It is this author’s belief that for a practice to qualify as evidence-based it must: be manualized for reproduction and dissemination; have performance and/or adherence measures; be associated with desired outcome; be feasible for a given setting/population; and be ecologically valid. Goldman, et al (2001) states that achieving consistently positive outcomes is at the heart of the definition of any evidence-based practice. Goldman makes the following points: not every problem has an evidence-based solution; and an evidence-based practice that works for a majority of persons who share similar symptom histories and needs, will not necessarily work for all such individuals.

Evidence-based practice for adolescent substance abuse
It is essential to understand the motivation for adolescent substance use. Lecca & Watts (1993) contend there are three motivations for adolescent substance use: a coping motive; a drug experience motive; and a peer motive.

Catalano, et al (1992) provides an excellent overview of risk factors for adolescent substance abuse, including the following macro, exo, meso, and micro components:

• laws and norms favorable toward behavior
• availability of drugs
• extreme economic deprivation
• neighborhood disorganization
• physiological factors
• family alcohol and drug behavior and attitudes
• poor and inconsistent family management practices
• family conflict
• low bonding to family
• early and persistent problem behaviors
• academic failure
• low degree of commitment to school
• peer rejection in elementary grades
• association with drug-using peers
• alienation and rebelliousness
• attitudes favorable to drug use
• early onset of drug use

Interestingly, the aforementioned risk factors also apply to delinquency, school refusal behavior, teenage pregnancy, violence, and mental illness. While Catalano, et al (1992) cites the risk factors for adolescent substance use and gives a more than adequate explanation, he offers no resolution for practitioners working with this group. If the above are risk factors for adolescent substance use, they are risk factors for adolescent relapse as well, and clinicians can use them to formulate relapse prevention plans.

Henngeler, et al. (2005) suggests three reasons why drawing conclusions about what works is more difficult in the field of adolescent substance abuse treatment than for juvenile offending.

First, relatively few studies have examined treatment effectiveness in the area of adolescent substance abuse, making it difficult to discern consistent patterns of outcomes across various treatment approaches. Second, the scientific rigor of much of this treatment research has significant limitations. For example, reductions in drug use of participants in uncontrolled studies (i.e., the treatment has no comparison group) are often given as evidence of the effectiveness of drug treatment, even though many other factors could have accounted for the reduction (e.g., maturation effects, regression to the mean effects). Furthermore, in controlled studies, investigators and reviewers often interpret time effects (i.e., positive change for participants across treatment conditions) as treatment effects (i.e., the change is due to the treatment per se). This conceptual misinterpretation has often led to the unsupported conclusion that everything works. Third, investigators tend to over-interpret favorable findings (i.e., when a favorable outcome is observed for only 10 measures, such as self-reported substance use. Yet, the outcome will be highlighted throughout the research report, even though it was not corroborated by the results of the drug screen measures on the same participants).

Based on the previous caveats, research views several approaches as reasonable for evidence-based practices for adolescents with substance abuse. The majority of reviewers conclude that family-based treatment approaches for adolescent substance abuse have shown the most promise. For example, Williams & Chang (2000) concluded that, “outpatient family therapy appears superior to other forms of outpatient treatment.” Waldron (2001) concluded that, “research findings provide ample evidence that family therapy is an effective treatment for adolescent substance abuse.” However it is Liddle and Dakof (1995) who best sum up the state of research on family-based treatment in their book, Efficacy of Family Therapy for Drug Abuse: Promising but Not Definitive.

Many difficult family therapy approaches have appeared in the literature, but few have empirical support. The following represents a list of promising approaches based on summaries and conclusions from the National Institute on Drug Abuse (NIDA, 1999), an agency that is charged by Congress to develop research based on the causes and treatments of substance abuse, and the Center for Substance Abuse Prevention, Schinke et al., (2001), which is charged with the mission of disseminating effective intervention programs.

Multisystemic Treatment (MST): Cited in both reports, MST has had exceptionally high rates of treatment engagement of substance abusing juvenile offenders (Henggeler, Pickrel, Brondino, & Crouch, 1996), and has produced favorable short-term (Henggeler, Pickrel & Brondino, 1999) and long-term (Henggeler, Clingempeel, et al., 2002) reductions in drug use.
Multidimensional Family Therapy (MDFT): MDFT (Liddle et al., 2001), cited by NIDA, has been the subject of considerable supported research. MDFT devotes substantive resources to building an alliance with each youth (e.g., about 40 percent of sessions are with adolescents alone) and reestablishing emotional connections between the adolescent and his or her caregivers (Liddle, 1999). This approach focuses more on family affective processes and less on behavioral conceptualizations of problems and their solutions. Nevertheless, the roles of extra familiar systems in maintaining problems are addressed through a case management process.

