ADOLESCENT TREATMENT FRAMEWORK AND
PRACTICE GUIDELINES
DRAFT document prepared for Project Fresh Light
by Scott Caldwell, MA CSAC
October 2008
Funding for this document was made possible by Project Fresh Light, under the Wisconsin
Adolescent Treatment Coordination Grant, TI-05-006, Substance Abuse and Mental Health
Services Administration, Center for Substance Abuse Treatment.
TABLE OF CONTENTS
I. Context for the adolescent treatment framework
 Introduction
 Adolescent treatment research
 Overview to the framework
II. Understanding adolescent development
 Psychosocial and neurobehavioral functioning
 Etiology of alcohol/drug problems
 Impact of alcohol/drugs
 Adolescents are not adults
 Common misconceptions about teens and alcohol/drug use
III. Ten elements of effective treatment programs
 Introduction
 Assessment, screening, treatment matching
 Systems integration
 Comprehensive, integrated approach
 Developmental relevance
 Family involvement
 Treatment engagement and retention
 Gender and cultural competence
 Outcome and process evaluation
 Continuing care, recovery management
 Qualified staff
IV. Red flags of adolescent treatment programs
V. Implementing evidence-based treatment
 Issues in dissemination
 Models of implementation
 Pitfalls and potentials
IV. References
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CONTEXT FOR THE ADOLESCENT TREATMENT FRAMEWORK
Adolescent alcohol and other drug (AOD) involvement and its related problems are a
growing concern among the Wisconsin public and policy makers. Almost one-third of Wisconsin
high school students reported recent binge drinking and 23% reported extensive (40 or more
times) lifetime experiences with alcohol use (WYRBS, 2007). Recent media reports have
highlighted the pervasiveness of Wisconsin’s underage drinking and its related problems.
Wisconsin teens also reported prevalent marijuana use with 20% reporting recent use and 14%
reporting extensive lifetime experiences (WYRBS, 2007). Although teen AOD involvement is a
community problem, Wisconsin’s substance abuse counselors and prevention specialists are in a
unique position to impact the prevalence and incidence of youth AOD involvement and related
problems. The call to providers from concerned parents, families, schools, and community
leaders could not be clearer: be effective!
In 2006 the Wisconsin Bureau of Prevention, Treatment, and Recovery obtained a State
Adolescent Substance Abuse Treatment Coordination “infrastructure” grant from SAMHSA.
Called Project Fresh Light (PFL), the purpose of this grant has been to make changes on the
systems level through multiple strategies and partnerships with the primary goal of improving
the design, delivery, and outcomes of adolescent AOD treatment services (PFL, 2006 February).
The PFL grant explicitly recognizes that adolescent services are impacted by multiple factors and
those system level improvements are necessary to promote effective service delivery on the
provider and program level.
What is the current state of the adolescent treatment system? Although very few studies
exist to address this question some recent findings from national and state surveys suggest the
following:

From 1992 to 2002 there was a 69% increase in the number of teens referred to treatment
nationally; however, during the same period in Wisconsin there was little change in the
rate of teen admissions within the public treatment system (Dennis, 2008).

In a national consensus of AODA treatment programs, adolescent facilities comprised
approximately 12% to 18% of all programs (Mark et al., 2006; McLellan, 2006).

In Wisconsin an estimated 7% to 11% of adolescents meet the diagnostic criteria for a
Substance Use Disorder (Dennis, 2008; WDHS, 2008); yet less than 1 in 20 receive
treatment services (Dennis, 2006).

Consistent with national data, the largest referral source (about 40%) for adolescent
treatment in Wisconsin is the juvenile justice system followed by “other” community
programs (about 33%) (Dennis, 2006).
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
Consistent with national data, outpatient treatment is now the most common level of
service for adolescents in Wisconsin (about 80% of total service levels); however,
Wisconsin has substantially lower numbers of intensive outpatient (about 8%) and shortand long-term residential (about 3%) service levels available for adolescents compared to
national averages (i.e., about 13% and 15%, respectively; Dennis, 2006).

In general, there is an inadequate number of adolescent programs to address the need and
lack of insurance coverage can be a significant barrier for accessing existing services
(McLellan, 2006; McLellan & Meyers, 2004).

Although there has been a recent proliferation of research-based and standardized
instruments for adolescent AODA assessment (Winters, 2001, 2006), a review of 144
highly regarded national adolescent treatment programs (including one in Wisconsin)
showed that less than half (45%) reported using a standardized instrument to assess
AODA and only 15% reported using a standardized instrument to assess mental health
(Brannigan et al., 2004).

Adolescent treatment providers may be insufficiently trained to address the unique
characteristics of teenagers (McLellan, 2006).

Treatment providers commonly use methods and approaches which have consistently
been shown to be ineffective (Miller & Wilbourne, 2002), that is, a significant researchpractice gap remains and is “so wide that it casts doubt on the viability of our current
treatment system” (McLellan, 2006, p. 276).
In summary, the Wisconsin adolescent treatment system appears to have an inadequate
number of programs with a restricted range of service levels to address the immense prevalence
of teen AODA; for the adolescent programs that do exist there are often access barriers; adequate
counselor training, and the implementation of standardized adolescent assessment instruments
and research-informed treatment methods are questionable. These are discouraging findings, to
say the least.
Fortunately, recent years have seen a tremendous increase in funding for adolescent
treatment research and implementation. The focus of these activities within the adolescent field
reflects several national trends in the larger AODA treatment field: movement toward
implementing evidence-based treatments; linking service funding to treatment outcomes; and
developing linkages to better integrate the treatment system with other relevant systems such as
criminal justice and primary care.
The purpose of this Adolescent Treatment Framework document is to describe the
advances in adolescent AODA treatment and to detail the research which informs the effective
delivery of services to adolescents and their families. Identifying the methods, approaches, and
elements of effective programs may help prepare Wisconsin adolescent treatment providers for
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the system changes which will impact the delivery of services while, most importantly,
promoting recovery among Wisconsin youth, their families, and their communities.
Adolescent Treatment Research
Creating a comprehensive framework of research-informed adolescent treatment would
not have been possible a decade ago. The term “adolescent treatment” has only recently
emerged. Historically, teenagers have been treated within adult programs and models of
addiction. This emphasized a 12-Step, disease-concept approach to addressing substance abuse
(Godley & White, 2006). Very few studies were available to inform the design, implementation,
and effectiveness of AODA treatment with adolescents (Wagner et al., 1999). In a review of the
outcome studies that existed during the 1970s, 1980s, and first part of the 1990s, Grella (2006)
concluded that “outcomes for adolescents in ‘adult’ programs were mixed, at best, particularly
for younger adolescents (p. 167).”
Today, there is an emerging specialty of adolescent treatment based on a robust science
(Miller & Carroll, 2006). The research reflects the growing understanding of adolescent AODA
as a complex biopsychosocial phenomenon with teenagers having unique treatment needs. In
what has been described as a “renaissance” of adolescent treatment research (Dennis, 2006;
Rowe & Liddle, 2006; White, Dennis, & Tims, 2002), there currently exists over 200 studies,
many of which represent high quality methodology with implications for effective clinical
practice (see Table 1).
Table 1. The history and current renaissance of adolescent treatment research.
Feature
1930 – 1997
1997 – 2005
No. treatment studies
No . randomized/quasi-experimental
Methodology
No. treatment manuals
Quality assurance adherence
Standardized assessment
Follow up rates
16
9
Descriptive/Simple
0
Rare
Rare
40% – 50%
200 +
44
More Advanced
30 +
Common
Common
85% – 95%
Source: Dennis (2006)
What do the recent outcome studies of adolescent treatment suggest? In general, post discharge
outcomes (e.g., one year) showed that, compared to admission, teen participants had:







Reduced AOD use
Reduced AODA symptoms
Increased rates of abstinence
Fewer mental health symptoms
Decreased arrests and involvement in criminal behaviors
Better school attendance and increased average grades
Better psychosocial and family functioning
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These general findings have been replicated across multiple evaluations of adolescent-specific
treatment (e.g., Brown et al., 2001; Chung & Martin, 2001, DATOS-A). Good treatment can
work for teenagers!
Although no one treatment approach is superior to another (NIDA, 1999; Carroll &
Rounsaville, 2007), several treatments tested with adolescents show consistent research support
(for reviews see Crome, 1999; Deas, 2008; Dennis, 2006; Dennis & White, 2002; Muck et al.,
2001; Vaughn & Howard, 2004). These include:

Motivational Enhancement Therapy (MET) or Motivational Interviewing (MI).
These methods are client-centered yet directive with the goal of assisting a teen in
resolving ambivalence and increasing motivation for AOD behavior change (Miller &
Rollnick, 2002). The counselor uses an empathetic and non-judgmental counseling style
to explore the pros/cons of AOD use and change, readiness for change, and to support
confidence for change (O’Leary Tevyaw & Monti, 2004). These methods typically are
delivered within individual sessions and appear to be particularly useful when “front
loaded” into services to increase teen engagement and retention in treatment (Aubrey,
1998).

Brief Interventions (BI). Typically employing MET or MI, these interventions range
from two to five individual sessions with the focus on engagement in services, enhancing
initial motivation for change, and developing change commitment (O’Leary Tevyaw &
Monti, 2004; Tait & Hulse, 2004). BI appears particularly useful for teens who show
mild-to-moderate substance abuse and who are not otherwise seeking services (Winters,
2005). Moreover, BI may be particularly relevant for AOD-involved teens presenting in
“opportunistic settings” such as schools, juvenile justice settings, primary care, and
hospital emergency departments (Monti et al., 2001).

Cognitive-Behavioral Therapy (CBT). CBT focuses on assisting a teen to develop the
skills necessary to make changes in AOD using behaviors. CBT focuses on the teen’s
patterns of thoughts, emotions, and behaviors which lead to AOD use and identifies the
high risk “triggers” for these patterns. Skills that are developed include self-monitoring,
avoidance of stimulus cues, altering reinforcement contingencies, and coping to manage
or resist urges to use (Kaminer & Waldron, 2006; Waldron & Kaminer, 2004). CBT can
be delivered in either individual or group sessions. There is some limited evidence for
better performance in the later context (Deas, 2008).

