Studies about Adolescent Community Reinforcement Approach

Numerous studies have been conducted comparing A-CRA to other modalities. It has been used in outpatient clinics, schools, homeless drop-in centers, with justice involved youth, and as continuing care following residential treatment  (Dennis et al., 2004; Godley, Godley, Dennis, Funk, & Passetti, 2007; Slesnick, Prestopnik, Meyers, & Glassman, 2007 as quoted by Hunter, et al., 2014b). A-CRA has been shown to have equivalent outcomes across genders and in African-American, Caucasian, and Latino ethnic groups  (Godley, Hedges, & Hunter, 2011, as quoted by Hunter, et al., 2014b). According to Robert Meyers who developed A-CRA, the program has never had a negative clinical trial, out performing the control group in every instance (Meyers, 2022). 

One study tested whether offering A-CRA therapy in a school setting was effective (Hunter, et. al, 2014a). The study analyzed data from a SAMHSA funded adolescent SU treatment initiative called Assertive Adolescent and Family Treatment (AAFT). This initiative provided grant money to organizations throughout the United States to implement A-CRA. Some of these organizations provided the A-CRA therapy in school based health clinics. The data from 2768 adolescents between the ages of 12 and 18 was used in the study. The majority, 2276 adolescents, received A-CRA therapy in a clinic setting and 492 students received school-based treatment. Compared to the clinic-based group, those who received A-CRA at school were less likely to be living in risky environments, have three or more years of substance use, prior substance use (SU) treatment, illegal activity involvement, or be involved in the juvenile justice system. The school based treatment centers had more female clients. A large percentage, 24%, of adolescents treated in the school-based setting self-referral to treatment, compared to .6% in the clinical treatment.

An assessment tool, the Global Appraisal of Individual Needs, was used to rate the participants in eight areas at intake and at six months. At the six month follow up, both groups scored the same in days of substance use, days of illegal activity, and days of trouble at school. The school based group spent less days in a controlled environment (incarceration). Participants in this group also reported that they had fewer days of trouble with their families. This statistic is surprising because fewer school-based adolescents received the caregiver. Forty-three percent of the clinic-based adolescents received these sessions, while only 25% of the school-based adolescents did.

Based on these measurements, researchers concluded that school-based interventions are just as, if not more, effective as the clinic-based treatments. A-CRA in a school-based setting may be a way to provide earlier intervention because the participants at these locations had lower scores in substance use and justice involvement at intake. According to the authors another advantage of the school-based interventions is that the school-based services also provided school staff with a countermeasure when they observe a student beginning to engage in problem behaviors. Also, providing SU treatment in schools may be an effective way to combat the outpatient treatment attrition that is common in clinic-based treatment (United States

Department of Health and Human Services, 2009 as quoted by Hunter, et al., 2014b).

Two other studies looked at the effects of A-CRA on justice-involved youth. The first study reviewed the data from fifty SAMHSA/CAST A-CRA grants (Hunter, et al., 2014b). The study included the data of 1,467 adolescents who self-reported illegal activities in the 12 months prior to their intake assessment. The treatment model consisted of a 3-month outpatient A-CRA episode of weekly, hour-long sessions followed by 3 months of Assertive Continuing Care (ACC). ACC uses A-CRA procedures, home visits, and assertive case management to continue to support individuals following their initial substance use treatment episode. The results of this study provided support that participation in A-CRA treatment by substance using adolescents who are engaging in illegal activity is associated with significant reductions in substance use and illegal activities at both 6- and 12-month follow-up assessments. Also, A-CRA was associated with significant reductions in juvenile justice involvement at the 12-month follow-up assessment. These results support the importance of maintaining treatment fidelity, as higher A-CRA Exposure Scale scores were related to greater reductions in substance use and illegal activities. 

