Treatment for marijuana abuse among adolescents increased dramatically during the 1990s, yet no consensus exists on how to best treat this clinical population. Well-controlled clinical trials are lacking and most treatments examined have had difficulty documenting the initial periods of marijuana abstinence. Prior research with adult substance abusers has demonstrated that contingency-management (CM) approaches based on the empirically derived principles of behavior analysis and behavioral pharmacology can enhance outcomes achieved with standard psychosocial therapies. The primary aim of our current research program is to extend our prior treatment development research by creating an effective and developmentally appropriate contingency-management intervention for adolescent marijuana abusers.

Effective treatments for adolescent marijuana abusers must address two important factors. First, adolescents rarely seek treatment on their own accord, but rather are brought to treatment by their parents. Accordingly, they frequently do not perceive their marijuana use as a problem and motivation to quit using and remain abstinent is low. In contrast, parents consider their child's marijuana use a problem and are motivated to take action, but do not have the knowledge or skills to effectively change their adolescent's behavior. Our contingency-management intervention includes two components designed to address these issues. The incentive program is designed to enhance the adolescent's engagement in the treatment process and engender initial marijuana abstinence by providing immediate positive reinforcement for documented abstinence. Secondly, to teach parents how to effectively use contingency management in the home environment to motivate their adolescent and better manage substance abuse and related behavior problems. Our intervention uses a contrived reinforcement-based program (incentives) to motivate initial marijuana abstinence, and a naturalistic reinforcement-based program (parent-directed contingency management) to maintain motivation and positive change. Our research group has focused on the development of contingency-management interventions for substance abuse for the following reasons:

First, these interventions are firmly grounded in the empirically derived principles of behavior analysis and behavioral pharmacology. Behavioral theories suggest that drug abuse is explained in part by the fact that the most immediate consequences of drug use are potent, reliable, and desirable, which serves to strengthen drug-taking behavior. For example, substance use typically results in intoxication, euphoria, and acceptance by a peer group. In contrast, most negative consequences of drug abuse are delayed or inconsistent (academic failure, arrest, physical injury, etc.). Moreover, most adolescent substance use is not detected by parents, teachers, or other adults, and thus avoids immediate aversive consequences. Hence, these negative consequences do not effectively compete with the more immediate and consistent positive effects of drug use (Azrin & Holz, 1966; Zeiler, 1977).

Contingency-management interventions follow from this behavioral theory of drug abuse. Contingency management is one of the most thoroughly researched and effective behavioral procedures for increasing drug abstinence and other treatment targets (e.g., attendance, medication compliance) across adult substance-dependence disorders (Bickel et al., 1997; Budney et al., 2000; Higgins & Silverman, 1999; Stitzer et al., 1989). Contingency-management interventions typically involve abstinence-based incentive programs that use results from systematic urine testing to provide positive reinforcement contingent on documented drug abstinence. These incentive programs effectively engage clients in treatment, engender greater drug abstinence than standard therapies, and enhance abstinence rates and other behavioral outcomes when added to other behavioral therapies.

Our treatment model
We have developed and are testing a contingency management intervention for adolescent marijuana abuse. In October 2000, the State of Vermont's Office of Drug and Alcohol Programs provided treatment service funding for us to develop an assessment and brief intervention for youth aged 12-18 with substance abuse problems. They asked that we develop an intervention based on our behavioral treatment research models that might eventually be integrated into community programs for adolescent substance abusers. In response, we developed an intervention that includes four components: individual motivational/behavioral counseling for the adolescent, behavioral parent training for the parent(s)/guardian(s), systematic urine drug and breath alcohol testing, and abstinence- and participation-based incentives. Because our funding contract primarily called for assessment/brief intervention and not comprehensive treatment, we developed a four-session program that incorporated these components.

