August 2006

Grant Results

SUMMARY

The Vera Institute of Justice partnered with the New York City Department of Juvenile Justice to develop, implement and conduct an outcomes evaluation of a model treatment program for juvenile offenders in the New York City juvenile justice system who meet clinical criteria for substance abuse or dependence.

Adolescent Portable Therapy or APT, as the model is known, provides drug treatment services to serious adolescent drug users under age 16. Services begin as soon as youths enter detention and continue without interruption through institutionalization and their return to family and community. The same therapist works with a youth throughout the treatment period.

Key Findings

  • More than 50 percent of youth enrolled in Adolescent Portable Therapy remained for at least 90 days of treatment in the community after their release.
  • Family functioning improved in the families of teens receiving Adolescent Portable Therapy. During the course of the intervention, the proportion of treatment families reporting an increase in "positive" family functioning rose from 70 to 80 percent, compared to a decrease among families in a control group that did not receive the therapy from 75 to 65 percent during the same time.
  • Substance use declined among youth who received Adolescent Portable Therapy. Three months after youths were released from detention and beginning treatment in the community, their alcohol and marijuana use declined significantly, compared to youth in the control group.
  • Adolescent Portable Therapy significantly reduced depression and traumatic stress among youth receiving treatment compared to youth in the control group.

Funding
Between 1999 and 2004, the Robert Wood Johnson Foundation (RWJF) supported the development and evaluation of the Adolescent Portable Therapy model through three grants to the Vera Institute of Justice totaling $1,107,930.

 See Grant Detail & Contact Information
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THE PROBLEM

Adolescents involved in the juvenile justice system are more likely than other adolescents to use and abuse drugs. A 1997 study by the National Institute of Justice and the Research, Development, and Evaluation Agency of the U.S. Department of Justice, found that more than 60 percent of juvenile offenders in eight of 12 cities surveyed tested positive for some illicit substance.

In recent years, the juvenile justice system has made progress in developing effective drug prevention and early intervention models. However, it has been less successful with a particularly troubled subpopulation: juvenile offenders who meet clinical criteria for substance abuse and dependence. These youth are likely to become adult addicts and to re-offend.

According to researchers at the Vera Institute of Justice, a New York City-based organization that researches and develops solutions to problems in the administration of justice, most juvenile justice systems lack:

  • A reliable way to identify these adolescents.
  • Enough services to treat them.
  • The ability to provide continuous treatment as they move through the system and return to the community.

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RWJF STRATEGY

RWJF has funded an array of projects focused on prisoners and prisons, including some supporting release and aftercare programs, and some focused on youth. Among the projects and programs RWJF has supported are:

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THE PROJECT

The Vera Institute of Justice partnered with the New York City Department of Juvenile Justice to develop, implement and test Adolescent Portable Therapy, a model treatment program for clinically dependent, substance-using offenders in the juvenile justice system.

The model emphasizes continuity of care and family-based services, providing adolescents with a single therapist as they move through different settings — including detention, residential programs and back to their homes.

A national advisory board provided guidance throughout the project, in both formal meetings and individual consultations with Vera staff and government agency partners. See Appendix 1 for a list of advisory board members.

Activities

Under the three RWJF grants, Vera Institute project staff:

  • Reviewed drug use patterns and trends among juveniles, identified a target population for services and designed Adolescent Portable Therapy (Grant ID# 036510).
  • Documented the launch of the Adolescent Portable Therapy intervention and identified and addressed start-up challenges, including refining eligibility criteria for participation (Grant ID# 040548).
  • Evaluated the Adolescent Portable Therapy model (Grant ID# 042697).

Under the planning grant (ID# 036510), researchers had intended to conduct a large survey of New York City's juvenile detention population to assess drug use. However, initial information-gathering identified the work of Linda Teplin, Ph.D., a researcher at Northwestern University (Evanston, Ill.), who had collected data from more than 1,800 teenage offenders in Chicago.

RWJF provided partial funding for Teplin's work (see Grant Results on ID# 041942). By adjusting the Chicago data to reflect the demographic characteristics (age, gender and race) of New York's juvenile offender population, Vera Institute staff was able to use these data, rather than conduct a separate survey.