Behavioral Therapy (BT). BT targets a teen’s AOD use related to environmental
contexts. Behaviors that promote AOD use are identified and behavioral change is
initiated through skill development. The essential elements of BT include functional
analysis of behavior, skills training (e.g., stress management, refusing AOD use, and selfregulation), and ongoing relapse prevention training (Deas, 2008).
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
Family-based treatments. These methods embody a focus on the family and ecological
contexts of the teen’s AOD involvement and related problems to reduce targeted familybased risk factors and to enhance the protective influences in a teen’s life. Family-based
therapies provide structure and flexibility to sessions in order to assist the family with
changing patterns of interaction that had reinforced the teen’s AOD behaviors, while
increasing support for the teen’s behavior change (Liddle, 2004).
With these treatment approaches showing consistent effectiveness with adolescents, each
was developed into a specific model. In the largest multisite clinical trial with youth to date, 600
adolescents were randomly assigned to participate in one of five treatment models as a part of the
Cannabis Youth Treatment (CYT) initiative. The majority of the 600 participating adolescents
were aged 15-18 (85%), male (83%), white (61%), from single parent families (50%), and
involved in the juvenile justice system (62%). On clinical characteristics, this sample was similar
or slightly more severe than a comparable sample of adolescents presenting to publically funded
treatment (Dennis et al., 2002b). The five models are briefly described in Table 2.
Table 2. Description of the Cannabis Youth Treatment models.
Treatment model
Key components
Motivational Enhancement
Therapy/Cognitive Behavioral
Therapy 5-Session (MET/CBT 5)



Integrates motivation enhancement for change with building the
skills necessary for abstinence
2 individual teen Motivational Interviewing sessions
3 group sessions for CBT skills training
Motivational Enhancement
Therapy/Cognitive Behavioral
Therapy 12-Session (MET/CBT
12)


2 individual teen Motivational Interviewing sessions
10 group sessions for CBT skills training
Family Support Network
(MET/CBT 12 + FSN for 22
sessions total)



Same as MET/CBT 12 plus…
6 parent psycho-educational sessions
4 family sessions, and case management as needed
Adolescent Community
Reinforcement Approach
(A-CRA, 14 sessions total)

Integrates skills training with improving social systems support
with particular targeting of family life
10 individual teen sessions
2 parent only sessions
2 family sessions, and case management as needed
Multidimensional Family Therapy
(MDFT, 15 sessions total)







Integrates family and multiple systems to reduce key risk factors
and to enhance protective influences
6 individual teen sessions
3 parent only sessions
6 family sessions, and case management as needed
Source: Diamond et al. (2002). Treatment manuals for these models are publically available and
can be accessed from: http://www.chestnut.org/LI/BookStore/index.html#Manuals
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The CYT treatment models represented distinct alternatives for adolescent AODA
treatment in terms of modality (individual, group, family), orientation (motivational, cognitivebehavioral, family systems), and dose (5 sessions, 12 sessions, 20+ sessions). The models were
also designed to be developmentally appropriate for adolescents, that is, taking into consideration
the unique characteristics of adolescent development. Each model was manualized and delivered
by highly trained clinicians. Intensive training, fidelity to the treatment model, and quality
assurance through ongoing direct supervision were central aspects of the study (Diamond et al.,
2002).
Results of the CYT study showed clinically meaningful and statistically significant
reductions from baseline (intake) to follow-up (one year) regarding AOD use and a variety of
related problems (Dennis et al., 2004; Titus & Dennis, 2006). Remarkably, the treatment models
showed similar effectiveness regardless of length of treatment or theoretical orientation (Dennis,
2006). For example, the five session MET/CBT model performed just as well as the 15 session
MDFT model. With these promising findings, some of the models are currently being tested in
community-based treatment programs under “real world” conditions (e.g., MET/CBT 5; Dennis,
Ives, & Muck, 2008).
In the past several years adolescent treatment EBTs have been developed and tested, and
several “best practice” model programs exist (e.g., Drug Strategies, 2003; Stevens & Morral,
2003). Increasingly, clinicians in the adolescent treatment field have access to the latest
innovations in research-based assessment instruments and treatment protocols (Muck & Butler,
2004). The increase in clinical research and dissemination activities underlie the emergence of
the specialty of adolescent treatment, that is, evidence-based services that are developmentally
relevant and congruent to the unique strengths, needs, and vulnerabilities of teenagers. This
Adolescent Treatment Framework reflects three levels of clinical research evidence:
1) Evidence-based treatment (EBT). An EBT is established after a specific treatment
model is tested under rigorous clinical research conditions and when positive results are
replicated. The randomized clinical trial is considered the gold standard of clinical
research and is the research methodology which typically establishes EBTs (Miller et al.,
2005). The five treatment models from the CYT experiment are considered EBTs.
2) Promising practices. This level of evidence is based on the accumulation of quasiexperimental and correlation clinical studies which consistently shows a particular
treatment approach or practice to have effectiveness.
3) Best practices. Based on expert consensus after an exhaustive review of the relevant
treatment research literature, best practices are likely effective, yet have often not been
confirmed by empirical testing. Treatment best practice guidelines exist for adolescent
services, most notably the Center for Substance Abuse Treatment’s Treatment
Improvement Protocols (TIPs) regarding AODA assessment and treatment (CSAT,
1998a, 1998b).
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The promising approaches to adolescent treatment and the EBTs which exist represent a
significant departure from the conventional “disease concept” approach embodied by the 12-Step
treatment model. Hence, possibly the greatest challenge facing the adolescent treatment system
today may be integrating treatment innovations into practice (Carroll & Rounsville, 2007; Liddle
& Frank, 2006).
Overview to the Adolescent Treatment Framework
This Adolescent Treatment Framework reflects the growing empirical basis of the
adolescent treatment specialty. The Adolescent Treatment Framework, as a guide to designing
and implementing effective treatment, is largely consistent with HFS 75. However, this
Framework goes beyond the administrative structure of HFS 75 to describe concretely and
comprehensively a set of practices relevant for effective treatment services with teenagers. This
document is designed to be useful for program managers, treatment providers, and policymakers,
and for family members and recovery advocates interested in effective youth treatment services.
The Framework is a living document and, as such, is subject to future revisions as we learn more
about what constitutes effective treatment with teenagers. Throughout the Adolescent Treatment
Framework, sources are cited and web-based links are made available when possible.
The Framework begins with an overview to the characteristics of adolescents from a
developmental perspective. Next, ten elements of effective treatment programs are presented
with elaboration of evidence-based, promising, and best practices with adolescents. Then,
practices that foster ineffective outcomes are identified to contrast effective practices. Finally,
guidelines for implementing EBTs are identified and discussed.
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UNDERSTANDING ADOLESCSENT DEVELOPMENT
Adolescence is generally defined as the second decade of life. For the purpose of this
document adolescence will be considered from age 12 to 18. Adolescence is the developmental
period which serves to transition young people from childhood into adulthood. As such,
adolescence is a unique and powerful period of development marked by changes in physical,
biological, cognitive, emotional, and social functioning. This section identifies the key normative
psychosocial tasks and neurobehavioral changes during adolescence, the etiology of adolescent
AODA problems, the impact that alcohol and marijuana can have on development, how
adolescents present differently than adults for treatment, and common misconceptions about
teens and substance use.
Adolescent Psychosocial and Neurobehavioral Development
Understanding normative adolescent development is critical for the design and delivery
of effective adolescent treatment services. Adolescence is marked by specific psychosocial tasks
which developmental psychologists have identified as individuation and autonomy development,
identity formation, and the development of intimacy and competency (see Table 3). Successful
completion of these tasks is critical for young people to be the best prepared for adulthood, that
is, the rest of their life.
Table 3. Key adolescent psychosocial developmental tasks.
Characteristics of Adolescence
Tasks
Individuation
Separation from parents or primary care givers
Autonomy
Establishing independence, including increased decision making
Relationships
Developing intimacy and closeness outside of family relations
Competency
Developing skills and abilities to prepare for adult responsibilities
Identity formation
Self-discovery of personal beliefs and values
Mirroring engagement in these psychosocial tasks are changes taking place in the brain.
With the advent of imaging technology, recent findings from neuroscience have expanded our
understanding of the opportunities and vulnerabilities adolescents face from a brain-behavior
perspective (Dahl, 2005). Preliminary data suggests that the brain undergoes profound structural
changes with the onset of adolescence and that the human brain does not reach full maturity until
about age 24. Key brain areas which appear to undergo significant remodeling during
adolescence include the nucleus accumbens, amygdala, and pre-frontal cortex (see Table 4).
Adolescent Treatment Framework DRAFT
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These still-developing brain areas are implicated in teen behaviors such as risk taking,
difficulties regulating strong emotions such as anger, and the propensity for engaging in low
Table 4. Still-developing brain areas during adolescence.
Brain area
Function
Implications for behavior
Nucleus accumbens
Directs motivation
Amygdala
Regulates emotion
Pre-frontal cortex
Judgment, decision-making, planning
ahead, impulse control
Propensity for low effort, high
reward activities
Moodiness, tendency to express
“hot” emotions such as anger
Tendency toward risk taking and
poor judgment
Source: Winters (2004)
effort, high reward activities. These brain changes reflect biologically-based and normative
processes, yet suggest that teenagers are vulnerable to AODA (Winters, 2004).
Neuroscientists studying addiction have identified two powerful brain systems implicated
in the development and maintenance of AODA: the GO! system and the STOP! system
(Childress, 2006). The GO! system underlies our powerful motivation for natural reward such as
food and sex and includes the brain’s reward circuitry as well as areas related to motivation and
memory. On the other hand, the STOP! system relates to our ability to manage or inhibit
impulses directed toward immediate reward and to weigh the future consequences of choices.
Both the GO! and STOP! systems are powerfully involved in the development and maintenance
of AODA problems, and interestingly, these very brain systems are still-developing during
adolescence (Childress, 2006; Winters, 2004). The teen brain shows heightened activity in the
socio-emotional and motivation-reward circuitry (GO!) (Steinberg, 2007), however, the teen
brain shows diminished ability to apply the “brakes” to inhibit behavior (STOP!). The
vulnerability of the brain to AODA during adolescence is reflected in the fact that approximately
90 percent of adults with AODA problems initiated drug involvement during adolescence.
The Etiology of Adolescent AODA
Although most teenagers will try alcohol and many will try tobacco or marijuana, most
will not develop AODA problems. Who is at risk for developing AODA? Research has
established a multitude of factors across biological, psychological, social, and environmental
domains which are predictive of adolescent AODA problems (Brook et al., 2006; Fergusson et
al., 2008; Hawkins et al., 1992; Hesselbrock & Hesselbrock, 2006; Kilpatrick et al., 2000;
Schinke et al., 2002; Sher et al., 2005; Swadi, 1999; Zucker, 2006). Selected risk factors are
presented in Table 5. There are several principles of risk. First, the more factors present, the
greater the probability of developing future problems. Second, risk factors operate interactively
across several domains. For example, poor attachment with parents or primary care givers and
excessive family conflict may be related to a teen’s strong association with an AOD-involved
and deviant peer group (Bray et al., 2003). And third, there is continuity between the presence of
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risk factors during childhood and emergence of AODA problems during adolescence, that is, for
young people who are at the greatest risk for developing AODA problems, multiple risk factors
tend to exist prior to the initiation of AOD use. In this way the processes that underlie
experimental AOD use are likely different than those that underlie problem use (Petraitis et al.,
1995).
Table 5. Selected risk factors for adolescent AODA.
Biological:
Psychological:
Socio-Environmental:








