Washington State currently has no TCs for the treatment of adolescent substance use.

2. Residential settings

Residential settings range from medically monitored hospital based placements to boarding schools for high risk youth. The most commonly utilized residential placement for chemically dependent adolescents is an inpatient non-hospital based treatment program. Adolescents with high levels of substance abuse and co-existing psychiatric problems are frequently treated in an inpatient hospital-based setting. Inpatient treatment typically ranges in length from 7-90 days depending on the program philosophy (e.g., AA based, behavioral, multidimensional) and services provided. Residential training schools have also been utilized for treatment of substance use and behavioral problems. These out-of-home placement programs focus primarily on teaching a trade or vocation that the individual can utilize in becoming a productive member of society, but also provide therapy for co-existing problems. More recently there has been the establishment of 'Boot Camps' for troubled adolescents with behavioral and substance use problems.

Residential programs share some features similar to the TCs and include the following elements (Jainchill, 1995):

• an initial short period (few days) of restricted contact with outside environment ("blackout") to enable detoxification from substances and outside stressors
• may or may not include medical monitoring
• a focus on educational needs and often assessment for academic difficulties such as learning disorders or attention deficit hyperactivity disorder
• a combination of group and individual therapy, usually cognitive-behavioral or supportive in nature
• stresses family involvement in treatment to varying degrees
• relapse prevention is a critical treatment component
• may recommend aftercare treatment, but typically does not provide this service
• stresses involvement in community self-help groups upon treatment completion

The most commonly utilized residential treatment for youth in Washington State is non-hospital based residential treatment. Programs contracted with the Division of Alcohol and Substance Abuse (DASA) are designated as "Level I" or "Level II", depending upon the program's ability to address co-existing mental health, psychiatric, and behavioral problems.

3. Outpatient treatment

Outpatient treatment, one of the least restrictive forms of treatment, is utilized extensively in treating adolescents with substance use problems. Outpatient treatment allows the adolescent to remain in his community providing him immediate opportunity to practice newly acquired skills or behavioral changes learned in treatment. In some cases, outpatient treatment may be preceded by an inpatient or detox treatment program, in other cases it stands alone as a treatment. Considerable variation in outpatient programs exists, but outpatient programs all share some common elements:

• outpatient therapy can be one of many modalities such as, AA based, cognitive-behavioral, supportive, insight oriented, family therapy or a combination of therapies
• there is no standard recommended length for outpatient treatment; length of treatment depends on the level of problem severity, referral and funding source
• intensity of treatment varies; some outpatient treatment, such as day hospitals, may meet five days a week; others may only meet one time a week
• relapse prevention is stressed
• involvement in community self-help groups during and after treatment is typically encouraged

In Washington State, the most common form of outpatient treatment for youth is an intensive outpatient program, which requires DASA certification for seventy-two hours of treatment services within a maximum of sixteen weeks.

4. Community monitoring

If substance use is present, but not yet problematic, substance use may be monitored through regular urinalyses, meetings with a parole or probation officer, or a case worker. In cases where criminal activity or flight is a concern, individuals may also be placed under house arrest, have a curfew, or be electronically monitored.

5. Self-help and other community based groups

Most forms of treatment include participation in a community based support group. Attendance in such self-help groups is often considered a form of aftercare. Self-help groups, such as Alcoholics Anonymous, provide a safe forum to discuss problems with other recovering adolescents. These programs also provide positive role models and emotional support. Programs such as the Big Brothers and Sisters programs can also provide an adolescent with emotional support and a positive role model.

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B. Continuing Care and Aftercare

Adolescents appear to be at particularly high risk for relapse after treatment, especially during the first 3-6 months following treatment. In a study of 75 adolescents (average age 15.6 years) treated in an inpatient chemical dependency program, 64% of the adolescents had relapsed by the third month following treatment and an additional 7% relapsed during the 4^th - 6^th month following treatment (Brown, 1989). Another study of 54 adolescents compared the percentage of adolescents who remained drug free 6 months following inpatient substance abuse treatment (abstainers) to adolescents who had minor relapses (no more than 30 days of substance use in the last 6 months) and those who had major relapses (regular heavy substance use). Of those who completed treatment, only 30% were classified as abstainers for the entire 6 month period following treatment (Brown, 1990). Moreover, a recent study of 139 adolescents who completed an inpatient program reported that 86% of the youth had at least one episode of substance use during the year following treatment (Myers, 1995).

Continued involvement in substance use and illegal activity are thought to be the result of an individual's failure to make a successful transition from the treatment setting to independent living. It is relatively easy for people to temporarily change undesired behaviors; however, it is much harder to maintain those behavioral changes. Individuals may make a serious commitment to abstinence and no involvement in illegal activity, but may not have the ability to fulfill that commitment without additional assistance (Peters, 1992; Beck, 1993). Gradually decreasing the frequency of treatment, or providing additional aftercare, is thought by some to be essential if an individual is to be successful in maintaining abstinence (Baskin, 1983; Brown, 1990; Brownell, 1986; Henggeler, 1991). Aftercare, or continuing care, services, however, should consist of more than just self-help activities (Leukefeld, 1993).

