II. PREDICTORS OF ALCOHOL AND OTHER DRUG USE

Although treatment programs for adolescent substance abuse have proliferated over the last 10 years, there have been relatively few treatment efficacy studies of these programs. Results from the studies that do exist, provide little evidence as to the efficacy of any single approach for treatment of adolescent substance use problems. Across studies there is, however, consistent support for the view that individual characteristics, family, peer, and school variables contribute directly or indirectly to variance in chemical dependency treatment outcomes. The greater the number of risk factors the greater the risk for development of substance abuse and delinquency (Battistich, 1996; Hawkins, 1995). In general, factors influencing treatment outcome can be divided into two groups which are discussed in detail below. These two groups of variables are internal, or personal, variables related to the individual's functioning in a variety of domains (e.g. psychological, academic, interpersonal), and external, or environmental variables (e.g. family situation, peers, community setting).

A. Internal Factors

1. Developmental aspects

Substance use does not invariably lead to a diagnosis of substance abuse or dependence.

In a study of 49 males and 52 females followed from age 3-18, adolescents who had experimented with drugs and alcohol were found to be psychologically better adjusted (less anxious, greater social skills, more flexible) than adolescents who had never tried drugs or alcohol, and better adjusted than adolescents who became heavy users of alcohol and drugs (Shedler & Block, 1990). Research has demonstrated that there is a group of adolescents who try minor delinquent behaviors, such as shoplifting and drug use as part of normal rebelliousness during the maturational process. Among these 'normal' adolescents delinquent behavior typically peaks between 15-17, while drug involvement increases during the teen years and peaks in the early twenties. There is, however, another group of adolescents that becomes seriously involved in substance use and criminal activity during their youth and continues that involvement into adulthood. It is likely that there are different etiologies involved in the development of 'experimental substance use' and the more 'life persistent substance use' (Hawkins, 1995; Moffitt, 1993). It is also likely that the majority of JRA adolescents are not merely experimenting with substance use and criminal behavior as part of normal rebelliousness and development, but that these adolescents constitute the group at high risk for ongoing, or life persistent, involvement in substance use and criminal activity as adults.

For those adolescents that are at highest risk for on-going problematic substance use and criminal activity it has been found that the greater the variety, frequency, and seriousness of childhood delinquency prior to age 10, the greater the risk that substance use problems and delinquency will continue into adulthood (Dobkin, 1995; Hawkins, 1995). For females, delinquency often takes the form of truancy, sexual acting out, and prostitution. For males it is more likely to be stealing, aggressive or noncompliant behavior toward authority, sexual and criminal offenses, and academic problems (Moran, 1994).

2. Substance use history

The most important predictor of chemical dependency treatment outcome in adolescents is the severity of prior substance use (Dembo, 1994c, Braukmann, 1985). Early onset of substance use has been associated with more severe psychiatric disorders, more family problems, more academic and occupational problems, greater health problems, and heavier substance use in mid-adolescence (Mezzich, 1992). An earlier age of onset of substance use, greater frequency of recent substance use, and use of drugs other than alcohol or marijuana have all been associated with negative treatment outcomes regardless of the treatment modality (Hawkins, 1995). Adolescents who begin drinking at a younger age (9 years old) report more days of binge drinking and more drinking in the month preceding incarceration than adolescents who began drinking at a later age (Morris, 1995). Adolescents with severe substance use problems tend to be older, and have used drugs for a longer time than those without substance use problems and this is especially true for males (King, 1996). Somewhat surprising is the finding that younger adolescents (12-14 years old) report more LSD and PCP use compared to older adolescents (15-17). Younger adolescents have also been found to be more likely to receive a DSM-III-R (an earlier version of the Diagnostic and Statistical Manual of Mental Disorders) polydrug abuse or dependence diagnosis compared to older counterparts (Westermeyer, 1994). Certainly young adolescents with substance use problems are at very high risk for exacerbation of drug use and its concomitant problems.

It has been well documented that alcohol is the drug most frequently involved in violent offenses such as assault and murder (U.S. Department of Justice, 1996). As many as 50% of adolescent and young adult murderers report that they were involved with alcohol at the time of their crime and that alcohol use had effected their impulse control (Fendrich, 1995). Recently a connection between marijuana use and delinquency has been reported. A study of juvenile detainees found that individuals whose urine drug screens were positive for marijuana at the time of arrest had twice as many prior non-drug felony arrests compared to juveniles whose drug screens were negative for marijuana. The authors of this study suggest that for adolescents entering the juvenile justice system, heavy marijuana/hashish use may be a marker for serious future delinquency and deepening drug use (Dembo, 1991).

