Assessment and Treatment Matching

Assessment (pretreatment screening) is an important first step to determine need for treatment. Unlike adults who often begin treatment once dependence or life-challenging problems emerge, youth may be referred to treatment primarily because of trouble at school or with the justice system. Understanding the extent to which youth have developed problems is a key to bringing appropriate resources to bear. Matching adolescents to appropriate treatment is based on considerations of age, gender, severity of problem (which is distinct from frequency and quantity of use), financial status, psychiatric comorbidity, cognitive functioning, and legal mandates (Jenson, Howard, and Yaffe, 1995; Brown, Tapert, Granholm, and Delis, 2000; Tarter, 1990; Tapert and Brown, 1999).

Distinguishing between use and abuse among adolescents is often more challenging than among adults. For example, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for substance use disorders were developed for adults and have significant limitations when applied to adolescents (Martin and Winters, 1998). Prematurely labeling teens as abusers can be harmful and may actually promote their progression from use to abuse. Those in need of treatment are also likely to have co-occurring psychiatric and psychological conditions.

Assessment is important to determine the type of treatment approach to which an adolescent may respond (Pickens and Fletcher, 1991; Bergmann, Smith, and Hoffman, 1995; Jainchill, Bhattacharyo, and Yagelka, 1995; Werner, 1995). If a program has a family component, there should be a thorough assessment of the family as well as an assessment of the multiple contexts in which the young person lives (e.g., family, peer, school). Treatment services provided to children of alcoholics and other drug users may be distinctly different from treatment services provided to those who do not have a situation in which other family members abuse and are dependent on substances.

Many adolescents experience academic problems and developmental delays as a result of alcohol and drug abuse and dependence. For these teens, remedial services are crucial. In addition, depending on the extent to which problems associated with alcohol and drug use disorders have interfered with their socialization, some teens may require residential treatment, whereas others may do better when treated on an outpatient basis.

Numerous adolescent screening instruments have been evaluated for reliability and validity, such as the Substance Abuse Subtle Screening Inventory (SASSI) and the Personal Experience Screening Questionnaire (PESQ) (Winters, Latimer, and Stinchfield, 2001). These tools help to identify what the teen needs, the severity of the problem, and whether the parent or other referring adult should contact a different kind of program than the one in which the assessment occurs. A comprehensive assessment provides a road map for developing an effective treatment plan tailored to the adolescent's specific needs. Assessment instruments that have been independently tested and recommended by treatment experts include the Comprehensive Addiction Severity Index for Adolescents (CAS-I) and the Global Assessment of Individual Needs (GAIN) (Drug Strategies, 2003).

Treatment approaches. A variety of therapeutic approaches have been developed. The following therapy strategies have been extensively researched:

The Twelve step approach, also known as the Minnesota Model and Twelve Step Facilitation, is highly structured and involves detoxification, psychological evaluation, general and individualized treatment planning, group therapy, lectures, and individualized counseling (Winters, 1999). Group counseling is a key therapeutic technique that includes those with alcohol and drug use disorders who are further along in the recovery process; they pass on their knowledge, experience, and values to newer patients. Participants study each of the Twelve Steps and are referred to Alcoholics Anonymous and Narcotics Anonymous meetings as part of their therapy after treatment to prevent relapse (Winters and Schiks, 1989). Many studies have been completed to evaluate the outcomes of the Twelve Step Facilitation method, yet few have been geared specifically to adolescents. One study found that adolescents who are motivated to attend Twelve Step meetings have improved treatment outcomes (Kelly, Myers, and Brown, 2002). However, more research is needed to assess the effectiveness of the Twelve Step approach and how these programs meet the developmental needs of teens (Kassel and Jackson, 2001).

