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Feature Articles -
Adolescents
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Written by Dr. Susan H. Godley and Mychele Kenney, MS, LCPC
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Thursday, 27 May 2010 10:10 |
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The implementation of Evidence-Based Treatment (EBT) is increasingly being encouraged by funders and considered best practice by many treatment professionals and accrediting bodies. There are now several EBTs that have been developed, tested and found effective with adolescents who have substance use disorders (Dennis et al., 2004; Springer & Rubin, 2009; Waldron & Turner, 2008). However, most of the EBT manuals that have been developed are designed for outpatient or community-based service delivery. Little has been written about how these treatments might be implemented in existing adolescent residential treatment programs. Moreover, many residential treatment professionals learn about these EBTs at conferences or by reading the literature, but find almost no information to help them tailor these approaches to residential settings. In the United States, most adolescent residential treatment programs use a modified version of the Therapeutic Community (TC) approach (Morral et al., 2003; Shane et al., 2003). The TC approach was originally developed by recovering individuals for adults, and modified to enhance its applicability for adolescents. Some of the hallmarks of this approach are phases of treatment that participants progress through based on their behavior in treatment, and an expectation that individuals will change in multiple life areas through what is learned from their peers in the community setting. As they progress through treatment phases, individuals earn additional privileges. Conversely, for rule infractions, individuals can lose privileges or receive punishments. Adaptations for adolescents have included: the use of less confrontation; increased emphasis on education; more supervision; and greater involvement of family (Jainchill, 1997). Since TC approaches have been so dominant for residential treatment, most residential programs for adolescents probably employ some of these components and elements of 12 Step approaches, and these sometimes may appear incompatible with EBTs. It is no small task to change any existing treatment program, and residential treatment systems present some unique challenges. The biggest difference between outpatient treatment and residential programs are the number of hours that youth are involved in services. In residential treatment, staff are responsible for youth 24 hours a day and must constantly monitor them and ensure they are engaged in productive and therapeutic activities for the requisite number of hours each day that are typically prescribed by state licensing. When programs have been in existence for a period of time, staff at all levels develop routines and can be resistant to change. Residential programs, in particular, employ a large number of shift staff who do not have the academic training or experience of licensed clinicians, so management must evaluate appropriate expectations for their skill level and determine how best to train them in new skills. Moreover, it has been documented that clinical staff in the substance use treatment field have high turnover rates, and these rates are probably highest among paraprofessional staff, which contributes to the difficulty of quality staffing for 24-hour programs. Finally, since most EBTs are not going to fully replace an existing approach in a residential treatment program, consideration must be given to how the new EBT will integrate with and enhance the treatment experience. Adolescent Community Reinforcement Approach
This article describes a case study of the implementation of the Adolescent Community Reinforcement Approach (ACRA) (Godley et al., 2001) in an existing residential program. A-CRA is a treatment that is based on the theory that it is possible to help individuals change their environment to one that is reinforcing without the use of alcohol or other drugs. Therapists are trained to acknowledge that adolescents begin using these substances because they find their use and the associated socialization reinforcing. A-CRA clinicians work to help individuals identify other reinforcers and learn ways to access them. Adolescents also learn to identify antecedent behaviors that precede substance use and other problem behaviors, and how to interrupt these behaviors so that they do not lead to substance use. The approach emphasizes positive interactions during therapy, which is a developmentally more appropriate approach with adolescents than confrontation. Clinicians are trained to draw from a menu of 17 procedures—many of which behavioral or cognitive behavioral—that can be used based on issues presented during a therapy session (e.g., functional analysis of substance use, problem solving). One of these procedures is a one-page Happiness Scale, which allows participants to indicate their happiness in multiple life areas on a 1 to 10 scale. This exercise leads to another procedure, during which the clinician helps the adolescent develop goals in areas with lower ratings that are specific, stated positively and measurable, and emphasizes that treatment is more about helping these young people with multiple problems find ways to enjoy life, and not just about quitting alcohol and drug use. Description of the Existing Residential Program. The residential program in which A-CRA implementation took place is a 54-bed program that serves adolescents from Illinois between the ages of 13 to 18. It has been in existence since 1985, and is separated into three units: a female unit and two male units (one of which is a specialized long-term unit for more chronic or behaviorally disordered young men). The program’s approach has evolved with multiple components including: 12 Step groups; skill building groups; individual, group and family counseling; and a token economy system used to reinforce positive behaviors and discourage negative behavior/rule infractions. Like the TC model described above, adolescents progress through different stages of treatment. Adolescents also can attend an onsite school. Each unit is staffed with clinicians who are either licensed (LCPC or LCSW) or certified by the State of Illinois as alcohol and drug counselors. Clinicians have primary responsibility for the treatment of five to eight individuals and work varied hours, including some evenings. These clinicians provide ongoing assessment of individual needs; individual, group and family therapy; discharge planning; and some case management activities, such as maintaining contact with referral sources, probation officers, outpatient counselors and schools. The shift staff are called residential counselors (RCs) and their job duties include: serving meals; making sure that adolescents attend treatment groups on time; checking chore completion; facilitating certain didactic groups; monitoring the adolescents at all times; providing crisis intervention when professional staff are not available; and collecting urine screens. Each unit has a clinical supervisor who hires, trains and provides regular supervision to unit staff. There are additional staff who support the core staff, including curriculum specialists, recreation specialists, nursing staff and a consulting psychiatrist who provides ongoing psychiatric evaluation, consultation and medication management. An associate director coordinates all three units, and a director oversees both residential and outpatient services. Motivation for Change. The impetus for considering the adoption of a new EBT was quality assurance data that revealed the residential program was experiencing difficulty engaging and retaining young women. For three consecutive years, the young women’s unit had high rates of premature discharges, with many of these individuals returning to juvenile court/detention. During the year before A-CRA implementation, the percentage of young women successfully completing the program decreased from 45 percent for the previous year to 42 percent, and the average length of stay was 35 days (for a program designed as a minimum 90 day). Furthermore, management staff felt the existing treatment approach was focused too much on punitive consequences and not enough on rewarding positive behavior. For example, the token economy system was primarily used to mete out punishments, rather than to shape healthier and positive recovery-oriented behaviors. Since Chestnut has a research and training division that had led the adaptation and evaluation of A-CRA and was training Center for Substance Abuse Treatment (CSAT)-funded adolescent treatment providers around the country in this approach as part of the Assertive Aftercare and Family Treatment initiative (AAFT; TI-06-007), it was a logical EBT to investigate. Residential treatment staff reviewed the treatment manual (Godley et al., 2001) and the research supporting it (Dennis et al., 2004; Slesnick, Prestopnik, Meyers & Glassman, 2007), and made the decision to pursue staff training in the model for the residential female unit. Assessing Readiness and Commitment to Change. The decision to adopt a new EBT, because it seems like a good idea, is the first step in a long journey. The next steps are to understand as fully as possible what will be involved during the process of learning and implementing the intervention, and then assess program readiness and commitment to adopt the intervention. In order to assess readiness and commitment, there are a number of factors that must be considered, including: how the EBT will be integrated into the existing program; how quickly changes will be implemented; expectations of different types of staff (e.g., primary therapists, residential counselors); what the training process will entail; whether there is an organization level commitment to sustaining the training and implementation effort; how fidelity will be maintained; and how training will be sustained on an ongoing basis. These questions were discussed during meetings with the program director (M. Kenney), key staff and one of the model developers (S. Godley). The clinical management team decided to add A-CRA to the existing treatment model by increasing the number of individual sessions clinicians provided to adolescents and to train RCs in strategically selected procedures, based on what would be most helpful to them and the adolescents in the residential program. After learning about the rigorous training and certification model (described in Godley, Garner, Smith, Meyers & Godley, in press), the program director made a commitment to adhere to these expectations and implement the model with fidelity to the research-tested manual. Over time, additional plans were made to address sustainability. Implementation Begins. The decision was made to implement the EBT gradually because experience with another implementation effort had shown that attaining buy-in from strategically chosen opinion leaders helped facilitate the implementation process. Initially, one clinician and the female unit’s clinical supervisor attended training and began the A-CRA dual (clinician and supervisor) certification processes. Clinician certification is based on A-CRA expert reviews of therapy sessions, which are recorded with a digital recorder and uploaded to a web-based system. Experts then listen to the session and rate clinicians on the components of each procedure they attempt to implement and write narrative comments about how to improve their implementation (see Godley et al., in press). The hope was that the first clinician would like the model, training and certification experience, and would then become an internal champion for the model and influence other staff positively. The initial feedback from this clinician was very positive, and she perceived that her clients were responding very well to her use of A-CRA procedures, in short, supporting how management believed A-CRA would enhance treatment and providing the confidence to move forward with the rest of the young women’s unit staff. The remaining clinicians were trained and expected to become certified in 19 A-CRA procedures because management felt it was important that participants receive all of these procedures during their treatment episode. The decision also was made that shift staff or RCs would be expected to become certified in three A-CRA procedures that were especially relevant to issues that routinely arose on the residential unit, often in the late evening hours when other staff were not present. These procedures were communication skills, problem solving and anger management. In this way, the RCs were able to help adolescents practice their skills numerous times in real-life situations on the unit. Thus, problem interactions between the young women on the unit or between adolescents and staff often became opportunities for practicing positive life skills, rather than situations in which negative consequences were assigned. Management staff were instrumental in encouraging both licensed clinicians and RCs to practice procedures with each other and record sessions using procedures with adolescents. Certain staff members (especially those who were not trained with this type of feedback) were reluctant or fearful of recording their work because they were anxious about receiving the narrative feedback and an “evaluative” score of their work. To address this barrier, management staff were liberal with praise for progress and began offering small incentives for staff who recorded sessions. Once staff received their feedback from the expert reviewers and discussed it with their supervisor, the positive way in which feedback was given helped lessen their anxiety. Interestingly, although many staff felt that the clients would be uncomfortable with the digital recording, this has not been the case. In more than two years, there has never been an adolescent in the residential programs who has refused to be recorded.