One consistent finding in research on adolescents is that although females typically begin drinking at a later age than males, drinking patterns of males and females do not differ significantly (Morris, 1995; Opland, 1995; Mezzich, 1994). It has also been found in an evaluation of 40 females and 42 males with substance abuse or dependence and conduct disorder diagnoses, recruited from drug treatment and juvenile detention centers, that there were no gender differences in rates of substance use disorder diagnoses or patterns of marijuana use. Results also indicated that generally the first drug used by females is tobacco, while for males it is alcohol (Mezzich, 1994). Gender differences in the use of drugs other than alcohol and marijuana have been reported in the literature.

A study of 1,574 male and 219 female incarcerated adolescents (mean age 15) found that females reported more use of cocaine (42% vs. 30%), crack (9.6% vs. 3.3%), LSD and sedatives (25.6% vs. 13.1% ) compared to males. Females also reported beginning use of these drugs at an earlier age than the males (Morris, 1995). For 820 females and 1,461 males with a diagnosis of substance abuse, however, males reported more use of LSD, other psychedelics, and marijuana compared to females (Opland, 1995). Males in this study also reported using marijuana at a significantly earlier age compared to females. Females reported using drugs for emotional escape more than males. Generally, fewer gender differences in substance use patterns are found in adolescents in chemical dependency treatment than those found in high school populations.

A recent study in Washington State of adolescents treated in residential treatment facilities found that the two most commonly used drugs were marijuana (92%) and alcohol (78%), followed by hallucinogens (20%), methamphetamine (11%), and cocaine/crack (11%) (Peterson, 1997). A significantly larger proportion of females than males reported using methamphetamine (22% vs. 5%). Significant gender differences also existed for the primary drug of choice with males more likely to report marijuana as their primary drug of choice (79% vs. 48%) and females more likely to report that alcohol was their primary drug of choice (31% vs. 12%).

A contradiction, appears to exist in the literature concerning adolescent substance use problems. Although African Americans are described as suffering most from substance use problems, they appear to have lower rates of substance use relative to other racial groups (Morris, 1995; Van Hasselt, 1993). Generally, the highest rates of substance use problems are reported by Caucasians and Native Americans, and the lowest by African Americans (Morris, 1995; Van Hasselt, 1993). Yet in a study of 1,801 adolescents, relative to Caucasians, African American adolescents were more likely to have been arrested for drunkenness, be victims of alcohol related homicide, and have been incarcerated for alcohol and drug related crimes (Morris, 1995). Adolescent drug use is perhaps the issue of most concern to African Americans (Van Hasselt, 1993). The finding that African American youth have lower rates of substance use is most likely due to the fact that most surveys of adolescent substance use are done in middle class high schools. African Americans are not well represented in these samples due to their higher school dropout rates and lower economic resources (Van Hasselt, 1993). African Americans who are in school are likely to be better functioning and less drug involved than those who have dropped out of school.

The aforementioned studies point to the importance of a detailed assessment of substance use in adolescents. The number of substances used, the frequency (e.g., number of days), and the intensity (amount of a substance used per episode of use) should all be assessed in the CDDA youth at entry to treatment and at each follow-up evaluation. Other indicators of substance use problems that should be measured are the number of convictions for drug related crimes and the number of additional admissions to a substance abuse treatment program following treatment. The proportion of positive urinalysis results for an adolescent can also be used as a measure of substance use severity.

a. Substance Use Relapse

There has been limited evaluation of the cyclical nature of relapse in teenagers (Brown, 1990; Myers, 1993). Although the goal of drug treatment is abstinence the majority of adolescents will have some continued use of alcohol or drugs before obtaining total abstinence. A recent study of 139 adolescents who completed an inpatient substance abuse treatment program found that 86% of the youth experienced at least one relapse during the year following treatment (Myers, 1996). Given that most adolescents in the CDDA program will not be entering treatment of their own free will, it is important to realize that not all adolescents will have total abstinence as a treatment goal.

