Comparative Effectiveness of Substance Abuse Treatment Programs for Adolescents: Results from Three Meta-analyses

Transcription

1 Comparative Effectiveness of Substance Abuse Treatment Programs for Adolescents: Results from Three Meta-analyses Emily E. Tanner-Smith Mark W. Lipsey Sandra J. Wilson Peabody Research Institute Vanderbilt University Acknowledgements This study was supported by contracts & HHSS C from the Center for Substance Abuse Treatment (CSAT) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA); Z-Tech subcontract S VU; and contract HHSN P from NIAAA. Opinions expressed in this presentation those of the authors and do not necessarily reflect the opinions or policies of CSAT, NIAAA, their staff, or employees. No conflicts of interest to disclose

2 Figure 1.1. Dependence on or Abuse of Alcohol and Illicit Drugs among Youths Aged 12 to 17: National Survey on Drug Use and Health Figure 1.2. Adolescent Treatment Admissions by Primary Substance: Treatment Episode Data Set

3 Background With so many adolescents enrolled in formal substance abuse treatment, a critical question is whether these programs are effective in reducing substance use Robust evidence of beneficial treatment effects in metaanalyses of adult-only or mixed-age samples Most prior reviews of treatment effects for adolescent samples tend to be narrative, limited to only a few specific treatment types, or focus only on randomized controlled trials Research Questions What is the comparative effectiveness of different types of treatment programs for adolescents with substance use disorders? How does substance use change after adolescents enter into substance abuse treatment? What methodological, participant, and treatment characteristics influence these changes? How do results from research-oriented treatment programs compare with results from more routine, realworld treatment programs?

4 The Project Three-pronged approach to summarize the effectiveness of treatment programs for adolescents with substance abuse issues 1. Meta-analysis of experimental & quasi-experimental studies comparing adolescents in a treatment group with a comparison group 2. Meta-analysis of pretest-posttest changes in substance use based on single group arms from experimental & quasi-experimental studies 3. Analysis of aggregate data from treatment providers using the GAIN instrument and reporting data to Chestnut Health Systems A Meta-analysis of Experimental and Quasi- Experimental Studies Emily E. Tanner-Smith & Mark W. Lipsey Peabody Research Institute Vanderbilt University

5 The Meta-analysis Comprehensive systematic review of substance abuse treatment programs aimed at reducing adolescent substance use. Eligibility requirements: Client-oriented programs targeting substances other than tobacco/caffeine Reporting of results for adolescents age exhibiting clinical levels of substance abuse or dependence Experimental and quasi-experimental research designs Published 1980 or after; reported in English Review Methods Comprehensive search for studies Major electronic databases: Dissertation Abstracts, ERIC, PsychInfo, PubMed, Social Services Abstracts, Sociological Abstracts Additional grey literature searches: NCJRS, CPDD presentations, CRISP, JMATE presentations, contact with researchers and providers, citations from study reports Four trained coders completed coding on 500+ items related to general study context, methods, participants, treatments, outcomes

6 Meta-analytic Sample 260 effect sizes representing posttest differences in substance use outcomes between non-residential treatment and comparison groups Originate from 48 experimental or quasi-experimental studies Represent 79 different treatment-comparison group combinations 105 alcohol outcomes, 41 marijuana/cannabis outcomes, 86 mixed substance use outcomes (e.g., SFS from GAIN), 28 other specific substance use outcomes (e.g., cocaine) Characteristics of the Studies Table 2.1. Weighted Means and Ranges of Study Characteristics (n = 260) Mean Minimum Maximum Publication year Conducted in U.S. 96% Journal publication 78% Randomized control trial 89% Pretest group difference effect size Average attrition 15% 0 72 Frequency of treatment contact (1 to 6 scale) Treatment duration (days) Pre-post interval (days)

7 Characteristics of the Study Participants Table 2.2. Weighted Means and Ranges of Study Participant Characteristics (n = 260) Mean Minimum Maximum Males in sample 71% White participants in sample 58% Average age (years) Clinically comorbid participants 55% Delinquency level (1 to 5 scale) Non-Residential Treatment Types Cognitive behavioral therapy (CBT) No branded programs; all generic cognitive behavioral therapy programs (n = 46; k = 15) Family therapy Functional Family Therapy (n = 15; k = 5) Multidimensional Family Therapy (n = 20; k = 7) Family Support Network (n = 4; k = 2) Multisystemic Therapy (n = 26; k = 5) Seven-Challenges (n = 2; k = 1) Other generic family therapy programs (n = 21; k = 5) Note: n = number of effect sizes; k = number of unique treatment-comparison combinations.