Family history of
AODA (genetic
vulnerability)
Early age of
initiation
Male
Difficult
temperament
Early onset puberty
Chronic sleep
difficulties dating to
childhood









Difficulties regulating
emotions (internalizing
symptoms, e.g.
depression, anxiety)
Behavioral undercontrol
(externalizing symptoms,
e.g., conduct disorder,
ADD/ADHD)
Early and persistent
problem behaviors
Trauma, victimization,
and extreme stress
experiences
Learning difficulties
Low self-efficacy
Low risk perception
Overestimation of AOD
use prevalence
Heightened thrill or
novelty seeking
Positive expectancies for
drug effects















Modeling of AODA (e.g., adult
family member, older sibling)
Family-based factors (see Table 9
below)
Disconnection from home or school
Truancy or excessive absences
from school
Poor academic performance
Underdeveloped social
competencies
Peer rejection dating to elementary
school
Poor refusal skills
Association with frequent AOD
involved peer group
Association with older peers
Attachment to antisocial norms and
values
Working 15+ hours weekly
Exposure to neighborhood risks
such as crime and violence
Easy access to AODs
Socio-economic extremes
Racial discrimination or prejudice
The biopsychosocial factors which underlie adolescent AODA should be identified
during intake for services in a standardized assessment. Because many of the psychological and
socio-environmental risk factors for teen AODA are malleable, or changeable, consideration of
them in treatment planning is critical to promote the best treatment outcomes. Effective
adolescent treatment services targets malleable risk factors for reduction or elimination.
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The Impact of AODA on Teenagers
Although teens presenting for AODA treatment are often involved with multiple drugs,
attention here is focused on the “gateway” drugs of alcohol, marijuana, and tobacco. For
adolescents presenting for AODA treatment in Wisconsin, alcohol (70%) and marijuana (65%)
were the most prevalent substances mentioned at intake. All other illicit substances, such as
cocaine, opiates, hallucinogens, methamphetamine, and inhalants were less than 10% in
prevalence (Dennis, 2006). Tobacco use is also widely prevalent among adolescents in AODA
treatment.
We increasingly know a great deal about the short- and long-term impact of alcohol and
marijuana on teenagers based on scientific studies. These understandings go beyond simplistic
“this is your brain on drugs” slogans to suggest complex interplay between pharmacological drug
effects, brain, and behavior.
Alcohol: The effects of regular alcohol use on teens include the following (Brown et al., 2008;
Clark, 2004; Tapert et al., 2004/2005):





Decreased health outcomes
Increased risk for HIV and STDs
Increased risk for mental health problems such as depression and anxiety (especially for
girls)
Increased risk for accidents, injuries, and mortality (especially for boys)
Adverse impact on the brain’s memory (hippocampus) and judgment (prefrontal cortex)
centers.
Marijuana: The effects of regular marijuana use on teens include the following (Dennis et al.,
2002a; Ellickson et al., 2004; Fergusson et al., 2008; SAMHSA, 2006):






Decreased academic performance
Increased risk for school dropout
Decreased immune system functioning with increased risk for respiratory illnesses
Increased risk for mental disorders, including psychosis
Increased risk for delinquency, violence, and conduct problems (especially for boys)
Physiological dependence marked by a clinically significant withdrawal syndrome
(Vandrey et al., 2005).
Alcohol and Marijuana Combined: The combination of alcohol and marijuana is common
among adolescent users and shows synergistic effects. When combining alcohol and marijuana,
teen users are 4 to 47 times more likely than non-users to have a wide range of dependence,
behavioral, school, health, and legal problems (Dennis, 2006).
Tobacco: Tobacco use is highly prevalence among adolescents presenting for AODA treatment
services and poses multiple long-term health risks, yet providers rarely address teen smoking.
Severity of nicotine dependence may be related to decreased treatment outcome and increased
Adolescent Treatment Framework DRAFT
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rates of post-treatment relapse. Conversely, clients who received treatment for nicotine
dependence during general AODA treatment tend to show overall better outcome compared to
clients who did not receive nicotine treatment (Ziedonis et al., 2006). Integrating tobacco
cessation into teen treatment may be feasible as well as effective (Myers & Kelly, 2006).
Adolescents are not Adults
Teens differ from adults on the clinical presentation and history of alcohol/drug use.
Compared to adults, teens typically have a briefer history of alcohol and drug involvement, fewer
consequences and health problems of protracted use, and more episodic use with a greater
number and different types of substances used. Because of the rapid period of developmental
growth, teens show a higher prevalence of co-occurring problems compared to adults, yet also
have a greater chance of “outgrowing” substance abuse problems (Deas et al., 2000). In the
process of treatment, teens tend to give different reasons for changing AOD use compared to
adults.
Common Misconceptions about Teenagers, AOD Use, and Treatment
Scientific understandings of adolescent development, AOD-involvement, and treatment
have rapidly expanded during the past decade. Yet treatment professionals and the public at large
may possess beliefs about teens and AOD use on myths and stereotypes commonly accepted
within contemporary society (Liddle, 1996). Because a therapist’s beliefs can influence clinical
outcomes, misconceptions about teens and AODs have the potential to undermine effective
services. What have we believed to be true about teens and AODs? How have we believed
treatment should work with teens? How do these beliefs impact delivery of services?
Empirical research offers a reliable source to inform – and sometimes challenge –
conventional concepts and practices within the adolescent treatment field. Table 6 highlights
some beliefs which have been challenged or refuted by research evidence.
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Table 6. Common misconceptions contrasted by research-based understandings
Misconception
Peer pressure is a primary factor of teen
AODA.
Better Understanding
Peer selection probably drives the robust
correlation between teen and peer AOD use
(Bauman & Ennett, 1996; Ungar, 2000).
Parents have little or no influence in their
teen’s use of AODs.
Parents are an enduring presence in an
adolescent’s life and can be a source of critical
protective influences (CASA, 2005; Collins et
al., 2000; Steinberg, 2001).
Parental involvement in services can interfere
with the counselor-teen therapeutic alliance,
therefore, parents should be discouraged
from involvement in services.
Family-based services involving parents typically
show better outcomes in treatment than individual
teen-based services (Kumpfer, 1999; Liddle,
2004).
If a teen is not motivated for treatment,
treatment will likely not work.
Teen motivation is not a pre-requirement of
effective services – it is a result (Baer & Peterson,
2002; O’Leary Tevyaw & Monti, 2004).
“Resistance” is a common trait of
adolescents with AODA problems in
treatment settings.
Teenagers’ resistance is best understood as a state
which is influenced by counseling style and
interpersonal context (O’Leary Tevyaw & Monti,
2004).
Treating substance abuse concurrently with
mental health problems likely leads to the best
outcomes (Mueser et al., 2006).
Effective mental health treatment cannot be
achieved until the teen’s AOD use is under
control.
Low self-esteem is an important etiological
Research has consistently shown no statistical
factor of teenage AODA and thus should be a correlation between teen self-esteem and AODA
target of treatment.
(e.g., Shedler & Block, 1990). That is, teens with
high self-esteem can engage in AODA and the
inverse can be true as well.
Education is an important component of
effective teen treatment, such as showing
films or providing didactic groups.
Increasing teenagers’ knowledge or insight has
not been shown to be effective in changing AOD
using behavior (Masterman & Kelly, 2003;
Miller, 2006).
Teenagers in treatment should be
discouraged from changing cigarette
smoking because it asks “too much, too
soon” in the recovery process.
Promoting smoking cessation during teen
treatment may enhance chances of long-term
recovery (Myers & Kelly, 2006; Ziedonis et al.,
2006).
Adolescent Treatment Framework DRAFT
15
TEN ELEMENTS OF EFFECTIVE PROGRAMS AND CORRESPONDING
BEST PRACTICES
What is the current state-of-the-art in adolescent AODA treatment services? The
following section is adapted from two reports published by Drug Strategies, a multidisciplinary
group of experts on adolescent treatment effectiveness. The first report, Treating Teens: A Guide
to Adolescent Drug Programs (Drug Strategies, 2003), identified nine key elements of effective
programs and 144 national programs that reflected excellence in the field. These programs
reflected the continuum of service levels from standard outpatient to inpatient and residential
services. The second report, Bridging the Gap: A Guide to Drug Treatment in the Juvenile
Justice System (Drug Strategies, 2005), identified eleven elements of effective AODA programs
within the juvenile justice system. Synthesizing both reports produced ten unique elements of
effective adolescent AODA treatment programs. Each program element is identified, then
described in terms of practices and approaches supported by the three levels of evidence (i.e.,
EBTs, promising practices, and best practices). The evidence cited is intended to be illustrative,
not exhaustive.
1. Assessment, Screening, and Treatment Matching
Assessment is defined as “the process and procedures by which a counselor or service
identifies and evaluates an individual’s strengths, weaknesses, problems and needs in order to
develop a treatment plan…” (HSF 75.02(6)). Comprehensive AODA assessment with
adolescents includes the following domains (CSAT, 1998a; Meyers et al., 1999; Winters, 2001,
2006): family, peer group, educational and vocational development, biomedical history, mental
health, cognitive, legal, ethnocultural. Research-based risk and protective factors are identified in
each of these domains (see Table 5) creating a comprehensive clinical picture of the young
person in developmental context. Examining an adolescent’s AOD-involvement includes the
following variables:






