An overview of the effectiveness of adolescent substance abuse treatment models
Youth and Society
Thousand Oaks
Dec 2001

Authors: Randolph Muck
Authors: Kristin A Zempolich
Authors: Janet C Titus
Authors: Marc Fishman
Authors: et al
Volume: 33
Issue: 2
Pagination: 143-168
ISSN: 0044118X
Subject Terms: Substance abuse treatment
Teenagers
Drug use
Models
Effectiveness
Social research

Abstract:

Recent reports describe alarming trends of adolescent drug use and a lack of treatment for substance use disorder symptoms. Early efforts in adolescent treatment relied on adult models that may not have considered the unique needs of adolescents.

Copyright SAGE PUBLICATIONS, INC. Dec 2001

Full Text:

Recent reports describe alarming trends of adolescent drug use and a lack of treatment for substance use disorder symptoms. Early efforts in adolescent treatment relied on adult models that may not have considered the unique needs of adolescents. Recently, there has been an increased emphasis in developing intervention models designed specifically for adolescents. This article provides descriptions of current approaches to adolescent substance abuse treatment and summaries of research assessing the effectiveness of these models.

Adolescent substance abuse has been a societal concern for some time. According to the Monitoring the Future Study (Johnston, O'Malley, & Bachman, 2001), adolescent drug use started increasing in the early 1990s and continued to do so until 1997. Not surprisingly, adolescents perceived lower risk of harm from drug use during this time. From 1992 to 1998, the number of adolescent substance abuse treatment admissions grew by 53% (from 96,787 to 147,899) (Dennis, Noursi, Muck, & McDermeit, in press). At the same time, fewer than 10% of adolescents reporting past-year substance use disorder symptoms have ever received treatment (Dennis & McGeary, 1999) despite the rise in substance use and the potential for long-term consequences.

In addition to the alarming trends in adolescent drug use and lack of treatment, the age at which adolescents are introduced to drug use appears to be decreasing. For instance, the age of first marijuana use has decreased from older than 18 in the 1960s, to 15 to 17 years of age in the late 1970s and early 1980s, to younger than 15 in the late 1980s and 1990s (Johnston et al., 2001). This trend is of particular concern because most adolescents who begin using marijuana on a regular basis at an early age have consistently been found to continue their use and/or increase their frequency and amount of use as well as show an increase in related problems over time (Perkonigg et al., 1999).

Adolescent substance abusers are different from adult substance abusers in a number of important ways, including drug use patterns and developmental and social factors (Winters, Stinchfield, Opland, Weller, & Latimer, 2000). Adolescents may be more susceptible than adults to the development of substance dependence syndromes, even in the absence of physiological withdrawal. The progression from casual use to dependence can also be more rapid in adolescents than in adults (Winters, 1999). Adolescents presenting for treatment typically demonstrate a higher degree of co-occurring psychopathology, which frequently precedes the onset of problem substance use and often does not remit with abstinence (Kandel et al., 1997; Riggs, Baker, Mikulich, Young, & Crowley, 1995; Rohde, Lewinsohn, & Seeley, 1996).

Motivation for treatment is a key factor in addressing adolescent substance use because adolescents presenting for treatment almost never enter as a self-referral. Instead, they are typically referred by a parent, juvenile justice system official (judge or probation or parole officer), school official, child welfare worker, or representative of some other community institution. State-of-the-art substance abuse treatment must also take into account what we know about how people change. Important research on how people change addictive behaviors (Prochaska, DiClemente, & Norcross, 1992)-later applied to a wide variety of other behavioral problems-has shown that people move through stages in the change process. The stages of change model has been applied to adolescents (Pallonen, 1998) and young adults (Pallonen, Murray, Schmid, Pirie, & Luepker, 1990). The stages were the same in these populations, although there were differences in distribution, speed of movement t! hrough stages, and tendency to relapse.

The consensus of clinical practitioners is that for a given degree of severity or functional impairment, adolescents require greater intensity of treatment than adults. This is often reflected by a greater tendency to place adolescents in more intensive levels of care (Mee-Lee, Shulman, Fishman, & Gastfriend, 2001) and in part indicates the need for strategies that are not so much rehabilitative as habilitative.

Clearly, adolescent substance abusers present with a complex constellation of problems requiring treatment approaches that address this multitude of needs. Early efforts in adolescent treatment were based on adult models that did not seem to consider the unique needs of adolescents. Recently, however, there has been an increased emphasis in developing and evaluating theoretically based and empirically supported substance abuse intervention models designed specifically for adolescents (Wagner, Brown, Monti, Myers, & Waldron, 1999).

The purpose of this article is to provide a summary of the effectiveness of evaluated models of adolescent substance abuse treatment. A comprehensive review of adolescent substance abuse treatment is beyond the scope of this article. Therefore, this review is confined to published studies that evaluate discrete treatment models (e.g., cognitivebehavioral approaches) and does not include studies that focus on broad treatment effectiveness issues, such as treatment setting (e.g., inpatient vs. outpatient) and length of treatment. A more comprehensive review can be found in a recent article by Williams, Chang, and the Addiction Centre Adolescent Research Group (2000). In addition to reviewing the documented effectiveness of adolescent treatment models, this article also outlines ongoing programs with evaluation protocols and methods that attempt to address some of the methodological concerns of previous studies and expand our understanding of the mechanisms of adolescent tre! atment.