In addition to strengthening skills acquired during treatment, aftercare, or a gradual decrease in primary care, should further assist in the development and maintenance of relapse prevention skills as well as in enhancing the adolescents ability to cope with family, social, and academic and/or occupational difficulties (Peters, 1992). Aftercare programs, and continuing care, should expand positive coping skills and understanding of motivation for drug use that was gained during treatment, while allowing the adolescent opportunity to practice these skills in their own environment (Bry, 1992; Sontheimer, 1993). Such skills and knowledge can greatly enhance the ability to remain abstinent, overcome cravings and urges to use drugs and decrease involvement in illegal activity (Beck, 1993). Therefore, it is recommended that CDDA youth be provided with a comprehensive continuum of care that stresses relapse prevention, positive coping skills, and continuation of gains made during treatment. This should greatly increase the chances for successful treatment outcomes for CDDA youth.

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C. Placement Decisions

Appropriate treatment referral is a complex issue and should be based on a comprehensive assessment of needs. It is generally recommended that an adolescent be treated in the least restrictive setting possible (Gartner, 1995; Greenwood, 1993). In treating adolescents who have criminal involvement, however, issues of community safety must also be considered when making placement decisions.

It is not uncommon for a clinician to determine treatment placement based on their own personal experience of who does and does not do well in a particular form of treatment, or on the basis of what services are currently available. In general, treatment placement decisions are made considering the individual's status in several areas of functioning in addition to their substance use problems. Examples of areas of functioning usually considered when determining treatment placement are:

severity of criminal history severity of psychiatric problems family situation developmental level academic or vocational functioning presence of physical, sexual or emotional abuse

physical health interpersonal functioning self esteem socialization skills empathy skills community environment

Severe problems in multiple areas (e.g., intravenous drug use, suicidal ideation, and homelessness) typically warrant a residential treatment setting such as an inpatient hospital based program. If an adolescent has few problems other than substance use (e.g., minor mood disturbance, slipping grades, minimally involved in criminal activity) an outpatient program is usually recommended.

There has been only one study, to our knowledge, that attempted to 'match' individuals to a specific form of treatment based on individual characteristics or problem severity profiles. This study of 296 adolescents treated in four outpatient programs and 157 adolescents treated in two inpatient programs across the U.S. found that those with more severe employment, social, family, and to a lesser extent, more psychological problems responded more positively to a longer term outpatient treatment program than a shorter term inpatient treatment. Furthermore, there was a greater reduction in post-treatment substance use for adolescents who were 'matched' to treatment condition using these variables compared to those that were not matched using these variables (Friedman, 1993). These results were only true for adolescents who did not require inpatient treatment for an initial detoxification, protection from overdose, or because they were at high risk for suicide. The authors caution readers that this was an exploratory study that had several methodological problems and further studies are required to determine the usefulness of these variables as treatment matching criteria.

To date, there are no standardized guidelines that are consistently used in making treatment placement decisions. The American Society for Addiction Medicine (ASAM) has proposed a set of detailed criteria for use in determining the most appropriate level of care along a continuum encompassing four levels: outpatient treatment, intensive outpatient/partial hospitalization, medically monitored intensive inpatient, and medically managed intensive inpatient. These criteria are not meant to be treatment/service matching criteria, which would address a broad range of individual needs, but to provide guidelines for placing adolescents with specific combinations of substance use related problems in appropriate levels of safe and cost-effective care (Gartner, 1995).

The ASAM criteria assist practitioners in determining the need for specific intensities of treatment through the use of markers relating to the need for detoxification, treatment resistance, comorbid disorders and relapse potential, as well as safety issues (Gartner, 1995). Although the ASAM criteria were established by a consensus panel of workers in the field and are widely circulated, there are several problems with ASAM criteria (Gartner, 1995). Categorizing levels of care can discourage individualized treatment plans. Also problematic is the treatment framework which does not allow for a gradual reduction in treatment intensity. The ASAM system can be difficult to use if a clinician does not have extensive experience with substance abuse patients. Furthermore, recommended treatment modalities are not always available, especially when inpatient treatment is recommended. Most problematic, however, is the fact that there are currently no reliable ways to measure the dimensions of functioning in adolescents assessed by ASAM criteria (Gartner, 1995). Nevertheless, ASAM criteria are still the most comprehensive and widely used placement criteria for determining chemical dependency treatment modality.