Parents and adolescents attend all four sessions. At each 90-minute session, the therapist first meets with the youth separately, then meets with the parent(s) alone, and then all meet briefly together. In Session 1, after a brief introduction that includes all attendees, the therapist conducts a DSM diagnostic interview, takes a substance abuse history with the adolescent, and discusses the youth's view of the problem and expectations of the process using a motivational interviewing style as described further in this article. Concurrently, the parent completes assessment materials in the waiting area. The therapist conducts a DSM diagnostic interview (regarding the youth) with the parent, discusses the problems and expectations from the parent(s) perspective, and introduces the contract parents will make with the teen about substance use while the adolescent completes assessment materials. Assessment instruments completed by the parent(s) and adolescent provide information on emotional and behavioral symptoms, school performance, social competence, beliefs about risk of substances and other risky behavior, behavior of friends, general areas of functioning, family problems, and readiness for changing substance use. In addition, the parent(s) completes self-assessments of their own emotional and behavioral functioning and parenting.

Cognitive-behavioral therapy (CBT)
We provide individual CBT to the teen in 40 minute, weekly sessions. We use the MET/CBT manual used in the Cannabis Youth Treatment trial (Dennis et al., preliminary findings). The format of the original MET/CBT is two individual sessions followed by three group sessions. Our decision to change the group sessions to individual sessions was made with experimental and clinical reasons in mind. First, there is empirical evidence that group therapies for adolescents with conduct problems might have detrimental effects on substance use due to negative peer influence (Dishion et al., 1999). Although these data need replication, given the choice, we opted for individual therapy to eliminate this possibility. Moreover, there is no evidence of the converse, that is, individual therapy is ineffective or worse than group therapy. Individual sessions also allow us to structure sessions such that the parent training and individual therapy can occur during the same clinic visit with the same therapist.

In the second session, the therapist and adolescent review and discuss assessment data via a written feedback report. Motivational interviewing is used to express empathy, deal with resistance, promote self-efficacy, and establish goals. The adolescent is introduced to the urine monitoring contingency-contract plan that will involve home-based, parental contingencies for substance use or abstinence. In sessions two-four, therapists also offer MET/CBT components designed to assist the adolescent develop and utilize skills for achieving and maintaining abstinence. These skills include: functional analysis of use patterns, marijuana (drug) refusal skills, enhancing social support, and coping with high-risk situations and relapse. In each session, the therapist provides a rationale for the specific skill, a presentation of skill guidelines, behavioral practice or role playing, and assignments for real life practice to be completed between sessions. A review and discussion of the assignment from the prior week always precedes the introduction of a new skill.

We have added one additional component, withdrawal coping training, to the CYT protocol that is theoretically consistent with this behavioral treatment approach and included in the coping-skills counseling provided in our studies with adults. Withdrawal coping training was initially developed because the majority of our marijuana-dependent adults reported a history of withdrawal when discontinuing their marijuana use and complained about withdrawal during treatment. Crowley and colleagues reported findings that suggest the same is true of adolescent marijuana abusers enrolled in treatment (Crowley et al., 1998). Therapists provide education concerning withdrawal symptoms and their expected time course. Relaxation, sleep hygiene, and imaginal rehearsal are provided as needed, and all teens receive a withdrawal-coping instructional tip sheet.

Urine monitoring for drug use
All teens provide urine specimens under direct staff observation according to a 1x weekly schedule during weeks one and two and a 2x weekly schedule during weeks three and four, for a total of six tests. All specimens are immediately screened for marijuana, cocaine, opioids, benzodiazepines, amphetamines, and methamphetamine. Teens and parents receive the results of the first two tests on their next visit to the clinic. After that, they receive the results within 10-15 minutes of providing the specimen. We use the Enzyme Multiplied Immunoassay Technique (EMIT, Dade-Behring) with a cutoff level of 50ng/ml for the primary active marijuana metabolite, 11-nor-delta-9-THC-9-carboxylic acid (THCCOOH) to determine marijuana abstinence. Cutoffs for the other substances tested are: cocaine- 300ng/ml, opiates-300ng/ml, methamphetamine-1000ng/ml, and benzodiazepine-300 ng/ml.

