Recovery Supports for Young People: What Do Existing Supports Reveal About the Recovery Environment?

Family involvement in treatment and recovery for substance use disorders among transition-age youth: Research bedrocks and opportunities

This article presents a narrative review and conceptual framework for research on family involvement across the continuum of substance use disorder (SUD) services for transition-age youth (ages 15-26). Though families are powerful resources for enhancing treatment and recovery success among youth with SUDs, they are not routinely included in clinical practice. This article summarizes youth SUD prevalence and service utilization rates and presents developmental and empirical rationale for increasing family involvement in services. It then describes key research issues on family involvement across the SUD services continuum: Problem Identification, Treatment Engagement, Active Treatment, Recovery Support. Within each phase, it highlights bedrock research findings and suggests promising opportunities for advancing the scientific knowledge base on family involvement. The main goals are to endorse family-oriented practices for immediate adoption in routine care and identify areas of research innovation that could significantly enhance the quality of youth SUD services.

Recommendations for improving adolescent addiction recovery support in six northwest tribal communities

American Indian and Alaska Native (AI/AN) communities offer tangible and intangible resources, including centuries of indigenous wisdom and resiliency, to support their young people in recovery from substance use disorders. At the same time, tribal youth returning home from residential or inpatient treatment are vulnerable to relapse, especially if they encounter the same environmental triggers in which their substance misuse developed. This study endeavored to learn about community stakeholder perceptions of existing strengths and needs for supporting recovering adolescents among six tribal communities of the Inland Northwest. Using a Tribal Participatory Research approach, we conducted Group Level Assessments with key stakeholders representing educators/coaches, medical and behavioral health providers, social service providers, cultural leaders/elders, and legal professionals among each participating tribe (N = 166). We used content analysis to identify emergent themes among participants' recommendations for improving recovery support. The five emergent themes were (1) Communication, Collaboration, and Accountability among Tribal Departments and Agencies; (2) Community-wide Education; (3) The Importance of Providing Wraparound/Supportive Services; (4) Youth-focused Education, Services, and Events; and (5) Recovery Coaching Model. AI/AN culture was infused within nearly all recommendations for improving recovery support that composed these themes. We discuss specific ways to implement these recommendations, including the forthcoming development of a culturally-grounded community-wide mental health training program developed specifically for, and with, these tribes.

Social-Ecological Predictors of Opioid Use Among Adolescents With Histories of Substance Use Disorders

Adolescent opioid misuse is a public health crisis, particularly among clinical populations of youth with substance misuse histories. Given the negative and often lethal consequences associated with opioid misuse among adolescents, it is essential to identify the risk and protective factors underlying early opioid misuse to inform targeted prevention efforts. Understanding the role of parental risk and protective factors is particularly paramount during the developmental stage of adolescence. Using a social-ecological framework, this study explored the associations between individual, peer, family, community, and school-level risk and protective factors and opioid use among adolescents with histories of substance use disorders (SUDs). Further, we explored the potential moderating role of poor parental monitoring in the associations between the aforementioned risk and protective factors and adolescent opioid use. Participants included 294 adolescents (M _age = 16 years; 45% female) who were recently discharged from substance use treatment, and their parents (n = 323). Results indicated that lifetime opioid use was significantly more likely among adolescents endorsing antisocial traits and those whose parents reported histories of substance abuse. Additionally, adolescents reporting more perceived availability of substances were significantly more likely to report lifetime opioid use compared to those reporting lower perceived availability of substances. Results did not indicate any significant moderation effects of parental monitoring on any associations between risk factors and lifetime opioid use. Findings generally did not support social-ecological indicators of opioid use in this high-risk population of adolescents, signaling that the social-ecological variables tested may not be salient risk factors among adolescents with SUD histories. We discuss these findings in terms of continuing care options for adolescents with SUD histories that target adolescents' antisocial traits, perceived availability of substances, and parent histories of substance abuse, including practical implications for working with families of adolescents with SUD histories.