EFFECTIVENESS OF ADOLESCENT TREATMENT MODELS

In 1998, most adolescents receiving treatment for substance abuse did so in an outpatient setting. Out of 147,899 adolescents in treatment, 69% were in outpatient programs, 11% in intensive outpatient programs, 6% in short-term residential programs, 9% in long-term residential programs, and 6% in other treatment settings (detoxification hospital inpatient, detoxification free standing, detoxification ambulatory, and hospital-based inpatient) (Dennis et al., in press). Whereas most treatment regimes incorporate a number of methods, current approaches to the treatment of adolescent substance use fall into the following four main modalities: 12 step, behavioral or cognitive behavioral, family based, and therapeutic communities. Each of these models views the problem of adolescent substance use-its etiology, maintenance, and resolution-from a slightly different angle (Bukstein, 1995; Winters, Latimer, & Stinchfield, 1999). The following sections provide brief explanations! of each approach and summaries of research assessing the effectiveness of the models. Due to the wide range of evaluation designs used, some study outcomes are described individually. When possible, however, results have been synthesized across studies to assist in conveying general findings of the treatment models' effectiveness.

THE 12-STEP TREATMENT APPROACH

Basic model. The 12-step approach-also known as the Minnesota Model or the Alcoholics Anonymous (AA)/Narcotics Anonymous (NA) approach-is the most widely used model in the treatment of adolescent drug abusers. Based on the tenets of AA and basic psycho- therapy, the 12-step model views "chemical dependency" as a disease that must be managed throughout one's life with abstinence as a goal (Winters et al., 2000). The backbone of 12-step treatment is step work, a series of treatment and lifestyle goals that are worked in groups and individually. The first 3 steps help the adolescent to be more honest, decide to stop using drugs and alcohol, and choose a new lifestyle. Steps 4 through 9, the action steps, help adolescents continue to be honest, develop and implement an action plan for a changed lifestyle, and correct past wrongs where possible. Steps 10 through 12 are the growth steps, which encourage adolescents to continue to work a recovery program throughout their lives. ! Typically, the first 5 steps are covered in the treatment program, whereas Steps 6 through 12 are addressed in aftercare and ongoing involvement in community self-help groups. Step work provides the basic structure for treatment and recovery.

Other components of 12-step programs include group therapy (the primary mode of treatment delivery in 12-step programs), individual counseling, lectures and psychoeducation, family counseling, written assignments (including step work), recreational activities, participation in aftercare, and attendance at AA/NA meetings in the community. Counselors in 12-step programs are often recovering substance users and serve as powerful role models for living a drug-free life. Although once available only in residential settings, 12-step treatment is now widely offered in both residential and outpatient settings.

Effectiveness. Studies examining the effectiveness of 12-step programs typically focus on comparisons between program completers and noncompleters rather than comparisons to other treatment models. Studies show that at 6-month follow-up, program completers had a significantly higher abstinence rate than noncompleters (Alford, Koehler, & Leonard, 1991; Brown, Myers, Mott, & Vik, 1994; Winters, Stinchfield, Opland, & Weller, 1999; Winters et al., 2000). Results at I- and 2-year follow-ups, however, are mixed. Both studies by Winters, Stinchfield, et al. (1999) and Winters et al. (2000) found completers' outcomes to be far superior to noncompleters' at the 12-- month follow-up. However, Alford et al. (1991) reported that abstinent/essentially abstinent rates fell sharply for boys and slightly for girls at 1-year posttreatment. There was no significant difference between completers and noncompleters by 2 years posttreatment.

Results for behavioral functioning show a similar pattern. Alford et al. (1991) reported that 45% of treatment completers were abstinent/ essentially abstinent and successfully functioning in school or a job and in family-social activities, whereas this was true for only 25% of noncompleters. At 1-year posttreatment, this difference narrowed to 29% versus 18% for completers and noncompleters, respectively, and further narrowed to 27% versus 23% at 2 years posttreatment.

In addition to comparisons with noncompleters, Winters et al. (2000) also compared outcomes of program completers to those for a wait-listed group of adolescents. Results show that program completers reported superior outcomes to adolescents in waiting list groups, who in turn did not differ significantly from the noncompleter group. This finding was consistent for both categorical (abstinence/minor relapse rates) and continuous (standardized drug use frequency scores) variable analyses.

THE BEHAVIORAL TREATMENT APPROACH

Basic model. Behavioral approaches focus on the underlying cognitive processes, beliefs, and environmental cues associated with the adolescent's use of drugs and alcohol and teach the adolescent coping skills to help him or her remain drug free. Whether called behavior therapy, cognitive therapy, or cognitive-behavioral therapy (CBT), all behavioral approaches view substance abuse as a learned behavior that is susceptible to alteration through the application of behavior modification interventions (Miller & Hester, 1989). The goal of behavioral approaches is to teach adolescents to unlearn the use of drugs and to learn alternative, prosocial ways to cope with their lives. Thus, "treatment focuses on the factors that precipitate and maintain episodes of substance use" (Kaminer, Burleson, Blitz, Sussman, & Rounsaville, 1998, p. 684). In particular, cognitive-behavioral techniques attempt to alter thinking as a way to change behavior. Behavioral techniques are used i! n residential and outpatient settings as part of group or individual therapies.

