TREATING TEENS Research Articles and Survey Intruments This section contains links to peer-reviewed published articles on teen treatment by Drug Strategies researchers as well as articles commissioned by Drug Strategies on related topics and the survey instruments used to create the program profiles. Click on links below to view the articles and instruments.
[toggle title=”Mail/Fax Survey”] Adolescent Treatment Provider Mail/Fax Survey
1. Facility Name: _________________________________________________
2. Facility Location:_______________________________________________
3. Other Branches:_______________________________________________
4. Year Established:______________________________________________
5. What levels of treatment does your program provide? (Check all that apply and briefly describe services and length of time)
Please answer the remainder of the questions for each adolescent level of care your program provides.
6. How do you define adolescent? _____________________________
7. Does the program offer special programming based on gender, age, ethnicity, criminal involvement, or any other issue? If yes, please describe.
8. What types of group sessions are offered (such as Marijuana Addiction, Eating Disorders, Gay and Lesbian, Anger Management, Relapse Prevention)?
9. Do you offer individual therapy? Yes No
10. Are you Licensed by:
11. Types of Licences:
___Youth treatment facility
12. Accredited by:
___Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
___Rehabilitation Accreditation Commission (CARF)
13. Is there one primary treatment modality or philosophy that guides your program?
___Cognitive Behavioral Therapy
___Motivational Enhancement Therapy
___Multidimensional Family Therapy
___Combination of modalities/philosophies; please explain
14. What is your smoking policy? Is it different for staff (and adults, if applicable)?
15. What is your policy for substance use by clients in your program? How strictly is the policy enforced?
16. Do you have a waiting list to enter your program? If no, can clients access your program on demand?
17. How are adolescents typically referred to your program?
18. Can adolescents access services at the facility without parental consent?
19. Number of adolescent treatment slots__________________________________
20. What is the average occupancy rate? ________________________________
21. What is the average length of stay?_________________________________
22. What is the ratio of staff to patients? __________________________________
23. What is the rate per day/month? _________________________________
24. How do people typically pay for services?
What forms of payment are accepted: (check all that apply)
___Sliding Fee Scale
[toggle title=”Telephone Survey”] Adolescent Treatment Provider Telephone Survey
Thank you for taking the time to participate in this telephone interview. I am going to ask you a series of questions about your adolescent treatment program. If your program has more than one level of care, please answer the question for each level.
1. Prior to admission, what is the procedure to determine eligibility (e.g., screening)?
2. Do you conduct an assessment prior to enrolling adolescents in your treatment program? If no, if and when do you conduct an assessment?
3. What assessment tool(s) do you use (including in-house assessment tools)? Do you use the same tool(s) for everyone?
If assessment tool is not nationally recognized, ask the following:
What types of information does the assessment provide (medical issues,
psychiatric, substance use, readiness and motivation)? How is it scored?
4. Are families assessed? If so, what assessment tools are used to assess the family?
5. Are teenagers ever referred to other placements, or deemed inappropriate for treatment, based on the assessment? What percentage of patients you assess are admitted to the program?
6. Who conducts the assessment(s)? What is their training?
7. Are adolescents reassessed to monitor progress? If yes, what tool is used?
8. Do you create a treatment plan? If yes, who creates the plan? How is it structured? (If not mentioned in the answer, ask if, and how, the plan takes into consideration the intensity of the substance abuse, mental health disorders, and different ages or maturity levels)
9. During treatment, do you ever refer the adolescent to other services outside the program? If yes, what services? How often does this occur?
Comprehensive, Integrated Approach
10. Is the program connected to:
Does the program remain in contact with the client’s home school?
Juvenile justice system
In addition to referrals, does the program maintain contact with the juvenile justice system?
The patient’s community
If yes, how does the program connect to these entities?
11. What is your treatment protocol for clients with a co-occurring mental heath disorder?
12. Do you provide any educational services? If yes, what are they?
13. How is the client’s physical health, including sexual health, addressed?
14. Is substance abuse within the peer group addressed during treatment? If yes, how?
15. Do you involve the family in treatment? If no, why not? If yes:
How do you get the family involved?
What services do you provide (e.g. educational and/or therapy sessions)?
How long do these services last?
Are these services based on a specific modality? (MST, Family Based)
Is family involvement mandatory?
16. How do programs stay connected to families; is the telephone utilized?
17. How do you work with families that are substance abusing themselves, are uninterested in participating, or have any other dysfunction?
18. Does the treatment address different ages and/or maturity levels? If yes, how does it differ?
19. Is a specific text or curriculum used? If yes, which one?
20. Is the protocol focused on concrete, rather than abstract, thinking? If yes, provide a few examples.
21. Are experiential/hands-on activities utilized? If yes, please describe.
22. Are adolescents integrated with adult patients during the rehabilitative process? If yes, how?
Content Designed to Engage and Retain Young People
23. What kinds of activities, strategies, and tools are used to engage adolescents in participating in the therapeutic process?
24. Are motivational enhancement techniques utilized?
25. Are special efforts made to engage the family to keep the adolescent engaged?
26. How does the program establish a therapeutic alliance?
27. What is the level of education of staff?
28. What specific qualifications (training/education) do direct service staff possess in:
Mental health issues
29. What are the qualifications for clinical supervisors? How is supervision of direct service staff carried out?
30. Is there an on-going training program? If yes, what topics are covered? How often are trainings conducted? Who conducts the trainings?
31. Is there a trained family therapist on staff?
32. What is the ratio of staff to clients?
33. What is your continuing care plan?
What length of time does the plan cover?
Is relapse prevention/planning part of the plan? If yes, describe.
Does the plan include home counseling or home contact? If yes, how often?
34. What kind of linkages does your facility have with services in geographic areas outside of the program’s vicinity? Are they accessed as part of the continuing care plan?
35. Does the intensity of treatment match the intensity of continuing care? If yes, how?
36. Do you link adolescents to Twelve Step meetings as part of their continuing care?
37. Are regular check-ups conducted following discharge? If so, what is the time frame? How are the check-ups conducted?
38. Are adolescents linked with community services upon discharge? If yes, which services?
Gender and Cultural Competence
39. Are adolescent boys and girls offered the same treatment? If not, how is it different for each gender? How do male and female specific sessions differ?
40. Does the program offer services for gay and lesbian youth? Minority youth?
41. If the program is co-ed, are there safety measures in place to ensure boundaries between patients and staff?
42. How are children disciplined if rules are not followed at your facilities?
Who carries out this discipline?
What is your policy on the use of force?
These questions are only needed for boot camps and other behavioral modification or juvenile justice programs:
43. Has there ever been an instance where a child has been seriously injured or died as a result of activities at the facility? If yes, how did this happen?
44. Have there ever been any legal suits against the facility? If yes, please explain.
45. Are there evaluations or any other type of studies completed on your program?
What were the results of this evaluation?
Can I receive a copy of the study?
Was the evaluation conducted internally or externally?
46. What common questions about your program and/or treatment do you get from parents?
By Sandra A. Brown, Ph.D.
Professor of Psychology and Psychiatry
University of California, San Diego
The comorbidity of substance use disorders (SUD) and other mental health disorders is one of the most prevalent and important challenges facing professionals treating youth today (Kendall & Charkin, 1992). As awareness of these joint problems in youth has increased over the past two decades, so has research. In the 1980s, 24 empirical studies were published of adolescent substance abusers with comorbid psychopathology, whereas in the 1990s over 125 such studies were published (Abrantes & Brown, In Press).
Comorbidity refers to the co-occurrence of two or more disorders (Perin & Last, 1995), which can be present simultaneously or sequentially. The disorder occurring first (Schuckit, Irwin & Brown, 1990) or the disorder with the most dominant symptoms (Klerman, 1990) is referred to as the primary disorder. The order of symptoms and disorder onset has important clinical implications for understanding both the causal pathways to the difficulties these youth face (e.g., Mueser, Drake & Wallach, 1998) as well as the likely clinical course following treatment (Abrantes & Brown, In Press). SUDs and mental health disorders of youth may reflect common risk (e.g., genetic predisposition), or be precipitated or exacerbated by each other (e.g., substance induced mood disorder; conduct disorder provoked by substance use disorder). The prevalence of these etiological pathways varies across mental health disorders and specific drugs of addiction.
Across all service sectors (i.e., alcohol and drug; mental health; juvenile justice) SUD youth are most likely to present with disruptive disorders, mood disorders or anxiety disorders. In adolescent substance abuse treatment programs, approximately two-thirds of youth evidence DSM Axis I psychopathology in addition to their drug problem. According to a recent review of research in this area (Abrantes & Brown, In Press), 54-95% of youth in alcohol and drug treatment have conduct or oppositional defiant disorder. Mood disorders are evident in approximately half of these teens and 15-42% exhibit anxiety disorders (e.g., PTSD; social phobia). In juvenile justice settings conduct disorders are the most common comorbid disorder with SUDs, whereas in inpatient mental health settings depressive disorders are as prevalent as disruptive disorders.
