Evaluating Reclaiming Futures: Final Performance Review

Transcription

1 ...to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshire s future. One Eagle Square Suite 510 Concord, NH (603) Fax: (603) Board of Directors Martin L. Gross, Chair John B. Andrews John D. Crosier Gary Matteson Chuck Morse Todd I. Selig Stuart V. Smith, Jr. Donna Sytek Georgie A. Thomas James E. Tibbetts Brian F. Walsh Kimon S. Zachos Evaluating Reclaiming Futures: Final Performance Review Executive Director Stephen A. Norton snorton@nhpolicy.org Deputy Director Dennis C. Delay ddelay@nhpolicy.org Research Associate Ryan J. Tappin rjtappin@nhpolicy.org Office Manager Cathleen K. Arredondo carredondo@nhpolicy.org Executive Director Emeritus Douglas E. Hall doughall@nhpolicy.org November 2007

2 Authors Ryan J. Tappin Research Associate Laura McGlashan Research Associate Acknowledgements The Center wishes to thank the court and probation staff from New Hampshire s juvenile drug courts and district courts for their assistance in gathering data for this report. Ray Bilodeau, Drug Court Clinical Director, Gary Fowler from the Administrative Office of the Courts, and Bill McGonagle of the Division for Juvenile Justice Services were particularly helpful in providing the Center with data. About this paper This paper is the final in a series of reports the New Hampshire Center for Public Policy Studies has published in connection with its independent evaluation of New Hampshire s Reclaiming Futures (RF) initiative. 1 The paper focuses on RF s impact on drug court operations, as well as its impact on youth in the drug court program. The paper is intended for members of the judiciary, juvenile justice professionals and other staff of the state s juvenile drug courts, and anyone else with an interest in juvenile justice in the state of New Hampshire. The Center was hired in 2003 by the Administrative Office of the District Courts to carry out a formal, independent evaluation of New Hampshire s Reclaiming Futures initiative in juvenile drug courts. New Hampshire is one of ten sites nationwide piloting the RF approach. The Center is performing the study in conjunction with a national evaluation, associated with the Chapin Hall Center for Children at the University of Chicago. The evaluation is funded by a grant from the Robert Wood Johnson foundation. 1 Reclaiming Futures is a program funded by the Robert Wood Johnson foundation. <

3 Evaluating Reclaiming Futures: Final Performance Review Contents Executive Summary... 1 Data and methodology... 5 Data sources...5 Limitations of the data... 6 Reclaiming Futures a new approach to helping teens overcome drugs and crime... 8 Teen drug use in NH is higher than the national average... 8 The courts start juvenile drug courts to address the problem of teen drug use... 8 Who are NH s drug court youth?... 9 New Hampshire s Reclaiming Futures initiative Implementing the RF model in NH s drug courts Use of screening has declined over the RF, but universal screening is forthcoming More RF youth received comprehensive assessments Service coordination has improved through central administrative support from RF.. 15 Treatment initiation and engagement Drug court completion remains the same but varies by court Youth spend nine months in the program More youth are being kept in the community One third of youth commit a new drug offense by one year after drug court Discussion Opening communication and standardized screening Introducing Evidence-Based Practices Administrative infrastructure developed, but with an uncertain future Community engagement remains a challenge NH s Reclaiming Futures project lessons learned and drug courts moving forward 28 Appendix Tables and Figures Table 1: Main process measures of the four Reclaiming Futures drug courts by RF program year... 4 Table 2: Admission dates for each RF year... 5 Table 3: Percent of drug court youth population from each jurisdiction... 6 Table 4: Risk factor characteristics of youth in the RF drug courts by jurisdiction... 9 Table 5: Percent of youth graduating drug court Table 6: Average number of drug court events by RF year Table 7: Percentages of youth placed out of the home and in detention Table 8: Prior and during program charges by RF year and termination status Table 9: Subsequent charges by RF year and termination status Figure 1: Percent of youth receiving a screening for AOD issues at intake Figure 2: Percent of youth receiving a comprehensive AOD assessment by RF year Figure 3: Percent of case plans with RF specific quality measures by RF year... 18

