The American Treatment System for Adolescent Substance Abuse: Formidable Challenges, Fundamental Revisions, and Mechanisms for Improvements
The multifaceted problems of adolescent substance abuse represent a pressing national concern. Despite research advances in efficacious treatment models for these youth, such as cognitive-behavioral therapy, multisystemic therapy, and multidimensional family therapy (Rahdert & Czechowicz, 1995; Wagner & Waldron, 2001), few substance-abusing youth receive treatment and are therefore unable to take advantage of these developments.
In 2001 (the latest data currently available), 1.1 million U.S. youth aged 12–17 were estimated to need substance abuse treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2001a, 2001b). Of these, 100,000 actually received treatment, leaving a gap of approximately one million untreated adolescents nationwide (SAMHSA, 2001a, 2001b). Female adolescents who abuse substances fare even worse than their male counterparts: although the percentage of male and female teens in the United States who needed substance abuse treatment was almost identical (4.9% vs. 4.8%), male adolescents were more likely to receive treatment (11.4% vs. 8.8%).
There are many reasons why adolescents fail to receive treatment. At the individual level, adolescents (perhaps even more than adults) fail to recognize an alcohol or other drug (AOD) problem or minimize the problem (Melnick, DeLeon, Hawke, Jainchill, & Kressel, 1997). Moreover, adolescent concerns about disclosing sensitive information to parents and competing priorities for multiproblem families render access problematic (Cheng, Savageaue, Sattler, & DeWitt, 1993; Cornelius, Pringle, Jernigan, Kirisi, & Clark, 2001; Ford, Milstein, Halpern-Fisher, & Irwin, 1997). While these individual problems are significant, there are already efforts to bring about problem recognition and motivation for change (Rahdert & Czechowicz, 1995; Wagner & Waldron, 2001).
The purpose of this chapter is to discuss an additional complicating factor that impacts adolescent treatment and goes beyond the individual youth and his or her family: the service delivery system. These systems (e.g., educational institutions, health care, juvenile justice, and mental health systems) are complex environments that offer opportunities to identify, treat, and monitor adolescent substance abusers. However, the architecture and operating procedures of these systems often serve to inhibit access to needed services and to confuse or confound coordination of complementary service delivery across systems. The result can be formidable challenges to the identification and subsequent intervention and treatment of the adolescent who uses, abuses, or is dependent upon substances. In the text that follows, we identify problems within the current “standard” system of care leading to failure to identify these adolescents, inadequate access to even basic substance abuse intervention for those identified, and failure to provide adequate amounts or types of services to those who do access the care system. We also present mechanisms for enhancements and conclude with a summary of three innovative approaches targeted to systems improvement.
IDENTIFICATION OF ADOLESCENTS WHO USE SUBSTANCES
Adolescents with varying degrees of substance use can be found throughout U.S. communities, coming into contact with a variety of settings and service systems. Identification of these teens, regardless of their level of use, is important so that targeted, developmentally focused interventions can be delivered (e.g., brief interventions, outpatient treatment, long-term residential treatment, all followed by the appropriate form of reintervention, step-down, or continuing care services). Such identification has the potential to reduce the morbidity and mortality related to this condition.
The settings within a community can be categorized into two tiers: (1) first-gate generalist settings, and (2) more specialized, problem-focused systems of care (e.g., mental health, child welfare). Generalist settings (e.g., health-care settings, schools) are settings where many adolescents can be found, and they have the opportunity to provide the “first gate” into needed behavioral health and social services. Specialized, problem-focused systems of care, by con trast, center on adolescents with more serious and specific problems (e.g., the mental health system, the juvenile justice system, the child welfare system, the drug treatment system). In a well-structured system, the general settings and the problem-focused systems would have the training and ability to screen and refer adolescents with presumptive evidence of substance use (or any other specific problem) (a) for a more in-depth assessment; or (b) to problem-focused agencies for intervention (e.g., mental health clinic, substance abuse program). Moreover, an optimized system would have interagency working arrangements in place to assure multidimensional service provision and continuity of care without unnecessary overlap of services.
With respect to early identification, it is important for early screening efforts to differentiate substance use from substance abuse or dependence. This is important for both the efficiency of system operation (i.e., conservation of more intensive services for those with more severe problems) and because these different stages of substance use require qualitatively different types of interventions (Wagner & Waldron, 2001; Winters, 1999).
An appropriate clinical response to identified substance use is likely to be one of a variety of recently developed brief interventions designed to prevent escalation of use into abuse or dependence and the associated penetration into the juvenile justice and social service systems that typically is associated with more severe use (Bilchik, 1995; Greenwood, Model, Rydell, & Chiesa, 1998; RAND, 1996; Wagner & Waldron, 2001; Winters, 1999). Because the effects of brief interventions may weaken after 12 months, the delivery of a brief reintervention is critical if prevention of escalation is to be maintained (Conners, Tarbox, & Faillace, 1992; Connors & Walitzer, 2001; Stanton & Burns, 2003; U.S. Department of Health and Human Services, 1993). In contrast to the appropriate clinical response to substance use, the appropriate clinical response to an identified case of abuse or dependence is likely to be much more intensive, structured, and long-lasting (Wagner & Waldron, 2001; Winters, 1999), designed to change (or slow) the trajectory of a long-term drug-using career. Thus, for both clinical and cost-effectiveness reasons, it is critical for both systems to be able to identify use, to differentiate use from abuse or dependence, to appropriately refer for a comprehensive assessment based on identification, and to provide rapid linkage to the appropriate level of clinical intervention for each type of case. As will be described below, we have found that both service tiers are deficient in these important skills.
Primary Care Settings
There are numerous studies documenting the failure of primary care settings to identify and differentiate individuals who use, abuse, or are dependent upon substances (Hack & Adger, 2002; Miller & Swift, 1996). This is problematic in that primary care clinics can be particularly good sites for adolescent substance-use case finding (National Association of State Alcohol and Drug Abuse Directors [NASADAD], 1998, 2002). In a recent survey, however, U.S. teens reported that the topic of substance abuse was rarely initiated. Only about one third of youth (35%) reported discussing substance use, even though about twice that number (65%) wanted it to be discussed. In order of preference, adolescents would like their health-care provider to talk with them about substance use (reported by 65%), smoking (reported by 59% of youth), and sexually transmitted diseases (STDs; reported by 61% of youth) (Ackard & Neumark-Sztainer, 2001; Klein & Wilson, 2002). Instead, physicians and/or nurses discuss diet, weight, and exercise with their adolescent patients. While these issues are, of course, very important, they should not be the only health issues discussed. When primary care providers do not initiate discussions about alcohol or drugs or are not attuned to the subtle signs of early use, the opportunity for identification and early intervention or treatment is missed.