Assessment of mental health disorders among youth in treatment for substance abuse varies remarkably. Mental health disorders are often screened for by using paper and pencil measures completed by the adolescent (e.g., Personal Experiences Screening Questionnaire (PESQ)) or parent (e.g., Child Behavior Checklist (CBCL)). Formal diagnoses require the use of well-standardized interview instruments such as the Diagnostic Interview Schedule for Children (DISC), Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS), or Composite International Diagnostic Interview (CIDI), and should include age of onset. Accurate assessments require information from the adolescent and corroborative information (e.g., parent). Urinalyses are critical in disintegrating mental health diagnoses as youth may have used substances of which they are not aware and which cause specific mental health symptoms (e.g., hallucinations) or exacerbate symptoms (e.g., depression) to a severity normally meriting a psychiatric diagnosis.
Recent studies of SUD youth indicate poorer outcomes for those with comorbid mental health disorders. In particular, disruptive disorders, anxiety disorders and severity of psychiatric symptoms have been associated with higher relapse rates and greater severity of post treatment drug involvement (Brown, 1999). It is unclear whether more adverse outcomes for this population are a reflection of poorer retention or compliance with treatment, more limited personal resources (e.g., coping skills; social supports), greater environmental risks (e.g., stressors), poorer client-treatment match, or some combination thereof. Although intervention research on SUD adolescents with comorbid mental health problems has not progressed as far as such research with adults, integrated treatment of the co-occurring problems appears critical (Dembo, 1996). For example, integrated interventions with youth with comorbid conduct disorder and SUDs have been shown to increase engagement and retention in treatment (Henngellar, Rodick, Borduin, Hanson, Watson & Urey, 1996), which has been identified as a critical aspect to treatment success (Hser, Grella, Hubbard, Hsieh, Fletcher, Brown, B.S., & Anglin, 2001). Similarly, integrated interventions involving family members facilitate engagement as well as retention of such youth (e.g., Liddle & Dakof, 1995), producing improved outcomes. At present, the efficacies of specific forms of intervention have not been well explicated for SUD youth with comorbid disorders; however, joint treatment of the SUD and psychiatric disorder appears advisable.
Comorbidity: Key Issues/Questions
1. Are mental health disorders routinely assessed?
2. Are standardized instruments used to make the diagnosis?
3. Is withdrawal taken into account before the mental health disorder diagnosis is made?
4. What are the training requirements of staff who make the diagnoses of mental health disorders?
5. Is corroborative information (e.g., parent interview; urinalysis) used to rule in or rule out a disorder which may be substance induced?
6. How are mental health disorders considered in the treatment plan?
7. Are staff trained to treat common mental health disorders in this setting?
8. Is treatment for mental health disorders conducted simultaneously or sequentially with treatment for substance use disorders?
9. Are mental health disorders reevaluated after periods of sustained abstinence?
10. Are psychiatrists and psychologists available for formal assessments, integrated treatment planning and interventions?
11. Are special efforts made to engage and retain youth with comorbid mental health and SUDs?
12. Are aggressive aftercare procedures in place to retain youths with comorbidity?
Abrantes, A.M., & Brown, S.A. (In Press). “Psychiatric comorbidity among substance abusing adolescents: Assessment issues in clinical research.” Clinical Psychology Review.
Brown, S.A. (1999). “Treatment of adolescent alcohol problems: Research review and appraisal.”NIAAA Extramural Scientific Advisory Board: Treatment. Chapter 14, pp. 1-26. Bethesda, MD.
Dembo, R. (1996). “Problems among youths entering the juvenile justice system, their service needs and innovative approaches to address them.” Substance Use & Misuse. Marcel Dekker Inc: US, 1996 Jan. 31 (1): pp. 81-94.
Henggeler, S.W., Rodick, J.D., Borduin, C.M., Hanson, C.L., Watson, S.M., & Urey, J.R. (1996). “Multisystemic treatment of juvenile offenders: Effects on adolescent behavior and family interactions.” Developmental Psychology, 22, 132-141.
Hser, Y.I., Grella, C.E., Hubbard, R.L., Hsieh, S.C., Fletcher, B.W., Brown, B.S., & Anglin, M.D. (2001). “An evolution of drug treatments for adolescents in 4 US cities.” Archives of General Psychiatry, 58, 689-695.
Liddle, H.A., & Dakof, G.A. (1995). “Family-based treatment for adolescent drug use: State of the science. In E.R.D.” Czechowicz (Ed.), Adolescent drug abuse: Clinical assessment and therapeutic interventions (Vol. NIH Publications No. 95-3908). Rockville, MD: National Institute on Drug Abuse.
Kendall, P.C., & Clarkin, J.F. (1992). “Introduction to Special Section: Comorbidity and treatment implications.” Journal of Affective Disorder, 8, 153,157.
Klerman, G.L., (1990). “Approaches to phenomena of comorbidity.” In J.D. Maser & C.R. Cloninger (Eds.), Comorbidity of mood and anxiety disorders (pp. 13-37). Washington, DC: American Psychiatric Press.
Meuser, K.T., Drake, R.E., & Wallach, M.A. (1998). “Dual diagnosis: A review of etiological theories.”Addictive Behaviors, 23 (6), 717-734.
Perrin, S., & Last, C.G. (1995). “Dealing with comorbidity.” In A.R. Eisen, C.A. Kearney, & C. Schaffer (Eds.), Clinical handbook of anxiety disorders in children and adolescent (pp. 412-435). Northvale, NJ: Jason Aronson, Inc.
Schuckit, M.A., Irwin, M., & Brown, S.A. (1990). “The history of anxiety symptoms among 171 primary alcoholics.” Journal of Studies on Alcohol, 51, (1), 34-41.
[toggle title=”Sources for Treating Teens”]
Complete List of Sources
U.S. Department of Health and Human Services
Center for Mental Health Services. Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. Annual Report to Congress. 1998.
Center for Substance Abuse Treatment. Adolescents and Young Adults in the National Treatment Improvement Evaluation Study. 1999.
–. National Estimates of Expenditures for Substance Abuse Treatment, 1997. 2001.
–. Screening and Assessing Adolescents for Substance Use Disorders. Treatment Improvement Protocol (TIP) #31, 1999.
–. Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Disease. Treatment Improvement Protocol (TIP) #11, 1995.
–. Strategies for Integrating Substance Abuse Treatment in the Juvenile Justice System: A Practice Guide. 1999.
–. “Substance abuse treatment and the state Children’s Health Insurance Program (CHIP)” TIE Communique, Special Issue, Fall 1999.
–. Treatment of Adolescents with Substance Abuse Disorders. Treatment Improvement Protocol (TIP) #32, 1999.
National Institute on Alcohol Abuse and Alcoholism. “Treatment of adolescent alcohol problems: Research review and appraisal.” NIAAA Extramural Scientific Advisory Board: Treatment. 1999.
National Institute on Drug Abuse. Adolescent Drug Abuse: Assessment and Treatment. 1994.
–. Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions. 1995.
–. Current Issues and Future Needs in the Assessment of Adolescent Drug Abuse. 1995.
–. Financing of Drug Treatment Service: Literature Review. 1997.
–. Monitoring the Future: National Survey Results on Drug Use, 1975-2001: Volume I, Secondary School Students. 2002.
–. Psychotherapy and Counseling in the Treatment of Drug Abuse. 1990.
–. Therapeutic Community: Advances in Research and Application. 1994.
–. Treatment Services for Adolescent Substance Abusers. 1985.
Substance Abuse and Mental Health Services Administration. Empowering Families: ADAMHA Monograph from the First National Conference on the Treatment of Adolescent Drug, Alcohol, and Mental Health Problems. 1992.
–. Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings. 2002.
–. Substance Abuse Treatment in Adult and Juvenile Correctional Facilities: Findings from the Uniform Facilities Data Set 1997 Survey of Correctional Facilities. 2000.
National Institutes of Health. “Access to substance abuse treatment for Medicaid clients improves with Oregon Model for financing treatment under managed care.” NIH Press Release, October 2000.
U.S. Department of Justice
National Institute of Justice. 1999 Annual Report on Drug Use Among Adult and Juvenile Arrestees. 2000.
–. Breaking the Juvenile Drug-Crime Cycle: A Guide for Practitioners and Policymakers. 2001.
Office of Juvenile Justice and Delinquency Prevention. Drug Offense Cases in Juvenile Courts, 1989-1998. OJJDP Fact Sheet #36, 2001.
–. Juvenile Offenders and Victims: 1999 National Report. 1999.
G.A. Aarons et al. “Prevalence of adolescent substance use disorders across five sectors of care.”Journal of the American Academy of Child Adolescent Psychiatry, 40(4):419-426, 2001.
A.M. Abrantes & S.A. Brown. “Psychiatric comorbidity among substance abusing adolescents: Assessment issues in clinical research.” Clinical Psychology Review (in press).
G.S. Alford et al. “Alcoholics Anonymous-Narcotics Anonymous model inpatient treatment of chemically dependent adolescents: A 2-year outcome study.” Journal of Studies on Alcohol, 52:118-126, 1991.
American Academy of Child and Adolescent Psychiatry. “Advocating for your child.” Facts for Families #74. Washington, DC: AACAP, 2000.
–. “Being prepared: Know when to seek help for your child.” Facts for Families #24. Washington, DC: AACAP, 1999.
–. “Substance abuse treatment for children and adolescents: Questions to ask.” Facts for Families # 41. Washington, DC: AACAP, 2000.
_. “Understanding your mental health insurance.” Facts for Families #26. Washington, DC: AACAP, 1999.
American Academy of Pediatrics. “Financing of substance abuse treatment for children and adolescents.” Pediatrics, 95(2):308-310, 1995.
