Adaptation of a trauma-informed intervention to prevent opioid use among youth in the legal system.

INTRODUCTION: Youth in the legal system are at high risk for opioid and other substance use problems and exhibit high rates of trauma exposure. Trauma-focused therapeutic approaches to prevent substance use show promise, but few evidence-based interventions are designed with justice-involved youth in mind. Consequently, implementing trauma-informed, evidence-based interventions within juvenile justice systems is challenging. The current paper describes the systematic adaptation of Trust-Based Relational Intervention (TBRI) as a family-centered substance use prevention program for youth transitioning from secure residential facilities. METHODS: The study utilized the ADAPT-ITT methodological framework to adapt TBRI Caregiver Training, an evidence-based, trauma-informed intervention designed to help caregivers support children and youth with histories of trauma. Phases of adaptation included (1) Assessment, (2) Decision, (3) Prototype Development, and (4) Testing and Integration. The adaptation process explored contextual factors (e.g., systems, facilities, and staff) and the needs of the new target population (i.e., youth in the legal system and their caregivers). Adaptations were made to both content (e.g., terminology and activities) and structure (e.g., session duration and delivery setting) with input from participants from the target population, key stakeholders, and content experts. RESULTS: The systematic adaptation of the intervention model resulted in a two-phase, four-component intervention package that can be implemented in juvenile justice settings as part of youth reentry services. The primary intervention, delivered while youth are in residential facilities, includes the TBRI Caregiver Curriculum, TBRI Youth & Young Adult Curriculum, and TBRI Nurture Groups. The secondary intervention, delivered after youth transition home, includes the TBRI Family Coaching Curriculum. CONCLUSIONS: Utilizing a systematic methodological framework to guide adaptation has implications for developing accessible, culturally relevant, and contextually appropriate interventions. Accounting for contextual factors and population needs can improve the fit of evidence-based interventions for youth in the legal system, facilitating uptake and ultimately improving outcomes for youth at risk for substance use problems. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04678960.

Adaptation of a trauma-informed intervention for youth involved in the legal system.

Background: Youth in the legal system (YILS) have high rates of trauma exposure, which are associated with increased risk of behavioral health needs (e.g., substance-use problems) and recidivism. Research suggests that a trauma-focused therapeutic approach can improve outcomes for YILS, but few evidence-based interventions (EBIs) are designed with justice-involved youth in mind. Consequently, implementing trauma-informed EBIs within juvenile justice (JJ) systems is challenging. The current paper describes the systematic adaptation of Trust-based Relational Intervention (TBRI) as a substance use prevention intervention for YILS and their caregivers. Methods: The current study utilized a methodology based on the ADAPT-ITT framework to adapt TBRI Caregiver Training, an evidence-based, trauma-informed intervention program. Phases of adaptation included (1) Assessment, (2) Decision, (3) Prototype Development, and (4) Testing and Integration. The adaptation process explored contextual factors (e.g., systems, facilities, and staff) and the needs of the new target population (i.e., YILS and their caregivers). Adaptations were made to both content (e.g., terminology and activities) and structure (e.g., session duration and delivery setting) in an iterative process with input from participants from the target population, key stakeholders, and content experts. Results: The systematic adaptation of the intervention model resulted in a two-phase, four-component intervention package that can be implemented in juvenile justice settings as part of youth reentry services. The primary intervention, delivered while youth are in residential facilities, includes the TBRI Caregiver Curriculum, TBRI Youth & Young Adult Curriculum, and TBRI Nurture Groups. The secondary intervention, delivered after youth transition home, includes the TBRI Family Coaching Curriculum. Conclusions: Utilizing an implementation science framework to guide adaptation has implications for developing accessible, culturally relevant, and contextually-appropriate interventions. Accounting for contextual factors and population needs can improve the fit of EBIs in juvenile justice, facilitating uptake and ultimately improving outcomes for youth. Trial registration: ClinicalTrials.gov Identifier: NCT04678960.

Preventing opioid use among justice-involved youth as they transition to adulthood: leveraging safe adults (LeSA).