4 Evaluating Reclaiming Futures: Final Performance Review 1 Executive Summary New Hampshire has one of the highest rates of teen drug use in the United States, and one of the highest percentages of youth who need treatment but do not receive it. 2 Moreover, drug charges against New Hampshire juveniles have increased by 60 percent between 1996 and 2002, even as the overall total delinquency charges declined. 3 In an effort to respond to this problem, seven of New Hampshire s 36 district courts have started juvenile drug court programs. Juvenile drug courts connect youth offenders to a coordinated system of drug and alcohol treatment in their communities, combined with the provision of strict court supervision and sanctions. To support their efforts to improve treatment for youth in the court system, the district courts sought and received funding from the Robert Wood Johnson Foundation for the Reclaiming Futures (RF) initiative. RF s main goals for improving juvenile drug courts have been to ensure that all youth receive a clinical assessment to identify treatment needs, coordinated treatment based upon a written case plan, and involvement in community activities that will strengthen their chances of success. Another primary goal of RF has been to institute standardized drug and alcohol screening for all youth entering the court system. To these ends, RF has funded a variety of activities, including training in evidence-based practices as well as staff to help volunteers develop activities for youth. RF has also funded administrative support for drug courts to improve the treatment approach and standardize those improvements across the drug court programs. This report focuses on the original four juvenile drug courts, which were the target of RF in New Hampshire. This paper is the final in a series of reports designed to provide ongoing feedback to those working with RF and the juvenile drug courts. It reviews data evaluating the RF program on a variety of different measures, focusing on RF s impact on drug court operations, and its impact on youth in the program. 1. New Hampshire s juvenile drug court system is managing a very troubled population of youth. Over half of the youth were multiple drug users, 71% had immediate family members who used substances, and 65% had a mental health issue of some kind identified before or during the program. During RF, these characteristics remained consistent, but some variation across jurisdictions existed. 2. RF has successfully put tools into place to centralize and standardize drug court operations. When RF started, the drug courts had no written guidelines or 2 Youth Risk Behavior Survey (YRBS), 2003 and the Substance Abuse and Mental Health Services Administration (SAMHSA) Household Survey of Drug Use, National YRBS data are available at New Hampshire data are available at SAMHSA data are available at 3 New Hampshire Center for Public Policy Studies. Teen Drug Use and Juvenile Crime. December 2004.

5 Evaluating Reclaiming Futures: Final Performance Review 2 standards, no way to aggregate or share information about program operations, and no methods for tracking progress towards goals. One drug court case managers was responsible for clinical supervision of all the programs. RF devoted considerable resources to improving these shortcomings by developing the drug courts administrative infrastructure. The tools RF put into place including the development of a drug court manual, the institution of a data-driven case management system, and the provision of administrative supports have helped to sustain the drug court model and expand it to other jurisdictions. The tools will also support RF s coordinated treatment approach, and allow for individual case management and ongoing program evaluation. 3. RF has been successful in instituting a standardized alcohol and drug screening process for all youth entering the court system, which opened communication between departments. RF succeeded in bringing the courts and the Department of Juvenile Justice Services (DJJS) together to jointly create a standardized screening process for all youth in the juvenile justice system. This is a significant accomplishment as several major barriers to implementing such a system existed. The use of a standardized screening tool is currently being implemented in the drug courts, and is expected to expand to all juvenile courts. This collaboration successfully fostered open and regular communication between the courts and DJJS. It remains to be seen whether this communication will continue after RF advisory meetings have been reduced. 4. RF has made significant progress toward its goal of ensuring that every drug court youth receive a comprehensive assessment. The number of drug court youth receiving a comprehensive assessment, as well as the number of assessments that were completed in a timely manner increased substantially over the course of RF. Moreover, the number of clinicians using an evidence-based tool, the Global Appraisal of Individual Needs (GAIN), has increased as well. RF has been the primary force driving the expansion of the GAIN in New Hampshire. 5. Despite the system changes and increased use of assessments, data on other main process measures have shown both decreases and inconsistencies. a. Screenings: Despite the successful institution of a system-wide alcohol and drug screening tool, the number of drug court youth who were screened for substance abuse problems has declined over the RF initiative. The decline may be largely related to the loss of administrative supports, which necessitated a change in screening procedures, and by direct referrals of youth to a comprehensive assessment in lieu of screening. b. Case plans: The use of written case plans increased slightly from before RF to RF. However, the quality of those case plans has generally decreased. And, there have been significant inconsistencies in the use and quality of case plans both across the RF years and jurisdictions, and even within the same jurisdiction. c. Program Completion: The percentage of youth completing drug court has remained constant since the RF initiative began. The number of graduates

6 Evaluating Reclaiming Futures: Final Performance Review 3 and youth removed from the program for non-compliance varies widely by jurisdiction and RF year. 6. Pro-social engagement and treatment access in the community continues to be a challenge. Although data were not available on the number of Pre RF youth involved in community activities, data collected by drug court staff indicate that 93% of youth in the later RF years were involved in community activities at some point in the program. However, few youth were engaged weekly and challenges to connecting youth with strength or interest based activities still remain. It is noteworthy that over the course of RF, fewer youth were placed outside the home. This suggests that more youth were successfully treated in their communities, and fewer youth were held in detention. 7. Recidivism rates of RF youth require further study. Almost half of drug court youth committed at least one new drug-related offense within two years of ending the program. Eighty-eight percent of youth incurred any new charge (drug and non-drug related) within the two years. However, the small number of youth with sufficient time elapsed after drug court makes a comparison of Pre RF to RF youth not possible. 8. Key data including the lack of severity of alcohol and/or drug problems, socioeconomic status, and presence of a concurrent mental health disorder are not readily accessible to those working in the juvenile justice system, and in some cases are missing altogether. The lack of accessible data prevents not only the meaningful evaluation of the drug court program that takes into account all factors influencing outcomes, but also the determination of the most appropriate and cost-effective interventions for juvenile offenders system-wide. 9. Despite RF s efforts to create consistency across the various drug court programs, the analysis shows a great deal of variation by jurisdiction in factors critical to understanding the potential success of RF. This is particularly evident with the use of out-of-home placement and the number of youth receiving comprehensive assessments. Sanctions, rewards, program admission and termination, and most services are carried out by the order of the presiding judge. Although drug court guidelines have been established, variation across courts remains. The jurisdictional variations in outcomes suggest that judicial leadership has played an important role in the drug court program and should be a critical consideration going forward.