We have also used one-step immunochromatographic tests (Rapid Test and Testcup: Dade-Behring) because of their ease of use and potential for easier dissemination to community clinics. However, the one-step tests appear to be overly sensitive, that is, they tend to provide positive results when the THCCOOH levels are below the putative cutoff of 50ng/ml. This is particularly problematic for our contingency-management programs as we seek to provide positive reinforcement for abstinence as soon as we are able to determine with accuracy that the teen has not been using. The greater sensitivity of the one-step delays this process by as much as one to two weeks.

Two weeks of marijuana abstinence are generally needed to allow sufficient time for marijuana to clear the teen's system (i.e., negative urinalysis test for THCCOOH, 50ng/ml cutoff. That is, if a heavy daily marijuana smoker abruptly stops using marijuana, it takes up to two weeks for her or his urine specimen to test negative at this cannabinoid level. Thus, we wait this period of time before implementing the incentive program and the parent contract; otherwise, a teen may stop using, provide a specimen, but would be denied the incentive and receive an at-home consequence because their specimen would be marijuana positive. Although this may still occur on occasion, we recommend that parents use relatively mild consequences that last only until the next urine drug test. Teens are clearly informed and repeatedly reminded about the need to be abstinent for one-two weeks before urinalysis testing will result in a marijuana-negative finding. The other drugs we are testing for typically take three to seven days post use to test negative on the EMIT system at their respective standard cutoff levels.

We considered alternative methods that would allow us to reinforce abstinence more expediently than two weeks post cessation of marijuana use. Theoretically, a more immediate reinforcer would enhance the effect of the incentive program and perhaps increase abstinence rates. However, alternatives such as the use of quantitative urine screens to document abstinence by showing reduced cannabinoids in the urine specimens during the first two weeks of cessation have cost and logistic problems in their own right. Moreover, the reliability and validity of using even the most sophisticated quantitation procedure (e.g., sequential creatinine-adjusted cannabinoid levels) have not been sufficiently established for use in clinical populations of heavy marijuana smokers. Certainly, quantitative testing would need to occur almost daily to allow reliable interpretation of the results.

Contingent incentive program
At each session, teens receive an incentive for participating in the session (completing the interview and forms, interacting with the therapist, and providing an observed urine sample). The participation incentive is used to increase the probability that teens will comply with the program, including urine monitoring. Incentives have a monetary value, but the adolescents never receive any cash. Instead, our incentives are gift certificates purchased by a staff member or donated (e.g., movie passes, restaurants/fast food certificates, music store certificates, sporting equipment, or activities). Incentives cannot be lost once earned.

During weeks two-four, teens receive incentives contingent on providing urine specimens that test negative for marijuana and other drugs. In addition, parents must report that the teen has not used alcohol since the last scheduled urine test. We provide parents with disposable breathalyzers and instruct parents to use them upon any suspicion of alcohol use. Parent reports of alcohol use must be confirmed either by home breath alcohol tests or the admission of use by the adolescent. In addition, failure to submit a scheduled urine specimen is treated as a drug-positive specimen. An adolescent who appropriately participates in each session and remains continuously abstinent throughout weeks two-four would earn incentives worth approximately $90.

Parent contingency management training
General goals for the parents are to (a) model appropriate behavior, (b) increase monitoring of their youth's behavior, (c) learn to develop clear, consistent, and effective consequences for substance use, and (d) develop equally effective methods to motivate abstinence. Beginning with the second session, each parent session begins with a review of the urine drug test results and parent's reports of adolescent alcohol or drug use. A primary component of the parent sessions involve a behavioral contract between the therapist, parent(s), and youth focus on the results of the drug testing. The contract specifies positive and negative consequences that the parent will implement in response to obtaining urinalysis test results or breath testing for alcohol use. In addition, parents are educated about the importance of modeling abstinence from illicit drug use and abstinence or moderation of alcohol use. At sessions three and four, therapists review the contract and whether the parent implemented the reward or consequence. If the contract was not implemented, therapists problem solve with the parents about what interfered with implementing the contract and any modifications necessary for the next week. At session four, parents are provided with a comprehensive assessment summary including recommendations for addressing substance abuse and related issues following the program.