Therapeutic communities (TCs) are a social-psychological form of treatment for addictions and related problems with a focus on resocializing those who attend. To date, TCs have been used in the United States only to treat adolescents with the most severe substance abuse and dependence problems. In the TC model, substance use disorders are viewed as symptoms of broader problems in life. The model uses a holistic treatment approach in a long-term residential setting where peers and professional staff serve as therapists in the treatment process. A key difference between TC and Twelve Step Facilitation is the TC philosophy that the individuals are responsible for their own addiction or recovery (De Leon, 1997).

A number of modifications are made to the TC model for use with adolescents: (1) stages reflect progress along behavioral, emotional, and developmental dimensions; (2) it is less confrontational; (3) adolescents have less control over management of the program; (4) there is more supervision; (5) neurological disorders are assessed (such as learning disabilities); (6) there is more emphasis on education than daily chores; and (7) there is enhanced family involvement (CSAT, 2000a).

Outcome studies for TC treatment programs have been inconsistent for adolescents (Jainchill et al., 1995; Pompi, 1994). As with all treatment modalities, length of stay is a critical factor for successful abstinence after completion of the program. In the case of TC, longer treatment periods are needed for adolescents than for adults (De Leon, 1985; Hubbard, Cavanaugh, Craddock, and Rachel, 1985; Sells and Simpson, 1979). More research must be carried out in this area in order to truly establish the effectiveness of the TC model with adolescents. Nonetheless, because there is evidence that it works with adults, it might be viewed as a promising therapy.

Cognitive behavioral therapy (CBT) refers to those approaches that focus primarily on an individual's thoughts and behaviors (Liese and Najavits, 1997). CBT has been used to treat many psychological problems, including depression, anxiety, stress, and anger. Since the 1980s, CBT has become widely used as a promising approach for alcohol and substance use (Liese and Najavits, 1997). CBT is also used to prevent relapse. This approach recognizes that there are internal and external cues that prompt an individual to drink. Beliefs (“drinking will help me relax”) and urges (“I need to have a drink!”) determine how an individual is likely to respond to these cues. Individuals often have facilitating beliefs (“I'll only have one drink”). All of this leads the individual to take action, often taking a drink.

CBT is very structured; for example, an objective is established and each session is used to monitor the mood of the individual, connect treatment from session to session, discuss problems, and provide training in coping strategies and skills to deal with problems. Homework is assigned between sessions. CBT often includes motivational interviewing to engage individuals in the treatment process (Liese and Najavits, 1997). CBT has been extensively researched, particularly as part of the federal Cannabis Youth Treatment study (Dennis et al., in press) and the Adolescent Treatment Model study (Perry et al., 2003). Evaluations suggest this is a very promising approach.

Family therapy takes many forms. Family therapies such as Multidimensional Family Therapy (MDFT) (Liddle et al., 2001) view adolescent alcohol and drug use as influenced by the community, the family, and peers. Treatment includes individual and family sessions, which can be held at home, at school, in the clinic, or in other areas of the community (CSAT, 2000c; NIDA, 1999). In therapy sessions, treatment of the adolescent focuses on building developmental skills, such as decision making, negotiation, and problem-solving skills (Liddle et al., 2001). Teens learn improved communication with other family members and coping mechanisms for stress. Similar sessions are held with family members, in which parents examine their parenting style and learn to have a positive influence on their child (Schmidt, Liddle, and Dakof, 1996).

Multisystemic therapy (MST) is a family-based, short-term intervention that has licensed agencies in 27 states and 12 countries (Henggeler et al., 1996; Henggeler, Melton, Brondino, Scherer, and Henley, 1997). These agencies annually treat more than 7,000 youth and their families. MST has been extensively researched, primarily by the criminal justice system, and has been shown to reduce recidivism and drug use.

Treatment programs often combine a variety of approaches. For example, Drug Strategies (2003) analyzed the most predominant treatment approaches among the 144 programs described in the Treating Teens guide. A total of 101 programs (70 percent) offered services based on a combination of treatment approaches. By far, the most widely used approaches were the Twelve Step model (66 percent of all programs) and CBT (58 percent). Four other approaches were featured by more than a dozen of the 144 programs: motivational enhancement therapy (19 percent), MST (19 percent), MDFT (13 percent), and TCs (13 percent).