Identity (Re)Construction of Female Adolescents with Substance Use Disorders

Identity formation is a developmental milestone for adolescents, and their identities are constructed and re-constructed through their interactions with others and contextual factors in their environment. When considering adolescents with substance use disorders (SUD), often this developmental milestone is misappropriated, misunderstood, and misrepresented. The purpose of this article was to explore how adolescents with substance use disorders form identity and construct a sense of self. Firstly, we explored the identity formation and reconstruction of 20 female adolescents with SUDs based on an in-depth grounded theory methodology (GTM) which included a situational analysis (SA). Secondly, we offered a theoretical model to explain identity construction and reconstruction of adolescents with SUDs that emerged from this research. We conclude this article with practical implications for treatment, and care of adolescents with SUDs.

What parents of adolescents in residential substance use treatment want from continuing care: A content analysis of online forum posts

BACKGROUND

Parents of adolescents in residential substance use (SU) treatment face a myriad of barriers to continuing care services. Growing research suggests that mobile health (mHealth) technologies can overcome common barriers to continuing care services, yet no work has addressed parents' needs. To gain insight into parents' continuing care needs, we analyzed online forum posts made by parents who received a novel mHealth intervention. Methods: Thirty parents received access to an online networking forum where they could connect with our adolescent SU expert or the community of parents also navigating their adolescent's post-discharge transition. In real-time, participants could ask questions and share information, experiences, and emotional support. Results: Twenty-one parents (70%) posted at least once; 12 parents made 15 posts to our expert, while 18 parents made 50 posts to the parent community. Thematic analysis uncovered five major themes: parenting skills; parent support; managing the post-discharge transition; adolescent SU; and family functioning. Conclusions: Parents discussed a range of topics directly and indirectly related to their adolescent's treatment. Incorporating networking forums into mHealth continuing care interventions offers parents a secure space to ask questions, share concerns, and gather information needed to support their adolescent's transition home.

Support Services for Young Adults With Substance Use Disorders

In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUDs) among young adults, this special article reviews principles of care concerning recovery support services for this population. Young adults in recovery from SUDs can benefit from a variety of support services throughout the process of recovery. These services take place in both traditional clinical settings and settings outside the health system, and they can be delivered by a wide variety of nonprofessional and paraprofessional individuals. In this article, we communicate fundamental points related to guidance, evidence, and clinical considerations about 3 basic principles for recovery support services: (1) given their developmental needs, young adults affected by SUDs should have access to a wide variety of recovery support services regardless of the levels of care they need, which could range from early intervention services to medically managed intensive inpatient services; (2) the workforce for addiction services for young adults benefits from the inclusion of individuals with lived experience in addiction; and (3) recovery support services should be integrated to promote recovery most effectively and provide the strongest possible social support.

Exploring recovery capital among adolescents in an alternative peer group

BACKGROUND

Recovery support models (RSMs) integrate peer supports and continuing care to promote sustained recovery for adolescents with substance use disorder. RSMs aim to build recovery capital (RC), the personal, social, and environmental resources required to sustain recovery. The Alternative Peer Group (APG) is an RSM that integrates pro-recovery peers and social activities into clinical practice. APGs aim to build adolescents' RC and help them establish pro-recovery social networks. The Recovery Capital for Adolescents Model (RCAM) is a proposed framework for identifying assets to enhance and barriers to address in supporting adolescents' recovery. The RCAM has never been directly applied in APG research so little is known about the process of building RC while participating in an APG.

METHODS

This study is a secondary analysis of semi-structured interviews with APG participants. Using a deductive analytic approach, the RCAM was systematically applied to participants' narratives to examine the model's utility for identifying recovery barriers and resources that promote adolescent recovery.

FINDINGS

This study's findings confirmed the RCAM's utility for identifying specific recovery assets and barriers to recovery faced by adolescents. APG participants' narratives generally reflected the RCAMs RC domains (financial, human, social and community) as proposed and added details to refine the model. Specific strategies employed by the APG to enhance RC and address recovery barriers are presented and illustrated with qualitative exemplars.

CONCLUSIONS

The RCAM is a useful model for identifying the multiple, interrelated factors inherent to adolescents' recovery experience and potential pathways of RC resource-building.