A commonly used behavioral intervention focuses on the development of coping skills. Particular skills to be taught are introduced and modeled. Using examples from the adolescents' lives is crucial to help engage them and convince them of their practical utility. Specific skills vary by program but may include drug and alcohol refusal skills, resisting peer pressure to use drugs and alcohol, communication skills (nonverbal communication, assertiveness training, and negotiation and conflict resolution skills), problem-solving skills, anger management, relaxation training, social network development, and leisure time management. New behaviors are tried out in low-risk situations (e.g., during group therapy role-plays and individually with a counselor) and eventually are applied in more difficult, real-life situations. Homework assignments, such as trying out a new behavior or collecting problem situations to discuss during therapy, are common. Staff members and parents are ! encouraged to provide positive reinforcement for the use of new behaviors.

Behavioral contracting is another technique used in behavioral approaches. The adolescent and counselor agree on a set of behaviors to be changed and develop weekly incremental goals for the adolescent. As each goal is reached, the adolescent is highly praised or otherwise reinforced. Behaviors are explicitly defined on the contract, with criteria and time limitations noted.

Effectiveness. To date, published studies examining the effectiveness of behavioral programs focus on the comparison of behavioral models to other treatment methods. For instance, Azrin and colleagues (Azrin, Donohue, Besalel, Kogan, & Acierno, 1994; Azrin, McMahon, et al., 1994) compared the effectiveness of a behavioral outpatient treatment program to that of a supportive counseling program. In the behavioral program, the number of adolescents using drugs by the end of treatment decreased by 73% compared with a decrease of only 9% of those receiving the comparison treatment. Drug use was measured in three ways at each session-adolescent selfreport, parent report, and urinalysis-and all three methods of measuring drug use showed substantial decreases during the course of the behavioral treatment. These measures showed only slight decreases during the nonbehavioral treatment, and the average number of days per month of drug use actually increased. For the behavioral p! rogram, reported alcohol use decreased by about 50%, whereas the comparison treatment showed an increase of 50%.

Looking at other measures of improvement for the behavioral program, the percentage attendance at school or work increased significantly, and a large decrease in average scores on the depression measure was observed. Parent satisfaction with the youth increased from a prebaseline rate of 42% to 72% overall satisfaction. Youth satisfaction with the parent increased from a prebaseline rate of 69% to 85%, although the difference was marginally significant. For the comparison, nonbehavioral program, the percentage attendance at school or work decreased only slightly as did the average scores on the depression measure. Parent satisfaction with youth and youth satisfaction with the parent remained unchanged at 50% and 63%, respectively. Substance use data and related measures were not collected posttreatment.

In their studies, Kaminer, Burleson, and colleagues (Kaminer & Burleson, 1999; Kaminer et al., 1998) compared CBT to interactional treatment (IT)-an insight-oriented outpatient group approach-to determine which treatment would provide improved outcomes for adolescent substance abusers who also were diagnosed with a psychiatric condition. The overall treatment completion rate was 47% (8 in the CBT group and 7 in the IT group). At the 3-month follow-up, adolescents who were in the CBT treatment significantly reduced the severity of their substance use compared with those assigned to IT. At the 15-month follow-up, no treatment group differences were observed on severity measures of alcohol use; drug use; psychiatric problems; problems with peers, family, or school; and legal problems.

Finally, in a study similar to the one described earlier, Kaminer, Burleson, and Jadamec (1999) compared CBT to psychoeducational treatment (PET) to determine which of the two treatments would provide improved outcomes for adolescent substance abusers. The CBT was administered similarly to the previous study; however, the program in this study was slightly shorter, lasting 8 weeks instead of 12. The PET addressed the dangers of using drugs and alcohol through a didactic process.

Kaminer et al. (1999) reported an overall treatment completion rate of 86%. At the 3-month follow-up, adolescents who completed CBT treatment and follow-up measures significantly improved on the severity of their peer problems as compared with those assigned to PET. In addition, a trend toward improvement on the drug and alcohol severity measures was observed for adolescents treated in CBT relative to those in PET.

THE FAMILY-BASED TREATMENT APPROACH

Basic model. Family-based approaches acknowledge the critical influence of the adolescent's family system in the development and maintenance of substance abuse problems. Most techniques are based on four family therapy models-structural, strategic, functional, and behavioral-alone or by combining effective parts of a number of models. "A family systems view of adolescent drug abuse focuses on the manner in which adolescent functioning is related to parental, sibling, and extended-family functioning, as well as to patterns of communication and interaction within and between various family subsystems" (Ozechowski & Liddle, 2000, p. 270). The family, then, is viewed as a collection of subsystems (e.g., parents and children), each with a variety of roles. Ideally, boundaries between subsystems are permeable enough for, say, an adolescent to feel comfortable seeking input from a parent on an important issue but not so permeable that the boundaries between parent and child ! roles are blurred. Problems arise when boundaries and roles are not clear or are inappropriate for a given family subsystem.