Types of drugs used (lifetime, past year, and past 30 day use); age of initiation
Frequency, quantity, route of administration
Reasons for use
Pros and cons of use (drug specific)
Perception of risk for drug effects
Identification of existing DSM-IV symptoms
Because the criteria for the DSM-IV Substance Use Disorder (SUD) were based
exclusively on clinical samples of adults, several cautions are in order when considering a SUD
diagnosis for adolescents (Chung & Martin, 2001, 2006; Martin & Winters, 1998; Martin et al.,
2006; Winters, 2001). First, dependence symptoms often precede abuse symptoms and therefore
teens who technically meet dependence criteria may not actually be substance dependent.
Second, highly prevalent symptoms among AOD-involved youth (such as tolerance – a
Adolescent Treatment Framework DRAFT
16
dependence symptom) do not have clear clinical specificity for teenagers. Third, the onesymptom threshold for an abuse diagnosis includes a large and diverse population of youth, thus
diminishing its clinical meaningfulness. Fourth, other problems’ symptoms with adolescents are
atypical or missing from the DSM (Martin et al., 1995). Recent SUD diagnostic research with
adolescents suggests that teens present along a continuum of drug-use severity (as opposed to the
DSM categorical approach) with a clinical range comprising mild to moderate abuse, abuse,
dependence, and physical dependence with the presence of withdrawal symptoms. That is, the
number of SUD symptoms present may better describe the severity of adolescent AOD
involvement than the type of symptoms, that is, abuse or dependence (Chung & Martin, 2001). A
proposed continuum of adolescent AOD use severity is depicted in Figure 1.
Figure 1. A diagnostic taxonomy of adolescent AOD involvement.
Experimental
Subclinical
Abuse
Initiation of use
followed by
occasional use
Pattern use
with
emerging
consequences
Patterned use
with recurrent
consequences
Psychological
Dependence
Physical
Dependence
Frequent use
with severe
consequences
Frequent use with
severe consequences
including withdrawal
Source: Felgus, Caldwell, & Hesselbrock (in press)
The advances in clinical assessment and the corresponding proliferation of standardized
assessment instruments for adolescents in recent years no longer justifies the need for programs
to use their own “in-house” tools (Winters, 2006). Reviews of available assessment instruments
can be found at www.drugstrategies.org or in published studies (CSAT, 1998a; Winters, 2001).
One assessment instrument increasingly being adopted by Wisconsin adolescent treatment
providers is the Global Appraisal of Individual Needs (GAIN; Dennis, 2008; PFL, 2006
November). This comprehensive and evidence-based instrument was designed specifically for
adolescents presenting for AODA treatment services and is currently required for any federallyfunded clinical research or service delivery.
Multiple problems are the norm for adolescents presenting for AODA treatment (Deas et
al., 2000; Dennis, 2006). The prevalence of co-occurring problems such as mental health, trauma
and victimization, behavioral and conduct problems, and crime/violence is estimated between
60% to 80% (Cornelius et al., 2006; Whitmore & Riggs, 2006). Selected assessment measures
reflecting co-occurring problems such as internalizing disorders (e.g., depressive, general
anxiety, and post-traumatic stress disorders) and externalizing disorders (e.g., conduct and
attention-deficit disorders) are presented in Figure 2. Identifying the existence and extent of cooccurring problems during assessment is necessary for strategic treatment planning, and
ultimately, for fostering the best treatment outcomes.
Adolescent Treatment Framework DRAFT
17
Figure 2. Prevalence of selected assessment measures at intake for adolescent AODA treatment.
This graph depicts the results
of an on-going data collection
project from multiple sites
nationally using the GAIN
assessment instrument.
Services represented the full
continuum of care. Adolescent
(N = 14,776) characteristics
included, age 15 to 17 (74%),
non-white (56%), and female
(27%).
Source: CSAT (2007)
The prevalence of these co-occurring problems among teenagers presenting for services
can be daunting for AODA counselors who otherwise may have limited training or experience in
mental health. Fortunately, several standardized screening instruments exist for reliable and
efficient identification of the possible presence of clinically significant mental health and
behavioral problems. In Wisconsin, two evidence-based screening instruments are widely used
(PFL, 2006 November): the Problem Oriented Screening Instrument for Teenagers (POSIT) and
the Global Appraisal of Individual Needs – Short Screen (GAIN-SS; Dennis et al., 2006). Each
identifies the possibility of a clinically significant internalizing disorder (e.g., depression,
anxiety, trauma) or externalizing disorder (e.g., ADHD, conduct), as well as the risk for
delinquency/aggression, or crime/violence. These instruments are publically available and
require minimal training to administer, score, and interpret. Treatment programs should have
clear protocols in place for how to handle referrals (internal or external) on the basis of screening
results.
Assessing teenagers’ motivation for change is another area with important clinical
implications. Assessment in this area includes:




Readiness for change
Confidence for change
Stage of change (substance specific)
Prior successes with change
Based on Prochaska and colleagues’ (1992) Stages of Change model, an estimated 80%
of adolescents present for treatment as either seeing no problems or risks from their AODinvolvement (pre-contemplation for change) or as ambivalent about change (contemplating
change); another 20% present already taking steps toward change (preparation for change). The
Stages of Change and Readiness and Treatment Eagerness Scale (SOCRATES) is a standardized
Adolescent Treatment Framework DRAFT
18
tool for assessing stage of change which has been psychometrically validated with a clinical
sample of adolescents.
Assessing a teen’s stage of change and motivation level has implications for initial
counseling strategies as well as treatment plan development. A “match” between a teen’s stage
and the counselor’s strategy is related to teen motivation for change, whereas a “mismatch” tends
to evoke resistance to change (Miller & Rollnick, 1991). For example, for a teen who perceives
both the pros and cons of AOD use (i.e., contemplating change), being told by the counselor
what the benefits of change could be with encouragement to begin taking steps toward change
would likely evoke this teen’s resistance. For a better “match” the counselor could seek to
explore the teen’s view of the pros and the cons in a non-judgmental counseling style to assist
the teen with resolving the dilemma about change.
Developmentally-informed assessment content and processes with adolescents includes
the following considerations:







Assessment should distinguish problems that have their origin and onset during
adolescence and problems that have their roots in earlier developmental periods
(childhood).
Adolescent problems should be distinguished between occasional, intermittent, or
enduring.
Several sources should be consulted when gathering clinical information. Although
teenagers’ self-report reliability has been shown to be fairly high (Winters, 2001),
supplementing teen self-report with collateral information from parents (or key family
members), mental health professional, social services, juvenile justice worker, or school
administrator is important to obtain a full picture of the teen in context.
“In-house” developed assessment questionnaires should be replaced with standardized
instruments normed for adolescent clinical samples.
Structured or semistructured assessment interviews lead to more accurate and reliable
findings than unstructured interviews (Winters, 2006).
Using Motivational Interviewing (Miller & Rollnick, 1991) prior to and following the
administration of assessment instruments, thus creating an “MI sandwich” process
(Martino et al., 2007), has been shown to increase treatment engagement among
adolescents (Aubrey, 1998)
Teens presenting with a high level of clinical severity should receive more intensive and
comprehensive services
Treatment matching is an important function of assessment in terms of level of services
(CSAT, 1998a; Meyers et al., 1999). The ASAM Placement Criteria (Mee Lee et al., 2001) was
specifically designed for adolescent treatment providers and has six dimensions which
correspond to several conventional assessment areas (see Table 7). Levels of treatment for
adolescents include: indicated prevention or brief intervention; standard outpatient; intensive
outpatient or day treatment; inpatient or short-term residential; and, long-term residential.
Adolescent Treatment Framework DRAFT
19
Table 7. ASAM Placement Criteria dimensions with corresponding assessment information.
ASAM dimension
Relevant assessment information
1
2
3
4
5
Acute intoxication or withdrawal potential
Biomedical
Emotional, behavioral, cognitive problems
Treatment readiness
Relapse, continued use
6
Recovery environment
SUD withdrawal symptom severity
Biomedical personal history
Presence and severity of co-occurring problems
Stage of Change; confidence and readiness
Number of SUD symptoms (severity); risk factors for
continued problems
Family- and peer-based risk and protective factors
Assessment data should clearly link to treatment planning with several general targets:





Reduce or eliminate SUD symptoms
Reduce or eliminate mental health symptoms
Decrease malleable risk factors
Enhance protective factors
Assessment continues as an ongoing process through the early stage of treatment
2. Systems Integration
Adolescents live their lives operating across multiple systems such as the family, peer
network, and school system. When teens present for AODA services multiple systems may be
already involved. Unfortunately, providers often work independently from each other and
services can be disconnected and fragmented. Nationally, about 50% of all referrals for
adolescent AODA treatment come from the juvenile court system (Dennis, 2006). Because the
AODA and juvenile justice systems have different regulatory and administrative structures in
addition to different funding streams, there are often many barriers to systems integration.
Compounding the problem of the system “silos” has been differences in philosophy, values, and
definitions of the problem and of effective responses. For example, juvenile justice emphasizes
accountability and public safety, whereas the AODA treatment system emphasizes rehabilitation
and support services. These two goals can sometimes conflict.
Although system differences exist, a great deal of overlap in common goals clearly exists.
Both AODA and juvenile justice systems seek to increase youth competency, functioning, and
health. Thus, systems integration through cross-discipline collaboration has potential to
maximize effective outcomes of adolescent treatment. Juvenile justice professionals offer
resources which can complement treatment services such as monitoring of a teenager’s
whereabouts and activities, drug testing to verify AOD use status, and provision of structured
activities and involvement in prosocial activities such as community service. Likewise, AODA
counselors can contribute to the public’s safety as adolescent AODA is strongly correlated with
crime and violence. Many of the same clients are shared by AODA counselors and juvenile
justice professional. Building partnerships across traditional system boundaries and sharing
Adolescent Treatment Framework DRAFT
20
resources to the end of common goals can thus create a “system of care” to better meet the needs
of adolescents and their families (Kraft et al., 2006)
Another potential of systems integration is AODA treatment services within the larger
health care system. The delivery of AODA specialist services is unique in that it is the only
sector of health care which emerged separately from primary care (McLellan, 2006). Patients
seen in primary care settings are rarely referred to AODA treatment by the primary care
provider. For example, in Wisconsin less than 5% of adolescents are referred to AODA treatment
from health care settings (Dennis, 2006). The disconnection between specialist AODA services
and the larger health care system has fostered isolation among treatment providers and
stigmatization of AODA. Fortunately, a new approach is emerging to bridge this divide. The
SBIRT model (Screening, Brief Intervention, and Referral for Treatment) is an innovative
approach to identifying patient AODA risk or problems in primary care, then responding through
brief intervention or referral for specialist AODA treatment. Increasingly, physicians, nurses,
health educators, and other health care professionals are receiving training to conduct SBIRT
services. With federal funding from SAMHSA, an SBIRT model for adolescent patients is
currently being developed for implementation in selected primary health care clinics across the
state through the Wisconsin Initiative to Promote Healthy Lifestyles (PFL, 2008 October).
3. Comprehensive, Integrated Approach
Adolescent AODA is complex and requires a comprehensive and integrated approach to
maximize effective outcomes. Multidisciplinary services should be available and tailored to
individual teen strengths and needs including:







AODA individual and group counseling
Mental health and psychiatric services
Medication management, including outpatient opiate maintenance
Medical services, sexual health consultation
Family involvement
Cross system collaboration with delinquency services, school social worker, health care
provider, or other relevant professionals
Adjunctive services such as recreational activities, yoga, art or music
Given that co-occurring AODA and mental health problems are the norm for adolescents
in treatment, a question that providers commonly ask is, “what should be treated first: the AODA
or mental health?” Although more research is needed to address this important question of
treatment sequencing, the preliminary answer is: treat both, at the same time. As Mueser and
colleagues (2006) state, “people receiving integrated treatment for their dual disorders tend to
have better substance abuse outcomes than individuals receiving traditional parallel or sequential
treatment.” Although integrated service delivery may not be practical as most AODA counselors
are not licensed mental health professionals, the importance of concurrent treatment of AODA
and mental health cannot be overstated. The ability for many teens with significant mental health
Adolescent Treatment Framework DRAFT
21
difficulties to achieve initial abstinence often depends on the reduction or management of mental
health symptoms. Conversely, the reduction or cessation of AOD-involvement may greatly
contribute to improvements in a person’s mental health.
As shown earlier in Figure 3, the experience of trauma and victimization is highly
prevalent among adolescents presenting for AODA treatment services. Although multiple
problems are the norm for teens, Dennis (2006) showed that for adolescents who were assessed
as having a history of high severity victimization, 75% showed five or more problems at intake
related to internalizing and externalizing disorders, conduct or behavioral problems, criminal
behavior, and severity of AODA. Comparatively, for those with moderate or low victimization
histories, 55% and 20%, respectively, showed five or more problems. The pervasive of
victimization and its powerful correspondence to multiple clinical problems has been “elephant
in our counseling rooms” (Dennis, 2004). Victimization and trauma must be properly assessed
and treated if services are to be successful.
Group treatment is the most commonly used modality for adolescent AODA services. It
is generally regarded as developmentally appropriate given the opportunities for prosocial and
recovery-oriented interactions and feedback with peers. It is also the most efficient and cost
effective treatment. Recent studies have called into question the clinical efficacy of group
treatment with adolescents who show conduct disorder for concerns related to “deviance
training” of other teens (Dishion et al., 1999). However, other experts have shown that AODA
group treatment for youth is safe and effective. Burleson and colleagues (2006) analyzed the
group session portion of Cannabis Youth Treatment experiment (N = 400) and concluded that
“group composition in terms of conduct disorder symptoms is not associated with worse…
outcomes. The results actually indicated that there was a slight advantage for youth with high
conduct disorder to be included in the groups with less symptoms (p. 4, emphasis in original).”
This similar finding was shown in a meta-analysis of treatment studies which showed that the
use of group CBT among juvenile offenders had efficacy across a number of outcomes
(Landenberger & Lipsey, 2005) and that adolescent the group CBT format may have increased beneficial
effects compared to individual CBT formats (Deas, 2008). Effective group treatments had several
common characteristics, including:




Structure within a larger treatment model (e.g., CBT)
Skills based
Smaller teen-counselor ratios
Attention to implementation, including direct supervision
4. Developmental Relevance
Developmental relevance is the core of what defines adolescent treatment services. As
discussed earlier, adolescents are not adults. Adolescents are engaged in unique and specific
psychosocial developmental tasks such as the individuation process, increasing independence,
developing competence and mastery, and challenging conventional norms while developing
Adolescent Treatment Framework DRAFT
22
personal identity. To maximize treatment effectiveness with teenagers, programs must provide
services that are developmentally relevant, that is, services that are congruent with the
developmental tasks that youth are already engaging. For example, providers who are respectful
of teens’ decision-making will be relevant to the adolescent individuation process, that is,
developing independence and autonomy (Baer & Peterson, 2002; Masterman & Kelly, 2003).
Other relevant treatment practices are presented in Table 8.
Table 8. Adolescent psychosocial development with implications for treatment practices.
Adolescent developmental
task
Relevant treatment practices and approaches
Individuation
Relational closeness
Respect autonomy, collaboration
Counselor empathy and therapeutic alliance; family involvement;
develop recovery support network
Roll with resistance
Cognitive and behavioral skill development
Identification with recovery; involvement in prosocial activities
Harm reduction; contingency management
Challenge authority
Competence
Identity formation
Risk taking
An area of study which has potential to greatly inform the developmental relevance of
AODA treatment with adolescents involves understanding the phenomenon of natural change
(DiClemente, 2006). This research recognizes that, on a population level, most people with
AODA difficulties tend to make changes on their own over time without the benefit of formal
treatment services. For example, 66% of teen cigarette smokers in Wisconsin reported at least
one attempt to quit during the past year (WYRBS, 2007). It is widely recognized among
researchers that teenagers who show AODA problems commonly “outgrow” these problems
(Deas et al., 2000), likely due to the role transitions and increased responsibilities that emerge
during young adulthood (DiClemente, 2006). Initial investigations (Wagner et al., 1999; Metrik,
2003) of how youth make AOD changes on their own suggest that teens favor the following
strategies: personal efforts (e.g., will power, self-control); family assistance (e.g., spending more
time with family); social network changes (i.e., making new friends or avoiding AOD-involved
friends); and increased involvement in structured activities (i.e., school, work, or recreation). The
strategies that adolescents use to initiate and maintain behavior changes on their own should be
integrated into the knowledge and practice base that informs evidence-based and best practices in
adolescent treatment (DiClemente, 2006) to maximize the developmental relevance of services.
5. Family Involvement
Because parents and family are an inherent and enduring aspect of child and adolescent
biological, psychological, and social development, their involvement in services is critical for the
best outcomes. Six decades of social science research points to the importance of parents in
successful developmental processes and outcomes (Collins et al., 2000; Darling & Steinberg,
1993; Steinberg, 2001). For this document, “parent” and “family” is widely defined to include
Adolescent Treatment Framework DRAFT
23
biological, as well as foster, step, adoptive, legal guardians, or primary care givers. Research
consistently shows that two domains of parenting are critical for promoting the best
developmental outcomes among children adolescents: parent involvement/responsiveness and
parent demands/ expectations (Steinberg, 2001; Steinberg & Levine, 1997). Involvement
includes expressing love, warmth, and support. Demands are age-appropriate and include
boundaries for appropriate behaviors, basic rules or guidelines, and accountability that is firm but
fair when rules are broken. As presented in Figure 3, high or low levels of each domain create
four general parenting styles.
Figure 3. Four general parenting styles.
Involvement/
Responsiveness
Demands/ Expectations
High
High
Low
Authoritative
Authoritarian
Low
Permissive
Unengaged
The parenting style associated with the best youth developmental outcomes is the
authoritative parent. Authoritative parenting – also known as “positive parenting” or “optimal
parenting” – tends to correlate with less adolescent AOD involvement, less internal distress and
conduct problems, and increased school performance (Baumrind, 1991). Parents of adolescents
presenting for AODA treatment likely reflect all of these parenting styles. Adolescent AODA is
a complex biopsychosocial phenomena with multiple causal factors. However, services that
support and teach authoritative parenting attitudes and skills will likely contribute an
adolescents’ successful change process and, ultimately, promote the best clinical outcomes.
Family treatment services work to reduce the family-based risk factors and to enhance the
protective factors that serve to influence the teens AOD-involvement and related problems
behaviors. These research-based factors are presented in Table 9. The evidence of effectiveness
for family-based AODA treatments for adolescents is well established (Kumpfer, 1999; Kumpfur
& Alvarado, 2003; Liddle, 2004). The research indicates that family-based services – compared
to individually-based teen services – shows been teen treatment engagement, reduced AOD use
and related behavioral problems, decreased teen psychiatric symptoms, improved school
attendance and performance, and better global family functioning (Liddle, 2004). Even within
individual teen sessions, family-related content and themes predicted treatment gains compared
to individual sessions without such a focus (Hogue et al., 2004).
Table 9. Family-based protective and risk factors for adolescent AODA
Protective factors
Adolescent Treatment Framework DRAFT
Risk factors
24














