reproductions supplied by edrs are the best that can be ... · g. other medical concerns that...

DOCUMENT RESUME

ED 443 038 CG 030 098

TITLE Treatment of Adolescents with Substance Use Disorders.Treatment Improvement Protocol (TIP) Series 32.

INSTITUTION Substance Abuse and Mental Health Services Administration(DHHS/PHS), Rockville, MD. Center for Substance AbuseTreatment.; CDM Group, Inc.

REPORT NO SMA-99-3345PUB DATE 1999-00-00NOTE 163p.; For other documents in the TIP Series, see CG 030

099-103 and CG 030 130-134.CONTRACT 270-95-0013AVAILABLE FROM National Clearinghouse for Alcohol and Drug Information,

P.O. Box 2345, Rockville, MD 20847-2345. Tel: 800-729-6686(Toll Free).

PUB TYPE Guides Non-Classroom (055)EDRS PRICE MF01/PC07 Plus Postage.DESCRIPTORS Adolescent Development; *Adolescents; Counselor Training;

*Drug Rehabilitation; Emotional Adjustment; Ethics; FamilyCounseling; Family Role; Illegal Drug Use; *Intervention;*Outcomes of Treatment; Program Development; *SubstanceAbuse

ABSTRACTThis TIP on the best practice guidelines for treatment of

substance abuse aims to help teach treatment providers about the latestinformation available to design and deliver better services to adolescentclients with substance use disorders. This publication represents advances inthe understanding of the immediate and long-term physiologic, behavioral, andsocial consequences of use, abuse, and dependency. Adolescent substance usersdiffer from adults in many ways, and this TIP explains how knowledge aboutthese differences will help treatment providers grasp why adolescents usesubstances and how substance use may become an integral part of theiridentity. A discussion on program design, policies and procedures, andevaluation, as part of program development for treatment, is provided. Othertreatment approaches such as therapeutic communities and 12-Step-BasedPrograms are detailed. It includes a discussion on contemporary familytherapy as another effective form of treatment. Youth with distinctivetreatment needs are considered in detail, including those in the juvenilejustice system; homeless youth; those with nonheterosexual identity; andthose with coexisting physical, behavioral, and psychiatric disorders. Itconcludes with a discussion of the legal and ethical issues of providingtreatment to adolescents. The following appendixes are included:"Bibliography," "Medical Management of Drug Intoxication and Withdrawal," and"Field Reviewers." (Contains 11 figures and 173 references.) (JDM)

Reproductions supplied by EDRS are the best that can be madefrom the original document.

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Points of view or opinions Stated in thisdocument do not necessarily representofficial OERI position or policy.

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Use PatternA. Problem(s) resulting from use or low-to-moderate

current useB. Problem(s) resulting from useC. Moderate-to-heavy recent useD. No recent moderate-to-heavy use

Medical ConcernsA. Low-to-moderate use without anticipated with-

drawalB. Subacute toxicityC. Social support for detoxificationD. Compliance regimenE. Premorbid/subacute toxicityF. Toxicity requires 24-hour medical monitoringG. Other medical concerns that outpatient treatment

cannot handleH. Morbid, acute toxicity (overdose) that may require

life supportI. All medically complicating conditions, including

those requiring life support/intensive careJ. No detoxification requiredK. Medical conditions that do not require life support/

intensive treatment servicesL. No special medical services required on site

IntrapersonalA. Less effective coping skillsB. Less competent emotional/cognitive functioningC. Still able to function in a nonstructured settingD. Ineffective but functional coping skillsE. Requires marginally structured settingF. Requires moderately structured settingG. Dysfunctional coping skillsH. Emotional/cognitive/psychiatric impairmentI. Requires 24-hour structured settingJ. Continuous psychiatric monitoringK. Requires long-term residential treatment, including

psychiatric and activities of daily living (ADL)services

L. Requires supervision in structured setting, ADL, andother psychosocial rehabilitation

InterpersonalA. Identified deficiencies in relationships with signifi-

cant others and history of substance use and/orother risk-related behaviors that increase thepotential for developing a psychoactive substanceuse disorder

B. Able to function in a nonstructured settingC. Requires marginally structured settingD. Requires moderately structured settingE. Dysfunctional relationships and behaviors that do

not pose an immediate threat to self or othersF. Behavior requires 24-hour structured careG. Dysfunctional relationships and behaviors that may

pose an immediate threat to self or othersH. Behavior requires psychiatric managementI. Behavior requires ADL services and possibly

psychiatric servicesJ. Behavior manageable within a structured settingK. Requires behavior management within a structured

setting which provides supervision, ADL, and otherpsychosocial. rehabilitation

EnvironmentalA. Environmental/contextual factors affect the indi-

vidual but do not warrant removal from currentliving situation

B. Needs to be supported by minimal treatmentC. Needs to be supported by moderate treatmentD. Needs to be supported by intensive treatmentE. Environmental/contextual factors dictate individual

must be removed from adverse influences of thecurrent living situation 4

Treatment ofAdolescentsWith SubstanceUse Disorders

Treatment Improvement Protocol (TIP) Series

32

Ken C. Winters, Ph.D.Revision Consensus Panel Chair

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health ServiceSubstance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment

Rockwall II, 5600 Fishers LaneRockville, MD 20857

This publication is part of the SubstanceAbuse Prevention and Treatment Block Granttechnical assistance program. All materialappearing in this volume except that takendirectly from copyrighted sources is in thepublic domain and may be reproduced orcopied without permission from the SubstanceAbuse and Mental Health ServicesAdministration's (SAMHSA) Center forSubstance Abuse Treatment (CS AT) or theauthors. Citation of the source is appreciated.

This publication was written under contractnumber 270-95-0013 with The CDM Group,Inc. (CDM). Sandra Clunies, M.S.,I.C.A.D.C., served as the CSAT Governmentproject officer. Rose M. Urban, M.S.W., J.D.,C.S.A.C., served as the CDM TIPs projectdirector. Other CDM TIPs personnel includedY-Lang Nguyen, production/copy editor,Raquel Ingraham, M.S., project manager,Virginia Vitzthum, former managing editor,

6

Mary Smolenski, Ed.D., C.R.N.P., formerproject director, and Mary Lou Leonard,former project manager.

The opinions expressed herein are the viewsof the Consensus Panel members and do notreflect the official position of CSAT,SAMHSA, or the U.S. Department of Healthand Human Services (DHHS). No officialsupport or endorsement of CSAT, SAMHSA,or DHHS for these opinions or for particularinstruments or software that may be describedin this document is intended or should beinferred. The guidelines proffered in thisdocument should not be considered assubstitutes for individualized client care andtreatment decisions.

DHHS Publication No. (SMA) 99-3345Reprinted 1999

Contents

What Is a TIP? vii

Editorial Advisory Board ix

Consensus Panel xi

Foreword xiii

Executive Summary and Recommendations xv

Substance Use Disorder Treatment and Adolescents xvi

Tailoring Treatment to the Adolescent xvii

General Program Characteristics xviii

12-Step-Based Programs xx

Therapeutic Communities xxi

Family Therapy xxii

Youths With Distinctive Treatment Needs xxiii

Legal and Ethical Issues xxv

Chapter 1Substance Use Among Adolescents 1

The Consequences 2

Treatment Needs 5

Chapter 2Tailoring Treatment to the Adolescent's Problem 9

Understanding the Problem 9

Factors Affecting Treatment Placement 10

The Continuum of Treatment 15

Chapter 3General Program Characteristics 27

Scope and Approach 27

Staffing 28

Perspectives on Counseling Youth 30

Program Components 31

Treatment Planning 34

Program Evaluation 36

iii

Contents

iv

Chapter 4Twelve-Step-Based Programs 39

The 12 Steps 39From AA to the Minnesota Model 40Incorporating the 12-Step-Based Approach 41Research Studies 43

Chapter 5Therapeutic Communities 45

The Generic TC Model 46Adolescents in TCs 47TCs With Adolescents 48Research Studies 53

Chapter 6Family Therapy 55

Family Therapy as a Recent Approach 56What Should the Program Staff Know? 60Research Studies 61

Chapter 7Youths With Distinctive Treatment Needs 63

Treatment in the Juvenile Justice System 63Homeless and Precariously Housed Youths 66Homosexual, Bisexual, and Transgendered Youths 68Youths With Coexisting Disorders 69

Chapter 8Legal and Ethical Issues 73

Consent to Treatment 73Privacy and Confidentiality 77A Final Note 98Endnotes 99

Appendix ABibliography 101

Appendix BMedical Management of Drug Intoxication and Withdrawal 113

Appendix CField Reviewers 123

Figures

1-1: Perceived Risk of Harm From and Use of Marijuana Among High School Students,1991 and 1995 2

1-2: Contrasts Between Confrontation of Denial and Motivational Interviewing 72-1: Treatment Stages and the Problem Severity Continuum 102-2: Adolescent Development: General Features of Early and Later Stages 112-3: Client Assessment Criteria 16

8

Contents

7-1: Status of Drug Courts in the United States 67

7-2: Number of Drug Court Programs Underway/Planned 68

8-1: Decision Tree 75

8-2: Sample Consent Form 80

8-3: Consent Form: Criminal Justice System Referral 86

8-4: Qualified Service Organization Agreement 97

WI"'at Is a TF-3?

Treatment Improvement Protocols (TIPS)

are best practice guidelines for thetreatment of substance use disorders,

provided as a service of the Substance Abuseand Mental Health Services Administration's(SAMHSA) Center for Substance AbuseTreatment (CSAT). CSAT's Office of Evaluation,

Scientific Analysis and Synthesis draws on theexperience and knowledge of clinical, research,and administrative experts to produce the TIPs,which are distributed to a growing number offacilities and individuals across the country.The audience for the TIPs is expanding beyondpublic and private treatment facilities forsubstance use disorders as substance usedisorders are increasingly recognized as a major

problem.The TIPs Editorial Advisory Board, a

distinguished group of substance use disorderexperts and professionals in such related fieldsas primary care, mental health, and socialservices, works with the State alcohol and drugabuse directors to generate topics for the TIPsbased on the field's current needs forinformation and guidance.

After selecting a topic, CSAT invites stafffrom pertinent Federal agencies and nationalorganizations to a Resource Panel thatrecommends specific areas of focus as well asresources that should be considered indeveloping the content of the TIP. Thenrecommendations are communicated to aConsensus Panel composed of non-Federalexperts on the topic who have been nominated

10

by their peers. This Panel participates in a seriesof discussions; the information andrecommendations on which they reachconsensus form the foundation of the TIP. Themembers of each Consensus Panel representtreatment programs for substance use disorders,hospitals, community health centers, counselingprograms, criminal justice and child welfareagencies, and private practitioners. A PanelChair (or Co-Chairs) ensures that the guidelinesmirror the results of the group's collaboration.

A large and diverse group of experts closelyreviews the draft document. Once the changesrecommended by these field reviewers havebeen incorporated, the TIP is prepared forpublication, in print and online. The TIPs can be

accessed via the Internet on the National Libraryof Medicine's home page at the URL:http: / /text.nlm.nih.gov. The move to electronicmedia also means that the TIPs can be updatedmore easily so that they continue to provide thefield with state-of-the-art information.

Although each TIP strives to include anevidence base for the practices it recommends,CSAT recognizes that the field of substance usedisorder treatment is evolving, and publishedresearch frequently lags behind the innovationspioneered in the field. A major goal of each TIPis to convey "front-line" information quickly butresponsibly. For this reason, recommendationsproffered in the TIP are attributed to eitherPanelists' clinical experience or the literature. Ifthere is research to support a particularapproach, citations are provided.

vii

What Is a TIP?

This TIP, Treatment of Adolescents With

Substance Use Disorders, updates TIP 4, publishedin 1993, and presents information on substanceuse disorder treatment for adolescent clients.Adolescents differ from adults both

physiologically and emotionally as they makethe transition from child to adult and, thus,require treatment adapted to their needs. Theonset of substance use is occurring at youngerages, resulting in more adolescents enteringtreatment for substance use disorders than hasbeen observed in the past. In order to treat thispopulation effectively, treatment providers mustaddress the issues that play significant roles inan adolescent's life, such as cognitive, emotional,physical, social, and moral development, andfamily and peer environment. This TIP focuseson ways to specialize treatment for adolescents,as well as on common and effective program

components and approaches being used today.

viii

Chapter 1 details the scope and complexity ofthe problem; Chapter 2 presents factors to beconsidered when making treatment decisions;and Chapter 3 discusses successful program

components. Chapters 4, 5, and 6 describe thetreatment approaches used in 12-Step-basedprograms, therapeutic communities, and familytherapy respectively. Chapter 7 discussesadolescents with distinctive treatment needs,such as those involved with the juvenile justicesystem. An explanation of legal issuesconcerning Federal and State confidentialitylaws appears in Chapter 8. Appendix B is atable on the medical management of substance

intoxication and withdrawal, which will appearin a forthcoming publication.

