Organizational Context and Individual Adaptability in Promoting Perceived Importance and Use of Best Practices for Substance Use

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.

E-Connect: Linking probation youth at risk for suicide to behavioral health services

OBJECTIVE

Youth involved in the justice system (YIJ) have higher rates of suicidal thoughts and behaviors (STB) and associated behavioral health (BH) problems, yet lower levels of service use compared to youth in the general population. This study examined the efficacy of e-Connect, a digital clinical decision support system (CDSS), at improving STB risk identification, referral, and linkage to BH services by probation officers. As the intervention spanned pre- and post-COVID-19 shutdown periods, we also examined the disruption in public agencies' service provision on study outcomes.

METHOD

Administrative record data (1,488 youth, ages 10-18 years, 56% male, 56% White) allowed examination of differences between care-as-usual (baseline) and e-Connect in screening, identification of STB and BH problems, referral, and treatment initiation.

RESULTS

Compared to care-as-usual, probation officers using e-Connect were over five times as likely to identify YIJ with STB (adjusted odds ratio [aOR] = 5.86; 95% confidence interval, CI [3.24, 11.7]) and over 11 times more likely to refer YIJ in need of BH services to treatment (aOR = 11.04; 95% CI [6.54, 19.43]). In turn, youth referred to treatment via e-Connect were nearly 17 times more likely to initiate (aOR = 16.92; 95% CI [9.17, 32.60]). Results remained unchanged during the pre- and post-COVID-19 shutdown periods.

CONCLUSION

e-Connect is one of the first digital STB screening, referral, and linkage-to-service systems that use CDSS technology to successfully assist probation officers in linking youth on their caseload to treatment. Such an approach may support identification of STB and cross-systems linkage in other youth-serving organizations, such as schools, that increasingly manage youth BH problems with minimal clinical support. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

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.

Methodological approaches to study context in intervention implementation studies: an evidence gap map

BACKGROUND

Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence.

METHODS

We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis.

RESULTS

Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes.

CONCLUSIONS

This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.

Racial/Ethnic Differences in the Effects of Adverse Childhood Experiences on Substance Misuse among Justice-Involved Children

Background: Adverse childhood experiences (ACEs) are linked to substance use (SU) and substance use disorders (SUD). However, this relationship has yet to be tested among justice-involved children (JIC), and it is unclear if racial/ethnic differences exist. This study aimed to determine: (1) whether ACEs are associated with increased risk of SU and SUD among JIC; and (2) if the effects of ACEs on SU and SUD are moderated by race/ethnicity. Methods: Bivariate and multivariate logistic regression analyses were employed to examine a statewide dataset of 79,960 JIC from the Florida Department of Juvenile Justice. Marginal odds were estimated to examine how race moderates the relationship between ACEs and SU and SUD. Results: Results showed higher ACEs scores were linked to SU and SUD. Black JIC were 2.46 times more likely, and Latinx JIC were 1.40 times more likely to report SU than white JIC. Specifically, Black and Latinx JIC with a higher average ACEs score were more likely to report SU but less likely to have ever been diagnosed with a SUD when compared to white JIC with equivalent ACEs. Conclusions: Study results highlight the need to develop trauma-informed and culturally appropriate interventions for SU and SUD among JIC.

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.

Substance Use Disorders as a Critical Element for Decision-Making in Forensic Assertive Community Treatment: A Systematic Review