A second study sought to verify the results of previous studies by conducting an independently randomized controlled trial (Henderson, et al., 2016). This study involved 126 youth between the ages of 12 and 17. All youth were under community supervision of the local juvenile probation department (JPD)—typically consisting of regular meetings with a JPO (weekly for most youth) and drug testing via urine specimens—through the duration of the study. Like the previous study, the treatment model consisted of three months of A-CRA therapy followed by three months of ACC. The control group of this study received services as usual (SAU) of one of the following services: drug education class; alternative education program administered by the juvenile probation program; individual counseling provided by counselors at the juvenile probation department or in the community, diversion, and family intervention.  Many of these services were not standardized or manualized interventions. Both groups had approximately the same planned duration and level of JPO involvement. Follow-up assessments were conducted at 3, 6, and 12 months following intake.

Youth in both treatment and comparison groups showed significant reduction in substance use frequency and problems. The proportion of youth reporting no use significantly increased, and among those reporting continued use frequency significantly decreased over time. Youth receiving A-CRA/ ACC decreased their problems associated with substance use significantly more than youth receiving services as usual. Problems associated with use were measured by the GAIN Substance Problem Scale, a 16 items assessment tool  alpha of which is a count of past-year symptoms related to any alcohol or drug use disorders, including abuse, dependence, substance induced health and psychiatric problems (Dennis, et al., 2006). A-CRA/ACC reduced these problems by 88% (compared to 72% with SAU) at 3 months and 74% (compared to 56% with SAU) at 12 months (Henderson, 2016). The fact that A-CRA/ACC performed better than a combination of five different SAU options suggests that services may actually be consolidated (with improved clinical outcomes and potential cost savings) by implementing A-CRA/ACC with justice-involved adolescents. Unfortunately, this study did not provide information about the participants’ illegal activity or justice involvement at their 6 and 12 month follow ups.

Resources

References

Dennis,Michael L., PhD, Chan, PhD, Ya-Fen, Funk, BS, Rodney R. (2006) Development and

Validation of the GAIN Short Screener (GSS) for Internalizing, Externalizing and Substance Use Disorders and Crime/Violence Problems Among Adolescents and Adults. The American Journal on Addictions, 15: 80–91, 2006. DOI: 10.1080/10550490601006055

Dennis, M., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J.,... Funk, R. R. 

(2004). The Cannabis Youth Treatment (CYT) study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197–213. doi:10.1016/j.jsat.2003.09.005

Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R., & Passetti, L. L. (2007). The effect of 

assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders. Addiction, 102, 81 –93. doi:10.1111/j.1360-0443.2006.01648.x

Henderson, PhD, Craig E.,Wevodau, PhD, Amy L., Henderson, PhD, Susan E., Colbourn, MS, 

Scholar L., Gharagozloo, PhD, Laadan, North, PhD, Lindsey W., Lotts, PhD, Vivian A.. (2016) An Independent Replication of the Adolescent-Community Reinforcement Approach with Justice-Involved Youth. The American Journal on Addictions, 25: 233–240. DOI: 10.1111/ajad.12366 

Hunter, Brooke D., Godley, Mark D. and Godley, Susan H , (2014). Feasibility of implementing 

the Adolescent Community Reinforcement Approach in school settings for adolescents with substance use disorders. Advances in School Mental Health Promotion, Vol. 7, No. 2, 105–122, http://dx.doi.org/10.1080/1754730X.2014.888224 

Hunter, Brooke D., Godley, Susan H., Hesson-McInnis, Matthew S., Roozen, Hendrik G. (2014) 

Longitudinal Change Mechanisms for Substance Use and Illegal Activity for Adolescents in Treatment. Psychology of Addictive Behaviors.  Vol. 28, No. 2, 507–515. DOI: 10.1037/a0034199 

Meyers, Robert. (2022, February 21). Adolescent Community Reinforcement Approach (A-CRA)

Training .MITC Training & Education. https://www.nmmitc.com/events/robert-j-meyers-phd-presents-adolescent-community-reinforcement-approach-a-cra-hosted-by-mitc

Slesnick, N., Prestopnik, J. L., Meyers, R. J., & Glassman, M. (2007). Treatment outcome for 

streetliving, homeless youth. Addictive Behaviors, 32, 1237– 1251. doi:10.1016/j.addbeh.2006.08.010

United States Government (2022, March 15). Youth.gov, Program Directory Search. 

https://youth.gov/evidence-innovation/program-directory?keywords=adolescent&field_pd_factors_risks_tid=All&field_pd_factors_protective_tid=All