Adolescents make fewer visits to primary care physicians than any other age group, in part be cause they generally are in good health, but also because they lack health insurance (Kokotailo, 1995; Newacheck, 1999). In fact, only about 38% of teens surveyed reported that they had a routine health-care source (Grove, Lazebnik, & Petrack, 2000). Hence, many adolescents use the emergency room (ER) as their primary source of medical care: studies report that approximately 16% of all ER patients are adolescents who present with numerous complaints: abdominal pain, injuries, gynecological problems, asthma, and diabetes (Grove et al., 2000; Lehmann, Barr, & Kelly, 1994; Melzer-Lange, & Lye 1996; Mader, Smithline, Nyquist, & Letourneau, 2001).
A major element in adolescent use of the ER is alcohol, such as alcohol-related injuries, motor vehicle accidents, and violence (Mader et al., 2001; Maio, Portnoy, Blow, & Hill, 1994). According to the National Pediatric Trauma Registry (Mader et al., 2001), 15.5% of all ER trauma patients were alcohol-positive adolescents (Mader et al., 2001).
Substance use other than alcohol has also been an increasing factor in ER use. For example, recent data from the American Association of Poison Control Center's Toxic Exposure Surveillance System show a growing number of teens (about 759 cases over a 5-year period) are presenting in the ER with tachycardia, hypertension, and agitation as a result of methylphenidate abuse (Klein-Schwartz & McGrath, 2003). Further, The Drug Abuse Warning Network (DAWN; i.e., the study that monitors ER utilization as a result of drug use) reports a 17% increase in ER drug-related episodes among youth ages 12–17 between 1999 and 2001 (SAMHSA, 2002b). Drug abuse deaths among teens seen in the ER accounted for approximately 20% of all DAWN cases (SAMHSA, 2003).
Thus, adolescents in general as well as those who use, abuse, and are dependent on substances frequent the ER. Despite this fact, substance use is rarely assessed or addressed by ER health-care staff. Indeed, it is remarkable that less than 50% of cases are referred to any form of drug treatment (Mader et al., 2001). Unless the substance-abusing youth is the driver of the car in an alcohol-related motor vehicle accident, referral for substance abuse assessment or intervention is rare (Mader et al., 2001).
Schools and School Health
Schools are among the most important institutions for adolescents, have the most efficient and continuous access to them, and thus constitute perhaps the most important site for initial case finding. Hence, schools are in a unique position to (1) identify substance-using youth needing treatment at earlier stages of impairment; (2) reduce the stigma of receiving treatment; and (3) increase access to care (Rappaport, 1999). However, while schools may have identified use among students through zero-tolerance policies, drug testing, and locker searches (Center on Addiction and Substance Abuse [CASA], 2001), they have not increased access to care, thereby making limited contributions to the subsequent well-being of these adolescents (Lear, 2002; Wagner, Kortlander, & Morris, 2001). In fact, only 11% of admissions to alcohol and drug treatment are from school referrals (SAMHSA, 2002c).
In fairness to school personnel, the identification of a student who uses substances can be problematic. First, few school districts provide the resources for appropriate identification of use among youth or for subsequent intervention. Student assistance programs (SAPs, which are similar to employee assistance programs [EAPs]) can be found in only 9.5% of school districts in the United States, and there is widespread variation in the types of SAPs and in how they are run (CASA, 2001; Wagner et al., 2001). When a SAP does exist, identification is compromised because few use standardized assessment measures. Second, only 36% of public schools and 14.4% of private schools offer alcohol and drug counseling to substance-using youth (CASA, 2001). Issues of inadequate reimbursement for assessment and intervention services and arguments over the appropriate level of responsibility of teachers and assessment specialists further hamper identification of the student who uses, abuses, or is dependent on substances (Lear, 2002). Combined, these issues seriously compromise a school's ability to play a major role in substance use intervention and call into question the true role of a school (e.g., should a school be responsible for case finding only and then partner with other organizations for intervention services?).
The situation has become even more problematic by the introduction of zero-tolerance policies, drug-testing programs, and locker searchers in the schools. These supposedly serve as deterrent and detective mechanisms and almost always have predetermined consequences. Zero-tolerance policies, introduced in 1994 to address weapons in schools, with Elementary and Secondary Education Act (ESEA) funding contingent on their enactment (Martin, 2000), quickly expanded to include a wide range of disciplinary issues such as drug use. As of 2001, 88% of schools across this country had zero tolerance policies for drugs, 87% for alcohol, and 79% for tobacco (CASA, 2001; ERIC, 2001), with most states treating minor or major incidents identically (e.g., in Maine, the policy was enforced for a high school girl who brought Tylenol to school for menstrual cramps [Rosenbaum, 2003]; in Georgia, an asthmatic child was barred by local school policy for carrying his asthma inhaler and died after a severe asthmatic attack while boarding a school bus [Reuters Health, 2002]). Rarely is an assessment and treatment referral a consequence. Instead, infractions are typically handled only by punitive measures such as suspension or expulsion, or referral to an alternative school (CASA, 2001; ERIC, 2001).
Drug Testing in Schools
Drug testing of public school students who participate in athletics or other extracurricular activities has been introduced to deter use among the larger student body. It seems paradoxical that youth who display those protective factors shown in research studies to reduce the likelihood and severity of substance use among youth (e.g., extracurricular activities, school bonding; Hawkins, Catalano, & Miller, 1992) would be targeted for drug testing. However, parents want to be sure that their children attend drug-free schools and school systems are regularly chided by parents and community groups to “get tough on drugs,” not only while students are in school but also when they are participating in school-related activities after school or on the weekends.
In a large, multiyear national study, researchers from the University of Michigan's Institute for Social Research concluded that drug testing of public school students (conducted in approximately 19% of all U.S. secondary schools) did not deter use (Yamaguchi, Johnston, & O'Malley, 2003). At each of three grade levels (i.e., 8, 10, 12), there were identical prevalence and frequency rates of drug use over the 12 months prior to the examination in the schools with and without drug-testing programs. These data are critical in that the Supreme Court's split decision upholding the constitutionality of drug testing in schools was highly influenced by the notion that drug testing among public school students is a deterrent to use. Hence, the debate over a student's right to privacy and unreasonable and suspicionless searches continues.
Not only has school-based drug testing not been found to deter use, Chaloupka and Laixuthai (2002) found that it can result in an increase in alcohol use. Aware that alcohol is almost impossible to detect after 1 day (as are cocaine and heroin), students decreased their use of marijuana but increased their use of alcohol (Chaloupka & Laixuthai, 2002; Zeese, 2002). Consequently, there is concern that school-based drug testing could pose a number of unintended effects vis-a-vis switching to more dangerous forms of drugs to avoid detection. Finally, and again paradoxically, teens in schools that had drug-testing programs tended to view drugs as less risky and believed that drug testing must have been initiated because more students were using drugs, beliefs that have been consistently shown to lead to increases in using behaviors.
