D. Paul Moberg, PhDAndrew Finch, PhD

Association of Recovery Schools2013 Annual Meeting

San Diego, CA

This research was supported by the National Institute On Drug Abuse of the National Institutes of Health under award number R01DA029785. 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 UL1TR000427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Thanks to our Co-Investigators Ken Winters and Mark Lipsey and to research staff and colleagues including Andria Botzet, Christine Dittel, Tamara Fahnhorst, Emily Fisher, Angela Forgues, Stephanie Lindsley, Patrick McIlvaine, Emily Tanner-Smith, David Weimer, and Holly Wegman.

Background—Recent Research on Adolescent Recovery

Logic model for Recovery High School Research

Our Current Research Study (NIDA funded) Our Cumulative Observations

◦ Variation in Schools and Structures◦ Dynamics of Recovery High Schools◦ Integration in community recovery care◦ Policies that facilitate Recovery High Schools◦ Sustainability

132,953 Total Episodes, representing 7.6% of youths needing treatment

Recent ResearchRecent Researchon on

Interventions and Interventions and Adolescent RecoveryAdolescent Recovery

Data:55 experimental or quasi-experimental studies69 research studies with pre-test to post-test dataGAIN study of “routine treatment practice” (103 OP, 30 res programs)

Participants:70% male58% whiteMean age about 16Symptoms of clinical level of substance use disordersAlcohol, marijuana most common60% comorbid mental health disorders

Treatment “generally appeared to work equally well irrespective of demographic characteristics”

Pretest-posttest analysis effect sizes showed significant reductions after treatment

Experimental or quasi-experimental studies generally showed significant result for focal treatment.

Randomized trial data suggest general effectiveness of: ◦ -Family therapy (FFT, MDFT, MST, etc.)◦ -CBT

“…many of the treatments…are at least somewhat effective in reducing substance use…”

Treatment Implementation Quality Scale:Program has a treatment manualStandard scripts/protocolProvides implementation feedback to treatment providersWas set up for research purposesDelivered by researchers

Implementation Quality was “strongly and significantly associated with better substance use outcomes” independent of what type of treatment was applied.

1. Therapeutic models involving multiple systems--School and family interventions are most influential (Waldron, 2008; Karki, 2012)

◦ Behavioral Family Systems Therapy (BFST) – reduced marijuana use for those with mild to moderate mental health diagnoses (Santisteban, 2003).

◦ Family Behavioral Therapy (FBT) – improved long term outcomes in adolescent conduct, reductions in their use of illicit drugs, school performance , mood and family functioning (Azrin, 2001)

◦ Multidimensional Family Therapy (MDFT) - long term outcomes for reduced substance use, delinquency, internalized distress and reduced risk in family, peer, and school domains (Waldron, 2008; Liddle, 2008 and 2009)

2. Individual Therapy ◦ Cognitive Behavioral Therapy (CBT)-- significant pre

to post treatment decreases in adolescent substance abuse (Liddle, 2008; Waldron, 2008; Becker, 2008)

3. Youth Empowerment approach ◦ Focus on personal responsibility, coping and problem

solving skills using Motivational Enhancement Therapy (MET), CBT and Multidimensional Family Therapy (MDFT) (Dennis, 2004)

4. Brief Motivational Interventions◦ MET, Motivational Interviewing (MI), CBT and MET

combined (Becker, 2008; S. Godley, 2010)

5. Community Support◦ Therapeutic Community (TC) outpatient treatment

models - reductions in substance use, criminal behavior, and psychological distress; improved psychological functioning (Morral, 2004; Jainchill, 2005)

◦ AA/NA attendance during and following treatment (Kelly, 2010; 2013)

◦ Assertive Continuing Care (ACC) promotes continuing care linkage and retention, long term abstinence from marijuana in study of residential treatment (M. Godley et al., 2007) but not for outpatient treatment (S. Godley et al., 2010)

After-school/after-care programs Assertive Continuing Care community-

based program Recovery classrooms (including school-day

support group meetings) Student Assistance Programs and

counselors

Recovery High Schools Therapeutic Boarding Schools with a

Recovery Emphasis Alcohol & Drug Treatment Center Schools Non-Traditional Schools of Choice with

Targeted Substance Abuse Programming◦ Alterative schools◦ Charter schools◦ Contract schools◦ Home schools ◦ Virtual/Online schools ◦ Area Learning Centers

Traditional Secondary Schools

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 state-recognized 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 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

Inputs Activities Short-term Outcomes (3-6 months)

Medium-Term Outcomes (6-12 mos)

Long Term Outcomes (24+ months)

Students post-treatment for substance use disorder

Recovery support/continuing care in school:-daily group-therapeutic cmnty -peer support-ind counseling-outside meetings-relapse prevention

Monitoring (UA)

Group support

Self efficacy  Problem Solving Cognitive expectancies Outside support sought if needed Self reveals if relapse

Reduced substance use:-Days Used-Quantity Used -UA clean Reduced substance related problems Reduced MH symptoms Reduced delinquent behavior Reduced risky sexual behavior

 Long term abstinence from drugs Alcohol use abstinent or non-risky levels No SUD symptoms  Fewer treatment episodes for MH Not incarcerated or “on paper” Seeks continuing care in case of relapse Overall positive health status

