Possible effectiveness of intervention using a self-teaching workbook in adolescent drug abusers detained in a juvenile classification home
Toshihiko Matsumoto, MD, PhD, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8553, Japan. Email: email@example.com
Aims: The purpose of the present study was to examine whether the possible effectiveness of the juvenile version of the Serigaya Methamphetamine Relapse Prevention Program (SMARPP-Jr.) self-teaching workbook we developed for relapse prevention of drug abuse depends on the severity of the subject's drug-related problems.
Methods: Subjects were 85 adolescent drug abusers who were detained in a juvenile classification home. We compared changes between the subjects' scores on rating scales administered both before and after interventions with the self-teaching workbook, and we examined associations between the effectiveness of the intervention and the severity of the subjects' drug-related problems.
Results: Regardless of the severity of their drug-related problems, the subjects' rating scale scores were significantly different after the intervention, which suggests that use of the workbook increased their awareness of the problems caused by drug dependence and their motivation to obtain treatment. However, use of the workbook did not significantly change their confidence in their capacity to resist drug craving.
Conclusion: Although the self-teaching workbook is a convenient intervention tool that can increase subject awareness and motivation for treatment, it is likely that continuous community-based support systems are required to prevent relapse.
MANY JUVENILE DRUG abusers in Japan are treated in judicial institutions, such as juvenile classification homes and juvenile training schools, rather than in psychiatric institutions. However, during their treatment in juvenile classification homes they receive little systematic education in how to prevent the recurrence of drug abuse, although juvenile training schools do provide this type of education as a part of remediation. The reason for this is that the adolescents in juvenile classification homes have not yet had a hearing in family court, and no court decision has been reached regarding whether they are a delinquent or guilty of a crime. In other words, similar to adults who are detained, they are still presumed to be innocent. As such, education in preventing drug relapse may draw criticism by the youths' attendants as a violation of their human rights, even if it is intended to benefit the youth. Additionally, the only function that juvenile classification homes are expected to perform is to assess delinquency and criminality, and some judicial professionals are concerned that remediation during the classification period may mask the true picture of the adolescents' behavior.
Nevertheless, from a mental health perspective, juvenile classification homes are an ideal place to provide an early intervention for juvenile drug abusers. Many drug-abusing adolescents can be treated in juvenile classification homes because of the wide spectrum of their residents. The residents of these facilities range from adolescents in the early stage of drug abuse who will be given a community-based penalty, such as tentative probationary supervision or probation, to those who are seriously addicted to drugs and who will be placed in juvenile training schools. Because the inventions occur soon after their arrests, it is easier for these adolescents to concentrate on the tasks provided during an intervention in a classification home. Moreover, the detainees are under stress while waiting for the judges' decision, and the classification home provides them with a tranquil environment removed from their relationships with drugs and drug abusers.
Based on this premise, with the cooperation of the director general of the institution, we previously conducted interventions for adolescents with drug-related problems in a juvenile classification home using a self-teaching workbook. We found that the workbook helped the adolescent drug abusers to deepen their understanding of their own drug-related problems and to become aware of the need to obtain help.1 Our studies using interventions with the juvenile version of the Serigaya Methamphetamine Relapse Prevention Program (SMARPP-Jr.)1 workbook represent the first intervention research to assess the possible effectiveness on drug abuse and dependence of an intervention that only uses a self-teaching workbook, although a study in the USA2 reported that a comprehensive intervention for alcohol abusers, including a self-teaching workbook, was effective. It is important to note that in our previous studies we did not determine whether the possible effectiveness of an intervention using the self-teaching workbook depended on the severity of the subjects' drug-related problems.
The purpose of the present study was to examine whether there is an association between the severity of the subjects' drug-related problems and the possible effectiveness of a self-teaching workbook.
During the 24-month period from January 2009 to December 2010, 2078 adolescents (1829 boys and 249 girls) were detained in a juvenile classification home ‘A.’ Irrespective of the alleged delinquency or crime for which they were taken into custody, those who met three criteria were selected as candidates for participation in this study. The criteria used were: (i) the initial medical examination by the attending physician revealed a history of illicit drug abuse; (ii) the initial medical examination resulted in a diagnosis of ‘harmful use’ or ‘dependence’ syndrome according to the ICD-103 or ‘F1: Mental and behavioral disorders because of psychoactive substance use;’ and (iii) the physician concluded that the adolescent had sufficient mental and linguistic capacities to use the workbook.