The cognitive-behavioral model of relapse is based on social learning theory. This model states that certain stressful situations in which an individual has inadequate resources to cope will increase the probability of relapse. Additionally, an individual's response to an episode of occasional use or a lapse will influence subsequent relapse. The model proposes that attributing a lapse to personal failure or a lack of control leads to the expectation of unsuccessful coping in the future, making further use more likely. An emotional reaction of guilt or self-blame also promotes continued use following a lapse. A larger repertoire of problem-and-emotion focused coping skills should, therefore, enable an individual to cope more effectively with stressful situations and avoid relapses (Myers, 1993). It is important to measure more than simply whether or not a youth has remained abstinent. Relapse to any drug or alcohol use is not necessarily the same as a return to problematic use. As described below some studies have made distinctions regarding gradations of relapse.

A study of factors related to relapse was done with 25 females and 32 males 6 months after they had completed an alcohol treatment program. In this study a lapse was considered to be any substance use as long as it did not occur for four or more consecutive days and amounted to less than a total of 30 days over a 6 month follow-up. A relapse was defined as at least 4 consecutive days of use with a brief relapse consisting of 14 or fewer days of consecutive use, and a severe relapse defined as 30 days of consecutive use. Extended abstinence was defined as 30 days of non-use. Social support was the biggest influence on the initial length of abstinence obtained. Abstainers had the fewest peers who continued to use drugs or alcohol, while the relapsers had the highest rates (Brown, 1993). Contradicting the idea that relapsers are exposed to more stressful situations, results found that adolescents who abstained from substance use for 6 months following treatment actually reported more stressful life events compared to those who had major relapses (Brown, 1993). There was a significant relationship between type of coping and total days of alcohol or other drug use, but the type of coping used did not predict categories of use such as minor relapser, major relapser. Use of wishful thinking (e.g., Wish I were a stronger person, Wish I could change what happened) was associated with more total days of use during the 6 month follow-up. Self blame was not found to be an important factor in relapses (Brown, 1993).

3. Academic and vocational functioning

Truancy and school dropout are associated with delinquency and substance use problems (Dembo, 1996; Hawkins, 1995; Ingersoll, 1997; Eggert, 1994). Youths who experience academic success are less likely to be involved in substance use and delinquent behaviors than those with poor academic performance. A study of 2,104 adolescents, average age 15, entering the Juvenile Assessment Center (JAC) in Tampa, Florida (Dembo, 1996) found that although 72% of the sample were still attending school, only 14% were at the age appropriate grade. It is estimated that the rate of substance abuse and corresponding need for treatment is 50% higher in school dropouts than among high school students (Joanning, 1992). A study of 1,000 high school students revealed that risk factors for truancy include low levels of self esteem and personal satisfaction, parental strain such as divorce or separation, and strong bonds with deviant peers (Eggert, 1994). Additionally, academic and behavioral problems at the end of elementary school, but not in grades 1-3, have been found to predict academic and behavioral problems such as substance abuse and delinquency in adolescence.

It is believed by some that adolescents turn to crime and selling drugs as a means of employment not enjoyment (Bradley, 1996). For students with academic under-performance school-to-work programs, which provide academic and job training or career academy programs have demonstrated some success in reducing delinquency and substance use problems. These programs allow the youth to focus efforts on getting a job in a particular area such as nursing or emergency service rather than going to college. Successful school-to-work programs also supply mentoring, intensive counseling, and a curriculum based on real life learning (Ingersoll, 1997). Unemployment and/or a lack of self sufficiency reduces an individual's self esteem. Therefore, new drug treatment programs need to address occupational issues whether using mentoring, tutoring, or some other program to enhance the employability of youth (Bradley, 1996).

While impairment in school performance has been found to differentiate substance abusing females from non-substance abusing females, this is not true for males (King, 1996). With regard to racial differences in academic performance, over a third of African Americans 18-19 years old have dropped out of school. African American's lower perceived benefit of education may be, in part, responsible for poor academic performance (Van Hasselt, 1993).

Clearly there is a strong association between academic performance and substance use. An important outcome of CDDA treatment programs should, therefore, be improved academic performance. Important variables to evaluate include changes in treated adolescents' truancy rates (including skipping classes and the general patterns of school attendance), the number of disciplinary problems incurred, as well as grades. If an adolescent is employed it is expected that effective treatment should also improve vocational functioning. Measures of vocational functioning which should be evaluated include fewer absences (including arriving late or leaving early) from work related to substance use, fewer disciplinary actions, and a more positive relationship with co-workers.

