Program Profile: Adolescent Community Reinforcement Approach (A-CRA)

This is a behavioral intervention for youth, which is designed to reduce drug and alcohol use and promote an abstinent lifestyle. The program is rated Promising. Participants showed a statistically significant reduction in alcohol use, other drug use, and depressive symptoms, and an increase in linkage to continuing care services, adherence to the continuing care model, and social stability. However, there was no statistically significant effect on high-risk behaviors or delinquency.

A Promising rating implies that implementing the program may result in the intended outcome(s).

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

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

A Promising rating implies that implementing the program may result in the intended outcome(s).

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

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

Program Goals/Target Population

The Adolescent Community Reinforcement Approach (A-CRA) is a behavioral intervention targeted to adolescents ages 12 and older, which seeks to replace structures supportive of drug and alcohol use with ones that promote an abstinent lifestyle. There are different protocols and guidelines depending on the population being served, but the overall goals of A-CRA are to reduce substance use and dependence, increase social stability, improve physical and mental health, and improve life satisfaction. 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 drug addiction or dealing with substance abuse issues.

Program Activities

Adolescents must first undergo a needs assessment and then complete a self-assessment on happiness and functioning in multiple areas. Based on these evaluations, therapists choose from 12 core and 7 optional A-CRA protocols that address problematic areas and emphasize prosocial behaviors, including problem-solving, stress-reducing, and anger-management skills; substance-abuse and relapse-prevention skills; and caregiver-relationship and communication skills. Role play and behavioral rehearsals are crucial elements of the skills training used in A-CRA. After therapy sessions, participants receive homework assignments where they practice skills learned during sessions and are encouraged to be part of positive leisure activities.

A-CRA is designed to include sessions with adolescents and parents/caregivers (separately and together) during the course of treatment. It has also been adapted for use with assertive continuing care, also known as aftercare, 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 youth experiencing homelessness.

Program Theory

A-CRA is derived from a social–ecological systems model (Bronfenbrenner 1979) in which behavioral trajectories and outcomes are believed to be the result of activities defined by or in response to the demands of specific social systems. This theory suggests that individuals—in this case, adolescents—behave in accordance with the settings or environments they inhabit, which include friends, family, and neighborhood. Based on this ecological framework, there are two ways to change negative behavior: 1) change the settings in which the individual conducts everyday activities, or 2) change the way the individual responds to influences from that particular setting (Slesnick et al. 2007). Thus, A-CRA is designed to remove youth from negative environments, such as living on the street or associating with substance-using peers, and place them in settings that promote healthy lifestyles and safe behavior.

Study

Godley and colleagues (2006) used a randomized block design to evaluate the effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), compared with usual continuing care (also known as aftercare), on participants’ early and sustained abstinence from substance use after discharge from a treatment facility in Illinois. To be eligible, participants had to meet the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) diagnosis of current alcohol or drug dependence, be between the ages of 12 and 17 years, and reside within one of the 11 targeted counties in Illinois. Potential participants were excluded if they left residential treatment within the first week, were a ward of the state child welfare department, were not returning to a targeted county after discharge, were considered to be a danger to themselves or others or displayed uncontrolled psychotic symptoms.

This resulted in a sample of 183 adolescents who gave consent and whose parents/caregivers gave consent, to be in the study. Of this sample, 71 percent were male, 73 percent were white, 18 percent were African American, and 9 percent were Hispanic or other; the mean age was 16.2 years. Most of the adolescents had prior involvement with the juvenile justice system (82 percent). All met the criteria for a substance use disorder, with many dependent on marijuana (87 percent) and alcohol (54 percent). Some were dependent on cocaine (15 percent) or other drugs (14 percent). Participants were assigned to one of two conditions: 1) the A-CRA treatment group, or 2) the usual continuing care (UCC) control group. There were no statistically significant differences on baseline demographic and clinical characteristics between the groups.

The treatment group, who received assertive continuing care (ACC) which included A-CRA, consisted of 98 adolescents. These participants received the same types of referrals to usual continuing care services, from their residential counselors, as participants assigned to the UCC condition. In addition, case managers provided 3 months of weekly home visits to youth and their caregivers to link participants to continuing care services. The control group, who received UCC, consisted of 78 adolescents. They received referrals to community outpatient substance abuse clinics; however, their UCC services varied, depending on how they were discharged. 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, at one of 12 treatment facilities in the 11-county target area.

The outcomes of interest were alcohol and other drug use, alcohol use, marijuana use, linkage to continuing care services, and high adherence to the criteria on the General Continuing Care Adherence (GCCA) Scale. Follow-up interviews occurred 3, 6, and 9 months after discharge (the CrimeSolutions review of this study focused on outcomes at the 9-month follow up). Abstinence from substance use was measured using the Global Appraisal of Individual Needs (GAIN) instrument and self-reporting. Urinalysis at intake and at the follow-up assessments was used to corroborate self-report data. Imbedded within the GAIN, the GCCA scale was based on an analysis of the common continuing care recommendations endorsed by 67 percent or more of the 12 UCC outpatient providers. These recommendations included regular attendance at weekly treatment and at weekly support meetings, receiving training in relapse prevention and communication skills, performing urine testing, having regular contact with school or work, and following up on referrals to other services.

