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| Emerging Models of Effective Adolescent Substance Abuse Treatment |
| Feature Articles - Adolescents | |
| Wednesday, 31 March 2004 | |
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Increased substance-use experimentation and substance-related problems among adolescents during the 1990s led to a significant increase in the number of youth seeking treatment services in the United States. In the wake of these trends, addiction counselors have been challenged to respond to the needs of clients who present with lowered age of problem development and problems of greater severity and complexity. Fortunately, there is a growing body of research to help addiction counselors meet this challenge. The number of published studies evaluating the effectiveness of adolescent substance abuse treatment has grown tremendously over the past 30 years, with most of that growth occurring since 1997. More than 65 percent of all adolescent treatment effectiveness studies were published within the past 5 years, with 14 published studies between 1970 and 1997, and 26 studies published between 1998-2002 (Dennis, 2002). The earlier studies were methodologically limited by small sample size, unmanualized treatment approaches, and marginal follow-up rates (Dennis, Dawud-Noursi, Muck & McDermeit, 2003; Ozechowski & Liddle, 2000). These weaknesses limited their scientific integrity and replicability, as did the fact that most of the tested interventions were of adolescent responses to treatment models originally developed for adults (Deas & Thomas, 2001; Muck, Zempolich, et al., 2001). In response to these issues, the Center for Substance Abuse Treatment (CSAT), National Institute on Drug Abuse (NIDA), and National Institute on Alcohol Abuse and Alcoholism (NIAAA)1began funding adolescent-specific treatment studies during the 1990s. In what has been called a renaissance of knowledge in the field (White, Dennis, & Tims, 2002), more than 100 adolescent treatment studies have been funded by these three agencies since 2002 (Dennis, November 2002). In this article, we provide a summary of emerging models of adolescent substance abuse treatment drawn from 34 epidemiological, clinical, and pharmacological studies originally reviewed in “The Effectiveness of Adolescent Substance Abuse Treatment: A Brief Summary of Studies through 2001” (Dennis & White, 2002) prepared for Drug Strategies’ “Treating Teens: A Guide to Adolescent Drug Programs” (2003). The full report (available at http://www.drugstrategies.org/) includes a detailed abstract of each study and additional summary materials.
Reviewing the literature
Description of included studies
Behavior therapies included Adolescent Community Reinforcement Approach (ACRA), Adolescent Group Therapy (AGT), Cognitive Behavior Therapy (CBT), Motivational Enhancement Therapy (MET) and Relapse Prevention (RP). Family therapies included Conjoint Family Therapy (CFT), Functional Family Therapy (FFT), Family Systems Therapy (FST), Multidimensional Family Therapy (MDFT), and Multi-Systemic Therapy (MST). “Other” programs using blended approaches included Chestnut Health System’s outpatient program and Thunder Road’s short-term residential program. Twelve-step models were described as Chemical Dependency (CD) Counseling, Hazelden Model, or Minnesota Model programs. Therapeutic communities approaches included Dynamic Youth Services, Gateway, Operation PAR, and Phoenix Academy. Psychopharmacological studies tested the effects of treating adolescent substance use disorders with lithium, sertraline, and fluoxetine. Continuing care models studied included the Assertive Continuing Care (ACC) approach. Engagement programs included the Strategic Structural Systems Approach. Many of the treatment manuals used within these studies are available from the following Web sites:
The number of research participants fluctuated from study to study. For example, one controlled trial of sertraline included 10 participants, while a large multisite study of 30 inpatient and residential programs followed 1,483 adolescents. The number of follow-up interviews conducted and length of follow-up period also varied greatly. Six studies completed interviews at treatment intake and treatment completion only. Of the 29 studies that conducted later follow-up interviews, 10 studies followed up with participants for only 6 months or less after treatment intake, and only four studies followed up with participants for longer than 15 months after treatment intake. Three of these four had 5-year follow-up periods. Follow-up rates also varied significantly, with one study following up only 25 percent of participants, and two studies achieving 100 percent follow-up rates (at only 3 months post-intake). The average follow-up rate across all studies and all follow-up periods was 80 percent. Initial treatment effects reported ranged from an increase of 15 percent in drug use following treatment to a reduction in drug use of up to 67 percent during the active phase of treatment. This averaged out to a 30 percent reduction of drug use across all of the studies reviewed. Long-term effects, in the few studies that measured them, showed evidence of both sustained effects of treatment in some adolescents and deteriorating effects over time in others, with most adolescents moving in and out of relapse and recovery, rather than remaining stationary either in recovery or relapse.