Techniques used by family therapists include observing the interactive patterns between members by encouraging them to speak directly to each other, pinpointing problems in interactions and their underlying relationship problems, and helping families improve their relationships. Techniques to clarify family roles and boundaries help families change maladaptive interaction patterns. The therapist's use of reframing or relabeling problem behavior-defining problem behavior in a new way-leads to new insights and opportunities to mend or develop relationships. Given the importance of day-to-day communication patterns between members, most family models stress the importance of having the entire family present for therapy.

Effectiveness. Studies examining the effectiveness of family-based programs also focus on the comparison of this model to other modes of treatment. Several studies have compared family-based models to education models of treatment (Joanning, Quinn, Thomas, & Mullen, 1992; Lewis, Piercy, Sprenkle, & Trepper, 1990; Liddle et al., 1999; Liddle & Hogue, in press). Lewis et al. (1990) reported that adolescents in a family-based therapy model showed a significant decrease in ratings of seriousness of drugs used from pre- to posttreatment, whereas adolescents in a family drug education program did not show similar decreases. Studies examining the amount of drug use (Joanning et al., 1992; Liddle et al., 1999) report greater reduction in drug use at immediate posttreatment using the family-based therapy model. Similar results are reported at 6-month (Liddle et al., 1999) and 12-month (Liddle et al., 1999; Liddle & Hogue, in press) follow-up.

Looking at factors related to substance use, Liddle and Hogue (in press) reported that multidimensional family therapy (MDFT) showed superior improvement in behavioral ratings of family competence and adolescent's grade point average from pretreatment to 12-- month follow-up. Joanning et al. (1992) also reported that at the 6month follow-up, adolescents in all treatment groups perceived that their communication with their parents had improved significantly. The adolescents' parents, however, did not share this perception.

Similar results were found when comparing family-based models to adolescent group therapy. Family systems therapy (Joanning et al., 1992) and MDFT (Liddle, Dakof, & Diamond, 1991; Liddle et al., 1999) resulted in greater improvement in reduction of drug use at immediate posttreatment than the adolescent group therapy model. This difference remained at 6- and 12-month follow-ups for the MDFT studies (Liddle et al., 1991, 1999; Liddle & Hogue, in press).

Looking at pre- to posttreatment differences in related factors, Liddle et al. (1999) found no significant differences between groups for problem behavior (poor anger control, interpersonal problems, impulsivity, mood swings, and antisocial, aggressive, and sexual acting out) or grade point average. However, adolescents receiving MDFT showed greater improvements in grade point average (Liddle et al., 1999; Liddle & Hogue, in press) and behavioral ratings of family competence (Liddle & Hogue, in press) at follow-up. No significant difference between groups was found for problem behaviors at follow-up (Liddle et al., 1999).

Friedman (1989) conducted a study comparing family therapy to a parent group method involving training in parent effectiveness, parent communication, and parent assertiveness. Both groups reported significant improvements in adolescent drug use, parent-adolescent communication, family behavior, and adolescent psychiatric symptoms from pretreatment to 9 months posttreatment. There was no significant difference between the groups in level of improvement.

Results from studies comparing multisystemic therapy (MST) (described in Borduin, 1999) to other treatment models show mixed findings. Compared to individual counseling, MST resulted in significantly fewer adolescents with a substance-related arrest during the 4 years following treatment (Henggeler et al., 1991). Compared to court-ordered sanction (e.g., curfew and school attendance), MST also resulted in significantly lower self-reported use of marijuana and alcohol at posttreatment. Analysis of other drug use (hallucinogens, amphetamines, barbiturates, heroin, and cocaine) was precluded due to a low base rate.

Less promising findings were reported in a study of adolescent offenders with substance abuse or dependence diagnoses (Henggeler, Pickrel, & Brondino, 1999). Henggeler et al. (1999) compared treatment effects of MST to those of the usual community services (typically a referral from the adolescent's probation officer to outpatient substance abuse services, including a 12-step program and adolescent group meetings). Most families in the community services group received neither substance abuse nor mental health services. At posttreatment, there was no significant difference between groups for use of marijuana, alcohol, and other drugs after adjusting for preexisting differences. Both groups showed a decrease in criminal activity with no significant difference between groups. Adolescents in the MST group did experience significantly fewer out-of-home placements (i.e., detention centers, jails, psychiatric or substance abuse hospitals, and residential treatment centers) ! from pretreatment to 6 months posttreatment than those in the community services group. In general, this study showed mixed results for the family-based model; however, Henggeler et al. (1999) suggested that the modest results may be a result of therapists' low adherence to the treatment protocol.