Contingency Management (CM): Cited by NIDA, CM (Donohue & Azrin, 2001) has produced promising results for substance-using adolescents. CM uses behavioral techniques to help youth: avoid situations associated with drug use; engage in pro-social activities incompatible with drug use; and change cognitions and feelings associated with drug use. Additionally, drug use is traced through frequent urine drug screens, and caregivers are empowered to reward abstinence and otherwise reinforce desired behavior change.

Brief Strategic Family Therapy (BSFT): BSFT (Szapocznik & Williams, 2000) cited by CSAP, also has received significant federal research support. BSFT is a structural family therapy approach in which adolescent drug abuse is viewed as the result of several types of maladaptive family interventions (e.g., inappropriate alliances scapegoating the adolescent). The therapist’s intervention initially aims at “joining” the family to gain an understanding of the types of repetitive family interactions that are linked with the identified problems. Later, the therapist actively restructures family relations with the goal of increasing the caregiver’s authority and facilitating more effective intra-family communication. (Although earlier studies failed to show differential treatment effects for BSFT, a recent report (Santisteban, et al., 2003) has demonstrated favorable short-term youth and family outcomes in comparison with group treatment.)

Functional Family Therapy (FFT): Though it is not cited in the NIDA or CSAP reports, FFT has been adopted by Waldron and her colleagues (Waldron, Slesnick, Brody, & Peterson, 2001) to treat adolescent substance abuse. The adaptation includes the integration of cognitive-behavioral therapy (CBT) strategies to teach the individual adolescent self-control and drug-refusal skills. CBT (Carroll, 1998) is a widely used, evidence-based treatment for substance abusing adults. The results of a randomized trial, (Waldron, et al, 2001), modestly supported the combined effectiveness of FFT/CBT over FFT in the reduction of adolescent drug use.

The challenge of co-occurring disorders
There is an increasing body of literature suggesting that among youth referred to substance abuse treatment, the majority have at least one co-occurring mental health disorder. Rates of co-occurring conduct disorder with substance use disorder (SUD) have been estimated to range from 50 to 80 percent in clinical populations (Myers, Brown & Mott, 1995; Milin, et al. 1991; Loeber, 1988). Other externalizing disorders, such as attention deficit hyperactivity disorder (ADHD), also are frequently referenced as co-occurring with SUD (Wilens et al. 1994; Kaminer 1992; Barkely et al. 1990) in adolescent treatment populations. The research literature reveals that internalizing disorders are associated with SUD as an antecedent of this disorder, as well as subsequent to the development of SUD. Mood disorders are second only to conduct disorders in their co-occurrence with SUD (Hovens, Cantwell & Kiriakos 1994; Bukstein, Glancy & Kaminer 1992; Deykin, Buka & Zeena 1992).

The association of post-traumatic stress disorder (PTSD) with SUD also has been supported in the research literature (Clark & Neighbors 1996). Reported rates of co-occurring PTSD and SUD in youths range from 25 percent for males to 75 percent for females (Kaminer 2004). Associations with subclinical trauma also have been noted in research studies as risk factor, frequently associated with youth engaged in substance abuse treatment (Dennis 2004).

A number of possible causal relationships exist between substance abuse and psychopathology. Several specific relationships are suggested by Meyer (1986), including: psychiatric symptoms or disorders developing as a consequence of substance use or abuse; psychiatric disorders altering the course of substance abuse; substance abuse altering the course of psychiatric disorders; psychopathology, both in the individuals and their families, as a risk factor for the development of substance abuse; and substance abuse and psychopathology originating from a common vulnerability. A critical opportunity exists within the mental health and substance abuse treatment systems to provide services that will address both disorders with the same staff, all of whom are cross-trained and understand substance dependence and mental illness.

Youth with co-occurring disorders in the juvenile justice system
Youths who are in the juvenile justice system often are left out of discussions of youths with co-occurring disorders of substance use and mental illness. Studies show that about half of all adolescents receiving mental health services have a co-occurring substance use disorder, and as many as 75 to 80 percent of adolescents receiving inpatient substance abuse treatment have a co-existing mental disorder. Adolescents with emotional and behavioral problems are four times more likely to be dependent on alcohol and illicit substances than are other adolescents; and the severity of a youth’s problem increases the likelihood of drug use and dependence, which are the two most frequently reported disorders that occur with substance abuse.

