On the learning curve: the emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse

Randomized controlled trial of osmotic-release methylphenidate with cognitive-behavioral therapy in adolescents with attention-deficit/hyperactivity disorder and substance use disorders

OBJECTIVE

To evaluate the efficacy and safety of osmotic-release methylphenidate (OROS-MPH) compared with placebo for attention-deficit/hyperactivity disorder (ADHD), and the impact on substance treatment outcomes in adolescents concurrently receiving cognitive-behavioral therapy (CBT) for substance use disorders (SUD).

METHOD

This was a 16-week, randomized, controlled, multi-site trial of OROS-MPH + CBT versus placebo + CBT in 303 adolescents (aged 13 through 18 years) meeting DSM-IV diagnostic criteria for ADHD and SUD. Primary outcome measures included the following: for ADHD, clinician-administered ADHD Rating Scale (ADHD-RS), adolescent informant; for substance use, adolescent-reported days of use in the past 28 days. Secondary outcome measures included parent ADHD-RS and weekly urine drug screens (UDS).

RESULTS

There were no group differences on reduction in ADHD-RS scores (OROS-MPH: -19.2, 95% confidence interval [CI], -17.1 to -21.2; placebo, -21.2, 95% CI, -19.1 to -23.2) or reduction in days of substance use (OROS-MPH: -5.7 days, 95% CI, 4.0-7.4; placebo: -5.2 days, 95% CI, 3.5-7.0). Some secondary outcomes favored OROS-MPH, including lower parent ADHD-RS scores at 8 (mean difference = 4.4, 95% CI, 0.8-7.9) and 16 weeks (mean difference =6.9; 95% CI, 2.9-10.9) and more negative UDS in OROS-MPH (mean = 3.8) compared with placebo (mean = 2.8; p = .04).

CONCLUSIONS

OROS-MPH did not show greater efficacy than placebo for ADHD or on reduction in substance use in adolescents concurrently receiving individual CBT for co-occurring SUD. However, OROS-MPH was relatively well tolerated and was associated with modestly greater clinical improvement on some secondary ADHD and substance outcome measures. Clinical Trial Registration Information-Attention Deficit Hyperactivity Disorder (ADHD) in Adolescents with Substance Use Disorders (SUD); http://www.clinicaltrials.gov; NCT00264797.

Retention of adolescents with substance dependence and coexisting mental health disorders in outpatient alcohol and drug group therapy

The aim of this study was to investigate characteristics that might enhance retention among adolescents attending outpatient alcohol and drug group therapy within a youth mental health setting. An important goal was to provide information for nurses and other clinicians who work with adolescents with coexisting substance use and mental health disorders. A retrospective file audit reviewed the files of 64 adolescents who attended a weekly alcohol and drug group between 2002 and 2004. Five characteristics were shown to have a significant impact on enhancing participant group retention. These were Māori and Pacific Island ethnicity, past or current legal charges, youth drug court (YDC) involvement, having a diagnosis of cannabis dependence, and a diagnosis of conduct disorder. Logistic regression found that YDC involvement on its own significantly predicted treatment retention. In an area of limited research, the findings from this study expand the literature on enhancing treatment retention for a vulnerable and hard-to-engage adolescent group with complex treatment needs, and highlight the need for further investigation of the potential role of the YDC. From a practice perspective, the findings support group therapy interventions as a cost-effective treatment modality for assisting adolescents with coexisting substance use and mental health issues, including those with conduct disorder and YDC involvement.

From assessment reactivity to aftercare for adolescent substance abuse: are we there yet?

This article addresses less developed areas of clinical research that are of great importance for better understanding the therapeutic process along the continuum of care in youth with alcohol and other substance use disorders (AOSUD). These include the rationale, design, mechanisms of behavior change (MBCs), implementation, monitoring, and outcome-based modification of treatment continuum for youth with AOSUD. The specific objectives are: (1) present current knowledge pertaining to the pretreatment phase including the effect of baseline assessment on treatment outcome; (2) address potential MBCs in treatment; (3) discuss the importance of aftercare, also known as continued care, to prevent postintervention relapse; (4) consider how reconceptualization of therapeutic paradigms might advance the field, in particular treatment algorithm or adaptive treatment strategies addressing poor response to treatment.