Other TIPs may be ordered by contacting the

National Clearinghouse for Alcohol and Drug

Information (NCADI), (800) 729-6686 or (301) 468-

2600; TDD (for hearing impaired), (800) 487-4889.

11

Editorial Advisory Bo

Karen Allen, Ph.D., R.N., C.A.R.N.

President of the National Nurses Society onAddictions

Associate ProfessorDepartment of Psychiatry, Community

Health, and Adult Primary CareUniversity of MarylandSchool of NursingBaltimore, Maryland

Richard L. Brown, M.D., M.P.H.

Associate Professor

Department of Family MedicineUniversity of Wisconsin School of MedicineMadison, Wisconsin

Dorynne Czechowicz, M.D.

Associate DirectorMedical/Professional AffairsTreatment Research BranchDivision of Clinical and Services Research

National Institute on Drug AbuseRockville, Maryland

Linda S. Foley, M.A.

Former DirectorProject for Addiction Counselor TrainingNational Association of State Alcohol and

Drug DirectorsWashington, D.C.

Wayde A. Glover, M.I.S., N.C.A.C. II

Director

Commonwealth Addictions Consultants andTrainers

Richmond, Virginia

Pedro J. Greer, M.D.Assistant Dean for Homeless EducationUniversity of Miami School of MedicineMiami, Florida

Thomas W. Hester, M.D.Former State DirectorSubstance Abuse ServicesDivision of Mental Health, Mental

Retardation and Substance AbuseGeorgia Department of Human ResourcesAtlanta, Georgia

Gil Hill

Director

Office of Substance AbuseAmerican Psychological AssociationWashington, D.C.

Douglas B. Kamerow, M.D., M.P.H.

Director

Office of the Forum for Quality andEffectiveness in Health Care

Agency for Health Care Policy and ResearchRockville, Maryland

Stephen W. LongDirector

Office of Policy Analysis

National Institute on Alcohol Abuse andAlcoholism

Rockville, Maryland

.12

ix

Editorial Advisory Board

Richard A. Rawson, Ph.D.

Executive DirectorMatrix Center and Matrix Institute on

AddictionDeputy Director, UCLA Addiction Medicine

Services

Los Angeles, California

Ellen A. Renz, Ph.D.

Former Vice President of Clinical SystemsMEDCO Behavioral Care CorporationKamuela, Hawaii

Richard K. Ries, M.D.

Director and Associate Professor

Outpatient Mental Health Services and DualDisorder Programs

Harborview Medical CenterSeattle, Washington

Sidney H. Schnoll, M.D., Ph.D.ChairmanDivision of Substance Abuse MedicineMedical College of Virginia

Richmond, Virginia

x 13

Consensus Panel

1997-98 RevisionConsensus Panel Chair.Ken C. Winters, Ph.D.

Associate ProfessorDepartment of PsychiatryUniversity of Minnesota Hospital and ClinicMinneapolis, Minnesota

1997-98 RevisionConsensus PanelGayle A. Dakof, Ph.D.

Research Assistant ProfessorCenter for Family StudiesDepartment of Psychiatry and Behavioral

Sciences

University of Miami School of MedicineMiami, Florida

Richard Dembo, Ph.D.Professor of CriminologyUniversity of South FloridaTampa, Florida

Nancy Jainchill, Ph.D.Senior Principal InvestigatorCenter for Therapeutic Community ResearchNational Development and Research

InstitutesNew York, New York

Michele D. Kipke, Ph.D.DirectorBoard on Children, Youth, and FamiliesNational Research CouncilInstitute of MedicineWashington, D.C.

John R. Knight, M.D.

Associate Director for Medical. Education

Division on AddictionsHarvard Medical SchoolAssistant in MedicineChildren's HospitalBoston, Massachusetts

Howard Liddle, Ed.D.Professor and DirectorCenter for Treatment Research on Adolescent

Drug AbuseDepartment of. Psychiatry and Behavioral

Sciences

University of Miami School of MedicineMiami, Florida

1992-93 Consensus Panel ChairS. Kenneth Schonberg

Director

Division of Adolescent MedicineMontefiore Medical CenterBronx, New York

xi

Consensus Panel

1992-93 Workgroup LeadersGerald D. Shulman

Executive DirectorMountain Wood Treatment CenterCharlottesville, Virginia

Susan Wallace

Caritas HousePawtucket, Rhode Island

Ken C. Winters, Ph.D.DirectorCenter for Adolescent Substance AbuseUniversity of Minnesota,

Division of Adolescent HealthMinneapolis, Minnesota

John ZachariahRegional AdministratorAmerican Correctional AssociationLaurel, Maryland

1992-93 Workgroup MembersBruce Abel, D.S.W., L.C.S.W.

Looking Glass Counseling CenterEugene, Oregon

Drew Alexander, M.D.Adolescent HealthDallas, Texas

Terry BeartuskExecutive Director

Thunder Child Treatment CenterSheridan, Wyoming

Cherrie Boyer, Ph.D.

Department of PediatricsUniversity of CaliforniaSan Francisco, California

xii

Peter Cohen, M.D.Medical DirectorChildren and Adolescents ProgramsRockville, Maryland

Richard Dembo, Ph.D.

Professor of CriminologyUniversity of South FloridaTampa, Florida

Elizabeth Cannon DuncanSouth Carolina Commission on Alcohol and

Drug Abuse TreatmentColumbia, South Carolina

Gary GironExecutive DirectorLa Neuve VidaSanta Fe, New Mexico

Raymond L. Hilton, Ed.D.Assistant SuperintendentDepartment of Children and Youth ServicesLong Lane School

Middleton, Connecticut

Mary Jane Salsbery, R.N., C.C.D.N.

Johnson County Adolescent Center forTreatment

Olathe, Kansas

Barbara ZugorExecutive DirectorTASC, Inc.

Phoenix, Arizona

15

Foreword

The Treatment Improvement Protocol(TIP) series fulfills SAMHSA/CSAT's

mission to improve treatment ofsubstance use disorders by providing bestpractices guidance to clinicians, programadministrators, and payors. TIPs are the resultof careful consideration of all relevant clinicaland health services research findings,demonstration experience, and implementationrequirements. A panel of non-Federal clinicalresearchers, clinicians, program administrators,and patient advocates debates and discussestheir particular area of expertise until they reacha consensus on best practices. This panel's workis then reviewed and critiqued by fieldreviewers.

The talent, dedication, and hard work thatTIPs panelists and reviewers bring to this highly

1-3

participatory process have bridged the gapbetween the promise of research and the needsof practicing clinicians and administrators. Weare grateful to all who have joined with us tocontribute to advances in the substance usedisorder treatment field.

Nelba Chavez, Ph.D.AdministratorSubstance Abuse and Mental Health

Services Administration

H. West ley Clark, M.D., J.D., M.P.H.,

CAS, FASAM

DirectorCenter for Substance Abuse TreatmentSubstance Abuse and Mental Health

Services Administration

Executive Summaryecom meL dations

his document, Treatment of Adolescents

With Substance/Use Disorders, is a revision

and update of Treatment ImprovementProtocol (TIP) 4, published in 1993 by the Centerfor Substance Abuse Treatment (CSAT) of theSubstance Abuse and Mental Health Services

Administration (SAMHSA). Like TIP 4, thisdocument aims to help treatment providersdesign and deliver better services to adolescentclients with substance use disorders.

In 1992, CSAT convened a Consensus Panelof experts on adolescent substance use disordertreatment to produce guidelines for treatmentprograms on designing and delivering effectiveservices to adolescent clients. The clientsaddressed in the TIP included, among others,young people involved with the juvenile andcriminal justice systems. CSAT also intended forthe Panel's guidelines to help governmentalagencies and treatment providers establish,fund, operate, monitor, and evaluate treatmentprograms for substance-using adolescents.

The result of that Panel's work was TIP 4,Guidelines for the Treatment of Alcohol- and Other

Drug-Abusing Adolescents. In July 1997, CSAT

convened a small Revision Panel to review TIP4. The Panel recommended changes anddeveloped content for this revised TIP.

Since the publication of TIP 4, the

understanding of substance use disorders andits treatment among adolescents has advanced.More is known today about the immediate and

long-term physiologic, behavioral, and socialconsequences of use, abuse, and dependency.New research attention has begun to examinethe effectiveness of various treatment methodsand components that meet the specific treatmentneeds of substance-using adolescents, and thisliterature is reviewed. However, the literature issmall. Fortunately, a large multisite, nationalstudy on the effectiveness of treatment foradolescent substance users is underway withfunds from the National Institute on DrugAbuse. CSAT is also conducting studies onadolescents, focusing on marijuana treatment,diversion programs in the juvenile justice system(JJS), and exemplary treatment programs. Thefield will likely mature greatly by the knowledgeadvanced from these studies.

The structure of the earlier TIP of separateinpatient and outpatient treatment chapters,which represented a continuum of serviceintensity, was viewed by the Revision Panel tobe less central to treatment decisions than acontinuum based on the severity of thesubstance use disorder. This shift in focus betterreflects clinical experience, extant treatmentresearch, and the recent changes regardingreimbursement by health care payors fortreatment. However, the Revision Panelretained a broad definition of treatment.Treatment is defined in this TIP as thoseactivities that might be undertaken to deal withproblem(s) associated with substance

1 7

xv

Executive Summary and Recommendations

involvement and with individuals manifesting asubstance use disorder. Although the Panelrecognizes that primary or secondary preventionof substance use are included in expandeddefinitions of treatment, the Panel limited thecontinuum of interventions to what istraditionally viewed as acute intervention,rehabilitation, and maintenance. The elementsof the continuum primarily reflect the treatmentphilosophies of providers, with less emphasis onsettings and modalities.

In addition to defining the treatment needs ofadolescents and providing a full description ofthe use of the severity continuum, the RevisionPanel focused attention on three common typesof treatment for adolescents today: 12-Step-based treatment, treatment in the adolescenttherapeutic community, and family therapy.The 12-Step model lies at the heart of manyadolescent treatment programs. Therapeuticcommunities (TCs) are an intensive type ofresidential treatment that is attracting attentionas a preferred approach for substance-usingjuveniles incarcerated in the justice system.Clinicians have found that effective treatment ofthe adolescent almost always involves thefamily, and the effectiveness of family therapyhas been documented extensively, particularlyamong those substance-using adolescents whoare normally the most difficult to treat.

This revision of the earlier TIP, then, offersguidelines for using the severity continuum tomake treatment decisions and for providingthree common models of treatment foradolescents with substance use disorders.Recommendations of the Revision Panel,supported by extensive clinical experience andthe literature, are summarized below. Theorganization of this TIP reflects the core facets ofinitiating, engaging, and maintaining the changeprocess for youths with substance use disorders.Chapter 1 details the scope and complexity ofthe problem. Chapter 2 covers factorsconsidered in making treatment decisions, and

xvi

Chapter 3 details the features of successfulprograms. Chapters 4, 5, and 6 introduce anddescribe the treatment approaches used in12-Step-based treatment, therapeuticcommunities, and family therapy, respectively.Chapter 7 discusses adolescents with distinctivetreatment needs, such as youths involved in thejuvenile justice system, homeless and runawayyouth, and youth with coexisting disorders.Chapter 8 describes the legal and ethical issuesthat relate to diagnosis and treatment ofadolescents.

This new TIP derives from CSAT's intentionto provide protocols that reflect the work nowbeing done by providers of high-qualitytreatment. As with other TIPs, this documentbrings the best knowledge from the field to Stateand local treatment programs. In order to avoidawkward construction and sexism, this TIPalternates between "he" and "she" for genericexamples. The companion document, TIP 31,Screening and Assessing Adolescents for Substance

Use Disorders, a revision of TIP 3, has also been

published (CSAT, 1999).