To design and implement the intervention, Vera project staff:

  • Interviewed 27 teens confined at Bridges, the intake center for juveniles entering detention in New York City, to identify substance users and to explore related life experiences and other mental health problems. These interviews supplemented and confirmed the adjusted Chicago data.
  • Attended state and national conferences on substance use; reviewed literature; and visited adolescent drug use treatment programs in Colorado, Florida, Illinois, Los Angeles, Oregon and South Carolina to gain a comprehensive knowledge of current programs.
  • Coordinated and facilitated cooperation among government agencies so that juvenile clients could participate in Adolescent Portable Therapy as they moved through the custody of various agencies. The agencies involved include:
    • New York City: Department of Juvenile Justice; Department of Mental Health; and the Probation Department.
    • New York State: Office of Children and Family Services (OCFS); Office of Alcohol and Substance Abuse Services; and the Division of Criminal Justice Services.
    • Federal government: Office of Juvenile Justice and Delinquency Prevention; and the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA).
  • Gained the support of the New York City Department of Juvenile Justice to target Adolescent Portable Therapy to young people who used substances most heavily. This key partner was initially more interested in serving youth who would be in custody the longest, not on providing continuous post-detention care.

Other Funding

The New York City Department of Juvenile Justice provides $1 million annually to operate the Adolescent Portable Therapy program. The federal Office of Juvenile Justice and Delinquency Prevention matched RWJF's first grant (ID# 036510) of $131,250 to plan the project. The New York State Division of Criminal Justice Services provided $400,000 in startup funding and the Center for Substance Abuse Treatment at SAMHSA provided $69,000 in funds for technical assistance.

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FINDINGS

Vera Institute staff estimated drug use in New York City under the planning grant (ID# 036510) and reported these findings in a proposal to RWJF for follow-up funding:

  • Some 49 percent of youth detainees in New York City meet clinical criteria for substance abuse or dependence; about 20 percent are daily or very heavy drug users.
  • Adolescents in detention who use drugs heavily have higher rates of mental health disorders than other adolescents in detention or in the general population.
    • Anxiety affects 27 percent of adolescents who use drugs heavily, compared to 23 percent of all adolescents in detention and 13 percent of the general adolescent population.
    • Some 23 percent of adolescents who are heavy users suffer from depression and other affective disorders, compared to 20 percent of all detained adolescents and 6 percent of the general adolescent population.
    • Some 64 percent of adolescents have disruptive behavior disorders, compared to 44 percent of all adolescents in detention and 10 percent of the general adolescent population.
  • Girls, who account for 18 percent of heavy drug users, are more likely than boys who are heavy users to have a mental health disorder. Among heavy drug users:
    • Some 46 percent of girls have anxiety disorders, compared to 19 percent of boys.
    • Some 39 percent of girls have affective disorders, compared to 16 percent of boys.
    • Some 75 percent of girls have disruptive behavior disorders, compared to 60 percent of boys.
  • Marijuana and alcohol use is very high among all adolescents who use drugs heavily, while the use of hard drugs differs by gender and race.
    • White and Hispanic teens are more likely than African-Americans to have used powder cocaine, heroin and psychedelics.
    • African-American teens are much more likely to have used crack cocaine than white or Hispanic youth.
    • Boys are more likely to have used heroin than girls.
    • White and Hispanic girls are more likely to have used powder cocaine and psychedelics than their male counterparts.

Results

Over all three grants, the project accomplished the following:

  • Researchers created and implemented Adolescent Portable Therapy for the most serious adolescent drug users, under age 16, within the juvenile justice system in New York City. The model was targeted at young people in detention who met clinical criteria for substance abuse and dependence and reported using drugs 30 or more times within a 30-day period.

    The model combines elements of two approaches shown to be effective with this population:
    • Cognitive-behavioral therapy, which considers substance abuse to be a learned behavior with underlying causes and cues.
    • Family-centered therapy, which views family relationships as both a cause and a solution to adolescent substance use and focuses on improving family communication and interaction.

    Key features of the model:
    • Treatment begins as soon as the youth enters detention and continues without interruption through institutionalization and return to family and community.
    • Treatment is most intense during the community phase and continues four to five months after the youth is released from detention.
    • The same therapist works with the youth throughout the treatment period, traveling to wherever the youth and the family are located.
  • During the study period, an average of 26 face-to-face Adolescent Portable Therapy sessions per client took place:
    • Some 16 sessions were conducted with the youth alone.
    • Seven sessions were conducted with the youth and family members or a caregiver.
    • Three sessions were conducted with family members or caregivers only.
  • Project staff established a section for Adolescent Portable Therapy or APT on the Vera Institute Web site. The page includes:
    • An overview of the model.
    • Downloadable copies of the treatment manual (completed after the grant period) and other publications.
    • A list of the project advisors.
    • The results of the evaluation (see Evaluation Findings).
    See the Bibliography for details.
  • Project staff made a number of presentations on the Adolescent Portable Therapy model and the evaluation findings. These included two presentations at the 2002 annual meeting of the American Society of Criminology and presentations in 2004 to researchers from the Urban Institute and RWJF staff. See the Bibliography for details.

