Treatment of Adolescents With Substance Use Disorders (Inserted Text comment margie savage 7/20/2006 7:09:17 AM ) [Front Matter] [Title Page] Treatment of Adolescents With Substance Use Disorders Treatment Improvement Protocol (TIP) Series 32 Ken C. Winters, Ph.D. Revision Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 DHHS Publication No. (SMA) 99-3283 Printed 1999 [Disclaimer] This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose M. Urban, M.S.W., J.D., C.S.A.C., served as the CDM TIPs project director. Other CDM TIPs personnel included Y-Lang Nguyen, production/copy editor, Raquel Ingraham, M.S., project manager, Virginia Vitzthum, former managing editor, Mary Smolenski, Ed.D., C.R.N.P., former project director, and MaryLou Leonard, former project manager. The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions. What Is a TIP? Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance use disorders, provided as a service of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities for substance use disorders as substance use disorders are increasingly recognized as a major problem. [Front Matter] Treatment of Adolescents With Substance Use Disorders The TIPs Editorial Advisory Board, a distinguished group of substance use disorder experts and professionals in such related fields as primary care, mental health, and social services, works with the State alcohol and drug abuse directors to generate topics for the TIPs based on the field's current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent treatment programs for substance use disorders, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration. A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so that they continue to provide the field with state-of-the-art information. Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance use disorder treatment is evolving, and published research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided. This TIP, Treatment of Adolescents With Substance Use Disorders, updates TIP 4, published in 1993, and presents information on substance use disorder treatment for adolescent clients. Adolescents differ from adults both physiologically and emotionally as they make the transition from child to adult and, thus, require treatment adapted to their needs. The onset of substance use is occurring at younger ages, resulting in more adolescents entering treatment for substance use disorders than has been observed in the past. In order to treat this population effectively, treatment providers must address the issues that play significant roles in an adolescent's life, such as cognitive, emotional, physical, social, and moral development, and family and peer environment. This TIP focuses on ways to specialize treatment for adolescents, as well as on common and effective program components and approaches being used today. Chapter 1 details the scope and complexity of the problem; Chapter 2 presents factors to be considered when making treatment decisions; and Chapter 3 discusses successful program components. Chapters 4, 5, and 6 describe the treatment approaches used in 12-Step-based programs, therapeutic communities, and family therapy respectively. Chapter 7 discusses adolescents with distinctive treatment needs, such as those involved with the juvenile justice system. An explanation of legal issues concerning Federal and State confidentiality laws appears in Chapter 8. Appendix B is a table on the medical management of substance intoxication and withdrawal, which will appear in a forthcoming publication. Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889. Editorial Advisory Board Karen Allen, Ph.D., R.N., C.A.R.N. President of the National Nurses Society on Addictions Associate Professor Editorial Advisory Board Treatment of Adolescents With Substance Use Disorders Department of Psychiatry, Community Health, and Adult Primary Care University of Maryland School of Nursing Baltimore, Maryland Richard L. Brown, M.D., M.P.H. Associate Professor Department of Family Medicine University of Wisconsin School of Medicine Madison, Wisconsin Dorynne Czechowicz, M.D. Associate Director Medical/Professional Affairs Treatment Research Branch Division of Clinical and Services Research National Institute on Drug Abuse Rockville, Maryland Linda S. Foley, M.A. Former Director Project for Addiction Counselor Training National Association of State Alcohol and Drug Directors Washington, D.C. Wayde A. Glover, M.I.S., N.C.A.C. II Director Commonwealth Addictions Consultants and Trainers Richmond, Virginia Pedro J. Greer, M.D. Assistant Dean for Homeless Education University of Miami School of Medicine Miami, Florida Thomas W. Hester, M.D. Former State Director Substance Abuse Services Division of Mental Health, Mental Retardation and Substance Abuse Georgia Department of Human Resources Atlanta, Georgia Gil Hill Director Office of Substance Abuse American Psychological Association Washington, D.C. Douglas B. Kamerow, M.D., M.P.H. Director Office of the Forum for Quality and Effectiveness in Health Care Editorial Advisory Board Treatment of Adolescents With Substance Use Disorders Agency for Health Care Policy and Research Rockville, Maryland Stephen W. Long Director Office of Policy Analysis National Institute on Alcohol Abuse and Alcoholism Rockville, Maryland Richard A. Rawson, Ph.D. Executive Director Matrix Center and Matrix Institute on Addiction Deputy Director, UCLA Addiction Medicine Services Los Angeles, California Ellen A. Renz, Ph.D. Former Vice President of Clinical Systems MEDCO Behavioral Care Corporation Kamuela, Hawaii Richard K. Ries, M.D. Director and Associate Professor Outpatient Mental Health Services and Dual Disorder Programs Harborview Medical Center Seattle, Washington Sidney H. Schnoll, M.D., Ph.D. Chairman Division of Substance Abuse Medicine Medical College of Virginia Richmond, Virginia Consensus Panel 1997-98 Revision Consensus Panel Chair Ken C. Winters, Ph.D. Associate Professor Department of Psychiatry University of Minnesota Hospital and Clinic Minneapolis, Minnesota 1997-98 Revision Consensus Panel Gayle A. Dakof, Ph.D. Research Assistant Professor Center for Family Studies Department of Psychiatry and Behavioral Sciences University of Miami School of Medicine Miami, Florida Consensus Panel Treatment of Adolescents With Substance Use Disorders Richard Dembo, Ph.D. Professor of Criminology University of South Florida Tampa, Florida Nancy Jainchill, Ph.D. Senior Principal Investigator Center for Therapeutic Community Research National Development and Research Institutes New York, New York Michele D. Kipke, Ph.D. Director Board on Children, Youth, and Families National Research Council Institute of Medicine Washington, D.C. John R. Knight, M.D. Associate Director for Medical Education Division on Addictions Harvard Medical School Assistant in Medicine Children's Hospital Boston, Massachusetts Howard Liddle, Ed.D. Professor and Director Center for Treatment Research on Adolescent Drug Abuse Department of Psychiatry and Behavioral Sciences University of Miami School of Medicine Miami, Florida 1992-93 Consensus Panel Chair S. Kenneth Schonberg Director Division of Adolescent Medicine Montefiore Medical Center Bronx, New York 1992-93 Workgroup Leaders Gerald D. Shulman Executive Director Mountain Wood Treatment Center Charlottesville, Virginia Susan Wallace Caritas House 1992-93 Consensus Panel Chair Treatment of Adolescents With Substance Use Disorders Pawtucket, Rhode Island Ken C. Winters, Ph.D. Director Center for Adolescent Substance Abuse University of Minnesota, Division of Adolescent Health Minneapolis, Minnesota John Zachariah Regional Administrator American Correctional Association Laurel, Maryland 1992-93 Workgroup Members Bruce Abel, D.S.W., L.C.S.W. Looking Glass Counseling Center Eugene, Oregon Drew Alexander, M.D. Adolescent Health Dallas, Texas Terry Beartusk Executive Director Thunder Child Treatment Center Sheridan, Wyoming Cherrie Boyer, Ph.D. Department of Pediatrics University of California San Francisco, California Peter Cohen, M.D. Medical Director Children and Adolescents Programs Rockville, Maryland Richard Dembo, Ph.D. Professor of Criminology University of South Florida Tampa, Florida Elizabeth Cannon Duncan South Carolina Commission on Alcohol and Drug Abuse Treatment Columbia, South Carolina Gary Giron Executive Director La Neuve Vida 1992-93 Workgroup Members Treatment of Adolescents With Substance Use Disorders Santa Fe, New Mexico Raymond L. Hilton, Ed.D. Assistant Superintendent Department of Children and Youth Services Long Lane School Middleton, Connecticut Mary Jane Salsbery, R.N., C.C.D.N. Johnson County Adolescent Center for Treatment Olathe, Kansas Barbara Zugor Executive Director TASC, Inc. Phoenix, Arizona Foreword The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance use disorders by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance use disorder treatment field. Nelba Chavez, Ph.D. Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Executive Summary and Recommendations This document, Treatment of Adolescents With Substance Use Disorders, is a revision and update of Treatment Improvement Protocol (TIP) 4, published in 1993 by the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration (SAMHSA). Like TIP 4, this document aims to help treatment providers design and deliver better services to adolescent clients with substance use disorders. In 1992, CSAT convened a Consensus Panel of experts on adolescent substance use disorder treatment to produce guidelines for treatment programs on designing and delivering effective services to adolescent clients. The clients addressed in the TIP included, among others, young people involved with the juvenile and criminal justice systems. CSAT also intended for the Panel's guidelines to help governmental agencies and treatment providers establish, fund, Executive Summary and Recommendations Treatment of Adolescents With Substance Use Disorders operate, monitor, and evaluate treatment programs for substance-using adolescents. The result of that Panel's work was TIP 4, Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents. In July 1997, CSAT convened a small Revision Panel to review TIP 4. The Panel recommended changes and developed content for this revised TIP. Since the publication of TIP 4, the understanding of substance use disorders and its treatment among adolescents has advanced. More is known today about the immediate and long-term physiologic, behavioral, and social consequences of use, abuse, and dependency. New research attention has begun to examine the effectiveness of various treatment methods and components that meet the specific treatment needs of substance-using adolescents, and this literature is reviewed. However, the literature is small. Fortunately, a large multisite, national study on the effectiveness of treatment for adolescent substance users is underway with funds from the National Institute on Drug Abuse. CSAT is also conducting studies on adolescents, focusing on marijuana treatment, diversion programs in the juvenile justice system (JJS), and exemplary treatment programs. The field will likely mature greatly by the knowledge advanced from these studies. The structure of the earlier TIP of separate inpatient and outpatient treatment chapters, which represented a continuum of service intensity, was viewed by the Revision Panel to be less central to treatment decisions than a continuum based on the severity of the substance use disorder. This shift in focus better reflects clinical experience, extant treatment research, and the recent changes regarding reimbursement by health care payors for treatment. However, the Revision Panel retained a broad definition of treatment. Treatment is defined in this TIP as those activities that might be undertaken to deal with problem(s) associated with substance involvement and with individuals manifesting a substance use disorder. Although the Panel recognizes that primary or secondary prevention of substance use are included in expanded definitions of treatment, the Panel limited the continuum of interventions to what is traditionally viewed as acute intervention, rehabilitation, and maintenance. The elements of the continuum primarily reflect the treatment philosophies of providers, with less emphasis on settings and modalities. In addition to defining the treatment needs of adolescents and providing a full description of the use of the severity continuum, the Revision Panel focused attention on three common types of treatment for adolescents today: 12-Step-based treatment, treatment in the adolescent therapeutic community, and family therapy. The 12-Step model lies at the heart of many adolescent treatment programs. Therapeutic communities (TCs) are an intensive type of residential treatment that is attracting attention as a preferred approach for substance-using juveniles incarcerated in the justice system. Clinicians have found that effective treatment of the adolescent almost always involves the family, and the effectiveness of family therapy has been documented extensively, particularly among those substance-using adolescents who are normally the most difficult to treat. This revision of the earlier TIP, then, offers guidelines for using the severity continuum to make treatment decisions and for providing three common models of treatment for adolescents with substance use disorders. Recommendations of the Revision Panel, supported by extensive clinical experience and the literature, are summarized below. The organization of this TIP reflects the core facets of initiating, engaging, and maintaining the change process for youths with substance use disorders. Chapter 1 details the scope and complexity of the problem. Chapter 2 covers factors considered in making treatment decisions, and Chapter 3 details the features of successful programs. Chapters 4, 5, and 6 introduce and describe the treatment approaches used in 12-Step-based treatment, therapeutic communities, and family therapy, respectively. Chapter 7 discusses adolescents with distinctive treatment needs, such as youths involved in the juvenile justice system, homeless and runaway youth, and youth with coexisting disorders. Chapter 8 describes the legal and ethical issues that relate to diagnosis and treatment of adolescents. This new TIP derives from CSAT's intention to provide protocols that reflect the work now being done by providers of high-quality treatment. As with other TIPs, this document brings the best knowledge from the field to State and local treatment programs. In order to avoid awkward construction and sexism, this TIP alternates between "he" and "she" for generic examples. The companion document, TIP 31, Screening and Assessing Adolescents for Substance Executive Summary and Recommendations Treatment of Adolescents With Substance Use Disorders Use Disorders, a revision of TIP 3, has also been published (CSAT, 1999). Substance Use Disorder Treatment and Adolescents In 1997, substance use among 12- to 17-year-old children rose to 11.4 percent with illicit drug use among 12- and 13-year-olds increasing from 2.2 to 3.8 percent, according to