Substance Use DisorderTreatment andAdolescentsIn 1997, substance use among 12- to 17-year-oldchildren rose to 11.4 percent with illicit drug useamong 12- and 13-year-olds increasing from 2.2

to 3.8 percent, according to the 1997 National

Household Survey on Drug Abuse conducted by

the Substance Abuse and Mental Health Services

Administration. Moreover, perceived risk ofharm from substance use is falling while theavailability of drugs is climbing. These trendsindicate a major national problem, especially asthe social and economic costs of adolescentsubstance use are becoming better understood.The onset of substance use is occurring atyounger ages, resulting in more adolescentsentering treatment for substance use disorders

18

with greater developmental deficits and perhapsmuch greater neurological deficits than havebeen observed in the past. Other consequencesof substance use and abuse include alcohol- anddrug-related traffic accidents, delinquency,sexually risky behavior, and psychiatric

disorders.Adolescent users differ from adults in many

ways. Their drug and alcohol use often stemsfrom different causes, and they have even moretrouble projecting the consequences of their useinto the future. In treatment, adolescents mustbe approached differently than adults because oftheir unique developmental issues, differencesin their values and belief systems, andenvironmental considerations (e.g., strong peerinfluences). At a physical level, adolescents tendto have smaller body sizes and lower tolerances,putting them at greater risk for alcohol-relatedproblems even at lower levels of consumption.The use of substances may also compromise anadolescent's mental and emotional developmentfrom youth to adulthood because substance useinterferes with how people approach andexperience interactions.

The treatment process must address thenuances of each adolescent's experience,including cognitive, emotional, physical, social,and moral development. An understanding ofthese changes will help treatment providersgrasp why an adolescent uses substances andhow substance use may become an integral part

of an adolescent's identity.Regardless of which specific model is used in

treating young people, there are several pointsto remember when providing substance usedisorder treatment:

m In addition to age, treatment for adolescentsmust take into account gender, ethnicity,disability status, stage of readiness to change,and cultural background.Some delay in normal cognitive andsocial-emotional development is oftenassociated with substance use during


adolescence. Treatment for adolescentsshould identify such delays and theirconnections to academic performance, self-esteem, or social interactions.Programs should make every effort toinvolve the adolescent client's family becauseof its possible role in the origins of the

problem and its ability to change the youth'senvironment.

in Although it may be necessary in certaingeographic areas where availability ofadolescent treatment programs is limited,using adult programs for treating youth is ill-advised. If this must occur, it should be doneonly with great caution and with alertness toinherent complications that may threateneffective treatment for these young people.Many adolescents have explicitly orimplicitly been coerced into attendingtreatment. Coercive pressure to seektreatment is not generally conducive to thebehavior change process. Treatmentproviders should be sensitive to motivationalbarriers to change at the outset ofintervention. Several strategies can be usedfor engaging reluctant clients to considerbehavioral change.

T iloring Treatment toThe A olescentAdolescent substance use occurs with varyingdegrees of severity. The degree of substanceinvolvement is an important determinant oftreatment, as are any coexisting disorders, thefamily and peer environment, and theindividual's stage of mental and emotionaldevelopment. This information should be usedto refer the client to appropriate treatment.

It is useful to consider a substance usecontinuum with these six anchor points:

is Abstinence

M Use: Minimal or experimental use withminimal consequences

xvii


o Abuse: Regular use or abuse with several andmore severe consequences

O Abuse/Dependence: Regular use over anextended period with continued severeconsequences

o Recovery: Return to abstinence, with a relapsephase in which some adolescents cyclethrough the stages again

gi Secondary abstinence

Treatment interventions fall along acontinuum that ranges from minimal outpatientcontacts to long-term residential treatment. Alllevels of care should be considered in making anappropriate referral. Any response to anadolescent who is using substances should beconsistent with the severity of involvement.While no explicit guidelines exist, the most

intensive treatment services should be devotedto youth who show signs of dependencythatis, a history of regular and chronic usewith thepresence of multiple personal and socialconsequences and evidence of an inability tocontrol or stop using substances.

AssessmentThe guidelines below show how the continuumcan be used in making a decision regarding theplacement of the adolescent. The Revision Panelcreated the guidelines based on clinicalexperience.

In making placement decisions, practitionersshould choose the most intensive level of careindicated by any single assessment criterion.

m When an assessment indicates the need for aparticular level of care that is not available, itis desirable to refer the adolescent to the nexthigher level of care, unless the assessmentindicates that such a placement would becounterproductive. Naturally, a higher levelof care may not be practical or available.

Assessment is an ongoing process. Decisionsabout level of care should be based on theadolescent's progress and changes in his

xviii

environment. Clients should have theopportunity to move back and forth acrossthe level of care continuum based on changesin these factors.

Assessors should have an indepth knowledgeof available services and their quality andintensity.

Q Adolescents may move into or throughdifferent treatment programs based on theirprogress and/or changes in the environment.Prior to each program change, indepth

reassessment must be completed and theresults communicated between providers.

General ProgramCharacteristics

20

Program design, a policies and procedures

manual, ongoing evaluation, and a plannedapproach to legal concerns make up theframework for a treatment program. Within thisframework, issues to consider include staffrecruitment and training, treatment components,treatment planning, and client services.

StaffingStaff members should represent the culturaldiversity of the program's client population. Inaddition, the facility's forms, books, videos, andother materials should reflect the culture andlanguage of the clientele. Innovative andintensive continuing education, staffdevelopment, and outreach efforts during staffrecruitment may be needed to improve culturalcompetence among staff. If a significant part ofthe client population is nonEnglish-speaking, atleast one staff member should be bilingual andbicultural. Someone on staff should be familiarwith disability issues and disability culture: Forexample, people who are deaf who useAmerican Sign Language have their ownculture.

Most important is to schedule staff training

periodically throughout the year. This is greatly

preferable to training presented in ad hocsituations to address crises or acute situations.Ongoing training should address a range ofspecialty topics, including the following:

Treatment approaches specific toadolescents and their familiesFamily dynamics and family therapyAdolescent growth and developmentSexual and physical abuseGender issuesMental health problemsDifferent cultural and ethnic values

PsychopharmacologyReferral and community resourcesCognitive impairmentsLegal matters

When recovering individuals are hired, theyshould have the same level of expertise andtraining required of other staff members in thesame position. Recovering individuals musthave clear evidence of abstinence from alcoholand drugs for 2 to 5 years.

Program ComponentsThe core components of many adolescenttreatment programs, regardless of theirtherapeutic orientation, include the following:

Orientation, the first step in treatment,clarifies to the adolescent what treatment is,her role in treatment, and the concept ofprogram expectations. Orientation should beconducted in a nonconfrontational style andtone in order not to raise the adolescent'sanxiety, which may already be heightened byother aspects of the treatment program.Daily scheduled activities of school, chores,

homework, and positive recreationalactivities can help adolescents learn newskills and provide them with an alternative totheir substance-using behavior and can helpensure that adolescents remain sober aftertreatment.


Peer monitoring in a group setting can helpthe client build the strength necessary tooverride peer pressure and harness theinfluence of the peer group in a positive

manner.Conflict resolution is often necessary given

that there is a high potential for conflictbetween young clients and program staff.Such conflicts can arise from a staff member'sinexperience in working with adolescents ora client's inability or unwillingness to meetprogram expectations, in which case thetreatment plan should be modified. In anyevent, staff should take a proactive stance in

resolving conflicts.Client contracts (e.g., behavioral contracts,

including substance-free contracts) arenegotiated and signed by both the adolescentand primary counselor; they lay out concretetreatment goals, expectations, time frames,and consequences (if the contract is notfollowed) that are mutually acceptable to theclient and counselor. They can help identifythe current level of the adolescent'sfunctioning and developmental markers,providing a baseline from which to monitorchange. They also give to adolescents a senseof control in going through treatment and adegree of investment in their well-being.Schooling, which generally focuses on

substance use and basic education, is one ofthe most important factors in an adolescent'srecovery. Whether the schooling is providedon or off site, it should be fully integratedinto an adolescent's program. Teaching staffshould be considered part of the treatmentteam. For adolescents who attend publicschools, a liaison between the school andtreatment program should be designated.Vocational training is an importantintervention and should be part of anadolescent's treatment. Appropriateinterventions include prevocational training,career planning, and job-finding skills

xix


training. Without these skills, many youthsmay be more likely to support themselvesthrough illegal activities and thus be moreprone to relapse.

The level of intensity of these components willvary considerably from outpatient to residentialtreatment.

Treatment PlanningAt a minimum, a treatment plan should identifythe following:

Problems of the client and the family,including substance use, psychosocial,medical, sexual, reproductive, and possiblepsychiatric disordersGoals that are attainable and help clients torecognize their involvement with substancesand to acknowledge responsibility for theproblems resulting from substance useStrengths and resources of the individual andthe family and ways to apply them toaddress treatment goalsObjectives that are realistic and measurablesteps for achieving each goal

Interventions such as treatment strategiesand services that are needed to achieve theobjectives

Educational, legal, and external supportsystems

The treatment plan should include pre-established times for evaluation and adjustmentof goals as necessary. Treatment programs alsoshould work closely with other entities that areinvolved in the treatment of adolescents, such asschool systems, child welfare, and juvenilejustice agencies. Interagency agreements, alsoknown as memoranda of understanding, shouldbe developed that describe payment policies,funding problems, mutual goals for clients, andintra- and interagency contracts. In addition, itis important to have an established practice ofexchanging signed releases of information fromeach shared client, insofar as the client agrees to

xx

the sharing of information, so that the involvedstaff members can more freely exchangeconfidential information about the client'sprogress.

12-Step-Based ProgramsIn programs like Alcoholics Anonymous (AA)

and Narcotics Anonymous (NA), sobriety ismaintained by carefully employing a 12-Stepphilosophy and by sharing experiences withothers who have suffered similar problems withsubstance abuse and dependency. Many clientswho are involved with AA/NA find anothermember who will serve as a sponsor andprovide guidance and help in times of crisiswhen the urge to return to drinking or drug usebecomes overwhelming.

Providers treating adolescents in a 12-Step-based program should bear the following inmind:

Substance use disorders are primary,multifaceted illnesses that exist in people ofall ages, including adolescents.

Persons with substance use disorders areindividuals who share a common problembut have unique and separate needs andtherefore should be treated with respect anddignity.

Once substance-using adolescents areinformed about addiction in anunderstandable way, they are capable ofhelping others, as long as they receive someguidance.

Use of group therapy is well suited toadolescents, who tend to rely heavily on peerexamples and approval.The principles of recovery outlined byAA/NA provide effective and proactivetools for continuing recovery from substanceinvolvement.

Once a person has lost control over his use ofsubstances as an adolescent, returning to

f)2

responsible and legal use as an adult may

require additional help and support.

Most 12-Step-based programs focus on the

first five steps during primary treatment, whilethe remaining ones are attended to duringaftercare. Below are ways to present the firstfive steps to adolescents so that their specializeddevelopmental needs can be addressed.

Step 1: We admitted we were powerless over

alcoholthat our lives had become

unmanageable. With adolescents, the primarygoal of this step is to assist them in reviewingtheir substance use history and to have themassociate it with harmful consequences.

E Step 2: We came to believe that a Power greater

than ourselves could restore us to sanity. To

convey this message, allow new clients tointeract with those who have been successfulin treatment and are leaving the program.Providers must help adolescents withcoexisting mental illnesses or cognitivedisabilities to understand that Step 2 refers toobtaining help to stop drug seeking and use

behavior.Step 3: We made a decision to turn our will and

our lives over to the care of God as we understood

Him. This step can be simplified by saying,"Try making decisions in a different way; take

others' suggestions; permit others to help you."

Using the phrase "Helping Power" instead of"Higher Power" can benefit some.Step 4: We made a searching and fearless moral

inventory of ourselves; Step 5: We admitted to

God, to ourselves, and to another human being

the exact nature of our wrongs. Steps 4 and 5

provide an opportunity to be accepted byanother person in spite of one's pastbehaviors and to take a "personal inventory"of those past behaviors.

Therapeutic CommunitiesAs a social-psychological form of treatment for

addictions and related problems, the TC has


been typically used in the United States to treatyouth with the severest problems and for whomlong-term care is indicated. TCs have twounique characteristics:

1. The use of the community itself as therapistand teacher in the treatment process

2. A highly structured, well-defined, andcontinuous process of self-reliant program

operation

The community includes the socialenvironment, peers, and staff role models.Treatment is guided by the substance usedisorder, the person, recovery, and right living.