Patient characteristics
From February 2001 through July 2002, we enrolled and treated 60 youth (53 male and 7 female) aged 13-18 (M=15.9 yrs) and their parent(s) into this program. Seventy-seven percent of the adolescents tested positive for marijuana at intake and/or self-reported marijuana use in the 30 days prior to their first appointment. In addition, 60 percent of the adolescents met DSM criteria for marijuana abuse and/or dependence, 38 percent for alcohol abuse and/or dependence, 40 percent for nicotine dependence, and 10 percent for other substance abuse and/or dependence. Parental reports on the Child Behavior Checklist (Achenbach & Rescorla, 2001) indicated that 47 percent of these adolescents were in the clinical range for externalizing problems such as aggressive and rule-breaking behavior, and only 8 percent for internalizing problems such as withdrawal, depression, anxiety, and somatic complaints. Adolescent reports about their own behavior on the Youth Self Report (Achenbach & Rescorla, 2001) indicated that 25 percent of these adolescents were in the clinical range for externalizing problems and 27 percent on internalizing problems such as withdrawal, depression, anxiety, and somatic complaints.

Predictors of treatment outcome
Out of the 46 teens that tested positive for THC and/or self-reported marijuana use in the 30 days prior to their first session, 24 (52 percent) tested negative for THC four weeks later. We tested family functioning and parenting practices, plus teen psychopathology at intake as predictors of four-week outcomes. Family functioning included cohesion, communication, disorganization, and lack of support. Parenting practices included involvement, positive parenting, inconsistent discipline, and poor monitoring. Youth psychopathology included parent and youth reports of internalizing and externalizing problems. Outcomes included whether or not the teen's observed urine drug test was negative for THC at four-weeks and the number of THC positive urine drug tests during the four-week program.

The strongest predictors of THC positive urine drug tests at four weeks and of the number of THC positive tests during the program were parent ratings of externalizing problems and poor monitoring at intake. The more externalizing problems the parent reported for the teen and the worse monitoring parents reported before the start of treatment, the less likely the teen was to stop smoking marijuana. Teen ratings of their own psychological symptoms, both internalizing and externalizing, did not predict whether they would stop or continue smoking marijuana. In addition, teens of parents who reported better family cohesion had fewer THC positive urine tests, indicating they used less marijuana over the four-week program. Teens of parents who reported a lack of support in the family had more THC positive urine tests, indicating they used more marijuana over the four-week program.

Program results
Our program appears to motivate higher rates of documented drug abstinence among adolescent marijuana users than has typically been reported in the literature. In addition, our results also highlight the importance of information provided by parents at intake as important predictors of adolescent substance abuse treatment outcome. Parent reports of child psychopathology, family functioning, and parenting were more predictive of adolescent treatment outcome than were adolescent reports about their own behavior and their perception of family functioning. The high rate and importance of youth conduct problems as predictors of poor outcomes among substance abusers has led us to incorporate evidence-based interventions for youth conduct problems into our substance abuse treatment program. Further, the importance of poor parental monitoring as a predictor of continued adolescent substance use has led us to focus on parenting interventions that directly target monitoring of teens. We are currently conducting a research study that compares a 14-week intervention that includes individual cognitive-behavior therapy for the teen, contingency management training for parents, plus incentives to the same cognitive-behavior therapy intervention for the teen without parent contingency management or incentives to test whether these components improve treatment outcomes relative to the current best practice intervention for adolescent marijuana abuse.

Catherine Stanger, PhD, is Research Associate Professor of Psychiatry and Psychology at the University of Vermont. Her research on the treatment of adolescent marijuana abuse is funded by the National Institute on Drug Abuse.