Parental involvement, emotional
responsiveness
Expression of love and care
Emotional support
Strong parent-child bond and attachment
Warm and friendly home environment
Quality family time
Frequent family dinners
Respectful communication
Clear and consistent rules and limits
Rules and limits are explained
No use of substances in home
Non-permissive messages about ATOD use
Monitoring and supervision of teen
activities and whereabouts
Consistent consequences that are not too
harsh or too lenient















Parental disengagement
Frequent criticism, low support
Stained parent-child bond
Excessive family conflict or violence
Marital discord
Minimal family time
Infrequent family dinners
Lack of or strained communication
Lack of or inconsistent rules and limits
Parental AODA
Parental mental health problems
Permissive messages about ATOD use
Minimal monitoring and supervision
Discipline which is excessively harsh or
lenient
Child abuse, neglect, or maltreatment
Source: CASA (2005); Hawkins et al. (1992); Kumpfer (1999); Schinke et al. (2002); Swadi
(1999).
Several evidence-based treatment models exist in which family involvement is central to
the adolescent’s treatment, including: Multidimensional Family Therapy (MDFT); Multisystemic
Family Therapy (MST); Brief Strategic Family Therapy (BSFT); Adolescent Community
Reinforcement Approach (A-CRA); Family Support Network (FSN); and Integrative Behavioral
and Family Therapy (IBFT). All show comparable treatment outcomes (Dennis, 2006; Liddle,
2004).
6. Treatment Engagement and Retention
One of the most robust predictors of successful AODA treatment outcome is length of
treatment. Those who complete treatment, on average, show significantly less AODA and related
problems than those who do not complete treatment. Although practice guidelines from the
National Institute of Drug Abuse recommends 90 days of involvement in services to maximize
treatment effectiveness (NIDA, 1999), the median length of stay for adolescents is only 60 days
with just 25% reaching the 90 day threshold (Dennis, 2006). Poor treatment retention has
historically plagued the adolescent treatment field and this is of great concern from both clinical
and business perspectives. Retaining teens in treatment is critical for achieving the best clinical
outcomes. Moreover, treatment retention serves programs’ financial stability and bottom line.
What are some common barriers to engagement in treatment for AOD-involved teens? At
the core of treatment engagement is motivation, and motivation reflects a state of readiness,
willingness, and ability (Miller & Rollnick, 2002). The following can be barriers to treatment
engagement for adolescents:
Low readiness to change:
Adolescent Treatment Framework DRAFT
25




Minimal consequences from AOD
use
Functional value of AOD use
Ambivalence
Environmental factors





Diminished self-efficacy
AOD effects are too strong
Multiple stressors
Mental health struggles
Environmental factors
Low confidence for change:
Low or high levels of readiness and confidence reflects four unique states of motivation for
change: 1) low readiness/high confidence; 2) high readiness/low confidence; 3) low
readiness/low confidence; and 4) high readiness/high confidence. Experience suggests that most
teens present for treatment in the first motivational state where readiness to make changes with
AOD use tends to be low but confidence for change is strong. Those who present in the second
state of motivation where readiness is high but there is low confidence usually indicates a more
severe level of addiction (e.g., to opiates) with many related consequences. Each motivational
state implicates specific counselor and program responses to increase motivation (readiness or
confidence, or both) for change.
There is a growing base of knowledge for how to increase adolescents’ engagement and
subsequent retention in services. Understanding motivation has become a central to the design
and delivery of effective AODA services (Miller, 2006). Instead of asking, “how much is this
teen in denial?” counselors increasingly ask, “how motivated is this teen for change?” (O’Leary
Tevyaw & Monti, 2004). The basics suggest that programs be accessible in terms of location and
affordability, have little to no wait time, have flexible hours of operation, and be welcoming to
teens and their families (Miller, 2008). Evidence also consistently points to the effectiveness of
motivational enhancement strategies such as Miller and Rollnick’s (1991, 2002) Motivational
Interviewing (MI) to promote treatment engagement. MI uses a empathetic and non-judgmental
counseling style to immediately begin building the counselor-teen alliance. Asking strategic
open-ended questions followed by careful listening with reflection maximizes the teen’s talking
time while gathering relevant assessment information. Ambivalence for change is normalized.
The initial treatment plan is developed collaboratively with emphasis placed on the teen’s
choices and responsibility. It can be useful to initially offer a “menu of options” for change
which can include a range of behaviors from AOD abstinence to harm reduction (e.g., reducing
the frequency or quantity of AOD use, changing the route of administration, changing to less
risky settings or situations). Although abstinence is always the goal of treatment services, a harm
reduction approach can get the change process started while increasing the teen’s engagement.
Increasing retention of adolescents in treatment through programmatic changes was
powerfully demonstrated by Aubrey (1998). In a study testing the efficacy of MI with an
adolescent sample, Aubrey randomly assigned adolescents presenting for outpatient AODA
treatment to either participate in a standardized assessment (control) or in a standardized
assessment with the addition of MI in the process. As depicted in Figure 4, at intake there were
no differences between teens in terms of AOD use. However, at three months the teens who had
Adolescent Treatment Framework DRAFT
26
received MI to start treatment showed significantly less illicit drug involvement than those teens
who participated in the assessment-as-usual condition.
Figure 4. Adolescent outpatient treatment outcome using Motivational Interviewing.
Additionally, the teens who received MI
to start treatment participated in
significantly more treatment sessions
(12.8 versus 5.8) and achieved a greater
percentage of days abstinent from drugs
(70% versus 43%) compared to those
teens who did not receive MI.
Source: Aubrey (1998)
Using an “MI sandwich” (Martino et al., 2007) protocol at intake appears to show great potential
for promoting teen engagement in services, that is, starting the session with 10 minutes of MI,
then administrating the assessment for 40 minutes, followed by 5-10 minutes of MI.
Parent involvement also plays a key role in adolescent treatment engagement (Liddle,
2004). Parents help coordinate the logistics of transportation, and insurance coverage or
payment. Encouragement by parents for their teen to attend treatment can make the difference.
Preliminary studies using MI with parents parallels the adolescent findings that parents who were
randomly assigned to receive three brief MI experiences during the course of their child’s
services were more engaged in treatment compared to the parents who did not receive MI
(Kadzin & Nock, 2005).
Brief Intervention (BI) shows promise as an effective way to engage teens in AODA
services. Although well established as a highly effective method for treating adult AODA
(Miller, 2000; Miller & Wilbourne, 2002), recent studies show BI to be promising with
adolescents both as a “stand alone” approach with mild-to-moderate substance abusers (Monti et
al., 2001; Tait & Hulse, 2003; Winters, 2005) as well as a “treatment readiness” approach to
prepare a person for standard outpatient services (Kadden et al. 2007; O’Leary Tevyaw & Monti,
2004). BI typically involves two to five structured sessions and would be considered within the
ASAM placement criteria system to be “.5” level of service (Mee Lee et al., 2001). By having a
low threshold for treatment engagement and by having no pre-requirements for teens to change,
BI minimizes several barriers for teens to become successfully involved in the treatment process.
Several empirically established BI models currently exist for adolescents and are shown in Table
10.
Table 10. Brief Intervention models developed for AOD-involved adolescents.
Adolescent Treatment Framework DRAFT
27
BI Model
Reference
Number & Type of Sessions
Teen Intervene
Winters (2003)


2 individual teen sessions
parent/guardian session
MET/CBT
Sampl & Kadden (2001)


2 individual teens sessions with
Motivational Enhancement Therapy
3 CBT group sessions
Family Check-Up
Dishion & Kavanagh (2003)



family assessment session
parent feedback session
family follow-up session
Cannabis Check-Up
Martin et al. (2005)




concerned other session
assessment session with teen
feedback session with teen
skills and strategies (CBT) session
(optional)
Each of these models uses MI and a FRAMES (Miller & Rollnick, 1991) approach:

Feedback: Personalized feedback is based on objective assessment results which are
delivered in a non-judgment manner.

Responsibility: Emphasis is placed on the teen’s personal responsibility for change.

Advice: Information can be offered, with the teen’s permission, about possible risks or
harmful effects of substance use. Information is always based on credible scientific
information.

Menu: A list of change strategies is offered to the teen, then the teen chooses the most
acceptable offering.

Empathy: Counselor empathy is a robust predictor of client motivation for change.
Empathy is expressed as reflective listening as the counselor seeks to understand the
teen’s perspectives and experiences.