Traditionally in the therapeutic community,job functions, chores, and other facilitymanagement responsibilities that help maintainthe daily operations of the TC have been used as

a vehicle for teaching self-development. Theday is highly structured, with time designatedfor chores and other responsibilities, groupactivities, seminars, meals, and formal andinformal interaction with peers and staff. Theuse of the community as therapist and teacherresults in multiple interventions that occur in all

these activities.For the adolescent, the community may be

even more crucial than for adults since the TCfunctions as family. This is an exceedinglysignificant function, since many youth in TCs

come from dysfunctional families.Modifications that are generally made in the

TC model for treatment of adolescents can besummarized as follows:

The duration of stay is shorter than for

adults.Treatment stages reflect progress alongbehavioral, emotional, and developmental

dimensions.Adolescent programs are generally lessconfrontational than adult programs.Adolescents have less say in themanagement of the program.

xxi


Staff members provide more supervisionand evaluation than they do in adultprograms.

o Neurological impairments, particularlylearning disabilities and related disorders,such as attention deficit/hyperactivity

disorder (AD/HD), must be assessed.There is less emphasis on work and moreemphasis on education, including actualschoolwork, in the adolescent program.Family involvement is enhanced in

adolescent programs and ideally should bestaged, beginning with orientation andeducation, then moving to support groups,therapy groups, and therapy with theadolescent. When parental support isnonexistent, probation officers, socialworkers, or other supportive adults in theyouth's life can participate in therapy.

Clinical wisdom suggests that the ideal durationof treatment for adolescents in a TC is 12 to 18months and that adolescents with very deep andcomplicated disorders cannot be treatedeffectively in 28 days.

Staffing in TCs continues to include non-degreed, recovering individuals as adjunctivestaff, as well as professionally trained, degreed

specialists. Having a nurse on site is ideal, inpart to provide cross-training for the counselors,particularly regarding the symptomatology ofaddiction. The nurse should be well-versed insexuality, reproductive health, and sexuallytransmitted diseases (STDs), includingdiagnosis, treatment, and issues surroundingpartner notification. Teachers in a TC programfor adolescents must have an understanding ofsubstance use disorders among youth.

TC residents move through stages ofincreasing responsibility and privileges. Toadvance to the next level, the adolescent mustdemonstrate responsibility, self-awareness, andconsideration for others. In adult TCs, the finalstage is taking some responsibility for operatingthe TC; this is not appropriate for adolescents,

for whom the staff plays the role of effectiveparents.

Ideally, TCs should provide their ownschools with licensed teachers as well as satelliteaftercare programs in the communities wherethe residents live. For adolescents, aftercareprograms should include a family therapycomponent. Programs should developcooperative working agreements with their localjuvenile probation departments to coordinatethe referral, screening, and followup and toensure this population's access to appropriatetreatment. Prevocational and vocationaltraining should be incorporated wheneverpossible.

A TC environment should help clients cometo terms with sexual issues (e.g., sexual identity,previous sexual abuse) through one-on-onecounseling, encounter groups, sex educationclasses, and other special sessions. Dating andsexual contact between clients should beprohibited. Boys' and girls' living spaces shouldbe separated. The longer term stay andincreased contact make TCs a good environmentfor counseling and education on other issuessuch as smoking and STDs.

Family Th r d py

Substance use disorder treatment programs canemploy family therapists to apply therapeuticapproaches that have proven effective withadolescents and their families. A therapist whopractices a family-based approach should haveformal, professional training in this method.Family therapy fits well into the regimen of

treatment where case management is used; italso has been proven effective in home-basedtreatment.

Contemporary family therapy approachesunderstand the importance of treatingindividuals as subsystems within the familysystem and as units of assessment and

intervention; in other words, each member of the

24

family is capable of being assessed and can act

as a unit of intervention, for example, by

changing his interactional patterns. Family-based treatments work with multiple units,including individual parents, adolescents,parent-adolescent combinations, and wholefamilies, as well as family members vis-à-vis

other systems. Contemporary familyapproaches also target extended systems, mostnotably an adolescent's peers, school, andneighborhood, which are believed to contributeto dysfunctional interactions in families.

The therapist's intervention aims to changethe way family members relate to each other byexamining the underlying causes of currentinteractions and encouraging new (andpresumably, healthier) ones. The therapistshould help family members appreciate how thevalues and perspectives of each family membermay differ from their own, but that differencesdo not have to be a source of conflict. Helpingthe family members solve problems together inthe therapeutic setting enables them to learnstrategies that can be applied with theadolescent in the home. Such maneuvers intherapy decrease family conflicts and improve

the effectiveness of communication.Family treatment also equips parents with

the skills and resources necessary to address theinevitable difficulties that arise in raisingteenagers. The family therapist's job is to helpparents regain their optimism and motivatethem to continue to help their teenager. Familytherapists should bolster the parents' self-confidence as parents while at the same timehelping them improve their parenting skills.Parents are taught how to provide age-appropriate monitoring of their teenager (e.g., toknow their friends, to know how they spendtheir time), set limits (e.g., negotiate with theyouth about reasonable curfews, schedules, andfamily obligations), establish a system of

positive and negative consequences, rebuild


emotional attachments, and take part inactivities with the adolescent outside the home.

Family therapy can include discussion of theeffects of the teenager's actions in extrafamilialsystemssuch as skipping an appointment witha probation officer or hanging out with peerslate at night on unsafe street corners wheredrugs are bought and sold. Then the therapistmight meet with the probation officer or ask theadolescent to bring a peer to a session to reviewthe problem from the youth's perspective.

Family therapists should be acutely aware ofthe complex of behaviors and systemicinteractions associated with recovering from asubstance use disorder. They also must beaware of cultural differences in family patternsand typical attitudes toward therapy.Adolescent substance involvement should beconsidered within the context of other problembehaviors such as delinquency and schoolproblems, necessitating new frameworks ofdiagnosis and assessment, as well as treatment.

Adolescent clients will benefit when thetreatment team, including substance abusecounselors, nurses, and doctors, working inconjunction with family therapists, have ageneral understanding of family therapy withinthe substance use disorder treatment setting.When they have this understanding, thetreatment team members can best support theefforts of the therapist and coordinate theircomponents of treatment with family therapy.

Most important in family therapy is thetherapeutic affiance between the therapist andadolescent. It is crucial for the therapist toemphasize to the client and family members thatthe purpose of the therapy is to help the client.

Youths With DistinctiveTreatment NeedsYoung people who have distinct concerns

related to coexisting psychiatric conditions,sexual orientation, involvement with the


criminal justice system, physical health, ordisplaced living conditions may not do well intraditional treatment programs. Therefore,treatment providers should offer individualizedtreatment, paying particular attention to theevents and circumstances that contributed to theclient's current situation. Problems that oftenaccompany substance use disorders includeillegal activity, homelessness, shamesurrounding sexual orientation, and coexistingphysical and mental disorders.

Youth in the Juvenile Justice SystemEvery young person involved in the juvenilejustice system should undergo thoroughscreening and assessment for substance usedisorders, physical health problems, psychiatricdisorders, history of physical or sexual abuse,learning disabilities, and other coexistingconditions. Juvenile probation officers can behelpful partners in the system of care. For theirpart, providers should educate the local juvenilejustice system about the importance of early

intervention and the resources available to it. Itis almost impossible to intervene here unless theyouth is removed from the environment thatbrought him into conflict with the juvenilejustice system in the first place (e.g., the home

neighborhood). Early intervention is critical inworking with adolescents who have come intocontact with the juvenile justice system.

Homeless YouthResearch shows that homeless youths are at highrisk for a wide range of problems, including

substance use disorders. Effective treatment forthis population hinges on recognizing theseyoung people's readiness for treatment. Foradolescents who are living on the streets,outreach becomes a primary intervention

strategy. Outreach programs should have inplace a "step-up" for homeless or inner-cityyouths to enter these programs, assisting themin negotiating the various obstacles that may be

xxiv

potential barriers to services. Street outreachworkers should focus on developing trustingrelationships with youths that, over time, caninfluence a young person to access treatmentservices for substance use disorders. Serviceproviders must meet with, talk to, and developrelationships with young people on the street toengage them in treatment. Returning homelessor runaway youth to their homes is not alwaysin their best interest because less than optimalconditions may exist in these homes. Treatmentproviders should explore the appropriateness ofother transitional living options for homelessyouth if necessary.

Once a homeless youth has entered thesystem, the next step is establishing a case

management plan that is based on a thoroughassessment of her needs. Possible servicesshould include finding housing, dealing withfamily problems, entering substance usedisorder and/or HIV-related treatment, andproviding schooling, sexual and reproductivehealth care, and job training. It may benecessary to prioritize the needs for servicesaccording to the individual's problems.

Homosexual, Bisexual, andTransgendered YouthAdolescence is a very lonely, high-risk time formany youths who have sexual identity issues.Many gay, bisexual, and transgendered youthshave no one in whom they can confide, andmost communities lack gay-identified services.

Gay-specific services are likely to be more

sensitive to the importance of not divorcing theissues of sexual identity from substance useproblems during the treatment process.Effective treatment for these youths involveshelping them to feel comfortable with, and totake pride in, their sexual identity.

Coexisting DisordersAny adolescent who is being treated forsubstance use disorders and is also taking

26

psychoactive medications for a coexisting

psychiatric disorder requires carefulpsychopharmacological management. Theseadolescents should also be given routine urinetesting as part of their treatment plan. Closescrutiny of adolescents with AD/HD isparticularly important for those who arereceiving substance use disorder treatment.Treatment providers and mental healthauthorities should develop programs together totreat youth with coexisting disorders. Cross-training can help staff of both programs developthe sensitivity and the clinical skills tounderstand coexisting disorders and to identifythe presence of either problem or both. Youthswho have coexisting disorders and are not onpsychoactive medications do better in programsthat provide both substance use disorder andmental health treatment together than inseparate programs. For more information oncoexisting psychiatric conditions and substanceuse disorders, refer to TIP 9, Assessment and

Treatment of Patients With Coexisting Mental

Illness and Alcohol and Other Drug Abuse.

Legal and Ethical IssuesBecause of the complexity of the consent issue,programs in States with laws that do not clearlyallow admission of adolescents without parentalconsent or notification should develop a specialadmissions policy. This policy should be based

on these variables:

State law regarding treatment of adolescents(i.e., whether parental consent and/ornotification is required)State law regarding program liability ifadolescent clients in need are turned awayThe family circumstances as related by theadolescent (the adolescent's view of hisfamily may be verified, with his consent, bycontacting an adult who knows the family

well)


The adolescent's age and emotional,cognitive, and social maturityThe kind of treatment the program providesThe program's financial capacity to providetreatment without reimbursement fromfamily

In Potential for exposure to a lawsuit should theprogram admit the adolescent

With the above factors in mind, the programshould assess its potential liability if theadolescent is admitted without parental consentin a State where such consent is required.

Programs Governed by FederalConfidentiality RegulationsAny program that specializes, in whole or inpart, in providing treatment, counseling, and/orassessment and referral services for adolescentswith substance use disorders must comply withthe Federal confidentiality regulations (42 C.F.R.

§2.12(e)). Although the Federal regulationsapply only to programs that receive Federalassistance, this includes indirect forms ofFederal aid such as tax-exempt status or State orlocal government funding coming (in whole orin part) from the Federal government.

Coverage under the Federal regulations doesnot depend on how a program labels its services.Calling itself a "prevention program" does notexcuse a program from adhering to theconfidentiality rules. It is the kind of services,not the label, that will determine whether theprogram must comply with the Federal law.

Information that is protected by the Federalconfidentiality regulations may be disclosedonly after the adolescent has signed a properconsent form. In some States, parental consentmust also be obtained. The adolescent mayrevoke consent at any time, and the consentform must include a statement to this effect. Theform must also contain a date, event, orcondition on which it will expire if notpreviously revoked. Once the consent form hasbeen properly completed, there remains one last

xxv


formal requirement. Any disclosure made withpatient consent must be accompanied by awritten statement that the information disclosedis protected by Federal law and that therecipient cannot further disclose or release suchinformation unless permitted by the regulations.Programs assessing or treating adolescents whoare involved in the criminal justice system or

juvenile justice system (juvenile court) must alsofollow the Federal confidentiality rules.

111, uty to WarnIf an adolescent's counselor thinks the teenagerposes a serious risk of violence to someone, thereare at least two questions that must beanswered:

1. Does a State statute or court decision imposea duty to warn in this particular situation?

2. Even if there is no State legal requirementthat the program warn an intended victim orthe police, does the counselor feel a moralobligation to warn someone?

The first question can only be answered by anattorney familiar with the law in the State inwhich the program operates. If the answer tothe first question is "no," it is advisable todiscuss the second question with a knowledge-

xxvi

able lawyer, too. A similar dilemma also ariseswhen providers know that an adolescent theyare treating is infected with HIV or if theadolescent has committed a criminal act.