The second tier of the services system (i.e., agencies that focus on a specific problem area) often fares no better with respect to identification of the adolescent who uses, abuses, or is dependent upon substances. Since adolescent substance use disorders (SUD) are clinically complex, typically compromising numerous life domains (behavioral, mood, family, legal), it is not surprising that substance-abusing adolescents are prevalent in many different service systems. In one of the first studies to date, Aarons and colleagues (2001) found that 62% of youth in the juvenile justice system, 41% of youth in the mental health system, 24% of youth in the special-education system, and 19% of youth in the child welfare system met criteria for a SUD. In each of these systems, adolescents had been assessed for some other disorder, illness, or problem behavior and were receiving some form of system-specific services (e.g., mental health services if in the mental health system, educational services if in the special education system). It is noteworthy that despite the high prevalence rates of SUD in these settings, most cases of SUD were not identified by staff in these systems. One must wonder whether and to what extent the unidentified SUD may have compromised the accuracy of the assessments for the targeted problems and the effects of the services that were provided.
Reasons for Lack of Identification
It is unfortunate that those delivering health or social services as part of larger agencies or systems (e.g., hospital systems, mental health systems) rarely screen for alcohol and drug problems (Center for Substance Abuse Treatment [CSAT], 2000). There are several reasons for this. First, there has been little effort to train key personnel from these various systems (e.g., school nurses, probation officers, case workers) in the use of some of the proven substance abuse screening instruments (CSAT, 2000; NASADAD, 1998; SAMHSA, 1993). With respect to health-care practitioners, sizable portions of physicians feel ill equipped to discuss these topics with their adolescent patients (Karam-Hage, Nerenberg, & Brower, 2001). In a survey assessing medical residents' perception of substance abuse knowledge and assessment skills, only half felt that they were adequately prepared to identify, manage, or refer a substance-abusing adolescent (Siegal, Cole, & Eddy 2000; Steg, Mann, Schwartz, & Wise, 1992). Further, staffs from diverse service systems do not possess sufficient knowledge of disorders outside of their respective disciplines to adequately diagnose or comprehensively assess comorbid conditions (NASADAD, 1998, 1999). These problems are compounded by systems issues that dictate exclusion of each other's clients, confidentiality requirements that stifle collaboration, and the lack of bridges between systems of care that limit coordination of need-based services (NASADAD, 1998, 1999). These issues alone and in combination cause a number of multi-problem youth to fall through the cracks.
Second, and intimately connected to the first reason, is the lack of reimbursement for screening and early intervention activities. Few states currently reimburse adolescent screening efforts outside the specialty sector substance abuse treatment system and there are a number of payment restrictions for AOD screening and diagnostic assessments within primary care settings (Buck & Umland, 1997; Rivera, Tollefson, Tesh, & Gentilello, 2000; CSAT, 2001). Even if the services are reimbursed through insurance programs, roughly 4 million adolescents in this country are without any form of health insurance, with additional youth covered by plans that do not provide for preventive care or behavioral health treatments (Center for Adolescent Health and the Law, 2000). As in all other areas of health and social services, the only sure way of increasing the probability of clinically recommended practices is through reimbursement.
Third, the complex interrelationships between the parents' right to know about assessment and the legal protection of the adolescent's privacy and confidentiality can further complicate identification. Adolescents want their health issues to be kept private and want to receive certain services without their parents' or guardians' consent (Ford & English, 2002; Ford et al., 1997). Without these guarantees, adolescents will forego services (Ford, Bearman, & Moody, 1999; Klein, Wilson, McNulty, Kapphahn, & Collins, 1999) until their problems escalate to a point when they can no longer be ignored. Fortunately, as illustrated below, most states give youth the sole authority to consent to assessment and treatment for those conditions in which parental knowledge would curtail adolescent treatment seeking (e.g., STD testing, alcohol or drug use).
• Twenty-five states and the District of Columbia accept minor consent for contraceptive services.
• Twenty-seven states and the District of Columbia accept minor consent for prenatal care.
• Forty-four states and the District of Columbia accept minor consent for alcohol and drug assessment and treatment.
• Twenty states and the District of Columbia accept minor consent for mental health services.
However, in some states that accept minor consent for services, (1) the physician has the discretion to notify the parent without the adolescent's consent (e.g., in Colorado, Oklahoma, and Louisiana [Colorado, 1995; Oklahoma, 1995; Louisiana, 1995]); and (2) parental involvement is required prior to the end of mental health or alcohol and drug treatment (Oregon; OAHHS, 2004). While statutes that give the adolescent the right to consent to treatment are vitally important, adolescents are not knowledgeable about what they can and cannot obtain without their parents' permission and there is movement to restore parental consent for all conditions (Boonstra & Nash, 2000; Cheng, Savageau et al., 1993; Ford et al., 1997; Marks, Malizio, Hoch, Brody, & Fisher, 1983). Mandated compliance with the Health Insurance Portability and Accountability Act (HIPPA) of 1996 may further complicate these issues. In section 164.502(g) of the Privacy Rule of December 2000, parents are generally able to access and control health information about their minor child. Consequently, they generally have access to all charts, medical records, etc., thereby affording them access to information their adolescent children may not want them to have. However, 164.502(g)(3)(ii) A&B states that if a state or other law permits a minor to obtain a particular health service without the consent of the parent, it is the minor and not the parent who has control over the information. If state or other applicable law is silent or unclear, service providers have the discretion to permit or prohibit parental access without interference from the Federal Privacy Rule.
Finally, critics of early identification argue that it unnecessarily widens the net for behavioral health services and stigmatizes at-risk youth or youth with low-level problem behaviors (Goldson, 2001; Kammer, Minor, & Wells, 1997). Although many in the substance abuse field advocate early identification so that brief interventions and/or referrals will result, the intended positive outcomes may not always occur. As indicated above, many and even most zero-tolerance programs are simply punitive, with no clear benefits for the substance-using adolescent who may wish to seek help. In contrast, if the same identification efforts were linked to programs of useful and desirable rehabilitative services, short-and long-term benefits to the substance-using adolescent could result. Thus, the philosophy of the setting and intent of identification (i.e., habilitative treatment or punitive expulsion or incarceration) can impact the outcome of the substance-using youth identified early. More research is needed to evaluate the effectiveness of various post–substance use identification strategies so that early identification and intervention programs can be based on empirical data rather than on individual or public opinion.
System Change Considerations
Improve Identification of Adolescent Substance Use, Abuse, and Dependence
When substance use is not identified and when differentiations between use and abuse or dependence are not made, the opportunity for interventions in general and for targeted interventions specifically is lost (e.g., brief interventions for use or the delivery of conjoint, complementary treatments for abuse or dependence). Obviously, it makes good clinical sense to encourage screening for substance use, abuse, and dependence within all sectors of the service delivery system (CSAT, 2000; SAMHSA, 1993). There is a need, however, to develop necessary training procedures, common definitions, reimbursement mechanisms, confidentiality safeguards, and protection from stigma and institutional backlash if this is to become standard clinical practice (Aarons, Brown, Hough, Garland, & Wood, 2001; Buck & Umland, 1997; Miller & Brown, 1997; Rivera, Tollefson, Tesh, & Gentilello, 2000; Tracy & Farkas, 1994).