7 Evaluating Reclaiming Futures: Final Performance Review 4 Overall, many process measures, highlighted in Table 1, have indicated an improvement in drug court operations over the course of Reclaiming Futures. It remains to be seen if these changes will continue in the drug courts as the financial support from RWJ has ended, and if the inconsistent measures will improve as operations become more institutionalized. Table 1: Main process measures of the four Reclaiming Futures drug courts by RF program year Drug Court youth Total youth Screened Assessed Engaged in community activities Written case plan completed Graduated Pre RF 41 93% 78% 56% 59% RF Year % 75% No data 58% 50% RF Year % 88% 74% 67% RF Year % 97% 93% 66% 48% Total RF % 85% N/A 64% 53% Total drug court youth % 83% N/A 62% 55% However as a result of program differences across the courts, inconsistencies in data availability, and the small numbers of youth in drug court documenting the full impact of drug courts will require further study into these variations and their effect on outcomes of interest that are beyond the scope of this report. Because of RF, the tools for ongoing program evaluation and outcomes research are now available internally. In the future, the courts should continue the resources necessary to carry out and improve evaluating the drug courts as well as continue to develop baseline performance goals and different definitions of youth success as a method to compare and measure program performance.

8 Evaluating Reclaiming Futures: Final Performance Review 5 Data and methodology The Center s evaluation compares drug court youth before Reclaiming Futures (RF) started in 2003 and to youth in drug court during the initiative, on a number of service and outcome measures. The youth in the study are from New Hampshire s four original juvenile drug courts in Concord, Laconia, Nashua and Plymouth. Youth were followed from the start of drug courts in August 2001 through the end of Table 2 shows the breakdown of the admission dates for each of the RF years. 4 Table 2: Admission dates for each RF year Program year Date of admission Pre RF August 1, 2001 June 30, 2003 RF year 1 July 1, 2003 June 30, 2004 RF year 2 July 1, 2004 June 30, 2005 RF year 3 July 1, 2005 June 30, 2006 Data sources The Center used several data sources throughout its evaluation of RF. Most of the data used in this report were gathered by Center staff from drug court youths paper files. The Center has also gathered qualitative data by attending RF trainings and meetings, and through interviews with drug court staff. Other data was provided by drug court staff to the Center and/or was obtained from administrative sources. A detailed description of the various data sources follows. 1. Drug court paper files The drug court youths paper files contain detailed information on drug and mental health assessments, case plans, youth alcohol and drug severity characteristics, 5 and the contents of all judicial orders issued during the program. Research staff reviewed these files at the courts and recorded their contents in a custom-made research database. 2. Drug court administrative database Drug court has implemented a case management database, funded by RF, to replace the old spreadsheet data collection protocol used by drug court staff. The Center used data collected in this database to describe treatment received, pro-social engagement, and community service participation. These data represent 71 RF youth in the later project years through July 1, Where noted, the Center also used data from the original drug court spreadsheets, which contain data on drug court youth admitted through December 31, The Center considers the start date for the RF years to be July 1, 2003, when RF began its trainings and interventions with drug court staff. The Center assigned any cases that were open on July 1, 2003 to the RF group if the youth served the majority of his or her time in drug court after July 1, 2003, under the RF intervention. 5 Assessments, case plans, and drug use history were often missing in the drug court paper files.