Finally, Szapocznik, Kurtines, Foote, Perez-Vidal, and Hervis (1983, 1986) compared conjoint family therapy (CFT; therapy with the entire family present for most sessions) to one-person family therapy (OPFT; therapy with only one family member present for most sessions). At immediate posttreatment, adolescents in both conditions showed significant improvement in clinical status (including drug abuse, impulse control, behavioral disturbance, and subjective distress), behavior problems (including conduct problems, delinquency, personality problems, and inadequate development), and family functioning. At follow-up (6 to 12 months posttreatment), adolescents in both groups continued to show improvements in clinical status and family functioning; however, adolescents in OPFT showed signifi- cantly more reduction in problem behavior and drug abuse than adolescents in CFT.

Clearly, family-based treatment of adolescent substance abuse has received much attention in the research literature. In their review of family-based therapy for adolescent drug abuse, Ozechowski and Liddle (2000) concluded that this model's efficacy in addressing adolescent drug abuse and externalizing and internalizing behavioral problems and symptoms of psychiatric comorbidity has received solid empirical support. They further concluded that related factors, such as improved family functioning, involvement in school, and reductions in peer-associated delinquent behavior, have also been shown to be significantly improved through family-based therapy.

THE THERAPEUTIC COMMUNITY TREATMENT APPROACH

Basic model. Therapeutic communities (TCs) are long-term residential programs reserved for adolescents with the most severe substance abuse and related problems. The traditional duration of stay is at least 15 months, although some TCs have adopted shorter lengths of stay based on progress (6 to 12 months). The philosophy behind the TC is that substance abuse is a disorder of the entire person resulting from an interruption in normal personality development and deficits in interpersonal skills and goal attainment. Thus, the purpose of the TC is to provide a psychologically and physically safe, nurturing, and structured environment in which the adolescent can develop more adaptive personal and social behaviors, attitudes, and beliefs (Jainchill, 1997). The social organization of the TC serves as a family surrogate for the adolescent and provides a therapeutic, supportive environment for the adolescent to mature and grow.

Life in a TC is highly structured, with days scheduled from early morning through the evening. Days are filled with school classes and tutoring, peer group and individual therapy, recreation, jobs, and occupational training. Management of the TC is the responsibility of the residents, and all adolescents are assigned ajob. Through progress and productivity, adolescents rise through the job hierarchy to positions of management or coordination. Participation by a family member is often a part of the TC experience. As in 12-step programs, counselors and primary staff members at TCs are often ex-clients who have been successfully rehabilitated in TCs.

Effectiveness. The Center for Therapeutic Community Research led an investigation of six TC treatment programs across nine sites (Jainchill, 1997; Jainchill, Bhattacharya, & Yagelka, 1995). Although programs varied on factors such as setting (urban vs. rural), planned duration of stay (6 to 18 months), and the size of their staff, all shared the basic features of a TC. Halfway through their planned stay of duration, 45% of adolescents were still in treatment, and significant positive changes were observed on most indicators of psychological status, such as self-esteem and behavioral indicators (trouble controlling violent behavior and serious thoughts of suicide in the past 30 days). About 44% of adolescents completed their treatment programs. At 6 months posttreatment, significant reductions were observed for inhalant, hallucinogen, and methamphetamine use. In addition, more than 66% of the adolescents reported that their alcohol use was either greatly reduced or at ! an abstinent level.

ADVANCES IN ADOLESCENT SUBSTANCE ABUSE TREATMENT'S OVERALL EFFECTIVENESS

The earliest studies of treatment effectiveness were large-scale national efforts that included adolescent samples such as the Drug Abuse Reporting Program (DARP) (Sells & Simpson, 1979; Simpson, Savage, & Sells, 1978) and the Treatment Outcome Prospective Study (TOPS) (Craddock, Bray, & Hubbard, 1985; Hubbard, Cavanaugh, Craddock, & Rachal, 1985). DARP found that adolescents in treatment-- including methadone maintenance, therapeutic communities, outpatient programs, detoxification, and other programs-showed reduced opioid use, slightly increased alcohol use, and levels of marijuana use that remained the same or increased after treatment. TOPS found that residential treatment resulted in reduced rates of daily marijuana use, alcohol and other drug use, and drug-related problems, whereas outpatient treatment showed mixed results.

A more recent study-the National Treatment Improvement Evalu- ation Study (NTIES) (Gerstein & Johnson, 1999)-found similar results, reporting that residential treatment was associated with reductions in using marijuana and cocaine and in alcohol intoxication. Results were mixed for adolescent outpatient treatment, which was associated with a slight reduction in using marijuana, no change in cocaine use, and a slight increase in alcohol intoxication.

Finally, the Drug Abuse Treatment Outcome Study for Adolescents (DATOS-A) (Grella, Hser, Anglin, Joshi, & Rounds-Bryant, 1999; Powers, Hser, Grella, & Anglin, 1999) reports that from baseline to 1-- year posttreatment, adolescents' rates of marijuana and alcohol use decreased. Results for cocaine use were mixed, with long-term residential treatment showing decreased use and short-term residential and outpatient drug-free treatment showing increased use at posttreatment.