BACKGROUND: Juvenile justice (JJ) youth are at high risk of opioid and other substance use (SU), dysfunctional family/social relationships, and complex trauma. The purpose of the Leveraging Safe Adults (LeSA) Project is to examine the effectiveness of Trust-Based Relational Intervention® (TBRI®; leveraging family systems by providing emotional and instrumental guidance, support, and role modeling) in preventing opioid and other SU among youth after release from secure residential facilities. METHODS: An effectiveness-implementation Hybrid Type 1 design is used to test the effectiveness of TBRI for preventing non-medical use of opioids among JJ-youth (delayed-start at the site level; a randomized controlled trial at participant level) and to gain insight into facility-level barriers to TBRI implementation as part of JJ re-entry protocols. Recruitment includes two samples (effectiveness: 360 youth/caregiver dyads; implementation: 203 JJ staff) from nine sites in two states over 3 years. Participant eligibility includes 15 to 18-year-olds disposed to community supervision and receiving care in a secure JJ facility, without active suicide risk, and with one caregiver willing to participate. Effectiveness data come from (1) youth and caregiver self-report on background, SU, psychosocial functioning, and youth-caregiver relationships (Months 0, 3, 6, 12, and 18), youth monthly post-release check-ins, and caregiver report on youth psychological/behavioral symptoms, and (2) JJ facility records (e.g., recidivism, treatment utilization). Fidelity assessment includes post-session checklists and measures of TBRI strategy use. Collected four times over four years, implementation data include (1) JJ staff self-report on facility and staff characteristics, use of trauma-informed care and TBRI strategies, and (2) focus groups (line staff, leadership separately) on use of trauma-informed strategies, uptake of new interventions, and penetration, sustainment, and expansion of TBRI practices. DISCUSSION: The LeSA study is testing TBRI as a means to empower caregivers to help prevent opioid use and other SU among JJ-youth. TBRI's multiple components offer an opportunity for caregivers to supplement and extend gains during residential care. If effective and implemented successfully, the LeSA protocol will help expand the application of TBRI with a wider audience and provide guidance for implementing multi-component interventions in complex systems spanning multiple contexts. TRIAL REGISTRATION: ClinicalTrials.gov NCT04678960 ; registered November 11, 2020; https://clinicaltrials.gov/ct2/show/NCT04678960 .

The TCU Drug Screen 5: Identifying Justice-involved Individuals with Substance Use Disorders.

The TCU Drug Screen II, a widely used instrument for identifying substance use problems, was originally developed based on Diagnostic and Statistical Manual of Mental Disorders III-R criteria. In 2013, the American Psychiatric Association revised the criteria and classification scheme for substance use disorders (SUDs) with the publication of the DSM-5. Subsequently, the TCU Drug Screen was modified to reflect the updated DSM-5. The current study examines the concordance of the TCU Drug Screen II and TCU Drug Screen 5 with adult and juvenile justice-involved samples. Both versions were administered to 305 adult male and 310 juvenile male justice-involved clients as part of standard intake procedures. Results revealed a high level of agreement between the two versions; however, the TCU Drug Screen 5 detected significantly more cases of SUDs, the majority of which corresponded to a mild SUD. Results documented appropriate discrimination in meeting diagnostic thresholds among both age groups, with fewer adolescents identified as having a disorder. Overall, the results suggest that the TCU Drug Screen 5 is comparable to the TCU Drug Screen II with the added potential benefit of DSM-5 conformity and severity specifiers.

Predictors of Physical Altercation among Adolescents in Residential Substance Abuse Treatment.

This study tested the hypothesis that basic social information-processing components represented by family conflict, peer aggression, and pro-aggression cognitive scripts are related to aggression and social problems among adolescents in substance abuse treatment. The sample consisted of 547 adolescents in two community-based residential facilities. Correlation results indicated that more peer aggression is related to more pro-aggression scripts; scripts, peer aggression, and family conflict are associated with social problems; and in-treatment physical altercation involvement is predicted by higher peer aggression. Findings suggest that social information-processing components are valuable for treatment research.

Recovery among adolescents: models for post-treatment gains in drug abuse treatments.

Recovery among adolescents undergoing substance abuse treatment was modeled in terms of pre-treatment motivation, therapeutic relationships, psychological functioning, treatment retention, legal pressures, DSM diagnoses, and client demographics. To address between program differences, a within-covariance matrix, based on 547 youth, was used. Applicability of the results across treatment modalities was also examined. The data were from the NIDA-sponsored DATOS Adolescent study. Results from structural equation models (estimated using Mplus) indicated that higher pre-treatment motivation predicted stronger counselor and in-treatment peer relationships, better counselor relationships and retention predicted less illegal drug use at follow-up, and DSM diagnosis was important in the treatment process. Overall, illegal drug use at follow-up was associated with post-treatment alcohol consumption, cigarette use, condom nonuse, psychological distress, criminality, and school non-attendance. The results document the importance of motivation and therapeutic relationships on recovery, even when taking into account the relative effects of legal pressures, DSM diagnoses, and demographics.

Predictors of change in the provision of services within outpatient substance abuse treatment programs.

The current study examines patterns and predictors of change over a 2-year period in whether outpatient core and wraparound services are offered on-site or by referral. A sample of 69 outpatient nonmethadone programs from 4 US regions provided organizational information across a 2-year period. Services provided within outpatient substance abuse programs were relatively stable over time, particularly with regard to core therapeutic services. The use of referral networks to provide a broader array of wraparound services increased, with programs adding services that reflect recent national initiatives toward program improvement, namely pharmacotherapy, medical diagnosis and treatment, and psychiatric services. Organizational factors such as parent affiliation, counselor caseload, staff size, budget change, and proportion of dually diagnosed clients were related to change in core and wraparound services. Dynamic organizational factors such as staff size and budgets can serve as barriers to and/or facilitate change in service provision over time and have managerial and policy implications.