the 1997 National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration. Moreover, perceived risk of harm from substance use is falling while the availability of drugs is climbing. These trends indicate a major national problem, especially as the social and economic costs of adolescent substance use are becoming better understood. The onset of substance use is occurring at younger ages, resulting in more adolescents entering treatment for substance use disorders with greater developmental deficits and perhaps much greater neurological deficits than have been observed in the past. Other consequences of substance use and abuse include alcohol- and drug-related traffic accidents, delinquency, sexually risky behavior, and psychiatric disorders. Adolescent users differ from adults in many ways. Their drug and alcohol use often stems from different causes, and they have even more trouble projecting the consequences of their use into the future. In treatment, adolescents must be approached differently than adults because of their unique developmental issues, differences in their values and belief systems, and environmental considerations (e.g., strong peer influences). At a physical level, adolescents tend to have smaller body sizes and lower tolerances, putting them at greater risk for alcohol-related problems even at lower levels of consumption. The use of substances may also compromise an adolescent's mental and emotional development from youth to adulthood because substance use interferes with how people approach and experience interactions. The treatment process must address the nuances of each adolescent's experience, including cognitive, emotional, physical, social, and moral development. An understanding of these changes will help treatment providers grasp why an adolescent uses substances and how substance use may become an integral part of an adolescent's identity. Regardless of which specific model is used in treating young people, there are several points to remember when providing substance use disorder treatment: ¨ In addition to age, treatment for adolescents must take into account gender, ethnicity, disability status, stage of readiness to change, and cultural background. ¨ Some delay in normal cognitive and social-emotional development is often associated with substance use during adolescence. Treatment for adolescents should identify such delays and their connections to academic performance, self-esteem, or social interactions. ¨ Programs should make every effort to involve the adolescent client's family because of its possible role in the origins of the problem and its ability to change the youth's environment. ¨ Although it may be necessary in certain geographic areas where availability of adolescent treatment programs is limited, using adult programs for treating youth is ill-advised. If this must occur, it should be done only with great caution and with alertness to inherent complications that may threaten effective treatment for these young people. ¨ Many adolescents have explicitly or implicitly been coerced into attending treatment. Coercive pressure to seek treatment is not generally conducive to the behavior change process. Treatment providers should be sensitive to motivational barriers to change at the outset of intervention. Several strategies can be used for engaging reluctant clients to consider behavioral change. Tailoring Treatment to The Adolescent Adolescent substance use occurs with varying degrees of severity. The degree of substance involvement is an important determinant of treatment, as are any coexisting disorders, the family and peer environment, and the individual's stage of mental and emotional development. This information should be used to refer the client to Substance Use Disorder Treatment and Adolescents Treatment of Adolescents With Substance Use Disorders appropriate treatment. It is useful to consider a substance use continuum with these six anchor points: ¨ Abstinence ¨ Use: Minimal or experimental use with minimal consequences ¨ Abuse: Regular use or abuse with several and more severe consequences ¨ Abuse/Dependence: Regular use over an extended period with continued severe consequences ¨ Recovery: Return to abstinence, with a relapse phase in which some adolescents cycle through the stages again ¨ Secondary abstinence Treatment interventions fall along a continuum that ranges from minimal outpatient contacts to long-term residential treatment. All levels of care should be considered in making an appropriate referral. Any response to an adolescent who is using substances should be consistent with the severity of involvement. While no explicit guidelines exist, the most intensive treatment services should be devoted to youth who show signs of dependency--that is, a history of regular and chronic use--with the presence of multiple personal and social consequences and evidence of an inability to control or stop using substances. Assessment The guidelines below show how the continuum can be used in making a decision regarding the placement of the adolescent. The Revision Panel created the guidelines based on clinical experience. ¨ In making placement decisions, practitioners should choose the most intensive level of care indicated by any single assessment criterion. ¨ When an assessment indicates the need for a particular level of care that is not available, it is desirable to refer the adolescent to the next higher level of care, unless the assessment indicates that such a placement would be counterproductive. Naturally, a higher level of care may not be practical or available. ¨ Assessment is an ongoing process. Decisions about level of care should be based on the adolescent's progress and changes in his environment. Clients should have the opportunity to move back and forth across the level of care continuum based on changes in these factors. ¨ Assessors should have an indepth knowledge of available services and their quality and intensity. ¨ Adolescents may move into or through different treatment programs based on their progress and/or changes in the environment. Prior to each program change, indepth reassessment must be completed and the results communicated between providers. General Program Characteristics Program design, a policies and procedures manual, ongoing evaluation, and a planned approach to legal concerns make up the framework for a treatment program. Within this framework, issues to consider include staff recruitment and training, treatment components, treatment planning, and client services. Staffing Staff members should represent the cultural diversity of the program's client population. In addition, the facility's forms, books, videos, and other materials should reflect the culture and language of the clientele. Innovative and intensive continuing education, staff development, and outreach efforts during staff recruitment may be needed to improve cultural competence among staff. If a significant part of the client population is non-English-speaking, at least one staff member should be bilingual and bicultural. Someone on staff should be familiar with disability issues Assessment Treatment of Adolescents With Substance Use Disorders and disability culture: For example, people who are deaf who use American Sign Language have their own culture. Most important is to schedule staff training periodically throughout the year. This is greatly preferable to training presented in ad hoc situations to address crises or acute situations. Ongoing training should address a range of specialty topics, including the following: ¨ Treatment approaches specific to adolescents and their families ¨ Family dynamics and family therapy ¨ Adolescent growth and development ¨ Sexual and physical abuse ¨ Gender issues ¨ Mental health problems ¨ Different cultural and ethnic values ¨ Psychopharmacology ¨ Referral and community resources ¨ Cognitive impairments ¨ Legal matters When recovering individuals are hired, they should have the same level of expertise and training required of other staff members in the same position. Recovering individuals must have clear evidence of abstinence from alcohol and drugs for 2 to 5 years. Program Components The core components of many adolescent treatment programs, regardless of their therapeutic orientation, include the following: ¨ Orientation, the first step in treatment, clarifies to the adolescent what treatment is, her role in treatment, and the concept of program expectations. Orientation should be conducted in a nonconfrontational style and tone in order not to raise the adolescent's anxiety, which may already be heightened by other aspects of the treatment program. ¨ Daily scheduled activities of school, chores, homework, and positive recreational activities can help adolescents learn new skills and provide them with an alternative to their substance-using behavior and can help ensure that adolescents remain sober after treatment. ¨ Peer monitoring in a group setting can help the client build the strength necessary to override peer pressure and harness the influence of the peer group in a positive manner. ¨ Conflict resolution is often necessary given that there is a high potential for conflict between young clients and program staff. Such conflicts can arise from a staff member's inexperience in working with adolescents or a client's inability or unwillingness to meet program expectations, in which case the treatment plan should be modified. In any event, staff should take a proactive stance in resolving conflicts. ¨ Client contracts (e.g., behavioral contracts, including substance-free contracts) are negotiated and signed by both the adolescent and primary counselor; they lay out concrete treatment goals, expectations, time frames, and consequences (if the contract is not followed) that are mutually acceptable to the client and counselor. They can help identify the current level of the adolescent's functioning and developmental markers, providing a baseline from which to monitor change. They also give to adolescents a sense of control in going through treatment and a degree of investment in their well-being. ¨ Schooling, which generally focuses on substance use and basic education, is one of the most important factors in an adolescent's recovery. Whether the schooling is provided on or off site, it should be fully integrated into an adolescent's program. Teaching staff should be considered part of the treatment team. For adolescents who attend public schools, a liaison between the school and treatment program should be designated. Program Components Treatment of Adolescents With Substance Use Disorders ¨ Vocational training is an important intervention and should be part of an adolescent's treatment. Appropriate interventions include prevocational training, career planning, and job-finding skills training. Without these skills, many youths may be more likely to support themselves through illegal activities and thus be more prone to relapse. The level of intensity of these components will vary considerably from outpatient to residential treatment. Treatment Planning At a minimum, a treatment plan should identify the following: ¨ Problems of the client and the family, including substance use, psychosocial, medical, sexual, reproductive, and possible psychiatric disorders ¨ Goals that are attainable and help clients to recognize their involvement with substances and to acknowledge responsibility for the problems resulting from substance use ¨ Strengths and resources of the individual and the family and ways to apply them to address treatment goals ¨ Objectives that are realistic and measurable steps for achieving each goal ¨ Interventions such as treatment strategies and services that are needed to achieve the objectives ¨ Educational, legal, and external support systems The treatment plan should include pre-established times for evaluation and adjustment of goals as necessary. Treatment programs also should work closely with other entities that are involved in the treatment of adolescents, such as school systems, child welfare, and juvenile justice agencies. Interagency agreements, also known as memoranda of understanding, should be developed that describe payment policies, funding problems, mutual goals for clients, and intra- and interagency contracts. In addition, it is important to have an established practice of exchanging signed releases of information from each shared client, insofar as the client agrees to the sharing of information, so that the involved staff members can more freely exchange confidential information about the client's progress. 12-Step-Based Programs In programs like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), sobriety is maintained by carefully employing a 12-Step philosophy and by sharing experiences with others who have suffered similar problems with substance abuse and dependency. Many clients who are involved with AA/NA find another member who will serve as a sponsor and provide guidance and help in times of crisis when the urge to return to drinking or drug use becomes overwhelming. Providers treating adolescents in a 12-Step-based program should bear the following in mind: ¨ Substance use disorders are primary, multifaceted illnesses that exist in people of all ages, including adolescents. ¨ Persons with substance use disorders are individuals who share a common problem but have unique and separate needs and therefore should be treated with respect and dignity. ¨ Once substance-using adolescents are informed about addiction in an understandable way, they are capable of helping others, as long as they receive some guidance. ¨ Use of group therapy is well suited to adolescents, who tend to rely heavily on peer examples and approval. ¨ The principles of recovery outlined by AA/NA provide effective and proactive tools for continuing recovery from substance involvement. ¨ Once a person has lost control over his use of substances as an adolescent, returning to responsible and legal use as an adult may require additional help and support. Treatment Planning Treatment of Adolescents With Substance Use Disorders Most 12-Step-based programs focus on the first five steps during primary treatment, while the remaining ones are attended to during aftercare. Below are ways to present the first five steps to adolescents so that their specialized developmental needs can be addressed. ¨ Step 1: We admitted we were powerless over alcohol--that our lives had become unmanageable. With adolescents, the primary goal of this step is to assist them in reviewing their substance use history and to have them associate it with harmful consequences. ¨ Step 2: We came to believe that a Power greater than ourselves could restore us to sanity. To convey this message, allow new clients to interact with those who have been successful in treatment and are leaving the program. Providers must help adolescents with coexisting mental illnesses or cognitive disabilities to understand that Step 2 refers to obtaining help to stop drug seeking and use behavior. ¨ Step 3: We made a decision to turn our will and our lives over to the care of God as we understood Him. This step can be simplified by