A major report, Youth with Co-occurring Mental Health and Substance Abuse Disorders in the Juvenile Justice System, was issued in December 2005 by the National Mental Health Association. The report outlines and reminds us that substance-abusing delinquents — specifically, youths in the justice system — are at especially high risk for co-occurring mental health disorders. The report states the following findings:

• Nearly two-thirds of incarcerated youth with substance use disorders have at least one other mental health disorder.
• A number of studies have shown an association between conduct disorder, ADHD, and substance abuse. For example, as many as 50 percent of substance abusing juvenile offenders have ADHD.
• Youth who have co-occurring conduct problems, ADHD, and substance use disorders have higher than normal rates of anxiety and depressive disorders; and the presence of ADHD in particular, worsens the prognosis of both the substance use disorder and the conduct disorder, increasing the likelihood of them persisting into adulthood.
• Among incarcerated youth with substance use disorders, nearly one-third have a mood or anxiety disorder.
• Delinquents with substance abuse and behavioral disorders, such as conduct disorder and ADHD, engage in higher rates of crime and exhibit more alcohol and illicit drug use than do youth with mood disorders; and are at higher risk for out-of-home placement and other poor outcomes.
• Many incarcerated youth are exposed to higher levels of traumatic violence, which may result in symptoms of post-traumatic stress as well as increased rates of substance use.

Adolescent girls in the juvenile justice system
In 1989, approximately 1.27 million youths were referred to juvenile court. Of those, approximately 118,700 to 186,000 met the criteria for at least one mental disorder. Further, it was found that the estimated number of youths having a diagnosable substance disorder ranged from 17,000 to 271,000 (Otto, Greenstein, Johnson, & Friedman, 1992).

A 1997 survey found that 84 percent of girls displayed the need for mental health assistance, compared to 27 percent of the boys, and that this number had increased over time. Conduct disorder was diagnosed most frequently (100 percent) followed by substance abuse (87 percent), mood disorder (80 percent), anxiety disorder (47 percent), and ADHD (20 percent) (Timmons-Mitchell et al. 1997).

Turner, Muck, Muck, Stephens, and Sukumar (2004) report concurrently that there are no well-researched and documented treatment protocols that adequately address both SUD and co-occurring mental health disorders. The implementation of co-occurring treatment interventions contains a unique set of challenges for programs that cut across many domains of organizational structure.

SAMHSA’s Integrated Dual Disorders Treatment: Implementation Resource Kit (Darmouth Psychiatric Research Center, 2003), includes tools to guide community mental health agencies through the steps to assess and change organizational structure for practicing integrated treatment. There are only a few pilot and/or published treatment studies specifically addressing the effectiveness of treatment for co-occurring disorders in youth.

Two evidence-based practices, MST and MDFT have potential application to this population of youth, and each is designed for specific targeted populations. MST is designed to treat youth involved in the juvenile justice system to reduce recidivism and mental health problems (Henggeler, Pickrel & Browndino 2000; Henggeler & Brondino 1995). MDFT is designed to treat youth with SUD (Liddle 2002). Both are attractive models in that they each utilize a home-based service delivery model and have a family focus for treatment. Both models have reported long-term positive outcomes in the domains they were developed to address. Positive outcomes also are reported for youth with co-occurring disorders when targeting youth with depression and substance abuse by integrating the cognitive-behavioral therapy (CBT) treatment interventions, to include social cognitive and family functioning.

Evidence-based practices for youth of color with co-occurring disorders
Absent in the literature on evidence-based practices for adolescents with co-occurring disorders, is any discussion as to whether the evidence-based practices that are efficacious for white youth are equally efficacious for youth of color who have co-occurring disorders. Some researchers believe that many of the evidence-based practices for co-occurring disorders are irrelevant to youth of color who are exposed to gangs, drugs, neighborhood disorganization, poverty, lack of opportunity, lack of recreational outlets, family chaos or dysfunction, and discrimination. They also feel that they have no ecological validity and fail to address the day-to-day challenges that adolescents — in particular, those of color — face. As previously stated, there are no well-researched and documented treatment protocols that adequately address both SUD and co-occurring mental health disorders in adolescents.

What evidence-based practices, if any, exist to address the co-occurring disorders of psychiatric and substance use disorders in youth of color? In Evidence-based Psychosocial Treatments for Ethnic Minority Youth: Review and Meta-analysis, Huey (2005) suggests we examine the following:

Anxiety-related Problems. Generally, the prevalence and structure of child anxiety disorders show little variation across ethnic groups (Ginsburg and Silverman, 1996; Last and Perris, 1993; Roberts, Solovitz, Chen,1996; Treadwell, Flannery-Schroeder, & Kendall, 1995). Thus, treatments that are efficacious with anxious children of European descent (Ollendick 1998) may also work for ethnic minority youth, because initial findings point to one treatment, CBT, that appears to be equally efficacious with minority and non-minority anxious youth.