Treatment settings. Five treatment settings exist for teens (CSAT, 2000c). Generally speaking, treatment settings can be ordered based on intensity. All of these treatment settings were initially designed for adults. A review of the literature reveals that there is little specific information about how these settings have been adjusted to meet adolescents' needs. Nevertheless, they are included here as a summary of treatment settings, beginning with the least intensive.

Brief interventions are often based on CBT. In this setting, interventions are typically delivered by physicians, counselors, or others who do not specialize in drug and alcohol use disorder treatment per se. Brief interventions typically involve single-shot programs that encourage self-help and self-management. They are relatively inexpensive to deliver. Studies by Rollnick, Heather, Gold, and Hall (1992), Miller and Rollnick (1991), and Monti et al. (1999) show that brief interventions can be an effective setting for treatment in a variety of situations, particularly for those who have not yet developed dependence or serious chronic problems associated with use.

Outpatient treatment services provide a broad range of intensity of care levels, but do not offer overnight supervision. The methods of treatment often focus on cognitive behavioral therapy and family therapy. The frequency of contact is adjusted to meet the specific needs of the presenting individual. In less intensive programs, 2 to 3 hours per week are common. More intensive programs can range from 9 to 20 hours per week and may include therapy on weekends.

Day treatment or partial hospitalization programs provide professionally directed evaluation and structured treatment after school, in the evenings, or on weekends. In the most intensive of the outpatient programs, the treatment provided may involve a combination of individual, group, and family therapy.

Inpatient treatment offers a range of intensity of care levels. Each type of inpatient treatment requires the patient to live temporarily in a safe and controlled treatment facility. The most intensive form of inpatient treatment involves 24-hour supervision by professional staff. Group home living, such as halfway houses, is the least intensive inpatient treatment setting. Intensity may be graduated with a short and intensive residential stay in a professional treatment facility, followed by a much longer adjustment period in “sober living” arrangements. The goal of inpatient treatment is to provide sufficient structure to allow the patient to make major life changes, while strictly limiting access to alcohol and drugs.

Detoxification settings are often included as part of a 28-day intensive inpatient treatment. Detoxification generally refers to a 3- to 5-day period of intensive medical monitoring and management of withdrawal symptoms. Physical withdrawal is uncommon for adolescents unless opiates or barbiturates have been the principal substances of abuse and dependence. Detoxification is rarely indicated for adolescents.

Comprehensive, Integrated Treatment Approach

Evidence shows that treatment is more effective if it is fully integrated into all aspects of an adolescent's life—school, home, family, peer group, and workplace. For example, with adolescents it is usually important for the treatment to involve the school. Treatment programs could help students keep up with their schoolwork and feel integrated into the school environment (Personal communication, John Knight, Harvard Medical School, June 1, 2001). Outpatient treatment might take place after school hours so it does not interfere with the positive social and academic aspects of school. Schools can help provide the social support and resocialization that is crucial to successful treatment outcomes (Personal communication, Ken Winters, University of Minnesota, June 1, 2001). In addition, adolescent substance abusers and those who are dependent on alcohol and other drugs are often involved with the criminal justice system. To be effective, treatment needs to be coordinated with decisions that are made by this system (Aarons, Brown, Hough, Garland, and Wood, 2001).

Family Involvement in Treatment

Family involvement is one aspect of a comprehensive, integrated approach to substance use disorder treatment, but deserves attention in its own right. Relationships are critically important in reducing teen drug use, and parents have a powerful influence on adolescent development throughout the teen years (Liddle et al., 2001). Research clearly supports the need for including families in therapy (Liddle et al., 2001). Family involvement usually includes education about treatment and how families can support the treatment process. Sometimes it involves having family sessions at the agency or even in the home that address family environment or structure.

