Preliminary Juvenile Justice Outcome Study
Case Series Study
Preliminary Trial of DBT with Incarcerated Adolescents
Preliminary Functional Impairment Outcome Study
Psychoactive substance use and violence are the most significant health threats to American adolescents. The special population of juvenile offenders who have evidenced both mental illness and substance abuse represent youth at the extreme end of the continuum of risk for adverse outcomes (Cocozza, 1992). Criminally involved youth who have co-occurring mental health symptoms and frequent substance use have significantly more impairment in their role performance at home, school, and the community than other criminally-involved youth (Vander Stoep & Trupin, 1999). Substance abuse has been shown to be a strong contributor to progression from adolescent conduct disorder to adult antisocial disorder (Myers et al., 1998; Brook et al, 1998,), aggressive and criminal behavior (Duncan, et al., 1997), and violent behavior (Stiffman, et al, 1996; Steadman, et al., 1998; Loeber et al, 1993). Interventions targeting multiple problem behaviors may deter the progression to persistent adult mental illness and substance use disorder and lifelong criminal offending. Co-occurring delinquency, substance use, and emotional dysregulation disproportionately affect African American youth. Of the over 210,000 U.S. juveniles who are held in detention facilities each year (OJJDP, 1997), 41% are African American (Snyder & Sickmund, 1999). Disproportionality has actually increased over the past two decades (Allen-Hagen 1991).
Henggeler et al (1998a) have developed a manualized ecologically-based intervention, multisystemic therapy (MST), which applies a systems approach (Minuchin, 1974) targeting family, peer, school, and neighborhood factors that place youth at continued risk of re-offending. By working with youth within their multiple natural contexts, MST has been shown to be successful in reducing criminal recidivism and out-of-home placements over follow-up periods of up to four years (Henggeler et al., 1995; Henggeler, 1996)
What remains relatively unspecified is what goes on at the individual-level of the intervention in sessions with youth. While this aspect of the intervention may be less relevant with youth who are “simply” delinquent, it is not irrelevant for youth with co-occurring illnesses. The Prime Time intervention aims to decrease the negative consequences of problematic substance use and the impairment caused by psychiatric symptoms by embedding within the MST framework an empirically-tested individual-level enhancement that address these co-occurring problems.
The target population for the Prime Time intervention is youth who: (1) have a recent (past three months) history of problematic or excessive substance use (2) exhibit signs of a psychiatric illness (i.e., Mood Disorder, Anxiety Disorder, PTSD), in addition to an externalizing behavior disorder, and (3) exhibit persistent antisocial behavior that has resulted in multiple incarcerations.
1. Pre-treatment engagement and motivational enhancement (pre-MST) Goals: (a) Enhance commitment of youth and family to engage and remain in treatment (b) Enhance motivation of youth to reduce substance use and antisocial behavior. (c) create shared treatment goals among parents, youth and therapist.
Prime Time will use three pre-treatment motivational interviews to engage youth and families, to increase motivation to change, and as an initial substance use intervention. The first two interviews will be performed by paraprofessional case aide and parent advocate staff who are chosen for their cultural competence/match to the client and family. The case aide will be the recruiter/screener who works with youth in the juvenile detention center. The parent advocate will be a person from the community who has experienced raising a child with co-occurring disorders and/or juvenile justice involvement. The parent advocate may be a parent of a former Prime Time client. These staff members will be trained to conduct the initial assessment and feedback sessions, occurring during the first week of recruitment. The content of the sessions is illustrated in the figure below. The parent advocate will conduct assessment and feedback sessions with the parent(s) or guardians in their homes. Simultaneously, the recruiter will conduct sessions with the adolescent in detention. The first session will involve an initial motivational interview where client/family concerns are elicited while the interviewer increases motivation to change. The second session will be a feedback session where objective data of risk and protective factors are presented with the intent of increasing the client and family’s commitment to participate in treatment. The final session will be led by the DBT therapist and will serve as a transition into treatment or action. With the Prime Time MST therapist, recruiter, and advocate participating, the DBT therapist will describe the treatment option, gain commitment, and create a plan of action.
2. The Prime Time intervention then applies MST to establish
an “ideal system of care” for each adolescent and family. The multisystemic
approach takes advantage of the unique resource opportunities available
within the extended kinship networks of African American families and empowers
adolescents and their families towards self-help (Boyd-Franklin, 1991).
Prime Time enhances MST with proven psychotherapeutic interventions that
address the youth’s mental health and substance abuse related impairment.
