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Adolescent Community Reinforcement Approach (A-CRA)

Topic Areas
Scientific Rating
Child Welfare Relevance
Substance Abuse Treatment (Adolescent)
2  — Supported by Research Evidence
Medium

About This Program

Target Population: Adolescents aged 12 to 25 with substance abuse issues

For children/adolescents ages: 12 – 25

For parents/caregivers of children ages: 12 – 25

Program Overview

A-CRA is a behavioral intervention that seeks to increase the family, social, and educational/vocational reinforcers of an adolescent to support recovery from substance abuse and dependence. The manual outlines an outpatient program that targets youth 12-25 years old with Diagnostic and Statistical Manual of Mental Disorders (DSM-5) cannabis, alcohol, and/or other substance use disorders. A-CRA also has been implemented in intensive outpatient and residential treatment settings. A-CRA includes guidelines for three types of sessions: adolescents alone, caregivers alone, and adolescents and caregivers together. According to the adolescent's needs and self-assessment of happiness in multiple areas of functioning, therapists choose from among 17 A-CRA procedures that address, for example, problem-solving skills to cope with stressors, communication skills, and participation in positive social and recreational activities with the goal of improving life satisfaction and eliminating substance use problems. The adult model, Community Reinforcement Approach (CRA), has also been rated by the CEBC.

Program Goals

The goals of the Adolescent Community Reinforcement Approach (A-CRA) are:

  • Promote abstinence from alcohol, marijuana, and other drugs
  • Promote positive social activity
  • Promote positive peer relationships and improved relationships with family
  • Motivate caregiver participation in the A-CRA treatment process
  • Promote the caregiver's support of the adolescent's abstinence from alcohol, marijuana, and other drugs
  • Provide information to the caregiver about effective parenting practices
  • Help the adolescent and caregiver(s) create a home and community environment conducive to recovery
  • Teach the adolescent problem-solving, communication, and other important skills through the use of role-playing

Logic Model

The program representative did not provide information about a Logic Model for Adolescent Community Reinforcement Approach (A-CRA).

Essential Components

The essential components of the Adolescent Community Reinforcement Approach (ACRA) include:

  • A toolbox of different procedures that clinicians are trained to use as appropriate with a participant
  • Flexibility by the clinician to decide when and if to use procedures
  • The procedures are:
    • Overview of A-CRA: Used during the initial session to describe the basic objective of the intervention and duration; includes an outline of procedures, sets positive expectations, and begins to identify the adolescent's reinforcers
    • Functional Analysis of Substance Use: Based on a description of a common episode/behavior, internal and external triggers are outlined, using/non-using behaviors are clarified, positive and negative consequences of the behavior are clarified, and examples of how the information would be used are discussed
    • Functional Analysis of Pro-Social Behavior: Based on a description of a common episode/behavior, internal and external triggers are outlined, the pro-social behavior is clarified, positive and negative consequences of the behavior are outlined, and examples of how the information would be used are discussed
    • Happiness Scale: The adolescent rates various areas of their life on a scale from 1 to 10 and the ratings are reviewed in order to help learn about the adolescent, learn what is going well in their life, and identify areas that might be appropriate for goal setting to improve their life
    • Treatment Plans/Goals of Counseling: The Happiness Scale is used to select a goal category and set a goal using guidelines (must be brief, positive, specific, and within the adolescent's control), and progress of goals set is reviewed in subsequent sessions
    • Increasing Pro-Social Recreation: The importance of a satisfying social life is discussed and new activities to sample are identified through use of problem-solving skills or a functional analysis of pro-social behavior
    • Systematic Encouragement: After an activity is identified (e.g., adolescent wants to become a member of the YMCA), appropriate questions are identified (e.g., cost, times facility is open), role-plays (e.g., phone call to the YMCA) are done, and an initial contact is made during the session, the experience is reviewed during the next session
    • Drink/Drug Refusal Skills: Includes enlisting social support, reviewing high-risk situations, presenting/reviewing options for assertive refusal, and role-playing refusal skills
    • Relapse Prevention: Includes administering the functional analysis for relapse, discussing the behavioral chain of events, and describing and setting up an early warning system
    • Sobriety Sampling: Includes negotiating a reasonable period of sobriety, developing a specific plan for maintaining sobriety until the next session, developing a back-up plan, and reminding the adolescent of reinforcers for sobriety
    • Communication Skills: Includes a discussion of why positive communication is important, a description/review of the three positive communication elements, and role-plays to practice skills
    • Problem-Solving Skills: Includes problem definition, brainstorming possible solutions, eliminating undesired suggestions, selecting a potential solution to try, generating and addressing possible obstacles, and deciding on a related homework assignment to be reviewed at the following session
    • Caregiver Overview, Rapport Building, and Motivation: Begins with an overview of A-CRA, sets positive expectations, reviews research regarding parenting practices for adolescent recovery, and keeps the discussion about the adolescent positive
    • Adolescent-Caregiver Relationship Skills: Includes the use of several activities to help improve the relationship between the adolescent and the caregiver(s)
    • Homework: To reinforce skills learned during sessions, adolescents and their clinician decide on a homework assignment, discuss anticipated obstacles, and review the homework at the start of the next session, where the clinician assesses the outcome, modifies the plan if necessary, and provides reinforcers
    • Job-Seeking Skills: Uses multiple strategies to teach the adolescent how to obtain and maintain a job
    • Anger Management Skills: Includes the identification of reinforcers to manage anger, assistance in recognizing anger, and techniques to manage anger.

