Within the federal government, foundations, states, and treatment programs, a burgeoning effort is underway to improve adolescent substance abuse treatment. This effort has been noted by others and described as an emerging renaissance in the treatment of adolescent substance use disorders (White, Dennis, & Tims, 2002). However, the dispersion of new knowledge about effective treatments is neither orderly nor uniform. It is virtually impossible to develop a complete picture of how this ongoing movement is being implemented across regions, states, or communities.

Developing the mechanisms necessary to systematically catalogue the changes that are occurring would be costly and time consuming. Moreover, given the rapidity of the ongoing changes in the field of adolescent treatment, any attempt to elaborate the state of the field would likely be out-of-date before it was released. For administrators, treatment programs, and the individual counselor, it is more important to know how to join this emerging movement and tap into the resources rapidly becoming available.

Resouces for state administrators
The formal substance abuse treatment system faces formidable obstacles for providing leadership and funding for sustaining, no less improving, the adolescent treatment system. In this period of reorganization of many state offices, including state substance abuse agencies, and the retrenchment of state governments to basic services due to fiscal constraints, support for adolescent treatment may be affected. Even before the current state budgetary crises, the majority of states did not have a dedicated individual responsible for adolescent treatment. Across states, responsibility for adolescent treatment resides in various departments of state agencies. Examples of the variation of state agencies responsible for adolescent substance abuse services are a Department of Consumer and Industry Services and a Department of Health and Environmental Control (Pollio, 2002).

Despite these obstacles, there are some noteworthy developments in states. For example, the State of Colorado has developed specific licensing standards for adolescent services and provides a dedicated full-time employee at the state level for the oversight and improvement of adolescent treatment services. In addition, the State of Vermont has undertaken the task of training their adolescent treatment providers in the delivery of an effective, manualized intervention from the Cannabis Youth Treatment Study Motivational Enhancement Therapy/Cognitive Behavioral Therapy: 5 sessions (MET/CBT5; see White, White, & Dennis, 2004, this issue). Vermont also has moved to standardize assessment and provide primary care physicians with the tools to screen and refer adolescents for substance use problems. For further information on developments in Colorado, contact Ms. Katie Wells at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it For further information on developments in Vermont, contact Dr. Win Turner at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Given competing demands, state administrators face a daunting challenge to stay abreast of the emerging field. Perhaps one of the best tools that state administrators can use to better understand the field of adolescent treatment and the needs of the programs they support was developed by the non-profit corporation Drug Strategies. Supported by a grant from The Robert Wood Johnson Foundation, Drug Strategies recently published “Treating Teens: A Guide to Adolescent Drug Programs” (2003). The initial goal was to provide information for parents on how to find and choose substance abuse treatment programs for their adolescents who may be in need of treatment. However, the final document and its companion Web site (www.drugstrategies.org) provide an adolescent treatment tour-de-force that can bring administrators up-to-date quickly.

Tools for treatment programs
Early models of adolescent treatment were built around adult interventions and did not address the unique developmental needs of youth (Muck et al., 2001). However, today there is clearly a shift in many adolescent programs toward manualized, developmentally appropriate treatment approaches which include standardized, comprehensive bio-psycho-social assessment to aid in treatment planning and clinical placement (Dennis et al., 2003).

A number of providers have embraced this ongoing change, and in fact have become significant players in the evolution of the adolescent treatment field. Many of these programs are highlighted in the Drug Strategies document. Along with information regarding assessment and clinical practice, contact information is provided for programs looking for information/discussion with other providers around the nation who have been able to catch the current wave of change.
Many programs face obstacles when attempting to implement change. Moving to standardized practice utilizing a manualized approach is not always easy for staff. Counselors generally have not been introduced to treatment manuals and their application in their formal training. While the shift to manualized treatment needs to be carefully nurtured, there is evidence that many counselors welcome the change to a more formal approach (Godley, 2003).