Expanding medical and nursing school curricula and developing addiction rotations within residency and nursing programs comprise a first step in skill enhancement. Research shows that 1-day to 6-month chemical dependency training programs improve (1) physician attitude toward patients with SUD; (2) SUD assessment skills; (3) comfort with discussing chemical dependency; and (4) knowledge of the addiction service system (Brauzer, Lefley, & Steinbook, 1996; Karam-Hage et al., 2001; Kokotailo, Fleming, & Koscik, 1995; Matthews et al., 2002; Siegal et al., 2000; Westreich & Galantar, 1997). Because not all adolescents who are identified as using AOD in these first-gate settings will require formal treatment (Rahdert & Czechowicz, 1995; Wagner & Waldron, 2001; Winters, 1999), teaching of motivational interviewing and brief interventions with appropriate follow-up contact should become a standard component in clinical training curricula. These practices have been shown to have widespread applicability and documented effectiveness even within ER settings (Barnett, Monti, & Wood, 2001; Greenwood et al., 1998; Monti et al., 1999; RAND, 1996). Further, because these interventions do not assume that the client is interested in changing, they are particularly relevant to adolescents who are generally disinterested in changing their behavior.
The training of public school and alternative-school personnel (as well as other systems' personnel such as social workers and correctional officers) to “spot” the signs of alcohol and drug use through undergraduate and graduate education, state qualification exams that include a set of identification-related questions, in-service programs, and orientation of new staff members is a step in the right direction (CASA, 2001). Bry and Attaway (2001) have trained staff to refer youth who display academic and conduct problems to school-based programs. This risk-focused approach has been found to consistently identify the student user and Bry's subsequent intervention has been effective in preventing increases in and problems associated with use. In either case, punishment-only policies will likely need to be revised so that when youth are identified, continued education and services in addition to clear consequences result (CASA, 2001). Further, for those who have repeat infractions, fail to follow through on assessment and treatment referrals, or fail to complete a required treatment, a program of graduated school-based sanctions (e.g., detention, in-school suspension) should be designed and made available for dissemination to a range of schools.
Common problem definitions.
As part of any training program, adoption of a common language with common definitions will be necessary. To this end, a focus on symptom multiplicity and severity rather than diagnosis has been suggested (Angold, Costello, Farmer, Burns, & Erkanli, 1999; NASADAD, 1998, 1999; Pollock & Martin, 1999; Winters, Latimer, & Stinchfield, 1999). First, research indicates that not all adolescents who have experienced serious consequences as a result of substance use will meet DSM-IV criteria for a substance use disorder (Pollock & Martin, 1999). Called “diagnostic orphans,” these youth present with serious use patterns and problems that require treatment (Pollock & Martin, 1999; Winters et al., 1999), but symptom constellations do not meet a specific diagnosis. Similar findings appear in the mental health literature, where symptoms may be at a subthreshold diagnostic level but serious functional impairment exists nonetheless (Angold et al., 1999). These issues call the applicability of the DSM system into question, can impact eligibility decisions and reimbursement mechanisms, and will require policy changes. At a minimum, however, the use of common assessment tools (or common data elements obtained from one of a list of approved tools) would initially address this complex topic by providing greater comparability of terms that can be used across discrete systems of care (e.g., mental health, substance abuse, juvenile justice; Meyers et al., 1999; NASADAD, 1999; U.S. Public Health System, 2000).
Within this definitional arena, training programs must also address differentiation of behaviors indicative of true problems from behaviors that are “typically adolescent.” Although adolescent assessment may seem simple at first glance, this developmental period presents unique challenges for the assessor (Meyers, Hagan, Zanis, & Webb, 1999; Meyers, Hagan, McDermott, Webb, Frantz, & Randall, submitted; Winters, Latimer, & Stinchfield, 2001). Because of the youth's state of biological, emotional, neurocognitive, and social development, youth will sporadically display challenging behaviors as part of the normal course of development (e.g., rebelliousness, defiance, moodiness, marijuana experimentation), and these behaviors do not automatically indicate the need for intervention. In other words, the presentation of “a problem behavior” with subsequent identification of “dysfunction and need for intervention” can be confounded by the normal course of development. False-positive cases result when normative developmental behaviors are considered aberrant and false-negative cases occur when problem behaviors needing intervention are thought to be “just a function of being an adolescent.” Consequently, training curricula need to address the various ways in which normative behaviors can be disentangled from problematic ones through modules teaching assessment of the typography, frequency, and age of onset of various behaviors.
Financing mechanisms will undoubtedly need to be improved if there is to be an increase in assessment services so that the adolescent who uses, abuses, or is dependent on substances is identified. This area is particularly challenging, with few proven answers. Consequently, economic research is needed so that informed decisions about resource allocation, alternative payment systems, public and private financing mechanisms, and development of responsive insurance packages can be made. Elimination of payment restrictions for screening and diagnostic assessments through changes in systems, policy, and public and private insurance will be needed to improve the identification process.
Continued attention to ways in which service access policies and data-sharing technologies affect confidentiality is vital. Facilitation of appropriate ways for adolescents to initiate contact with providers independently of families may enhance identification and subsequent engagement in substance abuse services (Flisher et al., 1997; Rappaport, 2001). To this end, providing teens with a listing of services that do or do not require parental consent or notification may be helpful.
ACCESS TO ADOLESCENT-SPECIFIC SUBSTANCE ABUSE TREATMENT
We have discussed the multiple and complex system level problems associated with identifying adolescents who use, abuse, or are dependent upon substances. It might be thought that once these hurdles are overcome, it would at least be comparatively easy for substance-abusing adolescents to access treatments suited to their needs. This is not the case even for adults with substance use disorders, and it is even worse for adolescents.
In a recent survey of a national sample of 175 adult substance abuse treatment facilities in the United States, McLellan and colleagues (2003) found a disturbing degree of erosion in the infrastructure of those programs. For example, this report found closure rates of 21% over a 16-month period; of the remaining sample, an additional 18% had been reorganized or taken over by a different company (in the case of privately owned programs) or a different agency (in the case of government-run programs). In addition, these researchers found turnover rates of over 50% among both the directors of these programs and their counseling staffs. The result was confusion at the staff level and disorganization of service delivery.
The situation is arguably worse for the substance abuse treatment programs that are specifically designed for adolescents. First, there have always been relatively few of these adolescent programs (White, 1998). In the early 1980s when it became apparent that adolescents with substance use disorders were a unique client group requiring specific assessment and particular therapeutic approaches (see Deas, Riggs, Langenbucher, Goldman, & Brown, 2000, for a discussion; Poulin, Dishion, & Burraston, 2001), traditional substance abuse treatment facilities had to adapt their adult-oriented programs if they were to accept and appropriately treat an adolescent clientele (Winters, Stinchfield, Op land, Weller, & Latimer, 2000). To be responsive to the needs of this age group, programs needed to address the key developmental tasks of adolescence within an ecological context that included individual (e.g., self-regulation) and proximal (e.g., peer, family) influences (Bronfenbrenner, 1986, 1989; Deas et al., 2000; Liddle & Hogue, 2001; Wagner & Waldron, 2001). Hence, to be considered adolescent-specific, interventions needed to be revised so that they were sensitive to and focused on identity formation, autonomy seeking, social-role development, moral and cognitive development, self-regulation, peer group influences, and family management practices. When faced with such an undertaking, few substance abuse treatment providers responded to this challenge. Only 37% of approximately 14,000 substance abuse treatment programs in this country offer services to adolescents (SAMHSA, 2001a).