Program Delivery

Child/Adolescent Services

Adolescent Community Reinforcement Approach (A-CRA) directly provides services to children/adolescents and addresses the following:

  • Substance abuse and dependence and other areas derived from the adolescent's happiness scale

Parent/Caregiver Services

Adolescent Community Reinforcement Approach (A-CRA) directly provides services to parents/caregivers and addresses the following:

  • Has an adolescent with substance abuse and dependence issues

Recommended Intensity:

Once per week for 50-90 minutes. It is not unusual for family sessions to last up to 90 minutes.

Recommended Duration:

Three months, although duration can be extended depending on individual need.

Delivery Settings

This program is typically conducted in a(n):

  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

Adolescent Community Reinforcement Approach (A-CRA) includes a homework component:

Each session ends with a homework assignment that pertains to the subjects discussed during the session. Each session begins with the review of the previous session's homework assignment.

Languages

Adolescent Community Reinforcement Approach (A-CRA) has materials available in languages other than English:

Dutch, French, Portuguese, Spanish, Swedish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Office space
  • Digital recorder
  • Computer/internet access
  • Personnel willing to complete the certification process

Manuals and Training

Prerequisite/Minimum Provider Qualifications

In general, clinicians should have at least a Bachelor's degree in a clinical field, but those with Master's degrees and more clinical experience, especially in cognitive behavioral approaches, may have better preparation to learn the model. The quality of a clinician's general counseling skills (e.g., empathy, genuineness, etc.) and their willingness to learn a manualized approach, record their sessions, and receive and respond to feedback on their performance are critical to achieving model certification. Those pursuing certification as clinical supervisors in the model should have a Master's degree.

Manual Information

There is a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contacts:
Training Type/Location:

Training is provided for both clinicians and supervisors via in-person and online formats. It is expected that each clinician will work with a supervisor who is pursuing certification or is already certified as a supervisor in the model, followed by a certification process that requires uploading digital recordings to a secure website for expert review and feedback, and attending cross-site coaching calls. Once a supervisor achieves certification, it is possible to train and certify clinicians at his/her own site with verification from Chestnut Health Systems.

Number of days/hours:

The initial training is 15 hours. The certification process requires recording treatment sessions (so this occurs during actual treatment hours); the average coaching and feedback review time is 14 hours. So on average, basic certification is 42 hours. After individuals have made progress in certification, additional training workshops are available for training in how to use the procedures to address other co-occurring disorders and for supervisors.