–. “Insurance coverage of mental health and substance abuse services for children and adolescents: A consensus statement.” Pediatrics, 6(4):860-862, 2000.
American Psychological Association. Family Psychology: Science-Based Interventions. 2001.
American Society of Addiction Medicine. ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, 2nd Edition, Revised. Chevy Chase, MD: ASAM, 2001.
–. The Impact of Managed Care on Substance Abuse Treatment. Chevy Chase, MD: ASAM, 1999.
N.H. Azrin et al. “A controlled evaluation, and description, of individual-cognitive problem solving and family-behavior therapies in dually-diagnosed conduct-disordered and substance-dependent youth.”Journal of Child & Adolescent Substance Abuse (in press).
N.H. Azrin et al. “Youth drug abuse treatment: A controlled outcome study.” Journal of Child & Adolescent Substance Abuse, 3:1-16, 1994.
N. Babbit. Adolescent Drug and Alcohol Abuse: How to Spot It, Stop It, and Get Help For Your Family. Sebastopol, CA: O’Reilly & Associates, Inc., 2000.
G. Bazemore & L. Nissen. “Mobilizing social support and building relationships: Broadening correctional and rehabilitative agendas.” Corrections Management Quarterly, 4(4):12-21, 2000.
G. M. Beschner & A.S. Friedman (eds). Youth Drug Abuse: Problems, Issues, and Treatment. Lexington, MA: DC Health, 1979.
S.M. Blake et al. “Recency of immigration, substance use, and sexual behavior among Massachusetts adolescents.” American Journal of Public Health, 91(5):794-800, 2001.
J.S. Brook et al. “Adolescent illegal drug use: The impact of personality, family, and environmental factors.” Journal of Behavioral Medicine, 24(2):183-199, 2001.
R.K. Brooner et al. “Psychiatric and substance use comorbidity among treatment-seeking opioid abusers.” Archives of General Psychiatry, 54:71-80, 1997.
S.A. Brown et al. “Correlates of success following treatment for adolescent substance use.” Applied & Preventive Psychology, 3:61-73, 1994.
S.A. Brown et al. “Four-year outcomes from adolescent alcohol and drug treatment.” Journal of Studies on Alcohol, 62:381-388, 2001.
O.G. Bukstein & R.E. Tarter. “Substance use disorders,” in C.E. Coffey & R.A. Brumback (eds),Textbook of Pediatric Neuropsychiatry. Washington, DC: American Psychiatric Press, 1998.
R.F. Catalano et al. “An experimental intervention with families of substance abusers: One-year follow-up of the Focus on Families Project.” Addiction, 94(2):241-254, 1999.
R.F. Catalano et al. “Evaluation of the effectiveness of adolescent drug abuse treatment, assessment of risks for relapse, and promising approaches for relapse prevention.” International Journal of Addictions, 25(9A & 10A):1085-1140, 1991.
Center for Adolescent Health & the Law. Adolescents in Public Health Insurance Programs: Medicaid and SCHIP. Chapel Hill, NC: Center for Adolescent Health & the Law, 1999.
J.J. Cocozza & K. Skowyra. “Youth with mental health disorders: Issues and emerging responses.”Juvenile Justice, 7(1), April 2000.
S.M. Colby et al. “Brief motivational interviewing in a hospital setting for adolescent smoking: A preliminary study.” Journal of Consulting & Clinical Psychology, 66(3):574-578, 1998.
R.F. Coombs. Cool Parents, Drug Free Kids: A Family Survival Guide. Boston, MA: Allyn & Bacon, 2002.
J. R. Cornelius et al. “Fluoxetine in adolescents with major depression and an alcohol use disorder: An open-label trial.” Addictive Behaviors, 26:735-739, 2001.
S.S. Covington. “Creating gender-specific treatment for substance-abusing women and girls in community correctional settings.” Paper prepared for the 6th Annual Research Conference of the International Community Corrections Association. Arlington, VA: 1998.
G.A. Dakof et al. “Predictors of engagement in adolescent drug abuse treatment.” Journal of the American Academy of Child & Adolescent Psychiatry, 40:274-281, 2001.
D. Deas & S.E. Thomas. “An overview of controlled studies of adolescent substance abuse treatment.” American Journal on Addictions, 10:178-189, 2001.
G. DeLeon (ed). Community as Method: Therapeutic Communities for Special Populations and Special Settings. Westport, CT: Praeger Publishers/Greenwood Publishing Group, 1997.
G. DeLeon. “The therapeutic community: Status and evolution.” International Journal of the Addictions, 20(6-7):823-844, 1985.
R. Dembo. “Problems among youths entering the juvenile justice system, their service needs and innovative approaches to address them.” Substance Use & Misuse, 31(1):81-94, 1996.
R. Dembo et al. “Juvenile crime and drug abuse: A prospective study of high risk youth.” Journal of Addictive Diseases, 11:5-31, 1991.
M.L. Dennis et al. “Main findings of the Cannabis Youth Treatment (CYT) randomized field experiment.” Archives of General Psychiatry (under review).
M.L. Dennis et al. “The Cannabis Youth Treatment (CYT) experiment: Rationale, study design and analysis plans.” Addiction, 97(s1):16-34, 2002.
M.L. Dennis et al. “The need for developing adolescent treatment models,” in S.J. Stevens & A.R. Morral (eds), Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study. Birmingham, NY: Hawthorn Press (in press).
J.J. DiIulio & J.B. Grossman. Youth Crime and Substance Abuse: Act-Now Strategies for Saving At-Risk Children. Philadelphia, PA: Public/Private Ventures, 1997.
T.J. Dishion et al. “When interventions harm: Peer groups and problem behavior.” American Psychologist, 54:755-764, 1999.
B. Donohue et al. “Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.” Journal of Child & Adolescent Substance Abuse, 8:1-13, 1998.
J.A. Farrow et al. Adolescent Drug and Alcohol Assessment Instruments in Current Use: A Critical Comparison. Olympia, WA: Washington State, Division of Alcohol and Substance Abuse, 1993.
Federation of Families for Children’s Mental Health & Keys for Networking, Inc. Blamed and Ashamed: The Treatment Experiences of Youth with Co-occurring Substance Abuse and Mental Health Disorders and their Families. Alexandria, VA: FFCMH, 2000.
K. Foxhall. “Adolescents aren’t getting the help they need.” Monitor on Psychology, 32(5):56-58, 2001.
A.S. Friedman. “Family therapy vs. parent groups: Effects on adolescent drug abusers.” American Journal of Family Therapy, 17:335-347, 1989.
B. Geller et al. “Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency.” Journal of the American Academy of Child & Adolescent Psychiatry, 37:171-178, 1998.
M.D. Godley et al. “A randomized field trial of an assertive continuing care protocol for adolescents discharged from residential treatment: Preliminary outcomes.” Journal of Substance Abuse Treatment (in press).
M.D. Godley et al. “Discharge status as a performance indicator: Can it predict adolescent substance abuse treatment outcome?” Journal of Child & Adolescent Substance Abuse (in press).
J. Greene. “Testing your teen for drugs.” On Health, September 24, 1999.
C. Grella et al. “Comorbidity among adolescents in drug treatment: Treatment processes and outcomes from the Drug Abuse Treatment Outcome Studies.” Paper presented at the College on Problems of Drug Dependence Conference in Acapulco, Mexico, June 1999.
C. Grella et al. “Drug treatment outcomes for adolescents with comorbid mental and substance use disorders.” Journal of Nervous & Mental Disease, 189(6):384-392, 2001.
R. Hamid et al. “Agreement between urinalysis and self-reported drug use.” Substance Use & Misuse, 34(11):1585-1592, 1999.
P.A. Harrison et al. Adolescent Treatment Completers One Year Later. St. Paul, MN: CATOR, 1989.
S.W. Henggeler. “The development of effective drug abuse services for youth.” In J.A. Egerston et al. (eds), Treating Drug Abusers Effectively. New York, NY: Blackwell Publishers, 1997.
S.W. Henggeler et al. “Effects of multisystemic therapy on drug use and abuse in serious juvenile offenders: A progress report from two outcome studies.” Family Dynamics of Addiction Quarterly, 1:40-51, 1991.
S.W. Henggeler et al. “Eliminating (almost) treatment dropout of substance abusing or dependent delinquents through home-based multisystemic therapy.” American Journal of Psychiatry, 153(3):427-428, 1996.
S.W. Henggeler et al. “Multisystemic treatment of juvenile offenders: Effects on adolescent behavior and family interactions.” Developmental Psychology, 22:132-141, 1996.
S.W. Henggeler et al. “Multisystemic treatment of substance abusing and dependent delinquents: Outcomes, treatment fidelity, and transportability.” Mental Health Services Research, 1:171-184, 1999.
S.W. Henggeler & S.K. Schoenwald. “The role of quality assurance in achieving outcomes in MST programs.” Journal of Juvenile Justice & Detention Services, 14(2):1-17, 1999.
Y. Hser et al. “An evaluation of drug treatments for adolescents in 4 U.S. cities.” Archives of General Psychiatry, 58(7):689-695, 2001.
Y. Hser et al. “National evaluation of drug treatment for adolescents.” Paper presented at the College on Problems of Drug Dependence Conference in Acapulco, Mexico, June 1999.
N. Jainchill. “Adolescent admission to residential drug treatment: HIV risk behaviors pre- and post-treatment.” Psychology of Addictive Behaviors, 13(3):163-173, 1999.