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EVALUATION

Project staff evaluated the Adolescent Portable Therapy model under Grant ID# 042697. Juvenile offenders were randomly assigned either to receive Adolescent Portable Therapy (247 people) or to a control group (245 people) that typically received no drug treatment services at all.

Using two standardized assessment tools — the Global Appraisal of Individual Needs (GAIN) and the Family Adaptability and Cohesion Evaluation Scale (FACES) — staff interviewed participants four times: at baseline when they entered detention, and at three, nine and 15 months after their release from detention.

Because the living situations of many youth and their families are unstable, ongoing participation is often a challenge. Staff worked to keep participants engaged by collecting extensive contact information, sending birthday cards and making regular home visits, among other strategies.

Evaluation Findings

Among the evaluation findings reported in an online report and to RWJF:

  • More than 50 percent of youth enrolled in Adolescent Portable Therapy remained for at least 90 days of treatment in the community after their release. This compares favorably with the national average of 27 percent retention in adolescent drug treatment programs.
  • Family functioning improved in the families of teens receiving Adolescent Portable Therapy. The proportion of treatment families reporting "positive" family functioning increased from 70 to 80 percent over the course of the study. During that same time, "positive" family functioning decreased among control families from 75 to 65 percent. (Online report)
  • Substance use declined among youth receiving Adolescent Portable Therapy.
    • Three months after being released from detention and beginning treatment in the community, 27 percent of adolescents in the treatment group reported using marijuana, compared to 54 percent of the control group.
    • Three months after being released from detention, 24 percent of adolescents in treatment reported using alcohol, compared to 42 percent of the control group.
    • Nine months after release (typically, several months after completing treatment), treatment youth still report less marijuana use than controls (29 percent versus 34 percent) and less alcohol use (27 percent versus 30 percent). (Online report)
  • Adolescent Portable Therapy reduced some mental health disorders among youth receiving treatment, compared to controls. Nine months after being released from detention:
    • Youths in treatment reported fewer symptoms of depression than controls (48 percent compared to 64 percent).
    • Youths in treatment reported fewer traumatic stress symptoms than controls (34 percent compared to 55 percent).
    • Youths in treatment reported less anxiety than controls (30 percent compared to 44 percent). (Online report)
  • Following detention, school attendance improved in both study groups (treatment and control) over time.
    • Three months after their detention ended, 55 percent of youths in treatment attended school more than 80 percent of the time; after nine months, 66 percent did so.
    • Three months after their detention ended, 44 percent of youths in the control group attended school more than 80 percent of the time; after nine months, 64 percent did so. (Online report)
  • Adolescent Portable Therapy did not significantly affect the rates at which adolescents were rearrested or placed into the custodial care of the Office of Children and Family Services. Within one year of re-entering the community:
    • Some 41.4 percent of youth receiving Adolescent Portable Therapy were rearrested, compared to 41 percent of the control group.
    • Similarly, 46.6 percent of youth in treatment and 45.3 percent of controls were placed in OCFS custody, indicating some significant instability in the individual's personal or family life. (Report to RWJF)

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CONCLUSIONS

The research team offered these conclusions about Adolescent Portable Therapy in a report to RWJF:

  • Using a computerized questionnaire to screen newly detained youth offenders for substance use problems identifies those who meet the criteria for Adolescent Portable Therapy more successfully than relying on detention center medical staff. Computer-based screening increased average monthly recruitment rates by sixfold, compared to medical staff screening.
  • Estimates of substance use based on self-reports are more accurate when they combine information on whether an adolescent used drugs or alcohol at all in the last month (measure of frequency) with information on when they last used a substance (measure of recency).
  • Adolescents who meet clinical criteria for substance dependence are twice as likely to participate in treatment as those who use substances regularly but do not meet those clinical criteria. Those clinical criteria predict engagement with the program more accurately than measuring frequency of drug use, or the type of substance used.
  • Abuse and a family history of drug and psychiatric problems most accurately predict the mental health problems of adolescents receiving Adolescent Portable Therapy. The best predictors of mental distress, in decreasing order of importance, were:
    • Being abused by a friend or family member.
    • Having a relative with substance abuse problems.
    • Experiencing emotional abuse.
    • Using drugs other than marijuana and alcohol.
    • Being in foster care.
  • Youth who participate in the community phase of Adolescent Portable Therapy for at least three months are three times as likely to meet their self-defined treatment goals as youth who participate for shorter lengths of time. This is consistent with National Institute on Drug Abuse findings that adolescents who stay 90 days or more in an outpatient drug treatment program have better outcomes.