Recovery schools for improving behavioral and academic outcomes among students in recovery from substance use disorders: a systematic review

This Campbell systematic review examines the effects of recovery schools on student behavioral and academic outcomes, compared to the effects of non-recovery schools. The review summarizes evidence from one quasi-experimental study (with a total of 194 participants) that had potential serious risk of bias due to confounding. Sizable portions of youth are in recovery from substance use disorders, and many youth will return to use after receiving substance use treatment. Youth spend most of their waking hours at school, and thus schools are important social environments for youth in recovery from substance use disorders. Recovery schools have been identified as educational programs that may help support youth in recovery from substance use disorders. This review focused on two types of recovery schools: RHSs, which are schools that award secondary school diplomas and offer a range of therapeutic services in addition to standard educational curricula; and CRCs, which offer therapeutic and sober support services on college campuses. This review looked at whether recovery schools (RHSs or CRCs) affect academic success and substance use outcomes among students, compared to similar students who are not enrolled in recovery schools.

Plain language summary

There is insufficient evidence to know whether recovery high schools and collegiate recovery communities are effective: Evidence that recovery high schools (RHSs) may improve academic and substance use outcomes is based on the findings from a single study with a serious risk of bias.The review in brief: Very limited evidence addresses the effectiveness of recovery high schools (RHSs). There is no rigorous evidence on the effectiveness of collegiate recovery communities (CRCs).It is unclear whether CRCs are effective in promoting academic success and reducing substance use among college students.What is the aim of this review?: This Campbell systematic review examines the effects of recovery schools on student behavioral and academic outcomes, compared to the effects of non-recovery schools. The review summarizes evidence from one quasi-experimental study (with a total of 194 participants) that had potential serious risk of bias due to confounding.What are the main findings of this review?: Sizable portions of youth are in recovery from substance use disorders, and many youth will return to use after receiving substance use treatment. Youth spend most of their waking hours at school, and thus schools are important social environments for youth in recovery from substance use disorders. Recovery schools have been identified as educational programs that may help support youth in recovery from substance use disorders.This review focused on two types of recovery schools: RHSs, which are schools that award secondary school diplomas and offer a range of therapeutic services in addition to standard educational curricula; and CRCs, which offer therapeutic and sober support services on college campuses.This review looked at whether recovery schools (RHSs or CRCs) affect academic success and substance use outcomes among students, compared to similar students who are not enrolled in recovery schools.What studies are included?: The included study of recovery high schools used a controlled quasi-experimental pretest-posttest design and reported on the following outcomes: grade point average, truancy, school absenteeism, alcohol use, marijuana use, other drug use, and abstinence from alcohol/drugs. The included study focused on a sample of U.S. high school students. There were no eligible studies of CRCs.What do the findings of this review mean?: Findings from this review indicate insufficient evidence on the effects of recovery schools on student well-being. Although there is some indication RHSs may improve academic and substance use outcomes, this is based on the findings from a single study. There is no available evidence on the effects of CRCs.No strong conclusions can be drawn at this time, given the lack of available evidence on RHSs and CRCs, and the serious risk of bias in the one RHS study included in the review. The evidence from this review suggests there is a clear need for additional rigorous evaluations of recovery school effects prior to widespread implementation.How up-to-date is this review?: The review authors searched for studies until September 2018. This Campbell systematic review was published in 2018.