The ASAM criteria are currently used by many Washington Division of Alcohol and Substance Abuse treatment programs to determine level of care. For the most part, decisions regarding placement of CDDA youth will be determined by juvenile courts who will not be utilizing the ASAM criteria. Since juvenile courts are typically in need of clinical input and guidance, it is recommended that DASA, in conjunction with JRA, provide juvenile courts a set of uniform guidelines regarding problem severity that can assist them in making appropriate CDDA treatment placement decisions.

Cultural factors should also be considered in treatment placement decisions. For some adolescents an out of home placement can severely disrupt family bonds. For some Native Americans and Pacific Northwest Indians it has been found that removing youth from their family can cause intense emotional strain, which can become counterproductive to treatment (Dinges, 1993). Therefore, it may be advantageous to place such adolescents in a more intensive outpatient setting even when inpatient treatment may seem more appropriate, or to make sure that if the adolescent is in an inpatient setting that there is frequent family contact.

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D. Treatment Outcome Studies

1. Studies prior to 1990

There is a scarcity of outcome studies on adolescent chemical dependency treatment. Prior to the 1990s most studies of adolescent chemical dependency treatment lacked scientific rigor and were mainly descriptive in nature. Overall, the treatment programs evaluated appeared to reduce so-called hard drug use in adolescents, but were not always successful in reducing use of alcohol and marijuana.

For example, data from the Drug Abuse Reporting Program (DARP) evaluated drug use in 5,406 adolescents who completed inpatient or outpatient treatment compared to those who did not complete treatment. The DARP treatment programs were aimed primarily at treating adult opioid abusers and were not specifically addressing adolescent alcohol and other drug use. Although there was a reduction in opioid use and criminal activity in treated adolescents, the majority of adolescents still used alcohol and marijuana extensively a year after treatment. Use of alcohol actually increased for treated African American adolescents (Sells, 1979).

In the Treatment Outcome Prospective Study (TOPS), 240 adolescents were evaluated one year after attending at least three months of either an inpatient or outpatient program. Adolescents treated in inpatient programs had more positive outcomes than those treated in outpatient programs. For inpatients, daily marijuana use decreased from 79% at treatment entry to 12% at the follow-up. Heavy alcohol use decreased from 54% to 41%, and criminal activity decreased from 53% to 36% over the follow-up period. For outpatients, there was a similar decrease in rates of criminal activity and alcohol use, but marijuana use increased from 48% to 58% during the follow-up period (Hubbard, 1983).

Early research did demonstrate the importance of length of time in treatment with outcome status. Using data from the Pennsylvania Data Collection System for 4,738 adolescents, discharge status of individuals treated in residential therapeutic communities (TCs) was compared to that of individuals treated in drug-free outpatient programs. Results indicated that for the TC subjects, length of time in treatment was the greatest predictor of improvement. The longer the length of stay, the more positive was the treatment outcome. For outpatient programs, length of time in treatment, however, was negatively related to outcome status (Rush, 1979). The authors concluded that adolescents who received inpatient care typically had more severe problems than those receiving outpatient treatment and therefore, required a longer period of time in order to successfully address their problems. Those adolescents who remained in outpatient treatment longest tended to have more severe problems compared to those who left outpatient treatment earlier. It was hypothesized that adolescents who remained in outpatient treatment the longest were generally less capable of achieving gains compared to those who completed treatment earlier. A 1986 study of client characteristics associated with positive substance abuse treatment outcome evaluated 5,000 adolescents treated in outpatient programs. Length of time in treatment, fewer previous admissions, being Caucasian, and having a primary drug problem other than marijuana were found to predict the greatest reductions in drug use (Friedman, 1986). These studies indicate that adolescents who are able to function in the community while receiving treatment have a better chance of doing well in outpatient treatment compared to those who require a more insulated environment to work on their problems.

Reviews (meta-analyses) of numerous studies of residential and outpatient programs for adolescents prior to the 1990s suggest that although the setting for treatment is important, the specific elements of treatment may actually be more meaningful (Anglin, 1990; Garrett, 1985). Cognitive-behavioral therapies, life skills training, family therapies, multimodal treatments that address numerous problem areas, and aftercare appeared to be the most effective approaches in reducing substance use in adolescents. Findings from more recent studies appear to confirm these early observations.