Schools (RHS or other HS):-Teachers-Counselors-Academics-Therapeutics/ Support  

Academics-Curriculum-Enrichment-Experiential and Comm Service lrng

Attendance Credits earned School satisfaction Therapeutic Satisfaction 

Test Scores GPA Graduation

 Pursuing Higher education Gainfully employed

Families 

-Fam Support-Parent Monitoring

-Parent satisfaction 

  Ongoing positive relationship with family

Peers New peer group based in school

-Reports positive peer behavior

Positive social functioning

Maintains positive peer group

Our Current Research Study Research Design Characteristics of Treatment

Programs and Recovery Schools

Characteristics of Participants Preliminary Results Challenges

Prior studies and reports (e.g., Moberg and Thaler, 1995; Moberg and Finch,

2008; Finch, 2003; Kochanek, 2010 ) suggest that RHSs are an effective component of continuing care for adolescents with SUDs.

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 ratio of RHS participation

Students and parents recruited from MN and WI substance abuse treatment settings and RHSs.

Comparison group of students not attending RHS selected from this pool using propensity score techniques with variables based on prior meta-analyses.

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 meta-analyses.

Site visits and interviews with schools and treatment facilities to better characterize the interventions.

 Recruit from:Baseline

SchoolType 

3 MonthsSchoolType  

6 MonthsSchoolType  

12 Months  LongerTerm

Follow-up?

TreatmentSettings

O0Non-RHS

O3Non-RHS

O6Non-RHS

O12 ??? O24

RHS (recruitment added)

O0 RHS  O3 RHS  O6 RHS  O12 ???  O24

O=Observation/interview of youth and parent

School Type=RHS or Non-RHS

Primary Analysis=Differential change from O0

to O12 for RHS vs Non-RHS students.

From Lipsey and Tanner-Smith’s (2010) meta-analysis (119 studies) of predictors of substance use treatment outcome (r=.30-.50):

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

Current study: 7 recovery high schools◦ 3 have closed in last 60 days◦ Plan to add 2 Wisconsin schools next year◦ Exploring Massachusetts, which has 4 schools◦ Descriptive Study: 17 schools plus one pilot in 7

states, including 8 RHSs in MN

School types:◦ Charter schools (3) – 1 remaining◦ Area Learning Centers/Schools-within-schools (4) – 3

remaining◦ Descriptive Study: 5 charters, 9 alternative

schools/ALCs, 3 private schools

Facilities for 7 RHS participants:

• 1 school building• 1 church• 2 community centers• 3 office complexes

Baseline

3-Month

6-Month

12-Mont

h

 

Total Intervie

ws to date

 Youth Interviews

12390

(82%)61

(68%)33

(64%)307

 Parent Interviews

127101

(89%)79

(81%)42

(79%)349

Total Interviews

250 191 140 75656

Number PercentAge (Mean= 16.4, s.d.= 1.1): 14

7 6 %

15 16 14 %

16 28 25 %

17 45 40 %

18 15 13 %

19 1 1 %

Sex: Male

60 54 %

Female 52 46 %

Race/ethnicity: Asian

10 9 %

Native American 5 5 %

African American 11 10 %

Caucasian 101 90 %

Hispanic 6 5 %

Other 2 2 %

Recruited from: Treatment Center

59 53 %

RHS 53 47 %

Mental Health Services:Inpatient/Resid. 44%Outpatient 72%

Alcohol/Drug Services:Inpatient/Resid. 60%Outpatient 86%AA/NA 64%

     Substance Use(3 months prior to treatment)

Mean (s.d.) Percent Used

Days alcohol (tlfb) 19.7 (23.0) 88 %Days marijuana (tlfb) 57.9 (32.0) 93 %

Days other drugs (tlfb) 28.0 (33.8) 76 %     Diagnostics (DSM-IV): Number Percent

Alcohol -Dependence 60 54 % -Abuse 18 16 %

Other Drug-Dependence 95 85 %

-Abuse 13 11 %Tobacco Dependence 70 62 %

Major Depression 80 71 %

Status at 3 Months

Attending RHS (n=36)

Not-RHS (n=38)

Total (n=74)

Entered study from Treatment center

 17%

 83 %

 49 %

       Used Alcohol (“to intoxication”)Used Marijuana*

28 %

33 %

30 %

53 %

29 %

43 %

Used Other Drugs 21 % 22 % 22 %       Depression Problems

62 % 68 % 65 %

       Attending School** 97 % 74 % 85 %At Traditional HS 0 % 29 % 15 %Other students “support my recovery”*

Strongly Agree Agree

  

39 %44 %

  

18 %39 %

  

29 %42 %

* p < .10** p < .05

Status at 6 months Attending RHS (n=26) Not-RHS (n=22)

 Days Used Alcohol* (mean and s.d. in past 90)

1.7 (4.3)  6.9 (9.8) 

Days used Marijuana**(mean and s.d in past 90)

2.4 (6.9) 19.6 (28.9)

Days Used Other Drugs(mean and s.d in past 90)

1.6 (4.7) 3.1 (7.5)

     

* p < .05** p < .01

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 have we learned based on our “Program of Research”?

RHSs are important option in continuum of recovery support, in particular serve students withCo-occurring disordersSevere substance use disordersHigh need for services and support

Most programs studied appear to be successful in supporting young people in recovery, and providing (at least transitional) academic services

RHS programs less successful in community institutionalization

Sustainability continues to be an issue

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

Questions?