The comparative effectiveness of Core versus Core+Enhanced implementation strategies in a randomized controlled trial to improve substance use treatment receipt among justice-involved youth.

BACKGROUND: Most justice-involved youth are supervised in community settings, where assessment and linkage to substance use (SU) treatment services are inconsistent and fragmented. Only 1/3 of youth with an identified SU need receive a treatment referral and even fewer initiate services. Thus, improving identification and linkage to treatment requires coordination across juvenile justice (JJ) and behavioral health (BH) agencies. The current study examines the comparative effectiveness of two bundled implementation intervention strategies for improving SU treatment initiation, engagement, and continuing care among justice-involved youth supervised in community settings. Exploration, Preparation, Implementation, Sustainment (EPIS) served as the conceptual framework for study design and selection/timing of implementation intervention components, and the BH Services Cascade served as the conceptual and measurement framework for identifying and addressing gaps in service receipt. METHODS: Part of a larger Juvenile-Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) Cooperative, this study involved a multisite, cluster-randomized control trial where sites were paired then randomly assigned to receive Core (training teams on the BH Services Cascade and data-driven decision making; supporting goal selection) or Core+Enhanced (external facilitation of implementation teams) intervention components. Youth service records were collected from 20 JJ community supervision agencies (in five states) across five study phases (baseline, pre-randomization, early experiment, late experiment, maintenance). Implementation teams comprised of JJ and BH staff collaboratively identified goals along the BH Cascade and used data-driven decision-making to implement change. RESULTS: Results suggest that Core intervention components were effective at increasing service receipt over time relative to baseline, but differences between Core and Core+Enhanced conditions were non-significant. Time to service initiation was shorter among Core+Enhanced sites, and deeper Cascade penetration occurred when external facilitation (of implementation teams) was provided. Wide variation existed in the degree and nature of change across service systems. CONCLUSIONS: Findings demonstrate the criticality of early EPIS phases, demonstrating that strategies provided during the formative exploration and preparation phases produced some improvement in service receipt, whereas implementation-focused activities produced incremental improvement in moving youth farther along the Cascade.

Recidivism Among Justice-Involved Youth: Findings From JJ-TRIALS.

Recidivism, and the factors related to it, remains a highly significant concern among juvenile justice researchers, practitioners, and policy makers. Recent studies highlight the need to examine multiple measures of recidivism as well as conduct multilevel analyses of this phenomenon. Using data collected in a National Institute on Drug Abuse (NIDA)-funded Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) cooperative agreement, we examined individual- and site-level factors related to 1-year recidivism among probation youth in 20 sites in five states to answer research questions related to how recidivism rates differ across sites and the relationships between individual-level variables and a county-level concentrated disadvantage measure and recidivism. Our findings of large site differences in recidivism rates, and complex relationships between individual and county-level predictors of recidivism, highlight the need for more nuanced, contextually informed, multilevel approaches in studying recidivism among juveniles.

Racial differences in college-student drinking.

Racial differences in drinking motives, protective behavioral strategies (PBSs), alcohol consumption, and alcohol-related problems were examined among college student drinkers (N = 443: 296 [66.8%] White, 147 [33.3%] Black). Survey participants were recruited from large undergraduate sociology classes and residence halls at the university. Key differences between Black and White college students in drinking behaviors, reasons for drinking (i.e., motives), and the use of PBSs were observed. These racial differences have implications for the implementation of prevention/intervention programs intending to reduce alcohol consumption and alcohol-related problems among college students.

The Impact of Abuse Trauma on Alcohol and Drug Use: A Study of High-Risk Incarcerated Girls.

This study examines the impact of abuse trauma (physical and sexual) on alcohol and drug use of high-risk girls (12-18 years of age) who were surveyed within the first two weeks of their incarceration. One-way ANOVA analyses and Tukey post-hoc tests indicate physical abuse with a weapon was associated with higher marijuana use and number of drugs used. Sexual abuse, especially within the past year increased marijuana use, alcohol use, number of drugs used, and alcohol and other drug (AOD) problems. Policy implications reflect the need for treatment protocols within substance abuse programs to address abuse trauma, particularly, forced sex which has occurred within the last year.

Impact of implementation interventions to improve substance use service delivery on recidivism among justice-involved youth.