Additional Resources:

There currently are additional qualified resources for training:

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Adolescent Community Reinforcement Approach (A-CRA) as listed below:

Chestnut Health Systems has EBT Coordinators available to discuss possible implementation of A-CRA with interested organizations and individuals. After an organization or individual expresses interest in learning the intervention, the EBT Coordinator will make contact and learn more about the organization or individual so that they can make recommendations regarding training. Once an organization makes a decision to proceed with training, orientation calls may be conducted with each site to review certification requirements for clinicians and supervisors. To contact an EBT Coordinator, an organization or individual can e-mail ebtxquestions@chestnut.org.

Formal Support for Implementation

There is formal support available for implementation of Adolescent Community Reinforcement Approach (A-CRA) as listed below:

An EBT Coordinator is designated to work with each agency and is available by phone and email to address any questions from clinicians, supervisors, or management regarding the certification process, coaching, or the website. In addition to follow-up email communication, the EBT Coordinator makes post-training site implementation calls 4- 6 weeks after initial A-CRA training to review early implementation decisions and paperwork and answer site questions.

Implementing staff will participate in bimonthly telephone coaching calls for clinicians and supervisors who are working towards certification. The calls are led by an A-CRA expert. These coaching calls focus on addressing any questions clinicians, supervisors, or management have regarding the use of A-CRA and helping them learn how to implement the interventions with high fidelity; the calls can also involve a special topic or sharing of ideas with other sites implementing A-CRA. Individual coaching calls are available to trainees in need of extra assistance throughout the certification process. A-CRA Progress Reports are sent every month to the site's Project Director or assigned A-CRA specialist. These reports are based on the site's progress with A-CRA.

Fidelity Measures

There are fidelity measures for Adolescent Community Reinforcement Approach (A-CRA) as listed below:

There is an A-CRA checklist and a rating manual. Currently, the rating manual is only provided to individuals who have been trained as expert raters and/or certified A-CRA clinical supervisors.

  • The citation for the checklist is: Smith, J. E., & Meyers, R. J. (2006). The Adolescent Community Reinforcement Approach (A-CRA) procedures checklist. Albuquerque, NM: University of New Mexico.
  • The citation for the manual is: Smith, J. E., Lundy, S. L., & Gianini, L. (2007). Community Reinforcement Approach (CRA) and Adolescent Community Reinforcement Approach (A-CRA) therapist coding manual. Bloomington, IL: Chestnut Health Systems. Contact ebtxquestions@chestnut.org if interested in purchasing the rating manual.

The following article describes the training for A-CRA raters: Garner, B. R., Barnes, B. N., & Godley, S. H. (2009). Monitoring fidelity in the Adolescent Community Reinforcement Approach (A-CRA): The training process for A-CRA raters. Journal of Behavior Analysis in Health, Sports, Fitness, and Medicine, 2(1), 43-54.

Implementation Guides or Manuals

There are implementation guides or manuals for Adolescent Community Reinforcement Approach (A-CRA) as listed below:

Sites implement by participating in a well-defined training and certification process, which is described on the A-CRA website (http://ebtx.chestnut.org/Treatments-and-Research/Treatments/A-CRA) and in the following manuscript: Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J., & Godley, M. D. (2011). A large-scale dissemination and implementation model for evidence-based treatment and continuing care. Clinical Psychology: Science and Practice, 18(1), 67-83.

Research on How to Implement the Program

Research has been conducted on how to implement Adolescent Community Reinforcement Approach (A-CRA) as listed below:

  • Garner, B. R., Godley, S. H., Funk, R. R., Dennis, M. L., Smith, J. E., & Godley, M. D. (2009). Exposure to Adolescent Community Reinforcement Approach treatment procedures as a mediator of the relationship between adolescent substance abuse treatment retention and outcome. Journal of Substance Abuse Treatment, 36, 252-264. doi:10.1016/j.jsat.2008.06.007
  • Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J., & Godley, M. D. (2011). A large-scale dissemination and implementation model. Clinical Psychology: Science and Practice, 18, 67-83. doi:10.1111/j.1468-2850.2011.01236.x
  • Hunter, B. D., Godley, M. G., & Godley, S. H. (2014). Feasibility of implementing the Adolescent Community Reinforcement Approach in school setting for adolescents with substance use disorders. Advances in School Mental Health Promotion, 7(2), 105-122.
  • Campos-Melady, M., Smith, J.E., Meyers, R. J., Godley, S. H., & Godley, M. D. (2017). The effect of therapists' adherence and competence in delivering the Adolescent Community Reinforcement Approach on client outcomes. Psychology of Addictive Behaviors, 31(1), 117-129.
  • Godley, M. D., Passetti, L. L., Subramaniam, G. A., Funk, R. R., Smith, J. E., & Meyers, R. J. (2017). Adolescent Community Reinforcement Approach implementation and treatment outcomes for youth with opioid problem use. Drug and Alcohol Dependence, 174, 9-16. doi:10.1016/j.drugalcdep.2016.12.029