4. Sexual/Physical/Emotional Abuse

Higher rates of substance abuse are reported by teenagers who were abused compared to non-abused teenagers. Roughly a third of female and 17% of male adolescents in substance abuse treatment report some form of sexual or physical abuse (Moran, 1994). Females are more likely to respond to abuse with depression or somatization while males respond with hostility and acting out behaviors. In other words females turn negative feelings inward while males are more likely to externalize their negative feelings (Moran, 1994). These differences are probably a factor of socialization differences that intensify during puberty. Abused female adolescents are also more likely to run away, spend time in detention, and be heavy drug users compared to non-maltreated females. Males who report sexual abuse have significantly higher levels of hostility, interpersonal sensitivity, behavioral problems, and obsessive compulsiveness, but not more drug use, compared to college aged peers with no history of abuse (Moran, 1994).

5. Interpersonal relationships

A 15 year study of youth in San Francisco reported that frequent substance users were more interpersonally alienated, emotionally withdrawn, and manifestly unhappy compared to non-drug users (Moran, 1994). It has also been found that interpersonal alienation at an early age predicts frequent use of marijuana at age 18 (Shedler, 1990). For females, earlier involvement with males can also be a risk factor for development of substance abuse and delinquency (King, 1996). Females with substance use problems are found to be more involved with opposite sex partners compared to non-substance using females, but this is not the case for male adolescents. It has been proposed that females who mature earlier (earlier age of menarche and development of secondary sexual characteristics) are more likely to be assimilated into older opposite sex peer groups. Since these older age peers are more likely to be involved with substance use this association places the adolescent female at greater risk for early substance use (Moffitt, 1993). A study of 28 females, average age 16, recruited from inpatient and outpatient drug clinics, however, found no significant relationship between the age of menarche with age of onset of drug use, frequency of alcohol use, or severity of substance use (Mezzich, 1992).

Studies have also demonstrated that those adolescents who are able to maintain abstinence after treatment tend to have the least exposure to peers who continue to use drugs or alcohol, while those that relapsed had the highest number of peers who continued to use drugs (Brown, 1990;1993).

Studies to date have not addressed racial differences in regard to the significance of interpersonal relationships in the development of substance use problems and/or delinquency.

Decreased feelings of interpersonal alienation should be considered a goal of chemical dependency programs for CDDA youth, since individuals who are less interpersonally alienated appear to be less likely to be substance users. It will also be important to evaluate the relative amount of time that an adolescent spends with substance abusing peers, as this increases the likelihood of relapse. Establishing relationships with prosocial non-substance peers could also be considered a result of an effective treatment program.

6. Sexual activity

Most youth in a juvenile justice setting are sexually active, have had multiple partners, and have engaged in unprotected sex. In 1990 the Juvenile Court Health Services in Los Angeles County surveyed 1,754 newly admitted juvenile detainees, 14.3% female, and found that 97% of males and 94% of females were sexually active and reported an average of 15 different prior sexual partners (Morris, 1992). Two-thirds of these youths reported never having used condoms. A 1991 survey studied AIDS awareness and knowledge among 219 females and 1,574 males (average age 15) incarcerated in either a short term (less than 3 months, n=451) or a long term facility (n=1,350). Knowledge of AIDS was poor; 15% reported that you could get AIDS from a mosquito, 21.3% were unsure if that was true, and 8.3% believed that you could get AIDS from a drinking glass (Morris, 1995). This was despite the fact that 86.4% of the facilities surveyed provided comprehensive AIDS education. In a 1995 study of 171 juveniles entering a detention center in Virginia, rates of sexually transmitted diseases were significantly higher in females compared to males (65-75% of females tested positive for a sexually transmitted disease compared to 9% of males). Since there was no significant difference in the rates of sexual activity between males and females (76% and 60% respectively), it was hypothesized that differences were due to the fact that females tended to have older age sex partners. These differences may also be because females appear to have greater physiological susceptibility to sexually transmitted diseases compared to males. Female gang members are an especially high risk group as they report high rates of sexual activity and little use of protection in sexual intercourse (Bjerregaard, 1993). Detained youths appear to begin involvement in risky behaviors early on and require early prevention programs regarding the risks for contracting sexually transmitted diseases.

Health care issues, in general, are more prominent for female juvenile delinquents than for males. Female juvenile delinquents use the health care system more than males and used more 'sick calls' compared to males. This is most probably a result of higher rates of somatization in the females while males have higher rates of acting out behaviors (Juvenile Justice Programs and Trends, 1996).

