There has been dramatic growth in the study and treatment of adolescent substance use disorders in the past decade. Accumulating clinical experience and research findings reveal the critical need for more rigorous approaches to post-treatment continuing care services for adolescents (White & Godley, 2003). This article: 1) provides a brief summary of the available data relevant to the continuing care needs of adolescents, 2) describes the Assertive Continuing Care (ACC) model and its preliminary outcomes, and 3) offers recommendations related to the future of continuing care services for adolescents treated for substance abuse and substance dependence.

The need for assertive continuing care
Adolescent substance use disorders present along a continuum. At one end these disorders may be of low severity and may not require professional intervention for improvement to occur. At the other end of the continuum, the disorder is characterized by relapse, which often leads to severe problems and may require repeated professional intervention. Adolescents presenting with the latter pattern are characterized by greater personal vulnerability (e.g., family history of substance problems, early onset of use, traumatic victimization), problem complexity (e.g., psychiatric comorbidity), and lower recovery capital (e.g., self-efficacy, family and social support) to initiate and sustain recovery (White, Dennis & Godley, 2002).

The issue of high problem severity and chronicity are concerns throughout the treatment system. Of people admitted to public treatment in the United States, 60 percent have been in treatment before (including 23 percent 1 time, 13 percent 2 times, 7 percent 3 times, 4 percent 4 times, and 13 percent 5 or more times) (OAS, 2001). In the recently completed Cannabis Youth Treatment study, 41 percent of the 600 adolescents in the study failed earlier attempts to quit substance use on their own, a quarter had one or more prior treatment episodes, and a third were re-admitted to treatment in the year following their discharge from the CYT study (White, Dennis & Godley, 2002). In the face of such evidence, there are growing calls to shift addiction treatment from an acute model of intervention (e.g., relatively brief residential or outpatient treatment without ongoing monitoring and support) to a model of sustained recovery management analogous to the treatment of other chronic health conditions such as coronary heart disease or diabetes (McLellan, Lewis, O’Brien & Kleber, 2000; White, Boyle, & Loveland, 2002).

The evidence supporting the need for this shift is substantial. Adolescents with multiple and severe problems are most often referred to residential programs that serve multi-county or multi-state catchment areas (Bukstein, 1995). The geographical distance between these treatment centers, the living environments of their clients, and the lack of post-treatment recovery support services (e.g., outpatient treatment, school-based recovery support groups) within their home communities pose significant challenges to providing continuity of care.

Even when outpatient resources exist, admission and/or retention in services is very low (Godley, Godley, & Dennis, 2001). Rates of relapse following adolescent substance abuse treatment are quite high, with studies reporting relapse rates of 60-80 percent in the year following residential treatment (Brown, Vik, & Creamer, 1989; Godley, Godley, & Dennis, 2001). Most such relapses occur within the first 90 days following discharge from treatment, with many occurring in the first few days and weeks following treatment (Dennis, Dawud-Noursi, Muck, & McDermeit, 2002). Such evidence has spawned calls to increase continuing care services following discharge from treatment (Kaminer, 2001).

It had been earlier assumed that adolescents could sustain treatment gains in their natural environment once recovery was initiated, but this assumption is challenged both by the above findings and additional evidence that many adolescents discharged from substance abuse treatment return to family and/or peer milieus characterized by multiple problems, active substance use, and minimal support for long-term recovery (Godley, Godley, & Dennis, 2001; Brown et al., 2002).

Continuing care services for adolescents vary widely across treatment programs, and may include step-down to lower levels of care, professionally directed continuing care groups, referral to self-help groups, and linkage to recovery homes (or other transitional living environments). Participation in continuing care services can reduce relapse rates (Donovan, 1998; McKay, 2001), but adoescent participation rates in continuing care are very low, with a recent study noting that only 36 percent of adolescents received any continuing care following discharge from treatment (Godley, Godley, & Dennis, 2001). Similarly, participation in recovery self-help groups such as Alcoholics Anonymous (AA) is associated with improved recovery outcomes (Kelly, Myers, & Brown, 2000), but adolescent participation in recovery self-help groups such as AA and NA suffers from lack of geographical accessibility (particularly young people’s meetings), low initial engagement rates in the transition from treatment to the community, and high dropout rates following initial exposure. In a recent study conducted at Chestnut Health Systems, adults were three times more likely to attend AA/NA or other self-help groups after treatment than adolescents (Godley, 2004).

In summary, most adolescents are precariously balanced between relapse and recovery in the months following their discharge from substance abuse treatment. The evidence of low levels of natural support, low levels of continuing care and self-help group participation, and high post-treatment relapse rates is generating calls for more effective models of continuing care that can anchor, amplify and sustain the gains made in primary treatment. Developing continuing care models for adolescents has been plagued by theoretical biases (the acute care model) and miscalculations (assuming adolescents and their family will follow through on passive referrals to continuing care and self-help groups), the lack of research on continuing care models, and the lack of financing frameworks for sustained recovery-support services.