When the availability of substance abuse service within other systems is reviewed, the picture is equally discouraging. The systems in which one would most expect adequate capacity for treatment of the adolescent substance abuser are the juvenile justice system and the mental health system. Despite increases in arrests for drug offenses among juveniles (Butts, 1997) and the continued use of substances among juvenile detainees (Arrestee Drug Abuse Monitoring [ADAM], 2003), only 37% of the 3,127 juvenile correctional facilities in the United States deliver substance abuse treatment (SAMHSA, 2002a). Compounding limited access is questionable service appropriateness. Of the 13 states that operate their own substance abuse treatment programs within their state Department for Juvenile Justice and Corrections, only 6 states require that these programs meet state AOD agency licensing and accreditation standards (NASADAD, 2002). Further, of the 25 states within which the state Department for Juvenile Justice and Corrections purchases substance abuse treatment, only 7 states (28%) exclusively do so from licensed providers.
Given the high rates of comorbidity, with up to 75% of SUD youth having a coexisting mental health disorder (Crowley & Riggs, 1995; Greenbaum, Foster-Johnson, & Petrilla, 1996), and the finding that two-fifths (41%) of youth in the mental health system meet criteria for a substance use diagnosis (Aarons et al., 2001), one would logically expect that the mental health system would have adequate capacity or at least referral linkages to substance abuse treatment. In a study of the purchasers of drug treatment, conducted by NASADAD (2002), the mental health system was not even recorded as a service purchaser. Among the major purchasers of services were drug courts (by 31 states), Temporary Assistance of Needy Families (TANF) and welfare-to-work programs (by 27 states), the juvenile justice system (by 25 states), and the child welfare system (by 24 states). Similarly, when NASADAD examined units of state government that operated their own drug treatment programs, only three states described drug treatment services operated by the state's Department of Mental Health. The two most common governmental units that operate their own programs are the Department of Corrections (38 states) and the Department of Child Welfare (7 states). Hence, neither the general community nor the justice system nor the mental health system have, by themselves, adequate capacity (and questionable appropriateness) for intervening with the adolescent substance abuser.
Lack of Credentialed Staff
No state in the United States offers adolescent-specific provider certification and only five states require adolescent-specific knowledge for licensure (Northwest Fronteir Addiction Technology Transfer Center, 2000; Pollio, 2002). At the national level, the National Association of Alcoholism and Drug Abuse Counselors (NAADAC) certification program employs a competency-based tiered system of national-level credentials: national certified addictions counselor, level I, national certified addictions counselor, level II, and master addictions counselor. There are no adolescent-specific knowledge requirements for any level, including the highest level (NAADAC, 2003). Since knowledge of adolescent development and skill and interest in treating youth are of paramount importance to treatment of adolescents (Deas et al., 2000; Winters et al., 2000), questions arise as to (1) whether the few staff who do treat adolescents are sufficiently skilled to do so, and (2) why state and national credentialing processes do not require adolescent-specific knowledge. This is particularly perplexing given that the NAADAC recently added a national tobacco addiction specialist certification program. Judging from the scientific literature, a national certification program for adolescent addiction specialist appears to be equally important. At the very least, incorporation of adolescent-specific knowledge requirements into all certification programs should result in a more informed group of providers.
Restricted Funding for Services
Compounding the paucity of properly credentialed adolescent services is the failure of programs to accept an array of insurance types: less than 50% of adolescent AOD programs accept Medicaid; less than two thirds accept private insurance; and less than two thirds have a sliding fee scale (SAMHSA, 2001a). Even when insurance is accepted, adolescents are the most uninsured group in this country, rendering many of them unable to finance their treatment (Ford et al., 1999; Klein et al., 1999). As stated earlier, approximately 4 million youth in this country are without any form of health insurance, with many more having insurance that does not cover behavioral health treatment (Center for Adolescent Health and the Law, 2000). Inadequate financing mechanisms and lack of insurance coverage, coupled with the insufficient number of adolescent programs, further reduces the already limited odds of gaining access to treatment once identified.
Summary of System Change: Focus on Access
Improvement in early problem identification is only the beginning to a very large and complex problem. If the system is to meet the needs of identified youth, other service system inadequacies will need to be addressed simultaneously: (1) the demand for adolescent substance abuse treatment—current demand already exceeds the system's capacity to intervene; and (2) inadequate financing mechanisms—too few dollars and too few funding mechanisms render it difficult to support a treatment episode.
System Change Considerations
Improving Access: Expand Treatment Capacity
Although the creation of additional adolescent-specific treatment slots would initially increase system capacity, it would fail to get at the roots of the problems discussed, and the impact on long-term improvement would be minimal. One of the important and fundamental problems associated with substance abuse treatment for adolescents is the large and rapid rate of relapse following treatment termination. Currently, about half of adolescents with SUD relapse (Winters et al., 2000), with 60%–70% doing so within the first 3–4 months following treatment (Brown, Vik, & Creamer, 1989). Although there is no doubt that additional adolescent-specific services are needed, if there were means by which treatment effects might be enhanced or extended even slightly, it would be possible to limit the cycling in and out of existing programs and thus increase system capacity (Dembo, Walters, & Meyers, in press). The delivery of evidence-based interventions by a properly trained and credentialed staff could go a long way toward this goal. To this end, the transfer of evidence-based interventions into real-world settings and revision of the credentialing process to include adolescent-specific licensure have the potential to increase treatment effectiveness, thereby increasing treatment availability and subsequent access. Until an adolescent-specific certification program can be developed, an immediate revision of the credentialing process must be undertaken so that adolescent-specific knowledge is incorporated as a requirement for licensures. In the short term, this change would have the effect of increasing the population of personnel who would at least be sensitive to the unique needs of this group. Establishment of the Clinical Trials Networks (CTN) of the National Institute on Drug Abuse (NIDA) and Addiction Technology Transfer Centers of the Substance Abuse and Mental Health Services Administra tion (SAMHSA) is a beginning step in this direction.
Improving Access: Expand Financing Mechanisms
The topic of financing for early intervention and drug treatment services has received much attention with little resolution. For example, development of targeted utilization rates based on epidemiological estimates of need for care has been suggested (CSAT, 2000; Minnesota Department of Human Services, 1997). Such a public funding mechanism would provide incentives to ensure that health plans and public funding streams identify, refer, and reimburse treatment for adolescents with an SUD. Increasing benefits in the private sector through parity and comprehensive coverage packages, improving the flexibility of funding, tying reimbursement to performance measures and quality treatment standards, and reallocating interdiction and incarceration funds to treatment have also been proposed (CSAT, 2000). Research examining the effects of these suggestions has been called for (CSAT, 2000; NIDA RFA# DA-03–003; NIDA PA-01-097), but the results of these empirical studies are not yet available. Nonetheless, revisions to the way in which services are reimbursed are critical if system improvement is to be realized.