Implementation Benefits. Overall, interactions between treatment peers and staff have become more positive, and they have a common language to use in certain challenging situations. For example, talking about an “Understanding Statement” (a component of communication skills) or “Cooling down” (a component of anger management) is commonplace. Since the model emphasizes a positive approach; focuses on each individual adolescent’s reinforcers; and encourages the use of praise, adolescents feel good about their time with clinicians and RCs. One example of changes related to increasing the availability of positive interaction is that prior to implementing A-CRA, the only attention that adolescents would receive after a urine test was if they tested positive for drugs; and this attention typically came with negative consequences attached. Adolescents are now praised for submitting negative (clean) urine screens (particularly when they return from passes to their home community).
Another benefit is that by incorporating RCs appropriately into this implementation effort, their training has become more systematic and focused to their role, and they have been able to learn important clinical skills. They are now seen more as part of the clinical team, and the adolescents appear more apt to respect their experience, knowledge and role on the unit. An added benefit is that several of the RCs have begun certification in procedures outside of Communication Skills, Anger Management and Problem Solving. The process has helped identify individuals who demonstrate potential to become clinicians, and it gives them opportunities for continued professional growth. Adolescents are given positive rewards including praise and behavior tokens, which can be exchanged for privileges like making a phone call, passes to leave the unit, or promotion to new levels. When participating in sessions with the RCs, they will often request to have a session to practice A-CRA related skills. The young women’s unit also has incorporated A-CRA procedures into its level system, identifying specific procedures that are appropriate, considering the level that the adolescent is at in his/her treatment experience. For example, prior to beginning overnight passes to their home environment, they should have participated in Refusal Skills and Relapse Prevention as well as Sobriety Sampling. Maintaining Model Fidelity. Maintaining fidelity is an important aspect to implementing any EBT. To emphasize the importance of attaining certification and maintaining model fidelity, policies have been written regarding these expectations, and job descriptions were re-written accordingly. By doing so, the management staff have demonstrated that competency in A-CRA delivery is just as important as other job duties like completing clinical records. Additionally, each month management staff produces and reviews a management report that provides data about where their staff are related to the certification process (e.g., number of digital sessions uploaded to the web tool, number of procedures passed), as well as competence shown during fidelity checks for those already certified. Clinical supervisors work with staff who are reluctant to record, or who are struggling to pass procedures during supervision sessions using a combination of review and role plays. It is important to note that a few staff in place at the beginning of the implementation project have not been able to adapt to the model, and if they could not, then objective criteria (based on reviews of in-session behaviors and progress in the certification process) were used to determine their continued appropriateness in their positions. Finally, quality improvement data suggested that retention on the unit had increased. In the year after implementation, for the first time in three years, the percentage of successful completions increased, from 42 percent in the prior year to 55 percent; and the overall length of stay increased in the year following implementation from 35 to 49 days across all discharge types (As Planned, Against Staff Advice (or AMA) or Administrative Discharge). Sustainability and Next Steps. Typically, funds are needed to support the training and implementation effort (e.g., training workshop, session ratings, management report production, coaching). Since the residential program was in the same organization as the national trainer, some in-kind services were provided, but these services were not going to be available on an ongoing basis. Since no new funds were available to help with sustaining the model, the implementation team had to be creative in developing mechanisms to sustain the training and certification process. Early on, a decision was made to train an individual who worked the night shift in how to rate the three procedures that RCs were required to learn. This individual had time available because adolescents were sleeping during this shift. The unit supervisor also completed the A-CRA clinical supervision process, which requires that an individual demonstrate appropriate A-CRA supervision skills during recorded supervision sessions and the ability to rate session recordings adequately when ratings are compared to an expert rater. Another aspect of this process is for one of the model developers to help shape an internal training process through iterative reviews of training agendas. This was done and a training team was developed, led by the Clinical Supervisor and the first clinician trained and certified in the model. The director of youth services also became a certified expert rater and took on the tasks of maintaining the certification workbooks (electronic spreadsheet for each staff member that shows ratings for each session and progress in certification), and assigning ratings to internal staff trained to do this. There are now regular trainings for new staff in A-CRA procedures. After the young women’s unit had been using A-CRA for a full year, management staff began discussing the possibility of bringing the model to the young mens’ units. Once again, the decision was made to implement in phases. Primarily due to the volume of recorded sessions that need to be reviewed during the initial certification process, it was decided to train staff on the shorter term male unit first. Also, staff on the long-term unit had the most concerns that the model would be inconsistent with their behavior management approach. In other words, they felt that A-CRA was too “soft” of an approach for the conduct disordered males. The short-term young men’s unit was trained in a similar manner to how the young women’s unit was trained, and the clinicians and the clinical supervisor were certified through combining help from the EBT training center and program resources. The young men’s unit has responded very favorably to the model and is experiencing some of the same success that the young women’s unit has experienced. Plans are now in place to spread the implementation to the long-term male unit. Recommendations for EBT Implementation in Residential Settings. Funding sources are increasingly requiring treatment programs to use EBTs, and parents are also asking questions about whether programs are using a treatment that has demonstrated effectiveness. As residential programs consider implementing EBTs, we suggest the following recommendations:
• Before EBT implementation begins, articulate the goal for implementing the EBT and how success will be measured.
• Anticipate implementation challenges (e.g., staff resistance to change) and how these might be addressed.
• Plan with key staff prior to implementation how an EBT will be integrated with the existing approach and how the existing approach may change. For example, if motivational interviewing was going to be implemented in a program that routinely uses confrontation and punishment, key staff would discuss how program practices would change to be more congruent with the new approach.
• Educate key staff about the training and competency requirements and ensure there is commitment from the top to fully implement the EBT with fidelity.