9 Evaluating Reclaiming Futures: Final Performance Review 6 3. Court charges data Charges data were obtained from the Administrative Office of the Courts database. 6 The data set received contained all youth charges from 2000 through June 2006 from all courts in the state of New Hampshire. 7 The data include charges occurring one year prior to a youth s entry into drug court, and charges occurring during and after drug court for 109 participants who were either graduated or terminated from the program. Limitations of the data Few youth in drug court creates a challenge to evaluation The small scale of drug court in New Hampshire creates challenges in statistically evaluating the underlying causes of any changes witnessed in the data. Ideally, the Center would compare Pre RF and RF youth by jurisdiction, while controlling for other factors likely to impact the outcomes being evaluated. Because of the small number of participants, however, most of the analyses aggregate data across jurisdictions when comparing Pre RF and RF youth, or by RF program year. Table 3 details the percent of youth from each jurisdiction in the Pre RF and RF groups to date. The percentage of youth from each jurisdiction varies across these groups, making it important to understand the variation between jurisdictions when analyzing differences between these groups. For example, Plymouth youth are much more heavily represented in the Pre RF group than the RF group. Thus, any unique conditions relating to these youth are more likely to have affected the Pre RF group. Table 3: Percent of drug court youth population from each jurisdiction Jurisdiction Percent of Pre RF group Percent of RF group Percent of total youth Concord 7% 25% 19% Laconia 27% 20% 22% Nashua 24% 28% 27% Plymouth 41% 27% 32% Total 100% 100% 100% Events that occur throughout a drug court case (such as placements or judicial orders) are analyzed based on RF years 1 through 3, and the total RF category reflects the sum of these three years. Data for youth admitted after RF year 3 has been only included when discussing AOD screening prior to admission to the program. 6 Youth dockets were retrieved from the database using the youth s full name, data of birth, address, and filing data of the index docket. Corrections to typographic errors and date of births were made; these dockets were then grouped by name and matched to the project s study ID in order to maintain confidentiality 7 Due to the implementation of a new statewide court database system, data from the Concord and Nashua courts were collected through the end of 2005.

10 Evaluating Reclaiming Futures: Final Performance Review 7 Data are missing on several factors that predict youth success, which prevents rigorous comparisons Important factors in predicting program success and outcomes could not be consistently measured using the court files or administrative data. These factors include AOD abuse severity as measured by a standardized evaluation instrument, mental health history, socioeconomic status, health status and insurance coverage, employment at entry into and exit from the juvenile justice system, and educational attainment. The Center also was unable to obtain specific data on the types and amount of substance abuse and/or mental health treatment services. Additionally, a youth who moved out of state or committed an offense outside of New Hampshire would not have his or her charges reflected in the Administrative Office of the Courts database; therefore, youths total number of prior or subsequent charges may have been underreported. Furthermore, the Center set out to perform a matched comparison study of drug court youth versus youth who were traditionally adjudicated in juvenile courts without drug court programs. Due to the lack and inconsistency of key data for youth in the traditional juvenile courts, including severity of an alcohol and/or drug abuse problem, socioeconomic status, and the presence of a concurrent mental health disorder(s) all strong predictors of recidivism 8 the Center could not be certain that comparison youth were truly representative of a drug court population. Therefore, we could not compare the two groups. 8 McClellan AT, Lewis DC, et al. Drug Dependence, a Chronic Medical Illness. JAMA. 2000; 284:

11 Evaluating Reclaiming Futures: Final Performance Review 8 Reclaiming Futures a new approach to helping teens overcome drugs and crime Reclaiming Futures 9 has sought to improve the quality and appropriateness of treatment received by substance abusing youth offenders while under the supervision of the juvenile justice system. The initiative s staff and advisory board have worked to make these improvements not by offering new programs, but by changing the way the treatment and juvenile justice systems interact with one another and respond to young offenders with substance abuse problems. The initiative focused its efforts on youth in New Hampshire s four original juvenile drug courts. Teen drug use in NH is higher than the national average An estimated 12 percent of New Hampshire teens, or 13,600 young people, have a problem with alcohol or drugs or both. 10 According to two independent surveys, a significantly higher percentage of New Hampshire teens use marijuana, as compared to youth across the nation. Alcohol and cocaine use is also higher than the national averages. 11 Furthermore, the SAMHSA survey indicated that New Hampshire is among the top ten states for the percent of teens needing but not receiving treatment for drug abuse. Over 7,000 adolescents under age 17 in New Hampshire do not receive the alcohol or other drug treatment services they need. 12 The seriousness of New Hampshire s juvenile drug problem is affirmed by the state s court statistics. Although rates of juvenile crime in most categories are low and falling in New Hampshire, the arrest rate of juveniles for drug crimes is the ninth highest in the United States. Drug charges against New Hampshire s juveniles rose by 18% between 2000 and The courts start juvenile drug courts to address the problem of teen drug use In an effort to address the problem of teen drug use, New Hampshire opened its first juvenile drug court at Plymouth District Court in The following year, three more drug court sites were added in Laconia, Concord, and Nashua. Three more drug courts have since begun operations in Claremont, Derry, and Berlin, with plans for continued expansion. The juvenile drug court program is designed to connect non-violent, drug involved youth offenders to alcohol and drug treatment in the community, combined with strict court 9 Reclaiming Futures is a project financed by the Robert Wood Johnson Foundation and managed by New Hampshire s Office of the Administrative Judge of the District Courts 10 Substance Abuse and Mental Health Services Administration survey 2002 and 2004 available on the web at > Accessed 20Sept Ibid. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance Survey, available on the web at < Accessed 20Sept Ibid. 13 New Hampshire Center for Public Policy Studies, Teen Drug Use and Juvenile Crime, December 2004.