Beyond general financing of treatment services and insurance coverage are additional issues unique to adolescents. First, of the 4 million uninsured adolescents, approximately 2.3 million are eligible for Medicaid or State Children's Health Insurance Program (SCHIP) (Center for Adolescent Health and the Law, 2000; Newacheck, 1999). Increased access to SCHIP is needed and may be accomplished through staff training within presumptive eligibility sites and use of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), Maternal and Child Health (MCH), and community-based staff to enroll teens. This would result in fewer uninsured adolescents, who would then have a greater probability of accessing the care that does exist. Concomitant attention is also essential in (1) developing mechanisms for health plans and providers to adapt medical records, billing and laboratory procedures to protect confidentiality (e.g., currently the insurance summary is sent to the customer [parent] listing payment or coverage of confidential services rendered to the patient [adolescent]); (2) disseminating accurate information to adolescent members about what services they can receive with their own consent; and (3) communicating clearly about confidentiality protections, particularly about what types of information are not confidential (Ford et al., 1999; Klein et al., 1999; Newacheck, 2000).
DELIVERY OF COMPREHENSIVE, NEED-BASED, AND DEVELOPMENTALLY SENSITIVE SERVICES
Once an adolescent is identified and able to access services, one might assume that the treatment provided would meet at least most of an adolescent's identified needs. Unfortunately, service delivery often falls short for several reasons. Because so few adolescents receive comprehensive assessments (Weinberg, Rahdert, Colliver, & Glantz, 1998), very few are provided with comprehensive need-based services (Delany, Broome, Flynn, & Fletcher, 2001; Dembo, 1995, 1996; Terry, VanderWaal, McBride, & Van Buren, 2000). In turn, few receive step-down or continuing care (Alford, Koehler, & Leonard, 1991; Spear & Skala, 1995; Brown, Meyers, Mott, & Vik, 1994; Winters, 1999). Finally, few adolescents are able to access services that even minimally address key developmental challenges of this period (e.g., individuation coupled with age-appropriate limit setting within the context of family-specific services).
Limited Assessment Practices
Despite research advances in adolescent assessment practices (Winters & Stinchfield, 1995), the standard clinical intake does not identify the full range of problems and strengths brought to a substance abuse treatment program by an individual youth, nor does it assess youth within a developmental context of measurement (Weinberg et al., 1998). In a typical program, an unstructured interview (generally with program- developed forms) is conducted to obtain an in-depth drug use history, a psychiatric review, and a physical examination. These components are the mainstay for treatment planning (Weinberg et al., 1998). As we and others have shown, adolescents with SUD are characterized by interconnected, complex problems (Hawkins et al., 1992; Fleming, Leventhal, Glynn, & Ershley, 1989; Helzer, 1981; Hirschi, Hindelang, & Weis, 1980; Meyers et al., 1999; Morrison, McCusker, Stoddard, & Bigelow, 1995; Prout & Chuzik, 1988; Winters & Stinchfield, 1995).
In a recent study of 205 youth in drug treatment (Meyers, Hagan, & McDermott et al., under review), many individuals had an array of problem behaviors, with typical onset occurring in early or middle childhood. Excluding tobacco, alcohol and other drugs were tried at approximately 11 years of age on average (11.3; SD = 2.5), with at least weekly use starting by the age of 13 (12.9; SD = 1.8). Alcohol, marijuana, hallucinogens, heroin, and cocaine tended to be the most predominant substances of abuse; 89% of the youth were daily cigarette smokers. With respect to mental health issues, 93% of youth had at least three symptoms of a mental health disorder at treatment admission, with 82% meeting criteria for an Axis I nondrug diagnosis by the age of 12 years. Family problems were prevalent in that 50% of the youth lived with active substance abusers, 53% had run away from home, 53% reported transient living arrangements, and 31% reported police or child welfare involvement with their family. Inconsistent discipline practices (46%), harsh discipline practices (35%), and a lack of supervision (46%) were also reported. In 21% of cases, youth assumed the adult or parental role within the household. Educational deficits were the norm, with 77% reporting a history of academic problems, 74% reporting attendance problems, and 80% reporting discipline problems. It is therefore not surprising that 57% of these teens had dropped out of school by the age of 15. Further, 75% had been or were currently involved with the justice system, 55% actively carried guns, and 43% had witnessed a murder or an attempted murder in their community. Eighty-three percent of the youth were sexually active; all (100%) reported hanging out with peers who either had AOD problems or were involved in the juvenile justice system.
In addition to these descriptive data illustrating the clinical complexities of substance-abusing youth, we empirically identified seven treatment-oriented youth prototypes (Meyers, McDermott, Webb, & Hagan, in press).
• General low-severity problems
• Moderate-severity delinquency and chemical dependency; low-severity psychosocial problems and sexual risk behavior
• Moderate-severity psychosocial problems and sexual risk behavior; low-severity delinquency and chemical dependency
• High-severity delinquency and sexual risk behavior; moderate-severity chemical dependency and psychosocial problems
• High-severity psychosocial problems and delinquency; moderate-severity chemical dependency and sexual risk behavior
• Very high-severity psychosocial problems; low-severity chemical dependency, delinquency, sexual risk behavior
• Very high-severity chemical dependency; moderate-severity psychosocial problems, delinquency, sexual risk behavior
These typologies suggest that adolescents in substance abuse treatment programs are a very diverse group of youth. While it is clear that effective treatment needs to address these multiple problems, neither the simple availability of multiple services nor even the broad, undifferentiated provision of multiple services appears to be appropriate for producing treatment gains. Instead, gains are most likely to be obtained when the facets of treatment relate directly (i.e., are matched) to the life areas of the teen that are in need of remediation (Meyers et al., 1999). Given the degradation of services available within many service programs (Delany et al., 2001; Etheridge, Smith, Rounds-Bryant, & Hubbard, 2001; SAMHSA, 2001b), service coordination between programs and systems will be necessary if treatment matching is to become a reality.
When limited assessments are conducted, there is a risk that services will focus on just a few issues or provide services that are irrelevant to a youth's profile. These scenarios are rarely associated with significant clinical benefits (Henggeler, Schoenwald, Pickrel, Rowland, & Santos, 1994; Kiestenbaum, 1985). Limited assessments can result in a cascading effect of inadequate treatment plans, incomplete treatment matching, limited service coordination, poor treatment engagement and retention, and poor utilization of scarce resources. In turn, this can lead the youth and the family to conclude that “treatment doesn't work.” Hence, once youth are identified and find access to substance abuse treatment, there is a strong need for the use of standardized multidimensional assessment tools.