These interventions are designed to reduce the immediate negative impact
of problematic substance use and mood/ behavioral dysregulation on youths’
functioning. The enhanced interventions are applied in order
to (1) increase motivation to engage in treatment and decrease problem
behavior, and (2) increase skills for regulate moods and behaviors while
reducing substance use. The MST intervention addresses ecological
factors, while the enhanced intervention targets the individual factors
of substance use, psychiatric symptoms, and treatment engagement and maintenance:
Click here for MST Venndiagram
Prime Time therapist/case managers will teach self-monitoring and behavioral
analysis skills to all family members as a group in the family home.
Therapists will also meet individually with the youth participants to provide
skills coaching and conduct chain analyses. For individual youth, DBT Skills
will be integrated with ongoing substance use reduction techniques.
Youth will be asked to self-monitor substance use behaviors concurrently
with keeping diaries of emotional responses. This self-monitoring
of substance use is the first step in the use reduction technique.
For family members, DBT Skills will be integrated into ongoing contingency management.
Over the past two years, we have conducted a number of studies and activities that have helped guide the development of the Prime Time intervention. We have: 1) enrolled 84 youth in the Project; 2) completed a study assessing the criminal outcomes of 24 Prime Time participants and 24 matched comparison youth; 3) conducted a case series study assessing in detail the clinical course of 13 Prime Time participants; 4) conducted a pilot trial of DBT with incarcerated adolescents; 5) assessed the relationship between changes in emotional regulation and role performance; 6) developed a structure for the treatment manual and begun outlining goals and objectives for individual sessions; and 7) developed a preliminary adherence protocol and begun to institute adherence checks within the Prime Time intervention.
of Prime Time Participants to Date
Of the 84 Prime Time Project participants to date, 54 (32 males and 22 females) are African American. Thirty-three African American youth are currently active in the project. Their ages range from 12-18 years, with 75% under the age of 16.
Family and School Situation and Functional Status: Over 95% of Prime Time participants are Medicaid eligible. All of the African American youth had at least one family member in the area with whom they were involved. Over 3/4 had been living with their mother or grandmother. Seven (14%) were in contact with both father and mother or aunt and uncle. Three quarters of Prime Time youth characterize their families using the Family and Child Environment Scale (FACES: Olson, et al., 1985) as separated or disengaged.
Only half of the African American youth were enrolled in school when they came into the Project, and a smaller percentage had been attending. Eighty percent of the youth were reading below grade level, and nearly 90% were below grade level in arithmetic and spelling. At the time of their enrollment in the Project, three quarters of the African American youth scored in the most dysfunctional ranges of the CAFAS home, school, and community scales.
Criminal History: All youth had 2 or more admissions
to the detention facility. Nearly half of the African American youth had
had 5 or more admissions. Over 2/3 had a history of committing violent
Psychoactive Substance Use Disorder and Diagnosed Psychiatric Illness: Fifty youth (58%) who have enrolled in the project to date have had both a psychoactive substance use disorder and diagnosed psychiatric illness. All but two of the dually diagnosed youth had mood disorders. The most prevalent mental health symptoms include reactivity of mood, impulsivity, and uncontrolled anger and aggression. Only half of these youth had experienced prior outpatient or inpatient mental health treatment.
Implications for Program Development. The
types and severity of psychoactive substance abuse and psychiatric symptoms
among Prime Time youth warrant specific targeted therapeutic interventions
applied within the framework of Multisystemic Therapy. We have found that
it is difficult to engage youth and their families in the MST intervention
without first targeting substance use and psychiatric symptoms. In our
experience thus far, substance use by youth has been the major factor in
youth who engage in the Prime Time intervention and those who don’t.
Youth who run away, return to jail or fail to participate regularly in
treatment are more likely to be heavy substance users than those who don’t.
Similarly, a number of youth have demonstrated a positive response to MST,
but have deteriorated once the intervention was completed because of relapse
into substance use.
Justice Outcome Study
Methods. The criminal records of 24 Prime Time participants and 24 other juvenile justice-involved youth over the course of a year. Prime Time participants were matched to comparison youth on the basis of currently being in detention, 2 or more prior admissions, age 12-17, adjudicated for a violent offense or documented history of violence, and diagnosable mental disorder. Comparison youth were chosen as the nearest consecutive admission to a Prime Time participant who met criteria. Wilcoxon matched-pairs signed ranks tests were performed to compare number of new charges prior to enrollment, and 3, 6, 9, and 12 months post-Prime Time referral for Prime Time participants and matched comparison youth. Reduction in sample size reflects number of participants completing a year of treatment at the time of the study rather than subject attrition.