Of the adolescents detained during the period of the study, 98 met the above criteria and all 98 were asked to participate in the study. Of these 98 adolescents, 89 subjects agreed to participate but four did not complete the workbook. As such, 85 (56 boys, 29 girls) adolescents participated in this study. Their ages ranged from 14 to 19 years, and their mean age (±SD) was 17.4 (±1.3) years. The drugs that the adolescents most frequently abused immediately prior to their detainment were cannabis (48.2%), methamphetamine (18.8%), toluene (15.3%), butane gas (14.1%), ketamine (2.4%), and 3,4-methylenedioxymethamphetamine (MDMA; 1.2%).
The self-teaching workbook used in the present study was prepared by simplifying the Serigaya Methamphetamine Relapse Prevention Program (SMARPP) workbook that we previously used in a comprehensive outpatient drug-dependence treatment program.4 The SMARPP workbook, which is based on the Matrix model5 used in the USA, is simplified by consultations with the staff of a juvenile classification home, and it is called SMARPP-Jr.1 The SMARPP-Jr. workbook consists of 12 parts that are designed to provide psychoeducation on drug abuse and dependence, training in coping skills for drug cravings, and resource information for recovering from drug abuse and dependence. If the subject completes one part per day, the entire workbook can be completed within the typically 2–3-week period of detention in a classification home.
Drug Abuse Screening Test, 20 items
The Drug Abuse Screening Test, 20 items (DAST-20) is a 20-item self-administered rating scale that was developed to screen for abuse of illicit and medicinal drugs.6 The Japanese version was prepared by the Hizen Psychiatric Center.7 This version was used in this study to assess the baseline severity of participants' drug-related problems prior to the intervention. Based on scores that can range from 0 to 20, the Japanese version of the DAST-20 is used to classify the severity of problems into the following five levels: ‘None’ (0 points), ‘Low’ (1–5 points), ‘Intermediate’ (6–10 points), ‘Substantial’ (11–15 points), and ‘Severe’ (16–20 points). However, because they were adolescents, we expected the subjects of this study would have had a relatively short history of drug abuse. Accordingly, we classified them into the following three groups based on their scores: ‘low dependence’ (1–5 points), ‘moderate dependence’ (6–10 points), and ‘high dependence’ (11–20 points).
Although the Japanese DAST-20 has not yet been standardized, the scale has been widely used in Japan7,8 because the items are phrased to ask about the presence or absence of psychosocial issues related to drug abuse. Therefore, the items have obvious face validity (i.e., the literal description of each item reflects the concept measured by the item).
Self-efficacy Scale for Drug Dependence
The Self-efficacy Scale for Drug Dependence (SSDD) consists of two parts and is an original self-administered rating scale that was developed and shown to be both valid and reliable by Morita and colleagues.9 It measures the degree of confidence (i.e. self-efficacy) a subject has in their ability to cope with drug cravings. The first part consists of five questions regarding general self-efficacy that transcends specific situations, and responses are made on a 5-point scale from 1 (not true for me) to 5 (true for me). The second part consists of 11 questions that ask about subjects' degree of confidence in their ability to refrain from abusing drugs in specific situations. It asks about situations such as ‘being tempted to use drugs’ and responses are made on a 7-point scale from 1 (not at all confident) to 7 (absolutely confident). We administered this scale before and after the intervention, and we compared changes in the total scores on the ‘General Self-efficacy’ and ‘Situation-specific Self-efficacy’ subscales and on the entire scale.