It has only been within the past 10 to 15 years that treatment effectiveness research has focused exclusively on outcomes for adolescents. Thus, research on the effectiveness of adolescent treatment is in its infancy. Few rigorous evaluations of effectiveness have been done, and of those studies that exist, many have methodological problems that make definitive conclusions difficult if not impossible.

Small sample sizes limit the use of analytical techniques and generalizability of findings. Lack of randomized assignment calls into question the cause of group differences. High drop-out rates complicate matters because adolescents who are difficult to contact or who refuse to participate in follow-up outcome studies are known to have significantly poorer outcomes than adolescents who are easy to contact and cooperative (Stinchfield, Niforopulos, & Feder, 1994).

Issues surrounding the assessment of adolescent substance use are also major concerns for these studies. Early studies tended to borrow assessment tools from the adult treatment field; these tools may not be appropriate for use with adolescents. Researchers often develop their own measure or index and fail to provide psychometric properties of the scale of index (Liddle & Dakof, 1995). Furthermore, the methodology is inconsistent across studies regarding the time period at which outcome is evaluated, the number of prior months of substance use being assessed, and how success is measured (Williams et al., 2000).

The variety of methods of assessing substance use-self-report, others' reports, and urinalysis-also poses problems for synthesizing findings across studies. Different assessment techniques are used across studies, making comparison difficult. Whereas some studies admirably attempt to combine methods in an effort to generate a reliable measure of substance use, these methods, again, differ across studies. Although there seems to be consensus that collecting information from a variety of sources is desirable in assessing adolescent substance use, the field would benefit from consistent methods in reconciling this information.

The wide range of level of participant substance use in study samples is another factor inhibiting the ability to draw strong conclusions from current findings. Some studies focus on adolescents with low levels of substance use (nonaddicts), whereas other studies have inclusion criteria of substance dependence or abuse. Still other studies use adolescent samples exhibiting wide ranges of levels of substance use. This latter scenario presents another concern because the inclusion of non-substance-using participants may mask actual treatment effects when analyzing in the aggregate. Finally, some studies simply fail to adequately measure or describe the substance use of the sample. Hopefully, as the body of adolescent treatment research grows, it will be possible to group studies with similar samples and assessment methods to draw stronger conclusions regarding the effectiveness of treatment models.

Despite the problems of early efforts in adolescent treatment research, Williams et al. (2000) concluded that the limited evidence of previous research points to several practices that appear to be important for treatment programs to understand and address. These include the need for programs to be accessible and provide treatment for a large number of individuals (because there is a great unmet need and treatment is shown to be better than no treatment); attend to the issues of treatment dropout and maximize treatment completion; include aftercare as a part of the continuum of care; provide comprehensive services that go beyond the reach of traditional substance abuse interventions, such as those that address educational, psychological, vocational, recreational, family, and legal concerns; include family therapy as a part of treatment; and engender parent and peer support, in particular regarding nonuse of substances. The authors stated that beyond this set of recommenda! tions, "there is insufficient evidence to make recommendations about other aspects of treatment" (p. 160).

Beginning in 1995, the federal Center for Substance Abuse Treatment (CSAT) sought to build on the limited research evidence about what works for adolescents. CSAT has funded 15 adolescent substance abuse treatment projects, including a rigorous evaluation of those models. The evaluation designs were developed in a manner to overcome many of the previously noted shortcomings of the earlier research (e.g., sample sizes larger than most previous studies, follow-up rates above 85%, follow-up intervals standardized, and common instrumentation for assessment and follow-up). CSAT further intends for treatment manuals to be developed and disseminated based on those models that are found to be effective.

In light of the scant data available to make recommendations about treatment interventions for youth using drugs and alcohol, CSAT has funded evaluation efforts to better understand the relative effectiveness and costs of different interventions. The Cannabis Youth Treatment (CYT) Program (Department of Health and Human Services [DHHS], 1997) and the Adolescent Treatment Models (ATM) (DHHS, 1999a) are two examples of CSAT's ongoing multisite studies that are at the forefront of developing new knowledge about effective treatment. CYT is a 3-year collaboration among CSAT and academic researchers and treatment providers in Bloomington and Madison County, Illinois; the Alcohol Research Center at the University of Connecticut; Operation PAR in St. Petersburg, Florida; and the Child Guidance Center at the Children's Hospital of Philadelphia. CYT was designed for adapting five promising treatment approaches in clinical practice and to test their effectiveness. It is the largest ! randomized evaluation ever conducted with adolescent marijuana users seeking treatment. It should be noted that all of the interventions are provided as outpatient services. The design of CYT was purposefully constructed to overcome many of the methodological problems that plagued earlier studies of adolescents in outpatient treatment settings.

The treatment programs are (see Figure 1):

1. Motivational Enhancement Therapy/Cognitive-Behavioral Therapy (MET/CBTS), a five-session treatment model with two individual sessions to support motivation for change and three group sessions on refusal skills; this approach is now available as a manual for replication (DHHS, 2001 a);

2. CBT 7, a treatment model to follow MET/CBTS; it provides additional group sessions;

3. Family Support Network, to supplement MET/CBTS or other treatment models with family support such as home visits, parent education, and case management;

4. Adolescent Community Reinforcement Approach, providing 14 individual sessions with the adolescent and/or a "concerned other" of the adolescent to focus on learning alternative skills to cope with problems and to work on changes in environmental cues and contingencies that may be related to ongoing substance use;

5. Multidimensional Family Therapy, a treatment model integrating substance abuse treatment with 12 weeks of family-focused intervention and additional phone calls and case management.