Limited Scope (and Appropriateness) of Services
Even if comprehensive assessments leading to prioritized but multifocused treatment planning can become standard clinical practice, another barrier will become even more apparent. Few if any programs are able to deliver even a minimal constellation of developmentally sensitive educational, social, or health services. Within the last few years, there has been a severe decline in the number and types of on-site services provided by adolescent substance abuse treatment programs in the United States (Etheridge et al., 2001). This occurs at a time when it is widely recognized that (1) treatment decisions for adolescents are better informed by pretreatment psychosocial factors than by drug use severity (Latimer, Newcomb, Winters, & Stinchfield, 2000), and (2) treatment effectiveness is contingent upon treatment for the array of comorbid dysfunctions within clinical samples (Kazdin & Weisz, 1998; Williams & Chang, 2000).
As a result of limited assessment and service decline, adolescents who are fortunate enough to obtain substance abuse treatment will probably not receive the type or amount of services required to minimally address their needs (Delany et al., 2001; Etheridge et al., 2001; SAMHSA, 2001b). Even adolescents are aware of service deficiencies: many of those who had received substance abuse treatment reported that their needs were not met by the services they received (Ethridge et al., 2001), with family and psychiatric needs most often going unmet (40%–50%). Since these are perhaps the two domains most comorbid with adolescent substance abuse, it is likely that these unmet needs may particularly compromise the effects of the services (typically drug counseling) that can be provided.
The effects of provided services can also be compromised if they are not developmentally focused. Adolescents are a unique client group in that (1) they are in a continuous state of social, biological, cognitive, and emotional development; and (2) risk taking and experimentation characterize normal development (Deas et al., 2000; Eccles et al., 1993; Gottlieb, Wahisten, & Licklieter, 1998; Greene, 1993). Consequently, evidence continues to mount demonstrating the effectiveness of interventions that address the developmental processes of social-identity development, peer group influences, self-regulation, moral and cognitive development (e.g., perspective-taking), and autonomy seeking (i.e., separation from the family [classic view] or movement toward family interdependence [contemporary view]; Deas et al., 2000; Wagner & Waldron, 2001). To obtain optimal effects, ecologically framed interventions that address individual and proximal factors are necessary (Bronfenbrenner, 1986, 1989; Liddle & Hogue, 2001). Because the family or household is a principle ecological context for child and adolescent development, targeted interventions with the family as a unit that address limit setting, monitoring and supervision, consistent discipline practices, and communication patterns are required to compliment individually based services. When there is limited availability of these core components, treatment delivery falls short of meeting individual needs. This has a negative impact on retention, one of the most consistent predictors of treatment outcome (Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997; Simpson, Joe, & Brown, 1997; Simpson, Joe, Broome et al., 1997). When the treatment landscape has been compromised by service deterioration and nondevelopmentally focused care, it is not surprising that few adolescents complete treatment, thus reducing their chances of having a good outcome (Battjes, Onken, & Delany, 1999; Williams & Chang, 2000; Winters, 1999).
Further complicating service delivery is the fact that step-down and continuing care services rarely follow an index treatment episode. Hence, the chronic nature of the substance use disorder is typically not addressed. Without less intensive step-down services there is a significant risk of relapse and return of substance abuse problems (Alford et al., 1991; Armstrong & Altschuler, 1998; Brown, Meyers, Mott, & Vik 1994; Latimer et al., 2000; Spear & Skala, 1995; Stewart & Brown, 1993; Winters, 1999; Winters et al., 2000). This causes readmissions to treatment, expending the already limited pool of resources.
System Change Considerations
Improve Delivery of Comprehensive Need-Based Services
As stated previously, research indicates declines in the number and type of on-site services in substance abuse treatment programs throughout the country. Since substance abuse treatment programs are part of a larger network of care (Denmead & Rouse, 1994), one would expect corresponding increases in the partnering between substance abuse treatment programs and other service providers (e.g., those within the mental health, educational, and sexual health systems) to compensate for service deficits. This is not occurring (Ethridge, Hubbard, Anderson, Craddock, & Flynn, 1997). Admittedly, obtaining out-of-program and continuing care services is not simple.
The larger network of care within which drug treatment programs operate consists of components that function as discrete entities, reporting to separate budget authorities and with minimal coordination among them—the so-called administrative “silos” (Dembo et al., in press; NASADAD, 2002; Solar, 1992). Competing priorities of these different entities, rigidly drawn boundary turfs and budgetary categories, competition for reimbursement dollars, and barriers to data sharing stifle collaboration (Gerstein & Harwood, 1990; Krisberg & Austin, 1993). In addition, with different eligibility criteria, various data collection and reporting requirements, and different coverage policies, codes, and procedures, it becomes clear why so many service providers operate independently from one another (Gerstein & Harwood, 1990; Johnson, 1999; Moss, 1998). Without system coordination, the same youth loops in and out of all treatment systems (Solar, 1992), with each intervention failure in one system accompanied by a repeat cost to some other sector of the system. Again, capacity is diminished and the pool of financial resources is unnecessarily reduced.
If comprehensive services are to be delivered through provider partnering, the development of interorganizational networks of care is critical (Baker, 1991; CASA, 2001; Krisberg & Austin, 1993; Kutash, Duchnowski, Meyers, & King, 1997; Marsden, 1998; Meyers & Davis, 1997; US Public Health Service, 2000; Murray & Belenko, under review; Rose, Zweben, & Stoffel, 1999). Such an undertaking requires substantial systems change and ongoing commitments. First, policymakers should begin to facilitate a change in “business as usual” by developing (1) new representative authority, governance structures, and funding streams; (2) universal, consolidated, and standardized data collection and reporting requirements; and (3) consolidated coverage policies, codes, and procedures (Gerstein & Harwood, 1990; Johnson, 1999; Moss, 1998). Next, partnering agencies could develop information-sharing partnerships and adopt written agreements—e.g., about the level at which information will be shared (i.e., case level, department or agency level, community level), when information will be shared, or the purpose and use of information sharing. This can be an effective way to provide coordinated, nonduplicative services through streamlined assessment and service referral activities, case management support, and availability of real-time information for necessary case plan adjustments (Meyers, 1998, 2000). Interdependence among these independent systems could be achieved by developing (1) centralized intake, referral, and case management services; and (2) colocation of services. To this end, all youth who present (or call) for services would be referred to the central intake unit (CIU). At the CIU, the youth would receive a standardized assessment followed by a case plan and referral to needed services. Referral may be back to the original system of contact or perhaps not, depending upon the case plan. Through colocating diverse services at the CIU or at various service sites (e.g., mental health services located at drug treatment programs) and holding staffing meetings at these locations, collaboration between provider and system can occur. Colocated services could also improve service compliance and retention because youth would not have to go to multiple locations to have their needs met. If service providers, service systems, and policymakers could commit to systems change and participate in an interorganizational network of care, competitors could become collaborators, limited resources could be better matched and maximized, and services could move from being fragmented to coordinated. All of this could ultimately improve the delivery of clinically appropriate, nonduplicative, and cost-effective services within a continuum of care. Within such a system, substance abuse treatment providers (as well as other types of providers) could then partner with agencies to provide services they do not offer but that youth need.
