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Center for Substance Abuse Treatment. Treatment of Adolescents with Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 32.)

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Treatment of Adolescents with Substance Use Disorders.

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Chapter 7—Youths With Distinctive Treatment Needs

Many adolescents who acutely need treatment for substance use disorders may be in circumstances that make early identification and treatment particularly difficult. Sometimes, legal, social, or health circumstances in a young person's life create unique problems that require attention. Youths in the child welfare and juvenile justice systems are at particularly high risk for developing a substance use disorder. More often than not, they have more risk factors than other children and fewer protective factors. For example, adolescents who have come into contact with the juvenile justice system can be expected to display severe problems surrounding family and social relationships, as well as coexisting mental, emotional, or physical difficulties (Dembo et al., 1991). Screening and intervention policies in primary care settings will help uncover both the substance use disorders and the problems that often accompany them: illegal activity, homelessness, shame surrounding sexual identity, and coexisting mental disorders.

Treatment in the Juvenile Justice System

Many young people who enter the juvenile justice system for relatively minor offenses, such as problems in school or at home, enter a cycle of failure reinforced by repeated instances of these problems. Most of the adolescents who come into contact with the juvenile justice system have already developed a number of functional problems. Many of these youths have had substance use disorders and other psychosocial concerns for some time, and many come from fractured or dysfunctional families. By the time these adolescents enter the juvenile justice system, they have developed serious substance use disorders and attendant psychosocial dysfunction.

For these reasons, early intervention is critical in working with adolescents who have had contact with the juvenile justice system. Every young person involved in the juvenile justice system, regardless of his charge, should undergo thorough screening and assessment for substance use disorders, physical health problems, psychiatric disorders, history of physical or sexual abuse, learning disabilities, and other coexisting conditions. Juvenile probation officers can be helpful partners in the system of care. For their part, treatment service providers should educate the local juvenile justice system about the importance of early intervention and what resources are available to them. Juvenile justice professionals should be required to have training in identifying and appropriately intervening with substance use in their clients. Having court-ordered treatment and monitoring may be the most effective approach to getting substance use disorder services to many adolescents. It is almost impossible to intervene unless the youth is removed from the environment that brought her into conflict with the juvenile justice system in the first place--that is, the home neighborhood.

Diversion Programs

Because the justice system is overwhelmed with a high case volume and limited resources--a judge in juvenile justice may handle thousands of cases a year--increased emphasis has been placed on diversion programs (sometimes called dispositional alternatives) for juvenile offenders. These alternatives have been shown to be highly effective in relation to the minimal resources invested in them. Juvenile detention facilities are designed to provide short-term care for juveniles awaiting adjudication or disposition. However, juveniles placed in detention facilities are unlikely to receive the special programs necessary for treatment or reintegration into society. For these reasons, alternatives to placing juvenile offenders in secure facilities have increased dramatically in recent years. The range of transitional programs that help to prepare youths to return to their communities has widened as well. The use of alternative placement resources will likely involve multiple agencies. Therefore, it is vital to have a single case manager to coordinate services and be the central monitoring and tracking source for each adolescent. It is important for juvenile program administrators to be aware of the pros and cons of each program and to place youths in the programs that are likely to be of most benefit to them. A number of approaches and types of settings are now being used, and the many options that are available make it possible to select the setting most conducive to a juvenile's treatment needs. Some of the available alternatives are described below.