Reporting Child Abuse and NeglectAll 50 States and the District of Columbia have

statutes requiring reporting when there isreasonable cause to believe or suspect childabuse or neglect. While many State statutes aresimilar, each has different rules about whatkinds of conditions must be reported, who mustreport, and when and how reports must bemade. Because of the variation in State law,programs should consult an attorney familiarwith State law to ensure that their reportingpractices are in compliance.

When a program makes such a report, itshould notify the family, unless the notificationwould place the child in further danger. Theprogram should also endeavor to continue towork with the family as the State investigatesthe complaint and the child protective processunfolds. Families should never be abandonedbecause of suspected abuse or neglect, andhealth care providers should be wary of makingjudgments until a comprehensive assessmenthas been completed by State authorities.

28

bstance Jse AmonAdo escents

Substance use by young people is on therise, and initiation of use is occurring atever-younger ages. Patterns of substance

use over the past 20 years have beendocumented by two surveysthe NationalHousehold Survey on Drug Abuse conducted bythe Substance Abuse and Mental Health ServicesAdministration (SAMHSA) and the Monitoringthe Future Study conducted by the NationalInstitute on Drug Abuse (NIDA). Data releasedin 1996 indicated that in the early to mid-1990s,

the percentage of 8th graders who reportedusing illicit drugs (i.e., drugs illegal forAmericans of all ages) in the past year almostdoubled, from 11.3 percent in 1991 to 21.4

percent in 1995 (NIDA, 1996a). Drug use byhigh school students also has risen steadily since1992. The survey also indicates that 33 percentof 10th graders and 39 percent of 12th gradersreported the use of an illicit drug within thepreceding 12 months (NIDA, 1996a). Theseestimates are probably low because the statisticsare gathered in schools and do not include thehigh-risk group of dropouts. Most of the recentincrease is attributed to marijuana use, whichrose significantly during this period.

An estimated 15 percent of 8th graders, 24percent of 10th graders, and 30 percent of 12thgraders reported having had five or more drinkswithin the preceding 2 weeks (Johnston et al.,1995). Slightly more than half of high school

students (grades 9 through 12) reported having

29

had at least one drink of alcohol during the 30days preceding a 1995 Centers for DiseaseControl and Prevention (CDC) survey (CDC,1996). It is further estimated that 9 percent ofadolescent girls and up to 20 percent ofadolescent boys meet adult diagnostic criteriafor an alcohol use disorder (Cohen et al., 1993).Furthermore, the proportion of daily smokersamong American high school seniors remainsdisturbingly high at about 20 percent.

The surveys have found that the perceivedrisk of harm from drug involvement has beendeclining while the availability of drugs hasbeen rising (NIDA, 1996a; SAMHSA, 1998a).

Particularly in the case of marijuana, sharpdeclines in harm perception have been observedamong 8th, 10th, and 12th graders (seeFigure 1-1). This shift has occurred at the sametime that marijuana use has spread (NIDA,1996a). Since 1991, the percentage of studentswho thought that regular marijuana use carries a"great risk" of harm has dropped from 79percent to 61 percent among 12th graders, from82 percent to 68 percent among 10th graders,and from 84 percent to 73 percent among 8thgraders (NIDA, 1996a). During the same period,reported use of marijuana within the precedingyear rose for all these grades by an average of 11percent (NIDA, 1996a).

Household products are abused as well asillegal drugs: The percentage of youths 12 to 17

years old who tried inhalants rose from 1.1

Chapter 1

100

90

80

70

60

50

40

30

20

10

0

8th graders

10th graders

12th graders

Perceived risk1991

Use Perceived risk

Source: Monitoring the Future Study, National Institute on Drug Abuse, 1996a.

1995Use

percent in 1991 to 2.2 in 1994 (NIDA, 1996a).

"Heroin chic" as exemplified by rock stars andfashion models has boosted the popularity ofthat drug among young people. Panel membersreported that in some areas, the adolescent useof heroin mixed with water and then inhaled hasincreased. Clearly, drug use trends amongyoung people are a major national concern.Within the context of national surveys offrequency of use, the prevalence of thosemeeting criteria for a diagnosis is becomingclearer. A 1996 statewide Minnesota surveyprovided the first systematic look at the rate ofsubstance use disorders in a large studentpopulation: 11 percent of 9th grade students and23 percent of 12th grade students met formaldiagnostic criteria as established in theDiagnostic and Statistical Manual of Mental

Disorders (American Psychiatric Association,

2

1994) for drug abuse or drug dependencedisorder (Harrison and Fulkerson, 1996).

The ConsequencesIn terms of public health, adolescent substance

use disorders have far-reaching social andeconomic ramifications. The numerous adverseconsequences associated with teenage drinkingand substance use disorders include fatal andnonfatal injuries from alcohol- and drug-relatedmotor vehicle accidents, suicides, homicides,violence, delinquency (Dembo et al., 1991),

psychiatric disorders, and risky sexual practices(Jainchill et al., in press). Longitudinal studieshave established associations betweenadolescent substance use disorders and(1) impulsivity, alienation, and psychological

30

distress (Hansell and White, 1991; Shed ler and

Block, 1990), (2) delinquency and criminal

behavior (National Institute of Justice, 1994),

(3) irresponsible sexual activity that increasessusceptibility to HIV infection (Di Clemente,

1990), and (4) psychiatric or neurologicalimpairments associated with drug use,especially inhalants, and other medicalcomplications (SAMHSA, 1996).

Substance use disorders that begin at an earlyage, especially when there is no remission of thedisorder, exact substantial economic costs tosociety (Children's Defense Fund, 1991). Thetrend toward early onset of substance usedisorders has increasingly resulted inadolescents who enter treatment with greaterdevelopmental deficits and perhaps muchgreater neurological deficits than have beenpreviously observed. Moreover, the risks oftraumatic injury, unintended pregnancy, andsexually transmitted diseases (STDs) are high inadolescents in general. Drug involvement that issuperimposed on these already high risks hasnumerous potentially adverse consequences thathave not yet been the subject of indepth studybeyond basic population studies.

MortalityAlcohol-related motor vehicle accidents exact aheavy toll on society in terms of economic costsand lost productivity. Nearly half (45.1 percent)of all traffic fatalities are alcohol-related, and it isestimated that 18 percent of drivers 16 to 20years olda total of 2.5 million adolescentsdrive under the influence of alcohol. Accordingto the Youth Risk Behavior Surveillance Systemconducted by the CDC, which monitors healthrisk behaviors among youths and young adults,unintentional injuries, including motor vehicleaccidents, are by far the leading cause of deathin adolescents, causing 29 percent of all deaths.An estimated 50 percent of these deaths arerelated to the consumption of alcohol (CDC,1998).

Substance Use Among Adolescents

Sexually-Risky PracticesAdolescents are at higher risk than adults foracquiring STDs for a number of reasons. Theyare more likely to have multiple (sequential orconcurrent) sexual partners and to engage inunprotected sexual intercourse. They are alsomore likely to select partners who are at higherrisk for STDs. Among females, those 15 to 19years old have the highest rates of gonorrhea,while 20- to 24-year-olds have the highest rate ofprimary and secondary syphilis (CDC, 1996).

Adolescents who use alcohol and illicit drugsare more likely than others to engage in sexualintercourse and other sexually risky behaviors.A positive correlation has been demonstratedbetween alcohol use and frequency of sexualactivity. In a 1990 Massachusetts survey ofadolescents 16 to 19 years old, two-thirdsreported having had sexual intercourse, 64percent reported having sex after using alcohol,and 15 percent reported having sex after usingdrugs (MacKenzie, 1993).

Substance use among adolescents isassociated with early sexual activity, animportant factor in the prevalence of STDs andHIV infection. The use of substances combinedwith sexual activity significantly decreases thelikelihood that a condom will be used duringsex. Substance use also can decrease anindividual's discrimination in the selection ofsexual partners and can increase the number ofpartners and the likelihood of risky sexualpractices (including anal intercourse), therebyheightening the risk of STDs (MacKenzie, 1993).

The CDC conducted its school-based YouthRisk Behavior Survey among a representativesample of 10,904 high school students in grades9 through 12. Among the survey's findings werethe following:

More than half-53.1 percentof thestudents had sexual intercourse at some time.Of these, 9 percent had initiated sexualintercourse before the age of 13.

3

Chapter 1

o An estimated 17.8 percent of students hadsexual intercourse with four or more sexualpartners during their lifetimes.

o Among the students, 6.9 percent reportedthat they had been pregnant or impregnatedsomeone.

o Of the currently sexually active students, 24.8percent reported that they had used alcoholor drugs prior to their last sexual intercourse(CDC, 1994).

Another drug use consequence related tosexual behavior is unwanted pregnancy. Eachyear, an estimated 4.9 percent of females underage 18nearly 200,000 young womengivebirth to a live infant (NIDA, 1996b). The livebirth rate among 18- to 24-year-olds is 34.7

percent (1.4 million women). Among both ofthese age groups, an estimated 12.4 percent usedalcohol, and 21.9 percent smoked cigarettes

during their pregnancies (NIDA, 1996b). Some5.7 percent used illicit drugs (marijuana orcocaine) while they were pregnant. The risks offetal alcohol syndrome, miscarriage, andrestricted fetal growth that accompanysubstance use during pregnancy result insubstantial economic and health costs each year.

The prevalence of early sexual activityamong adolescents emphasizes the need fortreatment programs to gather sexual historiesand to perform HIV and STD testing in thispopulation. Adolescents should beappropriately counseled about these tests,especially the implications of positive testresults. They should be assured that the resultswill remain strictly confidential (see Chapter 8for confidentiality issues).

Juvenile Delinquency and CrimeThe link between adolescent substance use andjuvenile delinquency is complex. There is astrong and consistent association betweenconduct disorder and substance use amongteenagers (Crowley and Riggs, 1995). Manyyoung people entering the juvenile justice

4

system have a host of problems ranging fromimpaired emotional, psychological, andeducational functioning to physical abuse,sexual victimization, and substance usedisorders (Dembo, 1996). A growing trend isthat most of the teenagers entering residentialtreatment for substance use disorders have beencriminally active and mandated to treatment bythe criminal justice system (Jainchill, 1997).

Drug testing data collected on male juvenilearrestees through the National Institute ofJustice (NIJ) confirm a strong and continuing

relationship between the extent of drug use andjuvenile crime (NIJ, 1997). An additional findingfrom the data is that the median positive rate formarijuana use among male juvenile arresteesincreased from 41 percent in 1995 to 52 percentin 1996.

Developmental ProblemsSubstance use can prevent an adolescent fromcompleting the developmental tasks ofadolescence, such as dating, marrying, bearingand raising children, establishing a career, andbuilding rewarding personal relationships(Havighurst, 1972; Baumrind and Moselle, 1985;Newcomb and Bent ler, 1989). Because

substance use changes the way people approachand experience interactions, the adolescent'spsychological and social development iscompromised, as is the formation of a strongself-identity. Adolescents' use of alcohol ordrugs may also hinder their emotional andintellectual growth. Some adolescents may usesubstances to compensate for a lack ofrewarding personal relationships. Instead ofdeveloping a sense of empowerment fromhealthy personal development, the substance-using adolescent is likely to acquire a superficialand false self-image as he becomes more deeplyentrenched in the drug experience (MacKenzie,

1993). Naturally, treating an adolescent withsubstance use disorders as early as possiblemaximizes the opportunity to stem these

32

initially short-term, but potentially long-term, ill

effects.

Treatment NeedsA recent study conducted by SAMHSA revealsthat treatment for substance use disorderssignificantly reduces substance use and criminalactivity (SAMHSA, 1998b). Administeringtreatment to adolescents, then, could greatlyprevent future substance use related-problemsas the adolescent transitions into adulthood.Understanding the relationship betweensubstance use and adolescent development iscrucial for designing effective interventions andtreatment strategies. Treatment efforts thatapproach young people as "little adults" arebound to fail. Rather, the treatment processmust incorporate the nuances of the adolescent'sexperienceincluding cognitive, emotional,moral, and social developmentso thattreatment providers can begin to grasp whysubstance use becomes a part of the identity of

these young people.Adolescence is a time when interpersonal

relationships are transformed and new cognitiveabilities emerge. The adolescent is for the firsttime forming an individual sense of self. Thepsychosocial changes associated with thepassage into adult society occur within thecontext of the significant physiological changesof puberty. Social relationships move from apredominant attachment to family to anincreased bonding and identification with peers.Teenagers also begin joining and identifyingwith institutions outside the familyschools,churches, Boy and Girl Scouts, political groups,and fan clubs. The extrafamilial bonding oftenhas a very pluralistic character, with peer groupsbeing only a visible and influential part.