Substance use disorders (SUD) are prevalent among justice-involved youth (JIY) and are a robust predictor of re-offending. Only a fraction of JIY with substance use problems receive treatment. This paper describes the impacts of system-level efforts to improve identification and referral to treatment on recidivism of JIY. A cluster randomized trial involving 20 county juvenile justice agency sites across 5 states was used to implement an organizational intervention (Core vs Enhanced) to juvenile justice staff and community-based treatment providers, working with 18,698 JIY from March 2014 to August 2017. Recidivism rates over four study time periods were examined. Logistic regression was used to predict recidivism as a function of site, need for SUD services, level of supervision, time, organizational intervention, and time x intervention interaction terms. Results indicated that Enhanced sites showed decreased levels of recidivism compared to Core-only sites, where it increased over time. Additionally, need for SU services, level of supervision, and site were significant predictors of reoffending. Findings suggest the potential value of facilitation of juvenile justice agency efforts to increasing identification of and referral to SUD services of JIY in need of such services for reducing further contact with the legal system.

Results of a national survey of substance use treatment services for youth under community supervision.

BACKGROUND: Despite the heightened risk for substance use (SU) among youth in the juvenile justice system, many do not receive the treatment that they need. OBJECTIVES: The purpose of this study is to examine the extent to which youth under community supervision by juvenile justice agencies receive community-based SU services and the factors associated with access to such services. METHODS: Data are from a nationally representative sample of Community Supervision (CS) agencies and their primary behavioral health (BH) partners. Surveys were completed by 192 CS and 271 BH agencies. RESULTS: SU services are more often available through BH than CS for all treatment modalities. EBPs are more likely to be used by BH than by CS. Co-location of services occurs most often in communities with fewer treatment options and is associated with higher interagency collaboration. Youth are more likely to receive services in communities with higher EBP use, which mediates the relationship between the availability of SU treatment modalities and the proportion of youth served. CONCLUSION: Findings identify opportunities to strengthen community systems and improve linkage to care.

HIV/STI Risk Behavior of Drug Court Participants.

Drug abusing offenders have high rates of HIV and other sexually transmitted infections (STI). To date, the HIV/STI prevention needs of offenders in drug court programs have been ignored. This multi-method study employed interviews to assess drug court professionals' perceptions of the need for an HIV risk reduction intervention to be integrated into the services provided to drug court participants. Then, surveys were completed by 235 drug court participants to assess whether their sexual risk behaviors affirmed the need for such an intervention. The survey also assessed demographic characteristics, drug use prior to program entry, HIV knowledge, and condom attitudes. The relationship between duration in the drug court program and sexual risk behavior was also examined. Implications for the development and delivery of HIV risk reduction interventions within drug court programs are discussed.

Using structured implementation interventions to improve referral to substance use treatment among justice-involved youth: Findings from a multisite cluster randomized trial.

INTRODUCTION: Youth involved in the justice system have high rates of alcohol and other drug use, but limited treatment engagement. JJ-TRIALS tested implementation activities with community supervision (CS) and behavioral health (BH) agencies to improve screening, identification of substance use service need, referral, and treatment initiation and engagement, guided by the BH Services Cascade and EPIS frameworks. This paper summarizes intervention impacts on referrals to treatment among youth on CS. METHODS: This multisite cluster-randomized trial involved 18 matched pairs of sites in 36 counties in seven states randomly assigned to core or enhanced conditions after implementing the core intervention at all sites for six months. Enhanced sites received external facilitation for local change team activities to reduce unmet treatment needs; Core sites were encouraged to form interagency workgroups. The dependent variable was percentage referred to treatment among youth in need (N = 14,012). Two-level Bayesian regression assessed factors predicting referral across all sites and time periods. Generalized linear mixed models using logit transformation tested two hypotheses: (H1) referrals will increase from baseline to the experimental period, (H2) referral increases will be larger in enhanced sites than in core sites. RESULTS: Although the intervention significantly increased referral, condition did not significantly predict referral across all time periods. Youth who tested drug positive, had an alcohol/other drug-related or felony charge, were placed in secure detention or assigned more intensive supervision, or who were White were more likely to be referred. H1 (p < .05) and H2 (p < .0001) were both significant in the hypothesized direction. Interaction analyses comparing site pair differences showed that findings were not consistent across sites. CONCLUSIONS: The percentage of youth referred to treatment increased compared with baseline overall, and enhanced sites showed larger increases in referrals over time. However, variations in effects suggest that site-level differences were important. Researchers should carry out mixed methods studies to further understand reasons for the inconsistent findings within randomized site pairs, and how to further improve treatment referrals across CS and BH systems. Findings also highlight that even when CS agencies work collaboratively with BH providers to improve referrals, most justice-involved youth who need SU services are not referred.

The Missing Link(age): Multilevel Contributors to Service Uptake Failure Among Youths on Community Justice Supervision.