Developmentally Appropriate Programs

Because of the rapid changes they are experiencing, adolescents are at risk for developing substance use disorders more quickly than adults (Dusenbury and Botvin, 1990; Sernlitz and Gold, 1986). Treatment for adolescent substance abuse and dependence must be grounded in an understanding of adolescent development (Liddle et al., 2001; Wagner, Brown, Monti, Myers, and Waldron, 1999). Treatment programs need to be sensitive to the multiple developmental issues that adolescents face (CSAT, 2000b). In contrast to adult treatment, adolescent treatment often needs to emphasize maturational issues, psychological issues, and emotional and sexual issues (Hird, Khuri, Dusenbury, and Millman, 1997; White, Dennis, and Tims, 2002). Treatment programs should be tailored to the different needs of older (16-to 18-year-old) and younger (12- to 15-year-old) adolescents (Personal communication, John Knight, Harvard Medical School, June 1, 2002), as well as to thinking styles of more concrete versus abstract thinkers.

Developmental and cognitive impairments are common, and providers need to be flexible in their use of activities (Wagner et al., 1999). The teenage years are the period during which young people gain autonomy. Adolescents in treatment are often not granted autonomy; this creates tension and frustration between the therapist and the teen (Personal communication, Nancy Jainchill, Center for Therapeutic Community Research, June 1, 2001).

Most programs in use were originally designed for adults (White et al., 2002; Dennis, 2002), and it is rare to find standalone programs for adolescents. Program models specifically designed for adolescents are more effective than programs based on adult regimens (Personal communication, Randolph Muck, Center for Substance Abuse Treatment, June 1, 2001).

In addition, programs need to use creative, hands-on techniques to make activities relevant to adolescents' concerns and developmental stages. For example, some programs give teen clients disposable cameras to take photos of friends and families, which then become a basis for generating group discussion. Some Twelve Step programs have tailored the individual steps to adolescent experiences. For example, to explain the step of powerlessness, the therapist reviews everyday occurrences to explore what adolescents can control and what they cannot.

Strategies to Engage and Retain Teens in Treatment

Effective programs are designed to engage and retain young people. Simply put, treatment cannot be effective if young people do not participate. At times, motivation to participate is a major barrier for adolescents, who often have other priorities. Motivational enhancement techniques and motivational interviewing are important and clearly have to be a part of engagement (Barnett, Monti, and Wood, 2001; Winters, 1999). The use of positive reinforcement helps with retention. Vouchers to promote attendance and the completion of activities allow program providers to reinforce positive behavior (Drug Strategies, 2003). Developing a therapeutic alliance—a climate of trust that facilitates behavior change—between the client and the counseling staff is an important way to retain teens in treatment. The therapeutic alliance is increased when a therapist helps the teen find things that are concrete, tangible, and relevant to him or her (Liddle et al., 2001). Addressing specific problems with family, school, or the juvenile justice system will help an adolescent stay engaged. Research shows that involving parents in therapy produces better engagement rates for adolescents, which may result in better treatment outcomes (Dakof, Tejeda, and Liddle, 2001).

It is also important to include good case management in treatment to ensure that young people participate and remember appointments (Personal communication, Michael Dennis, Chestnut Health Systems, June 1, 2001).

Qualified Staff

Staff should be trained to understand adolescent development, to recognize psychiatric problems, and to work effectively with families (Liddle et al., 2001). They need to have training and experience in diverse areas to meet the many needs of adolescents with substance use disorders, including problems with delinquency and learning disabilities. Although professional training and credentials are vitally important, positive, caring staff attitudes are also important in connecting adolescent clients to the treatment process (Drug Strategies, 2003).