Evidence for Optimism: Behavior Therapies and Motivational Interviewing in Adolescent Substance Abuse Treatment

This article reviews behavior therapies, motivational interviewing interventions, and combined behavioral-psychosocial therapies across 34 peer-reviewed publications. Studies were included if they involved youth with alcohol and other drug (AOD) use, included measures of AOD outcomes, and used controlled research designs with a control or comparison condition. The level of empirical support of the interventions was evaluated using established guidelines. The article determined that behavior therapies were "probably efficacious," and motivational interviewing interventions easily met the criteria for "promising." Because of small sample sizes, combined behavioral-psychosocial therapies marginally met the criteria for "promising." The findings from this article underscore the value of individual and group behavior therapies and motivational interviewing in helping reduce mild to serious AOD use among adolescents.

Management of the adolescent with substance use disorders and comorbid psychopathology

Substance use disorders are common in youth, and co-occurring psychiatric disorders are present in the majority of cases. This article reviews clinical considerations unique to the population, including intricacies of assessment and special treatment considerations. Several psychotherapeutic intervention models are discussed, including cognitive-behavioral therapy, dialectic behavior therapy, motivational enhancement therapy/motivational interviewing, family behavior therapy, multidimensional family therapy, and multisystemic therapy. Research on psychopharmacologic treatment is limited, and primarily focuses on mood disorders and attention deficit/hyperactivity disorder. To maximize outcome, recommendations based on practice parameters promote integration of treatment modalities versus serial or concurrent treatment of co-occurring substance use and psychiatric disorders.

Interrelations between patients' personal life events, psychosocial distress, and substance use

This study investigated interrelations between life events, psychosocial distress, self-efficacy, and substance use among patients manifesting substance use disorders. Gender differences in these interrelations were also explored. Patients (N = 352) were recruited during 2008 and 2009 from 16 Norwegian facilities. These patients completed a questionnaire with validated measurement instruments. Interrelations were investigated by SEM analysis. The results suggested that negative life events facilitated substance use and psychological distress. Positive life events were associated with self-efficacy, but weakly related to substance use. The results supported the notion that males are more prone to use substances when faced upon negative life events.

Long-term effect of community-based treatment: evidence from the Adolescent Outcomes Project

A growing literature on adolescent drug treatment interventions demonstrates the efficacy of "research therapies," but few rigorous studies examine the effectiveness of community-based treatments that are more commonly available to and utilized by youths and their families, the criminal justice system and other referring agencies. Even less is known about the long-term effects of these community-based treatments. This study evaluates the effects 72-102 months after intake to a widely disseminated community-based treatment model, residential therapeutic community treatment, using data from RAND's Adolescent Outcomes Project. Weighting is used to control for pre-existing differences between adolescent probationers disposed to Phoenix Academy and those assigned to one of six alternative group homes serving as the comparison conditions. Although Phoenix Academy therapeutic community treatment had positive effects on substance use and psychological functioning during the first 12 months following intake, we find no evidence of positive long-term effects on 16 outcomes measuring substance use and problems, criminal activity, institutionalization, psychological functioning and general functioning. We discuss the implications of these findings and the failure to maintain the effects observed during the first year follow-up.

Feasibility and outcomes of an innovative cognitive-behavioural skill training programme for co-occurring disorders in the youth alcohol and other drug (AOD) sector

There are limited treatment options available for young drug users with comorbid mental health problems who present to alcohol and other drug (AOD) services within Australia. While there is some evidence for the use of cognitive-behaviour therapy (CBT) in the treatment of co-occurring disorders, CBT is rarely used to address comorbidity in the AOD sector. This paper describes the development, implementation and evaluation of a brief cognitive-behavioural skills (BCBS) training programme for addressing comorbidity within two youth AOD services in Australia. Ten youth AOD workers completed a 2-day training programme in the BCBS. Training was evaluated using measures of trainees' cognitive-behavioural knowledge, attitudes towards mental health interventions and level of skills and confidence in each of the BCBS pre- and 6 months post-training. The BCBS training had a positive impact on the knowledge, skills and confidence of trainees and was perceived to be highly relevant and appropriate. These findings provide preliminary support for the feasibility and effectiveness of the BCBS training programme for workers within the youth AOD sector.

Family-based treatment for adolescent substance abuse: controlled trials and new horizons in services research

This article provides an overview of controlled trials research on treatment processes and outcomes in family-based approaches for adolescent substance abuse. Outcome research on engagement and retention in therapy, clinical impacts in multiple domains of adolescent and family functioning, and durability and moderators of treatment effects is reviewed. Treatment process research on therapeutic alliance, treatment fidelity and core family therapy techniques, and change in family processes is described. Several important research issues are presented for the next generation of family-based treatment studies focusing on delivery of evidence-based treatments in routine practice settings.