Depression. Despite elevated rates of depression among Latino youth (Roberts, Roberts, and Chen, 1997; Twenge & Nolen-Hoeksema 2002), treatment outcome data for minorities with affective disorders is rare. Consequently, the only treatments validated with ethnic minority youth were conducted outside the continental United States — in Puerto Rico. Rossello and Bernal (1999) randomly assigned 71 Puerto Rican adolescents with major depression or dysthymia to CBT, Interpersonal Psychotherapy (IPT), or wait list control (WLC). CBT focused on identifying and changing negative dysfunctional cognitions, engaging in pleasant activities, and improving interpersonal interactions. Despite positive findings by Rossello and Bernal (1999), further work is needed to test the efficacy of CBT with Latinos in the continental United States and with other ethnic minority youth.

Substance use problems. Recent surveys show ethnic disparities in the prevalence and trajectory of adolescent drug/alcohol use in the United States. When compared with Euro-American and Latino youth, Native American youth report higher levels of drug and alcohol use, whereas Asian American and African American youth report lower use (Bachman et al., 1991; NIDA, 2003). Furthermore, the negative consequences of drug use on criminal justice involvement, morbidity and mortality, and educational outcomes are particularly pronounced for African American, Latino, and Native American adolescents (NIDA 2003). Thus, the development of successful drug and alcohol treatments could disproportionately benefit ethnic minority youth.

Unfortunately, no well-established treatments for minority youth with drug use problems were found. However, one treatment, MDFT (Liddle, 1999), did meet criterion as probably efficacious for minority youth. MDFT is a family-based, multi-component treatment that targets the multiple systems (e.g., family, school, work, peer) that contribute to the development and continuation of drug use. At the youth level, therapists focus on building youth competencies by teaching communication and problem-solving skills. At the family level, therapists work to change negative family interaction patterns, and coach parents in ways to appropriately engage with their children. Therapists also help family members gain access to concrete resources such as job training and academic tutoring.

In a randomized trial with ethnic minority youth (42 percent Latino, 38 percent African American, 11 percent Haitian/Jamaican), MDFT was compared with peer group therapy, a group-based cognitive-behavioral treatment (Liddle, Rowe, Dakof, Ungaro, & Henderson, 2004). Using growth curve modeling, the authors found that MDFT led to more rapid decreases in marijuana use than peer group therapy. This finding replicated results from an earlier evaluation of MDFT with drug using, predominately Euro-American youth (Liddle et al., 2001).

MST, another family-based treatment, similarly met Type 2 efficacy criteria for
drug-abusing minority youth. In a recent evaluation, 118 juvenile offenders with co-occurring drug abuse/dependence disorders were randomly assigned to MST or usual community services (Henggeler, Pickrel, et al. 1999). At post-treatment, MST youth reported lower marijuana/alcohol use and “other” drug use, although effects were not maintained one year later. At the four-year follow-up, MST youth again showed lower marijuana use when outcomes were based on urine/hair samples. However, no long-term treatment differences in self-reported drug use were found (Henggeler et al. 2002). Ethnicity (African American vs. Euro-American) did not moderate treatment outcomes at either assessment period (Henggeler, Pickrel, et al. 1999; Henggeler et al. 2002).

Thus, at least two treatments show some success in treating minority youth with drug use problems. However, given the differential consequences of illicit drug use for minority youth (NIDA, 2003), more work is needed in this area.

Michael Dennis, Senior Research Psychologist of Chestnut Health Systems (2005), offers seven common strategies, that may be implemented by agencies and their staff.

• Standardize assessment and identify most common problems.
• Pool knowledge about what staff have done in the past, whether it worked, and what the barriers were.
• Identify system barriers (e.g., criteria to local access case management, mental health) that could be avoided if thought of in advance.
• Identify existing materials that could help and make sure they are readily available on site.
• Identify promising strategies for working with the adolescent, parents, or other providers.
• Develop a one- to two-page checklist of things to do when this problem comes up.
• Identify a more detailed protocol and trainer to address the problem and then, go for a grant to support implementation.

Conclusion
In our work with adolescents with co-occurring disorders (i.e., substance dependence and mental illness), it is imperative that we remind adolescents of their responsibility to stay focused, to attend their groups, to take their medication, to keep their doctors’ appointments, and to look for alternative ways to manage anger. It is equally important for staff to be held accountable for the practices utilized and to be able to justify their use.

There is a principle in therapy that is sometimes lost; that is, “Never ask a client to do something that we are not willing to do.” If we expect clients to be responsible for their behavior (and we should), we must be able to account for the practices we use in their treatment, because so much — their lives, in fact — are at stake.

Fred Dyer, PhD, CADC, is a internationally recognized speaker, trainer, author, and consultant who services school districts, social service agencies, corporations, mental health facilities adolescent, substance abuse prevention programs, youth camps, and probation offices in the areas of violence prevention, substance abuse, family and adolescent issues, and childhood.

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This article is published in Counselor,The Magazine for Addiction Professionals, April 2006, v.7, n.2, pp.28-35.

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