References
Achenbach, T. M., & Rescorla, L. A. (2001). Manual for ASEBA School-Age Forms and Profiles. University of Vermont, Research Center for Children, Youth, and Families: Burlington, VT.
Azrin, N. H., & Holz, W. C. (1966). Punishment. W. K. Honig (Ed), Operant behavior. Areas of research & application. (pp. 380-447). Appleton-Century-Crofts: New York, NY.
Bickel, W. K., Amass, L., Higgins, S. T., Badger, G. J., & Esch, R. A. (1997). Effects of adding a behavioral treatment to opioid detoxification with buprenorphine. Journal of Consulting and Clinical Psychology, 65, 803-810.
Budney, A. J., Higgins, S. T., Radonovich, K. J., & Novy, P. L. (2000). Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. Journal of Consulting and Clinical Psychology, 68, 1051-1061.
Crowley, T. J., MacDonald, M. J., Whitmore, E. A., & Mikulich, S. K. (1998). Cannabis dependence, withdrawal, and reinforcing effects among adolescents with conduct disorder symptoms and substance use disorders. Drug and Alcohol Dependence, 50, 27-37.
Dennis, M. L., Babor, T. F., Diamond, G., Donalson, J., Godley, S. H., & Tims, F. The cannabis youth treatment (CYT) experiment: Preliminary findings.
Dishion, T., McCord, J., & Poulin, F. (1999). When interventions harm: Peer groups and problem behavior. American Psychologist, 54, 755-764.
Higgins, S. T., & Silverman, K. (1999). Motivating behavior change among illicit-drug abusers: Research on contingency-management interventions. American Psychological Association: Washington, D.C.
Stitzer, M. L., Bigelow, G. E., & Gross, J. (1989). Behavioral treatment of drug abuse. T. B. Karasu (Ed), Treatment of psychiatric disorders: A task force report of the American Psychiatric Association (pp. 1430-1447). American Psychiatric Association: Washington, D.C.
Zeiler, M. (1977). Schedules of reinforcement: The controlling variables. W. K. Honig, & J. E. R. Staddon (Eds), Handbook of operant behavior (pp. 201-232). Prentice Hall Inc.: Englewood Cliffs, NJ.

A Few Key Points
When marijuana first appeared in the southwestern U.S. in the early 1900s, it was referred to as "loco weed," thought to have been created as part of an "evil plot to make children rebel against their parents." Sixty years later, it became the generational revolution's "panacea of peace and love," while adults attacked it for "rotting the minds" of America's children. Research has since proven both ideologies dubious. Over the course of the past 40 years research has begun to shed some light on this topic. The most interesting discovery was that many systems in the body have receptor sites in place, which accept the active molecule Tetrahydrocannabinol (THC) in marijuana. Ten years ago, the first natural, brain-producing THC-like substance was discovered, and metaphorically named Anandamide (Sanskrit for "peace and tranquility"). We continue to uncover benefits from this chemical, such as the brain's pleasurable response to it, and it's activity in memory, learning, and coordination. Does this mean everyone should advocate the legalization or usage of marijuana? No.

Many of the negative effects of THC come from the result of it taking over a normal stabilizing function of the body through a more powerful, external source. Recurrent and heavy usage of THC can produce an addictive state ? particularly in susceptible people. Over time, the body will no longer produce its own THC, causing heavy users to feel dysphoric unless use continues. This higher dose of external THC disrupts the memory, learning, and subdues one's ambition and drive - producing "amotivational syndrome," colloquially known as "slacking."

The amount and length of time one has been using appears to be critical in the findings. Studies, using highly sophisticated brain scans, suggest that early and heavy usage before the age of 17 shows decreases in the normal growth of gray matter in the brain, which occurs during these years. Conversely, those who have started using after age 17 do not show this effect. Albeit, clinical studies also confirm this decreased learning ability to be reversible after six months of THC abstinence. However, often these adolescents find themselves 5-10 years behind in career and social development, making it difficult to catch up. Furthermore, when smoked (the most common method of usage), marijuana has thousands of other chemicals in it, which include carcinogens and irritants.

In conclusion, marijuana can have profound effects, both acute and chronic. Unfortunately, the most vulnerable areas of learning, emotional growth, and changes in immune and hormone areas occur during the early teen years. Heavy daily use during these years can produce significant short-term effects in learning, emotional growth, and brain development, which can be detrimental to one's social advancement.

James F. Mulligan, MD, ASAM, is the full-time Medical Director of Seabrook House, located in Southern New Jersey. Dr. Mulligan is certified by both the American Society of Addiction Medicine and the Academy of Family Physicians. Seabrook House has been helping families find the courage to recover from alcoholism and drug addiction since 1974.

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