New Charges in Juvenile Justice System: Prime Time vs. Comparison Groups
Findings. Although the Prime Time group had significantly more charges prior to referral, they had significantly fewer new charges in each of the post-referral intervals (Selby et al., 1998).
Implications for Program Development. The preliminary findings are promising with regard to a primary goal of the Prime Time program, i.e., reversing the trajectory towards increased criminal behavior in high-risk adolescents. A second finding was that the actual number of days detained during the follow-up intervals did not differ significantly between the two groups. Prime Time youth often return to detention as a result of the program’s closer supervision and monitoring of compliance with the terms of probation. This finding emphasizes the role of “planned relapse” as a means of contingency management.
Case Series Study
Method. Between June and October 1997 a Case Series Study was conducted with the purpose of drawing an accurate depiction of the strengths and weaknesses of the Prime Time intervention, as applied with a cohort of participants. Lengthy structured interviews were conducted with Prime Time MST therapists/case managers focusing on the disposition of individual cases. Case vignettes were composed for 13 youth who were enrolled consecutively in the Prime Time program in early 1997. The vignettes described referral, engagement of the youth and family, intervention, and outcomes. Prime Time clinical staff (therapists, supervisors, case aides) read the 13 vignettes and formulated impressions of prevalent themes, specifically commonly reported barriers to successful referral, engagement, and treatment.
Two staff meetings were held where the clinical staff discussed and outlined their impressions of the case series study findings. These meetings then guided the work of a Program committee that recommended changes to improve the program to better meet the needs of youth and families. Below is a list of the primary issues which were addressed.
Issue #1. Prime Time
was only successful in engaging youth who could work with the program for
a period of time in detention prior to release to the community, so the
program changed to only accepted into the program only under the condition
that they have at least 10 days remaining in detention.
Issue #2. The social skills groups were failing because too many youth had not completed sufficient individual therapy to become “group ready." Modification # 1. Youth are accepted into the program only under the condition that they have at least 10 days remaining in detention.
Issue #3. Some probation counselors did not function as active team members, resulting in splitting, which was detrimental to the child and family. Modification # 3. The program accepts referrals from Prime Time-friendly probation counselors, who have a track record of positive collaboration with the program. By convening a series of joint meetings between the program and the juvenile justice system, the program has strengthened relationships with police, probation, and juvenile courts.
Issue # 4. Assessments were not being utilized fully to guide the intervention. Modification # 4. Staff were given a series of trainings on how to incorporate the results from assessments into individual and family therapy during Phase I of the intervention. This aspect of the program was manualized.
Issue # 5. There was a high unmet demand for case aides to help youth build recreational, social, academic, and vocational competencies. Modification # 5. A larger cadre of African American men and women were hired and trained as case aides, such that every Prime Time participant is assigned a case manager and a case aide at the time they are accepted into the program.
Issue # 6. What was going on in treatment was to a large extent a function of individual clinicians, rather than program protocol. Modification # 6. To improve adherence to MST principles, all clinicians participated in weekly trainings in multisystemic therapy. They have formed small groups, meeting weekly, which audiotape and rate sessions for adherence to MST principals.
Issue # 7. Family engagement, though critical for long-term success, was difficult due to families’ high degree of trouble, isolation, and mistrust. Modification # 7. Family advocates have been hired to work with families and community teams to bridge the gap of mistrust that African American families feel towards service systems.
Issue #8. Besides long-standing histories of antisocial behavior, Prime Time participants had serious psychiatric disorders and heavy substance involvement. These issues required exceptional care above and beyond multi-systemic therapy. Modification #8. Experienced clinicians began to modify two “best practices” available for motivational enhancement and mood regulation to be applied within the MST framework.
Trial of DBT with Incarcerated Adolescents
A strong linkage has been developed between Dr. Marcia Linehan’s Suicidal Behaviors Research laboratory and the University of Washington Division of Child and Adolescent Psychiatry. A number of clinicians in the division, including Dr. McCauley, have undergone DBT training and have begun to apply adaptations of this interventions with adolescents. One of the sites in which DBT is being pilot tested is on the mental health cottage of a Washington State Department of Corrections juvenile correctional facility. A pilot evaluation has assessed staff adherence, staff burnout, behavior of youth in the institution, and youth mental health symptoms, functioning, and offense behavior. Preliminary data were analyzed for 32 female juvenile offenders during the first 12 weeks of the intervention. The table below demonstrates that this cohort of female juvenile offenders has similar mental health problems as the Prime Time target youth.
