ASA8285 - SECTION 6: TREATING ADOLESCENT ALCOHOL AND OTHER DRUG USE
Characteristics of Adolescent Alcohol and Other Drug Users
Until recently, treatment approaches for adolescents were based upon adult treatment models (Kaminer, Burleson, Blitz, Sussman, & Rounsaville, 2004). However, clinicians and researcher have recognized that adolescent substance abusers have unique characteristics that impact their treatment needs including:
1. Briefer history of AOD use involvement
2. More likely to demonstrate episodic versus chronic AOD use
3. Less likely to suffer from the medical consequences of protracted use
4. Often use a greater number of different types of substances
5. Are undergoing rapid developmental changes which may mimic or exacerbate AOD effects
6. Are more likely to present with co-occurring problems such as psychiatric co-morbidity, family, school, legal, and community problems
7. Are more likely to “outgrow” or “mature out” of AOD problems by early adulthood without formal treatment
8. Are less likely to admit they have a problem with AOD use and voluntarily seek and participate in treatment
9. May be less amenable to adult treatment techniques such as confrontational-of-denial approaches to treatment given developmental issues associated with independence and autonomy (Institute of Medicine, 1996; National Institute on Alcohol Abuse and Alcoholism, 2004).
Therefore, it is very important to have programs that are specifically designed for the needs of adolescents and they are staffed with treatment personnel who are trained to work with adolescents. Drug Strategies (2003) identifies ten questions to ask an adolescent treatment program:
1. How does your program address the needs of adolescents?
2. What kind of assessment does the program conduct of the adolescent’s problems?
3. How often does the program review and update the treatment plan in light of the adolescent’s progress?
4. How is the family involved in the treatment process?
5. How do you engage adolescents so that they stay in treatment?
6. What are the qualifications of program staff and what kind of clinical supervision is provided?
7. Does the program offer separate single sex groups as well as male and female counselors for girls and boys?
8. How does the program follow up with the adolescent and provide continuing care after treatment is completed?
9. What evidence do you have that your program is effective?
10. What is the cost of the program?
There are four primary types of treatment settings: crisis intervention, inpatient treatment, outpatient treatment, and residential care/therapeutic communities (Bukstein, 1995; Roth & Fonagy, 1996).
1) Crisis Intervention and Evaluation: This type of intervention is used when an adolescent is brought to a hospital emergency room or other medical facility with some type of injury or medical condition suggesting an AOD use etiology or involvement or the adolescent comes to the attention of school officials or law enforcement for some type of AOD use or related problem. Treatment personnel have developed brief, focused interventions for adolescents in these types of situations that have proven to be very successful. After the initial contact, these programs use 4 to 8 sessions to do a more complete evaluation of the adolescent’s AOD problems and associated behaviors, an intensive program of psychoeducation to discourage further use, and focused individual and group counseling (Barnett, Monti, & Wood, 2001). This type of intervention can also function as a referral for those adolescents who need more comprehensive treatment.
Before any actual AOD treatment can occur, a minority of adolescents may need to be “detoxified” meaning that all drugs they are using need to get physically removed from their bodies. Withdrawal symptoms experienced as people come off of some drugs can be very severe and life-threatening. As a general rule, detoxification should always take place while under the care of a medical doctor or other qualified medical professional. Through appropriate use of medication, a physician can gradually step an addicted person down through the process of detoxification so that the withdrawal symptoms are minimized and no severe, life-threatening symptoms are experienced.
2) Inpatient Treatment: Inpatient or short-term treatment has a number of advantages over other treatment settings including control of the environment by preventing the adolescent from running away or bringing in contraband AOD, separation from problematic family circumstances and negative peer influence, and allowing for intensive treatment. This type of treatment is particularly recommended for adolescents who exhibit behavior indicating an actual or potential danger to self or others, adolescents requiring acute medical attention (e.g., withdrawal or significant medical complications of AOD use), and adolescents with significant coexisting psychopathology.