Gender and Cultural Competence

Good programs are based on an understanding of gender socialization and the cultural background of the patient. For example, there is a high correlation between childhood trauma and substance use disorders for girls and women. Often female substance abusers and those who are dependent on alcohol and other drugs have been sexually abused. A study comparing the incidence of trauma in adolescents with alcohol abuse and dependence to a control group found that adolescents with alcohol abuse or dependence were 18 to 21 times more likely to have a sexual abuse history. Of those adolescents who reported having both a sexual abuse history and alcohol abuse or dependence, 68 percent were females (Clark, Lesnick, and Hegedus, 1997). A study of women addicts found that not only was abuse (sexual, physical, and emotional) more frequent, but it occurred for longer periods of time and by more perpetrators than those in the control group (Covington and Surrey, 1997). In dealing with their emerging sexuality, girls may adopt a pattern of interaction in which they try to be pleasing to and subordinate to men. For these reasons, putting girls in a coed setting for treatment may be contraindicated. Furthermore, while boys and girls are both at risk for sexual abuse in interpersonal relationships as children, boys move out of risk in adolescence but girls continue to be at risk for sexual abuse (Covington and Surrey, 1997).

The context of drug use also differs for boys and girls. For example, girls often initiate alcohol or drug use in dating or in conjunction with their first sexual experience. In contrast, boys typically first use with other boys. For a girl it is not unusual for the first supplier to be the boy with whom she is involved (Dakof, 2000). Another difference that may affect treatment has to do with teens' responses to anger. Girls are more likely to turn anger inward, while boys direct their anger toward others. Girls often use alcohol and drugs in part to self-medicate (Dakof, 2000), whereas boys often use drugs as a means to enhance pleasure and excitement and as a rite of passage. When a boy gets into trouble and can no longer use, he may struggle with issues of how he can still feel like a man (Personal communication, Stephanie Covington, Institute of Relational Development, June 1, 2001).

Continuing Care

Alcohol abuse and dependence, like most medical or psychological disorders, tend to be chronic. Many adolescents will go back to using alcohol after they complete treatment (Bukstein, 2000). One-third of those who relapse do so in the first month after treatment, and two-thirds do so in the first 6 months. In contrast to adults, who tend to relapse because of negative affect or personal distress, adolescents appear to relapse more often as a result of peer pressure; it is also more difficult to successfully treat teens who believe that drinking alcohol will help with social interaction (Brown, 1990).

Continuing care is crucial to achieving long-term outcomes. Programs vary tremendously on whether and how much continuing care they provide; many outpatient programs do not include continuing care (Personal communication, Ken Winters, University of Minnesoata, June 1, 2001; Kaminer, 2001), yet good continuing care is increasingly viewed as critical (Godley, Godley, and Dennis, 2001). Teens who require intense treatment will also require intense continuing care (Fertman, 1991). If adolescents leave their home community to receive treatment, continuing care must be activated as soon as the young person returns to the community (Godley et al., 2001).

Treatment Outcomes

It is important to understand the potential of a program to produce results. Most treatment programs keep track of outcome data and are able to provide statistics, which suggest the effectiveness of the treatment and recovery strategies (Pickens and Fletcher, 1991; Bergmann et al., 1995; Jainchill et al., 1995; Werner, 1995). Evaluation is costly and difficult (Drug Strategies, 2003; Milby, 1981). However, evaluation not only validates effective approaches, it also provides information that is essential for improving or enhancing treatment strategies (Muck et al., 2001).

A number of evaluation studies of adolescent treatment programs have been conducted. Many of these studies have multiple methodological problems, including small sample sizes and no control group, as well as variation in operational definitions, terminology, and measures of outcome effectiveness (Williams, Chang, and Addiction Centre Adolescent Research Group, 2000; Kaminer, 2001), making it difficult to draw clear conclusions. Given data that were available a decade ago, reviews were able to make only the most basic conclusion: Any treatment is better than no treatment (U.S. Congress, Office of Technology Assessment, 1991). The best predictor of treatment outcome consistently has been the amount of time spent in treatment (Polich, Ellickson, Reuter, and Kahan, 1984). Success also appears more likely when skills training is part of the treatment and when families participate (U.S. Congress, Office of Technology Assessment, 1991). Attending continuing care activities, including self-help and support groups, also favorably influences outcomes (Bergmann et al., 1995).