• Develop a phased implementation plan to help increase the manageability of the implementation process and build on successes.
• Develop multi-level implementation performance indicators and monitor them on a regular basis (e.g., monthly). For example, these can include indicators of clinician progress, supervisor progress and program level progress (e.g., number of competency criteria passed, number of staff achieving competency, whether the supervisor is achieving competency).
• Use creativity in developing a plan to sustain the EBT after initial stages of implementation (e.g., involve shift staff in fidelity assurance work, praise staff for meeting fidelity goals over time).
Dr. Susan H. Godley is a Senior Research Scientist at the Lighthouse Institute of Chestnut Health Systems in Bloomington, IL and directs the Evidence Based Treatment Coordinating Center there. She has been a Principal or Co-principal Investigator on several CSAT, NIAAA, and NIDA adolescent studies.
Mychele Kenney, MS, LCPC is the Director of Youth Services at Chestnut Health Systems in Bloomington, Illinois.
Acknowledgements: This work was supported by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), CSS SAMHSA contract No. 270-07-0191. The opinions herein are solely those of the authors and do not represent the position of the U.S. Government. The authors would like to acknowledge the staff of Chestnut Health Systems’ Odyssey and Discovery Units, with special thanks given to Neal Hubbard and Kelly Luckey. The authors would also like to acknowledge Joan Hartman for her administrative support and commitment, Mark D. Godley for reviewing a draft of this article, and Stephanie Merkle for editorial assistance.
References
Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J. & Funk, R. R. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197–213.
Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J., & Godley, M. D. (in press). A large-scale dissemination and implementation model. Clinical Psychology: Science and Practice.
Godley, S. H., Meyers, R. J., Smith, J. E., Godley, M. D., Titus, J. C., Karvinen, T. & Kelberg, P. (2001). The Adolescent Community Reinforcement Approach (ACRA) for adolescent cannabis users, Cannabis Youth Treatment Manual Series Vol. 4 (DHHS Publication No. (SMA) 01–3489). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.
Jainchill, N. (1997). Therapeutic communities for adolescents: The same and not the same. In G. De Leon (Ed.), Community as method: Therapeutic communities for special populations and special settings (pp. 161–178). Westport, CT: Praeger.
Morral, A. R., Jaycox, L. H., Smith, W., Becker, K. & Ebener, P. (2003). An evaluation of substance abuse treatment services provided to juvenile probationers at Phoenix Academy of Los Angeles. In S. J. Stevens & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study (pp. 213–232). Binghamton, NY: Haworth Press.
Shane, P. A., Cherry, L. G. & Gerstel, T. (2003). Thunder Road adolescent substance abuse treatment program. In S. J. Stevens & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study (pp. 257–284). Binghamton, NY: Haworth Press.
Slesnick, N., Prestopnik, J. L., Meyers, R. J. & Glassman, M. (2007). Treatment outcome for street-living, homeless youth. Addictive Behaviors, 32, 1237–1251.
Springer, D. W. & Rubin, A. (2009). Substance abuse treatment for youth and adults: Clinician’s guide to evidence-based practice. Hoboken, NJ: John Wiley & Sons.
Waldron, H. B. & Turner, C. W. (2008). Evidence-based psychosocial treatments for adolescent substance abuse: A review and meta-analyses. Journal of Clinical Child and Adolescent Psychology, 37, 238–261.
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Feature Articles -
Adolescents
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Written by Jan Copeland, PhD and Greg Martin, PhD
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Wednesday, 26 May 2010 15:38 |
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Editor’s Note: This article was adapted from an article that ran in the Journal of Substance Abuse Treatment (JSAT), in accordance with a partnership agreement between Counselor Magazine and JSAT, to bridge the gap between research and clinical practice in the addiction field. Cannabis (marijuana) is used by approximately four percent of adults worldwide, with highest prevalence rates in Oceania (including Australia and New Zealand) and North America (UNODC, 2008). In the United States and Australia in particular, trends towards a reduction in cannabis use among adolescents in the eighth to twelfth grade, as indicated in the Monitoring the Future Surveys (Johnston, O’Malley & Schulenberg, 2009; AIHW, 2008); and among 14- to 19-year-olds in the Australian population surveys is laudable, however, these figures still represent a considerable population of young people who use cannabis. While most cannabis use remains experimental and irregular, the incidence and intensity of use typically increases over the mid- to late-teens (e.g., Coffey et al., 2000), before a decline in use from the mid-20s, which has been associated with the transition to new roles and responsibilities (e.g. Chen & Kandel, 1995). A minority of young people, however, report use patterns that increase the likelihood of long-term use and dependence, regular use of other drugs and exposure to cannabis-related harms. A range of studies identify early initiation and regular use in adolescence as significant risk factors for later problematic cannabis (and other drug) use, impaired mental health, delinquency, lower educational achievement, risky sexual behavior and criminal behavior (Copeland & Swift, 2009).
Few adolescents reporting substance use disorder symptoms receive treatment, although there have been large increases in those presenting for cannabis-related problems in the United States, typically to outpatient settings (Muck, Zempolich, Titus, et al., 2001). While there is still a developing evidence base, several clinical trials indicate that for this group family-based and cognitive behavioral therapies have yielded promising outcomes, particularly when supplemented by contingency management (Stranger, Budney, Kamon & Thostensen, 2009). To complement these tertiary treatments, there is clearly a need for active secondary prevention efforts to target young people at an early stage of their cannabis use in an effort to minimize problematic use; promote problem recognition; and facilitate informed choice regarding cannabis use and its potential consequences. Several recent studies on the use of brief motivational enhancement treatment (MET) approaches with adolescent substance users have shown promising results (see Monti, Colby and O’Leary, 2001 for a review). One of these approaches is the Cannabis Check-Up, a brief motivational intervention modeled after the Drinkers’ Check-Up for problem drinkers (Miller & Sovereign, 1989). The basic Check-up model comprises a two-session assessment and feedback intervention in which a clinician helps the participant to make informed choices regarding their substance use. The participant’s substance use is not labeled problematic and there is no confrontation regarding use. A non-judgmental atmosphere is provided, in which questions may be asked and the participant is accepted as the expert on his or her own life. No overt attempts are made to make participants change their use, unless requested by them. Two recently published feasibility studies, the Teen Marijuana Check-up (Berghuis et al.,2006) and the Adolescent Cannabis Check-up (Martin et al., 2005) employed similar brief (two to three session) motivational enhancement therapies. The studies targeted non-treatment seeking adolescents and focused recruitment efforts on schools and the general community, respectively. Both studies reported significant reductions in the frequency of cannabis use at three month follow-up. The absence of control groups, however, precluded drawing causal inferences regarding the impact of the intervention. Nonetheless, it was demonstrated that this type of intervention could attract young cannabis users and was rated positively by them. A subsequent randomized trial (Walker et al., 2006) examined the school-based brief intervention compared with a three-month delayed treatment control group. While, overall, participants significantly reduced their cannabis use during the follow-up period, there were no differences found between the two groups. The authors suggest that the baseline assessment itself (which included components such as the perceived “pros and cons” of cannabis use), may have prompted a self-evaluation and acted as a form of brief intervention.