Clinical supervision has proven to be the cornerstone for implementation of the newest manualized treatment approaches. While it is unrealistic to hold counselors accountable for the individual outcomes of each of their clients, the use of manualized treatments with good clinical supervision can improve the quality of treatment interventions. Counselors have a road map for the treatment process and supervisors can monitor and supervise adherence to the protocol. This is a major step forward for quality improvement, program management, and clinical practice. The clinical supervision process with the new manualized approaches uses audio-taping of sessions for the use of the individual counselor and the supervisor for the improvement of clinical practice.

“Connected” counselors
What can a counselor do to keep up on the latest research? Most counselors find themselves in states that are not able to provide active and ongoing assistance to adolescent providers. Treatment programs may not be at the forefront of the emerging adolescent treatment renaissance. It is difficult for counselors to keep up with the latest research and to understand how the findings, often from controlled academic environments, can be used within their own practice. Even if the counselor, within the context of a community provider setting, is able to keep abreast of the growing field of research on adolescent treatment, the practical implications within the community provider setting are often elusive.

A counselor who wants to become part of this growing movement to improve adolescent treatment can now join the effort by becoming a member of the national learning community for the improvement of the adolescent treatment field. The Society for Adolescent Treatment Excellence (SASATE) is a relatively newly formed organization to link researchers and practitioners interested in improving the practice of adolescent treatment. There are no dues, and no limitations on who joins, other than having a passion for youth treatment. The most vibrant part of this organization is a Listserv® electronic mailing list that links the leading adolescent treatment researchers and clinicians around the country. It is a forum where a frontline counselor can ask questions about clinical practice, new manualized treatment approaches, or the latest research findings in their areas of interest. Further, as new research is published, synopses of the studies will be posted on the Listserv that will allow clinicians to stay up-to-date with progress in the field, and to join discussions about the implications of the research on their clinical practice. To join SASATE, simply send an e-mail to This e-mail address is being protected from spam bots, you need JavaScript enabled to view it and request to be included in SASATE.

SASATE also has an annual conference linked with the College on Problems of Drug Dependence. The next conference is scheduled for June 18, 2004, in San Juan, Puerto Rico. The meeting will provide the opportunity for lunch with funders, and discussions on hot topics (last year focused on continuing care, and this year’s topic will include group therapy). Several travel awards are available for presenters on specific topics (e.g., gender, group therapy), students, and/or providers. For more information on SASATE, contact Dr. Michael Dennis at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it For information regarding potential travel awards, please see The College on Problems of Drug Dependence (http://www.cpdd.org/).

A number of initiatives funded by NIAAA, NIDA, and SAMHSA are currently in the field and will, over the next several years, bring new knowledge around a range of adolescent treatment issues, including effective interventions, the importance of and various models of continuing care, and the development of systems of care in communities to provide support to adolescents and their families within their communities. The SASATE Listserv is a place to keep abreast of all of these developments within the context of extremely busy daily schedules.

Current and emerging treatment information
Today there are manualized, developmentally appropriate treatment approaches for adolescents that have shown effectiveness. These manuals are widely available, and free. This is very good news for the field. Counselors and programs can begin using research-based approaches that they know are based on the best that is available in clinical practice, and have a research base. Further, for clinical supervisors and program managers, there now exist approaches with standards for adherence that can be used for clinical supervision and personnel management. The clinical interventions within programs can evolve from individualized “art” to proven approaches whereby the adherence to the model can be measured.

The Cannabis Youth Treatment (CYT) study resulted in five manuals of tested outpatient treatment approaches. These manuals cover a range of therapeutic interventions that involve individual, group, and family interventions. Individual clinicians and programs directors need to determine which one of these approaches is the best fit for their clinical practice and the presenting issues of their clientele. However, all of these approaches proved equally effective and were delivered at a relatively low cost (French et al., 2002). These manuals, along with forms and supports for clinical supervision can be downloaded, free, at www.chestnut.org, or ordered free-of-charge from the National Clearing House for Alcohol and Drug Information (NCADI) at 1-800-729-6686 (Ask for the Cannabis Youth Treatment Series, Volumes 1-5).