Executive Summary/Abstract

BACKGROUND: Substance use disorders (SUDs) among youth are a major public health problem. In the United States, for example, the incidence of SUDs increases steadily after age 12 and peaks among youth ages 18-23 (White, Evans, Ali, Achara-Abrahams, & King, 2009). Although not every youth who experiments with alcohol or illicit drugs is diagnosed with an SUD, approximately 7-9% of 12-24 year olds in the United States were admitted for public SUD treatment in 2013 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). Recovery from an SUD involves reduction or complete abstinence of use, defined broadly as "voluntarily sustained control over substance use, which maximises health and wellbeing and participation in the rights, roles and responsibilities of society" (UK Drug Policy Commission, 2008). However, SUDs are often experienced as chronic conditions; among youth who successfully complete substance use treatment, approximately 45-70% return to substance use within months of treatment discharge (Anderson, Ramo, Schulte, Cummins, & Brown, 2007; Brown, D'Amico, McCarthy, & Tapert, 2001; Ramo, Prince, Roesch, & Brown, 2012; White et al., 2004). Thus, multiple treatment episodes and ongoing recovery supports after treatment are often necessary to assist with the recovery process (Brown et al., 2001; Ramo et al., 2012; White et al., 2004).Success and engagement at school and in postsecondary education are critical to healthy youth development. For youth in recovery from SUDs, school attendance, engagement, and achievement build human capital by motivating personal growth, creating new opportunities and social networks, and increasing life satisfaction and meaning (Keane, 2011; Terrion, 2012; 2014). Upon discharge from formal substance use treatment settings, schools become one of the most important social environments in the lives of youth with SUDs. Healthy school peer environments can enable youth to replace substance use behaviors and norms with healthy activities and prosocial, sober peers. Conversely, many school environments may be risky for youth in recovery from SUDs due to perceived substance use among peers, availability of drugs or alcohol, and substance-approving norms on campus (Centers for Disease Control [CDC], 2011; Spear & Skala, 1995; Wambeam, Canen, Linkenbach, & Otto, 2014).Given the many social and environmental challenges faced by youth in recovery from substance use, recovery-specific institutional supports are increasingly being linked to educational settings. The two primary types of education-based continuing care supports for youth in recovery, defined under the umbrella term of "recovery schools" for this review, are recovery high schools (RHSs) and collegiate recovery communities (CRCs). RHSs are secondary schools that provide standard high school education and award secondary school diplomas, but also include therapeutic programming aimed at promoting recovery (e.g., group check-ins, community service, counseling sessions). CRCs also provide recovery oriented support services (e.g., self-help groups, counseling sessions, sober dorms) for students, but are embedded within larger college or university settings. The primary aims of RHSs and CRCs are to promote abstinence and prevent relapse among students, and thus ultimately improve students' academic success.OBJECTIVES: This review summarized and synthesized the available research evidence on the effects of recovery schools for improving academic success and behavioural outcomes among high school and college students who are in recovery from substance use. The specific research questions that guided the review are as follows: 1. What effect does recovery school attendance (versus attending a non-recovery or traditional school setting) have on academic outcomes for students in recovery from substance use? Specifically (by program type): a. For recovery high schools: what are the effects on measures of academic achievement, high school completion, and college enrolment?b. For collegiate recovery communities: what are the effects on measures of academic achievement and college completion?2. What effect does recovery school attendance have on substance use outcomes for students in recovery from substance use? Specifically, what are the effects on alcohol, marijuana, cocaine, or other substance use?3. Do the effects of recovery schools on students' outcomes vary according to the race/ethnicity, gender, or socioeconomic status of the students?4. Do the effects of recovery schools on students' outcomes vary according to existing mental health comorbidity status or juvenile justice involvement of the students? SEARCH METHODS: We aimed to identify all published and unpublished literature on recovery schools by using a comprehensive and systematic literature search. We searched multiple electronic databases, research registers, grey literature sources, and reference lists from prior reviews; and contacted experts in the field.SELECTION CRITERIA: Studies were included in the review if they met the following criteria:Types of studies: Randomized controlled trial (RCT), quasi-randomized controlled trial (QRCT), or controlled quasi-experimental design (QED).Types of participants: Students in recovery from substance use who were enrolled part-time or full-time in secondary (high school) or postsecondary (college or university) educational institutions.Types of interventions: Recovery schools broadly defined as educational institutions, or programs at educational institutions, developed specifically for students in recovery and that address recovery needs in addition to academic development.Types of comparisons: Traditional educational programs or services that did not explicitly have a substance use recovery focus.Types of outcome measures: The review focused on primary outcomes in the following two domains: academic performance (e.g., achievement test scores, grade-point average, high school completion, school attendance, college enrolment, college completion) and substance use (alcohol, marijuana, cocaine, heroin, stimulant, mixed drug use, or other illicit drug use). Studies that met all other eligibility criteria were considered eligible for the narrative review portion of this review even if they did not report outcomes in one of the primary outcome domains.Other criteria: Studies must have been reported between 1978 and 2016. The search was not restricted by geography, language, publication status, or any other study characteristic.DATA COLLECTION AND ANALYSIS: Two reviewers independently screened all titles and abstracts of records identified in the systematic search. Records that were clearly ineligible or irrelevant were excluded at the title/abstract phase; all other records were retrieved in full-text and screened for eligibility by two independent reviewers. Any discrepancies in eligibility assessments were discussed and resolved via consensus. Studies that met the inclusion criteria were coded by two independent reviewers using a structured data extraction form; any disagreements in coding were resolved via discussion and consensus. If members of the review team had conducted any of the primary studies eligible for the review, external and independent data collectors extracted data from those studies. Risk of bias was assessed using the ROBINS-I tool for non-randomized study designs (Sterne, Higgins, & Reeves, 2016).Inverse variance weighted random effects meta-analyses were planned to synthesize effect sizes across studies, as well as heterogeneity analysis, subgroup analysis, sensitivity analysis, and publication bias analysis. However, these synthesis methods were not used given that only one study met the inclusion criteria for the review. Instead, effect sizes (and their corresponding 95% confidence intervals) were reported for all eligible outcomes reported in the study.RESULTS: Only one study met criteria for inclusion in the review. This study used a QED to examine the effects of RHSs on high school students' academic and substance use outcomes. No eligible studies examining CRCs were identified in the search.The results from the one eligible RHS study indicated that after adjusting for pretest values, students in the RHS condition reported levels of grade point averages (= 0.26, 95% CI [-0.04, 0.56]), truancy (= 0.01, 95% CI [-0.29, 0.31]), and alcohol use (= 0.23, 95% CI [-0.07, 0.53]) similar to participants in the comparison condition. However, students in the RHS condition reported improvements in absenteeism (= 0.56, 95% CI [0.25, 0.87]), abstinence from alcohol/drugs (OR = 4.36, 95% CI [1.19, 15.98]), marijuana use (= 0.51, 95% CI [0.20, 0.82]), and other drug use (= 0.45, 95% CI [0.14, 0.76]).Overall, there was a serious risk of bias in the one included study. The study had a serious risk of bias due to confounding, low risk of bias due to selection of participants into the study, moderate risk of bias due to classification of interventions, inconclusive risk of bias due to deviations from intended interventions, inconclusive risk of bias due to missing data, moderate risk of bias in measurement of outcomes, and low risk of bias in selection of reported results.AUTHORS' CONCLUSIONS: There is insufficient evidence regarding the effectiveness of RHSs and CRCs for improving academic and substance use outcomes among students in recovery from SUDs. Only one identified study examined the effectiveness of RHSs. Although the study reported some beneficial effects, the results must be interpreted with caution given the study's potential risk of bias due to confounding and limited external validity. No identified studies examined the effectiveness of CRCs across the outcomes of interest in this review, so it is unclear what effects these programs may have on students' academic and behavioral outcomes.The paucity of evidence on the effectiveness of recovery schools, as documented in this review, thus suggest the need for caution in the widespread adoption of recovery schools for students in recovery from SUDs. Given the lack of empirical support for these recovery schools, additional rigorous evaluation studies are needed to replicate the findings from the one study included in the review. Furthermore, additional research examining the costs of recovery schools may be needed, to help school administrators determine the potential cost-benefits associated with recovery schools.