The current study builds on the promising findings of the Adolescent Cannabis Check-up (ACCU) (Martin et al., 2005) feasibility study with a randomized trial of the intervention. We targeted both young people directly, irrespective of their treatment seeking status, and worked with others in the general community to recruit participants for the study. Current study
The study assessed the efficacy of a brief (two session) motivational and cognitive behavioral intervention for adolescent cannabis users (ACCU) compared with a delayed treatment control (DTC) group in a randomized trial. It was hypothesised that quantity and frequency of cannabis use and symptoms of cannabis dependence would decrease significantly more in the group allocated to immediate intervention. Selection criteria. The target group were young people aged 14 to 19 years recruited from the general community. In order to make the intervention available to a range of young cannabis users, the inclusion and exclusion criteria were broad. Participants were required to be aged 14 to 19 years and to have used cannabis at least once in the past month. Reasonable fluency in English also was required. Adolescents were excluded if they showed evidence of significant cognitive impairment; if they had used more than 80 grams of alcohol per day on average and/or other illicit drugs more than twice weekly in the past 90 days; were current injecting drug users; or they had received treatment for drug or alcohol issues in the past 90 days. Procedure. The study obtained approval from the Human Research Ethics Committee at the University of New South Wales. A waiver of the requirement for parental consent for participants aged 14 to 18 was obtained to ensure their confidentiality (i.e., young people would not be required to self-disclose their cannabis use to parents in order to participate in the study). Recruitment efforts targeted both concerned parents and young people directly. Concerned parents were included in recognition of the reality that it is parents (or concerned others), rather than young people themselves, who most commonly seek assistance for an adolescent’s cannabis use (Muck et al., 2001). It was intended to enlist parents to assist in the recruitment of their young person into the study. Concerned parents who contacted study personnel were offered an opportunity (in person or by telephone) to discuss their specific concerns with a project clinician. General cannabis information and a discussion of communication skills were offered. The details of the intervention study also were discussed, with suggestions of strategies the parent might use to encourage the young person to participate. (Details of screening, randomization, procedure and data analysis can be found at Martin & Copeland, 2008). Participants were followed up by an independent researcher three months after their last involvement with the project. Participants were not paid for their involvement in the earlier sessions but were given a $25 gift certificate upon completion of the three-month follow-up interview. The intervention
The content of the intervention was manualized (see brief description below); and the overall style was non-judgmental with an emphasis on engagement and acceptance to promote a spirit of collaboration.
The intervention included rapport-building, and gave the young person discretion and responsibility for decision-making and behavioral change. Sessions were recorded on audio tape and audited by an independent clinician using a structured rating system to assess content delivery, adherence to the intervention protocol and therapist competence.
Session 1: Assessment interview
In the initial session, the clinician collected assessment data on the participant’s substance use, including: quantity and frequency of use; positive and negative consequences of use; the individual’s life goals; readiness for change; and support networks. This information is used to prepare a Personalized Feedback Report (PFR) that is reviewed with the participant in the feedback session conducted approximately one week later.
The assessment interview can be downloaded from http://ncpic.org.au/static/downloads/workforce/cannabisinfo/assessment-tools/accu-baseline-
assessment.pdf. The measures, such as the Adolescent Cannabis Problem Questionnaire (Martin, Copeland, Gilmour & Swift, 2006) and the time-line follow-back can also be downloaded from this site. The range of psycho-educational materials prepared for the study can be downloaded from http://ncpic.org.au/workforce/alcohol-and-other-drugworkers/cannabis-information/resources/. These include cannabis facts for both parents and young people, as well as tips for talking with a young person about cannabis.
Session 2: Feedback and skills session
This session was typically held about one week after the assessment session. The clinician provided structured feedback and discussion of information including the individual’s quantity and frequency of cannabis use; money spent; comparison of use with age-specific normative data; the pros and cons of using cannabis; pros and cons of increasing/decreasing use; and perception of interactions between cannabis use and the individual’s longer term goals using a Personalised Feedback Report (PFR). The PFR can be ordered at http://ncpic.org.au/workforce/alcohol-
and-other-drug-workers/cannabis-information/order-resource. While reviewing the PFR with the participant during the feedback session, the clinician uses MET strategies (e.g., open-ended questions, reflections, reframing, expressing empathy, and avoidance of argumentation) to elicit the participant’s active and candid involvement in the session (Lawendowski, 1998; Miller & Rollnick, 1991). The general focus is on encouraging the young person to explore the personal meaning and implications of the information in an open and balanced fashion. Ambivalence is accepted as normal and is explored to assist the young person to explicitly consider both the pros and cons of cannabis use and non-use. Where the young person might not acknowledge cons associated with his or her cannabis use, the technique of asking “how would you know when you have a problem?” can be employed. Expressions of motivation for change are reinforced and resistance is minimized by giving attention to motivation both favoring and opposing change. If participants clearly express a desire to change their cannabis use, the clinician supports their self-efficacy by discussing various change options, including self-managed change or referrals to local drug treatment providers. Following the provision of feedback a second (optional) component of the session was offered which aimed to provide interested participants with pragmatic strategies for quitting and reducing use. This included a discussion of the nature of cannabis dependence; recognition of personal triggers; managing craving; goal setting; planning for change; behavioral self-monitoring; and relapse prevention. The participant and clinician worked collaboratively through a self-help guide to personalize these strategies for the individual.
The client workbook for this session can be downloaded at http://ncpic.org.au/static/downloads/workforce/training/strategy-workbook.pdf. Results
Participants. Participants included 40 young people aged 14 to 19 with a mean age of 16.5 years; and were predominately male (67 percent), non-indigenous Australians (88 percent) who lived with their parents (78 percent). About half (53 percent) were currently at school or studying elsewhere, with a majority (80 percent) either studying or employed. Poly-drug use was common. The majority of the sample reported use of alcohol (93 percent) in the past 90 days, with smaller (but still substantial) proportions reporting use of ecstasy (53 percent), amphetamine (45 percent), and cocaine (18 percent) during that period. The mean age of first cannabis use was 12.4 years. The majority of participants (92.5 percent, n=37) reported having used on a daily or near daily basis at some time, with this pattern of use beginning on average at age 14.1 years. Participants varied widely in their reported quantity and frequency of cannabis use, with a mean of 65/90 using days and an average consumption of 1,140 cones (water pipes) in the 90-day period. This equates to a mean weekly intake of 88.7 cones. The great majority of the sample (92.5 percent, n=37) met DSM-IV diagnostic criteria for cannabis dependence. The average score on the Severity of Dependence Scale (SDS) was 7.4, indicating some concern among these young people about their own cannabis use. Using a cut-off score of 4 on the SDS to indicate probable cannabis dependence (Martin et al., 2006) this measure also classified the majority (87.5 percent) of young people as dependent. A copy can be downloaded from http://ncpic.org.au/static/downloads/workforce/cannabisinfo/assessment-tools/severity-of-dependence-scale.pdf. Outcome at three-month follow-up. Of the 40 participants in the study, 32 were successfully followed up at three months, giving an overall follow-up rate of 80 percent. Of the intervention group, 90 percent (18/20) completed both sessions of the intervention. The mean length to follow-up was 114 days. Significant between group differences, in favor of the ACCU group, were found on the change scores of both the days of use and the number of DSM-IV dependence criteria reported. Differential reductions on the mean cones per week measure did not achieve significance, due in part to negative skew and an extreme outlier in the DTC group (see Martin & Copeland, 2008 for detailed findings). With regard to dependence symptoms, there was a substantial change in the proportion of the ACCU group meeting DSM-IV criteria for dependence at follow-up, with a reduction of 35 percent (from 100 percent to 65 percent), as compared with the DTC group’s reduction from 85 percent to 80 percent.
Participant evaluation. The intervention was rated positively by participants. Confidential satisfaction questionnaires were completed by participants in the intervention group following feedback sessions. These confirmed the non-judgmental nature of the intervention and the perceived value of discussing cannabis use issues, receiving feedback, and exploring the pros and cons of using and change. As in the feasibility study, none of the participants endorsed the statement that the feedback meeting was a “waste of time,” and a large majority (80 percent) indicated that they would be interested in further meetings to discuss their cannabis use, if additional meetings were available. In terms of their overall satisfaction with their participation, 90 percent reported they were “very” or “extremely” satisfied. Discussion
The aim of the current study was to examine the efficacy of a brief intervention in reducing cannabis use and cannabis problems among young people who were not necessarily seeking treatment or attempting to moderate their cannabis use. The limited final sample size of 40 participants was determined by time and resource constraints rather than the results of a power analysis based on previous findings. The participants recruited into this study also had considerably higher levels of cannabis use and dependence than those recruited into the feasibility study (Martin et al., 2005). We did however successfully recruit and retain a sample regular, non-treatment seeking cannabis users, many of whom were dependent.
