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Program Profile: Adolescent Community Reinforcement Approach

Evidence Rating: Effective - More than one study Effective - More than one study

Date: This profile was posted on June 10, 2011

Program Summary

An outpatient program targeting 13 to 25 year olds that aims to replace activities supporting alcohol and drug use with positive behaviors that support recovery. The program is rated Effective. Participants were more likely to seek out and continue care services, abstain from substance use (in particular, marijuana), had less reported depression and internalized behaviors problems, and more social stability (i.e., working, receiving education, in a home or shelter, or receiving medical care).

This program’s rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Description

Program Goals/Target Population

The Adolescent Community Reinforcement Approach (A-CRA) is a behavioral intervention that aims to replace structures supportive of drug and alcohol use with ones that promote a clean and healthy lifestyle. A-CRA has three different protocols and guidelines, depending upon the population it is serving, but the overall goals are to reduce substance use and dependence, increase social stability, improve physical and mental health, and improve life satisfaction.

A-CRA is designed to include sessions with adolescents, parents/caregivers, and adolescents and parents/caregivers together during the course of treatment. It has also been adapted for use with Assertive Continuing Care, which provides home visits to youth following residential treatment for alcohol and/or substance dependence, and for use in a drop-in center for street-living, homeless youth. A-CRA is appropriate for youth between 13 and 18 years of age and young adults between 18 and 25 years of age suffering from substance addiction or dealing with substance abuse issues, though this same type of program has been used for adults dealing with substance abuse and dependence since the 1970s. (Additionally, early forms of A-CRA have been used with youth 18 years and younger since the early 1990s.)

Program Activities
Adolescents undergo a needs assessment and are asked to complete a self-assessment of happiness and functioning in multiple areas. Based upon these evaluations, therapists can choose from 19 A-CRA protocols that address problematic areas. These include building problem-solving, stress-reducing, and communication skills, as well as participating in prosocial activities. Role-playing and behavioral rehearsal is a crucial element of the skills training used in A-CRA. It is during these exercises that adolescents learn better communication and relapse-prevention skills. After therapy sessions, participants are given homework assignments where they practice skills learned during sessions and are encouraged to be part of positive leisure activities.

Program Theory

A-CRA is derived from a social ecological/systems model that believes behavioral trajectories and outcomes are the result of activities defined by or in response to the demands of specific social systems: people—in this case, adolescents—behave in accordance to the setting or environment they inhabit. This includes their friends and family, as well as the actual physical location where they live. Following this ecological framework, there are two ways to change a person’s negative behavior: change the settings in which individuals conduct everyday activities or change the way individuals respond to influences from that particular setting. A-CRA aims to remove youth from negative environments, such as living on the street or associating with substance using peers, and place them in positive settings that promote a healthy lifestyle and safe behavior.

Evaluation Outcomes

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Study 1
Participation in Care
At the 3 month follow-up, Godley and colleagues (2006) found that Adolescent Community Reinforcement Approach (A-CRA) participants were more likely than usual continuing care (UCC) participants to seek out, and keep attending, continuing care services, at 94 percent versus 54 percent, respectively. On average, A-CRA participants received more days of continuing care sessions than UCC participants. The median number of continuing care sessions attended was higher for A-CRA participants (15 sessions) than for UCC participants (2 sessions). All of these results were statistically significant.

Substance Use (Alcohol and Marijuana)
Abstinence rates were more than 20 percent higher for A-CRA participants in five of six substance comparisons, but only the abstinence rate for marijuana was statistically significant. At the 9-month follow-up, 41 percent of A-CRA participants reported sustained abstinence from marijuana, compared with 26 percent of UCC participants. Participants who reported sustained abstinence at the 3-month follow-up were more likely than participants who were not abstinent to report sustained abstinence at the 9-month follow-up, regardless of intervention assignment. Specifically, those reporting abstinence from marijuana at 3 months were 11 times more likely to remain abstinent at 9 months, those reporting abstinence from alcohol were 5 times more likely to remain abstinent, and those reporting abstinence from substances other than marijuana and alcohol were 11 times more likely to remain abstinent. The effect sizes for these findings were large (odds ratio=11.15, 5.47, and 11.16, respectively).

Study 2
Substance Use
At the 6-month follow-up, Slesnick and colleagues (2007) found that A-CRA participants had a greater decrease in overall reported substance use than participants who received the usual care control condition. Specifically, A-CRA youth had a 37 percent decrease, whereas those in the control condition had a 17 percent decrease in overall substance use. A-CRA participants also had a decrease in the reported frequency of substance use.