saying, "Try making decisions in a different way; take others' suggestions; permit others to help you." Using the phrase "Helping Power" instead of "Higher Power" can benefit some. ¨ Step 4: We made a searching and fearless moral inventory of ourselves; Step 5: We admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Steps 4 and 5 provide an opportunity to be accepted by another person in spite of one's past behaviors and to take a "personal inventory" of those past behaviors. Therapeutic Communities As a social-psychological form of treatment for addictions and related problems, the TC has been typically used in the United States to treat youth with the severest problems and for whom long-term care is indicated. TCs have two unique characteristics: 1. The use of the community itself as therapist and teacher in the treatment process 2. A highly structured, well-defined, and continuous process of self-reliant program operation The community includes the social environment, peers, and staff role models. Treatment is guided by the substance use disorder, the person, recovery, and right living. Traditionally in the therapeutic community, job functions, chores, and other facility management responsibilities that help maintain the daily operations of the TC have been used as a vehicle for teaching self-development. The day is highly structured, with time designated for chores and other responsibilities, group activities, seminars, meals, and formal and informal interaction with peers and staff. The use of the community as therapist and teacher results in multiple interventions that occur in all these activities. For the adolescent, the community may be even more crucial than for adults since the TC functions as family. This is an exceedingly significant function, since many youth in TCs come from dysfunctional families. Modifications that are generally made in the TC model for treatment of adolescents can be summarized as follows: ¨ The duration of stay is shorter than for adults. ¨ Treatment stages reflect progress along behavioral, emotional, and developmental dimensions. ¨ Adolescent programs are generally less confrontational than adult programs. ¨ Adolescents have less say in the management of the program. ¨ Staff members provide more supervision and evaluation than they do in adult programs. ¨ Neurological impairments, particularly learning disabilities and related disorders, such as attention deficit/hyperactivity disorder (AD/HD), must be assessed. ¨ There is less emphasis on work and more emphasis on education, including actual schoolwork, in the Therapeutic Communities Treatment of Adolescents With Substance Use Disorders adolescent program. ¨ Family involvement is enhanced in adolescent programs and ideally should be staged, beginning with orientation and education, then moving to support groups, therapy groups, and therapy with the adolescent. When parental support is nonexistent, probation officers, social workers, or other supportive adults in the youth's life can participate in therapy. Clinical wisdom suggests that the ideal duration of treatment for adolescents in a TC is 12 to 18 months and that adolescents with very deep and complicated disorders cannot be treated effectively in 28 days. Staffing in TCs continues to include non-degreed, recovering individuals as adjunctive staff, as well as professionally trained, degreed specialists. Having a nurse on site is ideal, in part to provide cross-training for the counselors, particularly regarding the symptomatology of addiction. The nurse should be well-versed in sexuality, reproductive health, and sexually transmitted diseases (STDs), including diagnosis, treatment, and issues surrounding partner notification. Teachers in a TC program for adolescents must have an understanding of substance use disorders among youth. TC residents move through stages of increasing responsibility and privileges. To advance to the next level, the adolescent must demonstrate responsibility, self-awareness, and consideration for others. In adult TCs, the final stage is taking some responsibility for operating the TC; this is not appropriate for adolescents, for whom the staff plays the role of effective parents. Ideally, TCs should provide their own schools with licensed teachers as well as satellite aftercare programs in the communities where the residents live. For adolescents, aftercare programs should include a family therapy component. Programs should develop cooperative working agreements with their local juvenile probation departments to coordinate the referral, screening, and followup and to ensure this population's access to appropriate treatment. Prevocational and vocational training should be incorporated whenever possible. A TC environment should help clients come to terms with sexual issues (e.g., sexual identity, previous sexual abuse) through one-on-one counseling, encounter groups, sex education classes, and other special sessions. Dating and sexual contact between clients should be prohibited. Boys' and girls' living spaces should be separated. The longer term stay and increased contact make TCs a good environment for counseling and education on other issues such as smoking and STDs. Family Therapy Substance use disorder treatment programs can employ family therapists to apply therapeutic approaches that have proven effective with adolescents and their families. A therapist who practices a family-based approach should have formal, professional training in this method. Family therapy fits well into the regimen of treatment where case management is used; it also has been proven effective in home-based treatment. Contemporary family therapy approaches understand the importance of treating individuals as subsystems within the family system and as units of assessment and intervention; in other words, each member of the family is capable of being assessed and can act as a unit of intervention, for example, by changing his interactional patterns. Family-based treatments work with multiple units, including individual parents, adolescents, parent-adolescent combinations, and whole families, as well as family members vis-_-vis other systems. Contemporary family approaches also target extended systems, most notably an adolescent's peers, school, and neighborhood, which are believed to contribute to dysfunctional interactions in families. The therapist's intervention aims to change the way family members relate to each other by examining the underlying causes of current interactions and encouraging new (and presumably, healthier) ones. The therapist should help family Family Therapy Treatment of Adolescents With Substance Use Disorders members appreciate how the values and perspectives of each family member may differ from their own, but that differences do not have to be a source of conflict. Helping the family members solve problems together in the therapeutic setting enables them to learn strategies that can be applied with the adolescent in the home. Such maneuvers in therapy decrease family conflicts and improve the effectiveness of communication. Family treatment also equips parents with the skills and resources necessary to address the inevitable difficulties that arise in raising teenagers. The family therapist's job is to help parents regain their optimism and motivate them to continue to help their teenager. Family therapists should bolster the parents' self-confidence as parents while at the same time helping them improve their parenting skills. Parents are taught how to provide age-appropriate monitoring of their teenager (e.g., to know their friends, to know how they spend their time), set limits (e.g., negotiate with the youth about reasonable curfews, schedules, and family obligations), establish a system of positive and negative consequences, rebuild emotional attachments, and take part in activities with the adolescent outside the home. Family therapy can include discussion of the effects of the teenager's actions in extrafamilial systems--such as skipping an appointment with a probation officer or hanging out with peers late at night on unsafe street corners where drugs are bought and sold. Then the therapist might meet with the probation officer or ask the adolescent to bring a peer to a session to review the problem from the youth's perspective. Family therapists should be acutely aware of the complex of behaviors and systemic interactions associated with recovering from a substance use disorder. They also must be aware of cultural differences in family patterns and typical attitudes toward therapy. Adolescent substance involvement should be considered within the context of other problem behaviors such as delinquency and school problems, necessitating new frameworks of diagnosis and assessment, as well as treatment. Adolescent clients will benefit when the treatment team, including substance abuse counselors, nurses, and doctors, working in conjunction with family therapists, have a general understanding of family therapy within the substance use disorder treatment setting. When they have this understanding, the treatment team members can best support the efforts of the therapist and coordinate their components of treatment with family therapy. Most important in family therapy is the therapeutic alliance between the therapist and adolescent. It is crucial for the therapist to emphasize to the client and family members that the purpose of the therapy is to help the client. Youths With Distinctive Treatment Needs Young people who have distinct concerns related to coexisting psychiatric conditions, sexual orientation, involvement with the criminal justice system, physical health, or displaced living conditions may not do well in traditional treatment programs. Therefore, treatment providers should offer individualized treatment, paying particular attention to the events and circumstances that contributed to the client's current situation. Problems that often accompany substance use disorders include illegal activity, homelessness, shame surrounding sexual orientation, and coexisting physical and mental disorders. Youth in the Juvenile Justice System Every young person involved in the juvenile justice system should undergo thorough screening and assessment for substance use disorders, physical health problems, psychiatric disorders, history of physical or sexual abuse, learning disabilities, and other coexisting conditions. Juvenile probation officers can be helpful partners in the system of care. For their part, providers should educate the local juvenile justice system about the importance of early intervention and the resources available to it. It is almost impossible to intervene here unless the youth is removed from the environment that brought him into conflict with the juvenile justice system in the first place (e.g., the home neighborhood). Early intervention is critical in working with adolescents who have come into contact with the juvenile Youths With Distinctive Treatment Needs Treatment of Adolescents With Substance Use Disorders justice system. Homeless Youth Research shows that homeless youths are at high risk for a wide range of problems, including substance use disorders. Effective treatment for this population hinges on recognizing these young people's readiness for treatment. For adolescents who are living on the streets, outreach becomes a primary intervention strategy. Outreach programs should have in place a "step-up" for homeless or inner-city youths to enter these programs, assisting them in negotiating the various obstacles that may be potential barriers to services. Street outreach workers should focus on developing trusting relationships with youths that, over time, can influence a young person to access treatment services for substance use disorders. Service providers must meet with, talk to, and develop relationships with young people on the street to engage them in treatment. Returning homeless or runaway youth to their homes is not always in their best interest because less than optimal conditions may exist in these homes. Treatment providers should explore the appropriateness of other transitional living options for homeless youth if necessary. Once a homeless youth has entered the system, the next step is establishing a case management plan that is based on a thorough assessment of her needs. Possible services should include finding housing, dealing with family problems, entering substance use disorder and/or HIV-related treatment, and providing schooling, sexual and reproductive health care, and job training. It may be necessary to prioritize the needs for services according to the individual's problems. Homosexual, Bisexual, and Transgendered Youth Adolescence is a very lonely, high-risk time for many youths who have sexual identity issues. Many gay, bisexual, and transgendered youths have no one in whom they can confide, and most communities lack gay-identified services. Gay-specific services are likely to be more sensitive to the importance of not divorcing the issues of sexual identity from substance use problems during the treatment process. Effective treatment for these youths involves helping them to feel comfortable with, and to take pride in, their sexual identity. Coexisting Disorders Any adolescent who is being treated for substance use disorders and is also taking psychoactive medications for a coexisting psychiatric disorder requires careful psychopharmacological management. These adolescents should also be given routine urine testing as part of their treatment plan. Close scrutiny of adolescents with AD/HD is particularly important for those who are receiving substance use disorder treatment. Treatment providers and mental health authorities should develop programs together to treat youth with coexisting disorders. Cross-training can help staff of both programs develop the sensitivity and the clinical skills to understand coexisting disorders and to identify the presence of either problem or both. Youths who have coexisting disorders and are not on psychoactive medications do better in programs that provide both substance use disorder and mental health treatment together than in separate programs. For more information on coexisting psychiatric conditions and substance use disorders, refer to TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse. Legal and Ethical Issues Because of the complexity of the consent issue, programs in States with laws that do not clearly allow admission of adolescents without parental consent or notification should develop a special admissions policy. This policy should be based on these variables: ¨ State law regarding treatment of adolescents (i.e., whether parental consent and/or notification is required) ¨ State law regarding program liability if adolescent clients in need are turned away Homeless Youth Treatment of Adolescents With Substance Use Disorders ¨ The family circumstances as related by the adolescent (the adolescent's view of his family may be verified, with his consent, by contacting an adult who knows the family well) ¨ The adolescent's age and emotional, cognitive, and social maturity ¨ The kind of treatment the program provides ¨ The