Although close to 85 percent of all adolescent substance abuse treatment is delivered in outpatient settings, there still exists a need for tested and evaluated models of residential care. In 1999, CSAT set out to find potentially exemplary adolescent treatment programs that heretofore had not had the opportunity to be rigorously evaluated. Ten programs were selected by a competitive process to be part of the Adolescent Treatment Models (ATM) study. These programs were evaluated with core measures developed for the CYT study. Outpatient, short-term residential, and long-term residential programs were selected and evaluated over the next three years. Research on treatment outcomes continues, but in terms of measures of reduced use of substances, and reduced problems related to substance use, these programs proved to be as effective as the CYT models.

Seven of the 10 programs have completed their treatment manuals and they are available, free at www.chestnut.org. These manuals differ from CYT, in that they are program manuals. CYT manuals describe a discrete treatment protocol, whereas the ATM manuals provide the treatment intervention as well as the structure of the entire treatment program. These manuals are particularly useful for program administrators/supervisors who are interested in developing a program structure to support an effective intervention. The program models are also outlined in a recent book, “Adolescent Substance Abuse Treatment in the United States” (Stevens & Morral, 2003).

A number of other publications developed by national leaders in the field of adolescent substance abuse treatment are available through NCADI. Individuals can visit www.health.org (click on “Publications”) or call 1-800-729-6686 to receive a catalogue of all of the currently available publications, which includes a Treatment Improvement Protocol (TIP #32) for adolescent treatment (for a media review of this publication, see page 78 of this issue).

Getting the necessary child/adolescent development training to frontline counselors can be a challenge for programs. The Center for Substance Abuse Treatment (CSAT) has supported regional ATTCs for a number of years. The ATTCs have been developing state-of-the-art, online training, at a minimal cost for frontline counselors. Encouragingly, a number of ATTCs have made one of their foci the training of adolescent substance abuse counselors. Their online courses are developed, and often hosted by the leading experts in the field of adolescent treatment. The national ATTC information can be accessed at www.nattc.org. Additionally, the Mid-Atlantic (www.mid-attc.org), Mountain West (www.mwattc.org) and New England (www.attc-ne.org) ATTCs are among the leaders in providing training in adolescent treatment.

Assessment tools
Effective treatment planning and clinical placement are dependent on accurate and comprehensive assessment. In its review of highly recommended adolescent treatment programs, Drug Strategies found very few programs that used standardized assessment instruments. Even fewer programs used assessment instruments that had been normed and validated for use with adolescents.

Two of the articles in this volume (Kaminer, 2003, Dennis, 2003) underscore the need to assess for mental health and issues of trauma within a population of youth presenting for substance abuse treatment. Across CSAT-funded adolescent programs, upwards of 70 percent of all youth presenting for treatment have concomitant mental health issues. In an ethnographic study of youth who received substance abuse and mental health treatment (Federation of Families, 2000), 100 percent reported that their mental health problems predated their substance abuse.

With increasing knowledge of the co-occurring substance use and mental health issues with which youth present for treatment, it is clear that comprehensive assessment is crucial. A standardized assessment with good reliability and validity for the adolescent population, which addresses mental health and physical health, as well as the familial and environmental milieu, is needed.

Of the standardized assessment instruments available for use with adolescents, Drug Strategies recognized two as useful for this purpose: (1) the Global Appraisal of Individual Needs (GAIN) and, (2) the Comprehensive Addiction Severity Index for Adolescents (CASI-A). These two instruments are comprehensive bio-psycho-social assessments that allow for treatment planning and clinical placement.

The GAIN is now the assessment instrument used by the majority of the CSAT funded adolescent treatment grantees, of which there are currently 70. The GAIN was also used in the CYT and ATM studies. The instrument, manuals, and training are available from Chestnut Health Systems and more information can be accessed at their Web site (www.chestnut.org). Translation of the GAIN into Spanish is currently underway.