Decreases in reported depression symptoms occurred with both A-CRA and usual care participants. The decreases in reported depression symptoms were greater for A-CRA participants than for usual care participants. A-CRA participants had a 43 percent reduction in depression symptoms, while the control group experienced a 23 percent reduction. Further analysis revealed a decrease in depression symptoms for younger (14 to 19 years of age) and older (20 years of age or older) participants in the A-CRA group. This same decrease was not evident for older participants in the usual care control group.

Internalized Behavior Problems
Decreases in reported internalized behavior problems occurred with both A-CRA and usual care participants. The decreases in reported internalized behavior problems were greater for A-CRA participants than for usual care participants.

Social Stability
Increase in social stability, as measured by the percentage of days during the intervention that a participant was working, receiving education, in a home or shelter, or receiving medical care, were greater for A-CRA participants than for usual care participants. A-CRA participants’ social stability increased by 58 percent, compared to the control group, whose social stability only increased by 13 percent.
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Evaluation Methodology

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Study 1
Godley and colleagues (2006) used a randomized design to evaluate the effectiveness of the Adolescent Community Reinforcement Approach (A-CRA) against usual continuing care. Participants in the study had to meet the Diagnostic and Statistical Manual of Mental Disorders (or DSM–IV) diagnosis of current alcohol or drug dependence, be between the ages of 12 and 17 years, and reside within one of the targeted intervention counties in Illinois. Participants were excluded if they left residential treatment within the 1st week, were a ward of the state, were not returning to a targeted county after discharge, or were proclaimed to be a danger to themselves or others due to psychotic symptoms. This resulted in a sample of 183 adolescents who assented, and whose parents/caregivers gave consent, to be in the study. The sample was 71 percent male, 73 percent white, and 18 percent African American; 45 percent were 17 or 18 years of age. A vast majority was unemployed (89 percent) and had prior involvement with the juvenile justice system (82 percent). All participants met criteria for a substance use disorder, with many being dependent upon marijuana (87 percent) and alcohol (54 percent). A minority were dependent upon cocaine (15 percent) or other drugs (14 percent).

The treatment group, those receiving A-CRA, had 102 adolescents. The treatment condition consisted of Assertive Continuing Care (ACC) with A-CRA. Case managers provided 3 months of home visits to youths who had been released from residential treatment centers. The control group, those receiving usual continuing care (UCC), had 81 adolescents. The UCC condition consisted of referrals to community outpatient substance abuse clinics. UCC varied, depending on type of discharge. Adolescents discharged “against staff advice” or “at staff request” received only a letter with information on where to go for further treatment. Adolescents discharged “as planned” received a continuing care appointment with a case manager, typically within 2 weeks of discharge. Follow-up interviews occurred 3, 6, and 9 months after discharge.

Abstinence from substance use was measured using the Global Appraisal of Individual Needs instrument and self-reporting. It was defined as the total number of days abstinent at follow-up periods. There were four follow-up periods spaced out at 3-month intervals, which resulted in observations at 3, 6, and 9 months after intake. Urinalysis at intake and at the follow-up assessments at 3, 6, and 9 months after intake was used to corroborate self-report data.

An intent-to-treat analysis was conducted on participants that had baseline and all three follow-up interview data, about 92 percent of the sample. Chi-square and t-tests were used to detect any differences in the type and amount of continuing care received. Lastly, logistic regressions were used to predict abstinence during continuing care by condition.

Study 2
Slesnick and colleagues (2007) conducted a randomized control trial of A-CRA with street-living, homeless youth from a drop-in center in Albuquerque, N.M. To be eligible for the study, participants had to be between 14 and 22 years of age, been living in the metropolitan area for at least 3 months, and met the DSM–IV diagnosis of having a substance disorder (alcohol or other drugs). These criteria produced a sample of 180 youth. Adolescents were randomly assigned to receive either a usual care condition or usual care with A-CRA. The treatment as usual, or control group, 84 adolescents, received a place to rest during the day; access to food, clothing, and showers; and case management services that linked youth with community resources, at their request. The treatment group, 96 adolescents, received 12 A-CRA therapy sessions and 4 HIV education/skills practice sessions in addition to usual care. Upon randomization into groups, all participants completed baseline assessments. Follow-up measures of outcomes were conducted at 6 months after all participants had received therapy. At the completion of baseline assessments, participants received a care package with blankets, toiletries, and food, and upon completion of the follow-up assessment they were paid $50.

