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SAMHSA Creates Resources for Teen Substance Abuse Treatment

By Rebecca A. Clay

The idea that adolescents need specialized substance abuse treatment—treatment different from that offered to adults—emerged from the field only within the past 20 years. Since then, many programs for treating adolescents have been established. But which ones work?

"In the past, these programs haven't had the money for evaluation," said Randolph D. Muck, M.Ed., Team Leader for Adolescent Programs in the Division of Services Improvement at SAMHSA's Center for Substance Abuse Treatment (CSAT). "They've had no way of knowing whether they were doing any good and neither did anyone else. They might claim success, but those claims were mostly based on anecdotal evidence."

To address this lack of information, CSAT launched the Adolescent Treatment Models (ATM) project in 1998 to identify promising programs at 10 sites and evaluate their effectiveness. Although the project is not yet completed, the programs—based on a wide variety of models—all show positive preliminary results.

A Research Gap

Adolescents have special needs that differ from adults. Motivation, for instance, can be a special problem for adolescents. They're much more likely than adults to be in treatment under duress and less likely to see their substance use as a problem.

In the late 1990s, practitioners started developing programs designed to meet these and other challenges. However, there were few evaluations of these programs. Those that did exist were marred by unstandardized approaches, small sample sizes, and inadequate followup.

Cover of Adolescent Substance Abuse Treatment in the United States written by Sally J. Stevens, Ph.D. and Andrew R. Morral, Ph.D. That started to change in 1997 with CSAT's Cannabis Youth Treatment (CYT) study. This large-scale program took five theory-based outpatient models for treating adolescent marijuana use, put them into practice, and evaluated their effectiveness. CSAT found that these models reduced adolescent substance abuse dramatically.

Following this study, CSAT staff decided to test and compare the effectiveness of several already existing treatment programs for adolescent drug use, including drugs other than marijuana. The result was the ATM project. Collecting a core set of the same data as the CYT study, the ATM project evaluated a wide range of existing programs that appeared promising. Models included inpatient and residential treatment programs as well as outpatient programs.

Drawing on the experience of approximately 2,000 adolescents, grantees collected data about substance abuse and other areas of interest at baseline, 6 months, and 12 months after the initial assessment.

Documenting Effectiveness

To the researchers' surprise, the ATM programs were just as effective as the CYT programs.

"Programs already in use typically have limited resources, haven't gone through a lot of rigorous evaluation, and are loosely based on theory," said Mr. Muck. "We figured that CYT would have better outcomes than the ATM projects, but that didn't turn out to be the case."

Overall, the ATM programs produced fairly substantial reductions in adolescents' substance use, emotional problems, and illegal activities in the year following intake, according to Michael L. Dennis, Ph.D., Director of the project's Data Coordinating Center and senior research psychologist at Chestnut Health Systems. There was a 50- to 60-percent reduction in the number of days adolescents used drugs, for example.

That's good news, according to Dr. Dennis. Although most parents and policymakers hope for zero drug use post-treatment, he explained, complete recovery isn't a very realistic goal without lots of aftercare. "Many people evaluate treatment as if substance abuse is an acute problem like a broken leg," he said. "What we need to do is switch to a chronic disease model. We'll see, as with cancer or hepatitis, that they're moving in and out of recovery."

That's especially true for adolescents, who tend to cycle in and out of recovery more than adults. In the ATM project, 20 to 30 percent of the adolescents were in recovery at the 1-year point, but more than two-thirds had periods of recovery during the year.

The project also found that different levels of treatment intensity produced different patterns of recovery. For adolescents in residential programs, drug use tended to drop off quickly and then start climbing again. Adolescents in outpatient treatment didn't see that kind of dramatic short-term reduction but instead reduced their use gradually. However, all the adolescents—whether in short-term residential, long-term residential, or outpatient treatment—ultimately achieved a similar level of recovery at the 1-year point.

Next Steps

While awaiting additional analysis and additional data, CSAT already is supporting efforts to make information about these models available to the field.

Photo of 3 adolescents Two of the ATM principal investigators have edited a book called Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study.

"All of us were struck by how little information there was about the real nuts and bolts of [adolescent treatment] programs," said co-editor Andrew R. Morral, Ph.D., principal investigator for the Phoenix Academy project and senior behavioral scientist at RAND's Drug Policy Research Center in Arlington, VA. "You could find programs' names in directories, but you wouldn't know what was in them." The book addresses this paucity of information by offering detailed descriptions of the ATM projects. Grantees are also preparing manuals describing their models so that other programs can replicate them.

New Avenues

The ATM results are also prompting new avenues of inquiry. "Now that we recognize that adolescents aren't just little adults, we need to recognize that not all adolescents are alike," emphasized co-editor Sally J. Stevens, Ph.D., principal investigator of the two Arizona sites and research professor at the University of Arizona's Southwest Institute for Research on Women. For example, drug use and treatment needs of girls differ from those of boys; some adolescents come from relatively supportive families and others do not; and the developmental level of adolescents even between ages 13 and 17 can differ tremendously. Moreover, treatment providers need to recognize that many adolescents live in chaotic, violent circumstances or environments in which drug use is only one of many problems, Dr. Stevens said.

An e-mail discussion group called the Society for Adolescent Substance Abuse Treatment Effectiveness listserv—an outgrowth of the ATM project—facilitates ongoing conversation and sharing of information. The listserv is open to anyone in the field.

"The adolescent treatment field is coalescing into a national group," said Mr. Muck. "Adolescent treatment providers and researchers weren't really organized before. Now we have a kind of learning community around the country."

To obtain a copy of Adolescent Substance Abuse Treatment in the United States contact Haworth Press at 1 (800) 429-6784 weekdays between 9 a.m. and 5 p.m., est. Or visit www.HaworthPress.com. To learn more about the listserv for the Society for Adolescent Substance Abuse Treatment Effectiveness, e-mail Donna Williams at dwilliam@samhsa.hhs.gov.

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