Self-Efficacy: Confidence of change is enhanced through examining past successes with
change and affirming current efforts. The counselor expresses optimism for change.
7. Gender and Cultural Competence
Historically, AODA treatment in the U. S. was based on models developed for white
middle class, male adult addicts – not for women, teenagers, or people of color. Relatedly, few
outcome studies have examined treatment models developed specifically for women or for
people of color (Miller et al., 2007). Multiculturalism has emerged as a major force in the
Adolescent Treatment Framework DRAFT
28
counseling field (Sue et al., 1992) and is receiving increasing attention within the AODA
treatment field (Straussner, 2001). Although a national survey of adolescent treatment programs
showed that programs accepted a wide range of cultural diversity among its clientele, the
demonstration of culturally competent service delivery was minimal (Mark et al., 2006). The
importance of culturally competent services was recently underscored by evidence suggesting
that counselor-teen matching on gender and race impacted treatment outcome (Wintersteen et al.,
2005). Wintersteen and colleagues analyzed counselor-teen matching on gender and race data
from the Cannabis Youth Treatment experiment and showed that treatment outcomes were
poorer when there was a mismatch between counselor-client on gender (i.e., female counselor,
male client) and on race (e.g., white counselor, black client). These findings point to the
importance of delivery gender and culturally competent services, as well as recruiting, hiring,
and retaining a diverse workforce in the adolescent treatment field.
The primary focus of the Adolescent Treatment Framework has been specific to the
design and implementation of AODA services with adolescents. As discussed earlier,
adolescence is a unique period of development marked by a number of universal developmental
tasks in which all young people engage, such as the individuation process and the formation of
identity. How these tasks are accomplished is greatly influenced by gender and culture. Gender
and culture have a profound influence on the following for AOD-involved adolescents:




Prevalence, patterns, attitudes, and subjective experiences of AODs, as well as reasons
for use (Wallace & Bachman, 1991)
Prevalence, patterns, and expression of AODA and mental health symptoms (Holder,
2006)
The salience and expression of particular risk and protective factors (Newcomb, 1995)
Attitudes toward help seeking and response to treatment and prevention activities
(Collins, 1993; Miller et al., 2007)
Thus, attention in assessment, treatment planning, and delivery of services should consider the
intersections between development (age, maturity level, onset of puberty), gender (biological
sex, conceptions of masculinity and femininity, identity, roles), and culture (race, ethnicity,
socioeconomic status, religion, language, acculturation, ability, geographic location).
As developed by the Wisconsin State Council on Alcohol and Other Drug Abuse
(SCAODA) Cultural Diversity Committee, cultural competency is defined as:
A process of developing proficiency in effectively responding in a cross cultural context.
It is the process by which individuals, agencies, and systems integrate and transform
awareness of assumptions, values, biases, and knowledge about themselves and others to
respond respectfully and effectively across diverse cultures, language, socioeconomic
status, race, ethnic background, religion, gender, sexual orientation, and ability. Culture
competence recognizes, affirms, fosters, and values the strengths of individuals, families,
Adolescent Treatment Framework DRAFT
29
and communities and protects and preserves the worth and dignity of each. (SCAODA,
2008)
A growing body of research shows that boys and girls differ in a number of key
psychosocial and neurobehavioral ways (see Table 11). There are three caveats before discussing
these differences: 1) difference does not imply “better” or “worse;” 2) differences here are
identified in general terms -- there will always be individual differences; and 3) by young
adulthood (early 20s) many of the earlier differences are no longer exist.
Table 11. Gender differences on key neurobehavioral and psychosocial variables.
Key areas of difference
Brain development
Stress response
Physical risk taking
Experience of trauma
Family
AOD USE
Girls
Boys
Matures, on average, 1.5 years
ahead of males; better
integrated frontal lobes; early
verbal skills
Nausea, unpleasant
Willing to take risks
Tendency to express as
internalizing symptoms;
implications for personal
identity
Report more support and
monitoring of behavior by
parents
More likely to initiate AOD use
with a close friend
Early visual-spacial skills; motor
coordination
Excitement, thrilling
Seek out risks
Tendency to express as
externalizing symptoms;
implications for personal power
Report less support and less
monitoring by parents
More likely to initiate AOD use
with an acquaintance or stranger
Given gender differences, what are the implications for the design and implementation of
AODA treatment services for boys and for girls?
The design and implementation of culturally competent AODA services will contribute to
the following outcomes:



Better treatment engagement
Better treatment access and utilization
Better outcomes from decreased AOD use and related problems to decreased risk factors
and increased protective factors
Fostering healthy adolescent development through the successful engagement in the key
psychosocial tasks (see Table 3) means being cultural competent. For example, separation from
parents in one youth cultural context may look very different in another youth cultural context.
[Author’s note: more background research is necessary to examine culturally- and gender-based
models of adolescent treatment. More content will be developed in this section.]
Adolescent Treatment Framework DRAFT
30
8. Outcome and Process Evaluation
Outcome evaluation is both an explicit requirement of HFS 75 and a critical element of
effective adolescent treatment programs. Why might program evaluation be important aspect of
quality treatment services? Evaluation allows for a more comprehensive and objective
understanding of the extent to which services are effective. Additionally, evaluation can shed
light on program and practice areas that are not showing effectiveness. In this way, evaluation
challenges a program to demonstrate effectiveness while reflecting on ways to improve the
design and delivery of those services. When implementing an evidence-based treatment (EBT)
evaluation is critical to ascertain that the treatment is indeed being implemented as designed (i.e.,
as a fidelity check) as well as how the outcomes may replicate earlier findings. As Miller and
colleagues (2005) note, “without on-going monitoring individual clinicians and programs only
need to report that they are delivering EBTs and indeed may incorrectly believe that they are
doing so (p. 273).”
In essence, outcome evaluation addresses the question, “To what extent does the
treatment show effectiveness and for whom?” There are a variety of research methodologies and
measures used to examine adolescent treatment outcomes. SAMHSA has established the
National Outcome Measures (NOMs) which publically funded treatment providers are required
to report to the appropriate county government agency (e.g., Department of Human Services).
See Table 12 for list of the evaluation domain and related measures. These measures are intended
to be illustrative, not exhaustive.
Table 12. Outcome domains and measures for AODA treatment.
Domain
Reduced problem
symptoms
Outcome




Abstinence from AOD use
Reduced AOD use
Reduced AODA symptoms
Reduced or absence of co-occurring
mental health symptoms
Education

Increased involvement in school
Legal problems

Decreased or no criminal behavior
Measures












Adolescent Treatment Framework DRAFT
Number of days using illicit drugs
during past 90 days
Number of days drinking (at least
one drink vs. binge drinking)
during the past 90 days
Perceived risk for AOD effects
SUD symptoms
Percent of days use with and
without environmental constraints
Confidence for change
Readiness for change
Increased attendance
Increased academic performance
(grades)
Number of police contacts
without arrests
Number of Arrests
Number of tickets
31



Family

Social/Peer Group



Increased family functioning
Decreased family conflict
Increased quality time spent with
family
Increased parent family management
practices
Decreased association with AODinvolved peers
Decreased AOD use in the peer
group setting
Increased recovery social supports









Retention

Increased retention in treatment

Access/Capacity



Perception of Care



Number of adolescents served by
age, gender, race, and ethnicity
Decrease wait list time
Satisfaction with services
Satisfaction with counseling staff

Time spent in juvenile detention
Parental monitoring, use of
discipline, and expectations for
teen behavior
Closeness and attachment
between parent(s) and teen
Number of weekly family dinners
Percentage of time spent with
AOD using peers
Percentage of friends who are not
AOD-involved
Percentage of time refusing offers
to use AOD with peers
Number of recovery meetings
attended
Number of sessions attended 30
days from intake
Demographic information
Number of days from initial
phone screening to intake
Usefulness, helpfulness, and
relevance of services
Note. Adapted from the National Outcome Measures, Brown (2004), Brown et al. (2006).
Outcome measures can be linked to the collection of assessment data at intake. In this
sense the clinical data of assessment later becomes “baseline” data for follow-up evaluation.
Measures should be administered at the completion of services and at follow-up point(s) in time.
The GAIN (Global Appraisal of Individual Needs) was designed as both an assessment and
evaluation tool, that is, for clinical assessment at intake and for administration after services in
the context of outcome evaluation. For outcome evaluation to be meaningful, the exact same
measures at intake should be used at discharge and at follow-up.
Initial measures obtained during assessment can also be used for process evaluation.
Process evaluation is distinct from outcome evaluation in that the client is still participating in
services. In this way, process evaluation provides immediate and time-sensitive feedback on the
effectiveness of the services for the individual (McLellan et al., 2005). Process measures are
obtained at intake and can be repeated administered during course of treatment at regular
intervals, for example every 30 days. Process measures can include:





Number of days drinking alcohol during the past 30 days
Number of days using illicit drugs during the past 30 days
Number of AOD symptoms (0 to 11 SUD symptoms)
Number of mental health symptoms
Readiness and confidence ratings (0 to 10 scale)
Adolescent Treatment Framework DRAFT
32
Thus, process evaluation utilizes highly salient clinical data to guide delivery of services based
on immediate feedback generated. Process evaluation can also be used to concretely measure
progress toward treatment plan goals. For example, if a treatment goal is the “reduce mental
health symptoms” results of a re-administered mental health screen or assessment can greatly
inform on treatment progress.
9. Continuing Care and Recovery Management
Continuing care has emerged as a critical component of effective treatment. Often
treatment gains are lost within the first 90 days of completion. The best predictor of outcome
from residential and inpatient treatment is what happens after treatment: those who “step down”
to a lower level of care are more likely to maintain gains versus those who are discharged with
no continuing care services in place. Yet nationally, only 10% of adolescents in treatment step
down to a lower service level. The need for developing robust continuing care protocols is
underscored by a recent study examining adolescent long-term cumulative recovery patterns
after participation in the Cannabis Youth Treatment experiment. At 30 months following
treatment, 3 out of 4 adolescents were described as either showing “sustained problems” (37%)
or as “intermittent: currently not in recovery” (39%), while 19% were described as “intermittent,
currently in recovery” and, remarkably, only 5% showed “sustained recovery” (Godley, Dennis,
et al., 2006).
To address this service gap clinical researchers have developed and tested models,
approaches, and practices to create continuing care as a central component of effective treatment,
including the following:

Assertive Continuing Care (ACC): This is a model designed as an add-on component
to adolescent treatment services (Godley et al., 2006, 2008). Results thus far show that
treatment gains are maintained in terms of better abstinence rates, less AOD use, and
better psychosocial functioning compared to youth who participated in aftercare-as-usual.

Telephone-based continuing care: An approach designed and tested with adolescents
which shows promise as a feasible and effective method (Burleson & Kaminer, 2007;
NIDA, 2005), and which is especially relevant for increasing access in rural areas.

Participation in Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)
meetings: Although understudied, recent evidence suggests that adolescents who attend
such self-help groups during and after treatment benefit (Brown, Myers, Abrantes, &
Kahler, 2008). Yet the possible benefits conferred to teenagers would likely be lost if
such meeting attendance was mandated or required by a treatment program.