12 Evaluating Reclaiming Futures: Final Performance Review 9 supervision and sanctions. By addressing youths substance abuse and other issues that contributed to criminal behavior, the program aims to improve the quality of their lives relationships, school and/or job performance, extracurricular activities and community connections and, ultimately, to end further illicit drug use and crime. Who are NH s drug court youth? As a group, drug court youth are troubled. A review of the youths individual case files revealed that many of their families are in crisis. Many drug court youth experienced significant trauma during their childhood: financial hardship, divorce, the death or incarceration of a loved one, domestic violence, physical abuse, sexual molestation, and suicide attempts. Youth enter the program with a wide range of challenges and needs. Sixty-nine percent of juveniles admitted to drug court had prior delinquency charges. 14 More than half of youth were multi-drug users 15 who began using at an early age 12 years old on average. Seventy-one percent of youth had at least one parent, grandparent, or sibling with a history of substance abuse problems. In spite of these complex drug histories, only 34% received substance abuse treatment before entering drug court, as shown in Table 4. Table 4: Risk factor characteristics of youth in the RF drug courts by jurisdiction Concord Laconia Nashua Plymouth Overall Demographics Average age at entry to drug court (years) Gender (% male) 84% 56% 67% 74% 68% Race (% white) 76% 94% 66% 94% 85% AOD History Average age of first use (years) Multi-drug user (uses other drugs in addition to marijuana and alcohol) 53% 58% 59% 55% 56% Received substance abuse treatment prior to drug court 41% 18% 47% 37% 34% Had parent/sibling/grandparent with a history of substance abuse 79% 64% 71% 70% 71% Mental Health 16 Received counseling prior to drug court, but had no diagnosis 75% 67% 54% 73% 67% Prior mental health diagnosis upon admission 38% 18% 29% 49% 34% Variation across the jurisdictions exists, particularly with race and with prior treatment. The two urban courts, Concord and Nashua, have a far great proportion of minority youth participating in drug court. In contrast, the two rural courts, Laconia and Plymouth, have few youth who received AOD treatment services before admission to the program. When 14 Not including the charge that initiated the referral to drug court. 15 Multi-drug user is defined as using drugs in addition to marijuana, alcohol and/or tobacco. 16 Due to missing data, mental health measures were based on only 64% of drug court youth.

13 Evaluating Reclaiming Futures: Final Performance Review 10 these data are aggregated by RF year or by termination status, there is little variation across the risk factors measured. 17 New Hampshire s Reclaiming Futures initiative RF has been working with the courts, probation, private treatment providers, and community groups to change how the juvenile justice system responds to young offenders who are involved with alcohol and drugs. RF sought to strengthen and improve the drug court programs by emphasizing comprehensive clinical assessments, coordinated services, individualized case plans, and youth involvement in community activities. In addition, RF worked with the courts and DJJS to implement a new screening procedure to identify alcohol and drug problems among all youth in the juvenile justice system, not just those involved in drug court. Juvenile drug courts were originally funded with a combination of court, state agency, and federal grant funds. As the program developed and outside funds were depleted, the courts restructured and reduced staffing. When RF started, three of the four drug court programs had been in operation for less than a year. There were no written guidelines or standards, no way to aggregate or share information about program operations, and no methods for tracking progress towards goals. One drug court case manager was responsible for the clinical supervision of all the programs. RF has devoted considerable resources to overcoming these shortcomings by developing the administrative infrastructure that includes a data-driven case management tool and drug court operations manual. In addition to providing administrative support, the RF initiative has been working toward the following specific goals: 1. Institute standardized screening to identify potential alcohol and drug use for every youth referred to the juvenile justice system, not just those in drug court, beginning in the four RF drug court jurisdictions. 2. Standardize and monitor drug court operations to provide a foundation for system improvements and track adherence to the RF coordinated services model. 3. Ensure that every RF drug court youth receives a comprehensive clinical assessment to assess severity of alcohol and drug use using a standardized, comprehensive assessment tool. 4. Ensure that every RF drug court youth receives coordinated, comprehensive services, using an individualized case plan that provides for the youth s involvement in appropriate treatment and positive activities to improve rehabilitation. 5. Improve treatment completion and drug court outcomes by ensuring the drug court programs adhere to the new, coordinated treatment model. The following sections of this report review RF s progress toward each of the goals, assess how well the RF model has been integrated into the drug courts, and analyze the 17 See Tables A-2 and A-3 in the appendix.