OBJECTIVES: Youths in the juvenile justice system often do not access needed behavioral health services. The behavioral health services cascade model was used to examine rates of substance use screening, identification of substance use treatment needs, and referral to and initiation of treatment among youths undergoing juvenile justice system intake and to identify when treatment access is most challenged. Characteristics associated with identification of behavioral health needs and linkage to community services were also examined. METHODS: Data were drawn from administrative records of 33 community justice agencies in seven states participating in Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System, funded by the National Institute on Drug Abuse (N=8,307 youths). Contributions of youth, staff, agency, and county characteristics to identification of behavioral health needs and linkage to community services were examined. RESULTS: More than 70% (5,942 of 8,307) of youths were screened for substance use problems, and more than half needed treatment. Among those in need, only about one-fifth were referred to treatment, and among those referred, 67.5% initiated treatment. Overall, <10% of youths with identified needs initiated services. Multivariable multilevel regression analyses revealed several contributors to service-related outcomes, with youths' level of supervision being among the strongest predictors of treatment referral. CONCLUSIONS: Community justice agencies appear to follow an approach that focuses identification and linkage practices on concerns other than youths' behavioral health needs, although such needs contribute to reoffending. Local agencies should coordinate efforts to support interagency communication in the referral and cross-system linkage process.

Adverse events and substance use among female adolescent offenders: effects of coping and family support.

This study examined a stress-coping model for substance use among female adolescents (N = 305, 69% African American) involved in the Mississippi juvenile justice system. Participants were interviewed in 2006 , regarding exposure to adverse and traumatic events, and they completed self-administered measures of social support from relatives, coping strategies, and questions on frequency of alcohol and other drug use. Results from nested regression models revealed that stressors are associated with drug, but not alcohol use. The use of supportive kinship ties and religion to cope were protective factors. The implications and limitations of the study are discussed.

A System-Level Intervention to Encourage Collaboration Between Juvenile Justice and Public Health Agencies to Promote HIV/STI Testing.

Justice-involved youth are at high risk for HIV and STIs, and justice agencies are uniquely poised to offer HIV/STI testing. However, testing in these settings is not routine and represents a missed opportunity. This study describes a system-level implementation intervention designed to increase access to HIV/STI testing through juvenile justice (JJ) and public health agency collaboration across six counties in six states in the United States. Local change teams, active facilitation, and training were utilized to facilitate agency partnerships and development of HIV/STI practice change protocols. Five counties established health and JJ partnerships and four counties successfully implemented their protocols. Sites with HIV/STI education and testing protocols behaviorally screened 98.5% of youth and tested 41.2% of those youth; 0% were HIV+ and 43.2% had an STI. The intervention provides a feasible, scalable solution, through promoting partnerships between JJ and health agencies, to link youth to testing and treatment services.

Bridging Systems to Implement HIV/STI Programming Within the Juvenile Justice System: Strengths and Challenges of a Local Change Team Approach.

Justice-involved youth are at risk for HIV/STIs but do not access services. The complex challenges of improving the delivery of health-related services within juvenile justice (JJ) settings warrant exploration of strategies to close this service gap. This study describes the successes and challenges of utilizing a local change team (LCT) strategy comprising JJ and health agency staff to implement HIV/STI programming in JJ settings, across six counties in six states in the U.S. Five focus groups comprising n = 28 JJ and health agency staff who served as LCT members were conducted. Results demonstrated the structured nature of the collaborative process and strength of commitment among LCT members were necessary for successful implementation of HIV/STI programming. The use of LCTs comprising membership of JJ and (behavioral) health systems has broader applicability to other health and behavioral health issues faced by youth on probation that JJ staff may feel ill equipped to address.

HIV/STI Service Delivery Within Juvenile Community Supervision Agencies: A National Survey of Practices and Approaches to Moving High-Risk Youth Through the HIV Care Cascade.

Justice-involved youth (JIY) are at considerable risk for human immunodeficiency virus (HIV), but are disconnected from treatment and prevention. Juvenile justice agencies providing community supervision (CS) are well positioned to provide HIV prevention, testing, and prompt referral to treatment for JIY. However, we lack an understanding of juvenile CS agency responses to HIV/sexually transmitted infection (STI) needs among JIY. We conducted a nationwide systematic assessment of how juvenile CS agencies identify, refer, and move youth through the HIV care cascade using a nationally representative sample of 195 juvenile CS agencies across 20 states. Two-thirds of CS agencies did not offer any HIV-/STI-related services, and 82% reported no collaboration with health agencies. Screening or referral for HIV risk behaviors was reported by 32% of the CS agencies and 12% for any intervention or prevention for HIV/STI risk behaviors. Between 21% and 30% of agencies were unaware of the location of local HIV/STI services. HIV/STI prevention training was not a priority for directors and was ranked second to last out of 16 training topics. Agencies where staff expressed need for HIV risk training and where specific court programming was available were more likely to provide or refer for HIV/STI screening and/or testing. Agencies were more likely to provide or refer for services if they provided pre-trial/pre-adjudication supervision, parole, or court programming. Considering the low provision of HIV/STI-related services and limited collaboration between health and justice agencies, interventions that promote cross-system collaboration designed to minimize barriers and facilitate identification, referral, and linkage to HIV services for JIY are necessary.