Recovery Management Check-Ups and Recovery Coaching: Recovery Management
(RM) is a set of emerging practices and philosophy which represents a paradigm shift in
Adolescent Treatment Framework DRAFT
33
the AODA treatment field. RM is changing the way we think about the delivery and
design of treatment (Washington Circle; White, Kurtz, & Saunders, 2006) and provides
an important alternative to the acute care model of addiction treatment. RM is based on
the following understandings:
o For some adolescents SUD can become a chronic condition
o Multiple treatment episodes are common
o Sustained abstinence or reduced use is difficult to achieve
Adding Recovery Management to the continuum of care suggests that monitoring and
other proactive interventions need to occur between primary episodes of care, and that there be a
shift in focus from intake matching to ongoing monitoring, matching over time, and strategies
that take the addiction cycle into account. RM Check-Ups (Scott, Dennis, & Foss, 2005) and
recovery coaching (Saunders, 2008) using peer-based recovery networks appear to be promising
approaches with teenagers. RM also has great potential to increase the cultural relevance of
AODA services with people of color for the following reasons (White & Sanders, 2004):






Broadened perspective on the etiological roots of AODA problems, including historical
and cultural trauma perspectives
Focus on building vibrant cultures of recovery within which individuals’ recovery can be
anchored
Proactive and hope-based approach to recovery engagement
Inclusion of indigenous healers and institutions within the RM team
Expanded menu of recovery support services
Culturally-grounded metaphors and rituals
10. Qualified Staff
Because of the unique clinical complexities of adolescents presenting for treatment
services, qualified staff are critical for effective treatment outcomes. Concerns have been
expressed by adolescent treatment experts that licensed addiction professional and those intraining who have little to no experience or training working with adolescents may have a
detrimental impact on the delivery of services with teens (e.g., McLellan, 2006; McLellan &
Meyers, 2004). To address the need for standards specific to adolescent treatment, in 2007 the
National Association of Alcohol/Drug Addiction Counselors (NAADAC) unveiled the
Adolescent Specialist Endorsement (ASE) in an effort to “address the need for professional
competencies for practitioners treating adolescents with substance use disorders (SUDs). The
ASE is intended to validate the specialized experience and training of adolescent addiction
professionals (p. 15)” (NAADAC, 2008). Although the development of such requirements will
likely show some overlap with competency standards established for adult treatment (e.g.,
Addiction Counseling Competencies, TAP 21), competency standards specific to counseling
adolescents will be a highly useful guide to promote effective services.
Adolescent Treatment Framework DRAFT
34
The following characteristics are offered as a preliminary set of competency standards to
promote qualified counseling staff who work with teens in AODA treatment settings.
Competency is defined as “specific counselor functions comprising requisite knowledge, skills,
and attitudes” (TAP, 2006, p. 170).
Knowledge:
 Understanding normative adolescent development from neurobehavioral and
psychosocial perspectives, and being able to contrast normative from risky
developmental trajectories
 Knowledge of the scientific research which highlights the short-and long-term effects of
AOD use on adolescents and their development
 Identification of the biological, psychological, and social risk and protective factors
which comprise the etiology of adolescent AODA
 Identification of the theories of adolescent experimental AOD use
 Knowledge of the intersection of AODA with co-occurring problems (mental health;
conduct): prevalence, etiology, course, prevention, and treatment
 Trauma and the impact on clinical severity and treatment outcome
 Identifying parenting styles and impact on adolescent development
Skills:
 Therapeutic alliance (accurate empathy, roll with resistance) with teens and parents or
key family members
 Implementation of an established evidence-based treatment such as MET, CBT, or
family-based model
 Use of standardized assessment and screening instruments (e.g., GAIN, POSIT) in terms
of administration, scoring, and interpretation
 Parent and family assessment
 Crisis intervention (suicide assessment)
 Cross-system collaboration (juvenile justice, mental health, school)
Attitudes:
 Teen resistance is not a trait but a state
 Family involvement in treatment is critical for maximizing treatment outcomes
 A harm-reduction approach to AODA is useful and relevant for many teenagers
 Understanding that there are multiple pathways to recovery for teens
 Administrative discharge for teen “noncompliance” or “resistance” is often inappropriate
and can be harmful (White, Dennis, & Boyle, 2005)
 Willingness to tape-record sessions for direct observation and feedback by supervisor
 Willingness to examine counter-transference
 Reflective listening as a criteria for hiring new staff (Miller, 2008)
Adolescent Treatment Framework DRAFT
35
RED FLAGS OF ADOLESCENT TREATMENT PROGRAMS: PRACTICES THAT
FOSTER INEFFECTIVE OUTCOMES
As this Framework has documented, there is a robust scientific basis for conducting
effective AODA services with adolescents. Yet many treatment policies, practices, and
approaches continue to be used with teens which have not been supported by research evidence.
These “red flags,” or concerning aspects, of existing treatment programs include the following:

Use of a confrontational counseling style in effort to promote behavior change (White &
Miller, 2007). Confrontation includes counselor behaviors such as: persuasion and
arguments for the person to change; emphasis on the benefits of change; presenting
information that refutes a teenager’s view on AOD use; explaining why the person should
make the change; telling the person how they could make the change (without
permission); emphasizing the importance of change. Research consistently shows that use
of a confrontational counseling style is, at best, ineffective (Miller & Wilbourne, 2002)
and may actually do harm to vulnerable populations such as adolescents (Peele, 1986;
White & Miller, 2007)

Education through groups, films, or lectures, or psychodynamic approaches. These
methods have consistently been shown to be ineffective in fostering behavioral change
for AODA (Miller, 2006; Miller & Wilbourne, 2002). In Miller’s (2006) words,
“knowledge-focused education and insight-oriented persuasion have been spectacularly
unsuccessful in changing substance abuse once established or in deterring its
establishment (p. 144).”

Emphasis on acceptance of a Substance Use Disorder diagnosis. Acceptance of diagnosis
has not been found to correlate with treatment outcome (Miller & Rollnick, 1991) and
can run the risk of evoking a teenager’s resistance to labeling (Baer & Peterson, 2002)

Using in-house developed questionnaires as assessment tools, that is, tools that are not
standardized or empirically tested. Unstructured interviews of teens have been shown to
be ineffective in adequately assessing the multidimensional and complex factors that are
critical to understand adolescent AODA and co-occurring problem (Winters, 2001,
2006).

Programs dominated by adult services with large teen-to-counselor ratios have been
shown to have diminished effectiveness for adolescent outcomes (Grella, 2006).

Discharge for AOD use. Common use of administrative discharge, or “kicking” people
out of AODA treatment, has been shown to have harmful effects on clients in general
(White, Dennis, & Boyle, 2005), and may be harmful to adolescents in particular.
Adolescent Treatment Framework DRAFT
36

Supervision that lacks direct observation (Miller, 2007). Direct observation of practice
with structured supervisor feedback provides a foundation for counselor skill and
competency development. Emerging evidence suggests that one-shot trainings – the most
common format of professional training in the AODA field – do little to actually improve
skills (Walters et al., 2005). Therefore, supervision is a key for counselor professional
development. Relatedly, supervision and monitoring of clinical practice is an important
component of evidence-based treatment implementation.
The frequent mention of the “research-practice gap” in professional and academic
publications strongly implicates that the above practices and approaches are widespread in the
AODA treatment system. With the emergence of evidence-based treatment models and best
practices guidelines in the adolescent treatment field, providers working with teenagers now
have a clear choice about their practice: use methods shown to be ineffective, or adopt researchinformed and tested methods for implementation.
IMPLEMENTATION OF EVIDENCE-BASED TREATMENTS
Although many advances have been made in clinical AODA assessment and treatment
with adolescents (Dennis, 2006; Liddle & Rowe, 2006) and innovations have been widely
disseminanted to programs and clinicians (Muck & Bulter, 2005), the actual implementation of
evidence-based treatments (EBTs) remains a key challenge for policy makers, program
administrators, and clinicians (Miller & Carroll, 2006). Even the most highly regarded
adolescent treatment programs in the U. S. showed substantial deficiencies in the 10 elements of
effective programs reviewed above (Burke & Early, 2003).
As discussed earlier, EBTs are typically based on a model in which a specified set of
activities is implemented such that independent observers can detect its presence and strength
(Fixsen & Blase, 2006). Three “degrees” of implementation have been identified (Fixsen,
Naoom, Blasé, Friedman, & Wallace, 2005): 1) paper implementation reflecting a change in
written policy and procedures – most organizations stop at this degree of implementation; 2)
process implementation reflecting changes in operating procedures related to training,
supervision, or documentation; however, these changes are only loosely related to the guidelines
specified by an EBT model; and, 3) performance implementation reflecting the adoption and
integration of the procedures and processes which drive implementation of an EBT.
Successful integration of innovation treatment practice depends on a variety of factors.
Organizational factors are key to understanding, especially organizational readiness to adopt
innovation. Similar to the Stages of Change for clients, Simpson (2002) identifies four stages of
Adolescent Treatment Framework DRAFT
37
organizational change for programs to successfully implement an EBT. First, exposure relates to
gaining knowledge of the innovation within a training overview. Second, adoption reflects a
formal decision by the program leadership accompanied by a positive attitude and commitment
by staff. Third, implementation requires in-depth training on how to use the approach, including
trial usage to test feasibility and potential. Fourth, confirmation and practice allows for the
experience of success and, ultimately, integration into routine practice.
Why would a treatment program consider implementing an EBT? The PROS:





Better client outcomes
Greater benefits to the community
Increase business viability
Increase ability to secure funding and reimbursement as the system moves toward
reimbursement for services outcomes (as opposed to service units)
Higher staff satisfaction for their professional development
Potential pitfalls of an EBT (Dennis, 2006; Miller, 2008). The CONS:






Can cause some staff turnover
Shines a light on staff or work place problems that would otherwise be ignored
Impacts a wide range of existing procedures and policies requiring modification and
provoking resistance
Failure without good senior staff leadership
Typically requires going for more funds from grant or other funders
Ongoing needs assessment will create demand for more change and more EBT.
Adolescent Treatment Framework DRAFT
38
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