2. Studies since 1990

Studies of substance abuse treatment for adolescents since 1990 are still relatively limited in number. Research, for the most part, has focused primarily on more traditional inpatient and outpatient substance abuse treatments. With a few exceptions, research results have found negative or inconsistent results regarding efficacy of single modality substance abuse treatment programs. Some of the more promising approaches combine multiple modalities of treatment, e.g. inpatient followed by intensive outpatient followed by aftercare.

a. Inpatient programs

Findings from studies of inpatient treatment have shown some encouraging results. For example, a 1991 study of 98 males and 59 females in an inpatient treatment program based on AA philosophy revealed that although there was some continued substance use, treated adolescents demonstrated improved social functioning, and higher abstinence rates compared to noncompleters at a 6 month follow-up (Alford 1991). Most interestingly were the differences in reductions of drug use for males and females. For males, abstinence rates for completers dropped from 71% at the 6 month follow-up to 48% at the one year follow-up, but increased from 27% to 44% for noncompleters. At the 2 year follow-up there was no difference in abstinence rates between male completers and noncompleters. For females, however, differences in abstinence rates between completers and noncompleters were maintained at the 6 month (79% versus 30%), one year (70% versus 28%), and two year follow-up (61% versus 27%; Alford 1991). Results also demonstrated that regardless of being a treatment completer or not, those who attended AA at least weekly were significantly more likely to be abstinent at the 2 year follow-up compared to those who did not attend AA regularly (84% vs. 50%).

A 1997 unpublished report of 366 adolescents who completed inpatient substance abuse treatment in Washington State reported that 14% remained abstinent for the full 18 months following treatment and 41% had been abstinent for the 6 months preceding the 18 month follow-up (New Standards Inc., 1997). Considerable improvements in academic, psychiatric, family/social and legal functioning were also observed. Moreover, abstinence rates for those who completed aftercare were twice as great (66% versus 30% were abstinent for at least 15 months of the 18 month followup period) as for those who were still in or did not attend aftercare. Similar to previous findings, a longer inpatient stay was associated with a more positive treatment outcome.

Another 1997 study compared chemical dependency treatment outcomes of 249 male and female juvenile delinquents assigned to 2 months of residential treatment to outcomes of 222 delinquents assigned to standard supervision with a probation officer. After two months of residential treatment 130 adolescents were then assigned, based on location of their residence, to receive 4 months of aftercare. Results indicated that those in the residential setting reported significant decreases in self-reported drug use and had a longer time to re-arrest compared to those in standard supervision. The aftercare component, however, appeared to have little benefit. In fact those in aftercare reported more delinquent behaviors and drug related crime compared to those not in aftercare. The authors suggested that the aftercare program may not have been comprehensive enough to meet the complex needs of these adolescents. Furthermore, the increased monitoring of substance use in the aftercare group provided greater opportunity for detection of technical violations of supervision and hence a greater likelihood of re-incarceration (Sealock, 1997).

b. Outpatient programs

An unpublished evaluation of 105 adolescents who completed outpatient substance abuse treatment in Washington State reported an 18 month post-treatment abstinence rate of 23% and an abstinence rate of 51% for the 6 month period preceding the 18 month follow-up. As found for inpatients, there was also an overall improvement in all areas of functioning following treatment. In this study, participation in aftercare was also associated with greater reductions in drug use than non-participation in aftercare (New Standards Inc., 1997).

This report did not focus on the therapeutic techniques used in the outpatient treatment programs, but most published studies of outpatient therapy typically compare various therapeutic interventions. Two types of treatment have demonstrated relatively consistent positive results: family therapies and cognitive-behavioral therapies (Henggeler, 1995; Sealock, 1997). For example, a 1992 controlled study evaluated three forms of adolescent outpatient therapy. Adolescents and their families were randomly assigned to either family systems therapy (FST, n = 31), adolescent group therapy (AGT, n= 23), or family drug education (FDE, n= 28). Controlling for time in treatment, FST appeared to be more effective in reducing drug use (54% abstinent) compared to the AGT (16% abstinent) or FDE (28% abstinent) over the course of treatment. FST also improved overall family functioning and other problem behaviors more than the other treatments (Joanning, 1992). Families and the adolescents were not, however, evaluated at a later date to determine post-treatment effects.

A study comparing 15 adolescents who received 6 months of outpatient behavioral treatment with 11 adolescents receiving 6 months of outpatient supportive therapy found positive effects for behavioral therapy. For those in supportive therapy 91% continued to use drugs in all but one month of the 6 month study. For adolescents in behavioral therapy, 73% used alcohol or other drugs during the first month, but this rate decreased to 27% by the sixth month. Frequency of alcohol or other drug use increased to about 9 days a month from 7 days initially for the supportive group, but decreased from 9 days to approximately 2 days a month for the behavioral group over the six months of treatment. Relative to pre-treatment use, alcohol use in the behavioral group decreased about 50% over the study period, while increasing about 50% for the supportive group. Additionally, there was a significant decrease in self-reported levels of depression for the behavioral group, but a slight decrease for the supportive group. Parental satisfaction with their adolescent's behavior also increased during treatment from 42% to 72% in the behavioral group, but remained around 50% for the supportive group (Azrin, 1994).