Adherence to the family's values evolves intoindependent thinking and the development of apersonal belief and value system. Abstractthinking, propositional logic (the ability to form


hypotheses and consider possible solutions), andmetacognition (the ability to think about thethought process itself) are essential abilities thatdevelop during the adolescent years. It standsto reason that these cognitive functions are vital

to the process of establishing therapeuticrelationships between therapist and client, andfor the client to gain insight into the adversecourse of substance use, as well as to engage inbehavioral change strategies.

Not all young people who experiment withsubstances develop clinical problems. In fact,some degree of experimentation with drugs istechnically normative; that is, most adolescentshave tried alcohol or illicit drugs at least once bythe time they turn 18 (Johnston et al., 1995). Theformidable task faced by every adolescenttobecome an independent and responsible adultis undertaken with strategies that may includeexploration, experimentation, risk taking, limittesting, and questioning of established rules andsources of authority. Experimentation withsubstances may be among these usuallyfunctional strategies, despite the potential harmand hazard associated with this behavior.However, substance use can lead to an abusiveand addictive pattern that requires more active,firm, and constant intervention.

Risk Behaviors of AdolescentsIt is useful to consider substance use duringadolescence within the context of the more

general spectrum of risk behaviors that markthis developmental period. Problem behaviortheory provides a useful conceptual frameworkfor understanding risk behaviors during theadolescent period. Problem behavior theorydefines risk behavior as behavior that can

interfere with successful psychosocialdevelopment (e.g., having deviant peers),whereas problem behaviors are risk behaviors that

lead to either formal or informal social responsesdesigned to control them (e.g., substance use)(Jessor and Jessor, 1977). In other words, risk

33 5

Chapter 1

behaviors increase the adolescent's vulnerabilityto a problem, whereas problem behaviors incurconsequences, such as discipline at home orschool. As Jessor and his colleagues observed inseveral investigations, problem behaviors tendto cluster in an individual; for example, those

who experiment with substance use also tend toengage in risky sexual practices and illegalbehavior (Jessor, 1991).

Risk behaviors can become a "risk behaviorsyndrome" (Du Rant et al., 1995a, 1995b) in thatproblem behaviors serve a common social or

psychological developmental goal, such asseparating from parents, achieving adult status,or gaining peer acceptance. These behaviorsmay also help an adolescent cope with failure,boredom, social anxiety or isolation,unhappiness, rejection, and low self-esteem.One example of a risk behavior syndrome is anadolescent's reported use of substances as ameans of gaining social status and acceptancefrom peers and, at the same time, counteractingdysphoria and feelings of low self-worth.

Tailoring Treatment to AdolescentsAs noted above, treatment for adolescents withsubstance use disorders works best when it isprovided and implemented with their particularneeds and concerns in mind. In this TIP, theRevision Panel used a broad definition of

treatment. Treatment is defined as thoseactivities that might be undertaken to deal withproblem(s) associated with substanceinvolvement and with individuals manifesting asubstance use disorder. Although the Panelrecognizes that primary or secondary preventionof substance use is included in expandeddefinitions of treatment, the Panel limited thecontinuum of interventions to what istraditionally viewed as acute intervention,rehabilitation, and maintenance. The elementsof the continuum primarily reflect the treatmentphilosophies of providers, with less emphasis onsettings and modalities.

6

Regardless of which specific model is used intreating young people (e.g., 12-Step-basedprograms, family therapy, therapeuticcommunities), there are several points toremember when providing treatment foradolescents.

Adolescents must be approached differentlythan adults because of their uniquedevelopmental issues, differences in theirvalues and belief systems, and unique

environmental considerations (e.g., strongpeer influences).

Not all adolescents who use substances are,or will become, dependent. Programs andcounselors must be careful not toprematurely diagnose or label adolescents orotherwise pressure them to accept that theyhave a disease: This may do more harm thangood in the long run.

al Programs should be developed to take intoaccount the different developmental needsbased on the age of the adolescent; younger

adolescents have different needs than olderadolescents.

11 Some delay in normal cognitive and

social-emotional development is oftenassociated with substance use during theadolescent period (Newcomb and Bent ler,1989). Treatment for these adolescentsshould identify such delays and theirconnections to academic performance, self-esteem, and social considerations.In addition to age, treatment for adolescentsmust also take into account gender, ethnicity,

disability status, stage of readiness to change,and cultural background.Programs should make every effort toinvolve the adolescent client's family becauseof its possible role in the origins of the

problem and its importance as an agent ofchange in the adolescent's environment.

os Although it may be a necessity in certain

geographic areas where availability of youthtreatment programs is limited, using adult

34

programs for treating adolescents is ill-advised. If this must occur, it should be doneonly with great caution and with alertness tothe inherent complications that may threateneffective treatment for these young people.Many adolescents have explicitly orimplicitly been coerced into attendingtreatment. However, coercive pressure toseek treatment is not readily conducive to thebehavior change process. Consequently,treatment providers must be sensitive tomotivational barriers to change at the outsetof intervention. There are several strategiessuggested by Miller and Rollnick forencouraging reluctant clients to considerbehavioral change (Miller and Rollnick,1991). Figure 1-2 provides an overview ofseveral of these strategies.


The rest of this document guides providersthrough the process of treating adolescents withsubstance use disorders. Chapter 2 coversfactors to consider in making treatmentdecisions. Chapter 3 details the features ofsuccessful programs. Chapters 4, 5, and 6,respectively, introduce and describe thetreatment approaches used in 12-Step-basedprograms, in therapeutic communities, and infamily therapy. Chapter 7 discusses adolescentswith distinctive treatment needs, such ashomeless and runaway youth, youth withcoexisting disorders, and youth involved in thejuvenile justice system. Chapter 8 describes thelegal and ethical issues that relate to diagnosisand treatment of adolescents.

1 1 .. r- 7i 1 Figure

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Confrontation of denial approach Motivational interviewing approachHeavy emphasis on acceptance of self as having aproblem; acceptance of diagnosis seen as essentialfor change

De-emphasis on labels; acceptance of"alcoholism" or other labels seen as unnecessaryfor change to occur

Emphasis on personality pathology, which reducespersonal choice, judgment, and control

Emphasis on personal choice and responsibilityfor deciding future behavior

Therapist presents perceived evidence of problemsin an attempt to convince the client to accept thediagnosis

Therapist conducts objective evaluation, butfocuses on eliciting the client's own concerns

Resistance is seen as "denial," a trait characteristicrequiring confrontation

Resistance is seen as an interpersonal behaviorpattern influenced by the therapist's behavior

Resistance is met with argumentation andcorrection

Resistance is met with reflection

Goals of treatment and strategies for change areprescribed for the client by the therapist; client isseen as "in denial" and incapable of making sounddecisions

Treatment goals and change strategies arenegotiated between client and therapist, based ondata and acceptability; client's involvement inand acceptance of goals are seen as vital

Source: Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive

Behavior. New York: Guilford Press, 1991. p. 53. Reprinted with permission.

3v 7

ai o:ing T:eaAdolesce-At's

etermining the appropriate level oftreatment for an adolescent is no smalltask. In addition to factors normally

considered when placing an individual intreatment for a substance use disorder, such asseverity of substance use, cultural background,and presence of coexisting disorders, treatmentprograms must also examine other variablessuch as age, level of maturity, and family andpeer environment when working withadolescents. Once these factors are assessed andthe problems are understood, the treatmentprogram can then match the adolescent with theproper type of treatment.

Understanding tneProblem

The Severity ContinuumResearchers and treatment professionals havefound it useful to characterize adolescentsubstance use behavior on a continuum ofseverity. The Classification of Child and Adolescent

Mental Diagnoses in Primary Care (American

Academy of Pediatrics, 1996) views substanceuse disorders as occurring on a continuum thatextends from the developmental variation ofexperimentation with substances throughproblem use, to the disorders of abuse anddependence. The degree of substanceinvolvement is an important determinant of

-men-, r-o the-obem

treatment, as are any coexisting disorders, thefamily and peer environment, and theindividual's stage of mental and emotionaldevelopment. This information should be usedto refer to the appropriate treatment.

It is useful to consider a substance usecontinuum with these six anchor points (Knight,

in press):

Abstinence

Use: Minimal or experimental use withminimal consequencesAbuse: Regular use or abuse with several andmore severe consequencesAbuse/Dependence: Regular use over an

extended period with continued severeconsequences

El Recovery: Return to abstinence, with a relapsephase in which some adolescents cyclethrough the stages againSecondary abstinence

Treatment interventions fall along acontinuum that ranges from minimal outpatientcontacts to long-term residential treatment; alllevels of care should be considered in making anappropriate referral (see Figure 2-1). Anyresponse to an adolescent who is usingsubstances should be consistent with theseverity of involvement. Although no explicitguidelines exist, it stands to reason that the mostintensive treatment services should be devotedto youths who show signs of dependencythat

36

Chapter 2

FirguivTreatment S.At and the RFobil en) Sevetity Continuum

DecisionPoint

Short-termIntervention

SecondaryPrevention

ModeratelyIntensiveTreatment

DecisionPoint

I

IntensiveTreatment

Problem Severity Continuum

is, a history of regular and chronic use, with thepresence of multiple personal and socialconsequences and evidence of an inability tocontrol or stop using substances.

Factors AffectingTreatment Placement

Developmental StagesYouth treatment providers should be sensitive tothe developmental differences amongadolescents and make the necessary adjustmentsto accommodate such differences. Thetreatment of a 13-year-old should not beidentical to that of an 18-year-old. Figure 2-2,below, provides some general developmentalfeatures that tend to distinguish younger fromolder adolescents, as well as some guidelinespertaining to professional behavior and attitudesthat reflect these differences. This is an

10

adaptation of the Adolescent DevelopmentTable created by the Advisory Council ofAdolescent Health and the ColoradoDepartment of Public Health and Environment(1998).

EthnicityUnderstanding substance use and abstinencewithin the client's cultural context will flowmost naturally from a broad base of knowledgeabout the client. The provider will be betterprepared, however, with some specificinformation about that culture. First, theprovider should find out if the client's parentsare first generation immigrants. Anyintervention with a teenager from an immigrantfamily will be enhanced by the provider'sknowledge about the background of the youthand his family. Norms, values, and healthbeliefs may differ across cultures, and thesefactors can have a significant impact on

37

Tailoring Treatment

oi Vsqeig

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Early Adolescence

.-0- ,1

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Later Adolescence

Cognitive Concrete Thinking: More Abstract Thinking:Thinking ® Emphasizes immediate reactions

to behaviorGreater use of inductive/deductivereasoning

May not be fully aware of laterconsequences

More introspective and more sensitiveto later consequences

Task Areas Beginning rejection of parental ® Insistence on independence, privacy1. Family guidelines May have overt rebellion or sulky

independence Ambivalence about wishes withdrawal; limits are often tested(dependence/independence)

2. PeersSocial Most often "best" friend is same Dating, intense interest in opposite sex;and Sexual sex sexual experimentation normal

Boygirl fantasies; little if any Risk-taking commonsexual experimentation Need to please significant peers of

either sex heightens3. School and Structured school setting Beginning to identify skills, interests

Vacation preferred Starting part-time job

4. Self-Perception Emphasis on "Am I normal?" Conformitybehavior that meets peerIdentity Tendency to use denial ("It can't group valuesSocial

Responsibilityhappen to me") Some continue to pursue group/peer

acceptanceValues Some are able to reject group pressure

if not in self-interestProfessional Provide firm, direct support Be an objective sounding board (but letApproach Convey limitssimple concrete adolescents solve own problems)To retain sanity,

staff should echoices

Do not align with parents, but do ®

Negotiate choicesBe role model

® Like teenagers be an objective caring adult ® Don't get too much history ("grandioseUnderstand E Encourage transference (hero- stories")development

® Be flexibleo Keep a sense

[I,

worship)Sexual decisionsdirectlyencourage to wait 0

Confront gentlyabout consequences,responsibilitiesConsider "What gives them status in

of humor o Encourage parental presence in the eyes of peers?"clinic, but interview teen alone Use peer group sessions

o Adapt systems to crises, walk-ins,impulsiveness, testingEnsure confidentialityAllow teens to seek care independently

C111

Chapter 2

treatment; for example, people from somecultural groups may see therapy as invasive,and others may want the extended familyincluded in family therapy sessions.