A goal of chemical dependency programs for CDDA youth should be to reduce the frequency of unprotected sexual activity in treated adolescents. Given the serious, and potentially life threatening, risks associated with unprotected sexual behavior, discouraging unprotected sexual activity could not only save the adolescent's life, but also could substantially reduce future health care costs.

7. Psychopathology

In the general adolescent population a strong correlation between substance use and other psychiatric problems is found. Substance use problems in 'normal' adolescents have been associated with high rates of antisocial behavior, depressive disorders, attention deficit hyperactivity disorder (ADHD), risk taking and sensation seeking behavior, borderline personality disorder, and suicide (Hawkins, 1995; Grilo, 1995; Neighbors, 1992). A 1997 evaluation of 192 youth served by residential chemical treatment facilities in Washington State found that 65% had received mental health services prior to treatment and that 45% were on some type of prescription medicine for mental health problems (Peterson, 1997).

Treatment outcome studies of adolescents in chemical dependence treatment have found that problems such as mood disorders, conduct disorder, paranoid ideation, and hostility are related to treatment outcome. Results are inconsistent; however, some studies report that adolescents with moderate to high levels of psychiatric severity have more positive treatment outcomes compared to those with low levels of psychiatric problems (Friedman, 1987), while other studies find that more psychiatric problems are related to poorer treatment outcome (Friedman, 1996).

Two pathways in the development of substance use problems have been proposed. The first, 'negative affect alcoholism/substance abuse' proposes that psychiatric symptoms, such as depression, precede substance use. Substance use may occur as a means of relieving or 'medicating' those symptoms. Substance use, however, usually exacerbates these symptoms and ultimately results in greater emotional distress and more overall problems. It has been suggested that this may be the more common pathway for female adolescents (Mezzich, 1992).

The second theory, 'antisocial substance abuse' or 'general deviance syndrome' proposes that substance use is just one of multiple deviant behaviors that are manifest in childhood and adolescence. Substance use, in this theory, is viewed as preceding the onset of psychiatric symptoms. Psychiatric symptoms develop as a result of substance use and other deviant behaviors. This may be the more common pathway to substance use problems and delinquency for males (Mezzich, 1992; Thomas, 1996).

It should be noted that females in the general population have rates of depressive disorders 2-3 times higher than those found in males, but males' rates of delinquency are 5-6 times those found in females. In the general population and in treatment settings, African Americans are less likely to meet criteria for psychiatric diagnoses compared to other racial groups. It appears that although African Americans are faced with greater stress and more risk factors for the development of substance abuse and delinquency (e.g. lower economic resources, more violence and drug use in community), they appear to be more resilient to the cumulative effects of those stressors compared to other racial groups (Vega, 1993).

a. Mood disorders

In chemical dependency treatment programs rates of major depression range from 25-50% (Dembo, 1994b; Mezzich, 1995). It has also been found that among adolescents being treated for severe emotional disturbance the rates of co-existing substance use problems are as high as 48% (Dembo, 1996; King, 1996). The more severe the alcohol and substance use, especially poly-drug use, the higher the rates of depression (Dembo, 1996; Neighbors, 1992). The more severe the depression, the higher the risk for suicide (Dembo, 1996; Eggert, 1994; Neighbors, 1992; King, 1996).

As with adult females, female adolescents are more likely than males to be diagnosed with a mood disorder (Vega, 1993; Thomas, 1996). In female, but not male, adolescents substance use has been linked to prolonged depressive episodes (King, 1996). Females with substance use problems also exhibit higher rates of suicidal thoughts, plans, and attempts compared to males (Thomas, 1996).

Compared to African Americans, Caucasians are reported to have higher rates of depression, suicidal thoughts and actions (Thomas, 1996). In a sample of adolescents at a juvenile assessment center in Florida, African Americans and Caucasians reported similar degrees of emotional distress and substance use, but twice as many Caucasians compared to African Americans had received prior mental health treatment and three times as many Caucasians had received prior drug treatment (Dembo, 1995). These results suggest that African American adolescents' emotional distress and drug use may not be as problematic for them, but it is also possible that they may in fact require mental health and drug treatment services as much as Caucasians. For African Americans, access to mental health or drug treatment services may be limited by their financial resources or by a lack of availability of such services in their communities. It is also possible that seeking formal mental health services is even less socially acceptable to African Americans than Caucasians, especially given that the majority of service providers tend to be middle class Caucasians (Vargas, 1991).