Results from the aforementioned inpatient and outpatient studies point to the importance of evaluating more than just substance use outcomes in assessing the efficacy of chemical dependency treatment programs. Following substance abuse treatment an adolescent may still demonstrate some substance use, but significant gains in other areas of functioning such as mental health, family relations, and criminal activity may have occurred, resulting in an improvement in overall functioning.

c. Multidimensional programs

Substance abuse treatment programs that address multiple problem areas are becoming more common and represent some of the most promising approaches for treatment of adolescent chemical dependency.

1. The Nokomis challenge program

Recently a sentencing alternative program for juvenile offenders with substance use problems, similar to the proposed CDDA project, was evaluated in Michigan. The Nokomis Challenge Program was a joint venture between public and private sector agencies and the Michigan Department of Social Services for adjudicated male juvenile felony offenders ages 14-18. The program was 12 months in duration with an 84 day residential component, as well as a 24 day experiential wilderness element. The program was modeled after a medium security training school which utilizes a reward system for appropriate behavioral changes. The residential component was followed by 9 months of community surveillance and continuing treatment. All components of treatment used similar elements such as cognitive-behavioral therapy, experiential education, prosocial skill development, group work, behavior modification, family therapy, and intensive supervision/probation, tracking and electronic monitoring.

Relapse prevention was a key in treatment and included four aspects: (1) identification of problem situations, (2) acquisition of a new skill set, (3) an opportunity to practice and reinforce the new skills, and (4) support in a community setting for integrating these skills into daily living. The residential component focused on the first three elements and the community surveillance focused on the fourth. Families were asked to assist in the treatment planning for their adolescent and were expected to attended biweekly meetings. Failure to do so resulted in the adolescent being returned to the detention center. Community surveillance was intense. Two case workers were generally assigned to each case (Castle, 1996).

A 2 year follow-up of 199 adolescents in a control group and 199 in the Nokomis group revealed that the program was no more effective than incarceration and standard probation in reducing drug use and delinquency, but actually cost $20,000 less per adolescent than incarceration and standard probation (Castle, 1996). Further evaluation of the Nokomis Challenge Program found that compared to a control group, the Nokomis youth had significantly more felony arrests after treatment. However, it was found that the Nokomis program was not properly implemented. For example, many of the required aftercare services were not provided and the control group actually received more family counseling than the Nokomis youth (Deschenes, 1996). The program may have in fact been effective if properly implemented. Results suggest that treatment is effective in reducing recidivism since those receiving the most services, the control group, had a lower arrest rate than those receiving fewer services. This study also indicates the importance of determining that a new program is properly implemented and delivers the proposed services.

2. Multisystemic therapy (MST)

MST is to date the only approach with published results demonstrating short and long term efficacy in reducing substance use and criminal activity in juvenile offenders (Henggeler, 1991). MST is a comprehensive approach to treating delinquency and drug abuse. The goal of MST is to provide a cost-effective family based treatment for antisocial youth. MST is a child focused, family centered intervention directed at solving multiple family problems across settings. It focuses on improving psychological functioning of youth and their families in order to reduce or eliminate the need for out of home placements. MST also focuses on removing the individual from delinquent peer groups and facilitating development of prosocial peer groups, viewing the parents as the key to accomplishing this task. School and vocational interventions seek to improve the individual's capacity for future employment and financial success. A commitment to ensuring that behavioral changes are made in the naturally occurring environment is central to the program.

MST is not a unique therapy but a collection of promising techniques such as strategic and structural family therapy, cognitive-behavioral therapy, and problem-solving and skills training. Therapists must be skilled with all these techniques and have extensive experience in treating adolescents. Therapy is delivered over 2-6 months with decreasing intensity. Many of the services are provided in the home and community settings to enhance family cooperation and increase treatment completion rates. The majority of interventions are done by therapists or by parents with a therapist's guidance. Therapy is directed by a set of intervention principles and change strategies which assume that there are different paths to the same behavior, therefore, treatment plans can be flexible.

Outcome studies of MST have been very promising. A study in South Carolina of 28 families in MST and 19 in usual services found a significant decrease in the use of alcohol and marijuana in the MST group compared to the usual treatment group (Henggeler, 1991). MST has also been found to be substantially less costly than traditional inpatient programs or incarceration (Tate, 1995). In a study of 96 adolescents at risk for an out-of-home placement, MST treated youths had half as many arrests as those receiving usual services a year after treatment. Furthermore, at a four year post-treatment follow-up only 4% of those in MST had a substance related arrest compared to 16% for those in individual counseling (IC). Even when those who dropped out or received very little MST or IC are included in the outcome evaluation the same reductions in drug related arrests were revealed (3% vs. 15%; Tate, 1995).