N. Jainchill et al. “Adolescents in therapeutic communities: One-year post-treatment outcomes.”Journal of Psychoactive Drugs, 32(1):81-94, 2000.
R. Jessor. “Risk behavior in adolescence: A psychosocial framework for understanding and action.”Journal of Adolescent Health, 12:597-605, 1991.
H. Joanning et al. “Treating adolescent drug abuse: A comparison of family systems therapy, group therapy, and family drug education.” Journal of Marital & Family Therapy, 18:345-356, 1992.
Y. Kaminer. “Adolescent substance abuse treatment: Where do we go from here?” Psychiatric Services, 52(2):147-149, 2001.
Y. Kaminer. “Contingency Management (CM) reinforcement procedures for adolescent substance abuse.” Journal of American Academy of Child Adolescent Psychiatry, 39:1324-1326, 2000.
Y. Kaminer & J.A. Burleson. “Adolescent substance abuse treatment: Cognitive behavioral therapy update.” Paper presented at Treating Adolescent Substance Abuse: State of the Science Conference in Coral Gables, FL, October 2001.
Y. Kaminer & J.A. Burleson. “Psychotherapies for adolescent substance abusers: 15-month follow-up of a pilot study.” American Journal on Addictions, 8:114-119, 1999.
Y. Kaminer et al. “Measuring treatment process in cognitive-behavioral and interactional group therapies for adolescent substance abusers.” The Journal of Nervous & Mental Disease, 186(7):407- 413, 1998.
Y. Kaminer et al. “Psychotherapies for adolescent substance abusers: A pilot study.” Journal of Nervous & Mental Disorders, 186:684-690, 1998.
E. Kaufman & P. Kaufmann (eds). Family Therapy of Drug and Alcohol Abuse. Boston, MA: Allyn & Bacon, 1992.
S.H. Kelder et al. “Depression and substance use in minority middle-school students.” American Journal of Public Health, 91(5):761-766, 2001.
P. Keller (ed). Innovations in Clinical Practice: A Source Book. Sarasota, FL: Professional Resource Exchange, 1989.
P.C. Kendall & J.F. Clarkin. “Introduction to special section: Comorbidity and treatment implications.”Journal of Affective Disorder, 8:153-157, 1992.
G.L. Klerman. “Approaches to phenomena of comorbidity,” in J.D. Maser & C.R. Cloninger (eds),Comorbidity of Mood and Anxiety Disorders. Washington, DC: American Psychiatric Press, 1990.
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H.A. Liddle. “Adolescent substance abuse derails development.” American Association for Marriage and Family Therapy: Clinical Update, 3(3), April 2001.
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C.S. Martin & K.C. Winters. “Diagnosis and assessment of alcohol use disorders among adolescents.” Alcohol Health & Research World, 22(2):95-105, 1998.
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K.R. Merikangas. “Implications of genetic epidemiology for the prevention of substance use disorders.” Addictive Behaviors, 25(6):807-820, 2000.
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P.M. Monti et al. “Brief intervention for harm reduction with alcohol positive older adolescents in a hospital emergency department.” Journal of Consulting & Clinical Psychology, 67:989-994, 1999.
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R. Muck et al. “An overview of the effectiveness of adolescent substance abuse treatment models.”Youth & Society, 33(2):143-168, 2001.
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T.J. Ozechowski & H.A. Liddle. “Family-based therapy for adolescent drug abuse: Knowns and unknowns.” Clinical Child & Family Psychology Review, 3(4):269-298, 2000.
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[/toggle][toggle title=”Denver JJI Treatment Network”]
Center for Network Development: Denver Juvenile Justice Integrated Treatment Network
2525 16th Street, Suite 100
Denver, CO 80211
The Denver Juvenile Justice Integrated Treatment Network (DJJITN) is an integrated treatment network for substance-abusing juvenile offenders in Denver. Created in 1995 by the Denver Juvenile Court and the Colorado Alcohol and Drug Abuse Division with funding support from CSAT, the goal of the Network is to expand conventional substance abuse treatment to include a more comprehensive array of services, including mental health, education, employment/ vocational, and physical health. Each year, the Network provides customized treatment for over 500 juvenile offenders, ages 10-21, through access to all of the necessary services on an on-going basis.
Over 40 government and community agencies are involved in the Network, which helps to coordinate agency services and develop common policies. The Network also trains participating agencies in best practices and promotes implementation of those practices. In conjunction with the Metropolitan State College, the network created a Center for High Risk Youth Studies that offers both baccalaureate and certificate programs. A Management Information System (MIS) was developed to allow multiple service providers and agencies to access information from each other’s systems, subject to limits due to confidentiality issues.
Each point of entry in the juvenile justice system (Probation, District Attorney’s Office, city diversion programs, Division of Youth Corrections detention and pre-trial detention diversion) performs a preliminary substance abuse screen (Substance Use Survey-1A) as part of their intake process. If the adolescent scores in the 50th percentile or higher, or if there is a clinical override, the youth is referred to one central point: the Denver Juvenile Justice Integrated Treatment Accountability for Safer Communities (TASC) program. Case managers, who are certified alcohol and other drug abuse counselors, and staff from some participating agencies conduct assessments, develop treatment plans, link juveniles with Network services, and conduct ongoing monitoring and follow-up. Core Network principles are that services are delivered based on needs and strengths identified through a comprehensive differential assessment process, and that service funds follow the presenting needs and strengths.
TASC requires participation of the family in the assessment, case management, and the treatment process, but a formal family assessment is not conducted. Families can be referred for a family strengths-based assessment through the Network’s Denver Juvenile Community Assessment Center. The Assessment Center provides assessment, service coordination, family advocacy, and brokerage services to families of at-risk youth as well as juvenile offenders. A range of community providers are prepared to provide a wide array of services coordinated through overarching case management and service coordination by Juvenile TASC and the Assessment Center.
The Network’s Family Task Force educates families about the juvenile justice system and its related services. Two Task Force publications, Family Guide to the Juvenile Justice System and Family Guide to Denver Public Schools have been used to train agency personnel and to teach families how their involvement at key points can help their children. The Task Force also provides a venue for families to educate Network members about what services they feel are needed and how to better involve families in the treatment system.
In 1999 the Network contracted with the Human Resources Consortium, a private consulting firm, to evaluate the effectiveness of the program by measuring juvenile offenders’ progress between intake and discharge. Outcome data indicate that among juveniles that received Network services:
• Abstinence increased from 20 percent to 52 percent;
• Ability to remain alcohol-and drug-free went from 19 percent to 49 percent;
• Positive family relationships improved from 24 percent to 40 percent; and
• Ability to respect and follow the law grew from 20 percent to 47 percent.
A 1998 survey of key decision makers in participating member agencies involved in the Network found an overwhelming majority surveyed (95 percent) reported the Network had a positive impact on information sharing; 84 percent reported the Network improved services to juveniles.
The Denver Juvenile Justice Integrated Treatment Network has been recognized by Harvard’s John F. Kennedy School of Government as “an outstanding innovation in government.” The Robert Wood Johnson Foundation is funding replication projects based on the Denver model in communities nationwide.
[/toggle][toggle title=”Interpreting Key Elements”]
Interpreting the Key Elements Within a Juvenile Justice Setting
By Laura Nissen, Ph.D., M.S.W.
Director, Reclaiming Futures
A National Program of The Robert Wood Johnson Foundation
National Program Office at Portland State University
Regional Research Institute for Human Services
Graduate School of Social Work
Introduction and Overview
An untold story of drug and alcohol abuse among the nation’s adolescents is the degree to which the juvenile justice system has become the de facto substance abuse treatment provider for young people in trouble with the law. As such, it struggles to reinvent itself to meet a rapidly growing demand for services that effectively help youths to change their lives.
Despite our best efforts to get substance abuse treatment to the youths who need it, the gap remains high between the haves and the have-nots. Estimates suggest that fewer than 10% of youth who appear to need treatment ever get it (Dennis, Dawud-Noursi, Muck and McDermitt, 2001). Our communities pay for this shortage of services in many ways. Compared to their non-drug using peers, those who abuse substances are 3 to 47 times more likely to end up in emergency rooms, do poorly in school, engage in disruptive behavior, find themselves in trouble with the law or be arrested (Dennis & McGeary, 1999). Many of these youths have co-occurring mental health problems, presenting even more challenges (Cocozza and Swowyra, 2000).
Contributing to the troubling equation at the local level are: a high availability of drugs and alcohol, an increasing number of adolescents with little to do, schools and community youth programs facing cutbacks, economic turmoil among families with few resources, and increasingly punitive attitudes towards juveniles. At the national level, the problems of delinquency and substance abuse cost millions of dollars, threaten public safety and disrupt other efforts to build strong communities.
Without intervention and application of an emerging base of evidence-based models, many of these youths will progress towards a more complex and entrenched association with delinquency, later addiction, crime and prison-making our failure to intervene even more costly. Providing substance abuse and related comprehensive services for juvenile offenders is a bargain compared to the long-term costs of the alternative. The lack of appropriate, accessible and effective substance abuse and related integrated services for youths before as well as within a juvenile justice setting should be viewed as one of the most important public health crisis in America.
