DESCRIPTION (provided by applicant): Many youth with the most serious mental health problems resulting from violence exposure and maltreatment never receive mental health services [MHS].8,11 These youth are disproportionately found in juvenile delinquent populations where 67% - 75% have impairing psychiatric disorders, 20% have severe mental disorders and more than 1/3 need ongoing clinical MHS care- a figure twice the rate of the general adolescent population.7-10-12 Girls are the most vulnerable, understudied and underserved but fastest growing delinquent subgroup, with data strongly suggesting they have the most serious MHS needs: 75-95% have histories of child maltreatment, 95-100% have poly-trauma histories of violence exposure, sexual assault and child maltreatment, up to 50% have current Post Traumatic Stress Disorder [PTSD] and substance and alcohol use disorders [SAUD] and they have higher rates of PTSD and suicidality than delinquent boys.7,10,12,26-28 However there are few, if any, rigorously tested interventions available in the juvenile justice system [JJS] for youth with these comorbid problems. Our primary aim in this proposed study is to evaluate the efficacy of Seeking Safety [SS], an intervention for concurrently treating comorbid PTSD and SAUD that also addresses self harm and negative affect regulation, for female delinquents. This study lays the groundwork for developing a model for importing evidence based treatment [EBT] to high-risk youth who gain the attention of the JJS. We will recruit 250 female delinquents, 13 to 18 years old, with comorbid PTSD and SAUD through the San Diego Probation Department's Girls' Rehabilitation Facility. Our primary aims are to 1) use a randomized control trial design to determine the efficacy of an 8-week, 24 session manualized PTSD/SAUD intervention, 13 compared to the 'treatment as usual' [TAU] (8-week, 24 sessions) provided by the Probation Department for SAUD problems and 2) determine if cognitive factors (verbal skills, executive function) are related to treatment outcomes for SS and TAU. Our secondary aims are to 1) evaluate possible modifications to the SS treatment for improving services to the subject population and 2) use this study as a model for importing EBTs to other high-risk youth in Child Welfare and the JJS by partnering with (a) UC San Diego Comprehensive Research Center in Health Disparities to determine the best approach for fostering collaborative relationships within the alliance of San Diego's community clinics and identify funding streams to provide community-based services for a larger high- risk youth population and (b) Center for Criminality & Addiction Research, Training & Application to learn how to disseminate data about EBTs for youth in JJS across the nation and explore strategies to train correctional officers to work more effectively with traumatized and SAUD youth. With unprecedented support and access through the San Diego County Juvenile Court and Probation Department and a currently embedded multi- disciplinary, translational research program (spanning neurocognitive, psychiatric, imaging, genetics research), we are in a unique position to implement this proposed study that bears far reaching policy implications.

PUBLIC HEALTH RELEVANCE: Youth who become involved with the Juvenile Court, either through the Child Welfare or Juvenile Justice system, demonstrate elevated rates of psychopathology and functional impairment, pose significant social and fiscal costs to society and often escape the attention of traditional mental health services. This research examines the efficacy of an evidence based intervention that simultaneously treats comorbid Post Traumatic Stress Disorder and Substance/Alcohol Use Disorders, the most prevalent comorbid pattern observed among high-risk and delinquent girls and a pattern that often results in future arrests (substance use, prostitution). This research will serve as a model for implementing and evaluating evidence based treatments with high-risk youth who gain the attention of the Juvenile Court but are traditionally underserved in the general community. NARRATIVE Youth who become involved with the Juvenile Court, either through the Child Welfare or Juvenile Justice system, demonstrate elevated rates of psychopathology and functional impairment, pose significant social and fiscal costs to society and often escape the attention of traditional mental health services. This research examines the efficacy of an evidence based intervention that simultaneously treats comorbid Post Traumatic Stress Disorder and Substance/Alcohol Use Disorders, the most prevalent comorbid pattern observed among high-risk and delinquent girls and a pattern that often results in future arrests (substance use, prostitution). This research will serve as a model for implementing and evaluating evidence based treatments with high-risk youth who gain the attention of the Juvenile Court but are traditionally underserved in the general community. __SpecificAimsTextDelimiter__ II. Statement of Hypotheses and Specific Aims The primary aim of this study is to evaluate the efficacy of Seeking Safety [SS], an intervention designed to concurrently treat comorbid Post Traumatic Stress Disorder [PTSD] and substance and alcohol use disorders [SAUD], when deployed in a correctional facility for female delinquents. Although evidence is building for the efficacy of SS in similar populations, sample sizes are small,[1-4] only three have utilized a randomized control design[1, 5, 6] and there are special considerations that may complicate treatment (fluid nature of admissions, commitments <3 months, early developmental poly-trauma, possible cognitive impairment). This research will lay the groundwork for developing a high-impact community model for applying best practice, evidence based treatment [EBT] interventions to delinquent youth who gain the attention of the Juvenile Court servicing Child Welfare and the Juvenile Justice System [JJS]. Ultimately, these best practices will be expanded to community-based post-release services that provide continuity of care, improve the overall mental health among these high-risk youth and reduce recidivism. The model will first be implemented with females because of the exceptionally high rate of trauma and comorbid PTSD and SAUD in this population. Existing research shows that among delinquent girls, 95- 100% have poly-trauma histories of violence exposure, sexual assault and child maltreatment, and ~50% of these girls have current comorbid PTSD and SAUD.