The sample of homeless youths studied contained 118 males and 62 females. On average, the sample was 19 years old. The racial/ethnic composition of the group was 73 whites, 54 Hispanics, 24 Native Americans, 6 African Americans, and 22 adolescents that were mixed or multiracial/ethnicity. The treatment and control groups did not differ significantly on any of the main variables of interest.

Demographic information was collected using an instrument created for the study. Substance use was measured with Form 90, which was developed by the National Institute on Alcohol Abuse and Alcoholism. Delinquent behavior was measured by the National Youth Survey Delinquency Scale and the Youth Self-Report. The adolescent version of the Coping Inventory for Stressful Situations and the Beck Depression Inventory were used to measure participants’ coping skills and depressive symptoms, respectively. Finally, items from the Health Risk Survey and the Homeless Youth Questionnaire were used to address knowledge, attitudes, and risk behaviors associated with HIV. All instruments and scales used have displayed adequate to strong reliability and validity.

Repeated measures analysis of variances (or ANOVAs), along with intent-to-treat analysis, were used to determine the effect of supplementing usual care with A-CRA on reducing substance abuse and promoting healthy behavior in these homeless adolescents.
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There is no cost information available for this program.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Godley, Mark D., Susan H. Godley, Michael L. Dennis, Rodney R. Funk, and Lora L. Passetti. 2006. “The Effect of Assertive Continuing Care on Continuing Care Linkage, Adherence, and Abstinence Following Residential Treatment for Adolescents With Substance Use Disorders.” Addiction 102(1):81–93.

Study 2
Slesnick, Natasha, Jillian L. Prestopnik, Robert J. Meyers, and Michael Glassman. 2007. “Treatment Outcome for Street-Living, Homeless Youth.” Addictive Behaviors 32:1237–51.
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Additional References

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These sources were used in the development of the program profile:

Dennis, Michael L., Susan H. Godley, Guy S. Diamond, Frank M. Tims, Thomas Babor, Jean Donaldson, Howard Liddle, Janet C. Titus, Yifrah Kaminer, Charles Webb, Nancy Hamilton, and Rod R. Funk. 2004.”The Cannabis Youth Treatment (CYT) Study: Main Findings From Two Randomized Trials.” Journal of Substance Abuse Treatment 27:197–213.

Godley, Mark D., Susan H. Godley, Michael L. Dennis, Rodney Funk, and Lora L. Passetti. 2002. “Preliminary Outcomes from the Assertive Continuing Care Experiment for Adolescents Discharged from Residential Treatment.” Journal of Substance Abuse Treatment 23:21–32.

Godley Susan H., Robert J. Meyers, Jane E. Smith, Tracy Karvinen, Janet C. Titus, Marak D. Godley, George Dent, Lora Passetti, and Pamela Kelberg. 2001. The Adolescent Community Reinforcement Approach for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 4 (DHHS Pub. No. 01–3489). Rockville, Md.: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

Meyers, Robert J., and Daniel D. Squires. (N.d). The Community Reinforcement Approach: A Guideline Developed for the Behavioral Health Recovery Management Project. Chicago, Ill.: Illinois Department of Human Services, Office of Alcoholism and Substance Abuse.
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Program Snapshot

Age: 12 - 22

Gender: Both

Race/Ethnicity: Black, American Indians/Alaska Native, Hispanic, White, Other

Geography: Rural, Suburban, Urban

Setting (Delivery): Inpatient/Outpatient, Home, Other Community Setting

Program Type: Alcohol and Drug Therapy/Treatment, Aftercare/Reentry, Classroom Curricula, Community Awareness/Mobilization

Targeted Population: Alcohol and Other Drug (AOD) Offenders

Current Program Status: Active

Listed by Other Directories: National Registry of Evidence-based Programs and Practices

Mark Godley
Director of Lighthouse Institute
Lighthouse Institute, part of Chestnut Health Systems
448 Wylie Drive
Normal IL 61761
Phone: 309.451.7800
Fax: 309.451.7761

Natasha Slesnick
Ohio State University
135 Campbell Hall
Columbus OH 43210
Phone: 614.247.8469
Fax: 614.292.4365