Traditionally, these types of programs had set time periods ranging from 28 to as much as 60 days, but reimbursement limits and managed care have shifted the basis of length of stays from a predetermined period of time to a length of time determined by the needs of the patient and the standards of the health care programs for reimbursement. In most health care plans today, to get reimbursement, programs are required to justify not only admission to the program, but continued treatment is based on response to treatment and the continued documentation of severity factors. Inpatient programs are usually staffed by multidisciplinary teams consisting of substance use specialists, physicians, social workers, counselors, and teachers.
3) Outpatient Treatment: Almost 85% of all adolescent substance abuse treatment is delivered in outpatient settings. There are many different types of outpatient programs but they share the characteristic that the adolescent resides either at home or in a less restrictive residential placement such as foster are or a group home. While outpatient programs may sacrifice some control, the primary advantage of such programs is that adolescents participate in treatment while remaining in the community with, presumably, exposure to the circumstances that may have contributed to the development and maintenance of their AOD problem. The programs can then help adolescents and their families actively learn to control these influences to eliminate or reduce AOD use. In addition, outpatient programs are usually less expensive than in-patient or residential programs. A common feature of many outpatient programs is involvement of the adolescent’s family, friends, and, probation, social service, and school personnel in the treatment program. Programs use a wide variety of professional and lay staff.
4) Residential Care and Therapeutic Communities: The difficulty in achieving success in short-term substance abuse treatment for some adolescents has lead to the development of intermediate and long-term treatment options. In most cases, adolescents who are sent to residential care have failed in other less restrictive treatment settings. Residential treatment programs range from one to nine months with some lasting as long as two or more years. Longer-term programs usually are admitting adolescents with not only AOD problems, but also other behavioral, psychiatric, and social problems.
All of these programs include significant educational components in addition to addressing the adolescent’s AOD and associated problems. While some programs offer family services, many of these programs are not located near where an adolescent’s family may live, so there may be little family/parental involvement except for encouraging family attendance during family weeks or weekends, and giving parents information about the adolescent’s progress in the program and what to do when they return home.
Many long-terms programs operate as what is called “therapeutic communities” (TC). The TC is often a more structured form of treatment usually based upon a combination of 12-Step, cognitive-behavioral, and community principles. The staff typically includes substance abuse counselors, teachers, counselors, and medical staff (Wagner & Waldron, 2001).
Treatment Placement Criteria
The American Society for Addiction Medicine (ASAM) has developed placement criteria based upon explicit decision-making rules. For admission, a clinician rates the adolescent along six dimensions: intoxication/withdrawal, biomedical complications, emotional/behavioral problems, treatment acceptance/resistance, relapse potential, and recovery environment, and the type of initial placement depends upon the severity criteria met within each dimension (Bukstein, 1995).
There is a tendency for some families to prefer residential treatment because they prefer someone else to deal with the problem (“out of sight and out of mind”). Their hope is that the treatment will be successful and the program will return to them a non-substance using adolescent. One of the major problems with residential programs is that most adolescents eventually return to their families and their communities and they may face the same challenges they faced when they were using AOD in these settings.
Most treatment professionals recommend that it is best for most adolescents to use the least restrictive treatment options first unless there are factors that warrant a more restrictive first treatment option. A more restrictive treatment option might be required in situations when the adolescent shows serious signs of AOD dependency and/or psychiatric co-morbidity, the adolescents lacks sufficient family or community support for recovery, the adolescent has failed in a less restrictive treatment environment, or the adolescent requests a more restrictive treatment environment.
It is usually easier to go from a less restrictive treatment environment to a more restrictive treatment environment when the less restrictive option is not successful. For example, if an adolescent is initially sent to a residential treatment program and if the program is not successful, there may be few options but to send the adolescent to another residential treatment program. Therefore, the decision to send an adolescent to residential treatment should consider the advantages and disadvantages of this treatment option, the cost and effectiveness of the treatment, and whether or not it is right for this adolescent at this time.
Components of Effective Alcohol and Other Drug Treatment
Drug Strategies (2004) has identified nine key elements of effective adolescent treatment:
1. Assessment and Treatment Matching—Accurate assessment is an important step in diagnosing substance abuse disorders and psychiatric conditions with a treatment plan that matches the severity of the problem.