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LESSONS LEARNED

  1. Identifying an appropriate and responsive contact person in each partner government agency is essential. When a problem arises or the project encounters resistance, the primary contact person within the partnering agency is in the best position to help resolve the issue. (Project Directors)
  2. Learn about a partner agency's history, staffing patterns and power dynamics. Although coordinating among government agencies is often difficult, time-consuming and sensitive, investing time to learn how these agencies operate can make the task easier. (Project Directors)
  3. Evaluators should work closely with project staff during an evaluation. The collaboration between evaluators and project staff gave evaluators a thorough understanding of the project and how it operates. Evaluators were able to report emerging trends to project staff so that problems could be identified and addressed quickly. (Project Directors)
  4. Allow flexibility and creativity in project replication. The replication of Adolescent Portable Therapy in New Hampshire (see After the Grant) illustrates how balancing fidelity and adaptation can enable an intervention to be replicated in diverse settings. (Project Directors)
  5. Include individuals who have practical, "on-the-ground" experience on advisory boards. The board's value to the project was enhanced by including members who had worked directly with juvenile offenders, in probation departments and elsewhere in the criminal justice system. (Program Officer)

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AFTER THE GRANT

Adolescent Portable Therapy continues in New York City with support from the Department of Juvenile Justice and other city agencies. Some of these funds will be used to conduct further analyses of recidivism findings.

Vera Institute also received a grant from SAMHSA's Young Offender Reentry Program to study the process by which youth offenders reenter the community.

With a grant from the federal Temporary Assistance to Needy Families (TANF) program, Vera will provide family-based treatment to assist youth returning home from congregate care or to prevent them from entering congregate care. The goal is to institutionalize Adolescent Portable Therapy and to provide services before youth enter the juvenile justice system.

Project staff is replicating the Adolescent Portable Therapy model in rural northern New Hampshire, demonstrating that the model can be applied outside urban environments, where culture and interagency relationships differ. Other states have also expressed interest in the program.

Project staff wrote a treatment manual, Adolescent Portable Therapy: A Practical Guide for Service Providers, as a practice and reference guide. The manual can be downloaded without charge from the section of the Vera Institute Web site devoted to APT. See the Bibliography for details.

Staff made presentations about the model and evaluation findings at the 2005 annual meeting of the American Society of Criminology and at the SAMHSA 2005 Joint Meeting on Adolescent Treatment Effectiveness.

Staff will also present at SAMHSA's 2006 Joint Meeting. The SAMHSA meetings are sponsored by multiple federal agencies and other organizations involved in substance abuse prevention and treatment. See the Bibliography for details.

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GRANT DETAILS & CONTACT INFORMATION

Project

Development, Implementation and Evaluation of A Portable Adolescent Treatment Model for the Juvenile Justice System

Grantee

Vera Institute of Justice (New York,  NY)

  • Expanding Knowledge of Substance Abuse and Drug Dependent Treatment for Juvenile Offenders
    Amount: $ 131,250
    Dates: July 1999 to December 2000
    ID#:  036510

  • Evaluation and Implementation of a Portable Juvenile Drug Treatment Demonstration
    Amount: $ 76,680
    Dates: June 2001 to August 2001
    ID#:  040548

  • Evaluation of a Portable Adolescent Treatment Model for the Juvenile Justice System
    Amount: $ 900,000
    Dates: January 2002 to August 2004
    ID#:  042697

Contact

Evan Elkin
(212) 376-3036
eelkin@vera.org

Web Site

http://www.vera.org/project/project1_1.asp

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APPENDICES


Appendix 1

Adolescent Portable Therapy Advisors

Joyce L. Burrell
Former Deputy Commissioner of Human Services
Division of Juvenile Justice Services
Philadelphia, Pa.

William P. Dickey
President
Dermot Company, Inc.
New York, N.Y.

Katherine Kraft, Ph.D.
Program Officer
Robert Wood Johnson Foundation
Princeton, N.J.

Scott MacDonald
Juvenile Division Director
Santa Cruz County Probation Department
Santa Cruz, Calif.

Anita Marton
Senior Attorney
Legal Action Center
New York, N.Y.