Programs to which non-English speakers arereferred should be able to provide services in thelanguage of clients and their families. Thisincludes bilingual staff and written materials ontopics ranging from program policies tobibliotherapy (a self-learning procedure bywhich the client reads and studies appropriateself-help material). Cultural competence is farmore than bridging language barriers, however.Treatment settings and providers shouldincorporate cultural traditions (e.g., specialholidays) into their treatment regimens. Also,cultural concerns should be addressed in clinicalstaff meetings, through interagencycollaborations, and at all levels of theorganization in order to enhance culturalsensitivity and competence.

GenderMany gender-related factors have a bearing onthe extent of the adolescent's involvement intreatment and on the treatment approach that ismost likely to be effective and appropriate.Adolescent females, for example, may needmore attention in regard to family problems; ithas been found empirically that femaleadolescent substance users have oftenexperienced severe parental rejection and sexualor physical abuse (Gross and Mc Caul,1990-1991). Family dysfunction, therefore, maybe a more critical component and indicator ofsubstance use disorders in adolescent femalesand may require more attention in treatment.Females also often need highly specializedservices, such as those for pregnant andparenting young women. Intervention fordomestic abuse also may be required forfemales.

12

Coexisting DisordersA coexisting disorder (also called a dual diagnosis)

most commonly refers to the coexistence of asubstance use disorder and a psychiatricdisorder. Adolescents with substance usedisorders are much more likely than theirabstinent peers to have such psychiatricdisorders (Kleinman et al., 1990; NationalInstitute on Drug Abuse [NIDA], 1998). Thebehavioral or mental conditions of childhoodmost often associated with substance usedisorders are conduct and oppositionaldisorders, attention deficit/hyperactivitydisorder (AD/HD), affective disorders (unipolarand bipolar depression), and anxiety disorders,including posttraumatic stress syndrome fromsexual or physical abuse (NIDA, 1998).

There is growing evidence that the presenceof conduct and oppositional disorders inchildhood are particularly predictive of lateradolescent substance use (Crowley and Riggs,1995). Also, the coexistence of more than onechildhood psychiatric disorder greatly enhancesthe risk for later substance use. In particular, thecoexistence of externalizing (behavioral) andinternalizing (emotional) disorders constitutes ahigh risk for substance use (NIDA, 1998). Otherdisorders associated with a higher risk forsubstance use include learning disorders(Latimer et al., 1997) and eating disorders(Harrison and Hoffman, 1989). A completeassessmentincluding a lifetime diagnosticevaluation, treatment trials, and clinical progressover timewill help to establish whether anadolescent has such a disorder in addition to thesubstance use disorder.

Coexisting disorders can interfere withtreatment for substance use disorders, and ifthey are left untreated, the client is morevulnerable to relapse. The ability of treatmentstaff members to identify and either treat these

39

disorders or provide appropriate referrals fortreatment can help guard against this possibility.For example, a consultant may be needed toconduct mental health assessments and toevaluate the need for pharmacotherapy, and theadolescent may be referred to an outpatientmental health program. It is important for staffmembers to be aware of the distinctive problemsof the young person who is diagnosed withsubstance use and other disorders. It is vital forthe treatment team to perform the functions ofgathering and sharing clinical data, formulatinga diagnosis, and planning intervention for theseclients with coexisting disorders.

To treat adolescents with coexistingdisorders, substance use disorder treatmentproviders and mental health providers mustdevelop programs together and ensure that staffmembers are cross-trained. Each program canmaintain its individuality, but services should beprovided in one location and arrangementsmade to accommodate each program'srequirements (see Chapter 7 for more discussionon youths with coexisting disorders).

PharmacotherapyWhen treating adolescents with coexistingdisorders, it is paramount for programs toconsider the client's need for appropriatemedication. For example, substance usedisorder treatment facilities should suspend"no-medication" rules for depressed adolescentswho have been prescribed antidepressants. Ofcourse, medication, whether for detoxification orthe treatment of psychiatric disorders, must beprescribed and dispensed under the direction ofa physician. It is recommended that youths withcoexisting disorders receive supplementalcounseling regarding their psychiatricmedication. Discontinuation of any medicationis a decision that should be made only inconsultation with a medical doctor. Abruptdiscontinuation of certain psychotropicmedications can be extremely dangerous.However, if the patient continues to use illicit

Tailoring Treatment

substances, the medication regimen should bereassessed. The relative risks and benefits of atemporary discontinuation of pharmacotherapy(until abstinence is achieved) should be carefullyconsidered.

The use of stimulant medication (forAD/HD) or minor tranquilizers (for anxietydisorders) is still controversial for adolescentswith substance use disorders. Some of thesemedications have significant potential foraddiction or abuse. Nonaddictive medications,as well as behavioral and psychotherapeuticinterventions, should be considered beforemedications with the potential for addiction orabuse are prescribed. For cases in which thesemedicines must be used, regular urine testingfor substances of abuse, and/or serologicaldetermination of therapeutic drug levels, isusually indicated.

Family FactorsThe risk of adolescent health and behavioralproblems, including substance use disorders,rises with lack of parenting skills, high levels offamily conflict, and poor bonding betweenparents and children. Recent national data ofadolescent health identified the importance ofconnectedness to parents and family as a keyfactor that protects adolescents, in a cross-cutting manner, from many problem behaviors,including substance use (Resnick et al., 1997).When parents have unclear expectations of theirchildren's behavior, apply disciplineinconsistently, or fail to reward their children forpositive or desirable behavior, their children'srisk for substance use disorders increases. Bothpermissiveness and excessively harsh parentingpractices can lay the groundwork for adolescentbehavioral problems and substance usedisorders (Patterson, 1982).

An adolescent's family also provides acrucial background to the child's substance usefor reasons both genetic and environmental.Children of parents with substance use

40 13

Chapter 2

disorders are at increased risk of developingsubstance use disorders themselves comparedwith children with nonsubstance-abusingparents (Cotton, 1979; McGue et al., 1992;

Schuckit, 1987). An assessment of the family'shistory of substance use will provide someinsights into the possible role of genetic factorsin the family lineage. Perhaps even morerelevant to the adolescent patient's immediateconcern is the need to evaluate the familyenvironment for risk and protective factors thatpertain to substance use. Salient environmentalfactors include parental modeling of substanceuse behaviors, permissive parental attitudestoward substance use, and substance use bysiblings (Hawkins and Fitzgibbon, 1993).

Clinicians working with adolescents withsubstance use disorders should consider thedegree of stability and commitment in thepatient's family in determining the mostappropriate treatment type and approach foreach individual. Ideally, the family should beinvolved in all phases of the adolescent'streatment, but in families characterized byextreme instability, conflict, physical or sexualabuse, and/or domestic violence, this may notbe possible or even advisable. It is important forproviders to remember that "family" mayinclude a broad spectrum of members, such asgrandparents, older siblings, and foster parents.

Social and Community FactorsSchool life, peer influences, the community, andthe media may also exert an influence on theadolescent's risk to initiate and maintainsubstance use (Newcomb and Bent ler, 1989).

Understanding their influences on an individualcan help a service provider pinpoint areas ofintervention relevant to the client's recovery.

Peer influencesAssociation with peers who use alcohol and/orillicit drugs, including involvement in gangs, is avery prominent risk factor associated withadolescent substance use (Winters et al., in

14

press). Adolescents in cohesive peer groupsmake substances available to each other,substance use is modeled by friends in thegroup, and peer group support and norms favorsubstance use (Oetting and Beavais, 1986). Also,because the role of substance use and otherdelinquency behaviors may influence theselection of friends, it is possible that substanceuse behavior may contribute to selecting peerswho are delinquent and happen to already beusing alcohol and/or illicit drugs as well (Farrelland Danish, 1993).

Environmental influencesThe socioeconomic level of a young person'scommunity is one important determinant for hisrisk of substance use. Rates of substance use arehigher in areas where alcohol and/or illicitdrugs are more easily available and where localnorms are more tolerant of their use. Substanceuse in these areas is also more likely to beassociated with crime. In addition, positive rolemodels for young people are often scarce orlacking. Not surprisingly, youths who identifywith individuals engaging in substance use andcriminal activities are more likely to engage inthese activities themselves. Youths who growup in communities where there is little or nosocial cohesiveness and attachment, a highpopulation density, and disorganizedneighborhoods are at greater risk of usingalcohol and illicit drugs, as well as developingother behavioral problems (Hawkins andFitzgibbon, 1993).

School factorsNo relationship has been found betweenintelligence level and the risk of substance use.Performance in school, however, does affect thisrisk (Friedman et al., 1985). Academic failurebeginning in the late elementary gradesincreases the likelihood that substance use willdevelop in adolescence (Hawkins et al., 1992).

This is true regardless of whether academicfailure stems from learning or behavioral

41

disorders, family conflict, or poor educationalquality. Lack of success and academiccommitment, as evidenced by problems such astruancy and insufficient time spent onhomework, is predictive of later substance use,which in turn increases the risk of substanceabuse (Newcomb and Bent ler, 1989).

The Continuum ofTreatmentThe various types of treatment approaches foradolescents with substance use disorders aredescribed in detail in upcoming chapters.Regardless of the modality or the setting inwhich it takes place, treatment can be seen astaking place on a continuum starting withoutreach, screening, and assessment to identifyyouths who are at risk or who are alreadyengaging in substance use. It continues throughthe stages of counseling and treatment tocontinuing care and support to reinforceabstinence.

Linking Assessment andTreatment PlacementThe variety of options for the treatment ofsubstance use disordersoutpatient, inpatient,and residential, as well as services that supportindependent livingcan be subdivided intospecific services for adolescents with substanceuse disorders. These services can be viewed as acontinuum ranging from pretreatment servicesfor at-risk adolescents and those in the earlyphases of substance use to more intensivetreatment for youths already having substanceuse disorders.

The differences among these levels oftreatment are both qualitative and quantitative;that is, the variation in intensity of service is

only one aspect of the continuum. Treatmentprograms also may differ considerably in theirindividual philosophies and approaches totreatment, in the treatment components they

Tailoring Treatment

offer, and in the types of professionalsemployed. Regardless of the specific elements,any program's services must match the needs ofthe adolescents it intends to serve, and the levelsof treatment and service options must respondto the internal and environmental realities of at-risk or substance-using adolescents. To that end,the original Consensus Panel developed thecontinuum shown in Figure 2-3, Client Assess-ment Criteria, bearing the following in mind:

m Levels of treatment and service options mustrespond to the internal and environmentalrealities of an adolescent who is at risk for orwho already has a substance use disorder.

IN The table must be comprehensible to-treatment providers with different levels of

clinical sophistication.m The table must be internally consistent and

reliable in making placement decisions.

In the model presented in Figure 2-3, thefollowing assessment criteria can be used todetermine the level and type of service that ismost appropriate for each individual. Forexample, assessment of an adolescent's recentsubstance use might indicate that she has atoxicity level that requires more than outpatientmedical management but is not severe enoughto require life support and intensive medication.This would suggest that the adolescent requirescare as a medically monitored inpatient. On theother hand, her emotional well-being mightreveal a great deal of distress, requiring 24-hourcontinuous psychiatric monitoring. Thefollowing areas can be evaluated in order toarrive at appropriate treatment placementdecisions:

® Use pattern: Pressure of consequences andproblems resulting from substance use, andlevel and recency of substance consumption

o Medical concerns: Toxicity, withdrawal, andother medical sequelae resulting fromsubstance use, as well as medical problems

4 215

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5152

unrelated to substance use, such aspregnancy, HIV/AIDS, domestic violence,and child abuse and neglectIntrapersonalCognitive: Substance-inducedimpairment in cognition and thinking, both

chronic and acute, including neurologicaldeficits as well as memory problems such asblackouts, short-term memory deficits, and

poor concentrationIntrapersonalEmotional: Emotionalfunctioning, which may range from aninability to experience emotions to extremely

negative emotional statesInterpersonalSocial: Interpersonalrelationships, social development, and socialconcerns such as employment, family,friends, and legal mattersEnvironmental: External influences, including

living conditions, housing, gang influence,

and family and school influences

The continuum of treatment underscores theimportance of understanding all of the factors

that bear on the adolescent's substance use.These factors must be included in acomprehensive assessment, which must in turn

incorporate information collected from the

adolescent's self-report, standardizedassessments, reports from family members, and

other collateral sources of information wheneverpossible in order to obtain a complete picture ofthe adolescent's social and environmental

situation.

Placement GuidelinesThe following guidelines indicate how thecontinuum can be used in making a decisionregarding the placement of the adolescent. TheRevision Panel created the guidelines based on

clinical experience.