Depression and suicide are major areas of concern for American Indians and Alaskan Native youth (Dinges, 1993). Results of a study of 124 American Indians and Alaskan Native youth (average age 16) with a diagnosis of depressive disorder found that 76% of the sample received another psychiatric diagnosis. Results also indicate that in these populations, depression precedes substance use problems. Family/parent conflicts and loss of cultural supports were strongly associated with the development of depression, suicidal ideation and suicide attempts in these populations (Dinges, 1993). Individuals in this study were not in a residential hospital setting, but rather in a boarding school that was not well equipped to deal with the adolescents' mental health needs. It will be of utmost importance to assess American Indians and Alaskan Native youth in the CDDA project for depression and suicide risk. Additionally, the family bonds and tribal views on mental health treatment should be taken into consideration when determining treatment placements.

b. Conduct disorder

Conduct disorder (CD) is defined by a pattern of violating the rights of others or violating societal norms and rules. Research demonstrates that CD frequently co-occurs with substance use problems (King, 1996). In a study of 76 male and 62 female adolescents, average age 15, it was found that CD was diagnosed more frequently in patients with substance abuse diagnoses compared to those without substance abuse diagnoses (75.4% vs. 34.8%; Grilo, 1995). It has also been found that the greater the number of CD symptoms the more severe the substance use problem will be (Grilo, 1995; Neighbors, 1992). Results suggest that in many adolescents CD precedes substance use (Riggs, 1995). Individuals that have CD preceding substance use problems may also be the individuals at highest risk for ongoing delinquency and drug use in adulthood.

CD has been found to be more common among adolescent males compared to females (Neighbors, 1992, Dembo, 1995). Interestingly, the presence of CD differentiates between substance and non-substance abusing female adolescents, but not between substance and non-substance abusing male adolescents (King, 1996). CD and alcohol and other drug abuse appear more tightly linked in females than male adolescents (King, 1996). In many delinquent males CD has been found to precede the development of depression and substance abuse (Riggs, 1995). To our knowledge, there is no research indicating racial differences in the rates of CD.

c. Attention Deficit Hyperactivity Disorder (ADHD)

Many adult addicts have reported having difficulties with hyperactivity as children (Meyer, 1992). This finding has resulted in increased study of the relationship of ADHD to substance abuse and CD in children and adolescents. The inability to concentrate and focus can lead to academic difficulties which in turn relates to a higher risk for development of substance use problems. It has also been suggested that for many adolescents ADHD may be associated with earlier onset of CD, depression and substance use (Riggs, 1995). It is currently believed that the combination of ADHD and CD together places a child at greater risk for substance abuse than the presence of either CD or ADHD alone (Bukstein, 1995). Studies of ADHD in adolescents with substance use problems are currently limited to examining co-morbidity of ADHD and substance use. A study of 1,613 normal youth aged 9-12 found that attention problems were second only to delinquency in predicting the development of problems such as substance use, police contacts, school performance problems, and use of mental health services by youth recruited over a 6 year period (Achenbach, 1995). As with CD, rates of ADHD are five times greater in males than in females. No studies have, to our knowledge, evaluated the impact of ADHD on chemical dependency treatment outcomes. No research to date has examined racial differences in rates of ADHD.

d. Aggression and Alienation

Unlike other predictors previously discussed, most research on aggressiveness does describe gender differences. Research has found that childhood aggressive behavior may be an indicator of adolescent problems. In a sample of 250 African American first graders there was a strong positive correlation between male aggressiveness and level of substance use 10 years later (Hawkins, 1995). Young males appear to be at greatest risk for assaultive violence as they feel the need to prove their manhood (Thomas, 1996).

Research demonstrates that the more severe the drug use the more likely an adolescent is to be involved in fighting (10-20% higher than non drug users; Thomas, 1996). A study of 412 males and 384 females followed from grades 9-12 which assessed beliefs about alcohol use, the age of onset of alcohol, tobacco, and other drug use, and frequency of adverse consequences resulting from substance use, found that aggressiveness and alienation were related to the age of onset of substance use and the frequency of adverse consequences experienced from substance use. Gender differences regarding the impact of alienation with the degree of use, age of onset, and problems associated with substance use were found. Males with low levels of alienation were less likely to use drugs and alcohol compared to males with high levels of alienation. Alienation appeared to be a protective factor for females with regard to onset, degree of use and to a lesser degree, the consequences of use, but had little effect in males on any of these variables. A direct effect between pro-use beliefs regarding drug and alcohol use with the age of onset for drug and alcohol use was found for males, but not for females (Thomas, 1996).