Stages of Change Readiness and Treatment Eagerness Scale
The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) is a self-administered rating scale consisting of 19 items. It was developed by Miller and Tonigan10 to assess a subject's awareness of problems caused by alcohol or drug dependence and their degree of motivation for treatment. The questions in the English version have a three-factor structure composed of ‘Recognition’ (Questions 1, 3, 7, 10, 12, 15 and 17), ‘Ambivalence’ (Questions 2, 6, 11 and 16), and ‘Taking Steps’ (Questions 4, 5, 8, 9, 13, 14, 18 and 19). Subjects with high scores in Recognition are considered to be acknowledging that they are having problems related to drug abuse and that they need to change their behavior because various harmful effects will occur if they continue to abuse drugs. Subjects with high scores in Ambivalence are indicating that they sometimes wonder whether they are in control of their drug abuse, are hurting other people, are an addict, or all three. Subjects with high scores in Taking Steps are indicating that they are already doing things to make positive changes regarding their drug problem or want help making these changes. Indeed, there is a positive correlation between total SOCRATES scores and the development of readiness for treatment,11 and subjects with higher scores were found to remain in treatment longer in a short-term intervention that was conducted with poorly motivated drug abusers.12
The Japanese version of the SOCRATES-8D is specifically designed for drug abusers and was prepared by one of the authors (O. Kobayashi) by back-translation. The Japanese version was used to assess the adolescents before and after the workbook intervention. Although the Japanese version has not gone through a standardization process, each item has high face validity. Moreover, since we have previously demonstrated that the scale has excellent internal consistency (Cronbach's alpha = 0.798),1 we compared the total SOCRATES-8D scores obtained before and after the intervention. Because the internal consistency of the individual sub-scales has not been established, the results for the sub-factors (Recognition, Ambivalence, and Taking Steps) are presented for reference purposes only.
This study was conducted at the discretion of the director of juvenile classification home ‘A’ as a part of the home's regular duties to ‘provide information to promote healthy youth development.’ The procedure was as follows.
Based on the initial examination by the attending physician at the home, adolescents who met the previously described criteria were selected as candidates. The physician proposed that they use the workbook by saying, ‘You have problems with drugs. Why don't you take this opportunity to learn about them?’ At the same time, the physician explained that ‘it is not compulsory, and whether or not you use the workbook will not affect your treatment.’ Once participants consented to use the workbook, they were immediately asked to fill out the DAST-20, SSDD, and SOCRATES (baseline assessment). They were asked to give their written consent after it was explained to them that signing the response sheet would be regarded as their formal consent to use the workbook.
The participants used the self-teaching workbook in their own room and at their own pace. Those who completed the workbook were immediately asked to fill out the SSDD and SOCRATES (post-intervention evaluation). These materials were distributed and collected by the attending physician, who was not involved in the subjects' classification or daily treatment.
The scores on the scales described above were anonymized in a linkable fashion (by the director of the medical section of the home, Chiba). The first author of this study was given the anonymized scores and analyzed the data. The Ethics Committee of the National Center of Neurology and Psychiatry approved all procedures, analyses, and publications.
The subjects were divided into three groups based on their DAST-20 scores. Changes in scores on the rating scales administered before and after the self-teaching workbook intervention were compared between the groups using the Wilcoxon signed-rank test. Continuous variables among the three groups were compared using one-way anova. If the one-way anova found a significant main effect, a Bonferroni's post-hoc test was performed to identify significant differences between any of the groups. All statistical analyses were performed using spss for Windows version 17.0 (SPSS, Chicago, IL, USA), and the significance level was set at P < 0.05, two-tailed.
The DAST-20 scores of the 46 participants ranged from 1 to 18 points, and the mean score [±SD] was 5.64 [±3.41] points. Based on their DAST-20 scores, we placed 46 of the 85 (54.1%) participants into the ‘low-dependence’ group, 28 (32.9%) participants into the ‘moderate-dependence’ group, and 11 (12.9%) participants into the ‘high-dependence’ group.
Table 1 shows the total scores of the three groups on each of the two drug dependence scales prior to the workbook intervention. There was a significant ifference among the three groups in the SSDD (P < 0.001). A Bonferroni post-hoc test revealed that the low-dependence group (P = 0.002) and the moderate-dependence group (P = 0.009) had significantly higher scores on the scale than the high-dependence group.