The Assertive Continuing Care Model
For the past 14 years, the Lighthouse Institute (the research division of Chestnut Health Systems) has worked to develop and evaluate an Assertive Continuing Care (ACC) model to enhance dolescent recovery outcomes. The ACC model differs in many significant ways from traditional “aftercare” programs. The model:
• shifts the responsibility for contact from the client to the service provider (thus allowing staff to meet with clients living a long distance from services and to minimize the significant “drop out” problem even when distance is not a factor,
• marshals recovery support services in the earliest transition from the treatment institution to recovery in the community,
• sustains such support longer than traditional outpatient models,
• uses an evidence-based, manual-guided continuing care protocol, and
• expands the target of continuing care beyond the adolescent to include the family/caregiver as well as other significant people in the post-treatment environment.

The ACC model combines the Adolescent Community Reinforcement Approach (developed for the Cannabis Youth Treatment study, see www.chestnut.org/LI/cyt) with case management aimed at facilitating the transition from primary treatment to sober living within the adolescent’s natural environment. The ACC model, delivered during the first 90 days following discharge from treatment, consists of 10 sessions between an assigned case manger and the adolescent, interim telephone contact between sessions, two sessions with the adolescent’s caregiver, and
two sessions with the adolescent and the caregiver. All sessions are conducted in a mutually agreed upon convenient
location, e.g., the client’s home, a local restaurant, or a local service facility.

The goals of the ACC model are to:
1) sustain recovery support in the transition from the treatment environment to the family and social environment of the adolescent starting in the first week after discharge,
2) increase the continuity and frequency of post-treatment contact with the adolescent,
3) monitor the post-treatment adjustment of the adolescent, including the early identification of thoughts, feelings and situations previously associated with substance use,
4) assist the adolescent in the development and refinement of cognitive and behavioral strategies to prevent relapse,
5) facilitate family communication,
6) actively link the adolescent and his/her family to resources that can address co-occurring problems,
7) actively link the adolescent to pro-recovery, pro-social relationships and activities, and
8) when necessary, re-intervene to shorten the duration and intensity of lapse/relapse and re-stabilize the recovery process.

We have found the ACC case manager to be one of the few sources of positive support in a youth’s life and the essential medium through which lessons learned in treatment could be applied to daily living.

The technical components of the ACC model include an assessment (functional analysis) of antecedents and consequences for both relapse (to develop prevention plans) and prosocial activities (to develop plans to increase), assignment of an ACC case manager before discharge from residential treatment which results in a pre-discharge get-acquainted meeting, a life-satisfaction survey, formulation of counseling goals, home visits, and ongoing case management services. The functional analysis of substance use provides a format for a case manager and a client to look at antecedents or triggers for use at the physical, emotional, social and behavioral levels and to dissect thoughts, feelings and behaviors associated with use. The functional analysis of prosocial behaviors assists the adolescent in identifying activities that support a positive, non-using lifestyle.

Considerable time is spent helping the adolescent identify and explore such activities, resolving obstacles to engaging in such activities and praising the client for engaging in these activities. The ongoing case management services involve monitoring (status assessment), service linkage and advocacy, and resolving problems as they arise (Godley, Godley, Karvinen, & Slown, 2001).

Supervision plays a critical role in ensuring that staff members delivering the ACC interventions are adhering to the model. Model fidelity is achieved by on-site monitoring of sessions by the supervisor and/or through review of recorded (usually audio-taped) sessions. Rating scales are used to assess each interview and to provide constructive feedback and praise related to the use of the ACC procedures.

Research on the ACC model demonstrated that when compared to standard aftercare, ACC produces superior continuing care engagement (a three-fold increase in linkage from treatment to continuing care when compared to statewide TEDS data and nearly twice as good as a randomly assigned control group), enhanced retention rates (a five fold increase in the median number of sessions attended), an expanded variety of continuing care services (e.g., family support, case management), and superior substance use outcomes (increased time between discharge and first use, reduced number of days using, increased probability of abstinence). In our first controlled study of standard aftercare and ACC, nearly twice as many ACC participants remained abstinent from marijuana and alcohol compared to usual continuing care participants (Godley, Godley, Dennis, Funk, & Passetti, 2002).