Participation in the intervention (ACCU) condition was associated with greater reductions in frequency of cannabis use and number of cannabis dependence symptoms reported over the follow-up period. Differential change between groups in the mean quantity of use per week was found but did not achieve significance. The potential clinical significance of the reduction in dependence symptoms reported, however, is evident in the substantially reduced proportion of the ACCU group meeting DSM-IV criteria for dependence at follow-up; reduced from 100 percent of the group at baseline to 65 percent at follow-up. An important finding of the study was that the intervention was valued by the participants. Despite many being coerced (or encouraged) to participate, a large majority of participants reported they were “very satisfied” with their participation and considered it useful. This current study has a number of limitations including small sample size in addition to the baseline group differences. The intervention was, however, considered useful by participants and associated with greater reductions in cannabis use than the delayed treatment condition. Given the high levels of dependence in the study population this positive impact is very encouraging. The application of the cannabis check-up approach to the population to whom was originally targeted; those young people experiencing problems associated with their use but not yet meeting dependence criteria—is a priority. Further evaluation in a range of settings where young people may have cannabis-related problems, including criminal justice settings, also is required. The intervention could also be easily adapted to more youth-friendly modes of delivery such as web-based interventions and in this way may access this harder to reach and less dependent group.
Jan Copeland, PhD is a professor at the University of New South Wales in Sydney, Australia and the director of the university’s National Cannabis Prevention and Information Centre.
Greg Martin, PhD is a researcher at the Health Services Research Centre at Victoria University of Wellington in New Zealand.
Acknowledgements: This study was funded by the National Health and Medical Research Council. The authors wish to acknowledge Roger Roffman and James Berghuis (University of Washington, Seattle), and Robert Stephens (Virginia State University) for generously sharing their intervention materials. References
Australian Institute of Health and Welfare (2008). 2007 National Drug Strategy Household Survey: First results (AIHW Cat. No. PHE 98). AIHW: Canberra.
Berghuis, J., Swift, W., Copeland, J., Roffman, R.A. & Stephens, R.S. (2006). The Teen Cannabis Check-up. In: R.A. Roffman, & R.S. Stephens (eds.), Cannabis dependence: Its nature, consequences and treatment (International Research Monographs in the Addictions). London: Cambridge University Press.
Chen, K. & Kandel, D.B. (1995). The natural history of drug use from adolescence to the mid-thirties in a general population sample. American Journal of Public Health, 85, 41–47.
Coffey, C., Lynskey, M., Wolfe, R. & Patton, G.C. (2000). Initiation and progression in cannabis use in a population-based Australian Longitudinal Study. Addiction, 95, 1679–1690.
Copeland, J. & Swift, W. (2009). Cannabis use disorder: epidemiology and management. International Review of Psychiatry on Cannabis & Cannabinoids, 21(2), 96–103.
Johnston, L.D., O’Malley, P.M. & Schulenberg, J.E. (2009). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2008 (NIH Publication No. 09–7401). Bethesda, MD: National Institute on Drug Abuse.
Lawendowski, L. A. (1998). A motivational intervention for adolescent smokers. Preventive Medicine 27, A39–A46.
Martin, G. & Copeland, J. (2008) The Adolescent Cannabis Check-up: randomised trial of a brief intervention for young cannabis users. Journal of Substance Abuse Treatment, 34(4), 407–414.
Martin, G., Copeland, J., Gates, P., & Gilmour, S. (2006). The Severity of Dependence Scale (SDS) in an adolescent population of cannabis users: Reliability, validity and diagnostic cut-off. Drug and Alcohol Dependence, 83(1), 90–93.
Martin, G., Copeland, J., Gilmour, S. & Swift, W. (2006). The Adolescent Cannabis Problems Questionnaire: psychometric properties. Addictive Behaviors, 31, 2238–2248.
Martin, G., Copeland, J., & Swift, W. (2005). Adolescent Cannabis Check-up: feasibility study. Journal of Substance Abuse Treatment, 29(3), 207–213.
Miller , W. R. & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: The Guilford Press.
Miller, W. R. & Sovereign, R. G. (1989). The check-up: A model for early intervention in addictive behaviors. In T. Loberg, W. R. Miller, P. E. Nathan, & G. A. Marlatt (Eds.), Addictive Behaviors: Prevention and early intervention (pp. 219–231). Amsterdam: Swets and Zeitlinger.
Monti, P.M., Colby, S.M. & O’Leary, T.A. (Eds.) (2001). Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions. New York: The Guilford Press.
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 and Society 33, 143–168.
Stanger, C., Budney, A.J., Kamon, J.L. & Thostensen, J. (2009). A randomized trial of continency management for adolescent marijuana abuse and dependence. Drug and Alcohol Dependence, 105 (3), 240-247.
UNODC (2008). 2008 World Drug Report. Vienna: United Nations.
Walker, D.D., Roffman, R.A., Stephens, R.S., Berghuis, J. & Kim, W. (2006). Motivational enhancement therapy for adolescent marijuana users: a preliminary randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 628-632.
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Feature Articles -
Adolescents
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Written by David E. Smith, MND, FASAM, FAACT, Barbara Nosal, PhD, MFT, Mickey Troxell, MS, CATC, CEAT II and Scott Sowle
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Wednesday, 26 May 2010 15:28 |
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Approximately 90 percent of individuals who develop chronic substance dependence disorders with associated severe mental, psychiatric and behavioral problems start using illicit substances while under the age of 18 (Dennis 2002). However, the largest and most alarming drug problem among adolescents are prescription drugs, particularly prescription opioids diverted from the mainstream medical system, thus further blurring the line between legal and illegal drugs. Prescription drug use among adolescents is a red flag for poly drug abuse, especially if onset is prior to the age of 15 (Brook, Brook, Gordan et al 1990). Unintentional death involving prescription drugs in adolescence has increased 150 percent between 2001 and 2009. In fact, in 2008 the leading cause of death among adolescents is drug overdose, exceeding even highway fatalities (Cermak 2009). More than one-third of adolescents who began abusing drugs in the last year reported their first drug was a prescription drug. Under the age of 15, non-medical use of a prescription drug is a major indicator of illicit drug use replacing marijuana as the leading “gateway drug” into the illicit drug culture with diversion of prescription opioids, particularly OxyContin, being more available to youth than heroin in illicit drug markets. In a study conducted by John Hopkins, reported deaths from prescription drug overdose rose 273 percent between 2006 and 2008. The spike in deaths can be associated to a dramatic increase in the use of powerful pain killers, such as oxycodone, OxyContin and percocet. Edward Krenzelok, Director of the Pittsburg Poison Control Center, cites that these opioid pain medications are “being tremendously over prescribed and people are not aware of the high risk associated with improper use.” Diversion of prescription opioids from the adult parents involving parent’s medicine cabinets is a major source of drugs for adolescents who abuse prescription medicine (GAO, 2009; Rawson, 2008; Rothman, 2008; Schuckit, 1987; Smith, 2009). If addictive disease onset is before the age of 15, the severity and duration of disability associated with the addiction is prolonged. However, as described by the National Institute of Drug Abuse (NIDA), the earlier the intervention to disrupt the addiction cycle, the shorter the severity and duration. Earlier interventions and more intensive treatment requiring an inpatient phase with appropriate aftercare in a continuing care model is indicated, as outlined by Timmen Cermak, MD, of the California Society of Addiction Medicine (CSAM) in his “Blue Print for Adolescent Addiction Treatment” (Cermak, 2009) and Rick Rawson, PhD of UCLA Integrated Substance Abuse Programs in his “Continuing Care Model” (Rawson, 2008). Children who have a family history of alcoholism face a four-times greater risk of alcoholism. Furthermore, some studies suggest that inherited biological traits and psychological characteristics link genetics and substance use with a pattern of poly-drug abuse.