Table 1. Comparison of the scores on the SSDD and SOCRATES-8D rating scales according to the severity of the subject's drug-related problems
|SSDD (±SD)||95.83 ± 9.691||83.71 ± 20.777||76.00 ± 25.43.6||8.765 (2, 82)||*P < 0.001|
|SOCRATES-8D, total score (±SD)||63.57 ± 9.050||67.61 ± 12.294||70.18 ± 9.261||2.53 (2, 82)||P = 0.086|
Table 2 shows the mean rating scale scores before and after the intervention. After the workbook intervention, the total scores on the SSDD (P = 0.044) and the scores for the ‘Situation-specific Self-efficacy’ sub-factor (P = 0.008) were significantly higher than before the intervention. However, no significant change was observed in the ‘General Self-efficacy’ sub-factor. In addition, the total SOCRATES-8D scores (P < 0.001) were significantly higher after the intervention. Furthermore, although reported for reference only, there were significant increases in the scores for the Recognition (P < 0.001), Ambivalence (P = 0.006), and Taking Steps (P < 0.001) sub-factors.
Table 2. Comparison between scores on the SSDD and SOCRATES-8D rating scales before and after the intervention (n = 85)
|SSDD||General self-efficacy score||22.48||3.83||22.33||4.59||1.146||0.252|
|Situation-specific self-efficacy score||66.79||14.60||69.44||10.44||2.654||0.008|
Table 3 shows the mean rating scale scores before and after the intervention for each of the three groups that were classified according to the severity of their drug-related problems. In the low-dependence group, the increase in scores for the ‘Situation-specific Self-efficacy’ sub-factor was statistically significant (P = 0.034), but there was no significant change in total scores on the SSDD. In contrast, the total SOCRATES-8D scores were significantly higher (P < 0.001). Although reported for reference only, scores for the Recognition (P = 0.001) and Taking Steps (P < 0.001) sub-factors were also significantly higher. In the moderate-dependence group, no significant increases were observed in the total scores on the SSDD and the scores for the sub-factors. However, the total SOCRATES-8D scores (P = 0.010) and the scores for the Taking Steps sub-factor (P = 0.003) were significantly higher. In the high-dependence group, no significant increases were observed in the total scores on the SSDD, although the scores for the ‘Situation-specific Self-efficacy’ sub-factor were significantly higher (P = 0.045). Additionally, the total SOCRATES-8D scores (P = 0.011) and the scores for the Recognition sub-factor (P = 0.016) were significantly higher.
Table 3. Mean scores before and after the intervention on the SSDD and SOCRATES-8D rating scales according to the severity of the subject's drug dependence
|Low (n = 46)||SSDD||General self-efficacy score||23.67||2.49||23.52||3.54||1.139||0.255|
|Situation-specific self-efficacy score||72.15||7.88||74.65||3.40||2.124||0.034|
|Medium (n = 28)||SSDD||General self-efficacy score||21.43||4.16||20.75||5.00||0.290||0.977|
|Situation-specific self-efficacy score||62.29||16.95||63.79||14.55||0.634||0.526|
|High (n = 11)||SSDD||General self-efficacy score||20.18||5.74||21.36||4.95||1.194||0.233|
|Situation-specific self-efficacy score||55.82||20.33||62.00||17.79||2.003||0.045|
The present study using interventions with the SMARPP-Jr.1 workbook is unique in that it is an intervention study that addresses drug-related problems at a juvenile institution. Although many juvenile institutions have offered remediation services to young drug abusers in Japan, to our knowledge, there have been no reports on the effectiveness of such interventions. This situation may be similar in other countries as the only academic article on the effectiveness of intervention to treat drug abuse at juvenile institutions that we could retrieve from the scientific literature concerned ‘physical training.’13 The fact that the present study included interventions for drug-related problems at a juvenile classification home where remediation is not mandated makes this study especially significant. In particular, 85 of the 89 adolescents who consented to participate in this study completed the nearly 50-page workbook. It is doubtful whether such a high completion rate would be obtained if similar interventions were implemented in another setting.
In the present study, a self-teaching workbook was assessed as an intervention tool for drug abusers detained in a juvenile classification home. Consistent with the results of our previous study using the same workbook,1 there was a significant increase in the total scores on the SSDD and a particularly prominent increase in SOCRATES-8D scores. These results appear to confirm that the self-teaching workbook more effectively increased the participants' awareness of problems and motivation for treatment (‘my problem is more serious than I thought it was’, ‘I need to get some help’) than their confidence in their ability to resist drug cravings (‘I can say no if someone asks me to take drugs’).