program's financial capacity to provide treatment without reimbursement from family ¨ Potential for exposure to a lawsuit should the program admit the adolescent With the above factors in mind, the program should assess its potential liability if the adolescent is admitted without parental consent in a State where such consent is required. Programs Governed by Federal Confidentiality Regulations Any program that specializes, in whole or in part, in providing treatment, counseling, and/or assessment and referral services for adolescents with substance use disorders must comply with the Federal confidentiality regulations (42 C.F.R. _2.12(e)). Although the Federal regulations apply only to programs that receive Federal assistance, this includes indirect forms of Federal aid such as tax-exempt status or State or local government funding coming (in whole or in part) from the Federal government. Coverage under the Federal regulations does not depend on how a program labels its services. Calling itself a "prevention program" does not excuse a program from adhering to the confidentiality rules. It is the kind of services, not the label, that will determine whether the program must comply with the Federal law. Information that is protected by the Federal confidentiality regulations may be disclosed only after the adolescent has signed a proper consent form. In some States, parental consent must also be obtained. The adolescent may revoke consent at any time, and the consent form must include a statement to this effect. The form must also contain a date, event, or condition on which it will expire if not previously revoked. Once the consent form has been properly completed, there remains one last formal requirement. Any disclosure made with patient consent must be accompanied by a written statement that the information disclosed is protected by Federal law and that the recipient cannot further disclose or release such information unless permitted by the regulations. Programs assessing or treating adolescents who are involved in the criminal justice system or juvenile justice system (juvenile court) must also follow the Federal confidentiality rules. Duty to Warn If an adolescent's counselor thinks the teenager poses a serious risk of violence to someone, there are at least two questions that must be answered: 1. Does a State statute or court decision impose a duty to warn in this particular situation? 2. Even if there is no State legal requirement that the program warn an intended victim or the police, does the counselor feel a moral obligation to warn someone? The first question can only be answered by an attorney familiar with the law in the State in which the program operates. If the answer to the first question is "no," it is advisable to discuss the second question with a knowledgeable lawyer, too. A similar dilemma also arises when providers know that an adolescent they are treating is infected with HIV or if the adolescent has committed a criminal act. Reporting Child Abuse and Neglect All 50 States and the District of Columbia have statutes requiring reporting when there is reasonable cause to believe or suspect child abuse or neglect. While many State statutes are similar, each has different rules about what kinds of Programs Governed by Federal Confidentiality Regulations Treatment of Adolescents With Substance Use Disorders conditions must be reported, who must report, and when and how reports must be made. Because of the variation in State law, programs should consult an attorney familiar with State law to ensure that their reporting practices are in compliance. When a program makes such a report, it should notify the family, unless the notification would place the child in further danger. The program should also endeavor to continue to work with the family as the State investigates the complaint and the child protective process unfolds. Families should never be abandoned because of suspected abuse or neglect, and health care providers should be wary of making judgments until a comprehensive assessment has been completed by State authorities. Chapter 1--Substance Use Among Adolescents Substance use by young people is on the rise, and initiation of use is occurring at ever-younger ages. Patterns of substance use over the past 20 years have been documented by two surveys--the National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Monitoring the Future Study conducted by the National Institute on Drug Abuse (NIDA). Data released in 1996 indicated that in the early to mid-1990s, the percentage of 8th graders who reported using illicit drugs (i.e., drugs illegal for Americans of all ages) in the past year almost doubled, from 11.3 percent in 1991 to 21.4 percent in 1995 (NIDA, 1996a). Drug use by high school students also has risen steadily since 1992. The survey also indicates that 33 percent of 10th graders and 39 percent of 12th graders reported the use of an illicit drug within the preceding 12 months (NIDA, 1996a). These estimates are probably low because the statistics are gathered in schools and do not include the high-risk group of dropouts. Most of the recent increase is attributed to marijuana use, which rose significantly during this period. An estimated 15 percent of 8th graders, 24 percent of 10th graders, and 30 percent of 12th graders reported having had five or more drinks within the preceding 2 weeks (Johnston et al., 1995). Slightly more than half of high school students (grades 9 through 12) reported having had at least one drink of alcohol during the 30 days preceding a 1995 Centers for Disease Control and Prevention (CDC) survey (CDC, 1996). It is further estimated that 9 percent of adolescent girls and up to 20 percent of adolescent boys meet adult diagnostic criteria for an alcohol use disorder (Cohen et al., 1993). Furthermore, the proportion of daily smokers among American high school seniors remains disturbingly high at about 20 percent. The surveys have found that the perceived risk of harm from drug involvement has been declining while the availability of drugs has been rising (NIDA, 1996a; SAMHSA, 1998a). Particularly in the case of marijuana, sharp declines in harm perception have been observed among 8th, 10th, and 12th graders (see Figure 1-1). This shift has occurred at the same time that marijuana use has spread (NIDA, 1996a). Since 1991, the percentage of students who thought that regular marijuana use carries a "great risk" of harm has dropped from 79 percent to 61 percent among 12th graders, from 82 percent to 68 percent among 10th graders, and from 84 percent to 73 percent among 8th graders (NIDA, 1996a). During the same period, reported use of marijuana within the preceding year rose for all these grades by an average of 11 percent (NIDA, 1996a). Household products are abused as well as illegal drugs: The percentage of youths 12 to 17 years old who tried inhalants rose from 1.1 percent in 1991 to 2.2 in 1994 (NIDA, 1996a). "Heroin chic" as exemplified by rock stars and fashion models has boosted the popularity of that drug among young people. Panel members reported that in some areas, the adolescent use of heroin mixed with water and then inhaled has increased. Clearly, drug use trends among young people are a major national concern. Within the context of national surveys of frequency of use, the prevalence of those meeting criteria for a diagnosis is becoming clearer. A 1996 statewide Minnesota survey provided the first systematic look at the rate of substance use disorders in a large student population: 11 percent of 9th grade students and 23 percent of 12th grade students met formal diagnostic criteria as established in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) for drug abuse or drug dependence disorder Chapter 1--Substance Use Among Adolescents Treatment of Adolescents With Substance Use Disorders (Harrison and Fulkerson, 1996). The Consequences In terms of public health, adolescent substance use disorders have far-reaching social and economic ramifications. The numerous adverse consequences associated with teenage drinking and substance use disorders include fatal and nonfatal injuries from alcohol- and drug-related motor vehicle accidents, suicides, homicides, violence, delinquency (Dembo et al., 1991), psychiatric disorders, and risky sexual practices (Jainchill et al., in press). Longitudinal studies have established associations between adolescent substance use disorders and (1) impulsivity, alienation, and psychological distress (Hansell and White, 1991; Shedler and Block, 1990), (2) delinquency and criminal behavior (National Institute of Justice, 1994), (3) irresponsible sexual activity that increases susceptibility to HIV infection (DiClemente, 1990), and (4) psychiatric or neurological impairments associated with drug use, especially inhalants, and other medical complications (SAMHSA, 1996). Substance use disorders that begin at an early age, especially when there is no remission of the disorder, exact substantial economic costs to society (Children's Defense Fund, 1991). The trend toward early onset of substance use disorders has increasingly resulted in adolescents who enter treatment with greater developmental deficits and perhaps much greater neurological deficits than have been previously observed. Moreover, the risks of traumatic injury, unintended pregnancy, and sexually transmitted diseases (STDs) are high in adolescents in general. Drug involvement that is superimposed on these already high risks has numerous potentially adverse consequences that have not yet been the subject of indepth study beyond basic population studies. Mortality Alcohol-related motor vehicle accidents exact a heavy toll on society in terms of economic costs and lost productivity. Nearly half (45.1 percent) of all traffic fatalities are alcohol-related, and it is estimated that 18 percent of drivers 16 to 20 years old--a total of 2.5 million adolescents--drive under the influence of alcohol. According to the Youth Risk Behavior Surveillance System conducted by the CDC, which monitors health risk behaviors among youths and young adults, unintentional injuries, including motor vehicle accidents, are by far the leading cause of death in adolescents, causing 29 percent of all deaths. An estimated 50 percent of these deaths are related to the consumption of alcohol (CDC, 1998). Sexually Risky Practices Adolescents are at higher risk than adults for acquiring STDs for a number of reasons. They are more likely to have multiple (sequential or concurrent) sexual partners and to engage in unprotected sexual intercourse. They are also more likely to select partners who are at higher risk for STDs. Among females, those 15 to 19 years old have the highest rates of gonorrhea, while 20- to 24-year-olds have the highest rate of primary and secondary syphilis (CDC, 1996). Adolescents who use alcohol and illicit drugs are more likely than others to engage in sexual intercourse and other sexually risky behaviors. A positive correlation has been demonstrated between alcohol use and frequency of sexual activity. In a 1990 Massachusetts survey of adolescents 16 to 19 years old, two-thirds reported having had sexual intercourse, 64 percent reported having sex after using alcohol, and 15 percent reported having sex after using drugs (MacKenzie, 1993). Substance use among adolescents is associated with early sexual activity, an important factor in the prevalence of STDs and HIV infection. The use of substances combined with sexual activity significantly decreases the likelihood that a condom will be used during sex. Substance use also can decrease an individual's discrimination in the selection of sexual partners and can increase the number of partners and the likelihood of risky sexual practices (including anal The Consequences Treatment of Adolescents With Substance Use Disorders intercourse), thereby heightening the risk of STDs (MacKenzie, 1993). The CDC conducted its school-based Youth Risk Behavior Survey among a representative sample of 10,904 high school students in grades 9 through 12. Among the survey's findings were the following: ¨ More than half--53.1 percent--of the students had sexual intercourse at some time. Of these, 9 percent had initiated sexual intercourse before the age of 13. ¨ An estimated 17.8 percent of students had sexual intercourse with four or more sexual partners during their lifetimes. ¨ Among the students, 6.9 percent reported that they had been pregnant or impregnated someone. ¨ Of the currently sexually active students, 24.8 percent reported that they had used alcohol or drugs prior to their last sexual intercourse (CDC, 1994). Another drug use consequence related to sexual behavior is unwanted pregnancy. Each year, an estimated 4.9 percent of females under age 18--nearly 200,000 young women--give birth to a live infant (NIDA, 1996b). The live birth rate among 18- to 24-year-olds is 34.7 percent (1.4 million women). Among both of these age groups, an estimated 12.4 percent used alcohol, and 21.9 percent smoked cigarettes during their pregnancies (NIDA, 1996b). Some 5.7 percent used illicit drugs (marijuana or cocaine) while they were pregnant. The risks of fetal alcohol syndrome, miscarriage, and restricted fetal growth that accompany substance use during pregnancy result in substantial economic and health costs each year. The prevalence of early sexual activity among adolescents emphasizes the need for treatment programs to gather sexual histories and to perform HIV and STD testing in this population. Adolescents should be appropriately counseled about these tests, especially the implications of positive test results. They should be assured that the results will remain strictly confidential (see Chapter 8 for confidentiality issues). Juvenile Delinquency and Crime The link between adolescent substance use and juvenile delinquency is complex. There is a strong and consistent association between conduct disorder and substance use among teenagers (Crowley and Riggs, 1995). Many young people entering the juvenile justice system have a host of problems ranging from impaired emotional, psychological, and educational functioning to physical abuse, sexual victimization, and substance use disorders (Dembo, 1996). A growing trend is that most of the teenagers entering residential treatment for substance use disorders have been criminally active and mandated to treatment by the criminal justice system (Jainchill, 1997). Drug testing data collected on male juvenile arrestees through the National Institute of Justice (NIJ) confirm a strong and continuing relationship between the extent of drug use and juvenile crime (NIJ, 1997). An additional finding from the data is that the median positive rate for marijuana use among male juvenile arrestees increased from 41 percent in 1995 to 52 percent in 1996. Developmental Problems Substance use can prevent an adolescent from completing the developmental tasks of adolescence, such as dating, marrying, bearing and raising children, establishing a career, and building rewarding personal relationships (Havighurst, 1972; Baumrind and Moselle, 1985; Newcomb and Bentler, 1989). Because substance use changes the