EMERGING TRENDS IN SYSTEM CHANGES
Despite the many challenges discussed, there is movement toward improvement in Community Assessment Centers (CACs), Juvenile Drug Courts, and CASASTART (described below) have been designed to address systemic barriers to appropriate intervention. Each includes a comprehensive assessment followed by coordination of need-based services provided through intersystem linkages. Although outcome data are scarce at this time, the innovations they represent warrant discussion.
Community Assessment Centers
Community Assessment Centers originated within the U.S. Office of Juvenile Justice and Delinquency Prevention (OJJDP) to address multiple and decentralized points of entry, inadequate assessment practices, scarce resources, system fragmentation, and lack of early intervention among at-risk and delinquent youth (Bilchik, 1995; Oldenettel & Wordes, 2000). There are 67 CACs distributed throughout the United States (e.g., California, Colorado, Florida, Kansas, Maryland, Nebraska) and a formal evaluation of their effectiveness is under way (National Council on Crime and Delinquency, 2003). Four interrelated components make up the CAC. First, these centers serve as a single point of entry (component # 1) into the entire system of care within a target community. All agencies regardless of the service system within which they are embedded (e.g., mental health, substance abuse) triage youth to the CAC. If the youth has been arrested, the arresting officer transports the youth to the CAC, where they are booked prior to being assessed. In other words, CACs function as a centralized intake facility for all sectors of a community's service system. Administration of a standardized screening instrument (e.g., Massachusetts Youth Screening Instrument [MAYSI-2]; Grisso & Barnum, 2000) is followed by a standardized comprehensive assessment (component #2), when indicated (e.g., Comprehensive Adolescent Severity Inventory [CASI]; Meyers, Hagan, et al., in press). Arrested youth also receive a risk assessment so that the level of needed security can be determined. Assessment data are reviewed by an interdisciplinary team comprised of CAC staff and colocated staff from multiple community agencies. The data are stored in an integrated management information system (component #3) for data sharing and performance monitoring and are synthesized into a case plan for ongoing case management (component #4). Colocated staff work with case management staff to minimize the red tape that case managers may face when accessing an array of community services. When implemented as designed, CACs (1) enable identification of issues that impede community youths' ability to function (whether they are in the juvenile justice system or not) so that (2) effective services can be delivered in a coordinated, nonduplicative fashion by systems staff working together for the purpose of (3) improving the functional status of youth (and possibly their families), thereby preventing penetration (or further penetration) into various systems of care (Meyers, 1998, 2000). Although evaluation data are not yet available in this area, CACs are nonetheless a promising approach to systems change for youth who use, abuse, or are dependent upon substances, regardless of their presenting problem or the system to which they present. Given the obvious potential of this approach, there is clear need for additional research and evaluation and, if effectiveness is shown, for dissemination and community training.
Juvenile Drug Courts
Although there are recent indications that violent crime has decreased among juveniles, youth crime overall is at unacceptably high levels, with younger and more impaired youth being arrested at an increasing rate (Snyder & Sickmund, 1999). As social services are reduced, the juvenile justice system has become the focal point for interventions with many youth. Hence, the justice system has responded by providing a number of innovative programs (Jenson & Howard, 1998; Office of Juvenile Justice and Delinquency Prevention, 1995).
One such program is the juvenile drug court (American University, 1997; Belanko, 2001; Office of Justice Programs Drug Court Clearinghouse and Technical Assistance Project, 1998). Modeled after adult drug court programs, juvenile drug courts (of which there are 167 as of June 2001; American University, 2001) combine identification of a youth's problems with systemic interventions monitored and enforced by the presiding judge. Although the name implies that drug treatment is the sole focus of these courts, juvenile drug courts generally take a multifaceted approach. Educational deficits, family problems, and behavioral difficulties are addressed by staff of local provider agencies who attend weekly meetings, share information, work together, and change intervention plans where indicated. Participating providers serve as a team delivering coordinated, noncompeting services to youth.
Outcome results are still preliminary, but there are a few studies that found reduced recidivism rates and increased time to rearrest among juvenile drug court participants (Belenko, 2001; Meyers, O'Brien, et al., under review). While additional research is needed, juvenile drug courts appear to be a promising systems intervention for substance-abusing juvenile offenders. These courts enact some of the core principles described above for a more effective systems approach to identifying and treating SUDs among adolescents.
CASASTART (Striving Together to Achieve Rewarding Tomorrows)
CASASTART, originally called the Children at Risk program, was developed by the National Center on Addiction and Substance Abuse (CASA) at Columbia University through foundation and U.S. Department of Justice funding to address service gaps among high-risk 8-to 13-year-olds, their families, and their communities (Murray and Belanko, under review). Similar to the programs discussed above, CASASTART forges a working partnership of schools, law enforcement, and community-based health and social service organizations, and all are housed under one roof. Through intensive case management, a coordinated constellation of eight core services is provided to varying degrees according to the needs of the youth and his or her family: social support; family services; educational services; after-school and summer recreational activities; mentoring; incentives; community policing; and criminal and juvenile justice interventions. Evaluation data illustrate that CASASTART participants were less likely to use or deal drugs, engage in violent crime, or be influenced by negative peers (Harrell, Cavanagh, & Sridharan, 1998). Further, these same youth were more likely to belong to positive peer groups and to advance to the next grade. These data suggest that CASASTART is a promising systems change model that results in positive outcomes among its participants.
Adolescents who use, abuse, or are dependent upon substances are served by a service delivery system that often (1) fails to identify them; (2) fails to make the important distinction between use and abuse or dependence and thus may make inappropriate referrals; (3) renders multiple barriers to treatment access for those who are referred; and (4) delivers fewer developmentally sensitive services than are indicated. As a result, a large group of adolescents who use, abuse, or are dependent upon substances are not being appropriately cared for at a time when there are more and better evidence-based treatment and intervention options than ever before (e.g., motivational interviewing, cognitive-behavioral therapy, multidimensional family therapy).
This chapter has shown that designing ways to address service system inadequacies is just as important as developing evidence-based interventions to treat the disorder itself. Hence, it is clear that the same type of focused research attention and political support that led to the recent developments in evidence-based treatments will be even more important to address service system inadequacies. Examination of ways to efficiently improve the identification of adolescent substance users through staff training, adoption of common definitions and mechanisms for assessment within a developmental context of measurement, and financing arrangements are all needed. The translation of evidence-based research into practice through technology transfer projects has the potential to improve adolescent outcomes, thereby improving access. The Clinical Trials Network within the National Institute on Drug Abuse and Addiction Technology Transfer Centers supported by the Center for Substance Abuse Treatment are a very good beginning in this endeavor. Although complex environments, service delivery systems are comprised of components primed for intervention and three integrative models have been developed. We recognize that systems reform will not be quick or easy and will undoubtedly require policy change and national leadership. But such reform is necessary if adolescents are to take advantage of improved interventions and curtail a trajectory of life-long problems.