Failure to link adolescents into continuing care and post-treatment relapse is the norm in the United States. Preliminary evidence suggests that ACC can:
• be implemented in community-based substance abuse treatment settings,
• enhance adolescent engagement in post-treatment continuing care services,
• increase the number of continuing care sessions attended by adolescents and their families, and
• lower relapse rates and may enhance at least short-term recovery outcomes (ACC’s effect on long-term outcomes is currently being tested).
The future of adolescent
continuing care
Our need to know what works in the arena of adolescent continuing care is part of a broader adolescent recovery research agenda. Plotting the diverse pathways and styles of adolescent recovery from substance use disorders will help define the roles various continuing care models may play in the recovery process.
In the meantime, there is an urgent need to replicate continuing care studies such as ACC in diverse service settings, with diverse populations, and to test models over longer periods of time. Further innovations in ACC and other continuing care approaches should seek to answer a number of critical questions such as:
• How can “treatment fatigue” (particularly following prolonged residential treatment) be reduced or ameliorated to increase continuing care participation? Models of assertive continuing care may incorporate contingency management (Higgins & Petry, 1999) to increase motivation to participate in continuing care.
• How can ACC be adapted to levels of care other than residential treatment? There is a marked absence of continuing care models for adolescents whose primary treatment was outpatient care.
• How do we shift ACC from a model
of transitional support between
treatment and the community to a model of long-term recovery support and management. The first adult experiments are being published of this reconceptualization of addiction treatment from acute intervention to recovery management (see Stout, 2001; Dennis, Scott, & Funk, 2003), but no such experiments have yet been completed with adolescents.
• How can affiliation and retention rates with AA/NA and other self-help groups be increased? What existing recovery self-help groups and practices (e.g., specialized meetings, youthful sponsors) and linkage strategies exert the most positive effects on the long-term resolution of adolescent substance use disorders?
• Does the integration of professional-based models of monitoring and early re-intervention with peer-based models of long-term recovery support improve recovery outcomes?
• Are particular types of continuing care services associated with different recovery outcomes across demographic and clinical subpopulations? For example, ACC models may work better for adolescents with co-occurring disorders, particularly adolescents with serious mental illness whose medication adherence may be enhanced via the ACC protocol.
• What difference in effects exist for other kinds of approaches that can be done assertively (i.e., counselor takes responsibility for initiating/maintaining contact with the client). ACC was studied as a face-to-face approach but telephone — or Internet-based ACC models should also be tested with youth; particularly lower severity youth. There is great potential for the use of telephone (see Stout, et al., 1999) and Internet-based systems of monitoring (e.g., ongoing quarterly recovery checkups) and Internet-based systems of mutual support for recovering adolescents (virtual support networks via bulletin boards and instant messaging).
• How could the ACC model be further adapted to shape pro-recovery, family and social (peer) environments? Studies are needed on the ecology of adolescent recovery and approaches for shaping pro-recovery family and peer environments.

A call for reflection
Research on continuing care for adolescents leaving substance abuse treatment is in its infancy. There are many unanswered questions, but one finding is striking: Most adolescents will need an assertive continuing care approach. We hope this article has stimulated additional thoughts about continuing care for adolescents from Counselor readers. We welcome your thoughts and ideas on these issues and look forward to hearing from you in future issues of Counselor. Through continued sharing of ideas and research, we can advance an agenda for the future: to further develop, refine, and evaluate models of continuing care services and incorporate those models within adolescent treatment programs across the country.

Mark D. Godley, PhD ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is the Director of Research at Chestnut Health Systems.

Julie B. Payton, LISW ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is the Director of Clinical and Program Development at the Butler County, Ohio, Alcohol and Drug Addiction Services Board.

References
Dennis, M. L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2002). The need for developing and evaluating adolescent treatment models. In S. J. Stevens, & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study. Binghamton, NY: Haworth Press.
Brown, S. A., Vik, P. W., & Creamer, V. A. (1989). Characteristics of relapse following adolescent substance abuse treatment. Addictive Behaviors, 14, 291-300.
Brown, S.A., D’Amico, E.J., McCarthy, D., & Tapert, S.F. (2001). Four year outcomes from adolescent alcohol and drug treatment. Journal of Studies on Alcohol, 62, 381-389.
Bukstein, O. G. (1995). Adolescent Substance Abuse: Assessment, Prevention, and Treatment. New York: John Wiley & Sons, Inc.
Dennis, M. L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2002). The need for developing and evaluating adolescent treatment models. In S. J. Stevens, & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study. Binghamton, NY: Haworth Press.
Dennis, M. L., Scott, C. K, & Funk, R. (2003). An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. Evaluation and Program Planning, 26, 339-352.
Donovan, D. (1998). Continuing care: Promoting the maintenance of change. In W. Miller & N. Heather (Eds.), Treating Addictive Behaviors (2nd ed.), New York: Plenum Press.
Godley, M.D. (2004). Unpublished data.
Godley, S.H., Godley, M.D., Karvinen, T. & Slown, L.L. (2001). The Assertive Aftercare Protocol: A Case Manager’s Manual for Working with Adolescents after Residential Treatment of Alcohol and other Substance Use Disorders. Bloomington, IL: Lighthouse Institute

This article is published in Counselor,The Magazine for Addiction Professionals, December 2004, v.5, n.6, pp.49-54

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