way people approach and experience interactions, the adolescent's psychological and social development is compromised, as is the formation of a strong self-identity. Adolescents' use of alcohol or drugs may also hinder their emotional and intellectual growth. Some adolescents may use substances to compensate for a lack of rewarding personal relationships. Instead of developing a sense of empowerment from healthy personal development, the substance-using adolescent is likely to acquire a superficial and false self-image as he becomes more deeply Juvenile Delinquency and Crime Treatment of Adolescents With Substance Use Disorders entrenched in the drug experience (MacKenzie, 1993). Naturally, treating an adolescent with substance use disorders as early as possible maximizes the opportunity to stem these initially short-term, but potentially long-term, ill effects. Treatment Needs A recent study conducted by SAMHSA reveals that treatment for substance use disorders significantly reduces substance use and criminal activity (SAMHSA, 1998b). Administering treatment to adolescents, then, could greatly prevent future substance use related-problems as the adolescent transitions into adulthood. Understanding the relationship between substance use and adolescent development is crucial for designing effective interventions and treatment strategies. Treatment efforts that approach young people as "little adults" are bound to fail. Rather, the treatment process must incorporate the nuances of the adolescent's experience--including cognitive, emotional, moral, and social development--so that treatment providers can begin to grasp why substance use becomes a part of the identity of these young people. Adolescence is a time when interpersonal relationships are transformed and new cognitive abilities emerge. The adolescent is for the first time forming an individual sense of self. The psychosocial changes associated with the passage into adult society occur within the context of the significant physiological changes of puberty. Social relationships move from a predominant attachment to family to an increased bonding and identification with peers. Teenagers also begin joining and identifying with institutions outside the family--schools, churches, Boy and Girl Scouts, political groups, and fan clubs. The extrafamilial bonding often has a very pluralistic character, with peer groups being only a visible and influential part. Adherence to the family's values evolves into independent thinking and the development of a personal belief and value system. Abstract thinking, propositional logic (the ability to form hypotheses and consider possible solutions), and metacognition (the ability to think about the thought process itself) are essential abilities that develop during the adolescent years. It stands to reason that these cognitive functions are vital to the process of establishing therapeutic relationships between therapist and client, and for the client to gain insight into the adverse course of substance use, as well as to engage in behavioral change strategies. Not all young people who experiment with substances develop clinical problems. In fact, some degree of experimentation with drugs is technically normative; that is, most adolescents have tried alcohol or illicit drugs at least once by the time they turn 18 (Johnston et al., 1995). The formidable task faced by every adolescent--to become an independent and responsible adult--is undertaken with strategies that may include exploration, experimentation, risk taking, limit testing, and questioning of established rules and sources of authority. Experimentation with substances may be among these usually functional strategies, despite the potential harm and hazard associated with this behavior. However, substance use can lead to an abusive and addictive pattern that requires more active, firm, and constant intervention. Risk Behaviors of Adolescents It is useful to consider substance use during adolescence within the context of the more general spectrum of risk behaviors that mark this developmental period. Problem behavior theory provides a useful conceptual framework for understanding risk behaviors during the adolescent period. Problem behavior theory defines risk behavior as behavior that can interfere with successful psychosocial development (e.g., having deviant peers), whereas problem behaviors are risk behaviors that lead to either formal or informal social responses designed to control them (e.g., substance use) (Jessor and Jessor, 1977). In other words, risk behaviors increase the adolescent's vulnerability to a problem, whereas problem behaviors incur consequences, such as discipline at home or school. As Jessor and his colleagues observed in several investigations, problem behaviors tend to cluster in an individual; for example, those who experiment with substance use also tend to engage in risky sexual practices and illegal behavior (Jessor, 1991). Treatment Needs Treatment of Adolescents With Substance Use Disorders Risk behaviors can become a "risk behavior syndrome" (DuRant et al., 1995a, 1995b) in that problem behaviors serve a common social or psychological developmental goal, such as separating from parents, achieving adult status, or gaining peer acceptance. These behaviors may also help an adolescent cope with failure, boredom, social anxiety or isolation, unhappiness, rejection, and low self-esteem. One example of a risk behavior syndrome is an adolescent's reported use of substances as a means of gaining social status and acceptance from peers and, at the same time, counteracting dysphoria and feelings of low self-worth. Tailoring Treatment to Adolescents As noted above, treatment for adolescents with substance use disorders works best when it is provided and implemented with their particular needs and concerns in mind. In this TIP, the Revision Panel used a broad definition of treatment. Treatment is defined as those activities that might be undertaken to deal with problem(s) associated with substance involvement and with individuals manifesting a substance use disorder. Although the Panel recognizes that primary or secondary prevention of substance use is included in expanded definitions of treatment, the Panel limited the continuum of interventions to what is traditionally viewed as acute intervention, rehabilitation, and maintenance. The elements of the continuum primarily reflect the treatment philosophies of providers, with less emphasis on settings and modalities. Regardless of which specific model is used in treating young people (e.g., 12-Step-based programs, family therapy, therapeutic communities), there are several points to remember when providing treatment for adolescents. ¨ Adolescents must be approached differently than adults because of their unique developmental issues, differences in their values and belief systems, and unique environmental considerations (e.g., strong peer influences). ¨ Not all adolescents who use substances are, or will become, dependent. Programs and counselors must be careful not to prematurely diagnose or label adolescents or otherwise pressure them to accept that they have a disease: This may do more harm than good in the long run. ¨ Programs should be developed to take into account the different developmental needs based on the age of the adolescent; younger adolescents have different needs than older adolescents. ¨ Some delay in normal cognitive and social-emotional development is often associated with substance use during the adolescent period (Newcomb and Bentler, 1989). Treatment for these adolescents should identify such delays and their connections to academic performance, self-esteem, and social considerations. ¨ In addition to age, treatment for adolescents must also take into account gender, ethnicity, disability status, stage of readiness to change, and cultural background. ¨ Programs should make every effort to involve the adolescent client's family because of its possible role in the origins of the problem and its importance as an agent of change in the adolescent's environment. ¨ Although it may be a necessity in certain geographic areas where availability of youth treatment programs is limited, using adult programs for treating adolescents is ill-advised. If this must occur, it should be done only with great caution and with alertness to the inherent complications that may threaten effective treatment for these young people. ¨ Many adolescents have explicitly or implicitly been coerced into attending treatment. However, coercive pressure to seek treatment is not readily conducive to the behavior change process. Consequently, treatment providers must be sensitive to motivational barriers to change at the outset of intervention. There are several strategies suggested by Miller and Rollnick for encouraging reluctant clients to consider behavioral change (Miller and Rollnick, 1991). Figure 1-2 provides an overview of several of these strategies. The rest of this document guides providers through the process of treating adolescents with substance use disorders. Chapter 2 covers factors to consider in making treatment decisions. Chapter 3 details the features of successful programs. Chapters 4, 5, and 6, respectively, introduce and describe the treatment approaches used in 12-Step-based programs, in therapeutic communities, and in family therapy. Chapter 7 discusses adolescents with distinctive treatment needs, such as homeless and runaway youth, youth with coexisting disorders, and youth involved in the Tailoring Treatment to Adolescents Treatment of Adolescents With Substance Use Disorders juvenile justice system. Chapter 8 describes the legal and ethical issues that relate to diagnosis and treatment of adolescents. Chapter 2 -- Tailoring Treatment to the Adolescent's Problem Determining the appropriate level of treatment for an adolescent is no small task. In addition to factors normally considered when placing an individual in treatment for a substance use disorder, such as severity of substance use, cultural background, and presence of coexisting disorders, treatment programs must also examine other variables such as age, level of maturity, and family and peer environment when working with adolescents. Once these factors are assessed and the problems are understood, the treatment program can then match the adolescent with the proper type of treatment. Understanding the Problem The Severity Continuum Researchers and treatment professionals have found it useful to characterize adolescent substance use behavior on a continuum of severity. The Classification of Child and Adolescent Mental Diagnoses in Primary Care (American Academy of Pediatrics, 1996) views substance use disorders as occurring on a continuum that extends from the developmental variation of experimentation with substances through problem use, to the disorders of abuse and dependence. The degree of substance involvement is an important determinant of treatment, as are any coexisting disorders, the family and peer environment, and the individual's stage of mental and emotional development. This information should be used to refer to the appropriate treatment. It is useful to consider a substance use continuum with these six anchor points (Knight, in press): ¨ Abstinence ¨ Use: Minimal or experimental use with minimal consequences ¨ Abuse: Regular use or abuse with several and more severe consequences ¨ Abuse/Dependence: Regular use over an extended period with continued severe consequences ¨ Recovery: Return to abstinence, with a relapse phase in which some adolescents cycle through the stages again ¨ Secondary abstinence Treatment interventions fall along a continuum that ranges from minimal outpatient contacts to long-term residential treatment; all levels of care should be considered in making an appropriate referral (see Figure 2-1). Any response to an adolescent who is using substances should be consistent with the severity of involvement. Although no explicit guidelines exist, it stands to reason that the most intensive treatment services should be devoted to youths who show signs of dependency--that is, a history of regular and chronic use, with the presence of multiple personal and social consequences and evidence of an inability to control or stop using substances. Factors Affecting Treatment Placement Developmental Stages Youth treatment providers should be sensitive to the developmental differences among adolescents and make the necessary adjustments to accommodate such differences. The treatment of a 13-year-old should not be identical to Chapter 2 -- Tailoring Treatment to the Adolescent's Problem Treatment of Adolescents With Substance Use Disorders that of an 18-year-old. Figure 2-2, below, provides some general developmental features that tend to distinguish younger from older adolescents, as well as some guidelines pertaining to professional behavior and attitudes that reflect these differences. This is an adaptation of the Adolescent Development Table created by the Advisory Council of Adolescent Health and the Colorado Department of Public Health and Environment (1998). Ethnicity Understanding substance use and abstinence within the client's cultural context will flow most naturally from a broad base of knowledge about the client. The provider will be better prepared, however, with some specific information about that culture. First, the provider should find out if the client's parents are first generation immigrants. Any intervention with a teenager from an immigrant family will be enhanced by the provider's knowledge about the background of the youth and his family. Norms, values, and health beliefs may differ across cultures, and these factors can have a significant impact on treatment; for example, people from some cultural groups may see therapy as invasive, and others may want the extended family included in family therapy sessions. Programs to which non-English speakers are referred should be able to provide services in the language of clients and their families. This includes bilingual staff and written materials on topics ranging from program policies to bibliotherapy (a self-learning procedure by which the client reads and studies appropriate self-help material). Cultural competence is far more than bridging language barriers, however. Treatment settings and providers should incorporate cultural traditions (e.g., special holidays) into their treatment regimens. Also, cultural concerns should be addressed in clinical staff meetings, through interagency collaborations, and at all levels of the organization in order to enhance cultural sensitivity and competence. Gender Many gender-related factors have a bearing on the extent of the adolescent's involvement in treatment and on the treatment approach that is most likely to be effective and appropriate. Adolescent females, for example, may need more attention in regard to family problems; it has been found empirically that female adolescent substance users have often experienced severe parental rejection and sexual or physical abuse (Gross and McCaul, 1990-1991). Family dysfunction, therefore, may be a more critical component and indicator of