It has been well established that the substance abuse patterns of youths in the juvenile justice system are dramatically higher than that of the general youth population, and that this relationship is a key precursor to a delinquent career (DiIulio and Baldwin Grossman, 1997). As their substance abuse problems go untreated, increasing numbers of these youths are likely to find themselves in trouble with the law.
In fact, although juvenile delinquency has decreased during recent years, there has been a dramatic increase in the numbers of offender youths entering the juvenile justice system on drug-related charges (U.S. Department of Justice, 1999). Specifically, there has been a 144% increase in juvenile drug abuse violations and a 183% increase in juvenile drug abuse cases that were formally processed among juvenile offenders in the last few years (U.S. Department. of Justice, 1999). One study showed that during the last 10 years there was a 291% increase in the rate at which young people were incarcerated because of drug involvement in general, and the increase in drug-related incarcerations for young black men during that same period was 539% (Schiraldi, Holman & Beatty, 2000). One result of these dramatic increases in justice’s focus towards youth and drugs is that the juvenile justice system has found itself as the largest single referral source for youths in publicly funded substance abuse treatment (Dennis & McGeary, 1999). Availability of consistent screening, assessment, and substance abuse treatment (or other services related to the frequent phenomenon of co-occurring disorders) is uneven nationally, further exacerbating a crisis in the capacity to address the problem. Only 36% of juvenile corrections facilities offer any type of substance abuse treatment (SAMHSA, 1997) and juvenile probation departments cite substance abuse treatment as one of their top four program expansion needs (Torbett, 1999).
During the last 15 years, the juvenile justice system has devised a variety of approaches to effectively intervene in this nexus of opportunity between the juvenile justice and public health/substance abuse treatment systems. One result is that an exciting basis of best practices is beginning to emerge to guide the way for future reform-though their adoption has been slow across the U.S. (Nissen, Vanderburg, Embree-Bever & Mankey, 1999; VanderWaal, McBride, Terry-McElrath, VanBuren, 2001). These approaches include such innovations as community assessment centers, juvenile drug courts, and integrated treatment networks, as well as the inclusion of juvenile justice-specific innovation strategies such as balanced and restorative justice, graduated sanctions, systems collaboration, integrated case management, strength-based approaches, and efforts to reduce the disproportionate confinement of youths of color. How can juvenile justice systems best utilize the nine key elements to begin to build a strong response to these trends and seek to build innovative and evidence-based solutions to substance abuse among their young offender populations? The following represents a beginning interpretation of the elements for use in the juvenile justice setting.
Focusing the Nine Key Elements in Juvenile Justice Settings
Assessment and Treatment Matching
In juvenile justice settings, youths enter from a variety of different sources. Juvenile justice professionals need to establish a youth intake process (whether in detention or in other contexts) that screens and assesses for the presence of substance abuse and related problems, no matter how and why they enter the system.
Further, in order to make a good referral “match” to treatment, a continuum of available treatment slots must be developed to meet the unique needs of youth offenders and their families. Some of the services must be available in detention and other locked settings, as well as among community providers who are specially knowledgeable about the drugs/delinquency cycle.
Comprehensive, Integrated Treatment Approach
In short, the needs of these youths are complex and defy a solution by any one agency or professional-no matter how capable. Community services tend to occur within what have become known most commonly as funding and professional “silos.” In order to meet the needs of youths and their families, the state-of-the art in treatment approaches in any youth-service endeavor generally involves learning to work across and between these systems, as well as within them. A comprehensive and integrated approach minimizes artificial barriers between systems and services, and provides services that will meet the needs of the people, not the systems involved. It also requires that dynamic case management will most likely be needed to support youths and their families through the particular legal complexities of juvenile justice, substance abuse treatment and other services.
Family Involvement in Treatment
Successful engagement of the family is often the key to the long-term success of youths in any type of formal service system. A juvenile justice contact represents a crisis for most families in which they are often simultaneously frustrated, bewildered at the complexity of the system, and anxious regarding the fate of their child. It can be even more complex and challenging if substance abuse is part of their youth’s and/or their family’s situation. The stigma associated with the combination of issues can be even more burdensome. Families served in the juvenile justice system may be financially challenged and may have limited linguistic and/or geographic access to people making decisions regarding their child’s case. They may have substance abuse and/or other health problems themselves. Likely they have other children, jobs, or situations that require their attention and may not be able to focus on dealing with multiple systems. Great care, planning and attention should be paid to providing adequate outreach, support, education, information and hope to families in this situation. They should be given the opportunity to be involved in their child’s case, as well as treatment, as full partners, and consistently given the message that although they are facing challenges-they can rise to the occasion and build a new start as a family together.
Developmentally Appropriate Program
Every service offered to youths in the juvenile justice system should reflect their unique strengths, orientations, and perspectives. They have a developmental need to be involved as partners in their treatment planning – and often provide powerful insights into their situation that professionals might miss. Because a youth has made some bad decisions- it doesn’t mean that he or she is incapable of learning and modeling better community norms given an inviting opportunity. Youths not only need developmentally appropriate treatment services, but a wide range of opportunities to extend beyond the traditional rehabilitative menu; these might include such things as civic engagement, youth leadership and service learning (Bazemore & Nissen, 2000). The ability of youths to learn, grow and experiment is their most important developmental strength-even in the juvenile justice setting. Be especially wary of treatment/intervention models that have only been used with adults. Until adapted for youth specifically, they can be of little value and even create additional problems.
Engage and Retain Teens in Treatment
A judge ordering treatment does not guarantee that a youth will become engaged and complete the treatment process. Especially if a youth has had multiple previous contacts with the system, special efforts must be made to overcome cynicism and skepticism about the potential of any professional helper to tell him/her anything he or she hasn’t heard before. Though it may seem obvious, it is important to approach system-experienced youth with a healthy respect. Their experiences of disappointment, ineffective or self-perceived injurious encounters with the juvenile justice system should be acknowledged rather than minimized. The most innovative programs serving youthful offenders get clients involved in dramatic ways, encourage leadership and ownership of the process, build on their strengths, challenge their behavior patterns that have proven ineffective to long-term success, and invite their ideas about how to improve their own lives and the lives of their families and community members.
Many staff enter the profession without adequate knowledge of current best practices, so staff training must reflect the rapidly emerging knowledge base across the various domains described. Without quality and regular infusions of training on new approaches, administrators and staff will likely devolve into use of outdated models that attempt to “scare” youth “straight,” push them to adopt a disease model that doesn’t reflect their unique perspectives, or inadequately addresses their needs for prosocial skill building and substance-free identity development. Structuring ways to become regular consumers of the research in both substance abuse treatment and juvenile justice innovations is critical to staying effective.
Gender and Cultural Competence
The data are staggering when noting the increase of youth of color involved in juvenile justice systems due to an alcohol/drug-related charge. Failing to acknowledge the unique challenges and opportunities to building more culturally responsive service options and capacities is essential to helping such youth get out of the system for good. To do this, not only should the best training and infusion of culturally-relevant best practices be adopted in substance abuse programs serving youth of color and their families, but communities of color should invited to dialogue about ways to combat the current trends and participate in efforts to decrease/eliminate disproportionate representation of youth of color in the juvenile justice system.
Additionally, girls represent the fastest growing sub-population of youth in the juvenile justice system today. Many of these clients have serious substance abuse problems for which extremely limited substance abuse and related treatment services exist. Building options for girls that are anchored in the special strengths and perspectives of this group must be an area of focus.
Substance abuse treatment works best when it extends beyond a brief active intervention phase and continues to support a youth once he/she begins to put new alcohol and drug-free identity building skills to work following the treatment process. This can be challenging once a youth leaves a locked setting or the periodic monitoring of a probation officer. Careful attention should be paid to helping such a youth find adequate and effective supports that assist his/her newly-forming delinquency and drug-free identity.
What does it mean to successfully address substance abuse and delinquency- A first challenge is to reframe the question. Advocates need to help communities understand that punishment alone is not a solution to a public health need. Successful outcomes must be expanded and couched in youth who are redirected, rehabilitated and reclaimed – not merely sanctioned. Programs need to listen to the public safety concerns of the communities in which they live-and rise to the occasion to demonstrate how investments in treatment add a measurable value in terms of more effective services and increases in public safety. Now more than ever, the emphasis on evidence-based practice should be clear and substantial. Youth and family successes should be illuminated based on use of state-of-the-art approaches. Mechanisms for tracking financial and public safety incentives should be encouraged.
To accomplish what is outlined above, most juvenile justice settings will need to push for changes systemically both within their own organizational boundaries as well as across the rest of the youth services (education, mental health, substance abuse treatment, child welfare, etc.) continuum. They will need to address such barriers as scarcity of resources for needed services and service development, “turf battles,” confidentiality issues, lack of linkages and coordination between agencies, slow infusion of best practices and youth/family centered approaches. They will need to involve the community differently to reflect the needs of these youths as a community challenge – not merely a justice problem.
Strategic and Shared Leadership
To change systems, leaders must mobilize. Since the challenge is greater than any one system’s ability to correct the problems singlehandedly, strategic and shared leadership must address the gaps and barriers on a community-wide basis, and find the community assets that provide the necessary change. This type of leadership includes developing a community-wide vision of success for youths and their families with dual challenges of substance abuse and delinquency, and attainable action steps to change systems to support and encourage this success. Identified leadership alliances should include not only the most obvious-such as juvenile court judges and treatment providers-but should extend to all relevant stakeholder groups representing both formal and informal stakeholders in a community. A well-developed leadership team stands ready to identify, advocate and move community energy and attention to investment in redemptive policies and approaches rather than punitive.