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

When more than 10 research articles have been published in peer-reviewed journals, the CEBC selects 10 for inclusion, with a preference for randomized controlled trials (RCTs) and controlled studies. The 10 articles chosen for the Adolescent Community Reinforcement Approach (A-CRA) are listed below:

Dennis, M. L., Godley, S. H., Diamond, G. S., Tims, F. M., Babor, T., Donaldson, J., & Funk, R. R. (2004). The Cannabis Youth Treatment (CYT) study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197-213. doi:10.1016/j.jsat.2003.09.005

Type of Study: Randomized controlled trial
Number of Participants: 600

Population:

  • Age — 13-18 years
  • Race/Ethnicity — 61% Caucasian/White, 30% African American/Black, 4% Hispanic/Latino, and 6% Other/Mixed
  • Gender — 83% Male
  • Status — Participants were adolescents and their families were recruited from sequential admissions to 4 treatment sites.

Location/Institution: Farmington, CT/University of Connecticut Health Center, Madison County, IL/Chestnut Health Systems, Philadelphia, PA/Children's Hospital of Philadelphia, and St. Petersburg, FL/Operation PAR

Summary: (To include basic study design, measures, results, and notable limitations)
This article presents the main outcome findings from two interrelated randomized trials conducted at 4 sites to evaluate the effectiveness of 5 short-term outpatient interventions for adolescents with cannabis use disorders. Trial 1 compared 5 sessions of Motivational Enhancement Therapy plus Cognitive Behavioral Therapy (MET/CBT5) with a 12-session regimen of MET and CBT (MET/CBT12) and another that included family education and therapy components (Family Support Network [FSN]). Trial II compared the 5-session MET/CBT with the Adolescent Community Reinforcement Approach (A-CRA) and Multidimensional Family Therapy (MDFT). All 5 Cannabis Youth Treatment (CYT) interventions demonstrated significant pre-post treatment improvements during the 12 months after random assignment to a treatment intervention in the 2 main outcomes: Days of abstinence, as measured by self-reports using Global Appraisal of Individual Needs (GAIN) (a standardized semi-structured interview), and the percent of adolescents in recovery (no use or abuse/dependence problems and living in the community). Overall, the clinical outcomes were very similar across sites and conditions. Limitations include its reliance on participant self-report and the lack of a no-treatment control group.

Length of controlled postintervention follow-up: 38-46 weeks.

Slesnick, N., Prestopnik, J. L., Meyers, R. J., & Glassman, M. (2007). Treatment outcome for street-living, homeless youth. Addictive Behaviors, 32, 1237-1251. doi:10.1016/j.addbeh.2006.08.010

Type of Study: Randomized controlled trial
Number of Participants: 180

Population:

  • Age — 14-22 years
  • Race/Ethnicity — 41% Anglo, 30% Hispanic, 13% Native American, 3% African American, 1% Asian, and 12% other
  • Gender — 64% Male and 34% Female
  • Status — Participants were all engaged through the only drop-in center for homeless youth in Albuquerque, had all been living in metropolitan area for at least 3 months, met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for Alcohol or other Psychoactive Substance Use Disorders, and met criteria for homelessness.