14 Evaluating Reclaiming Futures: Final Performance Review 11 recidivism of youth entering drug court before and during the RF initiative. The final section discusses RF s overall impact on the provision of youth services in the drug court program and examines implications for the future. Implementing the RF model in NH s drug courts Use of screening has declined over the RF, but universal screening is forthcoming One of RF s main goals has been to institute alcohol and drug screening for all youth entering the court system, beginning in the four RF drug court jurisdictions. Yet, the use of youth screenings has declined over the course of the initiative. Almost all Pre RF youth 93% had an AOD screening at intake. In the early RF years, youth referred to drug court were screened by drug court coordinators using various instruments, including a structured interview, the SASSI, and/or the CRAFFT. However, none of the youth who entered drug court after RF year 3 received a screening for potential substance abuse problems, as shown in Figure 1. Figure 1: Percent of youth receiving a screening for AOD issues at intake 100% 90% Youth receiving an AOD screening 80% Percent of drug court youth 70% 60% 50% 40% 30% 20% 10% 0% Before RF RF year 1 RF year 2 RF year 3 After RF year 3 Several factors may have contributed to the decline of screenings. The abolishment of the drug court coordinator positions as of the summer of 2006 reduced the level of administrative support, which may have led to the decrease in screenings for potential drug court youth. It is also possible that drug court staff may be directly referring some youth for a comprehensive assessment in lieu of screening. Furthermore, since RF has moved universal screening in the juvenile justice system forward, drug court staff may

15 Evaluating Reclaiming Futures: Final Performance Review 12 have reduced the use of other screening instruments in anticipation of the new screening protocols. Recently, RF succeeded in bringing the courts and DJJS together to jointly create a standardized screening process for all youth in the juvenile justice system. This is a significant accomplishment as there were several major barriers to implementing such a system. Barriers included opposition to screening by defense attorneys, and a lack of collaboration and the inability to come to a consensus among other key players, including the courts and juvenile probation. RF, the courts, and DJJS have agreed both on a screening tool, the Global Appraisal of Individual Needs Short Screen (GAIN-SS), and a procedure for implementation. Together they developed guidelines for administering the screening. These specify that the GAIN-SS shall be completed by the youth s probation officer upon a plea of true, or the entry of a finding of true by the court. If the youth refuses to participate with the GAIN-SS, the judge has the option to order a pre-dispositional investigation (PDI) and/or a mental health and substance abuse comprehensive assessment. Use of the GAIN-SS is currently being implemented in the drug courts and its use is expected to expand to all other juvenile districts in the near future. More RF youth received comprehensive assessments Part of the RF initiative was to ensure that every drug court youth receive a comprehensive clinical assessment to identify substance abuse problems as well as other treatment needs. Comprehensive assessment is considered necessary to ensure that the nature and severity of substance abuse problems are fully understood, and to identify mental health problems and other issues that may have implications for treatment. 18 In fact, 24 percent of youth who were assessed during drug court were found to have mental health problems that had never been identified previously. 19 To support its goal of ensuring youth receive comprehensive assessment, RF has worked toward instituting a new standardized clinical assessment tool that has been proven to consistently identify substance abuse as well as physical and mental health problems: the Global Appraisal of Individual Needs, or GAIN. Use of the GAIN has increased considerably The GAIN is an intensive, 64-page assessment tool that contains questions on substance use, health, and social functioning. It returns numeric scores as well as a narrative assessment report. Extensive training and certification are required before clinicians can administer the instrument. Before RF, there were no clinicians in New Hampshire certified in the use of the tool. 18 Allen J. Assessment of Alcohol Problems, An Overview, National Institute on Alcohol Abuse and Alcoholism, 19 New Hampshire Center for Public Policy Studies. Evaluating Reclaiming Futures: Performance Review 3. May 2006.

16 Evaluating Reclaiming Futures: Final Performance Review 13 RF has been the primary force driving expanded use of the GAIN in New Hampshire. It has provided extensive training and support. In previous reports, the Center found that adoption of the GAIN still posed a significant challenge for RF. Only three clinicians had been certified to use it and no GAIN assessments had been conducted. 20 It is projected that by the end of 2007, over 75 clinicians state-wide will have been trained to administer the GAIN, including 6 trainers. Regional trainings for providers are now held twice yearly. Furthermore, two of the state s ten community mental health centers are using the GAIN for youth assessment. 21 RF also has worked to have the GAIN approved as eligible for payment by Medicaid and the state. Originally, the Department of Health and Human Services (DHHS) did not recognize the GAIN as a reimbursable service. RF met with Medicaid administrators to explain what a GAIN assessment includes and to clarify the procedures necessary for payment. Together, RF and DHHS distributed this information to the judiciary, juvenile probation staff, and providers, who now understand the appropriate language to use to ensure payment for services. These interventions by RF were critical steps in supporting the growing acceptance and expanded use of the tool. Additionally, RF has played a critical role in convincing a major adolescent substance abuse treatment initiative to use the GAIN. RF succeeded in influencing the administrators of the new Adolescent Treatment Initiative (ATI) 22 to require all of its providers to use the GAIN. 23 ATI is a major initiative that is currently funding $5 million in adolescent substance abuse treatment across the state, so its adoption of the GAIN was a significant step toward continued and expanded use across the state. Finally, acceptance of the GAIN has been facilitated by the fact that it could improve the quality of treatment outside of the drug court programs for all New Hampshire youth. The GAIN s numeric scores allow providers to measure treatment outcomes, improving the state s ability to focus on treatment that works. In addition, some federal grants now require the use of the GAIN, so certified providers stand well-positioned to apply for those grants and bring new resources into the state. Overall, RF has facilitated an increase in pressure on evidenced-based tools, which will allow use of the GAIN to be sustained beyond RF. Use of the GAIN in drug court has also increased considerably. At the end of 2006, 35 drug court youth had been assessed using the GAIN, which is 30% of all RF youth and 53 % of those in RF Years 2 and 3. It remains to be seen whether use of GAIN assessments will improve outcomes, and whether drug court youth who receive GAIN assessments are being more appropriately 20 New Hampshire Center for Public Policy Studies. Evaluating Reclaiming Futures: Performance Review 2. November Maria Gagnon, MSW, Assistant Director, NH Adolescent Treatment Initiative, October ATI is funded by the New Hampshire Charitable Foundation and administered by New Futures, a private, non-profit advocacy group that works to reduce substance abuse in New Hampshire. 23 As described at a public meeting on the Adolescent Treatment Initiative in 2004.