substance use disorders in adolescent females and may require more attention in treatment. Females also often need highly specialized services, such as those for pregnant and parenting young women. Intervention for domestic abuse also may be required for females. Coexisting Disorders A coexisting disorder (also called a dual diagnosis) most commonly refers to the coexistence of a substance use disorder and a psychiatric disorder. Adolescents with substance use disorders are much more likely than their abstinent peers to have such psychiatric disorders (Kleinman et al., 1990; National Institute on Drug Abuse [NIDA], 1998). The behavioral or mental conditions of childhood most often associated with substance use disorders are conduct and oppositional disorders, attention deficit/hyperactivity disorder (AD/HD), affective disorders (unipolar and bipolar depression), and anxiety disorders, including posttraumatic stress syndrome from sexual or physical abuse (NIDA, 1998). There is growing evidence that the presence of conduct and oppositional disorders in childhood are particularly predictive of later adolescent substance use (Crowley and Riggs, 1995). Also, the coexistence of more than one childhood psychiatric disorder greatly enhances the risk for later substance use. In particular, the coexistence of externalizing (behavioral) and internalizing (emotional) disorders constitutes a high risk for substance use (NIDA, 1998). Other disorders associated with a higher risk for substance use include learning disorders (Latimer et al., 1997) and eating disorders (Harrison and Hoffman, 1989). A complete assessment--including a lifetime diagnostic evaluation, treatment trials, and clinical progress over time--will help to establish whether an adolescent has such a Ethnicity 24 Treatment of Adolescents With Substance Use Disorders disorder in addition to the substance use disorder. Coexisting disorders can interfere with treatment for substance use disorders, and if they are left untreated, the client is more vulnerable to relapse. The ability of treatment staff members to identify and either treat these disorders or provide appropriate referrals for treatment can help guard against this possibility. For example, a consultant may be needed to conduct mental health assessments and to evaluate the need for pharmacotherapy, and the adolescent may be referred to an outpatient mental health program. It is important for staff members to be aware of the distinctive problems of the young person who is diagnosed with substance use and other disorders. It is vital for the treatment team to perform the functions of gathering and sharing clinical data, formulating a diagnosis, and planning intervention for these clients with coexisting disorders. To treat adolescents with coexisting disorders, substance use disorder treatment providers and mental health providers must develop programs together and ensure that staff members are cross-trained. Each program can maintain its individuality, but services should be provided in one location and arrangements made to accommodate each program's requirements (see Chapter 7 for more discussion on youths with coexisting disorders). Pharmacotherapy When treating adolescents with coexisting disorders, it is paramount for programs to consider the client's need for appropriate medication. For example, substance use disorder treatment facilities should suspend "no-medication" rules for depressed adolescents who have been prescribed antidepressants. Of course, medication, whether for detoxification or the treatment of psychiatric disorders, must be prescribed and dispensed under the direction of a physician. It is recommended that youths with coexisting disorders receive supplemental counseling regarding their psychiatric medication. Discontinuation of any medication is a decision that should be made only in consultation with a medical doctor. Abrupt discontinuation of certain psychotropic medications can be extremely dangerous. However, if the patient continues to use illicit substances, the medication regimen should be reassessed. The relative risks and benefits of a temporary discontinuation of pharmacotherapy (until abstinence is achieved) should be carefully considered. The use of stimulant medication (for AD/HD) or minor tranquilizers (for anxiety disorders) is still controversial for adolescents with substance use disorders. Some of these medications have significant potential for addiction or abuse. Nonaddictive medications, as well as behavioral and psychotherapeutic interventions, should be considered before medications with the potential for addiction or abuse are prescribed. For cases in which these medicines must be used, regular urine testing for substances of abuse, and/or serological determination of therapeutic drug levels, is usually indicated. Family Factors The risk of adolescent health and behavioral problems, including substance use disorders, rises with lack of parenting skills, high levels of family conflict, and poor bonding between parents and children. Recent national data of adolescent health identified the importance of connectedness to parents and family as a key factor that protects adolescents, in a cross-cutting manner, from many problem behaviors, including substance use (Resnick et al., 1997). When parents have unclear expectations of their children's behavior, apply discipline inconsistently, or fail to reward their children for positive or desirable behavior, their children's risk for substance use disorders increases. Both permissiveness and excessively harsh parenting practices can lay the groundwork for adolescent behavioral problems and substance use disorders (Patterson, 1982). An adolescent's family also provides a crucial background to the child's substance use for reasons both genetic and environmental. Children of parents with substance use disorders are at increased risk of developing substance use disorders themselves compared with children with nonsubstance-abusing parents (Cotton, 1979; McGue et al., 1992; Schuckit, 1987). An assessment of the family's history of substance use will provide some insights into the possible Coexisting Disorders Treatment of Adolescents With Substance Use Disorders role of genetic factors in the family lineage. Perhaps even more relevant to the adolescent patient's immediate concern is the need to evaluate the family environment for risk and protective factors that pertain to substance use. Salient environmental factors include parental modeling of substance use behaviors, permissive parental attitudes toward substance use, and substance use by siblings (Hawkins and Fitzgibbon, 1993). Clinicians working with adolescents with substance use disorders should consider the degree of stability and commitment in the patient's family in determining the most appropriate treatment type and approach for each individual. Ideally, the family should be involved in all phases of the adolescent's treatment, but in families characterized by extreme instability, conflict, physical or sexual abuse, and/or domestic violence, this may not be possible or even advisable. It is important for providers to remember that "family" may include a broad spectrum of members, such as grandparents, older siblings, and foster parents. Social and Community Factors School life, peer influences, the community, and the media may also exert an influence on the adolescent's risk to initiate and maintain substance use (Newcomb and Bentler, 1989). Understanding their influences on an individual can help a service provider pinpoint areas of intervention relevant to the client's recovery. Peer influences Association with peers who use alcohol and/or illicit drugs, including involvement in gangs, is a very prominent risk factor associated with adolescent substance use (Winters et al., in press). Adolescents in cohesive peer groups make substances available to each other, substance use is modeled by friends in the group, and peer group support and norms favor substance use (Oetting and Beavais, 1986). Also, because the role of substance use and other delinquency behaviors may influence the selection of friends, it is possible that substance use behavior may contribute to selecting peers who are delinquent and happen to already be using alcohol and/or illicit drugs as well (Farrell and Danish, 1993). Environmental influences The socioeconomic level of a young person's community is one important determinant for his risk of substance use. Rates of substance use are higher in areas where alcohol and/or illicit drugs are more easily available and where local norms are more tolerant of their use. Substance use in these areas is also more likely to be associated with crime. In addition, positive role models for young people are often scarce or lacking. Not surprisingly, youths who identify with individuals engaging in substance use and criminal activities are more likely to engage in these activities themselves. Youths who grow up in communities where there is little or no social cohesiveness and attachment, a high population density, and disorganized neighborhoods are at greater risk of using alcohol and illicit drugs, as well as developing other behavioral problems (Hawkins and Fitzgibbon, 1993). School factors No relationship has been found between intelligence level and the risk of substance use. Performance in school, however, does affect this risk (Friedman et al., 1985). Academic failure beginning in the late elementary grades increases the likelihood that substance use will develop in adolescence (Hawkins et al., 1992). This is true regardless of whether academic failure stems from learning or behavioral disorders, family conflict, or poor educational quality. Lack of success and academic commitment, as evidenced by problems such as truancy and insufficient time spent on homework, is predictive of later substance use, which in turn increases the risk of substance abuse (Newcomb and Bentler, 1989). Social and Community Factors Treatment of Adolescents With Substance Use Disorders The Continuum of Treatment The various types of treatment approaches for adolescents with substance use disorders are described in detail in upcoming chapters. Regardless of the modality or the setting in which it takes place, treatment can be seen as taking place on a continuum starting with outreach, screening, and assessment to identify youths who are at risk or who are already engaging in substance use. It continues through the stages of counseling and treatment to continuing care and support to reinforce abstinence. Linking Assessment and Treatment Placement The variety of options for the treatment of substance use disorders--outpatient, inpatient, and residential, as well as services that support independent living--can be subdivided into specific services for adolescents with substance use disorders. These services can be viewed as a continuum ranging from pretreatment services for at-risk adolescents and those in the early phases of substance use to more intensive treatment for youths already having substance use disorders. The differences among these levels of treatment are both qualitative and quantitative; that is, the variation in intensity of service is only one aspect of the continuum. Treatment programs also may differ considerably in their individual philosophies and approaches to treatment, in the treatment components they offer, and in the types of professionals employed. Regardless of the specific elements, any program's services must match the needs of the adolescents it intends to serve, and the levels of treatment and service options must respond to the internal and environmental realities of at-risk or substance-using adolescents. To that end, the original Consensus Panel developed the continuum shown in Figure 2-3, Client Assessment Criteria, bearing the following in mind: ¨ Levels of treatment and service options must respond to the internal and environmental realities of an adolescent who is at risk for or who already has a substance use disorder. ¨ The table must be comprehensible to treatment providers with different levels of clinical sophistication. ¨ The table must be internally consistent and reliable in making placement decisions. In the model presented in Figure 2-3, the following assessment criteria can be used to determine the level and type of service that is most appropriate for each individual. For example, assessment of an adolescent's recent substance use might indicate that she has a toxicity level that requires more than outpatient medical management but is not severe enough to require life support and intensive medication. This would suggest that the adolescent requires care as a medically monitored inpatient. On the other hand, her emotional well-being might reveal a great deal of distress, requiring 24-hour continuous psychiatric monitoring. The following areas can be evaluated in order to arrive at appropriate treatment placement decisions: ¨ Use pattern: Pressure of consequences and problems resulting from substance use, and level and recency of substance consumption ¨ Medical concerns: Toxicity, withdrawal, and other medical sequelae resulting from substance use, as well as medical problemsunrelated to substance use, such as pregnancy, HIV/AIDS, domestic violence, and child abuse and neglect ¨ Intrapersonal--Cognitive: Substance-induced impairment in cognition and thinking, both chronic and acute, including neurological deficits as well as memory problems such as blackouts, short-term memory deficits, and poor concentration ¨ Intrapersonal--Emotional: Emotional functioning, which may range from an inability to experience emotions to extremely negative emotional states ¨ Interpersonal--Social: Interpersonal relationships, social development, and social concerns such as employment, family, friends, and legal matters The Continuum of Treatment Treatment of Adolescents With Substance Use Disorders ¨ Environmental: External influences, including living conditions, housing, gang influence, and family and school influences The continuum of treatment underscores the importance of understanding all of the factors that bear on the adolescent's substance use. These factors must be included in a comprehensive assessment, which must in turn incorporate information collected from the adolescent's self-report, standardized assessments, reports from family members, and other collateral sources of information whenever possible in order to obtain a complete picture of the adolescent's social and environmental situation. Placement Guidelines The following guidelines indicate how the continuum can be used in making a decision regarding the placement of the adolescent. The Revision Panel created the guidelines based on clinical experience. ¨ In making placement decisions, practitioners should choose the most intensive level of care indicated by any single assessment criterion. For example, an adolescent who is not currently using substances but who is actively psychotic would require inpatient treatment. ¨ When an assessment indicates the need for a particular level of care that is not available, it is desirable to refer the adolescent to the next