A tale of two systems: co-occurring mental health and substance abuse disorders treatment for adolescents

Co-occurring disorders present serious challenges to traditional mental health and substance abuse treatment systems. Among adolescents in need of behavioral health services, co-occurring disorders are highly prevalent and difficult to treat. Without effective intervention, youth with co-occurring disorders are at increased risk of serious medical and legal problems, incarceration, suicide, school difficulties and dropout, unemployment, and poor interpersonal relationships. In general, current service systems are inadequately prepared to meet this need due to a variety of clinical, administrative, financial, and policy barriers. This article presents an overview of co-occurring disorders among adolescents, highlights general considerations for co-occurring disorders treatment, reviews selected treatment models and outcomes, and discusses recommendations and best practice strategies.

Effectiveness of a peer-support community in addiction recovery: participation as intervention

The main purpose of the study was to determine whether a peer-support community programme would reduce relapse rates among clients recovering from substance addictions and homelessness and result in increased perceived community affiliation, supportive behaviours, self-determination and quality of life. Mixed methods were utilized including semi-structured interviews, participant observation and a pretest/post-test to evaluate changes on the quality of life rating, the Medical Outcomes Study-Social Support Survey, and the Volitional Questionnaire. Data from the prior year's permanent supportive housing programme were used for comparison of relapse rates. Significant reduction of risk of relapse was found in clients who participated in the programme. Significant differences were found on three subscales of the Medical Outcomes Study-Social Support Survey. Improvement that did not reach statistical significance was seen on the quality of life rating. Qualitative evidence supported improvements in perceived community affiliation and supportive behaviours.Evidence suggests that a peer-supported community programme focused on self-determination can have a significant positive impact on recovery from substance addictions and homelessness. Limitations include a small sample size and lack of a randomized control group.

Interventions for alcohol use and alcohol use disorders in youth

Designing effective interventions for adolescents with alcohol use disorders (AUDs) presents several challenges, not the least of which is the accurate diagnosis of these disorders. Diagnostic criteria for AUDs have been derived largely from clinical and research experience with adults. When these criteria were tested among adolescents, numerous developmental differences were found that may affect the applicability of AUD criteria to this age group. Despite the absence of clear diagnostic criteria for use with adolescents, research has identified interventions that show promise for use with youth. This article examines both environmental- and individual-level approaches to underage drinking prevention, including school- and family-based programs, and macroenvironmental and multicomponent comprehensive interventions. Finally, it describes brief and complex treatment interventions.

Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed.

The Effect of Positive Adolescent Life Skills Training on Long Term Outcomes for High-Risk Teens

This paper reports on long term follow-up data-12 months post intervention-from a clinical trial of an intervention designed to enhance teen resilience by supporting the development of social skills needed to make positive connections and overcome the influence of negative environmental influences. Sixteen adolescents aged 12 to 16 (10 boys and 6 girls) attending an inner city urban secondary school participated in a 32 week intervention study. Subjects were randomly assigned within sex to Teen Club plus Positive Adolescent Life Skills (PALS) or Teen Club intervention groups. The Problem Oriented Screening Instrument for Teenagers (POSIT) was used to measure the dependent variables (problems related to substance use, health, mental health, family relations, peer relations, education status, vocational status, social skills, leisure and recreation, and aggression). The small sample size limited the ability to determine statistical differences between the POSIT subscale scores for PALS plus Teen Club or Teen Club only interventions. Descriptive data suggest mixed results for both interventions and sex groups. Most important were reductions in mental health problems for all boys in both groups and only slightly increased numbers of problems in substance use for PALS boys and girls over time. Other trends by group and sex are reported.

Economic evaluation of adolescent addiction programs: methodologic challenges and recommendations

This article identifies and describes several methodologic challenges encountered in economic evaluations of substance abuse interventions for adolescents. Topics include study design, the choice of perspective, the estimation of costs and outcomes, and the generalizability of results. Recommendations are offered for confronting these challenges using examples from research on adolescent substance abuse and dependency/addiction.

Efficacy of outpatient aftercare for adolescents with alcohol use disorders: a randomized controlled study

OBJECTIVE

Relapse rates for treated adolescents with alcohol use disorders (AUDs) amount to approximately 60% at 3 to 6 months after treatment completion. This randomized controlled study tested the hypothesis that active aftercare may maintain treatment gains better than no active aftercare (NA).