More information on screening and assessment instruments for adolescents is available through the supplemental online information for the Drug Strategies document at www.drugstrategies.org, and through the National Institute on Alcohol Abuse and Alcoholism (NIAAA) at www.niaaa.nih.gov/publications/instable.htm. The NIAAA Web site is currently being updated with the latest information on screening and assessment instruments.

New research on the horizon
On September 30, 2003, CSAT funded 22 programs across the nation to replicate one of the CYT treatment protocols, MET/CBT5, within their treatment programs. Over the next three years this naturalistic experiment of the adaptation/adoption of this protocol into standard clinical practice will be tested. Additionally, a national certification program for supervisors and clinicians providing this intervention is under development. Individual sites are adding what they believe are clinically necessary adjuncts to the approach, including family sessions and case management. The intervention is being replicated in primary care, juvenile justice, student assistance, and community outpatient treatment programs. The CSAT supported Mid-Atlantic Addiction Technology Transfer Center (ATTC) has supported the development of training tapes for MET/CBT5 will soon be available to the field. Information on contacting the Mid-Atlantic ATTC is provided above.

There is increasing unanimity in the field that continuing care is absolutely critical for maintaining the gains youth have made in treatment. In the only published study to date following adolescents after residential treatment in either a usual continuing care or assertive continuing care condition (Godley, 2002), return to first use of cannabis and alcohol was substantially delayed for the assertive continuing care group. This study was a first step in attempting to understand the need, type, and dose of continuing care needed for youth.
In a related effort, CSAT has funded 17 residential treatment sites to provide continuing care services after the active phase of residential treatment. This program, known as Adolescent Residential Treatment (ART), and its Continuing Care Component, is beginning its second year of operation. Programs are exploring various models of continuing care (e.g., intensive case management, assertive community reinforcement, brief strategic family therapy) and will have much to add to the field in the next several years.

Assessment, clinical placement, treatment interventions, and continuing care are all pieces of a continuum of care. The ability to intervene with youth and step them up, or down, within a continuum of care is recognized as important for a treatment system. To explore how this might be realized within communities, CSAT funded cooperative agreements for the development of systems of care for adolescents with substance use disorders. This program, Strengthening Communities — Youth (SCY), is developing systems of care in a number of communities around the country. This program is also collaborating with SAMHSA’s Center for Mental Health Services Comprehensive Community Mental Health Services for Children and their Families program (Center for Mental Health Services, 1999).

The future of the field
Until recently, it was very likely that frontline administrators and counselors providing services for adolescents and their families were disconnected from the ongoing research in the field. It was not until the very end of the last century that research began pointing to effective strategies for adolescent substance abuse treatment. Further, the responsibility for adolescent treatment has been spread throughout a plethora of state agencies that may not have had the time or resources to foster treatment improvement. Fortunately, with the emergence of new treatment technologies and a growing community of individuals committed to adolescent services, there is the possibility for change at every level.

States, individual administrators, program directors, and clinicians have access to a wealth of recently developed tools for providing adolescent substance abuse treatment services and support. Over the coming years, an even broader array of adolescent treatment information will become available. It is now possible for administrators and clinicians to keep abreast of the rapidly evolving field of adolescent substance abuse treatment. Anyone whose goal is to support or provide state-of-the-art services can now join a learning community of substance abuse treatment professionals whose passion is to provide excellence in adolescent treatment. All can join together to share what has been learned, what works, and become part of a network of individuals interested in the improvement of the lives of youth and their families that present to treatment with substance use disorders.

Randolph D. Muck, MEd ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is a Lead Public Health Advisor and Team Leader for Adolescent Treatment programs at the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment.

Jutta Butler, BS ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is a Public Health Advisor for Adolescent Treatment Programs at the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment.

Note
The opinions expressed here are those of the authors and do not reflect official positions of the government.

Acknowledgement
The authors would like to thank Maria B. Martin of the Center for Substance Abuse Treatment’s Division of Services Improvement for her invaluable assistance in the preparation of this article.