Gang members account for a disproportionate amount of adolescent aggressive and criminal behavior (Juvenile Justice Programs and Trends, 1996). In the Rochester Youth Development study 262 female and 707 male adolescents (67.6% African American) were surveyed at age 13-15 and then 6 months after an intervention. Results indicated that gang members were more likely than non-gang members to have been involved in substance use and delinquency. Risk factors associated with gang membership included low self esteem, poverty, and feeling alienated from family and peers. A study by Elliott (1985) also found that feeling alienated from family and school predicted association with deviant peers (Bjerraard, 1993). The association with deviant peers in turn related to higher rates of substance use and criminal activity as well as gang membership. The possibility of increased sexual activity and membership in a strong peer group were two main reasons reported for choosing to belong to a gang. One gender difference found for gang members was that male gang members had much lower expectations of doing well in school compared to females (Bjerraard, 1993).

With regard to racial differences, in a study of 1,801 detained youth it was found that North American Indians and 'other' racial groups were the most likely (87.1% and 77%) to have been involved in at least one fight during the last year, while Asians were the least likely to have been involved in fights (37.5%; Morris, 1996). North American Native Indians were, however, least likely (35.4%) to be involved with a gang, while Asians were the most likely (65.6%).

Summary

The severity of co-morbid psychopathology can have a profound effect on an adolescent's chemical dependency treatment; therefore, it is important that psychological functioning of CDDA youth be assessed. However, since a thorough psychological evaluation can be costly and time consuming, it may not be possible to perform a full psychological evaluation on every CDDA adolescent to determine the presence or absence of major depression, ADHD, and conduct disorder. In the case of depression, an alternative assessment strategy is to assess depressive symptomatology, such as the number of days that an adolescent has felt depressed or had suicidal thoughts and measure the change in these symptoms from treatment entry to the follow-up evaluations. In the case of ADHD and conduct disorder a similar strategy can be utilized. Adolescents can be queried regarding their ability to focus and concentrate on a task (an indication of the possible presence of ADHD) and school functioning can also be used as an indication of problems in concentration. The presence of behavioral problems associated with conduct disorder (such as theft, violation of curfew) can be evaluated by a series of questions given at entry to treatment and then re-assessed at each follow-up point. The number of aggressive acts that the adolescent engages in over the follow-up periods can be used as an indicator of level of aggressiveness and hostility.

The degree of alienation felt by an adolescent can be ascertained from questions regarding the number of friends that they currently have, how they are getting along with their parents and siblings, and in general by asking directly about the degree of alienation that they experience in relation to their peers and friends (e.g., I feel that I am liked by my classmates). These procedures, as well as considering the number of hospitalizations or treatments for psychological problems, and use of psychiatric medications can all be used to assess general psychological functioning.

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B. External Factors

1. Familial factors

In general, adolescents' overall adjustment is related to the nature of their family environment (Brown, 1990). Negative family functioning is the strongest predictor of substance use and other problems (Friedman, 1991,1995; Rhodes, 1990).

Parenting styles have been linked to substance abuse and delinquency (Stice, 1993; Brown, 1990; Tarter, 1993). Parenting ordinarily consists of two elements, control and support. Disturbances in either area can cause problems with regard to substance use problems and delinquency (Stice, 1993; Brown, 1990). A study of 214 female and 240 male adolescents, ages 10.5-15.5, found that adolescents who were raised with either extreme parental control or extreme parental support were at greater risk for developing problem behaviors such as substance abuse (Stice, 1993). There is also some evidence that poor parental supervision and inconsistent discipline practices are predictive of substance use problems and delinquency (Dobkin, 1995; Hawkins, 1995; Dishion, 1988).

Conflict in families seems more salient than a broken home per se in the development of substance use and delinquency (Hawkins, 1995). Divorce or separation in the last year, loss of employment in last year, low level head of household occupation, and being abused in the family are all familial stressors found to be related to adolescent substance use (Hawkins, 1995; Stice, 1993; Brown, 1990).

