D. Paul Moberg University of Wisconsin

Transcription

1 D. Paul Moberg University of Wisconsin Andrew J. Finch and Emily Tanner-Smith Vanderbilt University Presented at the 30 th Annual Research & Policy Conference on Child, Adolescent and Young Adult Behavioral Health, Tampa, FL March 6, 2017.

2 Supported by the National Institute On Drug Abuse of the National Institutes of Health under award number R01DA This project has also benefited from the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS) grant UL1TR The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Lead investigators: Ken Winters, John Grabowski, and Sheila Specker, University of Minnesota and Luis Torres, University of Houston. Key Collaborators: Mark Lipsey, Emily Tanner-Smith, Emily Fisher Hennesey, Vanderbilt Andria Botzet, Christine Dittel, Tamara Fahnhorst, Patrick McIlvaine, UMN Stephanie Lindsley, Barbara Hill, Falon French, David Weimer, UW

3 ADOLESCENT SUD TREATMENT IN THE US 1.3 million (5.1%) youths needed treatment in ,000 received treatment at a specialty facility (about 11.2 percent of the youths who needed treatment) This left about 1.2 million who needed treatment for a substance use problem but did not receive it at a specialty facility. SOURCE: NSDUH, 2014

4 Chronic disease model of Substance Use Disorders becoming the norm Evidence that return from treatment to former peers and settings negatively effects outcome (e.g., Winters, 2004). Traditional schools a toxic environment for many young people.

5 A. Primary purpose is to educate students in recovery from substance use or co-occurring disorders; B. Meet state requirements for awarding a secondary school diploma, i.e. school offers credits leading to a staterecognized high school diploma, and student is not just getting tutored or completing work from another school while there; C. Intent that all students enrolled be in recovery and working a program of recovery from substance use and/or co-occurring disorders as determined by the student and the school; D.Available to any student in recovery who meets state or district eligibility requirements for attendance, i.e., students do not have to go through a particular treatment program to enroll, and the school is not simply the academic component of a primary or extended-care treatment facility or therapeutic boarding school. SOURCE: Association of Recovery Schools, 2013

6 Our Current Research Study Research Design Characteristics of Treatment Programs and Recovery Schools Characteristics of Participants Preliminary Results Challenges

7 Prior studies suggest that RHSs are an effective component of continuing care for adolescents with SUDs (e.g., Moberg and Thaler, 1995; Moberg and Finch, 2008; Finch, 2003; Kochanek, 2010; Moberg, Finch and Lindsley, 2014 ) Focal Question: Are RHSs cost effective in comparison to traditional high schools in preventing relapse, facilitating academic achievement, and reducing dropout for students recovering from SUDs Specific Aims: To assess, as compared to traditional high school students with treated SUDs: Behavioral outcomes for RHS students (less alcohol and other drug use, fewer mental health symptoms, and less delinquent behavior) Academic outcomes for RHS students (higher GPA, higher standardized test scores, better attendance, lower drop-out rates) Cost-benefit analysis of RHS participation (Weimer)

8 Students and parents recruited from MN, WI and TX substance abuse treatment settings and RHSs. Comparison group of students not attending RHS selected from this pool using propensity score techniques; use variables based on prior meta-analyses (Lipsey and Tanner- Smith, 2010). Interviews of students and parents at baseline, 3, 6 and 12 months; UA at baseline and 12 months; extensive measures including domains from Lipsey and Tanner-Smith s metaanalyses; Winter s PEI; Moberg and Finch s; Dennis s GAIN. Site visits and interviews with schools and treatment facilities to better characterize the interventions, and to provide level 2 data for multi-level modeling.

9 Recruit from: Baseline School Type 3 Months School Type 6 Months School Type 12 Months Longer Term Follow-up? Treatment Settings O 0 Non- RHS O 3 Non-RHS O 6 Non-RHS O 12 O 24 RHS O 3 RHS O 6 RHS O 12 O 24 O=Observation/interview of youth and parent School Type=RHS or Non-RHS Primary Analysis=Differential change from O 0 to O 12 for RHS vs Non-RHS students.

10 Recruit from: Baseline School Type 3 Months School Type 6 Months School Type 12 Months Longer Term Follow-up? Treatment Settings O 0 Non- RHS O 3 Non-RHS O 6 Non-RHS O 12 O 24 RHS (recruitment added) O 0 RHS O 3 RHS O 6 RHS O 12 O 24 O=Observation/interview of youth and parent School Type=RHS or Non-RHS Primary Analysis=Differential change from O 0 to O 12 for RHS vs Non-RHS students.

11 From Lipsey and Tanner-Smith s (2010) meta-analysis (119 studies) of predictors of substance use treatment outcome (r= ): prior substance use history attitudes toward substance use; intentions to use drugs or alcohol peer substance use and attitudes; peer antisocial behavior; availability of drugs from peers delinquency, aggression, antisocial behavior; impulsiveness, hyperactivity; antisocial attitudes school performance, achievement, grades; school bonding, attitudes toward school; school truancy, attendance religiosity social competence, social skills family antisocial behavior, substance use negative parenting; poor parent skills; weak family cohesion internalizing behavior/symptoms

12 Current study: 7 recovery high schools in MN -3 closed Added 2 Wisconsin schools 1 closed Added Houston Texas 2 schools, plus new one at UT- Austin Prior (R21) Descriptive Study: 17 schools plus one pilot in 7 states, including 8 RHSs in MN School types: Charter schools; Area Learning Centers/Schools-withinschools; Contract Alternative Programs (Horizon); District alternative partnership (Albuquerque); private non-profits.