2. Comprehensive, Integrated Treatment Approach—Program services must address all aspects of an adolescent’s life including school, job, juvenile justice, mental and physical health, peers, and the community.
3. Family Involvement in Treatment—Parents and guardians have a powerful influence on their adolescent’s development and the research shows that involving them in the adolescent’s treatment produces better outcomes.
4. Developmentally Appropriate Program—Treatment programs and materials need to be tailored to adolescents and their unique needs.
5. Engage and Retain Teens in Treatment—Program strategies and activities should build a therapeutic alliance between the therapist and the adolescent which facilitates behavior change.
6. Qualified Staff—Staff need to be knowledgeable about adolescent development and co-occurring mental disorders as well as AOD abuse and addiction.
7. Gender and Cultural Competence—Programs should recognize both gender and cultural difference in their treatment approach.
8. Continuing Care—Continuing care services include relapse prevention training, follow-up plans, and referrals to community resources.
9. Treatment Outcomes—There should be built-in mechanisms for the evaluation of treatment effectiveness (NIDA, 2003b).
Major Types of Treatment
Current approaches to the treatment of adolescent AOD use fall into three main modalities: 12-Step, Cognitive-Behavioral, and Family-Based (Bukstein, 1995; Winters, 1999). Each type of treatment modality views the problems of adolescent AOD use, its etiology, maintenance, and resolution, from a slightly different perspective. It very common today for programs to integrate a number of approaches in their total treatment plan (Wagner & Waldon, 2001).
The 12-Step approach (also known as the Minnesota Model or the Alcoholics Anonymous (AA)/Narcotics Anonymous (NA) approach) is the most widely used model in adult AOD treatment and it has had a significant influence on adolescent AOD treatment (Winters, Stinchfield, Opland, Weller, & Latimer, 2000). The 12-Step model views substance dependency as a disease that must be managed throughout one’s life, with abstinence as the only goal.
The AA/NA philosophy is rooted in the belief that change is possible, but only if addicted individuals recognize their problem with addiction and admit that they cannot control it. Acceptance of the disease model of addiction and commitment to an ongoing personal recovery program are necessary to achieve total abstinence from AOD. The model is based on four primary goals to be used as indication of progress:
1. Recognition that the addiction is a disease requiring life-long abstinence
2. Admitting that one is powerless over the addiction and in need of help,
3. Identifying specifically what needs to be changed in order to achieve help
4. Making these changes and developing a new life-style (Lawson & Lawson, 1992).
The backbone of 12-Step treatment is “step work,” a series of treatment and lifestyle goals that are worked on in groups, with sponsors, and individually. Step work provides the basic structure for treatment and recovery. Most 12-Step programs focus on the first five steps during primary treatment, while the remaining ones are attended to during aftercare.
1. Step 1: We admitted were powerless over alcohol—that our lives had become unmanageable.
2. Step 2: We came to believe that a Power greater than ourselves could restore us to sanity.
3. Step 3: We made a decision to turn our will and our lives over the care of God as we understood Him.
4. Step 4: We made a searching and fearless moral inventory of ourselves.
5. Step 5: We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
The first three steps help the person to be more honest, decide to stop using AOD, and choose a new lifestyle. Steps four through nine, the “action steps,” help the person to continue to be honest with themselves and others in their life, develop and implement an action plan for a changed lifestyle, and correct past wrongs where possible. Steps ten through twelve are the “growth steps” and encourage the person to continue to work on a recovery program throughout their life.
Other components of 12-Step programs include getting a sponsor (a recovering AOD user), group therapy, individual counseling, lectures and psycho-education, family counseling, written assignments (including step work), recreational activities, and participation in aftercare including attendance at AA/NA meetings in the community.
Group therapy is the primary mode of treatment delivery within most 12-Step programs. Non-structured, process-oriented groups have a primary goal of breaking through the denial of group members through confronting the person’s negative attitudes and behavior, hearing how other group members are handling their AOD problems, and developing positive relationships with non-substance users.