8 Non-Residential Treatment Types (cont.) Individual counseling (IC) No branded programs; all generic counseling programs (n = 29; k = 8) Motivational interviewing/motivational enhancement therapy (MET) Motivational interviewing programs (n = 34; k = 7) Motivational enhancement therapy (n = 36; k = 10) MET + CBT (MET/CBT) Branded MET/CBT-5 (n = 6; k = 3) Branded MET/CBT-12 (n = 12; k = 6) Unbranded generic MET/CBT (n = 10; k = 6) Non-Residential Treatment Types (cont.) Psychoeducational therapy (PET) Unbranded psychoeducational curriculum (n = 17; k = 7) Other generic educational programs (n = 38; k = 12) No treatment (No Tx) No treatment, assessment only, and delayed control groups (n = 70; k = 13) Other focal type Other mixed treatment types with few effect sizes (n = 120; k = 39) E.g., behavioral/contingency management, generic group counseling, skills training, vocational counseling, pharmacological, drug court, multi-service packages

9 Treatment Type Combinations Table 2.3. Number of Effect Sizes and Unique Groups Comparing Different Treatment Types CBT FAMIL IC MET MET/CBT OTHER PET NO TX Y CBT - 12 (3) (3) 16 (5) 7 (3) 2 (1) FAMILY - 18 (4) 0 10 (5) 34 (8) 14 (5) 0 INDV COUNS - 8 (1) 1 (1) 2 (2) 0 0 MET (2) 20 (5) 35 (9) MET/CBT - 6 (5) 2 (1) 0 OTHER - 4 (3) 25 (1) PET - 8 (2) NO TX - Note: Number of unique group comparisons shown in parentheses. Numbers do not sum to total because some treatment groups had multiple focal treatment types. Comparative Treatment Effectiveness Comparative treatment effectiveness examined for all direct pairwise combinations of most common treatment types (e.g., CBT vs. Family, CBT vs. MET-CBT) Meta-regression models with robust standard errors used to calculate covariate adjusted posttest effect sizes All models adjusted for method and subject characteristics that may confound group differences

10 Figure 2.1. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for CBT Note: Means above the red line indicate CBT produced worse outcomes than the comparison type; means below indicate CBT produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.2. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for Family Therapy Note: Means above the red line indicate FAM produced worse outcomes than the comparison type; means below indicate FAM produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies.

11 Figure 2.3. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for Individual Counseling Note: Means above the red line indicate IC produced worse outcomes than the comparison type; means below indicate IC produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.4. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for MET Note: Means above the red line indicate MET produced worse outcomes than the comparison type; means below indicate MET produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies.

12 Figure 2.5. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for MET-CBT Note: Means above the red line indicate MET-CBT produced worse outcomes than the comparison type; means below indicate MET-CBT produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.6. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for PET Note: Means above the red line indicate PET produced worse outcomes than the comparison type; means below indicate PET produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies.

13 Summary and Conclusions Most group comparison studies were relatively recent, conducted in the United States, and published in journal articles Although many studies compared focal treatment programs to no treatment, treatment as usual, or psychoeducational therapy control conditions; many compared two treatment programs to each other Several treatment-treatment combinations (e.g., Family vs. MET) had no direct pairwise evidence or too few comparisons available to make reliable statements of their comparative effectiveness Summary and Conclusions (cont.) Using direct pairwise evidence for the different treatment-treatment combinations available: Family therapy & MET were more effective than all other treatment types with which they were compared CBT and MET-CBT also tended to be more effective than minimal treatment exposure arms Individual counseling was less effective than all other treatment types with which it was compared PET, No treatment, and all other treatment programs tended to be less effective than other program types

14 A Meta-analysis of Pretest-Posttest Changes in Substance Use Emily E. Tanner-Smith Peabody Research Institute Vanderbilt University The Meta-analysis Comprehensive systematic review of substance abuse treatment programs aimed at reducing adolescent substance use. Eligibility requirements: Client-oriented programs targeting substances other than tobacco/caffeine Reporting of results for adolescents age exhibiting clinical levels of substance abuse or dependence Group arms from experimental and quasi-experimental studies Published 1980 or after; reported in English