METHOD

A total of 177 adolescents, 13 to 18 years of age, diagnosed with DSM-IV AUD, participated in nine weekly outpatient cognitive behavioral therapy group sessions. The 144 treatment completers were randomized into a 5-session in-person, brief telephone, or NA condition. Three alcohol use variables were the main outcome measures for 130 aftercare completers.

RESULTS

At the end of aftercare, the likelihood of relapse increased significantly compared with end of treatment outcomes. The likelihood of relapse for youths in NA, however, increased significantly more for youths in combined active aftercare (AA) conditions (p =.008). This effect was driven primarily by a significant sex x active aftercare interaction: girls showed no significant relapse under AA but relapsed significantly in NA. Youths enrolled in AA also showed significantly fewer drinking days (p =.044) and fewer heavy drinking days (p =.035) per month relative to NA.

CONCLUSIONS

In general, active aftercare interventions showed certain efficacy in slowing the expected posttreatment relapse process for alcohol use, with maintenance of treatment gains only for girls. Frequency of interventions, dose-response, duration of aftercare phase, and mediators of behavior change should be examined further to optimize aftercare for youths with AUD.

Adolescent-only substance abuse treatment: availability and adoption of components of quality

There are few studies of the availability and quality of adolescent-only treatment programs. Drawing upon existing samples of publicly and privately funded treatment programs, this research considers whether organizational characteristics are associated with the availability of adolescent-only programming and measures components of quality within these programs. Significant organizational correlates of adolescent-only services included organizational size, location within a hospital setting, center accreditation, adherence to a 12-step treatment model, and reliance on public sources of funding. In-depth interviews were then conducted with 154 managers of adolescent-only treatment programs regarding levels of care offered and service quality. The most prevalent levels of care were standard outpatient and intensive outpatient. Analysis of nine domains of treatment quality revealed a medium level of quality. Treatment quality was significantly greater in programs offering more intensive levels of care. These results are largely consistent with other recent research and suggest a need for continued quality improvement efforts in this treatment sector.

Developing integrated models of care within the youth Alcohol and Other Drug sector

OBJECTIVE

The aim of this paper is to describe an initiative in Victoria, Australia, aimed at improving the detection and management of co-occurring mental health issues within the youth Alcohol and Other Drug (AOD) sector.

CONCLUSIONS

Over the past 4 years, in partnership with local youth AOD services, we have developed a successful service model that addresses co-occurring mental health issues within the youth AOD sector. However, such capacity-building requires the full support of workers and senior management, and a cultural shift whereby the assessment and management of mental health issues are seen as a priority and core service issue. The capacity-building process was facilitated by embedding experienced mental health clinicians within each service to support and implement the initiative. This model offered learning opportunities through the modelling of relevant skills and the provision of 'on-the-job' training. Such approaches demonstrate that integrated models of care can be delivered within youth AOD services, although further research is needed to determine their effectiveness.

Treatment of comorbid adolescent cannabis use and major depressive disorder

The comorbidity of unipolar depression with substance use disorders (SUD) in adolescents is well established and accounts for 24 to 50 percent in clinical samples. Very little empirical data exist on the treatment of dually diagnosed youth. The objective of this paper is twofold: 1) We will review the literature on SUD and unipolar depression; and 2) we will provide guidelines for a combined pharmacological and psychosocial intervention based on a clinical case example.

Marijuana dependence and its treatment

The prevalence of marijuana abuse and dependence disorders has been increasing among adults and adolescents in the United States. This paper reviews the problems associated with marijuana use, including unique characteristics of marijuana dependence, and the results of laboratory research and treatment trials to date. It also discusses limitations of current knowledge and potential areas for advancing research and clinical intervention.

Neurobiological processes in adolescent addictive disorders

The purpose of this review is to summarize the neurobiological factors involved in the etiology of adolescent addiction and present evidence implicating various mechanisms in its development. Adolescents are at heightened risk for experimentation with substances, and early experimentation is associated with higher rates of SUD in adulthood. Both normative (e.g., immature frontal-limbic connections, immature frontal lobe development) and non-normative (e.g., lowered serotonergic function, abnormal hypothalamic-pituitary-adrenal axis function) neurobiological developmental factors can predispose adolescents to a heightened risk for SUD. In addition, a normative imbalance in the adolescent neurobiological motivational system may be caused by the relative underdevelopment of suppressive mechanisms when compared to stimulatory systems. These neurobiological liabilities may correspond to neurobehavioral impairments in decision-making, affiliation with deviant peers and externalizing behavior; these and other cognitive and behavioral traits converge with neurobiological factors to increase SUD risk. The progression to SUD acts as an amplifying feedback loop, where the development of SUD results in reciprocal impairments in neurobehavioral and neurobiological processes. A clearer understanding of adolescent neurobiology is a necessary step in the development of prevention and treatment interventions for adolescent SUD.