3. Other promising treatment approaches

In a December 5^th 1997 Satellite Conference, the Office of Juvenile Justice and Delinquency Prevention (OJJDP) discussed 3 other promising approaches to chemical dependency treatment for juvenile offenders. The programs discussed were the Escambia County Drug Court in Pensacola, the Denver Integrated Treatment Network program, and the South Carolina Bridge Program. These three programs share similar features:

• results from a comprehensive assessment procedure drive the treatment plan
• treatment is tailored to meet the individual's needs, providing therapeutic, academic, and medical services
• a team approach to treatment is taken
• individuals on the treatment team are all experienced in adolescent substance abuse treatment and are enthusiastic about the program
• treatment is at least a year in duration with frequency of contact decreasing over time
• family involvement is stressed
• there is extensive linking of community agencies and support groups in treatment
• relapse prevention is stressed
• there are frequent home visits for therapy and monitoring of progress
• therapy is strength based and utilizes a variety of techniques including individual and group therapy, cognitive-behavioral interventions, supportive therapy, and even inpatient treatment if warranted

MST also incorporates the features outlined above, with the exception of program length. There are, to date, no published outcome studies on these programs, but a 74% abstinent rate for treatment completers was reported in the conference for the Bridge Program. Re-arrest rates of 5% 18 months after treatment were reported for the Escambia Drug Court participants. The Denver Integrated Treatment Network reported a 19% reduction in recidivism rates over 1 year for treatment completers.

Summary

In conclusion, there are limited studies concerning the outcome of adolescent chemical dependency treatment programs. Results of existing studies indicate that adolescent substance abuse appears to be a complex, but treatable problem. Although there is evidence for the efficacy of both inpatient and outpatient substance abuse treatment, no one specific modality of treatment has demonstrated consistent efficacy in promoting lasting long term decreases in adolescent substance use. Rather than advocating for a specific modality of treatment, research findings suggest that the inclusion of specific elements of treatment are essential for positive treatment outcomes. Several promising approaches to adolescent chemical dependency treatment currently exist. Regardless of the setting, inpatient or outpatient, programs that use comprehensive assessment procedures, address multiple problems using a team case management approach, stress family involvement, use cognitive-behavioral techniques, deliver services in the home, and provide continuing care appear to be the most effective in treating substance abuse.

Using a comprehensive assessment procedure to formulate individualized treatment plans, the CDDA program will offer four different treatment options to chemically dependent juveniles. These programs will be: detention based outpatient, inpatient treatment, comprehensive outpatient, or standard outpatient. Based on results of the previously mentioned research studies, each of these alternatives should include family, social-cognitive interventions and address problems in multiple areas of functioning. The programs should also provide a continuum of care with services available to CDDA adolescents for a 12 month period.

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E. Elements Of Effective Treatment

Based on a review of the literature it is recommended that all CDDA treatment programs, regardless of modality, should, ideally, include the following elements:

• treatment should be delivered in the least restrictive setting, while considering issues of community safety
• treatment should be comprehensive and address the problems identified by the evaluation process (e.g., psychiatric disturbance, sexual abuse)
• treatment must involve the family, or a family substitute, in all aspects of treatment planning, discharge, and continuing care recommendations
• family therapy and cognitive-behavioral therapy should be utilized
• general life skills, decision making, and coping skills education and training should be provided
• relapse prevention should be stressed
• treatment should be a continuum of care, meaning upon discharge from a program additional services are provided, in decreasing frequency, so that each adolescent will have services available for at least 12 months

Continuum of care

Reported relapse rates as high as 71% for adolescents 3-6 months following treatment indicate the need to provide additional support if abstinence is to be successfully maintained. Although results regarding aftercare have been inconsistent, the most promising recent treatment approaches for chemical dependency treatment of juvenile offenders include a continuum of care. It is recommended that all CDDA youth be provided with a 12 month treatment regimen since the most promising treatment programs provided a 12 month continuum of care. This 12 month period would include time spent in the primary treatment assignment (e.g., 30 days in detention based treatment, 90 days in inpatient treatment) and a continuum of care for the remaining 9-11 months. The intensity of treatment should vary over the 12 months based on the adolescent's individual needs and treatment plan. It is recommended that treatment services provided in the continuum of care utilize familial and community resources. Ideally, this would mean that:

• a team of individuals, including substance abuse treatment specialists, teachers, parents, probation officers and social service agency case managers, work in cooperation to provide a continuum of a care
• a proportion of the services be delivered in the home at the convenience of the family
• strengths of the family and adolescent are stressed in treatment
• a flexible approach involving numerous therapy techniques is taken in treating the family and adolescent
• prosocial behaviors are reinforced
• relapse prevention is stressed
• formation of a prosocial peer group is strongly encouraged
• urine drug screens are randomly taken on adolescents and if results are positive, the frequency of treatment is increased
• frequency of therapy slowly decreases over time, allowing for practice and monitoring of treatment gains and the degree to which those gains are integrated into daily community life

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F. Factors Effecting Treatment Response

Even if all elements believed essential for a positive treatment outcome are included in a chemical dependency treatment program there are several other factors that can effect results of outcome studies of substance abuse treatment. The motivation of adolescents treated can effect the overall outcome of the treatment program. Despite being placed in the most appropriate treatment regimen, if an adolescent is not motivated, or ready to change, treatment may have little effect on an adolescent's substance use. Furthermore, if the adolescent is not engaged in treatment and leaves treatment prematurely, he is more likely to continue substance use.

