Study 1
Godley and colleagues (2006) used a randomized block design to evaluate the effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), compared with usual continuing care (also known as aftercare), on participants’ early and sustained abstinence from substance use after discharge from a treatment facility in Illinois. To be eligible, participants had to meet the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) diagnosis of current alcohol or drug dependence, be between the ages of 12 and 17 years, and reside within one of the 11 targeted counties in Illinois. Potential participants were excluded if they left residential treatment within the first week, were a ward of the state child welfare department, were not returning to a targeted county after discharge, were considered to be a danger to themselves or others or displayed uncontrolled psychotic symptoms.
This resulted in a sample of 183 adolescents who gave consent and whose parents/caregivers gave consent, to be in the study. Of this sample, 71 percent were male, 73 percent were white, 18 percent were African American, and 9 percent were Hispanic or other; the mean age was 16.2 years. Most of the adolescents had prior involvement with the juvenile justice system (82 percent). All met the criteria for a substance use disorder, with many dependent on marijuana (87 percent) and alcohol (54 percent). Some were dependent on cocaine (15 percent) or other drugs (14 percent). Participants were assigned to one of two conditions: 1) the A-CRA treatment group, or 2) the usual continuing care (UCC) control group. There were no statistically significant differences on baseline demographic and clinical characteristics between the groups.
The treatment group, who received assertive continuing care (ACC) which included A-CRA, consisted of 98 adolescents. These participants received the same types of referrals to usual continuing care services, from their residential counselors, as participants assigned to the UCC condition. In addition, case managers provided 3 months of weekly home visits to youth and their caregivers to link participants to continuing care services. The control group, who received UCC, consisted of 78 adolescents. They received referrals to community outpatient substance abuse clinics; however, their UCC services varied, depending on how they were discharged. Adolescents discharged “against staff advice” or “at staff request” received only a letter with information on where to go for further treatment. Adolescents discharged “as planned” received a continuing care appointment with a case manager, typically within 2 weeks of discharge, at one of 12 treatment facilities in the 11-county target area.
The outcomes of interest were alcohol and other drug use, alcohol use, marijuana use, linkage to continuing care services, and high adherence to the criteria on the General Continuing Care Adherence (GCCA) Scale. Follow-up interviews occurred 3, 6, and 9 months after discharge (the CrimeSolutions review of this study focused on outcomes at the 9-month follow up). Abstinence from substance use was measured using the Global Appraisal of Individual Needs (GAIN) instrument and self-reporting. Urinalysis at intake and at the follow-up assessments was used to corroborate self-report data. Imbedded within the GAIN, the GCCA scale was based on an analysis of the common continuing care recommendations endorsed by 67 percent or more of the 12 UCC outpatient providers. These recommendations included regular attendance at weekly treatment and at weekly support meetings, receiving training in relapse prevention and communication skills, performing urine testing, having regular contact with school or work, and following up on referrals to other services.
An intent-to-treat analysis was conducted on the participants for whom there was data at baseline and for all three follow-up interviews, which comprised about 92 percent of the sample. Chi-square and t tests were used to detect any differences in the type and amount of continuing care received. Logistic regressions were used to predict abstinence during continuing care by both condition and high adherence to continuing care. The study authors conducted a subgroup analysis to examine abstinence during the fourth to ninth month after residential treatment discharge. They compared A-CRA participants who showed high adherence to the criteria on the GCCA Scale and had been abstinent during the first 3 months after discharge, with control group participants.
Study 2
Slesnick and colleagues (2007) conducted a randomized controlled trial of A-CRA with street-living youth experiencing homelessness from a drop-in center in Albuquerque, New Mexico. To be eligible for the study, participants had to be between the ages of 14 and 22, have lived in the Albuquerque metropolitan area for at least 3 months with plans to remain for at least 6 months, have met the criteria for homelessness as defined by the U.S. Department of Health and Human Services, and have met the DSM–IV diagnosis of having a substance disorder (alcohol or other drugs). Of the total sample of 180 youth, 41 percent were white, 30 percent were Hispanic, 13 percent were Native American, 3 percent were Black (3 percent), 1 percent were Asian, and 12 percent identified as other. Most participants were male (66 percent), and had an average age of 19.2 years. There were no statistically significant differences between groups in any demographic characteristics at baseline, except for the number of alcohol use diagnoses (participants in the control group had a higher number of positive diagnoses, using criteria for DSM-IV diagnoses, than participants in the treatment group). No statistically significant differences were found for any of the other main variables (substance use, individual differences) at baseline.
Adolescents were randomly assigned to receive either a usual care condition (control group) or usual care with A-CRA (treatment group). The control group consisted of 84 adolescents who received a place to rest during the day; access to food, clothing, washer and dryer, and showers; and case management services that linked youth with community resources, at their request. The treatment group included 96 adolescents who received 12 A-CRA therapy sessions and 4 HIV education/skills practice sessions in addition to usual care. Recruitment began in November 2001 and ended in February 2005. Upon randomization into groups, all participants completed baseline assessments. Follow-up measures of outcomes were conducted at 6 months, after all participants had received therapy. Six-month assessments began in May 2002 and concluded in September 2005.
Outcomes of interest were alcohol and drug use, social stability, high-risk behavior, depression, and delinquency. The Form 90, developed by the National Institute on Alcohol Abuse and Alcoholism, was used to measure substance use. The percentage of days of alcohol and drug use was the primary dependent measure used in this study. Social stability was measured by the percentage of days in the period of work, education, being housed, and seen for medical care, as assessed on the Form 90. The adolescent version of the Coping Inventory for Stressful Situations and the Beck Depression Inventory were used to measure participants’ coping skills and depressive symptoms, respectively. The National Youth Survey Delinquency Scale and the Youth Self-Report were used to measure delinquent behavior.
Repeated measures analyses of variance (or ANOVAs), along with intent-to-treat analyses, were used to determine the effect of supplementing usual care with A-CRA on reducing substance abuse and promoting healthy behavior in these homeless adolescents. The study authors conducted subgroup analyses to examine differences in treatment effect by age, gender, and ethnicity.