Intervening early to reduce developmentally harmful substance use among youth populations

Early-onset or frequent substance use during adolescence increases the risk of developing mental health problems, as well as a range of other adverse outcomes (eg, alcohol or drug dependence, educational underachievement, health problems, social difficulties) during late adolescence and early adulthood. Increases in rates of risky drinking among young people are particularly concerning, suggesting that an effective, evidence-based alcohol policy and preventive framework needs to be developed. Restricting the supply of licit and illicit substances to adolescents, delaying the age that licit substances can be legally purchased, reducing positive media portrayals of substance use, and banning targeted promotions, should be universal, public prevention priorities. Mass-media campaigns need to deliver coherent and credible evidence-based messages to young people, utilising a broad array of dissemination strategies. Clear policy and guidelines for parents regarding appropriate alcohol use for adolescents also need to be developed. Prevention programs should target children and adolescents in families with parents who use drugs, young people who have been suspended from school, or those with mental health problems. Preventive screening and targeted brief interventions can be effectively delivered in a variety of settings by a range of health professionals.

Assessing fidelity in individual and family therapy for adolescent substance abuse

This study introduces an observational measure of fidelity in evidence-based practices for adolescent substance abuse treatment. The Therapist Behavior Rating Scale-Competence (TBRS-C) measures adherence and competence in individual cognitive-behavioral therapy and multidimensional family therapy for adolescent substance abuse. The TBRS-C assesses fidelity to the core therapeutic goals of each approach and also contains global ratings of therapist competence. Study participants were 136 clinically referred adolescents and their families observed in 437 treatment sessions. The TBRS-C demonstrated strong interrater reliability for goal-specific ratings of treatment adherence, and modest reliability for goal-specific and global ratings of therapist competence, evidence of construct validity, and discriminant validity with an observational measure of therapeutic alliance. The utility of the TBRS-C for evaluating treatment fidelity in field settings is discussed.

A practical framework for evaluating a culturally tailored adolescent substance abuse treatment programme in Molokai, Hawaii

OBJECTIVE

Successful substance abuse treatment requires many changes in behavior, attitude and skills. Culturally tailored approaches to substance abuse treatment have shown initial success, but are not yet accepted as best practice models. In order to document programme effectiveness of a new culturally tailored substance abuse treatment programme on the rural island of Molokai, Hawaii, the authors worked to develop a multi-level evaluation plan to measure behavior changes occurring after participation in activities targeting identified causes of substance abuse in the population of interest.

METHODS

The authors compiled interview results to develop a map of identified causes of substance abuse in the community studied. Strategic planning then identified the specific activities aimed at impacting identified root causes. A literature review was performed to document the effectiveness of such activities. An evaluation plan was developed to measure programme impact on antecedent conditions contributing to substance use in this community.

RESULTS

Prioritized causes of substance abuse in the target group included low self esteem, lack of self identity and life plan, and limited communication and conflict resolution skills. Activities targeting these conditions included cultural activities, group counseling, and individual counseling. Literature to support the benefit of addressing these factors was uncovered, and evaluation methodology was developed to measure changes in behaviors, attitudes, and practices, as a measure of programme success.

DISCUSSION

While programme evaluation data is still being collected, the authors have demonstrated a sound foundation for programme activities, and designed methodology for collecting meaningful data to measure programme effectiveness at changing important root causes of substance abuse in a rural Native Hawaiian community.