In the present study, we also examined whether the possible effectiveness of an intervention with the self-teaching workbook differed depending on the severity of abusers' drug-related problems. The marked increases in SOCRATES-8D scores did not differ between each of the three severity groups. Moreover, no significant changes were observed in the total scores on the SSDD in any group. As such, we suggest that our self-teaching workbook may be effective in increasing awareness of problems and motivation for treatment regardless of the severity of drug-related problems.
We believe that the changes in rating scale scores observed in each of the three groups indicate possible effectiveness of the brief intervention in adolescent drug abusers. In our clinical experience, high self-efficacy regarding drug dependence is often coupled with a subject underestimating the magnitude of their problem with drugs by tending to think ‘my problem is not that serious.’ Hence, deepening their awareness of their problems and increasing their motivation for treatment, rather than raising self-efficacy, could make remediation after transfer to a juvenile training school more effective. Moreover, it could make adolescents more likely to attend the clinic of a specialized medical institution in their community. Alternatively, adolescents gaining a deeper awareness of their problems may independently play a role in preventing a return to drug abuse.
Nevertheless, we need to consider the reasons why none of the three groups showed a significant increase in total scores on the SSDD. Although our workbook consists of many elements of cognitive behavior therapy that assist subjects to cope with drug cravings, using the workbook alone may not be a sufficient intervention for drug-abusing adolescents. As such, there remains a need for resources to support them in the community after their release from the juvenile classification home.
Although a need for community support remains, supporting adolescent drug abusers in their community is very difficult because there are no support resources for teenage drug abusers in Japan. As general psychiatry departments and child psychiatry departments are unable to provide useful support resources, teenage drug abusers are often referred to a psychiatric institution that specializes in drug dependence, and few psychiatric institutions that specialize in drug dependence have prepared treatment programs for teenage drug abusers. Indeed, several attempts to provide such a treatment program have been previously undertaken. The Hizen Psychiatric Center implemented an early intervention program that consisted of a series of three outpatient visits.7 Moreover, in collaboration with the Fukuoka Bar Association, inpatient treatment was provided for adolescents who were under tentative probationary supervision.14 Nevertheless, these interventions are limited because specialized psychiatric institutions are rare. Private rehabilitation facilities, such as the Drug Addiction Rehabilitation Center (DARC), are also rare. Meetings attended by large numbers of adult drug addicts are not always a comfortable treatment environment for adolescent drug abusers, especially for adolescents who have engaged in only minor drug abuse.
Based on the present situation, interventions that are conducted using a self-teaching workbook and in a juvenile classification is a realistic and efficient method of treatment because these homes house many and exclusively juvenile drug abusers, and this method does not require specialized human resources. Furthermore, this workbook can be used at a variety of institutions that deal with adolescent drug-related problems, including general psychiatric hospitals, juvenile training schools, and Family Courts. To make the SMARPP-Jr. self-teaching workbook available for use in a wide range of institutions, we will continue to develop it by further investigating its effectiveness and revising it based on our findings.
Finally, the present study contains three particularly important limitations. First, there was no control group. Thus, the possibility that the effects observed in this study are attributable to spontaneous changes that result from detention in a juvenile classification home cannot be excluded. Second, similar to the first limitation, responses on the self-administered rating scales may have been influenced by the subjects' status as detainees in a juvenile classification home awaiting a judicial decision. However, it was explained to them that their responses on the scales were totally independent of any decisions regarding their treatment or the decision of the court. Third, the dependent measures of this study were changes in scores on rating scales following an intervention. These measures represent a proxy for actual changes in behavior, such as a recurrence of drug abuse or use of support organizations in the community. Accordingly, the correlation between changes in scores on these rating scales and actual utilization of support resources or recurrence of drug abuse should be further investigated by outcome studies.
Despite these limitations, the present study is a valuable contribution to our understanding of relapse prevention because it is the first research to examine whether there is a correlation between the possible effectiveness of interventions that exclusively use a self-teaching workbook to attenuate substance abuse and dependence and the severity of drug-related problems.
This study has been supported by a Health Labour Research Grant by the Ministry of Health and Welfare, Research on Pharmaceutical and Medical Regulatory Science ‘A study on epidemiology of drug abuse and dependence, and social resources for relapse prevention’ (principal investigator, Wada K.).