  • Intensive community supervision. Under intensive community supervision, a youth remains in the community and must regularly report to an assigned probation counselor. This arrangement allows the adolescent to attend school and to maintain family relationships with minimal interruption. The planned frequency of the required contacts with the probation counselor may vary from several times a day to twice a week; less than twice a week is not considered intensive supervision. Telephone contact alone is not enough, although it may be used to supplement personal meetings.
  • Day reporting centers. As part of community supervision programs, reporting centers can be set up in accessible locations in the community, such as schools and shopping centers. Youths then report regularly to these stations according to their case plans. Some centers provide education, recreation, or social services.
  • Day treatment. Specialized day programs that include education and social services help youths develop social skills. They also provide supervision and control in a familiar setting. In many day treatment programs, youths take classes in the morning, participate in a group activity (such as playing sports) in the afternoon, and return home at night.
  • Evening and weekend programs. Direct supervision and programming similar to day treatment are also offered during evening and weekend hours. Tutoring, recreation, employment, and treatment services can be provided to supplement an adolescent's regular educational or work programs. Like day treatment programs, evening and weekend programs provide supervision in addition to education and social skills development.
  • Tracking. Tracking programs hire staff (usually part-time) to monitor youths and to report their compliance with specific requirements in areas such as school attendance, participation in counseling, and job performance. Whether working with other service providers or independently, trackers report regularly to the agency that has jurisdiction over the adolescent.
  • Electronic monitoring. Some youths are now released under the condition that they wear an electronic device that monitors their movements. The efficacy of such systems is debated by professionals and technicians in the juvenile justice system, but all agree that electronic monitoring alone is insufficient and that, to be successful, such tracking must be part of a multifaceted effort.
  • Home detention. Adolescents under home detention are supervised by their parents in their homes and are allowed to leave only to go to school or work. This type of treatment is well-suited for youths who do not require institutional security but need adult supervision and structure. Home detention is generally a short-term arrangement that is used until a detailed, long-range plan is developed.
  • Home tutoring. Supplementing regular educational programs with home tutoring helps to remedy adolescents' educational deficiencies, establishes contact with an adult role model, and provides supervision.
  • Mentor tutoring. Providing a trained adolescent tutor for a troubled youth can be extremely beneficial. In addition to educational tutoring, a mentor can offer advice, emotional support, and a respectful, caring relationship.
  • Work and apprenticeship. Some local businesses provide jobs or apprenticeships for juvenile offenders, generally in conjunction with an educational program. Such programs instill a work ethic, a sense of responsibility, and a feeling of accomplishment while enhancing community relations.
  • Restitution. Under court order, juveniles may be asked to try to rectify the damage they have caused their victims. Restitution may be in cash or in services amounting to a specific dollar value. Most frequently ordered in property crimes, restitution provides an alternative to incarceration, thereby reducing public costs while compensating victims.
  • Community service. Some offenders are required to provide services that benefit the entire community, such as cleaning up parks or working in nursing homes. This is a form of restitution that allows juveniles to contribute routine but worthwhile services. Community service projects must be clearly identified, and the juveniles in these programs must be properly supervised.
  • Volunteer programs. Volunteers are often available to tutor youths and to supervise work and recreational activities. They may also provide an additional service to youths as friends, role models, and listeners. Like regular employees, volunteers require training, specific job descriptions, and supervision.

For more information on alternatives for adolescents involved in the juvenile justice system, refer to TIP 21, Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System (CSAT, 1995d).

Juvenile Drug Courts

The caseloads of most juvenile courts in this nation have changed dramatically during the past decade. The increasingly complex nature of both delinquency among juveniles and substance use disorders has contributed to more serious and violent criminal activity and escalating degrees of substance use. Juvenile justice professionals recognize that the problems that bring a juvenile under the court's jurisdiction are affected by family factors, community factors, peer issues, and other individual and environmental variables.

The juvenile court traditionally has been considered an institution specifically established to address multiple needs of the juvenile. However, it is becoming clearer among juvenile justice practitioners that conventional practices are ineffective when applied to the problems of juveniles with substance use disorders. During the past 2 years, a number of jurisdictions have examined the experiences of adult drug courts to explore the possibility of adapting such systems for juvenile courts in the hopes of more effectively dealing with an increasing substance-using juvenile population. Interest in juvenile drug courts is developing rapidly across the country, with a number already operational or in the planning stage. The States of California, Florida, and Nevada have the greatest activity, but according to a recent report, 59 programs are underway or planned across 30 States (Drug Court Clearinghouse and Technical Assistance Project , 1997). See Figures 7-1 and 7-2.

Figure 7-1: Status of Drug Courts in the United States.

Table

Figure 7-1: Status of Drug Courts in the United States.

Figure 7-2: Number of Drug Court Programs Underway/Planned.