Location/Institution: Albuquerque, NM

Summary: (To include basic study design, measures, results, and notable limitations)
Participants were assigned to either the Adolescent Community Reinforcement Approach (A-CRA) or treatment as usual (TAU) condition. The Form 90, developed for National Institute on Alcohol Abuse and Alcoholism (NIAAA) funded Project Match, was the primary measure of the quantity and frequency of alcohol drug use. To assess individual problem behaviors, the National Youth Survey Delinquency Scale (NYSDS) structured interview was used, as well as the Youth Self-Report (YSR) of the Child Behavior Checklist (CBCL). To measure youths' coping, the adolescent version of the Coping Inventory for Stressful Situations (CISS) was used. Depressive symptoms were measured using the Beck Depression Inventory (BDI-II). Youth assigned to the A-CRA condition, compared to TAU, reported significantly reduced substance use and depression, and increased social stability. In both conditions, youth improved in other behavioral domains including substance use, internalizing and externalizing problems, and emotion and task-oriented coping. Limitations include participants were only assessed at posttreatment, were recruited conveniently from a sample already accessing a drop-in center indicating they might be more amenable to change or respond differently to treatment efforts than youth who do not access drop-in centers, the research assistants were not blinded to the treatment condition that youth were assigned, and youth were aware of the possible treatment conditions.

Length of controlled postintervention follow-up: 3 months or less.

Godley, S. H., Hedges, K., & Hunter, B. (2011). Gender and racial differences in treatment process and outcome among participants in the adolescent community reinforcement approach. Psychology of Addictive Behaviors, 25(1), 143-154. doi:10.1037/a0022179

Type of Study: Multisite pretest-posttest design
Number of Participants: 1,819

Population:

  • Age — 10-18 years
  • Race/Ethnicity — 33% Caucasian, 32% Hispanic, 15% African American, 15% Multiracial, 2% Native American/Alaska Native, 2% Asian, and 1% Other
  • Gender — 73% Male and 27% Female
  • Status — Participants were adolescents enrolled in outpatient substance abuse treatment programs.

Location/Institution: 27 sites across the U.S.

Summary: (To include basic study design, measures, results, and notable limitations)
The study examined whether initiation, engagement, dosage, treatment satisfaction, or outcomes for adolescents who received the Adolescent Community Reinforcement Approach (A-CRA) in a large implementation effort were equivalent by gender or racial group. Participants were assessed at intake and at 3 and 6-month follow-ups using the Global Appraisal of Individual Needs (GAIN) and the Treatment Satisfaction Scale (TxSS). Results indicated that nearly all adolescents in the sample reported being satisfied with treatment; however, male adolescents had significantly higher rates of treatment satisfaction than female adolescents, and African American adolescents had significantly higher rates of treatment satisfaction than Caucasian adolescents. All racial groups had significant increases in days abstinent from alcohol and other drugs and in the percentage in recovery across the measurement period, but did not differ from one another at the six-month follow-up. Female adolescents had a higher percentage of days abstinent from alcohol and other drugs and were more likely to be in recovery at the six-month follow-up than male adolescents. Limitations include a limited postintervention follow-up, no control group, high dropout rate for study participants, and minimal ethnic representation among Asians and Native Americans.

Length of controlled postintervention follow-up: 6 months.

Smith, D. C., Godley, S. H., Godley, M. D., & Dennis, M. L. (2011). Adolescent Community Reinforcement Approach outcomes differ among emerging adults and adolescents. Journal of Substance Abuse Treatment, 41(4), 422-430. doi:10.1016/j.jsat.2011.06.003

Type of Study: Retrospective matched groups design using propensity scores
Number of Participants: 303

Population:

  • Age — Mean=17.1 years
  • Race/Ethnicity — 30% Caucasian, 26.4% Hispanic, 21.5% African American, 2.6% Native American, and 19.5% Other/Biracial
  • Gender — 71.7% Male
  • Status — Participants were adolescents and emerging adults with substance use disorders.