Daniel Medeiros, M.D.
Medical Director, Behavioral and Mental Health Services
Mount Sinai Adolescent Health Center
New York, N.Y.

Randy Muck
Public Health Advisor
Center for Substance Abuse Treatment
Rockville, Md.

Laura Burney Nissen, Ph.D.
National Co-Director
Reclaiming Futures: Building Community Solutions to Substance Abuse and Delinquency
Portland State University
Portland, Ore.

Reginald Robinson
Counselor to the Chancellor and Visiting Professor of Law
University of Kansas
Lawrence, Kan.

Sr. Catherine Ryan
Bureau Chief
Juvenile Justice Bureau-Child Protection and Delinquency Division
States Attorney's Office
Cook County, Ill.


Appendix 2

Glossary

Clinical criteria for drug abuse and dependence — specific criteria defined in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (1994), the DSM-IV. As reported by the Vera Institute of Justice, the DSM-IV defines the criteria for substance abuse as one or more of the following occurring over a 12-month period:

  1. recurrent use resulting in failure to fulfill major obligations
  2. recurrent use in physically hazardous situations
  3. recurrent substance-related legal problems
  4. persistent use despite continuing problems exacerbated by the effects of the substance.

The DSM-IV defines the criteria for drug dependence as three or more of the following manifested over a 12-month period:

  1. increased tolerance
  2. withdrawal
  3. substance is taken in larger amounts or over a longer period than intended
  4. persistent desire or unsuccessful efforts to cut down
  5. a great deal of time is spent obtaining, using or recovering from use
  6. important activities are given up or reduced as a result of use
  7. use is continued despite knowledge of problems it causes.

Global Appraisal of Individual Needs (GAIN) — a series of measures and computer applications used clinically and in research with adolescents and adults that addresses substance use, physical health, risk behaviors, mental health, legal concerns and other topics.

Family Adaptability and Cohesion Evaluation Scale (FACES) — an instrument designed to assess family functioning by measuring family cohesion (the extent of attachment between family members) and family adaptability (a family's ability to change power structure, leadership roles and rules in response to situations and stress). Family type, determined from these two scales, ranges from rigidly disengaged to chaotically enmeshed. Higher functioning families generally fall in a midrange.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Latif Z and Parsons J. "Predictors of Engagement: Factors Influencing Youths' Adherence to Drug Treatment." Unpublished.

Parsons J. "Prevalence of Psychiatric Problems Amongst a Detained Population of Juvenile Drug Users." Unpublished.

Parsons J, Klossou E and Latif Z. "Predictors of Recidivism: Factors Influencing Juvenile Recidivism." Unpublished.

Reports

Adolescent Portable Therapy (APT). New York: Vera Institute of Justice, 2004. Available online.

Adolescent Portable Therapy: A Practical Guide for Service Providers. New York: Vera Institute of Justice, 2005. Available online.

Callahan J. Portable Drug Treatment for the Juvenile Justice System. New York: Vera Institute of Justice, 2000.

Callahan J and Froehle M. Arrested Development: Substance Abuse and Mental Illness Among Juveniles Detained in New York City. New York: Vera Institute of Justice, 2000. Available online.

Evaluating Portable, Family-Based Drug Treatment for Juveniles: Findings. New York: Vera Institute of Justice, 2005. Available online.

World Wide Web Sites

www.vera.org/project/project1_1.asp?section_id=5&project_id=4. The Adolescent Portable Therapy (APT) page on the Vera Institute of Justice Web site includes an overview of the model, downloadable copies of the treatment manual and other publications, a list of the project advisors and results of the Adolescent Portable Therapy evaluation. New York: Vera Institute of Justice.

Presentations and Testimony

Latif Z and Parsons J. "Predicting Recidivism: Lessons from a Strength-Based Drug Treatment Program," at the SAMSHA 2005 Joint Meeting on Adolescent Treatment Effectiveness, March 22, 2005, Washington. Presentation available online.

Ross T, Mino M and Flores E. "Client Identification Problems," at the 2002 American Society for Criminology Conference, November 15, 2002, Chicago. Abstract available online.

Ross T, Mino M and Flores E. "Initial Findings from the Evaluation of APT: A Drug Treatment Program for NYC Adolescents in Detention," at the 2002 American Society for Criminology Conference, November 15, 2002, Chicago. Abstract available online.

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Report prepared by: Mary B. Geisz
Reviewed by: Karyn Feiden
Reviewed by: Molly McKaughan
Program Officer: M. Katherine Kraft

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