higher level of care, unless the assessment indicates that such a placement would be counterproductive. For example, if intensive outpatient treatment is indicated but unavailable, day treatment should be the next recommendation, unless it is contraindicated. Naturally, a higher level of care may not be practical or available. ¨ Assessment is an ongoing process. Decisions about level of care should be based on the adolescent's progress and changes in his environment. Clients should have the opportunity to move back and forth across the level-of-care continuum on the basis of changes in these factors. ¨ There is as much, if not more, variability among treatment programs within a single intensity level as there is across treatment intensity levels. The assessor should incorporate this understanding when making placement decisions. Assessors should have an indepth knowledge of available services and the intensity of any particular treatment or service option. ¨ The assessment criteria shown in Figure 2-3 are interrelated and can be viewed together as an integrated system. This point is important in considering the most appropriate treatment level and the ability of the adolescent to move along the level-of-care continuum as treatment progresses or regresses. Prior to each program change, indepth reassessment must be completed in order to update information on the client's status and to obtain a current clinical picture of his situation. The American Society for Addiction Medicine is also in the process of developing placement guidelines for adolescents with substance use disorders. Levels of Treatment Outpatient treatment Outpatient services provide a broad range of intensity-of-care levels without overnight accommodation. Some of these levels may be used subsequent to inpatient treatment. It is common for some levels of outpatient counseling to implement the same treatment strategies as in inpatient counseling. Outpatient counseling as a treatment option is composed of sublevels of treatment characterized by increasing levels of intensity. Placement Guidelines Treatment of Adolescents With Substance Use Disorders Brief intervention Brief intervention generally takes less time than more formal treatment approaches. It is usually delivered by nonspecialists or paraprofessionals, emphasizes self-help and self-management, reaches large numbers of individuals, and is considerably less expensive than conventional treatment. Brief interventions, notably those based on motivational enhancement theory, have proven successful with adult alcohol users (Institute of Medicine, 1990; see also Rollnick et al., 1992; Miller et al., 1993). Typically, a brief intervention would include brief screening, anticipatory guidance, and psychoeducational interventions. This option is primarily appropriate for adolescents in the low-to-middle range of the severity continuum (experimental, regular, and problem use). This approach has also been demonstrated to be very effective in the emergency medical care setting by significantly increasing the likelihood that clients will keep followup appointments for subsequent treatment (CSAT, 1995a). See the forthcoming TIP, Brief Interventions and Brief Therapies for Substance Use Disorder Treatment, for a description of brief interventions and therapies that can be used in various treatment settings(CSAT, in press). Intervention in primary care settings Within the health care sector, there is a growing interest in primary care providers to practice brief interventions. Primary care providers are well situated to practice primary prevention of substance use disorders and to intervene when they suspect the possibility of substance use by adolescents under their care for other medical problems. The developmental model of substance use disorder progression, diagrammed in Figure 2-1, is useful for understanding the development of substance use disorders in teenagers and the type of intervention that is most appropriate at each stage. The time pressure in a managed care environment makes many primary care physicians reluctant to screen for substance use although health care guidelines recommend screening every adolescent patient for substance use disorders as part of routine medical care. Screening and intervention can be done in minutes--for example, during an office visit--using any of a number of screening instruments designed for adolescents (see the companion TIP 31, Screening and Assessing Adolescents for Substance Use Disorders [CSAT, 1999]). In geographic areas where substance use is highly prevalent, it is often useful to bring substance abuse counselors in routinely to meet with adolescents as part of the screening. These workers can establish a rapport with young patients and can arrange subsequent meetings with those who screen positively for problems. This approach helps to bridge the gap between primary care and substance use disorder treatment programs, where the risk of losing patients to followup is greatest, and obviates the need to make referrals to a treatment center. When substance use disorders are identified in an adolescent patient by a primary care provider, it is important to make the connection to a treatment program as quickly and directly as possible. Resources can be mobilized more immediately by having an established contact with a substance use disorder treatment provider who is willing to call or meet with adolescents, or even to visit those admitted to inpatient treatment. Making a direct and immediate contact with a treatment provider is highly preferable to merely giving an adolescent patient a referral card, name, or phone number, none of which may ever be used. However, making direct contact with a treatment provider requires the consent of the adolescent and may also require the consent of the parent. See Chapter 8 for information on legal and consent issues. Physicians treating adolescents should become familiar with treatment resources in the community and their approaches to treatment. Programs vary in intensity and philosophy, but abstinence is normally the goal; it will also help if the physician is familiar with several therapeutic communities that may be available, even if they are a distance away (Knight, 1997). The physician can recommend that the parents take part in treatment with the youth. Individual and family counseling may be needed, and the physician can refer the parents and youth to child-centered support groups, such as Alateen Levels of Treatment Treatment of Adolescents With Substance Use Disorders and Alatot. Also, if parents have a substance use disorder, they should be referred for an assessment. The physician should also inform the patient that she will continue to check the patient's progress in future visits and encourage the youth to discuss any substance use problems with her. Formal treatment interventions are generally indicated for adolescents who have progressed to abuse or dependency. Such problem users require more than a brief intervention during an office visit, and should be referred to a substance use disorder treatment specialist. The bottom line is that primary care staff members should be encouraged to consult with substance use disorder professionals about how they might best support treatment during ongoing contact with adolescents being seen for primary care. For a further discussion on brief interventions in primary care settings, see TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT, 1997). Outpatient counseling Outpatient counseling includes professionally directed evaluation and treatment typically for fewer than 9 hours per week in regularly scheduled sessions. In less intensive programs, 2 to 3 hours per week is common. Nonintensive outpatient treatment also may address related psychiatric, emotional, and social concerns. Intensive outpatient programs may be after-school or evening programs, often include some weekend programming, and may involve 9 to 20 hours of treatment per week. Day treatment or partial hospitalization Day treatment programs, sometimes referred to as partial hospitalization, provide professionally directed evaluation and treatment in a structured program. This is the most intensive of the outpatient treatment options and can be used for adolescents who demonstrate the greatest degree of dysfunction but do not require inpatient treatment. Day treatment may range from several hours per week to more focused and directed sessions for up to 5 days a week. Sessions may take place after school, in the evenings, or on weekends. The treatment provided may be some combination of individual, group, and family therapy. Inpatient treatment Inpatient treatment may include 24-hour intensive medical, psychiatric, and/or psychosocial treatment and residential care. The levels of the residential care continuum include a high level of supervision by professional staff members at the most intensive end and group home living with minimal professional involvement or supervision at the least intensive end. Detoxification Detoxification generally refers to a 3- to 5-day inpatient program with 24-hour intensive medical monitoring and management of withdrawal symptoms. Although physiological withdrawal symptoms are uncommon among adolescents, this level of care may be mandated by psychosocial circumstances, personal characteristics, or a history of using significant amounts of a substance associated with life-threatening withdrawal symptoms (e.g., benzodiazepines, barbiturates, heavy chronic alcohol use). Detoxification should be monitored by appropriately trained personnel under the direction of a physician or other personnel with specific expertise in management of addiction and abstinence syndromes. It is appropriate for adolescents with multiple problems, including those who need habilitation or with coexisting personality and substance use disorders. See Appendix B for information on medical management of substance use disorders. Residential treatment Residential treatment is a long-term treatment model that includes psychosocial rehabilitation among its goals. It may be directed by physicians or other professionals, and it is appropriate for adolescents with multiple problems, Levels of Treatment Treatment of Adolescents With Substance Use Disorders especially those with coexisting personality and substance use disorders. The duration of residential treatment can range from 30 days to as much as 1 year in some cases (as in the case of therapeutic communities), although managed care requirements continue to chip away at the maximum length of treatment allowed. Continuing Care The period right after completion of a treatment program, when the youth returns to family, peers, and the neighborhood, is often the time of greatest risk for relapse. It is for this reason that all forms of treatment should include some provision for continuing care. A continuing care program often takes the form of a structured and time-limited outpatient program and planning process that can provide ongoing support to the adolescent. Many continuing care programs have specialized groups that focus on making the transition from intensive treatment to a lower level of care. Most treatment programs also have specialized groups for relapse prevention. Having a history of relapse is common for adolescents in treatment for substance use disorders (Hoffman et al., 1993). If an adolescent in treatment experiences relapse, it is best viewed not as a failure of the treatment or the client, but rather as a common part of the early recovery process that needs to be factored into the treatment plan. As in chronic physical diseases such as leukemia or diabetes, relapse is an indication not for punishment or discontinuation of treatment, but for additional or intensified treatment. Relapse (or the lesser version known as a minor slip or lapse) should be viewed by treatment professionals as an opportunity for learning; for example, it can help teach young people that they do not have control over their substance use. Because an adolescent who has relapsed in the past is at greater risk for further relapses, it is important to evaluate those factors that are precipitants for relapse and to adjust treatment accordingly. An adolescent's coping style (i.e., the use of skills gained through treatment) and social resources are among the known protective factors for alcohol relapse (Brown, 1993). Self-help and peer support groups Self-help groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Al-Anon, and Alateen are valuable adjuncts to outpatient services and residential programs for teenagers during the recovery process, both during and after primary treatment. Self-help groups offer positive role models, new friends who are learning to enjoy life free from substance use, people celebrating sober living, and a place to learn how to cope with stress and other relapse triggers. Teenagers should ideally be referred to youth-oriented groups, led by responsible individuals, with a membership that is appropriate for the age, gender, and culture of the client (see Chapter 4). Group homes Sometimes referred to as halfway houses or independent living, group home living is a transitional living arrangement with different levels of specificity of treatment planning and staff supervision. Residents may work and/or receive educational or training services or treatment outside the group home. House responsibilities are shared, and the youths are involved in the house governance. Therapeutic foster home placements, a type of group home, involve a small group of adolescents being placed in a family situation, often with foster parents, who themselves may be recovering from substance use disorders. "Booster" sessions In the cognitive-behavioral model of treatment, recovering adolescents periodically return to the treatment program to meet with clinicians and review their skills for relapse prevention, self-management, and independent living. Recommendations and supportive and encouraging feedback are provided during these monitoring sessions. Consistent with the need for continuing care, booster sessions, often known as aftercare sessions, are important for Continuing Care Treatment of Adolescents With Substance Use Disorders any treatment experience. Chapter 3 -- General Program Characteristics The previous chapter examined the range of substance use disorders and related problems seen in adolescents. The chapter then applied those factors to treatment placement decisions. This chapter discusses how individual program components can best meet the needs of adolescent clients. Program design and administration, treatment components, client services, and a program's collaborative relationships are important considerations for practitioners or other staff members who are treating adolescents or referring them to an outpatient treatment setting. Scope and Approach A program's design, policy, evaluation, and legal approach are shaped by its underlying philosophies--the core values and beliefs from which treatment decisions arise. Mapping out these program features can provide a strong and flexible framework for providing services that are implemented