Cost-effectiveness analysis of four interventions for adolescents with a substance use disorder

Alcohol, tobacco, and illicit drug use among adolescents in the United States continues to be a serious public health challenge. A variety of outpatient treatments for adolescent substance use disorders have been developed and evaluated. Although no specific treatment modality is effective in all settings, a number of promising adolescent interventions have emerged. As policy makers try to prioritize which programs to fund with limited public resources, the need for systematic economic evaluations of these programs is critical. The present study attempted a cost-effectiveness analysis of four interventions, including family-based, individual, and group cognitive behavioral approaches, for adolescents with a substance use disorder. The results indicated that treatment costs varied substantially across the four interventions. Moreover, family therapy showed significantly better substance use outcome compared to group treatment at the 4-month assessment, but group treatment was similar to the other interventions for substance use outcome at the 7-month assessment and for delinquency outcome at both the 4- and 7-month assessments. These findings over a relatively short follow-up period suggest that the least expensive intervention (group) was the most cost-effective. However, this study encountered numerous data and methodological challenges in trying to supplement a completed clinical trial with an economic evaluation. These challenges are explained and recommendations are proposed to guide future economic evaluations in this area.

Engaging resistant adolescents in drug abuse treatment

In the first phase of a two-part treatment development study, families with a treatment-resistant drug-abusing adolescent (n = 42) were offered 12 sessions of Community Reinforcement and Family Training (CRAFT). This parent-focused intervention was designed to help parents facilitate their adolescents' entry into treatment, to support adolescents' subsequent behavior change, and to improve parent and family functioning. In the second phase, successfully engaged adolescents (n = 30) were offered 12 sessions of a multicomponent individual cognitive-behavioral therapy (CBT) targeting substance use and related problem behaviors. For parents and adolescents, measures were collected on pretreatment and posttreatment, with an additional follow-up assessment for parents at 3 months after treatment. Parents on CRAFT intervention experienced a significant reduction in negative symptoms, and 71% of parents were successful in engaging their resistant youths in treatment. The CBT intervention for engaged youths was associated with a statistically significant, but not clinically significant, reduction in marijuana use.

Outpatient drug abuse treatment for Hispanic adolescents

The objective of this article is to review the state of the science in evidence-based drug abuse treatments for Hispanic adolescents, highlight scientific opportunities, and offer recommendations to further the field of drug abuse treatment for this population. The article is divided into seven sections: boundaries for this review, drug abuse and associated problems, behavioral treatment, cultural issues in hispanic adolescent behavioral drug abuse treatment, pharmacological treatment, gender differences in treatment, and scientific opportunities/recommendations. Although only one treatment approach, Brief Strategic Family Therapy, has been empirically shown to be efficacious in treating Hispanic adolescent drug abusers, with some modifications other treatments may also have the potential to be efficacious with Hispanic adolescents. Family-based approaches, which typically appear to be most efficacious with adolescents in general, may also have the greatest potential to treat drug abuse in Hispanic adolescents.

Recent trends in adolescent substance use, primary care screening, and updates in treatment options

PURPOSE OF REVIEW

To provide a brief overview on trends in common substances of abuse in adolescents, a summary of tools to evaluate adolescent substance abuse in an outpatient setting, and an update of outpatient and inpatient treatment options.

RECENT FINDINGS

Recent national data suggest an overall slight decline in the use of tobacco, crystal methamphetamine, heroin, and club drugs. No significant change was noted in the use of alcohol, marijuana, and cocaine. Yearly screening of all adolescents for substance use is recommended. This can be accomplished in an office setting using mnemonics, structured interview techniques, and brief screens for substance abuse. If a problem is identified, various outpatient and inpatient treatments are available. Individual, family, and group therapy methods are available. Other options include acute detoxification programs, partial hospitalization, acute residential treatment, residential treatment centers and wilderness programs. Pharmacological treatments are available for nicotine, alcohol, and opioid addiction.

SUMMARY

Tobacco, alcohol, marijuana, and other drugs remain a significant problem among adolescents in the United States. Pediatricians should screen and assess all adolescents on a yearly basis. If a problem is identified, there are many options for treatment, including pharmacologic treatment as well as individual, family, or group therapy in an inpatient or outpatient setting.

Cannabis use by children and young people

A popular internet site describes cannabis as "a leafy plant, the leaves and flowering tops (buds) of which may be either smoked or eaten. It also comes in a more concentrated resinous form called hashish, and as a sticky black liquid called hash oil". It is said that users often report a pleasant "subjective enhancement of visual and auditory perception, sometimes with synaesthesia (sounds take on visual colourful qualities)" and the sense that time passes more quickly than real time, a "fatuous euphoria", as well as relaxation and relief from stress.