Gender-Specific Predictors of Recidivism Among DUI Offenders.

OBJECTIVE: Women are less likely than men to be arrested for driving under the influence (DUI) of alcohol or another drug, yet their proportion of DUI offenders is growing. Understanding how DUI recidivism risk varies for men and women is of practical utility for DUI assessment and intervention programs. The goals of the current study are to determine if there are different sets of predictors for men and women and whether gender-specific DUI recidivism risk scales perform better than a single recidivism scale for both men and women. METHOD: We rely on statistically driven techniques to develop gender-specific and total sample recidivism risk scales. We then test the ability of the scales to predict recidivism within 12 months among a large sample (N = 10,827, 22.3% female) of DUI offenders court mandated to a DUI intervention in Mississippi. RESULTS: Predictors of recidivism were drawn from measures of criminal history, substance use disorders, driving behaviors, and accidents. Gender-specific models yielded different sets of recidivism risk factors for men and women, with minimal overlap between the two. Male risk factors were criminal history and heavy alcohol consumption. For women, evidence of a substance use disorder was a unique predictor. Having a prior DUI arrest, driving behaviors, and a physical health consequence of alcohol or drug use (i.e., weight loss) were shared predictors for both sexes. CONCLUSIONS: Findings suggest that within broad categories of risk factors, the predictive validity of specific assessment items may vary by sex. Our methods represent progression toward more efficient prediction of DUI recidivists.

National Survey of Juvenile Community Supervision Agency Practices and Caregiver Involvement in Behavioral Health Treatment.

OBJECTIVES: This study sought to expand the sparse literature examining the extent to which family engagement interventions and the structural characteristics of juvenile community supervision agencies influence caregiver participation in youths' behavioral health (i.e., mental health and substance use) treatment. METHODS: We analyzed data from a national survey of juvenile community supervision agencies, conducted as a part of a Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System (JJTRIALS) Cooperative Agreement funded by NIH/NIDA. RESULTS: Findings indicated agencies employ a variety of family engagement strategies, with passive strategies like services referrals and flexible schedules being more common than active strategies like provision of family therapy. Multivariate prediction of caregiver involvement in behavioral health care showed the most consistent effects for rural-urban location of the agency; rural agencies more successfully engaged families in their youth's behavioral healthcare. Relatedly, the more family engagement services, the greater the involvement of families in behavioral health treatment. Agencies with a juvenile drug treatment court also showed greater involvement. CONCLUSIONS: Our findings that juvenile justice agencies are using multiple techniques to engage families, and that there is a relationship between use of these techniques and actual family engagement, would benefit from replication over time and in other jurisdictions. Analysis of data from a second wave of the national survey, recently completed, is expected to test the reliability of our findings over time, as well as identify whether and what kind of changes occurred in the two years following the first survey.

Juvenile justice staff endorsement of HIV/STI prevention, testing, and treatment linkage.

BACKGROUND: While involvement in the legal system offers an opportunity to educate, screen, and treat high-risk youth, research shows that staff attitudes toward these practices can serve as barriers to implementation. The current study investigates the degree to which JJ staff endorse HIV prevention, testing, and treatment linkage practices with youth under community supervision and examines differences between individuals who supervise youth (e.g., juvenile probation officer) and those working in non-supervisory roles (e.g., case manager, assessment specialist). METHODS: Juvenile justice staff consenting to participation in JJ-TRIALS completed an initial staff survey (N = 501). Survey items measured perceived importance of HIV/STI prevention (4 items); perceived importance of HIV/STI testing (7 items); and perceived importance of HIV/STI treatment linkage (8 items). RESULTS: Confirmatory Factor Analysis (CFA) was computed (SAS CALIS procedure) for each of the three domains. Findings suggest that while staff recognize that youth are at risk for HIV/STIs and require provision of HIV/STI prevention and treatment linkage, attitudes concerning the importance of procuring or providing testing services for youth is substantially lower. Furthermore, analytic models comparing staff with and without supervision responsibilities (computed using SAS PROC MIXED) indicated that attitudes differed by site and staff responsible for supervision rated HIV treatment linkage practices as less important compared to non-supervising staff. CONCLUSIONS: Establishing partnerships with health agencies equipped with resources and skillsets to provide HIV/STI testing and related services may be an effective model to promote greater awareness and use of best practices among JJ staff and more effectively address the unmet needs of this high-risk population of youth.