An intent-to-treat analysis was conducted on the participants for whom there was data at baseline and for all three follow-up interviews, which comprised 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. Logistic regressions were used to predict abstinence during continuing care by both condition and high adherence to continuing care. The study authors conducted a subgroup analysis to examine abstinence during the fourth to ninth month after residential treatment discharge. They compared A-CRA participants who showed high adherence to the criteria on the GCCA Scale and had been abstinent during the first 3 months after discharge, with control group participants.

Study

Slesnick and colleagues (2007) conducted a randomized controlled trial of A-CRA with street-living youth experiencing homelessness from a drop-in center in Albuquerque, New Mexico. To be eligible for the study, participants had to be between the ages of 14 and 22, have lived in the Albuquerque metropolitan area for at least 3 months with plans to remain for at least 6 months, have met the criteria for homelessness as defined by the U.S. Department of Health and Human Services, and have met the DSM–IV diagnosis of having a substance disorder (alcohol or other drugs). Of the total sample of 180 youth, 41 percent were white, 30 percent were Hispanic, 13 percent were Native American, 3 percent were Black (3 percent), 1 percent were Asian, and 12 percent identified as other. Most participants were male (66 percent), and had an average age of 19.2 years. There were no statistically significant differences between groups in any demographic characteristics at baseline, except for the number of alcohol use diagnoses (participants in the control group had a higher number of positive diagnoses, using criteria for DSM-IV diagnoses, than participants in the treatment group). No statistically significant differences were found for any of the other main variables (substance use, individual differences) at baseline.

Adolescents were randomly assigned to receive either a usual care condition (control group) or usual care with A-CRA (treatment group). The control group consisted of 84 adolescents who received a place to rest during the day; access to food, clothing, washer and dryer, and showers; and case management services that linked youth with community resources, at their request. The treatment group included 96 adolescents who received 12 A-CRA therapy sessions and 4 HIV education/skills practice sessions in addition to usual care. Recruitment began in November 2001 and ended in February 2005. 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. Six-month assessments began in May 2002 and concluded in September 2005.

Outcomes of interest were alcohol and drug use, social stability, high-risk behavior, depression, and delinquency. The Form 90, developed by the National Institute on Alcohol Abuse and Alcoholism, was used to measure substance use. The percentage of days of alcohol and drug use was the primary dependent measure used in this study. Social stability was measured by the percentage of days in the period of work, education, being housed, and seen for medical care, as assessed on the Form 90. 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. The National Youth Survey Delinquency Scale and the Youth Self-Report were used to measure delinquent behavior.

Repeated measures analyses of variance (or ANOVAs), along with intent-to-treat analyses, 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. The study authors conducted subgroup analyses to examine differences in treatment effect by age, gender, and ethnicity.

Subgroup Analysis

With regard to subgroup findings, Godley and colleagues (2006) conducted a subgroup analysis to predict the odds ratios between groups on abstinence during the fourth to ninth month after residential treatment discharge. Compared with control group participants, A-CRA participants (who had high adherence to the criteria on the GCCA and abstinence during the first 3 months after discharge) were 11 times more likely to remain abstinent from alcohol or drug use, more than 5 times more likely to remain abstinent from alcohol use, and 11 times more likely to remain abstinent from marijuana use. These differences were statistically significant.

In addition, Slesnick and colleagues (2007) conducted a subgroup analysis to examine differences in treatment effect by age, gender, and ethnicity. They divided participants into two age groups: younger (up to 19 years, mean age of 17.61 years) and older (20 years and older, mean age of 21.02 years). Results showed that both age groups showed a statistically significant decrease in depression over time. No statistically significant differences were reported for treatment effect by gender or ethnicity on any other outcome measures.

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

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, Pamela Kelberg. 2001. The Adolescent Community Reinforcement Approach for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 4. Rockville, Md.: U.S. Department of Health and Human Services, 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.

Bronfenbrenner, Urie. 1979. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, Mass.: Harvard University Press.

Dennis, Michael L., M. White, and M.I. Ives. 2009. “Individual Characteristics and Needs Associated with Substance Misuse of Adolescents and Young Adults in Addiction Treatment.” In Carl Leukefeld, Tom Gullotta, and Michele Staton Tindall (eds.). Handbook on Adolescent Substance Abuse Prevention and Treatment: Evidence-Based Practice. New London, Conn.: Child and Family Agency Press, 45–72.

Smith, Douglas C., Susan H. Godley, Mark D. Godley, and Michael L. Dennis. 2011. “Adolescent Community Reinforcement Approach (A-CRA) Outcomes Differ Among Emerging Adults and Adolescents.” Journal of Substance Abuse Treatment 41(4):422–30.