Figure 7-2: Number of Drug Court Programs Underway/Planned

Challenges

The process of developing and implementing juvenile drug courts must address several challenges, including

  • Counteracting the negative influences of multiple risk factors, most notably the presence of coexisting psychiatric disorders, peer deviance, and poor family dynamics
  • Addressing the needs of the family, especially families with substance use disorders and poor parenting practices
  • Complying with confidentiality requirements for juvenile proceedings while at the same time obtaining necessary information to adequately assess and refer the substance-using juvenile
  • Overcoming the typical lack of motivation to engage in the recovery process (since most youthful substance users have rarely hit bottom like long-term adult substance users)--along with those traits that typify the conduct-disordered juvenile offender, including a sense of invulnerability, lack of concern for one's future, and disinterest in conventional values, all of which complicate this motivational hurdle
  • Responding to numerous developmental changes that may occur in the adolescent during the course of extended supervision while under the court's jurisdiction

Characteristics

Although the importance of flexibility of juvenile court operations has been emphasized, several characteristics common to existing juvenile courts have been identified (Drug Court Clearinghouse and Technical Assistance Project, 1997):

  • Early and comprehensive intake assessments, with an emphasis on the functioning of the adolescent's family and the adolescent throughout the court process
  • A heavy emphasis on responding to the needs of the adolescent by coordinating the actions of the court, the school system, the treatment service provider, and other community agencies
  • Use of the case management approach, in which active and continuous supervision of the adolescent occurs throughout the assessment, referral, and treatment processes
  • Immediate use of both sanctions applied for noncompliance and incentives to recognize progress by the adolescent and the family

Homeless and Precariously Housed Youths

An estimated 750,000 to 1.3 million youths run away from their homes each year, and one-third of these are believed to become chronically homeless. A growing body of literature suggests that these young "street" people are at high risk for a wide range of problems, particularly substance use (Kipke et al., 1995, 1997).

Research among homeless youth in inner-cities indicates that most of these young people use multiple substances, although the types of substances used were found to vary among geographical areas of the country (Kipke et al., 1996). On the East Coast, for example, common substances of use were heroin and crack cocaine, whereas on the West Coast, the use of LSD, ecstasy, and methamphetamine was more common (Kipke et al., 1997). Substance use, defined according to DSM-IV criteria, has been found to be a pervasive problem among these youths. For example, 71 percent of inner-city homeless youths in Los Angeles were classified as having an alcohol and/or illicit substance use disorder (Kipke et al., 1997). In addition, as many as 30 percent of them reported intravenous drug use, and of these, 59 percent reported having shared needles and equipment on at least one occasion. Added to the risk of HIV posed by this practice are the additional risks associated with "survival sex"--the trading of sex for food, shelter, or drug money. As many as 40 percent of street youths are estimated to engage in this activity (Kipke et al., 1995).

Most street youths also have a long history of abuse and neglect: Over 50 percent of homeless adolescents report having experienced physical, sexual, and/or emotional abuse and neglect (Sibthorpe et al., 1995). Not surprisingly, many homeless youth turn to substance use in an effort to numb their emotional pain and cope with the uncertainty and instability of their lives.

Effective treatment of substance use disorders in this population hinges on the necessity of recognizing the importance of these young people's readiness for treatment. Also, entering a substance use disorder treatment system is a complicated process, and displaced youths are likely to require help in gaining access to services. Outreach programs should have in place a "step-up" for homeless or inner-city youths to enter these programs, assisting them in negotiating the various obstacles that may be potential barriers to services. These adolescents may require several street contacts before they are willing to trust anyone. Street outreach workers should focus on developing trusting relationships with youths that, over time, can influence a young person to access substance use disorder treatment services. A wide array of services should be readily available, especially emergency shelter services, residential treatment services, or transitional living services, depending on the individual's needs. Furthermore, most of these youths do not believe that their primary problems are related to their substance use. For adolescents who may or may not be receiving services but who are living on the streets, outreach becomes a primary intervention strategy. Service providers must meet with, talk to, and develop relationships with young people on the street to engage them in treatment (see the Levels of Treatment subsection in Chapter 2).

Once a homeless youth has entered the system, the next step is establishing a case management plan that is based on a thorough assessment of her needs. Possible services may include finding housing, dealing with family problems, entering substance use or HIV-related treatment, and providing job training, schooling, and sexual and reproductive health care. It may be necessary to prioritize the needs for services according to the individual's severity of problems.

Returning homeless or runaway youths to their homes after treatment is not always in their best interest because less than optimal conditions may exist in these homes. Many of these youths have parents with serious substance use disorders who may have been the first to expose their children to intravenous drugs. Treatment providers must make efforts to assess whether family reunification is appropriate for these youths. Returning them to a chaotic home environment after treatment is frequently not an appropriate discharge option. In these cases, treatment providers should collaborate with child welfare professionals to explore the possibility of other transitional living options for homeless youths.