In males the strongest correlation is with attention deficit/hyperactivity disorder as a predictor of early onset addiction, whereas with women, it is depression and eating disorders. Multi-variant analysis, however, makes it difficult to separate genetic factors from the disruptive, dysfunctional and traumatic child rearing environments of the active alcoholic family, irrespective of the socio-economic status of the dysfunctional family (Costello et al, 2002). Risk factors NIDA outlines the major risk factors for early onset of addiction as:
• genetic predisposition to addiction in first order relatives;
• co-occurring disorders proceeding the onset of addiction;
• childhood psychological trauma; and
• disruptive addictive child rearing environments.
Genetic factors appear to play less of a role in early onset addiction than in adult models, with psychosocial trauma and disruptive child rearing environment playing a bigger role. With adolescent females, sexual abuse in a dysfunctional family environment has shown the strongest correlation with early onset addictive behavior. In working with high risk traumatized adolescents, a very careful clinical approach is to treat both the trauma and the addiction in an integrative fashion. Traumatized adolescents with addiction disorders often have great difficulties learning recovery skills as their attention is focused on family conflicts aggravated by post-traumatic stress disorder (PTSD) (Guchereau, Jourkiv, Zametkin, 2009). Treatment
Addiction treatment with female adolescents is less effective unless the psychosocial trauma is dealt with. Covington has outlined a Women’s Integrated Treatment (WIT) model that emphasized gender specific trauma-useful curriculum for the treatment plan (Covington, 2008; Zweben, 2003). Guchereau classified that PTSD among adolescents is significantly under diagnosed with a majority of the studies emerging from the juvenile justice system. This has led to the belief that psychosocial trauma and addictive disorder occurs primarily in criminalized adolescents from lower socioeconomic populations which dominate the juvenile justice system. As youth move up the socioeconomic scale, they interface more with the medical system rather than the criminal justice system, and the medical system is much more likely to underreport psychosocial trauma.
This has led to the mistaken belief that there is less psychosocial trauma in middle and upper class adolescents with substance use disorder. In fact, clinical experience has shown that there is a high degree of trauma with early onset addiction, but that it is more hidden and less likely to be criminalized. Upper socioeconomic alcoholic parents with dysfunctional family environments involving physical and sexual abuse retain a veneer of respectability hidden from law enforcement, which often focuses on lower socioeconomic populations (Guchereau, 2009; Merikanges, Rounsaville & Prusoff, 1992). Studies of the criminal justice system have found that an individual who is poor and non-white is far more likely to be arrested and receive a felony conviction than a white, middle class offender for the same drug offense (Human Rights Watch, 2002; 2009). Adolescents need a different treatment model for drug addiction than adults, one that focuses on habilitation emphasizing the teaching of psychosocial skills. Adults, on the other hand, require a rehabilitation model that focuses on returning to preexisting recovery skills.
Early onset addiction with co-occurring symptoms requires more clinical skills to deal with trauma in the past because of the denial, shame and guilt that exists in both the patient and the family (Dennis, 2008). Gender-specific treatment approaches
Clinical experience at Newport Academy has found a very high incidence of psychosocial trauma in young women with early onset addiction. Recent work in the trauma field has focused on traumatized youth to initiate their drug use in order to self-medicate or calm their inner turmoil. This population of adolescents with trauma, that predicted the onset of substance abuse, has a higher incidence of co-occurring disorders, particularly depression and eating disorders in young women. Studies estimate that one in four adolescents will experience at least one traumatic event in their lifetime before the age of 16. Additionally, there is a high correlation between trauma and the risk for substance abuse later in life. Teens who experience trauma and substance abuse have much higher incidence of academic, psychological and social impairments (Costello, et al, 2002). To improve clinical outcomes with this population, a gender-specific residential treatment model (as outlined by Newport Academy) provides these adolescents—who otherwise would be very reluctant to disclose such trauma—a safe and nurturing environment to discuss their experiences.
Such gender-specific treatment models afford adolescents an environment in which to build strong peer support, which is essential in the treatment process. Peer interaction can help facilitate discussions on sensitive issues, such as those of sexuality, assertiveness training, body image issues, the development of strong same-sex role models and the formation of healthy boundaries. In particular, the specific needs of adolescent girls should be addressed with residential programs identifying and allowing for the differences and needs of adolescent boys and girls. At Newport Academy, the majority of female residents admitted to the program have experienced trauma—most notably sexual abuse, date rape and sexual coercion. This trauma is not defined by socioeconomic status, and girls in treatment often experience a cluster of symptoms, including: an inability to connect emotionally with other residents or staff members; intrusive thoughts and a re-experiencing of the traumatic event; depression; intense distress; body image issues; self mutilation; guilt; shame; and poor self-esteem. It is critical that any residential environment provide a safe and nurturing setting for adolescent girls to explore these sensitive issues without the obvious distractions that a mixed-gender environment would provide. Research has shown that females in a mixed gender residential program tend to hold back in group settings and have a reluctance to share issues related to sexuality, abuse or rape. Addiction treatment programs can greatly increase their effectiveness through programs that provide gender-specific programming where adolescents are provided a place of healing and where their own experiences can be openly shared and valued (Miller, 2003). Gender-specific adolescent training approaches for adolescent substance abuse and co-occurring disorders at Newport Academy involve creating a safe therapeutic arena where confrontational approaches are not tolerated. The key elements of the clinical program include: appropriate assessment; involving the family throughout the adolescent’s treatment with an Intensive Family Program designed specifically for the identified adolescent and family at week four; developmentally appropriate groups reflecting the differences between males and females; experiential groups to keep teens engaged and to foster a climate of trust; an integrated treatment approach that addresses all the various aspects of the adolescent’s development and needs; and a highly qualified staff trained in substance dependency, co-occurring mental health disorders and adolescent development. In short, effective treatment for adolescents with substance abuse and co-occurring trauma requires interventions that address the unique challenges of both disorders in a gender-specific residential environment.
Dr. David Smith is the Past President of the American Society of Addiction Medicine, Founder of the Haight-Ashbury Free Clinics in San Francisco, Adjunct Professor at the University of California, San Francisco and Chair of Addiction Medicine at Newport Academy.
Barbara Nosal, PhD, MFT is a licensed Marriage and Family Therapist and is the Clinical Director at Newport Academy.
Mickey Troxell, MA, CATC, CEAT II is a nationally recognized Masters Level Equine Therapist and provides Equine-Assisted Psychotherapy at Newport Academy.
Scott Sowle is the Co-Founder and Executive Director of Newport Academy.
References
Blum K., Noble, E.P., Sheridan P.J. et al. (1990). Allelic association of human dopamine D2 receptor gene in alcoholism. Journal of the American Medical Association 263:2055–2060.
Brook, J.S, Brook, D.W., Gordon, A.S. et al. (1990). The psychosocial etiology of adolescent drug use: A family interactional approach. Genetic, Social, and General Psychology 116:111–267.
Cermak T. (2009). “A Blueprint for Adolescent Addiction Treatment,” CSAM Review Council.
Costello, E.J., Erkanli, A., Fairbank, J.A. & Angold, A. (2002). “The prevalence of potentially traumatic events in childhood and adolescence.” Journal of traumatic stress, United States 15(2): 99–112.
Covington, S. (2008). “Women and Addiction: A Trauma-Informed Approach,” Journal of Psychoactive Drugs, SARC Supplement 5. 377–385.
Dennis, M., Barbor, T.F., Roebuck, M.C. & Donaldson, J. (2002). “The Changing the Focus: The Case for Recognizing and Treating Marijuana Use Disorders,” Addiction 97: 514–515.
