Adaptive Services in Drug Court

描述(由申请人提供)：这是一项第二次竞争续期拨款的申请，旨在扩大一系列旨在使毒品法庭的服务适应药物滥用罪犯需求的卫生服务研究。我们之前的研究表明，在毒品法庭上存在可靠和强大的配对效应，其中某些高危参与者在被要求出席频繁的、每两周一次的法庭司法地位听证会时，咨询出勤率、戒毒时间更长、毕业率更高。相比之下，无论庭审日程如何，低风险参与者的表现都相同。我们在另外两个司法管辖区复制了这种配对效果，然后使用前瞻性配对设计对其进行了确认，在该设计中，配对程序的结果被证明优于毒品法庭通常取得的结果。目前的应用程序将检查通过重新调整法庭听证和临床病例管理会议的剂量以响应参与者在该计划中的持续表现而获得的增量效用。我们精心设计了一种自适应算法，可以区分不遵守毒品法庭监管条件的情况(例如，没有提供咨询)和对干预措施的无反应(例如，提供药物阳性尿液)。我们明确指出，加强司法监督是不遵守规定的后果，加强临床病例管理服务是无反应的后果。我们在一项小规模的初步研究(N=30)中试行了自适应算法，以确认它对客户和工作人员都是可以接受的，在超过85%的实验完整性的情况下实施是可行的，并显示出在戒毒和毕业率方面引发临床有意义的改善的巨大希望。自适应算法的估计效应大小在不同的测量中从0.40到0.60不等，这表明比仅通过基线匹配程序获得的影响显著增加。大部分增量改善是针对低风险参与者的，他们在之前的配对程序中表现出的影响最小。我们现在建议在完全功率的实验试验中测试该自适应算法的增量效用。同意轻罪药物法庭的参与者将在进入时被随机分配到完全适应性干预或只进行基线匹配(每个细胞75人)。主要结果将是毕业率、进入毒品法庭期间以及进入毒品法庭后6个月和12个月的尿毒筛查结果，以及进入毒品法庭后24个月的再次逮捕率。次要结果将包括对艾滋病毒危险行为、医疗健康、精神健康、家庭/社会关系和就业的自我报告测量。最后，我们将进行探索性分析，以确定潜在的中介变量，这些变量可能有助于解释自适应算法改善结果的过程。被考察的潜在中介因素是(1)适应性反应的保真度和时间性，(2)参与者对程序正义的感知，(3)参与者对威慑的感知，(4)参与者对毒品法庭程序的满意度。公共卫生相关性：这项竞争性更新拨款将扩展一项旨在使毒品法庭的服务适应药物滥用罪犯需求的卫生服务研究计划。我们之前的研究表明，在毒品法庭上，高风险罪犯在法官的严格监督下表现得明显更好，具有可靠和强大的基线匹配效应。目前的项目将审查通过不断重新调整司法监督和临床病例管理服务的强度，以回应客户在该计划中的持续表现而获得的增量效用。

DESCRIPTION (provided by applicant): This is an application for a second competing-renewal grant to extend a line of health-services research aimed at adapting services in drug courts to the needs of drug-abusing offenders. Our previous studies demonstrated a reliable and robust matching effect in drug courts, in which certain high-risk participants had significantly better counseling attendance, longer durations of drug abstinence and higher graduation rates when required to attend frequent, bi-weekly judicial status hearings in court. In contrast, low-risk participants performed equivalently regardless of the schedule of court hearings. We replicated this matching effect in two additional jurisdictions and then confirmed it using a prospective matching design, in which outcomes from the matching procedure were shown to be superior to those achieved by drug court as-usual. The current application will examine the incremental utility gained by re-adjusting the dosage of both court hearings and clinical case-management sessions in response to participants' on-going performance in the program. We crafted an adaptive algorithm that distinguishes between non-compliance with supervisory conditions of the drug court (e.g., failing to show for counseling) and non-responsiveness to the interventions (e.g., providing drug-positive urines). We specified increased judicial supervision as the consequence for non- compliance and enhanced clinical case-management services as the consequence for non-responsiveness. We piloted the adaptive algorithm in a small preliminary study (N = 30) to confirm that it is acceptable to both clients and staff, feasible to implement with greater than 85% experimental integrity, and shows substantial promise for eliciting clinically meaningful improvements in both drug abstinence and graduation rates. The estimated effect sizes from the adaptive algorithm ranged from 0.40 to 0.60 across dependent measures, representing a significant increase in effects beyond what was obtained from our baseline-matching procedure alone. Much of the incremental improvement was derived for low-risk participants who had shown minimal effects from the prior matching procedure. We now propose to test the incremental utility of this adaptive algorithm in a fully powered experimental trial. Consenting misdemeanor drug court participants will be randomly assigned at entry to the full adaptive intervention or to baseline-matching only (n = 75 per cell). Primary outcomes will be graduation rates, urine drug-screen results during enrollment in drug court and at 6 and 12 months post-entry, and re-arrest rates at 24 months post-entry. Secondary outcomes will include self-report measures of HIV-risk behaviors, medical health, psychiatric health, family/social relationships and employment. Finally, we will conduct exploratory analyses to identify potential mediating variables that may help explain the process by which the adaptive algorithm improves outcomes. Potential mediators to be examined are (1) the fidelity and timing of adaptive responses, (2) participants' perceptions of procedural justice in the program, (3) participants' perceptions of perceived deterrence and (4) participants' satisfaction with the drug court program. Public Health Relevance: This competing-renewal grant will extend a program of health-services research aimed at adapting services in drug courts to the needs of drug-abusing offenders. Our prior studies demonstrated a reliable and robust baseline-matching effect in drug courts, in which high-risk offenders performed significantly better with intensive supervision from a judge. The current project will examine the incremental utility gained by continuously re-adjusting the intensity of both judicial supervision and clinical case-management services in response to clients' on-going performance in the program.