15 Meta-analytic Sample 311 effect sizes representing pretest-posttest changes (improvements) in substance use outcomes for nonresidential treatment and comparison groups Originate from 44 experimental and quasi-experimental, and studies Represent 98 different individual treatment or comparison group arms 139 alcohol outcomes, 40 marijuana/cannabis outcomes, 105 mixed substance use outcomes, 27 other specific substance Characteristics of the Studies Table 3.1. Weighted Means and Ranges of Study Characteristics (n = 311) Mean Minimum Maximum Publication year Conducted in U.S. 97% Journal publication 81% Randomized control trial 74% Outcome time frame (days) Pre-post interval (days) Average attrition 13% 0 69 Frequency of treatment contact (1 to 6 scale) Treatment duration (days)

16 Characteristics of the Study Participants Table 3.2. Weighted Means and Ranges of Study Participant Characteristics (n = 311) Mean Minimum Maximum Males in sample 65% White participants in sample 63% Average age (years) Clinically comorbid participants 47% Delinquency level (1 to 5 scale) Baseline substance severity (1 to 3 scale) Non-Residential Treatment Types Table 3.3. Most Common Focal Treatment Types Number of ESs Percent of Total Cognitive behavioral therapy (CBT) 27 9% Family therapy 42 14% Individual counseling (IC) 24 8% Motivational enhancement therapy (MET) 64 21% MET/CBT 7 3% Psychoeducational therapy (PET) 33 11% No treatment 58 19% Other 67 22% Note: Numbers do not sum to 311 because some studies had multiple focal treatment types.

17 Average Pretest-Posttest Changes Table 3.4. Weighted Means, 95% Confidence Intervals, and Between Studies Variance Components for Pretest-Posttest Effect Sizes, by Type of Substance Use Outcome N K Mean 95% CI τ 2 All substances combined (.44,.60).16 Alcohol (.22,.39).04 Marijuana (.38,.77).18 Mixed substance use (.52,.77).20 Other substance use (.01,.25).00 Note: Confidence intervals based on robust standard errors that account for clustering within studies. Method Factors Associated with Improved Outcomes Table 3.5. Unstandardized Coefficients, 95% Confidence Intervals, and Standardized Coefficients from Meta-Regression Models Predicting Pretest-Posttest Effect Sizes with Study Method Characteristics b 95% CI β Outcome timeframe (between-studies effect) (-.004,.0001) -.21 Pretest-posttest interval.002 (-.0001,.005).36 Study attrition.21 (-.29,.72).07 Randomized control group study.13 (-.14,.41).13 Note: Confidence intervals based on robust standard errors that account for clustering within studies. Regression model also controls for type of drug use outcome and group arm position in database. p <.10.

18 Participant Factors Associated with Improved Outcomes Table 3.6. Unstandardized Coefficients, 95% Confidence Intervals, and Standardized Coefficients from Meta-Regression Models Predicting Pretest-Posttest Effect Sizes with Study Participant Characteristics b 95% CI β Males in sample.003 (-.002,.01).13 White participants in sample (-.005,.001) -.10 Average age -.03 (-.08,.03) -.10 Clinically comorbid participants.01 (-.21,.23).01 Delinquency level -.09 (-.21,.04) -.23 Baseline substance severity -.08 (-.26,.09) -.10 Note: Confidence intervals based on robust standard errors that account for clustering within studies. Regression model also controls for type of drug use outcome, group arm position in database, and all method characteristics shown in Table 3.5. Treatment Characteristic Factors Associated with Improved Outcomes Table 3.7. Unstandardized Coefficients, 95% Confidence Intervals, and Standardized Coefficients from Meta-Regression Models Predicting Pretest-Posttest Effect Sizes with Treatment Program Characteristics b 95% CI β Frequency of treatment contact.09 (-.05,.24).20 Treatment duration (-.005, ) -.31 * Implementation standard normal scale score -.01 (-.17,.16) -.01 Note: Confidence intervals based on robust standard errors that account for clustering within studies. Regression model also controls for type of drug use outcome, group arm position in database, all method characteristics shown in Table 3.5, and all participant characteristics shown in Table 3.6. * p <.05.