smoothly and effectively and yet are individualized to meet each client's needs. Much of this information shows up in a program's policy and procedures manual. Although a program's funding and scope limit the number and depth of treatment components a program can provide, it is vital that the most critical components be identified and implemented with skill and timeliness. In addition, expectations for successfully completing treatment should be as clear and as objective as possible. Policies and Procedures Manual A program's policies and procedures manual provides guidelines for program operation. It also serves as a reference book for Federal, State, and local laws and regulations and for requirements for contract compliance. State licensing requirements may also include obligatory standards about what goes in a policy and procedures manual. Both the program staff and clients are protected by these regulations, which may include the following: ¨ A program mission statement identifying underlying program principles, including the program's commitment to a drug-free workplace ¨ Confidentiality procedures for clients as well as the staff ¨ Documentation guidelines and requirements for client charts, including reporting requirements for sexual and physical abuse and suicidal and violent behavior ¨ Personnel policies that describe ¨ Policies concerning critical incidents, such as involuntary commitment, emergency procedures (e.g., suicide, violence), and inappropriate behavior (e.g., drug use) during treatment In addition, HIV guidelines and staff training should describe the universal precautions recommended by the Centers for Disease Control and Prevention, specify who should know the HIV status of clients and family members, and outline the policies and procedures for HIV testing of clients and staff members. Programs may wish to designate a staff person as the AIDS trainer. This training helps to raise awareness of the HIV-related needs and concerns of adolescents. Also, guidelines should address precautions about hepatitis B and C and tuberculosis. Some strains of hepatitis are easily transmitted and may be more prevalent than HIV in certain communities. Hepatitis B vaccinations may be considered for at-risk staff members with significant client contact. Staffing Staffing decisions are best made with attention to program needs, job descriptions, and educational and experiential requirements for each position. It also must be determined which services will be provided on site by program Chapter 3 -- General Program Characteristics Treatment of Adolescents With Substance Use Disorders personnel and which are to be provided by arrangement with an external agency, program, or professional. If volunteers or interns are to be an integral part of the program, specific policies must be established regarding their supervision, training, and responsibilities. Staff members should represent the cultural diversity of the program's client population. In addition, the facility's forms, books, videos, and other materials should reflect the culture and language of the clientele. Innovative and intensive continuing education, staff development, and outreach efforts during staff recruitment may be needed to improve cultural competence among staff. If a significant part of the client population is non-English-speaking, at least one staff member should be bilingual and bicultural. Cultural differences should be addressed in clinical staff meetings, through interagency collaborations, and at all levels of the organization, with the goal of enhancing cultural sensitivity and cultural competence. For individuals with disabilities, the Americans With Disabilities Act of 1990 requires treatment facilities to be accessible to all clients, which may mean having a sign language interpreter and other specially trained personnel on staff. For more information on treating people with disabilities and coexisting disorders, see TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT, 1998). Core Staff The type of program and the range of services offered within a program determine treatment staffing patterns. The following positions should comprise a core staff: ¨ Program or clinical supervisor ¨ Substance use disorder counselors ¨ Therapists (preferably at a master's level with a certification in substance abuse treatment) The essential roles of core staff include ¨ Intake ¨ Screening ¨ Assessment (including a cultural assessment) ¨ Case management, including treatment planning and crisis intervention ¨ Substance use disorder treatment (individual, group, family) ¨ Providing specialized education on topics such as understanding substance use, HIV infection and AIDS, and other sexually transmitted diseases (STDs) ¨ Planning continuing care and treatment ¨ Record keeping and report writing Optional Staff As the intensity of the treatment increases, programs may require additional personnel. These professionals may be hired as part-time staff members or as consultants, or they may be provided by contract or through referral. They include: ¨ Psychiatrists ¨ Pediatricians, adolescent medicine specialists, internal medicine specialists, and/or family practitioners ¨ Psychologists ¨ Nurses ¨ Recreational therapists (leading activities in art, music, drama, wilderness outings, etc.) ¨ Occupational therapists ¨ Disabilities specialists, including sign language interpreters Core Staff Treatment of Adolescents With Substance Use Disorders ¨ Outreach workers ¨ Home intervention workers ¨ Continuing care workers ¨ Cultural advisors or spiritual leaders ¨ Students, interns, and fellows (from local colleges and universities) ¨ Vocational specialists ¨ Case managers Skills Development The complexities of an adolescent's needs and concerns require that the clinical staff be supervised. However, high-level skill or expertise may not be necessary for all staff members in all areas. Most important is regularly scheduled training that occurs periodically throughout the year. This is greatly preferable to ad hoc training presented to address crises or acute situations. Training on specialty topics should be available in the following areas: ¨ Changes in diagnostic criteria for substance use disorders (e.g., DSM-IV criteria) ¨ New substance use disorder treatment approaches specific to adolescents and their families ¨ Family dynamics and family therapy ¨ Adolescent growth and development ¨ Sexual and physical abuse ¨ Gender issues, including gender and sexual identities (e.g., gay, lesbian, transgender) ¨ Mental health problems (particularly depression, anxiety disorders, and conduct disorders) ¨ Awareness of different cultural and ethnic values ¨ Recreational and prosocial activities ¨ Psychopharmacology ¨ Group dynamics and group therapy ¨ Suicidal behavior ¨ Grief and loss ¨ Referral and community resources ¨ Management of oppositional and violent behaviors ¨ Cognitive impairments (learning disabilities, cognitive disorders, and organic mental disorders) ¨ Legal matters (custody and juvenile justice concerns, child abuse and neglect reporting requirements, and duty-to-warn issues) ¨ Treatment planning and documentation ¨ HIV/AIDS ¨ Other health matters (STDs, tuberculosis, hepatitis, nutrition) ¨ Gangs ¨ Drug dealing Staff Members in Recovery Treatment programs often use recovering substance abusers as staff members. Staff members who are themselves in recovery can offer unique hope, role modeling, and insight into dependency, addiction, and recovery. When recovering individuals are hired, they should have the same level of expertise and training required of other staff members in the same position. Recovering individuals must have clear evidence of at least 2 to 5 years of recovery demonstrated by regular attendance at 12-Step meetings, a current sponsor, and continuous abstinence from substances other than those prescribed by a physician. Skills Development Treatment of Adolescents With Substance Use Disorders Certification and Credentials Each State has different requirements for the certification of substance abuse counselors. Certification is available in many disciplines; for example, a nurse can be certified in chemical dependency, and a physician can become a certified addictions specialist. Records documenting these credentials are necessary. Programs should encourage all staff members to become certified and support their continuing education efforts to enhance their clinical competence in their specialty. Supervision and Evaluation A supervisory review of each staff member's performance should be conducted on a regular basis. Opportunities for self-evaluation and feedback from other staff and team members can be included in the evaluation process. The program's manual on policies and procedures should specify how the program deals with staff turnover, burnout, relapse, and related staff problems, as well as specific procedures for staff reviews. Supervision should include training staff on program procedures and policies, developing clinical skills, monitoring performance and providing feedback, identifying clinical limitations, addressing transference and countertransference (such as relationships and identification between the adolescent and treatment personnel), and dealing with staff concerns. Perspectives on Counseling Youth Understanding how adolescents perceive and react to treatment is crucial in developing appropriate counseling techniques to address their substance use. Treating an adolescent like an adult will likely result in failure--counseling adolescents requires sensitive yet firm approaches. An adolescent treatment program should have explicit and impartially administered standards for behavior. It should emphasize treatment of every participant in a personal, respectful, and hopeful manner. The program staff should maintain an optimistic tone and be dedicated to serving and helping its clients, while exercising authority without seeming authoritarian. The staff should also ensure that every participant is protected from possible harassment, such as teasing and hazing, by other program clients. When youths do not abide by the treatment program guidelines, they must be held responsible for their conduct, but in a manner that avoids a confrontational style or indicators of mistrust. It is also important that youth be helped in fulfilling their responsibilities in a way that would typically be inappropriate for adults. For example, if an adolescent does not show up on time for an outpatient program, he should be called immediately and reminded to attend. Program Components Many adolescent treatment programs, regardless of their therapeutic orientation, include significant shared components, some of which are described below. The level of intensity of these components will vary considerably in outpatient and residential treatment. Orientation This initial stage in treatment is very important to the adolescent. Many new activities may be threatening to the adolescent, and coming into treatment can intensify feelings of fear and self-consciousness. Moreover, adolescents frequently have incomplete and inaccurate information about the nature of substance use disorders and treatment programs. The client may have heard that very negative things happen in treatment and that "people really get on your case." The awkwardness experienced by adolescents may also be intensified. During adolescence, many situations can increase a young person's anxiety level. Anxiety can be acted out in many negative ways, including leaving or running away from the program. Sometimes, the acting-out behavior is so disruptive that the client may have to be discharged Certification and Credentials Treatment of Adolescents With Substance Use Disorders by the staff. Thus, it is important that the orientation to treatment be structured to provide relief from anxiety. One main component of orientation is explaining to adolescents what treatment is, as well as what it is not, in a nonconfrontational style and tone. If the youth has a mistaken notion about the nature of treatment, the chances for treatment success may be lowered. Young people come into treatment with many different expectations. It will help the adolescent to know the meanings of such terms as chemical dependency, expectations, and unmanageableness. But definitions must be clear and not too abstract, given that some adolescents may be unable to grasp complex concepts. Orientation also provides an opportunity to clarify the adolescent's role. Videos of activities to be experienced in treatment can be shown. Orientation should include the concept of program expectations. This term is preferable to the term rules, which implies staff dictates or commands (Winters and Schiks, 1989). Having expectations implies ownership by the client and promotes responsibility from him. Communication of essential principles and expectations can start during orientation and continue throughout the treatment process. Daily Scheduled Activities Most adolescents who require treatment for substance use disorders have been preoccupied with the use of substances to the exclusion of participation in positive recreational activities and the development of basic living skills. When the substance use is removed, they may not know how to use their time appropriately. A prescribed daily schedule of school, chores, homework, and especially recreation can significantly help with this relearning process. In outpatient programs, staff members can work with adolescents and their families to schedule activities for the client during the hours away from treatment; in residential programs, scheduling can be more elaborate. A full schedule with many different group activities has been shown to work well with adolescents (Winters and Schiks, 1989). Adolescents who have centered their leisure time on the use of substances may resist learning new skills and often equate staying clean with boredom. Youths who engage in thrill-seeking behaviors by using rock cocaine seem especially susceptible to anhedonia, an inability to experience pleasure, because of the boredom that sets in afterward. Encouraging the adolescent client to take advantage of community recreational resources and to develop socially appropriate recreational habits will help ensure that she remains sober following treatment. Adolescent treatment programs can provide many recreational opportunities to their clients with relatively little expense. For example, a program might establish an athletic period during which it takes groups of youths to the local "Y" to play basketball. Chess, ping pong, computer games, and other sports and games can be provided at the treatment site. Peer Monitoring Given the important influence of peers on an adolescent's behavior and attitudes, it stands to reason that pressure from peers often keeps the client from achieving treatment goals. Although this pressure occurs in social times rather than within structured program activities, it must be addressed during treatment. Group therapy can help the client build the strength needed to override peer pressure and harness the influence of the peer group in a positive manner. In a process guid