Dennis, Michael L., Iues, Melissa, White, Michelle K. & Muck, Randolph (2008). “The Strengthening Communities for Youth (SYC) Initiative: A Cluster Analysis of the Services Received, Their Correlates and How They Are Associated With Outcomes.” Journal of Psychoactive Drugs Vol 40 (1) pp 1–16.
Guchereau, M., Jourkiv O., Zametkin, A. (2009). “Mental Disorders Among Adolescents in Juvenile Detention and Correctional Facilities: Posttraumatic Stress Disorder is Overlooked.” Journal of the American Academy of Child and Adolescent Psychiatry, 481–340.
GAO. (2009). Methadone Associated Overdose: Factors Contributing to Increased Deaths and Efforts to Prevent Them. Report GAO 09-341, a report to congressional requesters.
Human Rights Watch. (2002). Punishment and Prejudice: Racial Disparities in the War on Drugs. Report, May 2000. Vol. 12 (2).
Human Rights Watch. (2009). Decades of Disparity: Drug Arrests and Race in the United States. Report, March 2, 2009. 22pp. www.hrw.org/en/
reports/2009/03/02/decades-disparity?
Krenzelok, Edward P., Rita MRVOS. (2009). Profile of medication identification requests managed by a U.S.-certified regional poison information center. Clinical Toxicology, 47, 364–365.
Merikanges, K.R., Rounsaville, B.J., & Prusoff, B.A. (1992). “Familial factors in vulnerability to substance abuse.” Glantz, M. and Picken, R. (eds.) Vulnerability to Abuse. Washington, DC: American Psychological Association, 75–97.
Miller, N. (2003). Consideration of Gender Specific Factors in the Development of Adolescent Alcohol and Other Drug Interventions and Treatment. Gender Differences in Drug Addiction and Treatment: Implications for Social Work Intervention with Substance-Abusing Women. Social Work, 40 (1), 45–54.
Rawson, R.A. (2008). “What is Substance Abuse Treatment and What is It Supposed to Do” CSAM Review Council.
Rothman, B., O’Gorman, P. (2008). Working With Traumtized and Addicted Adolescents. Counselor, 9 (6), 24–29.
Schuckit, M.A. (1987). Biological Vulnerability to Alcoholism. Journal Consulting and Clinical Psychology, 55, 301–309.
Smith, D.E. (2009). “Addictive Disease in Adolescence: A 40-Year Addiction Perspective” Counselor Magazine, 42–45.
Zweben, J. (2003). Special Issues in Treatment: Women. In Principles of Addiction Medicine, 3rd Edition. Chevy Chase MD: ASAM. 569–580.
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Feature Articles -
Adolescents
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Written by William L. White, MA, Arthur C. Evans, Jr., PhD, Sade Ali, MA, Ijeoma Achara-Abrahams, PhD and Joan King, APRN, BC
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Wednesday, 26 May 2010 15:08 |
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Addiction professionals across the country are being asked to lead or participate in efforts to shift addiction treatment from an “emergency room” model of acute biopsychosocial stabilization to a model of sustained recovery management (RM) and to nest addiction treatment within larger recovery-oriented systems of care (ROSC). These federal, state and local innovations have focused primarily on the redesign of adult addiction treatment services. This article summarizes a technical report prepared for the City of Philadelphia on potential advantages and limitations of recovery as an organizing concept for services to children (under age 13), adolescents (age 13 to17) and transition age youth (age 18 to 25). The report offers recommendations on how services for these populations can be integrated into recovery- and resiliency-focused behavioral health care systems transformation efforts. The full report (48 pages, 182 research citations) is available at http://www.facesandvoicesof
recovery.org/pdf/White/ChildAdolescents.pdf. Historical context
Since 2004, the City of Philadelphia has been engaged in a recovery-focused behavioral health care systems transformation process that has mobilized the community to create a recovery vision and align service concepts, practices and contexts (e.g., regulatory policies, funding mechanisms) to support long-term recovery for individuals, families and neighborhoods. Federal, state and local behavioral health policy and planning bodies are evaluating the extent to which recovery can be used as an organizing concept for child and adolescent (C & A) services. There is growing interest in creating recovery-oriented systems of care for youth that are family-driven; developmentally appropriate; culturally nuanced; highly individualized; and focused on youth resilience, strengths and empowerment. However, questions remain about the potential advantages and disadvantages of the recovery concept applied to services for children, adolescents and transition age youth. The average age of onset of AOD use of adolescents entering addiction treatment in the United States is now below age 13. This lowered age of onset of alcohol and other drug use is the most socially and clinically significant American drug trend of the past century. Lowered age of initial AOD use is linked to greater risk of developing a substance use disorder; accelerated problem development; greater severity of AOD-related consequences; and higher rates of post-treatment relapse. The concept of recovery is more applicable to children, adolescents and transition age youth today than at any previous time in the country’s history. Child development also can be adversely affected by AOD-related problems of parents or siblings. Children in AOD-affected families are at increased risk for developing such problems as well as experiencing other adverse developmental outcomes. Conversely, the recovery of a parent with AOD-related problems enhances the health and developmental outcomes of his or her children. Adding to such positive effects are specific interventions that enhance the recovery and resilience of children who have been negatively impacted by parental substance dependence. Recovery of adolescents and transition age youth
In 2008, 8 percent of youth aged 12 to 17 and 21 percent of transition age youth in the United States met diagnostic criteria for a substance use (alcohol or illicit drugs) disorder, but less than one in ten of these young people received specialized addiction treatment. More than 4,900 facilities in the United States currently specialize in the treatment of adolescent substance use disorders, and youth-focused recovery mutual aid meetings in the U.S. have significantly increased in recent years. The importance of these resources is underscored by the consistent research finding that earlier treatment for a substance use disorder (in terms of both age and duration of use) leads to better long-term recovery outcomes. There are evidence-based, brief therapies that have proven effective aids in recovery initiation, but most adolescents are precariously balanced between recovery and relapse in the months following such therapy. Long-term recovery stability is enhanced by sustained post-treatment monitoring and support, stage-appropriate recovery education, assertive linkage to communities of recovery and, if needed, early re-intervention. Unfortunately, such extended care and support is rare. In spite of these limitations, a growing number of young people are using recovery as a conceptual framework to reconstruct their identities and interpersonal relationships following significant and sustained AOD-related problems. Conceptual frameworks for organizing child and adolescent services
The concepts of “system of care,” “wraparound services,” “positive youth development” and “resilience” have served as organizing frameworks for C & A services in recent decades. Resilience is the achievement of positive developmental outcomes in spite of personal and environmental risk factors. Resilience-based systems of youth development seek to reduce risk factors and increase protective factors at personal, family and environmental levels. Resistance is: an innate hardiness that allows one to be exposed to an infectious agent without becoming ill; and/or the act of refusing or ceasing AOD use as an act of cultural or political survival (particularly within historically disempowered communities of color). Recovery from a substance use disorder entails three critical ingredients: sobriety, global health (physical, cognitive, emotional, relational, spiritual) and citizenship. These elements of recovery have yet to be fully defined and measured for youth. Recovery management (RM) is a philosophy of organizing addiction treatment and recovery support services to enhance pre-recovery engagement, recovery initiation, long-term recovery maintenance and the quality of personal/family life in long-term recovery. Recovery-oriented systems of care (ROSC) encompass the complete network of indigenous and professional services and relationships that can support the long-term recovery of individuals and families affected by AOD problems as well as the creation of values and policies in the
larger cultural and policy environment that are supportive of these recovery processes. Approaches to RM and ROSC for adults and for youth share many elements in common. Efforts are currently underway to identify distinctive changes in services for children, adolescents and transition age youth that need to occur within the movement to RM and ROSC. Rather than think of recovery, resilience and resistance in either/or terms, it is helpful to think of systems transformation guided by all of these concepts. Many child and family advocates are embracing these concepts as complementary. Primary Prevention, Early Intervention, Treatment and Recovery Support
Addiction treatment and recovery support services for parents constitute a strategy of prevention for their children. The impact of these services can be further amplified by involving children in the treatment of their parent and by providing specialized services designed to enhance the child’s recovery from the developmental insults of parental addiction and to enhance the child’s future resilience and resistance to AOD-related problems. Some programs (e.g., the Betty Ford Center) have invested considerable resources in the development of services to children affected by parental substance dependence. The treatment of every adult parent should include child-focused prevention and early intervention services aimed at breaking the intergenerational transmission of AOD-related problems. RM and ROSC involve an integration of primary prevention, early intervention, treatment and recovery support services aimed collectively at breaking the intergenerational transmission of AOD problems. Advocates and critics