In March of 2002, The Robert Wood Johnson Foundation officially funded 11 communities nationally to begin a new generation of community demonstration projects addressing the need to build community solutions to substance abuse and delinquency. Putting the above described principles to work across a variety of communities in the U.S., this five-year demonstration initiative offers an important opportunity for systems to reinvent their approaches, contribute to the development of best practices for the youth in the juvenile justice system and build sustainable systems changes and community leadership for long-term success. To learn more about these approaches, the communities, and other resources, please visit the Reclaiming Futures website at www.reclaimingfutures.org
Bazemore, G. & L. Nissen (2000). “Mobilizing social support and building relationships: Broadening correctional and rehabilitative agendas.” Corrections Management Quarterly, 4 (4), 10-21.
Cocozza, J.J. & K.R. Skowyra (2000). “Youth with mental health disorders: Issues and emerging responses.” Juvenile Justice 7 (1), 6-16.
Dennis, M.L., Dawud-Noursi, S., Muck, R.D., McDermitt, M. (In press). “The need for developing and evaluating adolescent treatment models.” In S.J. Stevens & A.R. Morral (Eds.) Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study. Binghamton, NY: Haworth Press.
Dennis, M.L. & McGeary, K.A. (1999). “Adolescent alcohol and marijuana treatment: Kids need it now.” TIE Communique (pp. 10-12). Rockville, MD: Substance Abuse and Mental Health Service Administration, Center for Substance Abuse Treatment.
DiIulio, J.J. & J. Baldwin Grossman (1997). “Youth crime and substance abuse: Act-now strategies for saving at-risk children.” Philadelphia, PA: Public/Private Ventures.
Nissen, L.B., J. Vanderburg, J.Embree-Bever, J. Mankey (1999). ” Strategies for integrating substance abuse treatment in the juvenile justice system: A practice guide.” Washington, DC: Center for Substance Abuse Treatment.
Schiraldi, V., B. Holman and P. Beatty (2000). “Poor prescription: The costs of imprisoning drug offenders in the United States.” Washington, DC: Justice Policy Institute.
Substance Abuse and Mental Health Services Administration (1997). ” Substance Abuse Treatment in Adult and Juvenile Correctional Facilities.” Findings from the Uniform Facility Data Set, 1997 Survey of Correctional Facilities. Washington, DC: SAMSHA.
Torbet, P. (1999). “Holding juvenile offenders accountable: Programming needs of juvenile probation departments.” Pittsburgh, PA: National Center for Juvenile Justice.
U.S. Dept. of Justice, Office of Juvenile Justice and Delinquency Prevention (1999). “Juvenile offenders and victims: 1999 national report.” Washington, DC: U.S. Department of Justice.
VanderWaal, C.J., McBride, D.C., Terry-McElrath, Y.M., VanBuren, H. (2001). “Breaking the juvenile drug-crime cycle: A guide for practitioners and policymakers.” Washington, DC: National Institute of Justice.
Key Policy Recommendations Regarding Substance Abuse in the
Juvenile Justice System
1. Federal and state governments, foundations and other organizations with national influence should increase their leadership roles in educating the public and policymakers about the relationship between substance abuse and juvenile delinquency, as well as evidence-based methods of interrupting this destructive cycle. Advocates should continue efforts to redirect trends from primarily punitive strategies to more redemptive approaches that include family, cultural and community-based orientations.
2. While increases in evidence would be desirable, the recent “renaissance” in research regarding effective substance abuse treatment is sufficient to reinforce and retool existing service delivery systems and raise the standard of care for youths with substance abuse problems in the juvenile justice system.
3. The shortage of substance abuse treatment for this group should be discussed as a public health crisis in which known services that can increase both public health and public safety are not being deployed adequately.
4. Improvements and dissemination of clinical advances should be balanced with evidence that retooling systems of care to increase their coordination, cross-system communication and integrated care plans is equally essential to improving youth and family outcomes.
5. More opportunities for synergy should be encouraged between advances in efforts to address substance abuse in the juvenile justice system with other juvenile justice reforms such as disproportionate minority confinement reduction, detention reform, attention to co-occurring mental health disorders, and creation of balanced and restorative justice models.
6. Attention to the substance abuse treatment needs of youths not yet in the juvenile justice system should continue to remain a priority-and treatment on demand should remain a goal for this group among others. To do otherwise is to indirectly contribute to the practice of net-widening in which youths (especially those in the public sector) end up in the juvenile justice system to access a treatment resource better deployed outside of a confined setting.
Strength-Based Bill of Rights for Youth in the Juvenile Justice System
1. I have the right to be viewed as a person capable of changing, growing and becoming positively connected to my community no matter what types of delinquent behavior I have committed.
2. I have a right to participation in the selection of services that build on my strengths.
3. I have a right to contribute things I am good at and other strengths in all assessment and diagnostic processes.
4. I have a right to have my resistance viewed as a message that the wrong approach may be being used with me.
5. I have the right to learn from my mistakes and to have support to learn that mistakes don’t mean failure. I have the right to view past maladaptive or antisocial behaviors as a lack of skills that I can acquire to change my life for the better.
6. I have the right to experience success and to have support connecting previous successes to future goals.
7. I have the right to have my culture included as a strength and services which honor and respect my cultural beliefs.
8. I have the right to have my gender issues recognized as a source of strength in my identity.
9. I have the right to be assured that all written and oral, formal and informal communications about me include my strengths as well as needs.
10. I have a right to surpass any treatment goals which have been set too low for me, or to have treatment goals which are different than those generally applied to all youth in the juvenile justice system.
11. I have a right to be served by professionals who view youth positively, and understand that motivating me is related to successfully accessing my strengths.
12. I have a right to have my family involved in my experience in the juvenile justice system in a way that acknowledges and supports our strengths as well as needs.
I have a right to stay connected to my family no matter what types of challenges we face.
13. I have the right to be viewed and treated as more than a statistic, stereotype, risk score, diagnosis, label or pathology unit.
14. I have a right to a future free of institutional or systems involvement and to services which most centrally and positively focus on my successful transition from institutions.
15. I have the right to service providers who coordinate their efforts and who share a united philosophy that the key to my success is through my strengths.
16. I have the right to exercise my developmental tasks as an adolescent; to try out new identities; to learn to be accountable and say I’m sorry for the harm I’ve caused others – all of which is made even more difficult if I’m labeled a “bad kid.”
17. I have the right to be viewed and treated as a redeemable resource and a potential leader and success of the future.
Developed by Laura Burney Nissen, Ph.D., MSW, CAC III, 1998
[toggle title=”National Accreditation”]
By Drug Strategies
All exemplary adolescent drug treatment programs included in Treating Teens: A Guide to Adolescent Drug Programs have been licensed by their respective states to provide addiction services. However, requirements for such licensure vary from state to state, making it difficult to compare programs nationwide. At the same time, half of the 144 teen treatment programs described in Treating Teens have also been accredited by one or more of the three leading organizations that have established national standards for drug treatment programs: the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Rehabilitation Accreditation Commission (CARF), and the Council on Accreditation (COA).
The Joint Commission, founded in 1951, is a nonprofit organization dedicated to improving safety and quality of care in organized health care settings such as hospitals, ambulatory care organizations, assisted living communities, and laboratories. Each year, the Joint Commission accredits more than 16,000 health care organizations, including over 1,600 organizations engaged in behavioral health care, developmental disabilities, foster care or addiction services. Its members are the American College of Physicians, the American College of Surgeons, the American Dental Association, the American Hospital Association and the American Medical Association. The Joint Commission develops accreditation standards, awards accreditation decisions, and provides ongoing education and consultation to health care organizations. The Joint Commission’s standards provide an objective evaluation process to help in measuring, assessing and improving performance. The standards are divided into individual-focused functions (for example, assessment, care, education, rights, responsibilities and ethics) and organizational functions (leadership, management of the environment of care, human resources and information systems, etc.).
Founded in 1966, CARF, a nonprofit organization, has the support of over 25 national organizations which approve the goals of its accreditation process. These include the American Academy of Physical Medicine and Rehabilitation, the American Psychiatric Association, Goodwill Industries International and the National Association of Alcoholism and Drug Abuse Counselors. Over the past 35 years, the CARF standards have evolved through the active participation of providers, consumers and purchasers of services and are viewed as “national consensus standards” rather than ones derived solely from research.
The CARF standards cover seven areas: organizational leadership and responsibility; organizational management; quality improvement; general program standards; behavioral health core program and specific populations (such as criminal justice or children and adolescents); employment and community core services; and network administration when two or more organizations establish formal agreements to deliver rehabilitation services. Each area is divided into subsections, each with its own standards. For example, organizational management is divided into five categories: information management; fiscal management; human resources; communication; and accessibility, health, safety and transportation.