The treatment manuals for Interventions 2 through 5 are currently under development and will be available to the public through the National Clearinghouse on Alcohol and Drug Information (1-800- 7296686).

The CYT interventions have proven to provide results that are superior to previously studied outpatient interventions for substance-- involved youth. As they become available, ongoing findings from the project will be posted at www.chestnut.org/li/CYT. Preliminary findings on the effect of the CYT interventions are shown in Figures 1 and 2.

The ATM program was developed to identify existing potentially exemplary treatment models that heretofore had not had the resources to support a rigorous evaluation. The initiative is evaluating the effectiveness of the models related to individual client outcomes and cost. The effectiveness of the models will be compared with other studies of adolescent substance abuse treatment (the core data set and follow-up periods are consistent with the CYT effort to allow comparison). Effective models will be codified into treatment manuals for the purposes of dissemination, replication, and further study. This will be one of the first efforts to compare a variety of existing treatment modalities, perform case-mix adjustment, manualize the approaches, con- duct a cost-effectiveness analysis, and have high follow-up rates (currently more than 1,500 adolescents recruited with a follow-up rate of over 85%). In addition, large treatment samples of African American, Hispanic, Native Am! erican, and adolescent females are study participants.

One promising approach that was investigated early in the ATM program was the Seven Challenges Program (Schwebel, 2000). Seven Challenges incorporates a knowledge base of adolescent development, and it also matches the stage of change with appropriate interventions and relevant goals. Preliminary findings (Stevens, 1998) showed both a statistically significant reduction in substance use and aggressive behavior and improvements in related domains of functioning.


[IMAGE TABLE] Captioned as: FIGURE 1:

More than half of the adolescents enrolled in these CSAT-- supported projects are involved in the juvenile justice system. This finding is consistent with what is found in the general population of youth receiving treatment in publicly funded programs, where the justice system is the single largest source of referral (Dennis et al., in press). In part because of the vast numbers of youth in treatment who are involved with the justice system, CSAT in 1995 funded a juvenile justice system demonstration program in three metropolitan areas. The goal of this program was to link the appropriate treatment and ancillary service providers with the justice system to facilitate the referral and treatment services for substance-using adolescents involved in the justice system. A document was produced to inform other jurisdictions about the intervention in one of the sites and provide information to assist them in their efforts to institute similar systems of care for justice-involved! adolescents (DHHS, 1999b).


[IMAGE GRAPH] Captioned as: FIGURE 2:

Based on learning from the evaluation of treatment models and the Juvenile Justice Treatment Network, two new community-based interventions have been developed. First, the Robert Wood Johnson Foundation is set to launch a new initiative, Reclaiming Futures (Robert Wood Johnson Foundation, 2001), to build more seamless systems of care and further the learning about how systems interventions can improve outcomes for justice-involved adolescents. Second, CSAT will fund three to five communities to develop a continuum of careearly identification, referral, treatment, and continuing care/aftercare-- to provide a seamless service system for youth in need of substance abuse interventions (DHHS, 2001b).

The almost simultaneous fielding of two systems-level initiatives for adolescents, one by a federal agency and the other by a private foundation, is not a coincidence. The recent history of identifying models of treatment for adolescents that are effective provides the foundation for assisting communities to initiate evidence-based practices for youth. Experience with systems interventions, both for adults (Scott, Muck, & Foss, 2000; Wickizer et al., 1994) and youth (DHHS, 1999b), suggests that institution of evidence-based treatment models and systems/infrastructure development for communities and their youth will yield better individual outcomes, better service delivery, continuity of care, earlier engagement in the treatment process, and better satisfaction with treatment.

Although many questions still remain, it is clear that much progress has been made to identify effective models of adolescent substance abuse treatment. Furthermore, ongoing studies such as the CYT and the ATM programs are making progress in addressing methodological concerns while showing promising preliminary findings. Treatment manuals produced by these projects will greatly facilitate improvements in evaluation methodology and increase the transportability of treatment models. Explorations investigating the integration of adolescent treatment with restorative justice models are currently under way. Hopefully, this overall increased emphasis on developing and improving treatment models that target adolescents' special needs will result in more effective treatment and decreasing trends of adolescent substance use.

As communities begin to adopt best practices and develop systems of care for adolescents in need of substance abuse treatment, they are likely to converge in some localities with ongoing restorative justice programs. Given the preponderance of justice-involved youth in the treatment system, it is extremely important that these two fields communicate and maximize their service delivery. The state of evidence about the effectiveness of adolescent substance abuse treatment provides many opportunities for enhancements to assist in improving relapse and treatment retention rates. The potential for integration of existing treatment models with restorative justice principals may provide additional advancements to the field. Community-based treatment that involves establishing or supplementing a continuum of seamless care is a natural nexus for application of adolescent substance abuse treatment and restorative justice practices. Issues surrounding the integration of these fields! are discussed in an article by Kraft, Muck, and Bazemore (2001 [this issue]).

