Adaptive Services in Drug Court

说明（由申请人提供）：这是第二笔竞争性续期补助金申请，目的是扩大一系列保健服务研究，使毒品法庭的服务适应滥用毒品罪犯的需要。我们之前的研究表明，在毒品法庭中，某些高风险参与者在被要求参加频繁的、每两周一次的司法状况听证会时，有更好的咨询出席率、更长的戒毒持续时间和更高的毕业率。相比之下，无论法庭听证会的时间安排如何，低风险参与者的表现都一样。我们在另外两个司法管辖区复制了这种匹配效应，然后使用前瞻性匹配设计证实了这一点，其中匹配程序的结果显示优于毒品法庭通常取得的结果。当前的应用程序将检查通过重新调整法庭听证会和临床病例管理会议的剂量来获得的增量效用，以响应参与者在项目中的持续表现。我们精心设计了一种自适应算法，区分不遵守毒品法庭监督条件（例如，未能显示咨询）和不响应干预（例如，提供药物阳性尿液）。我们将加强司法监督作为不遵守规定的后果，并将加强临床病例管理服务作为不响应的后果。我们在一项小型初步研究（N = 30）中试用了自适应算法，以确认客户和员工都可以接受，实验完整性大于85%的情况下实施可行，并显示出在药物戒断和毕业率方面有临床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值之间从0.40到0.60不等，这表明，与单独使用基线匹配程序获得的效果相比，效果显著增加。大部分增量改善来自低风险参与者，他们在先前的匹配过程中表现出最小的影响。我们现在建议在一个全功率的实验试验中测试这种自适应算法的增量效用。同意轻罪毒品法庭的参与者将在进入时随机分配到完全适应性干预或仅基线匹配（每个细胞n = 75）。主要结果将是毕业率，毒品法庭登记期间和入药后6个月和12个月的尿液药物筛查结果，以及入药后24个月的再逮捕率。次要结果将包括艾滋病毒风险行为、医疗健康、精神健康、家庭/社会关系和就业的自我报告措施。最后，我们将进行探索性分析，以确定可能有助于解释自适应算法改善结果的过程的潜在中介变量。潜在的调节因素包括：(1)适应性反应的保真度和时间，(2)参与者对程序正义的感知，(3)参与者对感知威慑的感知，以及(4)参与者对毒品法庭项目的满意度。公共卫生相关性：这项竞争性更新赠款将扩大一项保健服务研究方案，目的是使毒品法庭的服务适应滥用毒品罪犯的需要。我们之前的研究表明，在毒品法庭中存在可靠的基线匹配效应，在法官的严密监督下，高危罪犯的表现明显更好。当前的项目将根据客户在项目中的持续表现，通过不断调整司法监督和临床病例管理服务的强度，来检验所获得的增量效用。

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.