Although there can be a genetic predisposition to developing an addiction, exposure to problem behaviors in the family may be a stronger predictor of an adolescent developing problem behaviors. If an adolescent's parent(s) or siblings are involved in substance use they are more likely to develop a substance use problem than an adolescent whose family does not currently engage in substance use. Furthermore, having a parent or sibling convicted of a crime, or involved in delinquent behaviors is predictive of adolescent criminal involvement (Hawkins, 1995; Dishion, 1988).

Few studies have addressed gender and racial differences in relation to familial factors and development of substance use and delinquency. Familial factors do appear to be more important in the development of substance use in females than males (Friedman, 1991,1995; Hawkins, 1995). The extended family living arrangement, common among African Americans, appears to provide augmented support and resources for the family and is associated with reductions in deviant behaviors. Involvement of the family is crucial in implementing behavioral change in inner city African Americans who rely heavily on their families for support (Van Hasselt, 1993).

There are limited investigations of the relationship between familial variables and adolescent chemical dependency treatment outcomes. Studies have found that a positive description of one's family is associated with better treatment outcome (Friedman, 1991; Stice, 1993). Research shows that family involvement during residential or outpatient treatment is associated with more positive outcomes, and the shorter the residential stay the less disruption to the family bond and community support systems. This results in a greater chance of the adolescent integrating positive gains made in treatment into their community life (Juvenile Justice Programs and Trends, 1996). Having a family environment that is supportive of an adolescent obtaining independence was found in one study to be the best single predictor of improvement in substance abuse treatment (Friedman, 1991).

Genetic risk has not been directly associated with treatment outcome for adolescents, but level of pretreatment exposure to substance abuse has been linked to poorer treatment outcomes. In a 6 month follow-up of adolescents treated for substance abuse, abstainers reported the least exposure to familial alcohol and drug use while major relapsers reported the greatest exposure (Brown, 1990). Results of one study reported that African Americans and Hispanics were more likely than other racial groups to report family substance use (Vega, 1993).

A reduction in family conflicts that arise because of, or related to, an adolescent's substance use problems should be reduced as a result of an effective treatment intervention. A decreased number of adolescent runaway episodes, and an improved rating of parental satisfaction with their adolescent's behavior can be viewed as indicators of reduced family conflict.

2. Poverty

Extreme social and economic deprivation are related to the development of substance use and delinquency (Hawkins, 1995). Poverty places children at risk for school dropout, serious delinquency and substance use. Over one half of students from poor families do not graduate from high school (O'Donnell, 1995). Poverty is associated with fewer coping skills and more potential for family violence, child abuse, and neglect (Van Hasselt, 1993). Living in neighborhoods with high population density and high rates of criminal behavior have also been identified as a predictor of criminal behavior and to a lesser degree substance abuse (Hawkins, 1995). Length of residence in a community is related to the degree of social bonding in individuals and this in turn is predictive of delinquency and related problems (O'Donnell, 1995).

African Americans are exposed to greater risk for substance abuse with regard to living situations compared to Caucasians. Over 35% of African American families live at or below the poverty level. Compared to Caucasians, a greater proportion of African Americans have no working head of the household (33% vs. 14%). While 62% of African American families are divorced, separated, widowed, or never married this is true of only 33% for Caucasian families. Additionally, more African American children are born to unwed mothers (58%) or adolescent mothers (28%) than in Caucasians (28% and 14% respectively; Van Hasselt, 1993). All of these factors are associated with increased risk for substance use.

Summary

Substance use in adolescents is a complex issue. In order to effectively treat substance use problems, multiple areas need to be addressed. Improved functioning in areas such as school performance, peer and family relationships, and psychopathology serve to decrease risk factors associated with development of protracted substance use while increasing protective factors that decrease the likelihood of continued problematic substance use. Based on the aforementioned research studies an effective substance abuse treatment program should result in improvements in several areas of functioning. Improvements in these areas of functioning will be measured by the effectiveness standards listed below.

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C. Effectiveness Standards: Changes in Adolescent Behavior

1. Reductions in substance use will be assessed by:

• the frequency of substance use; the primary measure will be a reduction in the total number of days of substance use over the intervening period
• the intensity of substance use; the primary measure will be a reduction in the number of times a day a drug is used
• the number of substances an individual currently uses
• the proportion of positive urinalyses collected over the intervening period
• the number of re-convictions for alcohol or drug related offenses in the intervening period
• re-admission to a chemical dependency treatment program (detox, inpatient, or outpatient) over the intervening period
• the number of emergency room visits
• the number of inpatient medical hospitalizations