Homosexual, Bisexual, and Transgendered Youths

During the adolescent years, some young people explore a variety of sexual relationships with both the same and opposite sexes. It is during this time of experimentation that they begin to develop a sexual identity, including whether they see themselves as heterosexual, homosexual, bisexual, or transgendered (that is, biologically of one sex but identifying primarily with the opposite sex). Youths who begin to develop a nonheterosexual identity have a high risk of being ostracized by family and friends, leading many to become integrated into adult gay cultures in which substance use is greater (Cabaj, 1989; Myers et al., 1992). Rates of depression, anxiety, and suicidal ideation and attempts are high in these groups (Remafedi et al., 1991). Others may turn to substance use in response to having experienced physical or sexual abuse or as a result of homelessness.

Whatever scenario led to their current circumstances, these youths are at high risk for developing serious substance use disorders. It is often the case that these youths do not bring their problems and concerns to the attention of health care providers because it would mean disclosing their sexual identity and risking further alienation. Many of these youths have no one in whom they can confide, and most communities lack gay-identified services. Such services can be important in these situations because of issues of protecting client identity. Also, gay-specific services are likely to be more sensitive to the importance of not divorcing the issues of sexual identity from substance use disorders during the treatment process. Effective treatment for these youths incorporates helping them to feel comfortable with, and to take pride in, their sexual identity.

Youths With Coexisting Disorders

Substance-abusing and substance-dependent adolescents often have coexisting physical, behavioral, and psychiatric disorders. Traditional treatment for substance use disorders may not be effective in addressing the specific problems associated with these coexisting disorders. The following section discusses specialized and adjunctive services that may be needed for coexisting disorders.

Physical Health Problems

Adolescents with chronic physical illnesses are at high risk for substance use disorders. This is particularly the case for those with pain-related syndromes, such as sickle cell anemia, migraine headaches, and arthritis, for which treatment with opioid analgesics is often required. Other illnesses that require long-term, intensive medical intervention, such as cystic fibrosis and chronic renal failure, take a toll on both physical and emotional health. Clinicians should consider that this may, in turn, increase the risk for misuse of psychoactive substances. Chronic illness may also put teenagers at risk for substance use disorders because they may feel that using substances is the only way that they can relate to a peer group.

Distinguishing between appropriate treatment for pain and an individual's abuse of analgesic drugs is often difficult, particularly when individuals develop symptoms of tolerance to large doses of narcotics that are used as part of treatment. It is important to remember that addiction is defined as the use of substances despite adverse consequences, preoccupation with use, and the development of tolerance or withdrawal, and not tolerance or withdrawal alone. Many individuals undergoing treatment for chronic pain develop physiological tolerance to opioid medications and will suffer withdrawal if the medication is abruptly discontinued. This does not necessarily mean, however, that they are addicted. Clinicians must determine whether the narcotic treatment is improving or worsening the patient's quality of life and whether the patient is developing a preoccupation with obtaining and using the substance.

When this question does arise, however, frequent and open communication among all treatment professionals is essential. One physician should be assigned to write all prescriptions, and patients may be asked to sign a contract to this effect. In acute situations where a patient appears to be in pain and is requesting medication, it is best to err on the side of giving treatment. That is, administer the requested medication under controlled conditions (e.g., admit to the hospital or treatment facility) and then consult with a physician who is specially trained in the treatment of pain and addiction. This approach prevents sudden, dangerous withdrawal and helps to build the patient's sense of trust. If a patient is exaggerating symptoms or reporting a fictitious illness, there will be ample time later to address these problems.

Whenever there is a suspicion of a coexisting substance use disorder and a medical illness, the treatment team must simultaneously assess and treat both problems. There may be a tendency for treatment professionals to focus on only one of the coexisting disorders; in other words, either the patient has a real pain syndrome or he has a substance use disorder. The treatment provider should recognize when the patient has a coexisting disorder and address both the real chronic pain or distress and the substance use disorder. When an individual is admitted to treatment, a complete physical assessment should be conducted; when new or recurrent physical complaints arise, a complete reassessment should be performed. See TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities, for further discussion on this topic (CSAT, 1998)

Patients with severe or life-threatening illnesses, particularly HIV infection and AIDS, may require hospitalization and ongoing psychotherapy to deal with the physical and emotional effects of these conditions. HIV-infected patients who develop AIDS may escalate their substance use, with the rationalization that they now have nothing to lose. It helps to make these patients understand that their substance use is likely only to hasten the progress of their disease and that AIDS is being increasingly managed as a chronic rather than a fatal illness. (Refer to the forthcoming revised TIP, Treatment of Persons with HIV/AIDS and Substance Use Disorders [CSAT, in press].)

