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.)
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.
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.
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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).
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.
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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