CHILD VICTIMIZATION AND PARENTAL MONITORING AS MEDIATORS OF YOUTH PROBLEM BEHAVIORS.

This study examines the effects of family characteristics, parental monitoring, and victimization by adults on alcohol and other drug (AOD) abuse, delinquency, and risky sexual behaviors among 761 incarcerated juveniles. The majority of youth reported that other family members had substance abuse problems and criminal histories. These youth were frequently the victims of violence. Relationships between victimization, parental monitoring, and problem behaviors were examined using structural equation modeling. Monitoring was negatively related to all problem behaviors. However, type of maltreatment was related to specific problem behaviors. The effects of family substance abuse and family criminal involvement on outcomes were mediated by monitoring and maltreatment. The study underscores the need to provide family-focused and trauma-related interventions for juvenile offenders.

Predictors of justice system involvement: Maltreatment and education.

Decades of research have established that experience of abuse and/or neglect in childhood is related to negative outcomes, such as juvenile delinquency. Existing research has shown that involvement in child welfare services is also related to juvenile delinquency, particularly for children who are victims of neglect. Research has also identified educational factors such as chronic absenteeism as significant predictors of involvement in the juvenile justice system. However, little research has investigated the combined influence of educational factors, child abuse, and involvement in child protective services on justice system involvement. The current study examined the influence of educational factors and involvement in child protective services on justice system involvement. The study utilized records from an educational database of children who attended a school within a county of Mississippi in any year from 2003 through 2013. Cases were then matched with records from the county Youth Court, Law Enforcement agencies, and Child Protection Services. A multivariate logistic regression controlling for gender, race, current age, and time at risk was conducted to involvement in the justice system. In general, educational factors were stronger predictors of justice system involvement than allegations of maltreatment.

Psychometric properties of the Short Inventory of Problems (SIP) with adjudicated DUI intervention participants.

We used responses of two large samples of court-ordered participants from a statewide alcohol/driving safety program to investigate factor structure, score reliability, and criterion-related validity of the Short Inventory of Problems (SIP). Exploratory and confirmatory factor analyses, using both item-level and subscore-level data, support a one-factor structure for the SIP. Internal consistency score reliability estimates were consistent across samples and high enough to warrant use for making decisions about individuals. Item response theory model calibration of the scale, using a two-parameter logistic model, yielded consistent estimates of location and discrimination (slope) across samples. Estimated scale scores correlated moderately with an independent indicator of alcohol problems and poorly with an indicator of risky driving behavior, lending evidence of convergent and discriminant validity. We judge the SIP as adequately described by a single factor, that the joint person-item scale is coherent, and scores behave consistently across samples. (PsycINFO Database Record

The Juvenile Justice Behavioral Health Services Cascade: A new framework for measuring unmet substance use treatment services needs among adolescent offenders.

OVERVIEW: Substance use and substance use disorders are highly prevalent among youth under juvenile justice (JJ) supervision, and related to delinquency, psychopathology, social problems, risky sex and sexually transmitted infections, and health problems. However, numerous gaps exist in the identification of behavioral health (BH) problems and in the subsequent referral, initiation and retention in treatment for youth in community justice settings. This reflects both organizational and systems factors, including coordination between justice and BH agencies. METHODS AND RESULTS: This paper presents a new framework, the Juvenile Justice Behavioral Health Services Cascade ("Cascade"), for measuring unmet substance use treatment needs to illustrate how the cascade approach can be useful in understanding service delivery issues and identifying strategies to improve treatment engagement and outcomes for youth under community JJ supervision. We discuss the organizational and systems barriers for linking delinquent youth to BH services, and explain how the Cascade can help understand and address these barriers. We provide a detailed description of the sequential steps and measures of the Cascade, and then offer an example of its application from the Juvenile Justice - Translational Research on Interventions for Adolescents in the Legal System project (JJ-TRIALS), a multi-site research cooperative funded by the National Institute on Drug Abuse. CONCLUSION: As illustrated with substance abuse treatment, the Cascade has potential for informing and guiding efforts to improve behavioral health service linkages for adolescent offenders, developing and testing interventions and policies to improve interagency and cross-systems coordination, and informing the development of measures and interventions for improving the implementation of treatment in complex multisystem service settings. Clinical Trials Registration number - NCT02672150.