Founded in 1977 by the Child Welfare League of America and Family Service America, the Council on Accreditation (COA) is an international, nonprofit accrediting organization for children, youth, and family services. COA sets standards covering organizational, management, and service practices. The organizational and management standards (governance, fiscal management, human resources management, quality improvement) are applicable for all agencies, regardless of type of services provided. In recognizing the unique aspects of service delivery systems, separate standards were created for public and private (nonprofit and for profit) agencies. The service standards cover specific protocols for 38 types of social and behavioral healthcare programs including substance abuse, opiod treatment, residential and day treatment. Development of the standards is conducted on a consensus basis by soliciting input from service providers, funders, policymakers and consumers based in the United States and Canada. Similarly, COA uses a peer review process to accredit organizations; CEOs, senior administrative staff, clinical staff, and recently retired staff from established COA accredited organizations, as well as faculty from schools of social work, comprise the over 900 volunteer peer network who conduct on-site visits to evaluate an organization’s performance. In 2001, COA accredited or was in the process of accrediting more than 1,400 private and public organizations.
Accreditation from all three organizations is based on compliance with standards listed in their manuals. All list primarily the same standards but have grouped these standards into different categories. Organizations must have implemented these standards for several months prior to the accreditation survey, which will be verified by verbal and written information, on-site observations, documents provided by the organization to the accrediting body, and interviews with consumers and staff. This process is designed to help organizations identify and correct problems and improve the quality of care and services provided. In addition, the on-site survey provides an opportunity for consultation and education.
Accreditation from these three organizations can influence consumer decisions, facilitate third party payments, reduce exposure to legal action, increase community confidence and enhance an organization’s prestige. Accreditation is increasingly used as a prerequisite to establish eligibility for insurance reimbursement from managed care plans.
The process of obtaining accreditation, however, requires significant expenditure of time (on average one year) and financial resources (separate fees may be charged for accreditation, peer review team site visit and maintenance of accreditation)-assets often scarce in many organizations, particularly small ones. Despite growing interest in providing accountability, many quality programs may not wish to go through the comprehensive accreditation process since their state licenses provide eligibility to receive state funds. Some programs believe they are very effective even without obtaining national accreditation. In any case, the demand for teen drug treatment programs far exceeds the supply thus reducing the financial need for national accreditation.
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Screening and Assessment Instruments
By Dr. Ken C. Winters
Professor, Department of Psychiatry
Center for Adolescent Substance Abuse Research
University of Minnesota
I. Screening Instruments
Several adolescent substance abuse screening tests are available. These tools are useful because they can briefly estimate the severity of a youth’s problem. Given their preliminary nature, screening measures typically call for conservative scoring decisions. For example, terms such as “probable substance abuser” or “needs a comprehensive assessment” are often used to describe an individual’s test score. A screening tool’s full value is appreciated when it is used to determine whether a more complete assessment should be conducted.
Adolescent Alcohol Involvement Scales (AAIS)
The AAIS is a 14-item self-report (Mayer & Filstead, 1979) scale that looks at the type of alcohol abuse and how often it occurs. Questions on the AAIS address topics such as, the last drinking episode, reasons for the initial drinking behavior, the situation in which the drinking occurred, short and long-term effects of drinking, the adolescent’s perception about drinking, and the ways in which others perceive his/her drinking. The severity of the adolescent’s alcohol abuse is determined by their overall score, which can range anywhere between 0 and 79. The major scales include non-user/normal, misuser, and abuser/dependent. The test scores are related to a substance abuse diagnosis as well as ratings from other sources. These other sources include independent clinical assessments and the adolescent’s parents, as well as the consistency for each individual- ranging from .55 in a clinical sample to .76 in a general sample (Moberg, 1983). The norms for both of these samples are available in the 13-19 year-old range.
Adolescent Drinking Index (ADI)
The ADI (Harrell & Wirtz, 1989) is a 24-item self-administered test that examines adolescent drinking. It does so by measuring psychological, physical, and social symptoms as well as loss of control. This test is written at a fifth grade reading level. The results of this test provide a single score as well as two subscale scores. The subscale scores include, self-medicating drinking and rebellious drinking. These two scales are intended as research scales. The reliability of the ADI is good. Results are shown to be consistent and accurate (coefficient alpha, .93-.95) in measuring the severity of adolescent drinking problems. Studies show a moderate correlation with alcohol consumption as well as significant differences between groups with different levels of alcohol problem severity. In addition, there was a hit rate of 82% in classification accuracy of the ADI (Harrell & Wirtz, 1989). This means that 82% of the time, when a drinking problem was identified using this scale, the test was accurate in classifying the drinking as a problem and the test accurately determined the level of severity of the drinking problem.
Adolescent Drug Involvement Scale (ADIS)
Moberg and Hahn (1991) modified the AAIS (described above) to address drug use problem severity. The ADIS is a 13-item questionnaire written at an eighth grade reading level. This scale correlates (.72) with drug use frequency and (.75) with independent rating by clinical staff. When matched up with the frequency of drug use and the ratings that clinical staff gave, the scale correlates with their findings, therefore providing evidence of the validity of this test.
Client Substance Index (CSI)
This 113-item test (Moore, 1983) is based on Jellinek’s 28 symptoms of drug dependence. Scores on the CSI reflect the degree of drug dependence, ranging from no problem, to misuse of substances, to chemical dependency. CSI scores have been shown to discriminate normal from drug treatment samples (Moore, 1983).
Client Substance Index-Short (CSI-S)
The CSI-S (Thomas, 1990) was developed and evaluated as part of a larger Substance Abuse Screening Protocol through the National Center for Juvenile Justice. This tool is a 15-item, yes/no self-report instrument that was adapted from Moore’s (1983) multi-scale Client Substance Index. The objective of this brief screen is to identify juveniles within the court system who are in need of additional drug abuse assessment. When tested again and again, the results are comparable (coefficient alpha =.84-.87). The test also has the ability to discriminate groups defined according to the severity of their criminal offense (Thomas, 1990).
Drug and Alcohol Problem (DAP) Quick Screen
This 30-item screening questionnaire has a yes/no/uncertain response format. The DAP was tested in a pediatric setting (Schwartz & Wirtz, 1990), in which the authors report that about 15% of the respondents said yes to 6 or more items. From this, they determine the cut-off score for “problem” drug use to be inclusive of 6 or more responses of yes to the items on the scale. The items contribute to the score, however the validity and reliability of this test are not available.
Drug Use Screening Inventory-Revised (DUSI-R)
The DUSI-R is a 159-item instrument that documents the level of involvement with a range of drugs. It also describes the severity of consequences related to such involvement. The scale provides scores on 10 problem density subscales. Some of these subscales are: substance use, behavior problems, and psychiatric disorder. In addition to these 10 subscales, there is one lie scale. This is used for reliability purposes to ensure honesty in the respondents or identify inconsistencies within the responses. Domain scores were related to DSM-III-R substance use disorder criteria in a sample of adolescent substance abusers (Tarter, Laird, Bukstein, & Kaminer, 1992). An additional psychometric report provides norms and evidence of scale sensitivity (Kirisci, Mezzich, & Tarter, 1995).
Personal Experience Screening Questionnaire (PESQ)
The PESQ (Winters, 1992) is a brief 40-item screening instrument that consists of a scale that measures the severity of the drinking problem (coefficient alpha, .91-.95), drug use history, select psychosocial problems, and response distortion tendencies (“faking good” and “faking bad”). Norms for normal juvenile offender and drug abusing populations are available. The test is estimated to have an accuracy rate of 87% in predicting the need for further drug abuse assessment (Winters, 1992).
Problem Oriented Screening Instrument for Teenagers (POSIT)
This 139-item self-administered yes/no instrument is part of the Adolescent Assessment and Referral System developed by the National Institute on Drug Abuse (Rahdert, 1991). It addresses 10 functional adolescent problem areas: substance use, physical health, mental health, family relations, peer relationships, educational status, vocational status, social skills, leisure and recreation, and aggressive behavior/delinquency. The need for further assessment has been determined by cut scores that have been established rationally, or confirmed with documented proof providing procedures (Latimer, Winters, & Stinchfield, 1997). Convergent and discriminating data for the POSIT have been reported by several investigators (Dembo, Schmeidler, Borden, Chin Sue, & Manning, 1997; McLaney et al., 1994).
Rutgers Alcohol Problem Index (RAPI)
The RAPI (White & Labouvie, 1989) is a 23-item questionnaire that focuses on the consequences of alcohol use in regards to family life, social relations, psychological functioning, delinquency, physical problems and neuropsychological functioning. The RAPI, when used as a screening device among heavy alcohol users, was found to correlate highly with the DSM-III-R requirements for substance use disorders (.75-.95) and when used on a large general population sample, the RAPI was found to have high internal consistency (.92) (White & Labouvie, 1989).
Substance Abuse Subtle Screening Inventory (SASSI)
Miller’s (1985) 81-item adolescent version of the SASSI shows scores for several scales. Those scales are: face valid alcohol, face valid other drug, obvious attributes, subtle attributes, and defensiveness. The validity of this test is proven by its high correlation with the MMPI cut scores for chemical dependency and the SASSI’s high correspondence with diagnosis of substance use disorder at intake (Risberg, Stevens, & Graybill, 1995).
II. Comprehensive Assessment Instruments
The field also consists of several comprehensive assessment instruments. These measures provide a detailed assessment of the multiple problems and strengths of the adolescent. Such information is important in helping to determine if the adolescent has clinical-level problems and to construct a treatment plan. Thre types of comprehensive assessments are reviewed: interviews that include an assessment of substance use disorders, interviews that primarily focus on psychosocial functioning, and multi-scale questionnaires.