Evidence Base on Outpatient Behavioral Treatments for Adolescent Substance Use, 2014-2017: Outcomes, Treatment Delivery, and Promising Horizons

This article updates the evidence base on outpatient behavioral treatments for adolescent substance use (ASU) since publication of the previous review completed for this journal by Hogue, Henderson, Ozechowski, and Robbins (2014). It first summarizes the Hogue et al. findings along with those from recent literature reviews and meta-analytic studies of ASU treatments. It then presents study design and methods criteria used to select 11 comparative studies subjected to Journal of Clinical Child and Adolescent Psychology level of support evaluation. These 11 studies are detailed in terms of their sample characteristics, methodological quality, and substance use outcomes. Cumulative level of support designations are then made for each identified treatment approach. These cumulative designations are virtually identical to those of the previous review: ecological family-based treatment, individual cognitive-behavioral therapy, and group cognitive-behavioral therapy remain well-established; behavioral family-based treatment and motivational interviewing remain probably efficacious; drug counseling remains possibly efficacious; and an updated total of 5 multicomponent treatments combining more than 1 approach (3 of which include contingency management) are deemed well-established or probably efficacious. Treatment delivery issues associated with evidence-based approaches are then reviewed, focusing on client engagement, fidelity and mediator, and predictor and moderator effects. Finally, to help accelerate innovation in ASU treatment science and practice, the article outlines promising horizons in improving youth identification and access, specifying and implementing pragmatic treatment in community settings, and leveraging emerging lessons from implementation science.

'Pickle or a cucumber?' administrator and practitioner views of successful adolescent recovery

INTRODUCTION

Adolescent substance use disorders often involve a recurring cycle of treatment and relapse. The academic and practical definition of addition recovery for adults has been debated; yet, elements determining a successful adolescent recovery aside from abstinence have not been delineated. Thus, we sought to explore how practitioners and administrators define "success" in recovery and how they foster youth progress towards success.

METHODS

Using a qualitative design, we purposively selected and visited treatment and recovery services sites and interviewed practitioners and administrators (N = 13). Sites included recovery high schools (N = 2), alternative peer groups (N = 4), and one treatment center. Two authors analyzed the data using the constant comparative method.

RESULTS

Success emerged from the interviews in three primary themes (1) factors demonstrating success, (2) progress that highlights success, and (3) factors enabling success and two sub-themes (1) use of metaphors and (2) use of specific examples. A variety of factors and processes were discussed as indicators of success. Multiple practitioners stated that sobriety and length of abstinence were not the best success measures; yet, sobriety and education were mentioned most often.

CONCLUSIONS

A key finding of this study, which has not been addressed in existing qualitative studies of youth recovery, is that the understanding of recovery was so diverse and multi-dimensional and provided a view of success beyond sobriety, highlighting the various facets from which practitioners must operate and address recovery. This demonstrates the need for researchers to carefully conceptualize how they operationalize adolescent recovery.

Youth recovery outcomes at 6 and 9 months following participation in a mobile texting recovery support aftercare pilot study

BACKGROUND AND OBJECTIVES

We examined youth recovery outcomes at 6- and 9-months post-participation in an aftercare pilot study called Educating and Supporting inQuisitive Youth in Recovery (ESQYIR) that aimed to investigate the utility of a 12-week mobile texting recovery support intervention.

METHODS

A total of 80 youth [Mage 20.4 (SD = 3.5)] were randomized to a mobile texting aftercare intervention or an aftercare-as-usual control group. Both groups received identical data collection protocols with psychosocial and behavioral assessments occurring at baseline, during the trial (months 1 and 2), at discharge from the trial (month 3), and 3-, 6-, and 9-month post-intervention follow-ups.

RESULTS

Mixed modeling showed that youth who participated in the mobile texting aftercare intervention were less likely to test positive for their primary drug compared to youth in the aftercare-as-usual condition during 6- and 9-months follow-ups (p < .01). Additionally, youth in the aftercare intervention reported significantly higher self-efficacy/confidence to abstain during recovery (p < .05) and were more likely to participate in recovery-related behaviors (self-help and goal-directed extracurricular activities; p < .05) than those in aftercare-as-usual at the 6- and 9-month follow-ups.

CONCLUSIONS

Results suggest that delivering a structured, behavioral-based wellness aftercare intervention using mobile texting can be an effective for sustaining recovery outcomes in youth over time compared to youth who receive aftercare-as-usual.

SCIENTIFIC SIGNIFICANCE

This study shows that a mobile-texting aftercare intervention sustained effects at 6- and 9-months post-intervention for young people in substance use recovery.