13 RHS Facilities : School building (shared with other programs) Church classrooms or basements Community centers Office complexes Industrial/office parks

14

15 Baseline 3 Month 6 Month 12 Month Total Interviews Youth Interviews (90%) 238 (81%) 210 (71%) 1005 Parent Interviews (90%) 266 (88%) 252 (83%) 1097 Total Interviews

16 Substance Use (Timeline Follow Back; Sobell & Sobell, 1992) Days used alcohol (past 90) Days used marijuana (past 90) Days used other drugs (past 90) Percent Abstinent (past 90) Academics Student-reported average grades in English/reading, math, or other subjects (mostly F s [0] to mostly A s [4]) Mental Health (MINI-SCID; Sheehan et al., 1999) Number of mental health diagnoses (major depression, mania, generalized anxiety, panic, OCD, PTSD, eating disorder, delusions, hallucinations, ADHD, ASPD)

17 Propensity scores used to balance RHS and non- RHS students on baseline characteristics: Controls for potential confounding and to address lack of randomization to groups. Propensity scores were estimated using a large set of baseline covariates expected to predict the selection mechanism and/or any of the outcomes (guided by Lipsey and Tanner-Smith s meta-analytic work) Average treatment effects of RHS attendance on 6-month outcomes: Multilevel regression models with school-level random effects used to estimate program effects on outcomes Multiple imputation used to handle missing data

18 Demographics M (SD) or % Age 16.4 (1.0) Male 50% White 86% African-American 7% Other race/ethnicity 7% Alcohol abuse/dependence 15%/48% Other Drug Abuse/Dependence 12%/82% Prior treatment for substance use disorder 100% Co-Morbid Mental Health Condition 93% *Pruned of students outside propensity score balanced range

19 Baseline Substance Use (90 days pretreatment) M (SD) or % Days used alcohol (past 90 days) 19 (25) Days used marijuana (past 90 days) 55 (35) Days used other drugs (past 90 days) 30 (35) Percent abstinent 2% Baseline Academics Self-reported grades 2.4 (1.0) Self-reported truancy (days) 2.2 (1.2) Absenteeism (days) 4.8 (7.9) MH Symptoms (Mini-SCID, lifetime) Any diagnosis 93% Number of diagnoses 3.5 (1.9)

20 SU Treatment History Inpatient/residential 59% Outpatient 84% AA/NA 64% MH Treatment History Inpatient/residential 38% Outpatient 80% Ever psychiatric medication 88% Days of mental health services in past (59)

21 Meets criteria for: Percent Any of the nine disorders 94 Major depressive disorder 80 Generalized anxiety disorder 64 Obsessive-compulsive disorder 12 Panic disorder 38 Posttraumatic stress disorder 31 Antisocial personality disorder 45 Manic episode 17 Hypomanic episode 20 Suicide risk 44

22 Outcome (past 90 days) RHS Students Comparison Students Mean Days used Alcohol 2.0 (6.8) 5.4 (12.3) Mean Days used Marijuana 8.8 (22.9) 25.8 (34.9) Mean Days used Other Drugs 3.2 (11.7) 7.1 (20.7) Abstinent 58% 29%

23 Outcome b 95% CI Effect Size (Cohen s d) Odds Ratio Days used alcohol [-6.6, 2.4] Days used marijuana * [-27.7, -1.1] Days used other drugs [-14.8, 1.3] Abstinence 1.40* [0.1, 2.7] 4.06 b = unstandardized regression coefficient indexing RHS difference in means (or log odds ratios) after adjusting for propensity scores and baseline scores. d = Cohen s d standardized mean difference effect size, estimated as the difference in adjusted means divided by unadjusted pooled standard deviation. OR = odds ratio effect size, adjusted for propensity scores and baseline scores. p <.10. *p <.05.

24 Outcome B 95% CI Effect Size (Cohen s d) Grades 0.21 [-0.17, 0.59] 0.26 Truancy 0.01 [-0.65, 0.67] 0.01 Absenteeism 5.05* [-9.55, -0.55] b = unstandardized regression coefficient indexing RHS difference in means after adjusting for propensity scores and baseline scores. d = Cohen s d standardized mean difference effect size, estimated as the difference in adjusted means divided by unadjusted pooled standard deviation. *p <.05.

25 Major depression Generalized anxiety Obsessive-compulsive Panic Posttraumatic stress Antisocial personality Mania Hypomania Suicide risk Proportion meeting diagnostic criteria RHS (discharge) RHS (follow-up) Non-RHS (discharge) Non-RHS (follow-up)

26 Accrual/recruitment more difficult than anticipated; low flow from treatment to RHS. Variable treatment experiences modalities, repetition, intensity, dual disorder emphasis Stability of RHSs resource and institutionalization difficulties. Variable longevity of RHS participation by students what dose is meaningful?

27 What have we learned based on our Program of Research? RHSs are important option in continuum of recovery support, in particular serve students with Co-occurring disorders Severe substance use disorders High need for services and support Deserving of multi-system braided funding!

28 Most programs studied appear to be successful in supporting young people in recovery, and providing (at least transitional) academic services Substance use outcomes are very positive based on rigorous quasi-experimental analysis using propensity scoring to equate groups. Academic outcomes show promise but effects are small Mental Health Outcomes show similar reductions in symptomatology in RHS and comparison group RHS programs less successful in community institutionalization Sustainability continues to be an issue; is model viable given small size of programs?

29 RHS s vary significantly in school structure and organizational home Recovery Schools are very dynamic in nature Policies that facilitate Recovery Schools vary by state (macro level policy) and community or school district (micro level policy) Sustainability of individual schools is tenuous we are trying to sort out factors that are important!

30 Questions and Dialogue?