17 Evaluating Reclaiming Futures: Final Performance Review 14 matched with services compared to youth who do not receive the GAIN. In previous reports, the Center found that most non-gain assessments were fairly comprehensive: 84 percent identified alcohol and drug problems, 88 percent found mental health issues, and 41 percent noted strengths. 24 These percentages are comparable to those found in the GAIN assessments completed during RF. Overall, the use of assessments in drug court has increased The Center recorded every assessment contained in a youth s drug court paper file. This count included assessments by licensed alcohol and drug counselors, comprehensive assessments by psychologists and other clinicians, pre-dispositional investigations (PDIs) by probation officers that included an AOD assessment, and/or GAIN assessments. 25 Any one of these assessments identify the severity of a youth s alcohol and drug problems and meet the standards for comprehensive assessment set by RF in the drug court manual. In Performance Review 3, the Center found that the use of assessments in drug court had not increased. Since that time, the Center finds that there has been a substantial increase in the use of assessments, particularly during RF years 2 and 3, as shown in Figure 2. Eighty-eight percent of RF year 2 youth and 97% of RF year 3 youth received an assessment. This is a substantial increase over the years before RF, during which, only 78% of youth received an assessment. 24 These are the percentage of assessments that identified issues, not the percent of youth who had issues. Some youth have multiple assessments. 25 The Center did not count any assessment completed more than six months prior to entry into drug court because it would be considered too old to be clinically valid, per RF Director.

18 Evaluating Reclaiming Futures: Final Performance Review 15 Figure 2: Percent of youth receiving a comprehensive AOD assessment by RF year 100% 90% Received a comprehenisve AOD assessment Assessed within 60 days of admission 80% 70% Percent of drug court youth 60% 50% 40% 30% 20% 10% 0% Before RF RF year 1 RF year 2 RF year 3 There has also been an overall increase in the number of youth receiving timely assessments. 26 Fifty-nine percent of Pre RF youth were assessed within 60 days of entering drug court, as compared to 65% of youth during the RF years combined. The percentage of youth receiving timely assessments steadily increased to 88% in RF year 3. As reported in Performance Review 3, the results vary by jurisdiction. The Center reported that Nashua had the lowest percentage of assessments. Nashua continues to lag behind the other three drug court sites on overall assessments during three of the four RF years. Whereas the other sites assessed 82% of drug court youth or more during RF, Nashua assessed approximately only one-third of its youth in the first RF year. Interestingly, however, the percentage of Nashua youth receiving assessments increased substantially during RF years 2 and 3 at an average of 87%. Service coordination has improved through central administrative support from RF After youth are comprehensively assessed, RF seeks to ensure that they receive comprehensive services that are coordinated across state and community agencies. 26 Data on timely assessments does not include PDIs, representing assessments received by a community provider outside of the juvenile justice system. Assessments performed six months prior through 60 days after admission are included.