Although programs usually have a multidisciplinary staff, most of the treatment is provided by counselors who are recovering from their own AOD addictions through their own involvement in 12-Step programs. 12-Step treatment is widely offered in both residential and outpatient settings. In addition, many other types of treatment programs incorporate aspects of the 12-Step model into their program or will recommend that people in their programs become involved in AA/NA meetings as a part of aftercare in the community.
While 12-Step principles have proven to be effective for many adults in achieving recovery, there can be problems in using this treatment approach with adolescents (Marlatt, 1998; NIAAA, 2004; Winters, Stinchfield, Opland, Weller, & Latimer, 2000). First, it is very important for adolescents to attend AA meetings in the community that are designed specifically for adolescents or at least where there are a significant number of adolescents in attendance. The availability of adolescent role models for recovery and the presence of abstinent peers for friendship and support is the basis for the success of this approach.
Second, traditionally, most AA oriented programs viewed the AOD abuse as always the primary problem and as the primary cause of any additional problems plaguing the individual. The “pure” AA/NA approach stressed that individuals need only to accept their status as addicts, follow the 12 steps, and attend meetings to get better.
This approach was seen as the only way for meaningful recovery. As a result of this orientation, many of AA programs paid little attention to the other problems in the adolescent’s life. The belief was that by achieving abstinence, the other problems would or could be solved, although little direct, specific, or immediate attention might be given to these problems.
Increasingly, programs that are 12-Step based are recognizing that for adolescent AOD abuse treatment to be successful, programs need to be more comprehensive including the broad goal of making significant changes in the adolescent’s total lifestyle.
Third, one area of debate in programs that use a 12-Step approach, is the use of medications to treat AOD abuse and associated problem behaviors. There are three broad potential targets areas for psychopharmacological treatment: 1) treatment of withdrawal effects, 2) specific treatment for the AOD use behavior itself, and 3) treatment of coexisting psychiatric disorder(s) (Bukstein, 1995).
There has been the traditional belief in 12-Step programs that medications should be used in addicted individuals only in cases of medical emergency in the belief that “drugs” are why the person is in treatment in the first place. However, with the research that is proving the effectiveness of psychopharmacological treatment for these co-morbid conditions, more 12-Step based programs are allowing or even encouraging their use.
Finally, most 12-Step based programs use confrontational tactics to “break through the denial” and rationalizations that people often use to support their AOD use and try and persuade them that they must accept the fact that they have a life-long AOD problem.
While many adolescent may be willing to admit they currently have gotten into some trouble with their AOD use, they are usually unwilling to see themselves as having an addictive disease that is a life-long problem for which complete abstinence is the only solution. As a result they may be unwilling to participate in programs using this treatment orientation. In conclusion, to be successful, 12-Step programs need to be tailored to the unique needs of adolescents.
Cognitive-Behavioral approaches (including what is called behavioral, cognitive, or cognitive-behavior) focus on the underlying cognitive processes, beliefs, and environmental cues associated with adolescent’s use of AOD. The basic goal of these types of programs is to teach adolescents coping skills to help them remain AOD-free. These approaches view AOD abuse as a learned behavior rooted in adolescents’ cultural context that defines AOD-related beliefs and behaviors as a meaningful aspect of their lives.
The goal of behavioral approaches is to teach adolescents to “unlearn” the use of AOD and to learn alternative, pro-social ways to cope with their lives. This approach believes that behavior is mediated by thoughts and beliefs and cognitive-behavioral techniques attempt to alter thinking about drug use as a way to change the behavior.
Cognitive-behavioral interventions take into account the cognitive development of the adolescent. For those at low levels of cognitive development programs are firmly structured with clear, noncomplex, behavioral guidelines and provisions for successful experiences with ample positive reinforcement. For adolescents at moderate levels of cognitive-social development, the treatment environment is less structured than for those at lower levels of cognitive development, and they often use a guided discovery orientation. Finally, adolescents at more advanced levels of cognitive-social maturity usually prefer complexity and have the capacity to deal with analysis of complex individual and interpersonal situations.