Substance Use Disorder Interviews
Adolescent Diagnostic Interview (ADI)
The ADI (Winters & Henly, 1993) tests for symptoms associated with psychoactive substance use disorders (descriptions can be found in the DSM-III-R and DSM-IV). This instrument follows a structured interview format and it also measures information related to demographics as well as social class. It takes a look at the substance use consumption history, and the way a person functions in society in relation to mental health. Evidence for the interview’s interrater agreement, test-retest reliability, the test’s relationships to alternative measures of problem severity, and its agreement with independent diagnoses have been reported (Winters & Henly, 1993; Winters, Stinchfield, Fulkerson & Henly, 1993).
Customary Drinking and Drug Use Record (CDDR)
The CDDR (Brown, Meyers, Lippke, Tapert, Stewart & Vik, 1998) is a research-focused, structured interview that measures alcohol and other drug use consumption for both recent (prior 3 months) and lifetime periods. The interview tests DSM-III and DSM-IV substance dependence symptoms (including a detailed assessment of withdrawal symptoms) and several types of consequences of alcohol and other drug involvement. Psychometric studies provide evidence that the CDDR is reliable over time and across interviewers (average one-week test-retest coefficients for all major content domains is .91), discriminates community youths from substance-abusing youths, and converges with alternate measures (Brown et al., 1998).
Substance Use Disorders Diagnostic Schedule (SUDDS)
This instrument is a diagnostic checklist that is specific to DSM-III-R criteria (Hoffmann & Harrison, 1989). It should be used cautiously among adolescents. This is because several of the items are not appropriate for young people’s experiences and the content coverage is pretty weak when it comes to school consequences and peer use issues. The SUDDS is accompanied by other measures that assist in determining the level of client treatment care based on client placement criteria from the American Society of Addiction Medicine (Level of Care Index, Mee-Lee & Hoffmann, 1992a and Recovery Attitude and Treatment Evaluator, Mee-Lee & Hoffmann, 1992b). The SUDDS current and lifetime ratings have been shown to be pretty even with independent clinical diagnoses in an adult sample (overall agreement, 71%-100%) (Davis, Hoffmann, & Luehr, 1992), although there have been no psychometric evaluations of the interview with adolescents.
Psychosocial Functioning Interviews
Adolescent Drug Abuse Diagnosis (ADAD)
The ADAD is a 150-item structured interview that looks at the following content areas: medical status, drug and alcohol use, legal status, family background and problems, school/employment, social activities and peer relations, and psychological status. The interviewer uses a 10-point scale to rate the patient’s need for additional treatment in each content area. These severity ratings translate to a problem severity dimension (no problem, slight, moderate, considerable, and extreme problem). The drug use section includes a detailed drug use list and how often the use occurs, and a brief set of items that looks at specific areas of drug involvement (e.g., polydrug use, attempts at abstinence, withdrawal symptoms, use in school). Psychometric studies on the ADAD, using a broad sample of clinic-referred adolescents, provide favorable evidence for its reliability and validity (Frideman & Utada, 1989). A shorter form (83 items) of the ADAD intended for treatment outcome evaluation is also available.
Adolescent Problem Severity Index (APSI)
The APSI was developed by Metzger and colleagues (Metzger, Kushner, & McLellan, 1991) of the University of Pennsylvania/VA Medical Center. The APSI provides a general information section that addresses the reason for the assessment and the referral source, as well as the adolescent’s understanding of the reason for the interview. Additional sections of the APSI include drug/alcohol use, family relationships, education/work, legal, medical, psycho/social adjustment, and personal relationships. Some concurrent validity for the alcohol/drug section has been empirically demonstrated (Metzger et al., 1991) and predictive validity evaluations are underway.
Comprehensive Addiction Severity Index for Adolescents (CASI-A)
The CASI-A is a structured interview developed by Meyers (1991). It covers several areas, including the following: education, substance use, use of free time, leisure activities, peer relationships, family (including family history and intrafamilial abuse), psychiatric status, and legal history. At the end of many major topics, there is space provided for the interviewer’s comments, severity ratings, and ratings of the quality of the interviewee’s answers. An interesting feature of this interview is that it incorporates results from a urine drug screen and observations from the interviewer. Psychometric studies on the CASI-A are being conducted by the author.
Teen Severity Index (T-ASI)
Another adolescent version of the ASI was adapted by Kaminer, Bukstein & Tarter (1991). The T-ASI consists of seven content areas: chemical use, school status, employment-support status, family relationships, legal status, peer-social relationships, and psychiatric status. A medical status section was not included because it was thought to be less relevant to adolescent drug abusers. Patient and interviewer severity ratings are rated on a 5-point scale for each of the content areas. Preliminary data indicate adequate interrater agreement and initial validity data (Kaminer, Wagner, Plummer, & Seifer, 1993).
Adolescent Chemical Health Inventory (ACHI)
The ACHI (Renovek, 1988) consists of 128 items that address use problem severity and several psychosocial factors. Some of the psychosocial scales measure family closeness, depression, alienation, family support, family chemical use and physical and sexual abuse. The ACHI additionally screens for defensiveness. The test is self-administered through use of a personal computer. Validity data collected for the ACHI indicate that the instrument is able to differentiate between adolescent drug abusers and non-abusers.
Adolescent Self-Assessment Profile (ASAP)
This self-administered, 225-item, multi-scale inventory (Wanberg, 1992) was developed on the basis of many variable research studies by Wanberg and colleagues. The instrument provides an in-depth assessment of drug involvement, including how often drug use occurs, the consequences and benefits of drug use, as well as the major risk factors associated with such involvement (e.g., deviance, peer influence). Supplemental scales, which are based on common factors found within the specific psychosocial and problem severity domains, can be scored as well. Extensive reliability and validity data based on several “normal” groups are provided in the manual.
Chemical Dependency Assessment Profile (CDAP)
This 232-item self-report questionnaire assess 11 dimensions of drug use, including expectations of use (e.g., drugs reduce tension), physiological symptoms, the amount used and how often the use occurs, and attitude toward treatment. A computer-generated report is provided. Limited normative data are available thus far on only 86 subjects (Harrell, Honaker & Davis, 1991).
Hilson Adolescent Profile (HAP)
The HAP consists of 310 true-false items that cover 16 scales, two of which measure alcohol and drug use. The other content scales correspond to characteristics found in psychiatric diagnostic categories (e.g., antisocial behavior, depression) and psychosocial problems (e.g., home life conflicts). Normative data have been collected from clinical patients, juvenile offenders, and normal adolescents (Inwald, Brobst, & Morissey, 1986).
Juvenile Automated Substance Abuse Evaluation (JASAE)
The JASAE (ADE Inc. 1987) is a computer-assisted, 108-item (T/F) instrument that is based on a similar adult measure, the SALCE. The JASAE produces a 5 category score, ranging from no use to drug abuse (including a suggested DSM-IV classification), accompanied by a summary of drug use history. The instrument also includes a measure of life stress and a scale for test-taking attitude. The JASAE has been shown to discriminate clinical groups from nonclinical groups.
Personal Experience Inventory (PEI)
The PEI is a 276-item, multi-scale questionnaire that measures chemical involvement problem severity (10 scales), psychosocial risk (or protective) factors (12 scales), and the tendency for subjects to distort responses (5 scales). Supplemental problem screens measure eating disorders, suicide potential, physical/sexual abuse, and parental history of drug abuse. The scoring program provides a computerized report that includes narratives and standardized scores for each scale, as well as other clinical information. Extensive normative and psychometric data (including test-re-test reliability and convergent and predictive validity) are available (Winters & Henly, 1989; Winters, Stinchfiled & Henly, 1996).
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The Effectiveness of Adolescent Substance Abuse Treatment:
A Brief Summary of Studies Through 2001
Michael L. Dennis & Michelle K. White (2003)
Bloomington, IL: Chestnut Health Systems.
To support the development of Drug Strategies’ Treating Teens: A Guide to Adolescent Drug Programs (2003), we have summarized the major adolescent substance abuse treatment studies that had been completed and been published (or submitted for publication) through 2001. The summary is divided into the following sections:
Click here to download an Excel file version of this article. The Excel file includes a printer-friendly version of the article’s “Detailed Study Abstracts.”
The development of this summary was supported by funds from Drug Strategies, the Robert Wood Johnson Foundation and the Center for Substance Abuse Treatment (contract no. 277-00-6500). The opinions expressed in this summary are based on the authors’ interpretation of the literature published on the treatment models in each column (see citations in the appendix) and do not represent official positions of Drug Strategies, the Robert Wood Johnson Foundation or any agency of the government. Questions, comments and additions should be addressed to Michael L. Dennis, Chestnut Health Systems, 720 West Chestnut, Bloomington, IL 61701, email@example.com or 309-827-6026.
Please cite as: Michael L. Dennis & Michelle K. White (12/19/2002). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through 2001, (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems.
Go to an abstract of “An In-Depth Survey of the Screening and Assessment Practices of Highly Regarded Adolescent Substance Abuse Treatment Programs”, published in the Journal of Child & Adolescent Substance Abuse, January, 2010.
Go to “Does Higher Cost Mean Better Quality? Evidence from Highly Regarded Adolescent Drug Treatment Programs”, published inSubstance Abuse Treatment, Prevention, and Policy, 2007.
Go to “The Quality of Highly Regarded Adolescent Substance Abuse Treatment Programs: Results of an In-depth National Survey”, published in the Archives of Pediatric and Adolescent Medicine, 2004.