Alcohol, drugs, and attention-deficit/ hyperactivity disorder: a model for the study of addictions in youth

There has been increasing interest in the developmental origins of substance use disorders (SUDs) in children and adolescents. Because of its early onset, high prevalence and known risk for SUD, attention deficit hyperactivity disorder (ADHD) is a model developmental disorder to evaluate in context to SUDs. A selected review of the literature was undertaken examining ADHD as an antecedent disorder to subsequent SUD. ADHD and its co-occurring comorbid psychopathology increase the risk for cigarette smoking and SUD and is associated with greater SUD severity and chronicity. The treatment of ADHD appears to decrease the risk for cigarette smoking and SUD. ADHD is an important antecedent disorder in children and adolescents worthy of further targeted preventive efforts to diminish the risk for cigarette smoking and SUD.

Providing effective substance abuse treatment for young-offender populations: what works!

Previous research has documented a strong linkage between substance abuse and criminal activity among young offenders. Consequently, the provision of effective substance-abuse interventions for this population is of paramount importance to the criminal justice system. This article explores the literature on the treatment of substance abuse in offender and nonoffender populations. It reviews three major areas: pretreatment variables (eg, gender and psychopathology), in-treatment variables (eg, program targets, program setting, client-treatment matching), and posttreatment variables (eg, aftercare). The article concludes with a list of empirically derived guidelines for the effective development and implementation of substance-abuse treatment programs for adolescents.

Translating research findings into practice: example of treatment services for adolescents in managed care

An important question in the alcoholism treatment field is how research findings can be translated into real-world clinical practice. Researchers have developed a new research-practice integration (RPI) model that can both drive the formulation of studies and new research questions and promote improvements in treatment quality. The hallmark of this model is a collaborative relationship between the key stakeholders in both alcohol and other drug (AOD) treatment and research, including health plan administrators and clinicians, treatment program administrators, psychiatry and primary care departments, patients and their families, purchasers, and researchers. The issue of technology transfer is especially relevant in the realm of adolescent AOD treatment. The implementation and feasibility of the RPI model are illustrated by a case study of a managed health care plan's treatment services for adolescents with AOD dependence. In this setting, key research findings are being used to shape the plan's adolescent health services.

An Interactive Voice Response (IVR) System for Adolescents with Alcohol Use Disorders: A Pilot Study

In order to understand predictors of relapse among adolescents treated for alcohol use disorders (AUD), it is important to accurately assess the daily circumstances associated with use. This pilot study investigates the feasibility and acceptability of an interactive voice response (IVR) system in adolescents with AOSUD. Twenty-six adolescents 14 to 19 years old, with a mean age of 16.8, who were enrolled into an adolescent treatment program for AUD consented to make phone calls for 14 successive evenings to an IVR system and answer 14 questions pertaining to daily use of alcohol and other drugs. The subjects were compensated for their participation. A satisfaction questionnaire was administered at the end of the study. Participants completed 72% of scheduled recordings, with an average of 10.1 calls per subject. Most participants reported that they answered the questions honestly and accurately and were very much satisfied with the IVR system. The preliminary data presented here suggests that the use of IVR for the purpose of generating daily reports in youth is feasible and acceptable. The utilization of IVR systems should be explored to improve efficacy and attainment of generalizability to heterogeneous adolescent populations and lifestyles including for other psychiatric disorders.

Suicidal Ideation among Adolescents with Alcohol Use Disorders during Treatment and Aftercare

The objectives of this study are to assess the magnitude and course of suicidal ideation during outpatient treatment and aftercare for adolescents with alcohol use disorders (AUD). One hundred seventy-seven adolescents meeting eligibility criteria, including no past 30-day suicidal behavior, participated in 9 weeks of outpatient cognitive-behavioral group therapy. Treatment completers were randomized into: (1) No-Active, (2) In-Person, or (3) Telephone aftercare conditions for a period of 12 weeks. No specific intervention for suicidal behavior was provided during the study. The Suicide Ideation Questionnaire (SIQ-JR, Reynolds, 1988) was administered at baseline, end of treatment, and end of aftercare. The results are as follows, a higher baseline suicidal ideation was associated with higher retention at the end of treatment and through aftercare. The In-Person Aftercare condition showed a significant decrease in suicidal ideation, relative to the No-Active Aftercare condition. There was a trend for similarly reduced severity of suicidal ideation in the Telephone Aftercare condition. In conclusion, the type of aftercare and resulting decrease in AUD may play a role in the reduction in suicidal ideation. The mechanism of change by which suicidal ideation is reduced in adolescents in treatment for AUD needs to be further explored.