Common features in most of these types of programs include: employing motivation-enhancing techniques to establish a strong treatment alliance and improve treatment engagement and retention; identifying patterns of AOD use, skills deficits, and dysfunctional attitudes that then become targets for intervention; enhancing coping strategies to deal with AOD cravings and associated problems; strengthening problem-solving and communication skills and the ability to deal with high-risk situations; and identifying enjoyable activities and people incompatible with AOD use.
A commonly used behavioral intervention focuses on the development of coping skills. These techniques involve teaching the adolescent particular skills such as AOD refusal skills, resisting peer pressure to use AOD, communication skills, problem-solving skills, anger management, relaxation training, social network development, and leisure-time management.
New behaviors are tried out in low-risk situations (i.e. during group sessions, role playing, individual counseling sessions) and then tried in more difficult, real-life, situations. Behavioral contracts are also often used with the adolescent and the counselor (and usually the family) agreeing on a set of targeted behaviors with the adolescent receiving rewards for accomplishing each desired behavior or task (Reinecke, Dattilio, & Freeman, 1996).
Family Therapy Approaches
One of the most influential factors in an adolescent’s life is the family system, including the family of origin and the various other family systems and subsystems that operate through an individual’s life (Dishion, 2002). AOD abuse has been described as a “family disease” (Connors, Donovan, & DiClemente, 2001; Goodwin & Warnock, 1991; Onken, Blaine, & Borden, 1997).
A growing body of research has identified family related factors as important influences in the development and maintenance of substance abuse problems (Ross, 1994; Waldron, 1997). Not only does the family influence the developmental course of AOD problems, but the AOD problems of family members influence the family as a whole.
Family biology and family dynamics not only contribute to an individual’s risk for development of AOD use problems, but the family can also provide protective and recovery factors. Many, if not most, substance abusers consider treatment in response to some form of external pressure by family members (Fagan, 2004; Fals-Stewart, O’Farrell, & Birchler, 2003; Schonert-Reichl, 2003; Thomas & Ager, 1993). Therefore, the family can play a significant important role in initiating and sustaining the treatment process.
Family-based approaches emphasize the critical role familial factors play in the development and maintenance of adolescent AOD abuse. There is considerable evidence to indicate that it is not so much who the parents are, rather, it is their parenting skills that are critical to understanding risk and protection. Family related factors such as parental, relatives, and sibling AOD use and abuse; poor parent-child relationships; and poor parental management of the adolescent’s behavior are seen as risk factors for AOD abuse among adolescents.
Treatment is oriented toward addressing these risk factors as they are seen as a key in the adolescent’s total recovery process. Treatment focuses on interventions aimed to change the way family members relate to each other and helping families to better solve their problems. The primary assumption of family-based approaches is that effective child and adolescent management practices can be taught to parents that will result in a reduction of the problem behaviors (Donohue & Azrin, 2001; Fals-Stewart, Birchler, & O’Farrell, 1996; Richardson, 2001; Schaefer, 1987).
Dishion and Kavanagh (2003) have developed a family-based treatment model that focuses on:
1. Self-help (supporting families who want to make changes on their own through resources such as reading books or watching video tapes)
2. Brief family interventions (one to four sessions on specific topics that have emerged as concerns using the basic model of problem-solving, incentives for positive behavior, and setting limits and monitoring)
3. School monitoring (establishing a system of communication between the school and the parents to ensure periodic reports on behavior, attendance, and completion of school work)
4. Parent networking (getting different parents together to share problem-solving strategies)
5. Family therapy and support (including a therapist who represents the parents and one who represents the adolescent)(also see Liddle, Dakof, Parker, Diamond, Barrett, & Tejeda, 2001; Liddle, Dakof, Diamond, Holt, Aroyo, & Watson, 1992 and what they call “multidimensional family therapy”).
Research Support for Therapy and Treatment
By the time adolescents enter substance treatment, they often have reaped the cumulative psychological, health, and social consequences of earlier developmental adversities and behavior problems. Most adolescents are often poorly motivated for treatment; have psychiatric problems; worsening academic, family, and behavior problems; and a limited range of coping and social skills. They are also likely to lag in important adolescent developmental tasks, including individuation, moral development, and conceptualization of future educational, vocational, and family goals (Riggs, 2003).