Two additional factors that may effect outcomes are methodological in nature. First, it is important that all individuals who entered the treatment program be contacted for follow-up evaluations. If only subjects who benefited from treatment are available for follow-up it may be incorrectly concluded that the treatment is generally effective. Treatment completion and dropout rates should be considered when interpreting outcome evaluation results. The follow-up rates of an outcome study should, ideally, be above 80%. Second, treatment programs must also actually deliver the services that they propose to provide. This is frequently referred to as treatment fidelity. If a program can not be successfully implemented it may demonstrate a negative outcome, but if the program had been successfully implemented it may have produced positive results. Many studies of chemical dependency treatment fail to evaluate what services were actually provided to patients.

1. Motivation for treatment and stages of change

The Transtheoretical Model of Change (TTM) states that individuals progress through five stages of change when altering behaviors: precontemplation, contemplation, preparation, action, and maintenance (Migneault, 1997). In this model of change it is also assumed that when acquiring a new behavior one increases the positive ratings of that behavior while decreasing the negative views of it. In ceasing a behavior one tends to increases the negative views of the behavior while decreasing the positive aspects. This balancing of the pros and cons of a behavior is referred to as using a decisional balance (Migneault, 1997). The TTM has been used to investigate many behaviors in adults, but has been used in few studies of behavior change in adolescents.

Only three studies to date have found that motivation level was useful in predicting treatment outcome for adolescents. Two studies done by Friedman and colleagues (1986, 1994) found, based on a few questions regarding the perceived importance of getting help for substance use problems, that greater motivation was associated with more positive outcomes and generally less treatment dropout. Interestingly, adolescents who were highly motivated to obtain employment reduced their levels of drug use less than those who were not interested in obtaining employment. It could be that these adolescents had more stressors and were self medicating or that they had more money for drugs and, therefore, had developed more severe substance use problems that were harder to treat (Friedman, 1994). A study of 234 adolescents revealed that a stronger desire for treatment was moderately associated with a lower frequency of drug use from intake to a 6 month follow-up and a higher likelihood of abstinence over the 6 month follow-up. When the sample was divided into high, medium and low levels of motivation/problem recognition, those with low levels of motivation were found to be more likely to use drugs during the follow-up period compared to those with high levels of motivation (54 vs. 29%). Being prepared to make changes at treatment intake was one of the best predictors of treatment progress (Cady, 1996). No relationship, however, was revealed between level of motivation and the number of days spent in treatment or the likelihood of completing treatment.

Assessing adolescents' level and nature of motivation and readiness for change for chemical dependency treatment is a complicated issue. Adolescents usually enter treatment under pressure from parents or an involved agency, such as JRA and frequently under-estimate the need for treatment and severity of their substance use at treatment entry. Furthermore, there are few established, reliable and valid instruments available for the assessment of motivation or readiness for change in adolescents. The two questionnaires that do exist for assessment of motivation in adolescents specifically, the Problem Recognition Questionnaire (Cady, 1996) and the Decisional Balance Inventory (Migneault, 1997) demonstrate some promise, but have been used only in limited populations. Further evaluation of these instruments is required in order to determine their usefulness in populations of chemically dependent juvenile offenders.

In adults there is an established relationship between intake level of motivation, readiness for change and treatment outcome. Some researchers believe that motivation should be assessed at intake and treatment should be tailored to the individual's readiness for change and motivation (Friedman, 1994). As can been seen from the research studies discussed above, results indicate that there is a moderate association between level of motivation and the degree of post-treatment drug use. Therefore, the adolescent's motivation is not the sole factor in determining outcome. An adolescent may have a desire to change their substance use, but not have the capacity or opportunity to make those changes (Friedman, 1994). The behavior of the therapist early on in treatment can also have a profound effect on the subsequent behaviors of the adolescent in treatment (Friedman, 1994; Kaminer, 1992). Therefore, it is not recommended by researchers that treatment be denied to individuals based on their level of motivation or readiness for change, but rather that this factor be considered when evaluating the adolescent's treatment outcome (Cady, 1996; Friedman, 1994; Migneault, 1997).

Given the paucity of research on adolescent motivation for chemical dependency treatment, especially with juvenile offenders, and the lack of established means to evaluate motivation, it is not recommended that assessment of motivation be required for the CDDA youth at this time. Currently WAC 440-22 requires the assessment of motivation for adolescents entering chemical dependency treatment programs. This measure of motivation can be utilized in an exploratory analysis of the relationship between motivation and treatment outcome of CDDA youth attending DASA approved programs which must comply with these standards.