Relapse to alcohol and other drug use in treated adolescents: review and reconsideration of relapse as a change point in clinical course

Relapse serves as an early warning sign of a failure to maintain desired behavioral change. Although rates of and time to relapse appear to be similar for treated adolescents and adults, this critical review of the literature on adolescent relapse begins with an overview of developmental differences between adolescent and adult substance users that need to be considered when studying relapse. A summary of rates of relapse in treated teens is followed by a review of results on the predictive validity of different relapse definitions. Next, characteristics of teens' initial relapse in terms of substances involved, situational context, and factors associated with relapse are described. Because relapse is ideally understood in the context of longer-term patterns of use, the review also discusses the extent to which early episodes of use mark clinically significant change points in post-treatment course, and how knowledge of longer-term clinical course is essential to understanding the relapse process and mechanisms underlying the maintenance of behavioral change.

Self-efficacy as a predictor of treatment outcome in adolescent substance use disorders

Youth substance abuse relapse prevention was examined as a function of patients' situational self-efficacy (SE), their confidence to abstain from substance use in high-risk situations. An increase in SE has been shown to be enhanced by cognitive behavioral therapy (CBT) in adults. Eighty-eight adolescent substance abusers were randomly assigned to either CBT or psycho-education (PET) group therapy. Substance use and SE were assessed at end of treatment, 3- and 9-months after the end of planned treatment. Increased SE predicted subsequent abstinence independently from drug urinalysis and treatment condition only during treatment, while previous substance use predicted subsequent self-efficacy. CBT was not differentially effective than PET in promoting SE. It is recommended that potential mediators and moderators of SE in the treatment of adolescent substance abuse should be further explored.

Profiles of drug use behavior change for adolescents in treatment

This study was designed to replicate and extend previous research on post-treatment responding by identifying trajectories of change on the basis of an empirical classification strategy and to examine predictors of those change trajectories identified. Treatment response was examined for 232 adolescents with substance use disorders who participated in one of two randomized controlled trials evaluating family and cognitive behavioral interventions in an outpatient treatment setting. Cluster analysis was used to identify, empirically, homogeneous groups of individuals who display common internally consistent patterns of change over the course of treatment.

Substance misuse and psychiatric comorbidity in adolescents

PURPOSE OF REVIEW

Many young people are misusing and becoming dependent on multiple substances (especially nicotine, alcohol, and cannabis), with a complex variety of psychological effects.

RECENT FINDINGS

Analysis of interactions between smoking, drinking, and cannabis use indicates that the relationship between substance use and psychiatric comorbidity is primarily explained by regular smoking. In some studies the use of cannabis on a regular basis was associated with an increased risk of psychiatric illness. This is by no means the case for all studies, so this area of work remains controversial. Children with attention deficit hyperactivity disorder who are substance misusers have a poorer prognosis than those without it so there is concern about treatment with stimulant drugs: this fear appears not to be substantiated by one study. Young people with anxiety disorders are at increased risk of substance use disorders. Clinical trials for adolescent substance abuse treatment have provided support for the benefits of cognitive behavioural interventions. There is an accumulating evidence base for pharmacological treatment for adult substance misusers that can inform treatment for younger patients. It is estimated that, of those adolescents who were likely to be in need of help, only about 9% received treatment.

SUMMARY

Since psychiatric disorders beginning in childhood may continue into adult life, there is an opportunity to intervene to prevent or reduce conditions complicated by substance misuse, if services are accessible. The need for longitudinal work is vital to explore the patterns of comorbidity, and implement and evaluate appropriate treatment interventions.

Adolescent substance abuse treatment: evidence-based practice in outpatient services

Adolescent substance use disorder (SUD) is a serious public health concern. The majority of youth with SUD receive outpatient treatment. There is a pressing need to improve treatment outcome due to high rates of both premature treatment termination and relapse during and after treatment completion. Reviews of the latest innovations in the treatment of adolescent substance abuse and the recent completion of several randomized clinical trials examining singular and integrative treatment modalities have established empiric support for the efficacy of adolescent treatment. Despite some prominent differences in treatment modalities, design, and methodology, recent studies have reported remarkably similar short-term outcomes. Taken together, the findings represent significant developments in treatment outcome research, and lay the foundation for continued future research addressing important challenges. Potential directions include improving short- and long-term outcomes, enhancing motivation for treatment, improving engagement strategies, identifying challenges associated with psychiatric comorbidity, addressing patient-treatment matching, and developing aftercare programs.