Not all adolescents with AOD problems need formal treatment. “Natural recovery” appears to be the rule rather than the exception in adult and adolescent recovery. In fact, only a minority of former AOD abusers have been involved in any type of formal treatment (Sobell, Ellingstad, & Sobell, 2000). Research shows that a substantial portion of adolescents make efforts to reduce or cease their AOD use independent of formalized treatment programs and even those adolescents who are in treatment, many of them change their behavior, not as a result of factors in the program, but they use other resources to make meaningful changes.
Understanding these “self-change” or “natural recovery” factors can help to enhance the effectiveness of all intervention efforts and to potentially reach portions of the adolescent population that do not currently seek or participate in formal treatment (Brown, 2001).
A growing body of research and clinical experiences indicates that treatment for adolescents is most effective when it attends to the adolescent’s psychosocial problems in addition to their AOD use problems (Dennis, Dawud-Noursi, Muck, & McDermeit, 2003). Reviews of studies that have examined the effectiveness of various treatment approaches for adolescent AOD abuse have concluded that there are a number of consistent findings:
1. Adolescents need developmentally appropriate assessment tools and treatment protocol.
2. Multiple co-occurring problems are the norm among adolescents with substance use problems and as a result they need comprehensive services;
3. Adolescents are involved in multiple systems competing to control their behavior;
4. Adolescents’ responses to treatment are highly variable;
5. Relapse and continued problems are the norm among adolescents who have received substance abuse treatment, but completion of treatment and continued care as an extension of treatment are very important for treatment success;
6. The most effective treatment models share common elements (they have qualified staff; recognize gender and cultural differences in their treatment approach; they address engagement and motivation for treatment; use a manual-guided, developmentally appropriate treatment protocol; involve families in the treatment process; utilize more quality assurance and clinical supervision; and are assertive in providing continued care after treatment);
7. The less effective treatment models share common elements (they rely on passive referrals, education units alone, “probation services and usual,” or non-standardized “outpatient services as usual”) (Drug Strategies, 2004; National Institute on Drug Abuse, 2003; Weinberg, Rahdert, Colliver, & Glantz, 1998; White, White, & Dennis, 2004; Winters, 1999).
The research shows that for adolescents, substance abuse treatment is superior to no treatment (Pinsof & Wynne, 1995). While there is relatively little longitudinal research, average sustained abstinence rate after one year is about one-third of those receiving treatment (Weinberg, Rahdert, Colliver, & Glantz, 1997; Williams, Chang, & Addiction Centre Adolescent Research Group, 2000).
Researchers have found that while there is generally insufficient evidence to compare the effectiveness of different types of treatment, there is evidence that outpatient family therapy is superior to other forms of outpatient treatment. The research shows that family therapy (but not family psycho-education or support groups) is effective in engaging and retaining AOD abusing adolescents in treatment and in reducing their rates of AOD abuse (but not necessarily abstinence) and it is cost effective (Shadish, Ragsdale, Glaser, & Montgomery, 1995; Waldron, 1997; Weinberg, Rahdert, Colliver, & Glantz, 1998).
However, the research shows that family therapy is not quite as effective in reducing problems in other life areas such as psychological and psychiatric problems and family functioning (Grella, Yih-Ing, Joshi, & Rounds-Bryant, 2001).
Pretreatment variables most consistently related to successful outcome for adolescent AOD users are: 1) lower AOD use, 2) peer and parental support, and 3) better school functioning. Treatment variables most consistently related to outcome are: 1) treatment completion, 2) family involvement, and 3) programs that provide comprehensive services.
Post-treatment variables most consistently related to outcome are: 1) attendance in aftercare and 2) peer and parental support. There is no good empirical evidence to support one type of treatment setting over another, length of treatment, or whether certain types of adolescents are best treated by certain types of programs (Williams, Chang, and Addiction Centre Adolescent Research Group, 2000).
In conclusion, the goal is the match the adolescent and his/her AOD use and associated problems with the type of treatment that will best attend to his/her needs. If this is done, treatment can be successful.