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RANDOLPH MUCK

Center for Substance Abuse Treatment

KRISTIN A. ZEMPOLICH

Logicon/ROW Sciences

JANET C. TITUS

Chestnut Health Systems

MARC FISHMAN

Johns Hopkins University

MARK D. GODLEY

Chestnut Health Systems

ROBERT SCHWEBEL

Psychologist

AUTHORS' NOTE: This article includes information from a report prepared for the Illinois Governor's Conference on Substance Abuse Prevention, Intervention, and

Treatment for Youth, held August 30-31, 1999, in Chicago. Preparation of the document was supported by the Cannabis Youth Treatment Cooperative Agreement (T111320) and a contract with the Adolescent Treatment Models Project (270-98-- 7047), both funded by the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, and a grant from the National Institute on Alcohol Abuse and Alcoholism (1 ROl AA 10368). Address correspondence to Randy Muck, Center for Substance Abuse Treatment, Rockwall II, Suite 740, 5515 Security Lane, Rockville, MD 20852.

Randolph Muck, M.Ed., is a team leader/public health adviser in the federal Center for Substance Abuse Treatment's (CSAT's) Division of Practice and Systems Development. Mr Muck is responsible for federal programs evaluating the effectiveness of adolescent treatment models and is the chair of the CSAT adolescent working group. He recently developed a new grant program for strengthening communities for youth, which supports establishing a community-based continuum of care for youth with substance abuse problems. Prior to joining CSAT, Mr. Muck worked for 16 years with the Department of the Army as a clinician, clinical director, and administrator for substance abuse and mental health treatment programs for soldiers and family members. He also helped develop the first military program to provide substance abuse treatment services for adolescentfamily members living on a military facility outside of the continental United States. Kristin A. Zempolich, M.S., a Research Analys! t at Logicon/ROW Sciences, provides analytic support to several programs including the Center for Mental Health Services (CMHS) Consumer Operated Service Program (COSP) and the National Institute of Drug Abuse (NIDA) Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program. Under the Center for Substance Abuse Treatment (CSAT) Technical Assistance for Knowledge Development and Applications and Specified Demonstration Programs contract she provides support in developing the Program for Rehabilitation and Restitution. Her prior research interests include personality, measurement issues, and criminal and aggressive behavior, evaluation methodology and assessment instrumentation.

Janet C. Titus, Ph.D., is a research psychologist in the Lighthouse Institute of Chestnut Health Systems in Bloomington, Illinois. Currently, she serves as the data coordinating center co-principal investigator (co-PI) for the adolescent Persistent Effects of Treatment study as well as the coordinating center co-PI and project coordinator for the Cannabis Youth Treatment cooperative agreement. She has served as an assessment trainer for the Adolescent Treatment Models study. Dr Titus is leading an analysis of trauma/victimization in adolescents and its relationship to comorbidity and treatment outcomes and collaborating on the development of other presentations and papers. Her current research interests include the role of spirituality in substance use recovery and substance use/treatment in the deaf and hard-of-hearing population.

Marc Fishman, M.D., is a member ofthe faculty of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School ofMedicine. He serves as the medical director of Maryland Treatment Centers, a regional behavioral health care provider, which includes Mountain Manor Treatment Center in Baltimore, a program for inpatient and outpatient treatment ofdrug-involved and dual-diagnosis adolescents. He is also principal investigator (PI)for the Baltimore site of the CSATAdolescent Treatment Models project. Dr Fishman is the chair ofthe work group on adolescent placement criteria for the American Society of Addiction Medicine (ASAM) and served as coeditorfor the most recent edition ofASAM's Patient Placement Criteria (PPC 2-R).

Mark D. Godley, Ph.D., has served as the director of Chestnut Health System's research division, the Lighthouse Institute, since 1987. He currently is the PIofthe National Institute on Alcohol Abuse and Alcoholism-funded randomized trial of the Assertive Aftercare Project for adolescents being discharged from residential treatment and is a co-PI

of the CSAT-funded Cannabis Youth Treatment experiment. He codirects the biennial Illinois Youth Survey of more than 10,000 junior and senior high school youth and is one of the principal architects of Illinois 's state-of-the-art approach to planning and evaluating community-based prevention programs. His research interests include the management of substance abuse as a chronic condition and adolescent treatment outcome research. Robert Schwebel, Ph.D., a clinical psychologist, developed the Seven Challenges drug treatment program for adolescents, which is now used across the country. He is the author of Saying No Is Not Enough (2nd ed., 1998), Keep Your Kids Tobacco-Free (2001), and other books. As the resident psychologist at Parent Soup (www.parentsoup. com) of ivillage, Dr Schwebel answers parenting questions. Active in the media, he has appeared on a number of talk shows including Oprah, various CNN interviews, and The Today Show. Recently, he wrote the booklet Help! ing Your Children Navigate Their Teenage Years: A Guide for Parents for the White House Council on Youth Violence.


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