References
Center for Mental Health Services (1999). Annual Report To Congress on the Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. Atlanta, GA: ORC Macro.
Center for Substance Abuse Treatment (2002). Treatment of Adolescents With Substance Use Disorders. Treatment Improvement Protocol 32 (SMA) 02-3647. Rockville, MD; Center for Substance Abuse Treatment.
Dennis, M.L. (2004). Traumatic victimization among adolescents in substance abuse treatment : It is time to stop ignoring the elephant in our counseling room. Counselor Magazine, 5(2): 36-40 (this issue).
Dennis, M.L., Dawud-Noursi, S., Muck, R.D., & McDermeit (Ives), M. (2003). The need for developing and evaluating adolescent treatment models. In S.J. Stevens, & A.R. Morral (Eds.), Adolescent drug treatment in the United States: Exemplary models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press.
Drug Strategies. (2003). Treating teens: A guide to adolescent drug programs. Washington, DC. Drug Strategies.
Federation of Families for Children’s Mental Health and Keys for Networking, Inc. (2000, October) Blamed and ashamed: The treatment experiences of youth with co-occurring substance abuse and mental health disorders and their families. http://www.mentalhealth.org/publica
tions/allpubs/KENO02-0129/default.asp.
French, M.T., Roebuck, M.C., Dennis, M. Diamond, G., Godley, S. Tims, F., et al. (2002). The economic cost of outpatient marijuana treatment for adolescents: Findings from a multisite experiment. Addiction, 97 (Suppl. 1), S84-S-97.
Godley, M.D., Godley, S. H., Dennis, M.L., Fuk, R. & Passetti, L. (2002). A randomized field trial of an assertive aftercare protocol for adolescents following discharge from residential substance abuse treatment: Preliminary outcomes. Journal of Substance Abuse Treatment, 23, 21-23.
Godley, S. H, White, W., Diamond, G., Passetti, L., Titus, J. C. (2001). Therapist reactions to manual-guided therapies for the treatment of adolescent marijuana users. Clinical Psychology: Science and Practice, 8(4): 405-417.
Kaminer, Y. (2004). Dually diagnosed teens: Challenges for assessment and treatment. Counselor Magazine, 5(2): 62-68 (this issue).
Muck, R., Zempolich, K.A., Titus, J.C., Fishman, M., Godley, M.D., Schwebel, R. (2001). An overview of the effectiveness of adolescent substance abuse treatment models. Youth & Society, 33(2): 143-168.
Pollio, D.E. (2002). Training and certification needs for adolescent addiction treatment. Presentation to the Center for Substance Abuse Treatment/Robert Wood Johnson Foundation Adolescent Treatment Summit. Rockville, MD.
Sampl, S. & Kadden, R. A. (2001). Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions, (DHHS Publication No. (SMA) 01-3486, Cannabis Youth Treatment (CYT) Series, Volume 1). Rockville, MD; Center forSubstance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Retrieved from: http://www.chestnut.org/LI/cyt/products/MCB5_
CYT_v1.pdf.
Stevens, S.J. & Morrall, A.R. (2003). Adolescent Substance Abuse Treatment in the United States, New York: Haworth Press.
White, M.K., White, W.L., Dennis, M. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor Magazine, 5(2): 24-28 (this issue).
White, W. L., Dennis, M., Tims, F.M. (2002). Adolescent treatment: Its history and current renaissance. Counselor, 3(2): 20-23.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2004, v.5, n.2, pp. 12-17.

---

Comments

Add New Search RSS

Write comment
Name:
Email:	do not notifynotify
Title:
UBBCode:	-color-aquablackbluefuchsiagraygreenlimemaroonnavyolivepurpleredsilvertealwhiteyellow -size-tinysmallmediumlargehuge
	Please input the anti-spam code that you can read in the image.

Powered by !JoomlaComment 3.25

3.25 Copyright (C) 2007 Alain Georgette / Copyright (C) 2006 Frantisek Hliva. All rights reserved."