Emotional and Mental Disorders

The coexistence of adolescent substance use and mental or behavioral disorders is relatively common (Bukstein, 1997). Because these two sets of problems are integrally related and often difficult to disentangle, it is probably best to treat the cluster of disorders together. Attention to the treatment of only the substance use or only the other disorder may not result in optimal outcomes. Treatment providers and mental health authorities should develop programs together to treat youths with coexisting disorders. Cross-training can help staff of both programs develop the sensitivity and the clinical skills to understand the dual diagnosis and to identify the presence of either problem or both.

Substance use by adolescents with coexisting and behavioral disorders has received considerable discussion in the adolescent literature. Whereas the prevalence of diagnosable behavioral disorders among clinical adolescent populations has a solid empirical base (Kaminer, 1994), there are still questions about the extent to which the coexisting disorders are the cause or the effect of the substance use and how one may alter the course of the other (Meyer, 1986). However, studies among adolescents being treated for substance use disorders reveal a high prevalence of coexisting disorders, primarily mood disorders (particularly depression), conduct/oppositional defiant disorder, and attention deficit/hyperactivity disorder. In a recent review of this literature, Kaminer reported quite variable coexisting psychiatric rates among adolescents having substance use disorders, although various studies indicate a trend of over half of the subjects having at least one psychiatric disorder, with conduct disorder being the most prevalent (Kaminer, 1994).

Once a youth with a mental or behavioral disorder begins to use substances, both problems tend to worsen. Because it is believed that a major reason for substance use among emotionally disordered youths is to cope with negative affects (such as anxiety or depression), there may be a rebound effect on the coexisting disorder if the substance use is discontinued. For example, a youth who drinks heavily to self-medicate anxiety may become even more anxious when she reduces or quits drinking. The Panel recommends that any adolescent who is being treated for a substance use disorder and is also taking psychoactive medications for a coexisting mental or emotional disorder should have routine urine testing as a part of her treatment plan. For more information on coexisting psychiatric conditions and substance use disorders, refer to TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (CSAT, 1994).

Attention Deficit/Hyperactivity Disorder: A Special Case

Attention deficit/hyperactivity disorder (AD/HD) has been diagnosed with increasing frequency over the past decade, perhaps owing partly to an increased awareness of the disorder. A growing body of literature indicates that youths with AD/HD are at high risk to develop a substance use disorder, particularly if AD/HD coexists with conduct disorder (e.g., Wilens et al., 1994; Windle and Windle, 1993). In addition, the persistence of AD/HD symptoms has been associated with elevated risk for substance use disorder in late adolescence and early adulthood (Biederman et al., 1995). Young people with AD/HD are impulsive and inattentive and so may require adjustment in the treatment regimen in order to address these problems. A significant percentage of adolescents with AD/HD also have specific learning disorders. Such information-processing problems can impair their ability to understand adequately the components of treatment that require listening and verbal skills. For example, such deficits may make group therapy a difficult and even painful process for AD/HD-afflicted youths.

AD/HD complicates the treatment of substance use disorders. Dextroamphetamine and methylphenidate, both of which are potential drugs of abuse, are currently the medications of choice and are sometimes the therapeutic approach of choice for treating childhood AD/HD. The increasing frequency with which AD/HD has been diagnosed over the last decade has brought with it concern over the increased potential for abuse of the AD/HD medications (Cantwell, 1996). The small body of literature that has focused on this issue has yielded mixed results, with some studies reporting both worsening of risk for substance use disorders and improvement in risk, depending on the variable and substance assessed (Weiss and Hechtman, 1993). There are anecdotal reports that a black market in schools has developed in which youths sell stimulants to their peers. Methylphenidate can be ground up and insufflated like cocaine, and in this form it can cause sudden cardiac arrest.

Any adolescent who is being treated for a substance use disorder and is also taking psychoactive medications for a coexisting psychiatric disorder should have routine urine testing as part of his treatment plan. Close scrutiny of the psychopharmacological management of AD/HD is particularly important in such youths who are receiving treatment for substance use disorders. The bottom line is that psychoactive agents often have a high potential for abuse, and they should be used with extreme caution in adolescents with substance use disorders.

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