Studies of treatment efficacy often focus on the characteristics of the individual who does well in treatment (Kaminer, 2001; Williams, Chang, and Addiction Centre Adolescent Research Group, 2000). There is an extensive literature that documents which adolescents have the best prognosis for success in treatment. Factors that predict success include having a higher socioeconomic status, attending school or other educational programs, and being older when substance use began. Adolescents who are not involved in opiate or multiple substance use or criminal behavior and who have fewer problems initially are more likely to have positive outcomes (U.S. Congress, Office of Technology Assessment, 1991; Sernlitz and Gold, 1986; Cambor and Millman, 1991).

Different approaches appear to be better suited to youth who have several definable characteristics. For example, the highly structured TC environment may work best for delinquent or antisocial youth. On the other hand, outpatient programs appear to be better suited to those who have been productive at some point in the past—including those who are pursuing an education (Polich et al., 1984).

Programs Should Be Comprehensive and Offer an Integrated Treatment Approach

A comprehensive, integrated treatment approach ensures that the program addresses all of an individual teen's treatment needs, which may include addressing mental health problems, family dysfunction, learning disabilities or school failure, and physical health concerns. In addition, this approach should connect adolescents and their families with an array of community services. Treatment providers, often funded by the health care system, should coordinate with all settings in which teens in need of treatment interact—school, home, family, peer group, and where appropriate, the criminal justice system and the workplace. Policies set and services provided by agencies such as the U.S. Department of Education and the U.S. Department of Justice, local school districts, local court agencies, and agencies that receive block grant funding from the Substance Abuse and Mental Health Services Administration should support high-quality, coordinated programming across these settings.

Treatment Should Be Developmentally Appropriate

Research is needed to determine whether and the extent to which treatment programs originally developed for adults are appropriate when used with adolescents. Adolescents should receive treatment separately from adults. Staff should be trained to understand adolescent development and respond appropriately to the challenges that adolescents present. Good programs are based on an understanding of gender socialization and the cultural background of the patient. National guidelines for staff training to understand the developmental needs of teens should be developed. Nationally recognized guidelines for ensuring the safety of adolescent patients, particularly females, also should be developed.

Treatment Programs Should Actively Work to Retain Teens

Programs should adopt specific strategies for motivating adolescents to participate in treatment that can help with retention. Most adolescents enter treatment through the criminal justice and education systems. When treatment is mandatory, teens' intrinsic motivation to complete treatment is low. Motivation is important to successful treatment outcomes. Elements need to be integrated into programs that provide rewards and incentives that are meaningful to participants. These elements should be considered an essential part of the program and should be fully funded.

New preliminary data from CSAT's Adolescent Treatment Model study (Perry et al., 2003) indicates the importance of the therapeutic relationship in retaining youth in treatment. The therapeutic relationship builds a climate of trust between a therapist and a client that facilitates behavior change. Qualities in therapists that foster this relationship include flexible, intelligent thinking, good interpersonal skills, and genuine empathy. Research efforts on the importance of the therapeutic relationship should continue, and the findings should be disseminated widely to treatment providers.

Treatment Needs to Include Continuing Care

Continuing care is crucial to achieving long-term outcomes. Continuing care is often one of the weakest features of adolescent treatment programs nationwide (Drug Strategies, 2003). Programs should institute a process of continuing care that includes relapse prevention, training, follow-up plans, referrals to community resources, and periodic check-ups after completing treatment in order to help teens avoid recidivism.

Treatment Programs Need to Be Evaluated

Establishing the effectiveness of treatment programs is crucial. Federal agencies should fund the collection and analysis of outcome data so that treatment effectiveness can be determined. A federal research priority should be to determine which treatment approaches are most effective with different types of youth.