Introduction: The prevalence of substance use disorders in forensic populations is high. They are an important factor linked to negative outcomes in mentally ill offenders and are detrimental to forensic or non-forensic outcome measures. In contrast, substance use disorders are often underdiagnosed and undertreated, especially in forensic settings. Forensic Assertive Community Treatment is a forensic adaptation of regular assertive community treatment, combined with essential elements of forensic rehabilitation theories. Little is known however on the effectivity of forensic assertive community treatment when it comes to substance use disorders or what their exact role is on the outcome measures. In this paper, we explore how SUD is treated in Forensic assertive community treatment and how it relates to the forensic and non-forensic outcome measures. Methods: We performed a systematic review (PRISMA) of forensic Assertive community treatment teams that followed the main evidence-based principles of regular assertive community treatment and added basic elements of forensic rehabilitation. We analyzed articles the Psychinfo and Medline databases dating from 2005 to 2020. Fifteen studies fit the search criteria and were included in the analysis. The Quality of the studies was assessed using the Newcastle-Ottawa scale. Results: SUD was highly prevalent in all studies. Patients entered FACT through two pathways, either from a care continuum or directly from prison. The severity of SUD at intake emerges as a critical element when deciding which pathway to choose, as a high severity-score at the start of FACT follow-up was linked to recidivism. While differing in method all studies offered integrated SUD treatment. These included evidence-based techniques like CBT, therapeutic communities, and Substance Abuse Management Module. Though results on SUD outcomes were mixed 4 studies mentioned abstinence in 50-75%. The severity of SUD tended to increase initially and to stabilize afterwards. Conclusion: Severity of SUD at intake emerges as a decisive element in decision-making on entering FACT teams directly from prison or through a care-continuum. The ways to provide SUD treatment varied and outcomes for SUD were mixed. SUD was found to be detrimental to forensic and non-forensic outcome measures, such as recidivism or hospitalizations during FACT treatment.

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.

Critical Factors Influencing Interorganizational Relationships Between Juvenile Probation and Behavioral Health Agencies

Although interorganizational relationships (IORs) are essential to the effective delivery of human services, very little research has examined relationships between juvenile justice agencies and behavioral health providers, and few studies have identified the most critical organizational and individual-level characteristics influencing IORs. Across 36 sites, juvenile probation officials (n = 458) and community behavioral health providers (n = 91) were surveyed about characteristics of their agencies, themselves, and IORs with each other. Generalized Linear Mixed Models were used to analyze the data. The strongest predictors included Perceived Organizational Support and individual Adaptability. Implications for research, theory and practice 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.

Improving Substance Use Services for Juvenile Justice-Involved Youth: Complexity of Process Improvement Plans in a Large Scale Multi-site Study

Despite the high prevalence of substance use disorders among juvenile offenders, most do not receive services. System-level process improvement plans to address unmet service needs can be optimized by combining data-driven decisions and facilitated meetings with behavioral health stakeholders. This paper operationalizes and analyzes the level of specified complexity among process improvement plans evident within 36 juvenile probation and drug courts across 7 states. To inform more effective implementation strategies, this analysis identifies and prioritizes promising courses of agency enhancement toward addressing unmet substance use needs.

Substance use prevention services in juvenile justice and behavioral health: results from a national survey

BACKGROUND

This study examined the national availability of substance use prevention (SUP) within juvenile justice (JJ) and their primary behavioral health (BH) providers, and the relationships between the availability of SUP and agency-level measures of organizational structure, staffing, and youth characteristics. A three-stage national probability sampling process was used to select participants for a national survey that included, among other facets of community supervision (CS) and BH practices, questions on agency characteristics, youth characteristics, whether the agency/provider directly provided SUP services, and whether the agency/provider directly provided substance use and/or mental health treatment. This paper focuses on SUP services along with agency/provider and youth characteristics related to providing SUP.

RESULTS

The response rate for both CS agencies (n = 195) and BH providers (n = 271) was 96%. Complex samples logistic regression initially examined univariate associations of each variable and identified candidates for a final multivariate model. Overall, only one-third of CS and BH providers reported offering SUP services, with BH providers being significantly more likely than CS agencies to provide SUP services. In addition, likelihood of SUP was significantly lower among agencies where the substance use distribution of the caseload was below the median. Controlling for master's level staff and the substance use distribution, CS agencies were about 67% less likely to offer SUP when compared to BH providers.

CONCLUSIONS

Given the high rates of substance use among justice-involved youth and that substance use is an established risk for several negative behaviors, outcomes, and health conditions, these findings suggest that evidence-based prevention services should likely be expanded in justice settings, and perhaps included as part of CS programs, even when youth do not initially present with SU service needs.

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.