Location/Institution: 28 SAMHSA-funded outpatient treatment sites

Summary: (To include basic study design, measures, results, and notable limitations)
This study compares outcomes between adolescents and emerging adults with substance use disorders who received the Adolescent Community Reinforcement Approach (A-CRA). Propensity score matching was used to create a weighted comparison group of adolescents who had similar demographic characteristics, clinical severity, and treatment retention as the group of emerging adults (ages 18-25). It should be noted, however, that over 75% of the emerging adults were age 18. Emerging adults and adolescents both reduced their substance use at follow-up. However, emerging adults were less likely to be abstinent and in remission and had more days of alcohol use when compared with adolescents. Limitations include that the effects observed here are for emerging adults that were admitted to predominantly adolescent programs, that the statistical analyses used did not fully account for the nesting of clients within therapists and within sites, and that less than 25% of the emerging adult sample was age 19 or older, limiting generalizability to the entire emerging adult group.

Length of controlled postintervention follow-up: 3 or 6 months.

Hunter, B. D., Godley, S. H., Hesson-McInnis, M. S., & Roozen, H. G. (2013). Longitudinal change mechanisms for substance use and illegal activity for adolescents in treatment. Psychology of Addictive Behaviors, 28(2), 507-515. doi:10.1037/a0034199

Type of Study: Multisite pretest-posttest design
Number of Participants: 1,467

Population:

  • Age — Mean=15.8 years
  • Race/Ethnicity — 14% African American, 35% Caucasian, 29% Hispanic, 16% Mixed, and 6% Other
  • Gender — 25% Female
  • Status — Participants were adolescents who presented to substance use treatment and reported past-year engagement in illegal.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The current study investigated: (a) The relationships of exposure to the Adolescent Community Reinforcement Approach (A-CRA) with reductions in substance use, illegal activity, and juvenile justice system involvement in adolescents diagnosed with a substance use disorder, and (b) The pathways by which reductions in the target behaviors were achieved. This study is a secondary data analysis of longitudinal data from a large-scale implementation effort for A-CRA. Measure utilized was the Global Appraisal of Individual Needs (GAIN) and The Illegal Activity Scale, and the A-CRA Exposure Scale. Results indicate participation in A-CRA had a significant, direct association with reduced substance use; a significant, indirect association with reduced illegal activity through reductions in substance use; and a significant indirect association with reduced juvenile justice system involvement through reductions in both substance use and illegal activity. In addition, post hoc analyses using a bootstrapping strategy provided evidence that reductions in substance use partially mediated the relationship between A-CRA and illegal activity. Limitations include reliance on self-reported measures, and nonrandomization of subjects.

Length of controlled postintervention follow-up: 6 and 12 months.

Godley, S. H., Hunter, B. D., Fernández-Artamendi, S., Smith, J. E., Meyers, R. J., & Godley, M. D. (2014). A comparison of treatment outcomes for Adolescent Community Reinforcement Approach participants with and without co-occurring disorders. Journal of Substance Abuse Treatment, 46, 463-471. doi:10.1016/j.jsat.2013.10.013

Type of Study: Multisite pretest-posttest design
Number of Participants: 2,484

Population:

  • Age — Not specified
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were adolescents enrolled in outpatient substance abuse treatment programs psychiatric problems.

Location/Institution: Northeast/Mid-Atlantic , Northeast/New England , Southeast/South Atlantic, Midwest, Southwest, West/Mountain, and West/Pacific

Summary: (To include basic study design, measures, results, and notable limitations)
This study examined the relationship between Adolescent Community Reinforcement Approach (A-CRA) participation with treatment engagement, retention, and satisfaction, and with substance use and emotional problem outcomes. Measure utilized was the Global Appraisal of Individual Needs (GAIN) and the Treatment Satisfaction Scale. Results indicate that at the 12-month follow-up, adolescents classified as externalizers or those with both externalizing and internalizing problems had significantly greater improvement in their days of abstinence and substance problems relative to adolescents with substance use disorders only. Additionally, adolescents reporting symptoms of internalizing, externalizing, or both externalizing and internalizing disorders had significantly greater improvements in days of emotional problems relative to adolescents with substance use disorder only. Limitations include five treatment agencies were dropped from the analysis for having 12-month follow-up rates less than 50%, and an additional 10% of the sample was dropped due to uncompleted 12-month follow-up interviews, reliance on self-reported measures, and may not be generalizable to adolescents receiving substance use treatment other than A-CRA.

Length of controlled postintervention follow-up: 12 months.