2. Treatment completion and dropout

High dropout rates are a serious problem in chemical dependency treatment research. If an adolescent drops out of treatment they are more likely to return to their pre-treatment level of substance use than if they remain in treatment (Stinchfield, 1994). Treatment dropout can be viewed as a lack of motivation to change or possibly as a sign that treatment is not providing the adolescent with appropriate services (Henggeler, 1996). Typically, individuals who remain in treatment are easier to locate for follow-up evaluations, are more motivated to reduce their substance use and have better outcomes than those who fail to complete treatment (Stinchfield, 1994). Outcome results from extant studies with a significant number of non-contacted subjects (usually treatment dropouts) may over-estimate outcome and not be generalizable to the non-contacted group.

Research findings regarding the importance of specific factors in predicting adolescent treatment dropout are generally inconclusive, but do suggest that adolescents with moderate to severe levels of psychopathology are less likely to complete treatment compared to those with low levels of psychopathology (Feigelman, 1987; Stewart, 1994). Only one study has examined gender differences in dropout rates. A study of 93 males and 49 females in drug treatment, average age 16.4, found that for males five variables predicted treatment dropout; heavy alcohol and polydrug use, more self esteem problems, more peer problems, and less use of substances other than alcohol, tobacco, and marijuana were associated with high dropout rates. For females, less poly drug use, and greater self esteem problems were the primary factors associated with high dropout rates (Blood, 1994).

In order to decrease dropout rates several strategies have been attempted. Successful techniques include decreasing the waiting time to enter treatment, providing more frequent treatment contacts, utilizing therapists with high levels of commitment, and provision of concrete services and home visits. Multisystemic Therapy (MST), which is typically delivered in the home has reported completion rates as high as 98% for a 130 day treatment regimen (Henggeler, 1996). Other promising forms of treatment discussed in a recent OJJDP conference also make use of home visits to increase rates of treatment completion. Treatment retention and completion rates for adolescents with less severe substance use problems have been found to be highest for those treated in outpatient drug free settings. This is especially true for Caucasians (Friedman, 1986). A Washington State evaluation, however, found that treatment completion rates for youth treated in an intensive inpatient program (n=139) were higher (52%) than those for youth treated in a standard outpatient program (n= 435; 27%), or an intensive outpatient program (n= 525; 7%; Wickizer, 1992).

3. Treatment adherence

It can not necessarily be assumed that the services proposed to be delivered to adolescents in a treatment or intervention program are actually delivered. The level of compliance with program objectives is an essential component which can have an impact on the effectiveness of the program. For example, without evaluating treatment fidelity, an evaluation of the Child Developmental Project (CDP), an elementary school based intervention, found only limited evidence that the program reduced rates of alcohol and drug use. When treatment fidelity was considered results indicated that youth in programs with strong or moderate levels of program implementation demonstrated a greater decrease in alcohol and marijuana use compared to youth in the control programs (Battistich, 1996). This program would have been determined to be ineffective if treatment fidelity was not taken into consideration. The evaluation of the Nokomis Challenge Program discussed earlier, provides another example of the importance of assessing treatment fidelity. In that case, the proposed treatment services were not provided as assumed, resulting in the erroneous conclusion that the program was ineffective in treating substance abuse. Furthermore, the control group actually received more services than those in the Nokomis program (Deschenes, 1996).

Summary

Research indicates that in evaluating the efficacy of substance abuse treatment programs it is important to consider the degree to which the proposed services are actually delivered and treatment dropout/completion rates. Each of these factors can have an impact on treatment outcome. Information regarding motivation for change and readiness for treatment for adolescents entering chemical dependency treatment is relatively limited at this time and it is, therefore, not recommended that an evaluation of motivation be performed on CDDA youth.

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G. Elements of Program Effectiveness- Program Implementation and Integrity

It is recommended, based on this literature review, that treatment fidelity of the CDDA programs be evaluated at six month intervals, at least initially, to ensure that similar services are being delivered across programs (e.g., outpatient programs all provide the same type and intensity of services). Program implementation and integrity can be assessed by:

• the level of service adherence to treatment guidelines for chemical dependency treatment programs for CDDA youth

• the number of direct treatment hours provided
• the overall program completion and dropout rates
  • the degree to which adolescents and their families are satisfied with the treatment program
  • the degree to which the CDDA programs are successful in linking JRA supervision services, community-based services, and families (or family substitutes) in treatment of the youth

The agency's ability to meet regular deadlines will also have a bearing on the evaluation of its effectiveness. Regular reporting to Juvenile Rehabilitation Association, Division of Alcohol and Substance Abuse, and the University of Washington research team will be considered an essential element of a successful treatment program.

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