19 Evaluating Reclaiming Futures: Final Performance Review 16 Coordinated treatment that addresses multiple needs is considered to be the most effective in helping youth overcome substance abuse. 27 RF has supported the development of a drug court operations manual and a case management system One of RF s first tasks was to create drug court operations manual. RF staff developed the manual based on a series of meetings with court and probation personnel. The manual sets standards for drug court operations, including requirements for the critical components of the RF treatment approach, such as assessments, case plans, and youth involvement in pro-social activities in their communities. It emphasizes involving the broader community in the development of the drug court program. The manual is one tool RF is using to promote its treatment approach across all drug court sites. Furthermore, the probation staff working in the juvenile drug courts has also developed an additional operations manual. This manual provides probation staff with guidelines for working with youth in the drug court program. It includes administrative forms as well as procedures and guidelines for the various components of drug court, such as phases, treatment, and graduated sanctions and incentives. Another tool RF funds allowed to develop was a case management system for all drug courts. This system is a computerized database, which aims to collect and manage individual case information consistently and efficiently. RF and the courts hired the Center to develop the system under the direction of the Drug Court Clinical Director, an RF funded position. RF designed the case management system to promote the RF treatment approach. The treatment team uses it during their weekly meetings to enter data on assessments, case planning, pro-social activities, treatment attendance, and other critical components of the RF model. The case management system will allow drug court staff to monitor adherence to the drug court manual and to the RF treatment approach, by generating reports on each drug court s progress concerning various components of the RF model. The courts have launched the database in all six drug courts, and it is being managed by the Drug Court Clinical Director. Drug court staff has begun to use the case management database to provide the treatment teams and judges weekly updates for each youth. These reports detail a youth s treatment, pro-social engagement, school involvement, drug tests, and other important information that judges can use to determine rewards, sanctions, and other next steps for each case. Treatment teams The RF drug courts coordinate treatment and supervision of youth through weekly meetings of a treatment team, which discusses the progress and needs of the youth and 27 Rutherford B and Banta-Green C. Adolescent Substance Abuse Treatment: A Review of the Literature. ADAI Technical Report Alcohol and Drug Abuse Institute, University of Washington. 1998

20 Evaluating Reclaiming Futures: Final Performance Review 17 his or her family. The coordination of services that occurs from the drug court treatment teams is unique in New Hampshire s juvenile justice system. The team generally includes a clinician, the youth s probation and parole officer, a court clerk, a representative from the youth s school, and individual(s) from the community supporting the youth. Families may attend the meetings to participate in the case planning. RF staff has worked with the treatment teams to promote the RF coordinated treatment approach and to support its implementation. The RF Drug Court Clinical Director and RF Project Director have provided support to the drug court teams. In many drug courts across the country, the judge is a central member of the treatment team. However, in New Hampshire s juvenile drug courts the judge does not participate in treatment team meetings. Drug court staff has indicated that it would be inappropriate for the judge to discuss a case prior to the hearing. However, in several cases, the judge s orders have completely disregarded, or significantly modified, treatment team recommendations. It is not known how these changes have impacted the drug court program, including staff morale, inter-agency relationships, and in the youth s cases themselves. Use of case plans remained inconsistent RF s drug court manual requires treatment teams to develop individualized case plans and to involve families in the process. The plans are used to coordinate treatment and to focus the team on the youth s strengths and rehabilitation goals. Drug court case plans outline the services needed and the goals to be accomplished during drug court. Some of the drug courts used case plans before RF began, but RF has been working to increase their use. RF also has been working to ensure that the goals included in the plans are individualized, and that they include pro-social activities that build youths strengths. The Center has been tracking these changes in the use of these plans during RF. 28 The percent of youth with case plans increased overall from 56% before RF to 64% for youth in all RF years combined. However, the quality of case plans has generally decreased. And, there have been significant inconsistencies in the use and quality of case plans both across the RF years and jurisdictions, and within the same jurisdiction. Figure 3 illustrates the percent of case plans with specific quality measures by RF year. 28 The Center measured if a case plan contained a particular element of quality or not. Individualized goals address a youth s particular needs such as Attend weekly treatment sessions with (clinicians name) and submit to twice-weekly drug tests. Goals that are not individualized could apply to any youth such as Stop using alcohol and drugs.

21 Evaluating Reclaiming Futures: Final Performance Review 18 Figure 3: Percent of case plans with RF specific quality measures by RF year 100% 90% Case plan was indivdualized Case plan had pro-social goals 80% 70% Percent of drug court youth 60% 50% 40% 30% 20% 10% 0% Pre RF RF year 1 RF year 2 RF year 3 The percentage of files with case plans reached a high of 74% during RF Year 2, but declined again in RF year 3. At the same time, interestingly, the percentage of plans with individualized goals was 68% in RF year 2, whereas, in all the other RF years, plans containing individualized goals exceeded 90%. Case plans varied by jurisdiction. For example, few of the Laconia case plans during RF contained individualized pro-social goals, despite the resources RF invested in developing those opportunities. The decrease in the number of case plans during year 3 is due to a decrease in case plans in three of the jurisdictions. And, the overall increase in case plan quality in Plymouth was primarily attributable to a change in format that was spearheaded by the Drug Court Clinical Director. Case plans goals were inserted into the treatment team agenda every week, thus keeping the case plans updated and relevant and focusing the team on the youth s individualized goals. Drug court staff has indicated that the centralized drug-court database has replaced the paper file version of the case plan. Nevertheless, the Center located case plans in the paper files for youth admitted after the database was implemented. And, in only one case was there an electronic version where there was no case plan in the paper file. Drug court staff has raised this, as well as proper use of the drug court database, as a point for ongoing improvement and training.