[7-12] Their histories are characterized by both early and chronic exposure to trauma that frequently results in high-risk delinquent behaviors leading to repeated arrests (e.g., prostitution, substance use). To effectively intervene, we must bring the best practices to bear in treating these vulnerable youth. The SS goals are to reduce PTSD symptoms, drug and alcohol use (frequency/amount), and harmful behaviors (deliberate self harm, suicidality, risky sexual practices). We will implement a randomized clinical trial (RCT) of our proposed treatment protocol with 250 adjudicated female delinquents from the San Diego County Probation Department's Girls' Rehabilitation Facility [GRF], a locked placement for Wards of the Court and the State of California. These high-risk adolescents will range in age from 13 to 18 years old. All girls entering GRF will be screened for psychiatric disorders and SAUD. Girls with comorbid current PTSD and SAUD who assent to participate will be randomly assigned to one of two conditions: the experimental SS intervention or the treatment as usual [TAU] group (i.e., the status quo treatment provided by the Probation Department: Alcoholics Anonymous/Narcotic Anonymous). The treatment period lasts 8 weeks, with both interventions having 24-sessions in a group format. The proposed SS treatment protocol includes psychoeducation regarding SAUD and PTSD, development of grounding and coping skills, recognizing triggers, asking for help, self-advocacy, reduction of harm exposure and self harm, integrating the split self, setting boundaries, managing anger and negative affect, building social support, identifying community resources, problem solving and termination/maintenance planning. Both groups will have access to psychiatric care, independent of this proposed study, as part of the commitment to GRF. Cognitive testing will occur at baseline. Initial characterization of the total sample will be performed at baseline and outcome measures will be administered at post-intervention (8-weeks) at GRF and 3-and 6-month follow- up in the community. Primary Aims: Specific Aim 1:To assess the efficacy of SS[13] in a Probation facility for delinquent girls with poly-trauma histories, compared to TAU. Key outcomes will include changes in PTSD and SAUD symptoms, post-release delinquent involvement and other self-harm activities (such as deliberate self injury, prostitution). Hypothesis 1a: After 8 weeks of treatment, SS participants will show significantly reduced PTSD (fewer number of symptoms and less severe symptoms) from pre-treatment and have fewer and less severe symptoms than TAU control participants. Hypothesis 1b: SS participants will maintain their treatment gains in reduced PTSD symptomatology and severity better than TAU controls at 3 and 6 month follow-up. Hypothesis 1c: SS participants will show greater reduction in drinking (fewer days drinking, less alcohol consumed per occasion than pre-arrest), substance use (fewer days using drugs, less amount used per occasion than pre-arrest) in the 3 and 6 month follow-up. Hypothesis 1d: SS participants will have less contact with justice agencies (e.g., violations of probation, arrests, incarcerations) due to new offenses in the 3 and 6 month follow-up than TAU participants. Specific Aim 2: To determine if cognitive factors (e.g., verbal skills, executive function) predict treatment adherence, retention to follow up and treatment outcomes. Hypothesis 2a: Greater verbal skills, which may facilitate comprehension of treatment goals or ability to complete homework assignments, and participation during treatment (SS and TAU), will be strongly associated with SS and TAU outcomes at 8-weeks post-treatment. Hypothesis 2b: Stronger executive skills, which may allow for greater generalization from treatment and incarceration settings to the real world environment post-discharge, will be associated with better SS and TAU outcomes at 3 and 6 month follow-up in the community. Secondary Aims: Secondary Aim 1: To evaluate what SS modifications may be needed to tailor this intervention to the specific needs of adjudicated delinquents based on collected feedback from youth, therapists and the Probation Department. Secondary Aim 2: To use the proposed study as a model for importing EBTs to other youth in Child Welfare and the JJS and work with community organizations to provide local programming open to a larger range of at- risk and high-risk youth. 1) We will partner with the UC San Diego Comprehensive Research Center in Health Disparities and San Diego County community organizations to assess the feasibility of implementing Seeking Safety in community clinics for released juvenile delinquents as well as other high-risk youth. 2) We will partner with the Center for Criminality & Addiction Research, Training & Application to determine the feasibility of training correctional officers to work with traumatized and substance using youth in Probation Departments throughout California and develop a national dissemination plan.