Incidence of Functional Impairment among Female Offenders on the Mental
Health Cottage in the DBT Study
|Percent With Moderate to Severe impairment on the CAFAS||92||83||58||58||50|
The primary targets of the DBT intervention included reduction
in disruptive behaviors that interfere with youths’ participation in rehabilitation
activities. To measure the effectiveness of the interventions, daily
logs were completed for objectively measurable incidents of aggression, school disruption, room confinement, and parasuicidal acts as well as punitive responses by program staff. In the 10 months of the intervention, the frequency of classroom disruption, aggressive behavior, suicidal behavior and room confinement, showed a significantly declining trend in the targeted treatment cottage.
Implications for Program Development. This study demonstrates the efficacy of applying DBT to a non-specifically diagnosed group of mentally ill juvenile offenders. The professional and paraprofessional staff of the mental health unit of a state juvenile detention facility were able to learn and apply the DBT skills training program. The youth in the detention facility are comparable to youth enrolled in Prime Time in terms of severity of criminal offences and mental health symptoms. The effectiveness of DBT in this population also shows promise. A major challenge of the MST intervention is to have the youth succeed in structured settings (school, work, and community-based group) despite high levels of emotional and behavioral dysregulation.
Functional Impairment Outcome Study
The Child and Adolescent Functional Assessment Scale (CAFAS) was used to measure impairment and improvement in functioning in 5 domains (Role Function, Behavior toward others, Mood, Thinking and Substance use) at intake, 6 months and one year after enrollment in Prime Time. 28 youth were assessed at these time points. The Prime Time intervention applied with these youth included MST, as well as a brief Motivational Enhancement intervention. Repeated measure MANOVA was used to determine the relationship among mood, behavior and substance use and change in role functioning over one year. Role functioning was categorized as “improved” or “not improved” based on the clinical judgement that an improvement would be characterized as mildly improved functioning in two out of three domains (school, home community) or moderate improvement in a single domain. Of the 28 Prime Time participants followed for one year, 12 were classified as “improved.” The question of interest in this study was the possible difference in mood, behavioral or substance use functioning in youth who demonstrated improvement in the primary MST targets of school, home and community functioning vs. those who did not. The results of the multivariate test demonstrated that the three measures were significantly related to outcome (F(3,24)=4.33, p=.014). The univariate tests revealed significant interactions among Mood (F(1,28)=10.37, p=.003)and Behavioral (F(1,28)=5.69, p=.025) functioning over time and role functioning improvements. This interaction was not found for substance use (F(1,28)=.608, p> .05), which improved uniformly for participants regardless of role improvement.
Implications for Program Development. This study demonstrates
the interrelation among mood, behavioral and role functioning outcomes.
Youth who improve their ability to function in school, work and at home
also show a decrease in behavioral and emotional impairment. While
causality cannot be determined it is important to note that the entire
sample was receiving a uniform MST intervention while the interventions
for mood and behavioral dysregulation were left unspecified. This
argues for a uniform approach to these domains such as DBT.
1. Over the next three years, we will carry out three development activities:
1) completing the Prime Time Intervention Manual
The Prime Time Intervention Manual will operationalize and standardize individual-level enhancements targeting psychoactive substance use disorder and diagnosed psychiatric illness in African American adolescents. Since there is considerable uniformity in the major psychiatric issues that are appropriate targets for this intervention and because we are in the early stages of development of this psychosocial treatment approach, we will apply the same treatment protocol to each youth who meets eligibility criteria and is assigned to the experimental group. In the future, we will apply tests to determine the optimal timing, ordering, and content of sessions and modules for individuals with different types of presenting problems and at different stages in their development.
2) developing adherence measures
Monitoring adherence has become an essential ingredient of treatment research and development (Kazdin, 1986). Recent evidence from the development of the MST model has shown better client outcomes to be associated with better adherence (Henggeler, et al, 1997). An important goal of this project will be to develop a protocol to study clinician adherence to the Prime Time intervention. One challenging aspect of meeting this goal is that the intervention brings to bear a number of complementary, but distinct treatment approaches. The adherence study will be made up of four different studies that focus on critical elements of the intervention. The first and second activities will be conducted with all study subjects, and the third activity will be conducted with Prime Time subjects, only.
3) conducting a pilot intervention outcome study.
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