19 Figure 3.1. Adjusted Pretest-Posttest Effect Sizes by Treatment Type Tx Type ES (95% CI) Indv Couns No Tx PET MET Other MET/CBT CBT Family 0.31 (0.06, 0.56) 0.32 (0.20, 0.43) 0.39 (0.27, 0.51) 0.44 (0.34, 0.53) 0.44 (0.23, 0.66) 0.57 (0.31, 0.82) 0.63 (0.45, 0.81) 0.77 (0.63, 0.91) Pretest-Postest Improvements Over Time Note: Means to the right of the red line indicate a beneficial improvement in substance use over time (i.e., lower substance use, higher abstinence, etc.). Estimates adjusted for drug outcome type, method, and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Summary and Conclusions After entry into non-residential substance abuse treatment programs, most adolescents showed significant reductions in their substance use The smallest observed reductions were for alcohol and other specific substance use outcomes (e.g., cocaine use) Longer treatment duration was associated with less improvement in substance use outcomes over time (i.e., smaller pretest-posttest changes)

20 Summary and Conclusions (cont.) Relative strength of improvement in substance use varied by focal treatment type: Participants in family therapy, CBT, and MET/CBT programs exhibited the largest improvements in substance use over time Participants in individual counseling and no treatment control groups exhibited the smallest improvements in substance use outcomes over time However, participants in all types of treatment programs reported significant reductions in substance use over time (even no treatment or practice as usual conditions) Examining the Effectiveness of Adolescent Substance Abuse Treatment Using the Global Appraisal of Individual Needs (GAIN) Monitoring and Measuring System Sandra Jo Wilson Peabody Research Institute Vanderbilt University

21 Presentation Overview Brief discussion of the GAIN and the kinds of adolescent substance abuse treatment programs that use the GAIN instrument. Using the GAIN as an additional source of information about the effectiveness of substance abuse treatment for adolescents. Identify characteristics of the adolescents in treatment and characteristics of the treatment programs that are associated with greater (or smaller) reductions in substance abuse. Global Appraisal of Individual Needs (GAIN) The GAIN is a standardized interview designed by Dr. Michael Dennis and his colleagues at Chestnut Health Systems (Dennis et al., 2003). The GAIN can be used to support: Diagnosis, placement, treatment planning, and outcome monitoring Program evaluation and clinical research Designed to be collected at intake, and at 3, 6, 9, and 12 months post-intake. For this project, we are using a de-identified dataset of both outpatient and residential treatment programs for adolescents.

22 Outpatient Programs Funded under several CSAT funding initiatives (e.g., EAT, SCY, and CYT). 103 outpatient treatment programs serving over 9,000 adolescent clients (27 represented in the meta-analysis). Predominantly male clients (average 73% male across programs). Mixed ethnic backgrounds: Across all programs, 48% Caucasian, 22% Hispanic, 15% African American, and 15% other minority. Average age at intake was 16. Substance Use Histories for Clients in Outpatient Programs Adolescents presented with multiple substance use histories, with 82% presenting with alcohol use, 90% presenting with marijuana use, and 59% presenting with illicit drugs other than alcohol or marijuana. Adolescents primary substance was predominantly marijuana (61%). Significant proportions of clients had antisocial/delinquent histories and/or mental health histories. 45% with court or probation contact 63% with co-occurring mental health symptoms

23 Outpatient Treatment Types Table 4.1. Outpatient Treatment Types and Dosage Information # n Duration (days) Sessions/ week Completion % ACRA Family Systems Treatments FSN MDFT MST MET/CBT & CBT Treatments MET/CBT MET/CBT MET/CBT CBT Outpatient Treatment Types (cont.) Table 4.1 (cont). Outpatient Treatment Types and Dosage Information Other Treatment Types # n (days) Duration Sessions/ week Completion % 7 Challenges Chestnut Health Model Thunder Rd. IOP EMPACT Family Therapy Group Therapy Motivational Interviewing Student Assistance Case Management Outpatient unspecified

24 Targeting of Programs Nearly all treatment programs served high proportions of adolescents who used alcohol and marijuana. ACRA, Thunder Rd., and EMPACT served proportionately larger numbers of adolescents who used amphetamines, crack/ cocaine, or opiates. ACRA served a high proportion of amphetamine users. Thunder Rd. served a high proportion of opiate users. EMPACT served a high proportion of crack/cocaine users. In general, the programs in the other group tended to serve adolescents with greater substance use problems and higher use frequencies. Substance Use Outcomes Composite variable indexing substance issues, abuse, dependence, and problems, frequency of use, and abstinence. (Substance Use Problems) Not drug-specific Used 6-month post-intake outcomes, providing that it occurred after treatment and had less than 50% attrition. For longer programs, 9- or 12-month outcomes were used. For high attrition programs 3-month outcomes were used. Across all programs, substance use problems were significantly lower (better) at the posttest than at intake.