Garner, B. R., Hunter, B. D., Smith, D. C., Smith, J. E., & Godley, M. D. (2014). The relationship between child maltreatment and substance abuse treatment outcomes among emerging adults and adolescents. Child Maltreatment, 19(3-4), 261-269. doi:10.1177/1077559514547264

Type of Study: Pretest-posttest with control group (Secondary data analysis)
Number of Participants: 3,555 (858=Adults; 2,697=Adolescents)

Population:

  • Age — Adolescents: 12-17 years, Adults 18-25 years
  • Race/Ethnicity — Adolescents: 42.7% Hispanic, 26.5% Caucasian, 12.4% African American, 12.3% Mixed, and 6.1% Others; Adults: 40.8% Hispanic, 22.5% Caucasian, 20% African-American, 13.7% Mixed, and 3% Other
  • Gender — Adolescents: 21.9% Female; Adults: 25% Female
  • Status — Participants were adolescents enrolled in outpatient substance abuse treatment programs psychiatric problems.

Location/Institution: Northeast/Mid-Atlantic, Northeast/New England, Southeast/South Atlantic, Midwest, Southwest, West/Mountain, and West/Pacific

Summary: (To include basic study design, measures, results, and notable limitations)
The primary aim of the current study was to examine the relationship between a broad measure of child maltreatment and several key outcomes for a large clinical sample of emerging adults (n = 858) and adolescents (n = 2,697). Data for the current study were collected as part of the Assertive Adolescent and Family Treatment (AAFT) project. Participants were enrolled in either Adolescent Community Reinforcement Approach (A-CRA) or Assertive Continuing Care (ACC). The secondary aim was to examine the extent to which the relationship between child maltreatment and treatment outcomes differed between emerging adults and adolescents. Measure utilized was the Global Appraisal of Individual Needs (GAIN) and the A-CRA Procedures Checklist. Results indicate emerging adults and adolescents who experienced child maltreatment reported significantly greater reductions over time on several treatment outcomes (e.g., substance use, substance-related problems, and emotional problems). Overall, analyses did not support differential relationships between child maltreatment and changes over time in these substance use disorder treatment outcomes for emerging adults and adolescents. The one exception was that although emerging adults with child maltreatment did reduce their HIV risk over time, their improvements were not as great as were the improvements in HIV risk reported by adolescents who had experienced child maltreatment. Limitations include nonrandomization of participants, generalizability due to ethnicity, study data were based on participant self-report, and length of follow-up.

Length of controlled postintervention follow-up: 3 and 6 months.

Godley, M. D., Passetti, L. L., Subramaniam, G. A., Funk, R. R., Smith, J. E., & Meyers, R. J. (2017). Adolescent Community Reinforcement Approach implementation and treatment outcomes for youth with opioid problem use. Drug and Alcohol Dependence, 174, 9-16. doi:10.1016/j.drugalcdep.2016.12.029

Type of Study: Multisite pretest-posttest design (Secondary data analysis)
Number of Participants: 1,712

Population:

  • Age — Adolescents: Mean=15.65 - 15.85 years
  • Race/Ethnicity — Adolescents: Not specified
  • Gender — Adolescents: 979 Female
  • Status — Participants were adolescents with substance use disorders.

Location/Institution: 27 sites across the U.S.

Summary: (To include basic study design, measures, results, and notable limitations)
This paper compares adolescents with primary opioid problem use (OPU) to those with primary marijuana or alcohol problem use (MAPU) who received up to six months of Adolescent Community Reinforcement Approach (A-CRA). Data for the current study were collected as part of the Assertive Adolescent and Family Treatment (AAFT) project. Measure utilized was the Global Appraisal of Individual Needs (GAIN) and the Treatment Satisfaction Scale (TxSS). Results indicate at intake that adolescents in the OPU group were more likely than those in the MAPU group to be Caucasian, older, female, and not attending school; to report greater substance and mental health problems; and to engage in social and health risk behaviors. There was statistical equivalence between groups in rates of A-CRA treatment initiation, engagement, retention, and satisfaction. Both groups decreased significantly on most substance use outcomes, with the OPU group showing greater improvement; however, the OPU group had more severe problems at intake and continued to report higher frequency of opioid use and more days of emotional problems and residential treatment over 12 months. Limitations include lack of control group, generalizability due to ethnicity, and study data were based on participant self-report.

