIN Initial Profile: Crime/Violence(Range based range of clinical/logical/statistical rules)
25% 33%
5% 8%
51%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%V
iol.
Con
flic
t-T
acti
c
Pro
pert
yC
rim
e
Inte
rper
sona
lC
rim
e
Dru
g C
rim
e
Cri
me
Vio
lenc
e
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
55
GAIN Initial Profile: Environmental Risk(Range based range of clinical/logical/statistical rules)
39%
64%54%
28%
0%
10%20%
30%
40%50%
60%
70%
80%90%
100%
Liv
ing
Env
.R
isk
Voc
atio
nal
Env
. Ris
k
Soci
al E
nv.
Ris
k
Env
iron
men
tal
Ris
k
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
56
GAIN Initial Profile: Internalizing Disorders(Range based range of clinical/logical/statistical rules)
3%15%
1% 9% 9%24%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Som
atic
Dep
ress
ion
Suci
de R
isk
Anx
iety
-F
ear
Tru
ama
Inte
rnal
izin
g
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
57
GAIN Initial Profile: Externalizing Disorders(Range based range of clinical/logical/statistical rules)
20%12% 14% 20%
0%
10%20%
30%
40%50%
60%
70%
80%90%
100%
Inat
tent
iven
ess
Hyp
erac
tivi
ty-
impl
usiv
e
Con
duct
Dis
orde
r
Ext
erna
lizi
ng
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
58
GAIN Initial Profile: Personality Disorders(Range based range of clinical/logical/statistical rules)
53%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cau
tiou
s(C
lust
er A
)
Impl
usiv
e(C
lust
er B
)
Wor
ryin
g(C
lust
er C
)
Tot
alP
erso
nali
ty
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
59
GAIN Initial Profile: General Factors / Stress(Range based range of clinical/logical/statistical rules)
26%44%
10% 12%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Em
ploy
men
tP
rob.
S
choo
lP
rob.
Vic
tim
izat
ion
P
erso
nA
xis
IV
O
ther
Axi
sIV
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
60
GAIN Initial Profile: Other Problem Scales(Range based range of clinical/logical/statistical rules)
12%2% 4%
17%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hea
lth
Gam
blin
g
Soci
alSu
ppor
t
Lif
eSa
tisf
acti
on
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
61
GAIN Initial Profile: Measures of Behavior Change (Range based range of clinical/logical/statistical rules)
41%
3% 10% 14%
41%23%
3%4%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Su
bsta
nce
Use
Hea
lth
Em
otio
ns
Rec
over
yE
nvir
onm
ent
Ille
gal
Act
ivit
y
Scho
ol
Wor
k
Fin
anci
al
Low
Mod.
High
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
62
GAIN Initial Number of Problems Mod/Hi
98%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No. ofProblems
No SR prob
1 Prob.
2 Probs.
3 Probs.
4 Probs.
99.4% endorsed one or more problems
(98.4% 4 or more)
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
63
GAIN Treatment Planning/Placement Grid
Problem Recency/Severity
None Past Current (past 90 days)*
Low-Mod | High Severity Treatm
ent History
Non
e Past C
urren
t .
1. No Problem
2. Past problem Consider monitoring and relapse prevention.
3. Low/Moderate problems; Not in treatmentConsider initial or low invasive treatment.
4. Severe problems;Not in treatment Consider a more intensive treatment or intervention strategies.
0. Not LogicalCheck under- standing of problem or lying and recode.
5. No current problems; Currently in treatmentReview for step down or discharge.
6. Low/Moderate problems; Currently in treatment Review need to continue or step up.
7. Severe problems; Currently in treatmentReview need for more intensive or assertive levels.
* Current for Dimension B1 = Past 7 days
64
0% 20% 40% 60% 80% 100%
AT
RF
AT
RF
AT
RF
AT
RF
AT
RF
AT
RF
AS
AM
B1.
Into
x/W
ithd.
AS
AM
B2
Bio
med
ical
AS
AM
B3.
Psy
ch/B
ehA
SA
M B
4.R
eadi
ness
AS
AM
B5.
Rel
. Pot
.A
SA
M B
6.E
nviro
n.
Inconsistent No problem Past Prob Low/Mod Prob High Prob No Prob in Tx L/M Prob in Tx H Prob in Tx
Reclaiming Futures as or more severe than Regular Adolescent Treatment
Source: King County Adolescent Treatment (n=1860) vs. Reclaiming Futures (n=404)
65
OtherCommon
TreatmentPlanning
Needs
Source: King County Adolescent Treatment (n=1860) vs. Reclaiming Futures (n=404)
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Strengths/Soc Sup.
Cont. Care
Case management
Environmental Risk
Copying with stress
Getting into Treat.
Child Maltreatment
Need for Change
Behavior Control
School Problems
Anger Management
Other Vocational Help
Detox / Withdrawal
Recovery Coach
HIV intervention (Sex)
Tobacco Cessation
Self Help / Support
Job Placement
Family Fighting
Scheduling
Adolescent Treatment
Reclaiming Futures
RF Need more help w coming from Cont. Env.-Case management-Evnrionmental Risk-Child Maltreatment-Behavior control-Anger Management-Vocational Issues-Detox/Withdrawal-Self Help Support-Scheduling
66
Variance Explained in 10 NOMS Outcomes
\1 Past month \2 Past 90 days *All statistically Significant
26%
24%
11%
25%
15%
33%
26%
18%
14%
8%
24%
0% 5% 10% 15% 20% 25% 30% 35%
No AOD Use
No AOD related Prob.
No Health Problems
No Mental Health Prob.
No Illegal Activity
No JJ System Involve.
Living in Community
No Family Prob.
Vocationally Engaged
Social Support
Count of above
Percent of Variance Explained
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
67
Best Level of Care*: Cluster A Low - Low (n=1,025)
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
Best Level of Care*: Cluster A Low - Low (n=1,025)
99.6%
0.4%0%
20%
40%
60%
80%
100%
120%
Outpatient Higher LOC
% B
est
Pre
dic
ted O
utc
om
es
* Based on Maximum Predicted Count of Positive Outcomes
68
Best Level of Care*: Cluster C Mod-Mod (n=1209)
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
Best Level of Care*: Cluster C Mod-Mod (n=1209)
30.2%
7.6%
23.6%
38.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Outpatient IOP OPCC Residential
% B
est
Pre
dic
ted O
utc
om
es
* Based on Maximum Predicted Count of Positive Outcomes
69
Best Level of Care*: Cluster F Hi-Hi (CC) (n=968)
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
Best Level of Care*: Cluster F Hi-Hi (CC) (n=968)
81.5%
8.6%
0.0%
9.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Outpatient IOP OPCC Residential
% B
est
Pre
dic
ted O
utc
om
es
* Based on Maximum Predicted Count of Positive Outcomes
70
Best Level of Care*: Cluster G Hi-Mod (Env/PH) (n=749)
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
Best Level of Care*: Cluster G Hi-Mod (Env/PH) (n=749)
94.1%
5.9%0.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Outpatient IOP/OPCC Residential
* Based on Maximum Predicted Count of Positive Outcomes
71
Substance use disorders have a physical, developmental, and chronic nature and are of particular relevance to the juvenile justice system
Standardized assessment is needed because there are multiple overlapping and complex problems
There is a continuum of measurement from screening to comprehensive assessment
Moving along this continuum requires more investment, but also gives more information to the individual, clinician and program
Conclusions
Questions?