25 Disclaimer Keep in mind that we are talking about reductions in substance use problems from intake to follow-up and (on the next few slides) identifying factors that are associated with those changes. Without a control group, we cannot know definitively whether the factors caused the improvements we observed. It is possible that adolescents in treatment programs not part of this study, or adolescents receiving no treatment at all, would show similar improvements. Some unmeasured characteristic of treatments or adolescents that overlaps with the variables we have in the dataset may be responsible for the improvements. Factors Associated with Improved Outcomes Programs with more attrition exhibited larger reductions in substance use problems ( = -.26*). Adolescents with more serious problems failed to participate in the follow-up interviews. Programs with larger proportions of males exhibited smaller reductions in substance use problems ( =.19*). Programs with larger proportions of clients with mental health histories exhibited smaller reductions in substance use problems ( =.37*). Programs with higher proportions of clients with alcohol use problems exhibited smaller reductions in substance use problems ( =.21*). Note: regression coefficients are standardized; *p <.05.

26 Factors Associated with Improved Outcomes Treatment length and treatment completion rate were not significantly associated with outcomes. On average longer or shorter treatments did not exhibit different outcomes, nor did programs with higher or lower completion rates. To compare the treatment types, we compared ACRA, the MET/CBT and CBT treatments, and the family systems group (FSN, MDFT, MST) to all the other programs. The group of other programs showed significantly larger reductions in substance use problems than ACRA, MET/CBT & CBT, and the family systems programs. Program ES (95% CI) Mean Change (95% CI) ACRA 0.47 (0.42, 0.52) MET/CBT & CBT 0.51 (0.50, 0.52) Family systems tx 0.59 (0.55, 0.62) Other 0.83 (0.81, 0.85) (Larger Reductions in SU Problems) Prepost Reductions in Substance Use Problems Figure 4.1. Adjusted Post-treatment Substance Use Problem Outcomes by Broad Treatment Types

27 EMPACT Student Assistance Thunder Rd. IOP Group Therapy Motivational Interviewing Family Therapy Chestnut Health Systems Case Management Seven Challenges Outpatient unspecified Post-treatment reductions in SU problems (larger # = greater reductions) Figure 4.2. Adjusted Post-treatment Substance Use Problem Outcomes For Programs in the Other Group Notes: Bubbles proportionate to the number of programs contributing to the average. All estimates adjusted for attrition, pretest, participant characteristics, and treatment dosage. CBT/MET-12 FSN ACRA CBT/MET-5 CBT/MET-7 CBT MDFT MST Post-treatment reductions in SU problems (Larger # = More Reductions) Figure 4.3. Adjusted Post-treatment Substance Use Problem Outcomes For ACRA, Family, MET/CBT & CBT Notes: Bubbles proportionate to the number of programs contributing to the average. All estimates adjusted for attrition, pretest, participant characteristics, and treatment dosage.

28 Residential and Institutional Programs Funded under a variety of CSAT funding initiatives (e.g., ART, ATM) 30 residential treatment programs serving over 2,500 adolescent clients. Programs served a predominantly male client base; average program was 74% male. Adolescent clients came from diverse ethnic backgrounds: 30% Caucasian, 30 % other minority, 22% Hispanic, 19% African American Average age at intake was 16. Substance Use Histories for Clients in Residential Programs Adolescents were predominantly poly-substance users and tended to have more serious problems than adolescents in the outpatient programs. 86% presenting with alcohol abuse, 80% presenting with marijuana use, and 81% presenting with illicit drugs other than alcohol or marijuana. Significant proportions of clients had antisocial/delinquent histories and/or mental health histories. 55% in juvenile facilities on average 81% with co-occurring mental health symptoms