Lessons learned from the literature 1) Adolescents need developmentally appropriate assessment tools and treatment protocol. While the field has advanced in taking into account the special developmental needs of adolescents, research studies underscore the significant differences that exist between adolescent and adult substance use disorders and their effective treatment.
2) Multiple co-occurring problems are the norm among adolescents with 3) Adolescents are involved in multiple systems competing to control their behavior. Most adolescents with substance use disorders are trying to meet the needs and demands of many — family, peers, school, work, the criminal justice system, and often mental health and behavioral health counselors/program requirements, but researchers to date have not adequately studied adolescents’ lives in their contexts, instead looking only from the view of the treatment system. The Robert Wood Johnson Foundation has launched “Reclaiming Futures,” an innovative approach with juveniles in the justice system in 10 U.S. cities. The comprehensive, integrated approach builds from an ecological model and seeks to use community collaborations to improve upon current attempts to treat the large number of adolescents in the juvenile justice system who also abuse alcohol and/or drugs (see pages 69-73 of this issue, for more information). 4) Adolescents’ responses to treatment are highly variable. Treatment effects range from no effect to sustained abstinence and all points in between (e.g., early abstinence followed by clinical deterioration, clinical deterioration followed by sustained abstinence, cycling in and out of abstinence and substance use). 5) Relapse and continued problems are the norm among adolescents who have received substance abuse treatment. Although treatment interventions produce positive and sustained effects in some adolescents, relapse continues to be common following treatment, particularly in the first 3-12 months after treatment. Recovery for many adolescents takes multiple attempts and episodes of care spanning many years. This finding suggests the need for assertive post-treatment monitoring, sustained recovery support services, and early re-intervention when indicated. 6) The most effective treatment models share common elements. The most effective treatment models in the studies reviewed here addressed engagement and motivation for treatment; used a manual-guided, developmentally appropriate treatment protocol; involved families in the treatment process; utilized more quality assurance and clinical supervision; and were assertive in providing continued care after treatment. 7) Common elements also exist among interventions that showed no change or minimal change in substance use or symptoms. Interventions that relied on passive referrals, educational units alone, “probation services as usual,” or unstandardized “outpatient services as usual” did not produce reductions in drug use or related problems. In short, we are learning much about the nature and complexity of adolescent substance use disorders, and we are beginning to find more effective approaches for their treatment. Research to date suggests that the most effective adolescent treatments of the future will use multi-dimensional assessment tools and assertive systems of outreach and engagement; will be multidisciplinary, developmentally appropriate, family-centered, and closely supervised for model fidelity and appropriate individualization; and will use systems of assertive continuing care and support following acute intervention and problem stabilization.
Applying the research
Federal and state support
Technology transfer
Methodological limitations
Promising areas
As ambitious as this sounds, much of this work is currently underway. A randomized trial comparing five different outpatient treatments as part of CSAT’s Cannabis Youth Treatment (CYT) study and an evaluation of ten different exemplary treatment programs currently in practice (the Adolescent Treatment Models (ATM) study) have recently been completed. These studies used the same follow-up time points and measures [the Global Appraisal of Individual Needs (GAIN); Dennis et al., 2002 — see www.chestnut.org/li/gain for more information]. The GAIN is also being used as part of dozens of studies ranging across levels of care, systems, and population. There have also been recent advances in pharmacological treatments with adolescents, particularly with work currently underway as part of NIDA’s clinical trials network. The treatment of adolescent substance use disorders is rapidly evolving into a science-based professional specialty. Addiction counselors have much new information to draw upon to enhance their clinical effectiveness in working with adolescents, and the quantity of such information will explode in the next decade. The greatest beneficiaries of this new information are and will continue to be the young people and their families served by addiction counselors across the country.
Acknowledgement
Footnotes 2 The numbers add up to more than 34 due to multiple treatment types being evaluated within a single study. Michelle White, MS ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is a Research Projects Manager at Chestnut Health Systems, Bloomington, Ill., and doctoral candidate at the University of Illinois at Urbana-Champaign, Sociology department.
Michael L. Dennis, PhD ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) a senior research psychologist at Chestnut Health Systems, is responsible for developing the Global Appraisal of Individual Needs (GAIN) measurement battery.
References This article is published in Counselor,The Magazine for Addiction Professionals, April 2004, v.5, n.2, pp. 24-28.              |
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