Advocates of applying the recovery concept to C & A services extol the concept’s holistic, developmental perspective; emphasis on hope, empowerment and choice; integration of spirituality as a healing/protective force; emphasis on thriving rather than just symptom remission; compatibility with system of care and positive youth development approaches to youth service design; inclusion of such issues as historical trauma and social stigma; and its emphasis on the role of social connectedness in adolescent health. Critics of applying the recovery concept to C & A services contend that recovery is misapplied to children because it: implies returning to a previous level of functioning; brings with it the social stigma attached to addiction; lacks a holistic, developmental perspective because of its “disease” trappings; and works only if integrated with the concept of resilience. Efforts to transform C & A services as part of RM and ROSC initiatives should capitalize on those added values recovery brings to the organization of C & A services while seeking to minimize any unforeseen harm that could come from applying this concept to children and adolescents (e.g., risk of over-diagnosis, coerced treatment and financial exploitation of families by the “troubled teen industry”). Embracing and integrating resilience and recovery may be the best means of achieving this added value while minimizing any potential misapplication or exploitation of the concept of recovery. The Philadelphia Focus Groups
Members of focus groups (providers, parents and youth) conducted in the City of Philadelphia felt that recovery and resilience were compatible concepts that called for developmentally-informed models of care; family inclusion/direction and leadership; peer support and leadership; a continuum of support; community integration and mobilization of community recovery/resiliency support resources; trauma-informed care (and addressing violence within the trauma framework); and culturally competent care. A particular group of youth much discussed in the Philadelphia focus groups was transition age youth who were “aging out” of the child service system and were no longer eligible for continued C & A services. Hope was expressed that new approaches to such transition planning could be developed given the ROSC emphasis on long-term, stage-appropriate recovery support. Voices from the youth focus groups pleaded for a system of care that would see them as individuals rather than as a disorder and relate to them from a position of respect and authenticity. Summary and recommendations
The report ends with a set of recommendations in the following areas:
• concepts and language of systems transformation;
• representation and leadership;
• recovery visibility of youth;
• collaboration and partnership;
• a continuum of (personal/family/community) recovery support;
• practice guidelines; assessment and treatment/recovery planning;
• recovery-focused treatment;
• youth-focused peer recovery culture; and
• evaluation of effects of systems transformation on children and adolescents, their families and on C & A service providers.
Addiction professionals working with children and adolescents will find much in the report that will help them respond to these issues as they arise within their local communities.
Acknowledgements: Work on this paper was supported by the Great Lakes Addiction Technology Transfer Center/Center for Substance Abuse Treatment/Substance Abuse and Mental Health Services Administration, the Philadelphia Department of Behavioral Health and Mental Retardation Services (DBH/MRS), and the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment (HHSS2832007006I/TO HHSS28300003T Subcontract No: s8440). The opinions expressed are the views of the authors and do not necessarily reflect the official positions of DBH/MRS, CSAT, SAMHSA, DHHS, or the Federal Government.
William L. White, MA is a Senior Research Consultant at Chestnut Health Systems and author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America.
Arthur C.Evans, Jr., PhD is associated with the Philadelphia Department of Behavioral Health and Mental Retardation Services.
Sadé Ali, MA: is associated with the Philadelphia Department of Behavioral Health and Mental Retardation Services. Ijeoma Achara-Abrahams, PhD: is associated with the Philadelphia Department of Behavioral Health and Mental Retardation Services.
Joan King, APRN, BC: is associated with the Philadelphia Department of Behavioral Health and Mental Retardation Services.
Feedback on this article or the full report can be sent to
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Recommended Reading
Friesen, B. J. (2005). The concept of recovery: “Value added” for the children’s mental health field? Focal Point: Research, Policy and Practices in Children’s Mental Health, 19(1), 5-8.
Friesen, B. J. (2007). Recovery and resilience in children’s mental health: Views from the field. Psychiatric Rehabilitation Journal, 31(1), 38-48.
Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R., & Passetti, L. L. (2007). The effect of Assertive Continuing Care on continuing care linkage, adherence, and abstinence following residential treatment for adolescents with substance use disorders. Addiction, 102, 81–93.
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White, W., & Godley, S. (2007). Adolescent recovery: What we need to know. Student Assistance Journal, 19(2), 20–25.
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Feature Articles -
Adolescents
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Written by National Institute on Drug Abuse (NIDA)
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Wednesday, 03 June 2009 13:54 |
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Imagine the teenager who walks into his parent’s bathroom looking for ibuprofen (e.g., Advil) for a headache. As he’s scanning the shelves, he sees a pill bottle labeled “hydrocodone” (or Vicodin). Something seems familiar about this—oh yeah, some kids at a party last weekend were raving about how great these pills made them feel. The teen takes two, hoping his mother won’t notice—which she may not since they were prescribed six months ago following dental surgery.
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Feature Articles -
Adolescents
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Written by Gabrielle Pelicci, PhD
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Wednesday, 03 June 2009 13:50 |
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John has been a resident at Sober College three times in the past three years for addiction treatment. Prior to that, he was a client of five other facilities, including a long-term therapeutic boarding school. John has been on depression medication for several years, and despite the excellent care he has received, he has relapsed a dozen times and attempted suicide twice.
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Feature Articles -
Adolescents
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Written by David E. Smith, MD, FASAM, FAACT
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Wednesday, 03 June 2009 13:16 |
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My career in Addiction Medicine began more than 40 years ago when I founded the Haight Ashbury Free Medical Clinic during the “Summer of Love” following my training at the University of California at San Francisco. As “Young Doctor Smith,” I dealt with young people who came for the Bay Area counterculture seeking “Drugs, Sex and Rock & Roll” and “Better Living through Chemistry,” only to see my neighborhood go from fantasy of psychedelics to a nightmare of speed. We dealt primarily with bad trips and methamphetamine psychosis with its associated medical and psychiatric problems (Brokaw, 2008; Owen, 2006).
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Feature Articles -
Adolescents
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Written by James Garbarino, PhD
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Friday, 11 July 2008 16:59 |
How can we best approach the question, “Why are adolescents violent?” To do so effectively, we need a perspective on human development that begins with the realization that there are few hard and fast simple rules about how human beings develop; complexity is the rule rather than the exception.
Rarely, if ever, is there a simple cause-effect relationship that works the same way with all people in every situation. Rather, we find that the process of cause and effect depends upon the child as a set of biological and psychological systems, set within the various social, cultural, political and economic systems that constitute the context in which developmental phenomena are occurring.
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Feature Articles -
Adolescents
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Friday, 31 March 2006 16:00 |
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Group therapy has been the most commonly employed treatment modality for adolescents with substance use disorders (SUD). Evidence has been accumulating in support for the efficacy of diverse forms of group therapy that have been utilized with adolescents, such as 12-step (Winters et al., 2000), psychoeducation (Kaminer et al., 2002) and cognitive behavioral therapy (Dennis et al., 2004; Kaminer et al., 1998; 2002; Waldron et al., 2001). However, it has been argued that aggregation of youths who display problem behavior in group interventions may, under some conditions, produce clinically induced negative effects on all participants (Dishion et al., 1999).
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