29 Residential Treatment Types Table 4.2. Residential Treatment Types and Dosage Information # n Duration (days) Sessions/ week Completio n % ACRA MET/CBT & CBT Treatments MET/CBT-5* MET/CBT-12* CBT Therapeutic Communities Phoenix Academy Dynamic Youth Community Mountain Manor Thunder Rd Other Therapeutic Community *programs delivered in correctional facility Residential Treatment Types (cont.) Table 4.2 (cont). Residential Treatment Types and Dosage Information Other Programs # n Duration (days) Sessions/ week Completio n % La Cañada Group-based (correctional)* Walking in Beauty on the Red Rd Hazelden Adolescent Recovery Other group therapy (correctional)* Other 12 Step Residential unspecified *programs delivered in correctional facility

30 Comparisons with the Outpatient Programs Adolescents in residential treatment programs tended to have more extensive drug, delinquency, and mental health histories. Residential programs were shorter in duration than outpatient programs, but had greater service frequency (averaging 4x/week for residential programs vs. 1x/week for outpatient programs). Disclaimer With only one or a few programs in each treatment type category, differences between treatments in substance use outcomes become confounded with differences between programs in the characteristics of the youth they serve as well as the differences in implementation characteristics across programs. What was observed for a single program in one category may not necessarily be characteristic of that treatment type in a general sense. Any observed differences at the program level could just as easily be due to the different configurations of demographic characteristics or substance use histories, or differences in dosage and implementation, in addition to differences in effectiveness for particular modalities.

31 Substance Use Outcomes Composite variable indexing substance issues, abuse, dependence, and problems, frequency of use, and abstinence. (Substance Use Problems) Not drug-specific Used 6-month post-intake outcomes, providing that it occurred after treatment and had less than 50% attrition. For longer programs, 9- or 12-month outcomes were used. For high attrition programs 3-month outcomes were used. Across all programs, substance use problems were significantly lower (better) at the posttest than at intake. On average, adolescent clients had fewer substance problems and issues, used on fewer days, and were more abstinent after treatment. Factors Associated with Improved Outcomes Attrition was significantly associated with better outcomes, as would be expected if the most serious cases failed to complete the follow-up interview ( = -.28*). Longer treatments were significantly associated with fewer substance use problems ( = -.62*) None of the treatment types produced significantly better outcomes than the other treatments, though statistical power is low and small numbers in each category meant that we grouped different programs into the other category. Note: regression coefficients are standardized. * p <.05.

32 ACRA Dynamic Youth Community Phoenix Academy Other 12 Step Other CBT Other Walking in Beauty on the Red Rd. Hazelden: Adolescent Recovery Thunder Rd. Other Gp. Therapy (correctional) Other Therapeutic Community La Cañada Group-based (correctional) Mountain Manor MET/CBT-5 MET/CBT Reductions in Substance Use Problems Post-treatment Figure 4.4. Adjusted Post-treatment Substance Use Problem Outcomes by Treatment Type Notes: Bubbles proportionate to the number of programs contributing to the average. All estimates adjusted for attrition, pretest, and treatment length. Summary and Conclusions On average, the outpatient and residential adolescent substance abuse treatment programs in our sample evidenced statistically significant improvements in substance use problems after treatment. For outpatient programs, days abstinent* (out of 90) increased from 52 to 64 days on average. For residential programs, days abstinent* (out of 90) increased from 21 at intake to 45 at follow-up. Adolescents in substance abuse treatment endorsed fewer abuse and dependence symptoms at follow-up. *adjusted for time in confined settings.

33 Summary and Conclusions (cont.) The most common outpatient programs were MET/CBT- 5 and ACRA (Adolescent Community Reinforcement Approach). Programs with more males, and higher proportions of clients with mental health and alcohol problems tended to show less improvement on average. Though all treatment types showed improved outcomes, those improvements were significantly smaller for CBT, MET/CBT, the family systems programs, and ACRA when compared to all other programs. Summary and Conclusions (cont.) The most common residential programs were variations on the therapeutic community model. With only 30 residential programs in the sample, it was difficult to examine the influence of client and treatment characteristics in detail. But, longer residential programs tended to evidence greater improvements in substance use problems. No treatment type was statistically better than any other treatment type, though we had only one example of many of the treatments.

34 Contact Information Emily Tanner-Smith: Mark Lipsey: Sandra Wilson: