Diagnosing antisocial personality disorder among substance abusers: the scid versus the MCMI-II.

There is much controversy among social scientists and clinicians over the proper measurement of antisocial personality disorder (ASPD). The degree to which various diagnostic measures differ in their assessment of ASPD among substance abusers is not known. This study assessed the degree of agreement between a semistructured clinical interview and a self-report inventory on a diagnosis of ASPD among substance abusers. The Structured Clinical Interview for DSM-III-R (SCID-II), a clinically generated instrument, and the Millon Clinical Multiaxial Inventory (MCMI-II), a self-report inventory, were administered to 275 clients randomly assigned to two therapeutic communities (TCs). Based on the limited existing literature, it was hypothesized that there would be minimal agreement between the diagnosis of ASPD by the two scales. This hypothesis was supported. The kappa statistic indicated low agreement between the scales (kappa = 0.27), with the MCMI-II diagnosing ASPD more often than the SCID-II. The low agreement on a diagnosis of ASPD may be due to the different types of information collected by the two scales. The SCID-II emphasizes observable behavioral criteria, while the MCMI-II emphasizes pathological personality traits. The focus of the MCMI-II on pathological personality traits may more accurately diagnose ASPD in substance-abusing populations in which the majority of the clients have extensive criminal histories. Definite conclusions regarding the proper measurement of ASPD in substance-abusing samples is difficult without additional empirical evidence.

A comparison of saliva testing to urinalysis in an arrestee population.

Past studies have concluded that individuals under criminal justice supervision often underreport their recent use of illicit drugs. To address this underreporting, objective biological measures, such as urine, saliva, and hair testing, have been used to gain better estimates of illegal drug use. While urinalysis is generally recognized as the reference standard, a method recently introduced in nonlaboratory settings for ascertaining drug use-saliva testing-may offer an alternative to urinalysis. To date, however, no studies have compared saliva testing to urinalysis among criminal justice populations. In the current study, urine and saliva specimens were collected from 114 adult arrestees interviewed as part of Maryland's Substance Abuse Need for Treatment among Arrestees (SANTA) project. With urinalysis as the reference standard, analysis of the saliva test results indicated sensitivity of 100% and specificity of 99% for cocaine and sensitivity of 88% and specificity of 100% for heroin. For marijuana, however, the saliva results indicated a sensitivity of only 5%. Anecdotal reports from the field suggest that saliva may have some advantages over urine because of the ease of collection, invulnerability to adulteration, and minimal personal invasiveness. These findings suggest that a more comprehensive study to evaluate the efficacy of saliva testing in field research may be warranted.

Opening the black box. The impact of inpatient treatment services on client outcomes.

This study examined the effects of specific services provided in therapeutic communities (TCs) to treatment outcomes. Findings are compared to prior analyses of treatment outcomes from the District of Columbia Treatment Initiative (DCI) that did not utilize the treatment service information. A subsample of DCI clients randomly assigned to two TC programs, who had remained in inpatient treatment for at least 60 days, were included in the analyses (n = 371). Logistic regression results illustrated that the level of vocational education services received was positively associated with completing treatment, and participation in group services was associated with decreases in postdischarge arrest. In addition, clients who received a greater number of all inpatient services were more likely to complete treatment and were less likely to be arrested after discharge. Findings suggest that TC programs should consider offering more vocational education and group treatment services to enhance prosocial behavior following treatment discharge.

Predictors of treatment outcomes in men and women admitted to a therapeutic community.

This study compared factors that predict treatment outcomes in men and women randomly assigned to two therapeutic communities differing primarily in length of inpatient and outpatient treatment. Based on the prior research literature comparing treatment outcomes of men and women, we formulated the following research question: Do factors that predict drug use at follow-up, postdischarge arrest, and employment at follow-up differ for men and women? Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. Separate regression analyses were conducted for men and women for each of the three outcome variables. The results showed that the predictors of outcome for men and women were similar. Clients who completed the 12-month treatment programs had better outcomes regardless of gender. Men and women who completed treatment were characterized at follow-up by substantial reductions in drug use and arrests and by increased employment. Results further suggested that the longer residential treatment program had a particularly beneficial impact on women. Number of prior arrests was also associated with postdischarge outcomes for women. Women with more arrests at admission were more likely to have a postdischarge arrest and less likely to be employed at follow-up. This finding provides invaluable information about which women may be at greater risk for relapse and in need of additional services. We conclude that completion of treatment is the key predictor of treatment outcomes for both men and women.

Comparing the impact of standard and abbreviated treatment in a therapeutic community. Findings from the district of Columbia treatment initiative experiment.

This study examines the efficacy of providing Enhanced Abbreviated or Standard Inpatient treatment and Outpatient treatment to drug-abusing clients. The experiment randomly assigned 412 clients to two therapeutic community programs, which differed primarily in planned duration. This study addressed limitations of prior research, as it used random assignment of clients to treatment programs, achieved high follow-up rates and used objective measures of drug use and criminal history. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. Completing the entire 12-month program (inpatient and outpatient) was more important than duration of inpatient program attended. Regardless of program, completers had substantial reductions in posttreatment drug abuse and arrests. A 12-month course of treatment including at least 6 months in a therapeutic community followed by outpatient treatment can produce marked reductions in drug abuse and crime among persons who complete both phases.

Therapeutic community treatment for substance abusers with antisocial personality disorder.

This study compared treatment outcomes of substance abusers with and without antisocial personality disorder (APD) randomly assigned to two therapeutic communities, differing primarily in length of inpatient and outpatient treatment. We hypothesized that APD clients would be less likely to complete treatment, more likely to test positive for drugs and recidivate at follow-up, and that APD clients in the Standard program would have more favorable outcomes than those in the Abbreviated Inpatient program, because of the Standard program's longer inpatient treatment. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. APD clients were as likely to complete treatment as other clients, and they exhibited the same patterns of reduced drug use and recidivism as did non-APD clients. Treatment program attended was unrelated to outcomes. Substance abusers diagnosed with APD can benefit from treatment in a therapeutic community combined with outpatient care.

The validity of self-reports of drug use at treatment admission and at followup: comparisons with urinalysis and hair assays.

Studies conducted in the 1970s and early 1980s concluded that people will provide valid information about their illicit drug use when research interviews are conducted under appropriate conditions. Recent studies of treated and untreated populations using improved urinalysis techniques as well as hair analysis techniques indicate that the validity of respondents' self-reports of recent drug use may be considerably less than previously reported and may differ according to a number of factors. Results are presented from a study of clients participating in the Washington, DC, Treatment Initiative study who were assessed for drug use by interview, urinalysis, and hair analysis. At intake, almost all clients who tested positive had reported their use of heroin but fewer clients had reported their cocaine use. At posttreatment followup, clients underreported both heroin and cocaine use. Findings from treatment outcome studies that fail to validate and adjust their estimates of self-reported recent drug use should be interpreted with considerable caution.

A structural model examining the relationship between physical child abuse, sexual victimization, and marijuana/hashish use in delinquent youth: a longitudinal study.

A structural model of the relationships among physical abuse and sexual victimization experiences, marijuana/hashish use (measured by self-report and urine test data) and self-reported delinquent behavior (theft crimes, index offenses, crimes against persons, drug sales and total delinquency) over time was tested in a longitudinal study of juvenile detainees. The hypothesized model was supported by the data. Theoretical, research and policy implications of the results are drawn.

Recidivism among high risk youths: a 2 1/2-year follow-up of a cohort of juvenile detainees.

We report some results from a longitudinal study of juvenile detainees. Analyses were directed toward determining whether the youths' alcohol or other drug use and their emotional/psychological problems at entry into the detention center predicted subsequent arrests for new offenses during the 24 and 30 months following their initial interviews. Statistically significant relationships were found between the youths' demographic characteristics (age, race, gender), referral history, reason for placement in the detention center, cocaine use (as measured by urinalysis), and recidivism. The magnitude of these relationships increased with the length of the follow-up period.

Concordance of three measures of cocaine use in an arrestee population: hair, urine, and self-report.

This article reports on the comparison of self-reported cocaine use with urinalysis outcomes and radioimmunoassay of hair samples for cocaine. The data is based on a voluntary sample of approximately 300 arrestees, tested and interviewed anonymously. The study reports high rates of request compliance for both urine and hair samples, and affirms a relatively high degree of underreporting of cocaine use. Radioimmunoassay of hair appears to detect considerably larger degrees of cocaine use than are detected by urinalysis. The differential rates of detection between hair and urine are less dramatic in subjects who appear to be high rate users.

Recidivism among high-risk youths: study of a cohort of juvenile detainees.

We report some results from an ongoing, longitudinal study of juvenile detainees. Analyses were directed toward determining whether the youth's alcohol or other drug use and their emotional/psychological problems at entry into the detention center predicted subsequent arrests for new offenses. Statistically significant relationships were found between the youths' demographic characteristics (age, race, gender), referral history, reason for placement in the detention center, and cocaine use (as measured by urinalysis) and recidivism. However, the magnitudes of these relationships were low to moderate in value, suggesting that a longer follow-up period is needed to more meaningfully study this issue.

Juvenile crime and drug abuse: a prospective study of high risk youth.

Results from an ongoing, longitudinal study of juvenile detainees focusing on the relationship between their drug use and delinquency/crime, are summarized. Three hundred and ninety-nine youths were first interviewed in 1986/87, and 41 percent were found to be urine positive for recent drug use at the time of detention. We reinterviewed 305 of the youths approximately one year later, and found their drug use and delinquency persisted, and in some cases increased, over time. Treatment intervention is needed for the drug involved youths in the study to reduce their cycle of drug use and crime.

Examination of the relationships among drug use, emotional/psychological problems, and crime among youths entering a juvenile detention center.

Urine testing and confidential interviews of youths entering a juvenile detention center in a southeastern city produced some striking results in regard to their drug use, delinquent behavior, and emotional/psychological problems. Recent users of marijuana/hashish and cocaine had higher rates of referral to juvenile court for property and drug offenses than nonusers. The results suggest that interviewing and urine testing of youthful detainees for drug use at the point of entry into secure detention is a promising method for screening youngsters with histories of delinquent behavior. Implications of these findings are drawn.

A longitudinal study of the relationships among alcohol use, marijuana/hashish use, cocaine use, and emotional/psychological functioning problems in a cohort of high-risk youths.

There is increasing recognition that children involved in the justice system often have serious, multiple problems in the areas of physical abuse, sexual exploitation, and alcohol/other drug use (ADM). Using data collected in a longitudinal study of detained juveniles, we test a model of the relationships of these problems. Significant over-time interrelationships are found among these problems. Research and policy implications of these important findings are drawn.

U.S. drug policy in the 1990s: insights from new data from arrestees.

What has been overlooked in recent years, and what the new findings presented in this paper indicate, is that even as there has been a welcome and dramatic drop in middle-class and causal drug use in the United States, revealed by the National Household Survey and the High School Senior Survey, there remains a stubborn hard core of drug use in criminals. Data from the newly established Drug Use Forecasting (DUF) program suggest that the arrestee population contains many of the frequent users of cocaine in the United States. These arrestees are part of a deviant segment of the population having multiple behavioral, vocational, and educational deficits. The danger exists that as drug use declines in the middle class, this residual group of dysfunctional drug users will become a national scapegoat subject to extremely harsh societal reactions, or alternatively, be neglected and "written off" by the larger society. A more humane alternative is to take advantage of the access to these persons that the criminal justice system affords to address their drug use and associated problems.

Physical abuse, sexual victimization, and illicit drug use: replication of a structural analysis among a new sample of high-risk youths.

Mounting evidence of serious adverse consequences of childhood physical and sexual abuse has important implications for public health officials and care providers. Given the potential impact on social policy of this area of inquiry, programmatic research is needed for the validation of theoretical models across populations and over time. This study, based on a sample of high-risk youths, replicates a structural model that specified the influence of child physical and sexual abuse on self-derogation and drug use. Results suggest that for male and female youths, physical abuse and sexual victimization had a direct effect on self-derogation and illicit drug use, and an indirect effect on drug use that was mediated by self-derogation. Moreover, structural coefficients for the model were found to be identical across gender. Subsequent analyses demonstrated the equivalence of the structural model of child physical and sexual abuse on drug use across two study cohorts. Implications for the identification and treatment of youths in high-risk groups are discussed.