Length of controlled postintervention follow-up: 3, 6 and 12 months.

The following studies were not included in rating A-CRA on the Scientific Rating Scale...

Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R., & Passetti, L. L. (2007). The effect of assertive continuing care on continuing care linkage, adherence, and abstinence following residential treatment for substance use disorders in adolescents. Addiction, 102, 81-93. doi:10.1111/j.1360-0443.2006.01648.x

Note: This study was not used in the rating of A-CRA due to the model being offered with additional case management services. Prior to discharge from residential treatment, participants were randomly assigned to receive either usual continuing care (UCC), available at outpatient clinics in the 11-county study area, or assertive continuing care (ACC) involving case management and the Adolescent Community Reinforcement Approach (A-CRA) via home visits. Self-reported interview data were collected at intake, 3, 6, and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months. ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC also resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence. Limitations include the lack of statistical power to reliably measure the direct effect of ACC on abstinence, long-term outcomes were limited to 9 months postresidential discharge, reliance on self-reported measures, and the findings are from a single residential program site.

Godley, M. G., Godley, S. H., Dennis, M. L., Funk, R. R., Passetti, L. L., & Petry, N. M. (2014). A randomized trial of Assertive Continuing Care and contingency management for adolescents with substance use disorders. Journal of Consulting and Clinical Psychology, 82(1), 40-51. doi:10.1037/a0035264

Note: This study was not used in the rating of A-CRA due to the model being offered with additional case management services. The present article reports the results of a randomized trial to assess the degree to which three experimental approaches were more successful at engaging youth in post residential continuing care and maintaining AOD abstinence during the 12 months following residential discharge relative to a Usual Community Care (UCC) alone condition: (a) Contingency Management (CM); (b) ACC, a multicomponent intervention combining Adolescent Community Reinforcement Approach (A-CRA) with behavioral, CBT, and case management elements; and (c) CM + ACC, a combination of both approaches. Measure utilized was the Global Appraisal of Individual Needs (GAIN). Results of the present study demonstrated that both the CM and ACC conditions resulted in significantly more days of abstinence from alcohol and illicit drug use than UCC over a 12-month period, and participants in both conditions were more likely to be in remission at the 12-month follow-up. In addition, CM and ACC resulted in significantly fewer days spent in residential treatment, juvenile detention, and hospitals over the 12-month period. Limitations include generalizability due to small number of Hispanic participants and small sample size.

Additional References

Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J., & Godley, M. D. (2011). A large-scale dissemination and implementation model for evidence-based treatment and continuing care. Clinical Psychology: Science and Practice, 18, 67-83.

Godley, S. H., Meyers, R. J., Smith, J. E., Godley, M. D., Titus, J. C., Karvinen, T., & Kelberg, P. (2001). The Adolescent Community Reinforcement Approach (ACRA) for adolescent cannabis users (DHHS Publication No. (SMA) 01-3489, Cannabis Youth Treatment (CYT) Manual Series, Volume 4). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Retrieved from the University of Stirling's website: http://www.dldocs.stir.ac.uk/documents/ACRA_CYT_v4.pdf.

Godley, S. H., Smith, J. E., Meyers, R. J., & Godley, M. D. (2009). Adolescent Community Reinforcement Approach. In D. W. Springer & A. Rubin (eds.), Substance abuse treatment for youth and adults: Clinician's guide to evidence-based practice (pp. 109-201). Hoboken, NJ: John Wiley & Sons, Inc.

Contact Information

Mark D. Godley, PhD
Agency/Affiliation: Chestnut Health Systems
Website: ebtx.chestnut.org/Treatments-and-Research/Treatments/A-CRA
Email:
Phone: (309) 451-7800
Fax: (309) 451-7761

Date Research Evidence Last Reviewed by CEBC: February 2021

Date Program Content Last Reviewed by Program Staff: July 2020

Date Program Originally Loaded onto CEBC: April 2010