In making placement decisions, practitionersshould choose the most intensive level of careindicated by any single assessment criterion.

Tailoring Treatment

For example, an adolescent who is notcurrently using substances but who isactively psychotic would require inpatient

treatment.When an assessment indicates the need for aparticular level of care that is not available, itis desirable to refer the adolescent to the nexthigher level of care, unless the assessmentindicates that such a placement would becounterproductive. For example, if intensiveoutpatient treatment is indicated butunavailable, day treatment should be thenext recommendation, unless it iscontraindicated. Naturally, a higher level of

care may not be practical or available.Assessment is an ongoing process. Decisionsabout level of care should be based on theadolescent's progress and changes in hisenvironment. Clients should have theopportunity to move back and forth acrossthe level-of-care continuum on the basis of

changes in these factors.There is as much, if not more, variabilityamong treatment programs within a single

intensity level as there is across treatmentintensity levels. The assessor shouldincorporate this understanding when makingplacement decisions. Assessors should havean indepth knowledge of available services

and the intensity of any particular treatment

or service option.The assessment criteria shown in Figure 2-3are interrelated and can be viewed togetheras an integrated system. This point isimportant in considering the mostappropriate treatment level and the ability ofthe adolescent to move along the level-of-care continuum as treatment progresses orregresses. Prior to each program change,

indepth reassessment must be completed inorder to update information on the client'sstatus and to obtain a current clinical picture

of his situation.

5321

Chapter 2

The American Society for AddictionMedicine is also in the process of developingplacement guidelines for adolescents withsubstance use disorders.

Levels of Treatment

Outpatient treatmentOutpatient services provide a broad range ofintensity-of-care levels without overnightaccommodation. Some of these levels may beused subsequent to inpatient treatment. It iscommon for some levels of outpatientcounseling to implement the same treatmentstrategies as in inpatient counseling. Outpatientcounseling as a treatment option is composed ofsublevels of treatment characterized byincreasing levels of intensity.

Brief interventionBrief intervention generally takes less time than

more formal treatment approaches. It is usuallydelivered by nonspecialists or paraprofessionals,emphasizes self-help and self-management,reaches large numbers of individuals, and isconsiderably less expensive than conventionaltreatment. Brief interventions, notably thosebased on motivational enhancement theory,have proven successful with adult alcohol users(Institute of Medicine, 1990; see also Rollnick etal., 1992; Miller et al., 1993). Typically, a briefintervention would include brief screening,anticipatory guidance, and psychoeducationalinterventions. This option is primarilyappropriate for adolescents in the low-to-middlerange of the severity continuum (experimental,

regular, and problem use). This approach hasalso been demonstrated to be very effective inthe emergency medical care setting by

significantly increasing the likelihood that clientswill keep followup appointments for subsequenttreatment (CSAT, 1995a). See the forthcomingTIP, Brief Interventions and Brief Therapies for

Substance Use Disorder Treatment, for a

description of brief interventions and therapies

22

that can be used in various treatment settings(CSAT, in press).

Intervention in primary care settingsWithin the health care sector, there is a growinginterest in primary care providers to practicebrief interventions. Primary care providers arewell situated to practice primary prevention ofsubstance use disorders and to intervene whenthey suspect the possibility of substance use byadolescents under their care for other medicalproblems. The developmental model ofsubstance use disorder progression,diagrammed in Figure 2-1, is useful forunderstanding the development of substanceuse disorders in teenagers and the type ofintervention that is most appropriate at eachstage.

The time pressure in a managed careenvironment makes many primary carephysicians reluctant to screen for substance usealthough health care guidelines recommend

screening every adolescent patient for substanceuse disorders as part of routine medical care.

Screening and intervention can be done inminutesfor example, during an office visitusing any of a number of screening instrumentsdesigned for adolescents (see the companion TIP32, Screening and Assessing Adolescents for

Substance Use Disorders [CSAT, 19991).

In geographic areas where substance use ishighly prevalent, it is often useful to bringsubstance abuse counselors in routinely to meetwith adolescents as part of the screening. Theseworkers can establish a rapport with youngpatients and can arrange subsequent meetingswith those who screen positively for problems.This approach helps to bridge the gap betweenprimary care and substance use disorder

treatment programs, where the risk of losingpatients to followup is greatest, and obviates theneed to make referrals to a treatment center.

When substance use disorders are identifiedin an adolescent patient by a primary careprovider, it is important to make the connection

to a treatment program as quickly and directlyas possible. Resources can be mobilized moreimmediately by having an established contact

with a substance use disorder treatmentprovider who is willing to call or meet withadolescents, or even to visit those admitted toinpatient treatment. Making a direct andimmediate contact with a treatment provider ishighly preferable to merely giving an adolescentpatient a referral card, name, or phone number,none of which may ever be used. However,making direct contact with a treatment providerrequires the consent of the adolescent and mayalso require the consent of the parent. SeeChapter 8 for information on legal and consentissues.

Physicians treating adolescents shouldbecome familiar with treatment resources in thecommunity and their approaches to treatment.Programs vary in intensity and philosophy, butabstinence is normally the goal; it will also helpif the physician is familiar with severaltherapeutic communities that may be available,

even if they are a distance away (Knight, 1997):The physician can recommend that the

parents take part in treatment with the youth.Individual and family counseling may beneeded, and the physician can refer the parentsand youth to child-centered support groups,such as Alateen and Alatot. Also, if parentshave a substance use disorder, they should bereferred for an assessment.

The physician should also inform the patientthat she will continue to check the patient'sprogress in future visits and encourage theyouth to discuss any substance use problemswith her. Formal treatment interventions aregenerally indicated for adolescents who haveprogressed to abuse or dependency. Suchproblem users require more than a briefintervention during an office visit, and should bereferred to a substance use disorder treatmentspecialist. The bottom line is that primary carestaff members should be encouraged to consult

Tailoring Treatment

with substance use disorder professionals abouthow they might best support treatment duringongoing contact with adolescents being seen forprimary care. For a further discussion on briefinterventions in primary care settings, see TIP

24, A Guide to Substance Abuse Services for Primary

Care Clinicians (CSAT, 1997).

Outpatient counselingOutpatient counseling includes professionallydirected evaluation and treatment typically forfewer than 9 hours per week in regularlyscheduled sessions. In less intensive programs,2 to 3 hours per week is common. Nonintensiveoutpatient treatment also may address relatedpsychiatric, emotional, and social concerns.Intensive outpatient programs may be after-school or evening programs, often include someweekend programming, and may involve 9 to 20

hours of treatment per week.

Day treatment or partial hospitalizationDay treatment programs, sometimes referred toas partial hospitalization, provide professionallydirected evaluation and treatment in astructured program. This is the most intensiveof the outpatient treatment options and can beused for adolescents who demonstrate thegreatest degree of dysfunction but do notrequire inpatient treatment. Day treatment mayrange from several hours per week to morefocused and directed sessions for up to 5 days a

week. Sessions may take place after school, inthe evenings, or on weekends. The treatmentprovided may be some combination ofindividual, group, and family therapy.

Inpatient treatmentInpatient treatment may include 24-hourintensive medical, psychiatric, and/orpsychosocial treatment and residential care. Thelevels of the residential care continuum includea high level of supervision by professional staffmembers at the most intensive end and grouphome living with minimal professional

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involvement or supervision at the least intensiveend.

DetoxificationDetoxification generally refers to a 3- to 5-dayinpatient program with 24-hour intensivemedical monitoring and management ofwithdrawal symptoms. Although physiologicalwithdrawal symptoms are uncommon amongadolescents, this level of care may be mandatedby psychosocial circumstances, personalcharacteristics, or a history of using significantamounts of a substance associated with life-

threatening withdrawal symptoms (e.g.,benzodiazepines, barbiturates, heavy chronicalcohol use). Detoxification should bemonitored by appropriately trained personnelunder the direction of a physician or otherpersonnel with specific expertise in managementof addiction and abstinence syndromes. It isappropriate for adolescents with multipleproblems, including those who need habilitationor with coexisting personality and substance usedisorders. See Appendix B for information onmedical management of substance usedisorders.

Residential treatmentResidential treatment is a long-term treatmentmodel that includes psychosocial rehabilitationamong its goals. It may be directed by

physicians or other professionals, and it isappropriate for adolescents with multipleproblems, especially those with coexistingpersonality and substance use disorders. Theduration of residential treatment can range from30 days to as much as 1 year in some cases (as inthe case of therapeutic communities), although

managed care requirements continue to chipaway at the maximum length of treatmentallowed.

Continuing CareThe period right after completion of a treatmentprogram, when the youth returns to family,

24

peers, and the neighborhood, is often the time ofgreatest risk for relapse. It is for this reason thatall forms of treatment should include someprovision for continuing care. A continuing careprogram often takes the form of a structuredand time-limited outpatient program andplanning process that can provide ongoingsupport to the adolescent. Many continuing careprograms have specialized groups that focus onmaking the transition from intensive treatmentto a lower level of care.

Most treatment programs also havespecialized groups for relapse prevention.Having a history of relapse is common foradolescents in treatment for substance usedisorders (Hoffman et al., 1993). If an

adolescent in treatment experiences relapse, it isbest viewed not as a failure of the treatment orthe client, but rather as a common part of the

early recovery process that needs to be factoredinto the treatment plan. As in chronic physicaldiseases such as leukemia or diabetes, relapse isan indication not for punishment ordiscontinuation of treatment, but for additionalor intensified treatment. Relapse (or the lesserversion known as a minor slip or lapse) shouldbe viewed by treatment professionals as anopportunity for learning; for example, it canhelp teach young people that they do not havecontrol over their substance use.

Because an adolescent who has relapsed inthe past is at greater risk for further relapses, itis important to evaluate those factors that areprecipitants for relapse and to adjust treatmentaccordingly. An adolescent's coping style (i.e.,the use of skills gained through treatment) and

social resources are among the known protectivefactors for alcohol relapse (Brown, 1993).

Self-help and peer support groupsSelf-help groups such as Alcoholics Anonymous(AA), Narcotics Anonymous (NA), Al-Anon,and Alateen are valuable adjuncts to outpatientservices and residential programs for teenagersduring the recovery process, both during and

P. El

after primary treatment. Self-help groups offerpositive role models, new friends who arelearning to enjoy life free from substance use,people celebrating sober living, and a place tolearn how to cope with stress and other relapsetriggers. Teenagers should ideally be referred toyouth-oriented groups, led by responsibleindividuals, with a membership that isappropriate for the-age, gender, and culture ofthe client (see Chapter 4).

Group homesSometimes referred to as halfway houses orindependent living, group home living is atransitional living arrangement with differentlevels of specificity of treatment planning andstaff supervision. Residents may work and/orreceive educational or training services ortreatment outside the group home. Houseresponsibilities are shared, and the youths are

Tailoring Treatment

involved in the house governance. Therapeuticfoster home placements, a type of group home,involve a small group of adolescents beingplaced in a family situation, often with fosterparents, who themselves may be recoveringfrom substance use disorders.

"Booster" sessionsIn the cognitivebehavioral model of treatment,recovering adolescents periodically return to thetreatment program to meet with clinicians andreview their skills for relapse prevention,self-management, and independent living.Recommendations and supportive andencouraging feedback are provided during thesemonitoring sessions. Consistent with the needfor continuing care, booster sessions, oftenknown as aftercare sessions, are important forany treatment experience.

5" 25

3 General ProgramCharacteristics

The previous chapter examined the rangeof substance use disorders and relatedproblems seen in adolescents. The

chapter then applied those factors to treatmentplacement decisions. This chapter discusseshow individual program components can bestmeet the needs of adolescent clients. Programdesign and administration, treatmentcomponents, client services, and a program'scollaborative relationships are importantconsiderations for practitioners or other staffmembers who are treating adolescents orreferring them to an outpatient treatmentsetting.

Scope and ApproachA program's design, policy, evaluation, andlegal approach are shaped by its underlyingphilosophiesthe core values and beliefs fromwhich treatment decisions arise. Mapping outthese program features can provide a strong andflexible framework for providing services thatare implemented smoothly and effectively andyet are individualized to meet each client'sneeds. Much of this information shows up in aprogram's policy and procedures manual.

Although a program's funding and scopelimit the number and depth of treatmentcomponents a program can provide, it is vitalthat the most critical components be identifiedand implemented with skill and timeliness. In

addition, expectations for successfullycompleting treatment should be as clear and asobjective as possible.

Policies and Procedures ManualA program's policies and procedures manualprovides guidelines for program operation. Italso serves as a reference book for Federal, State,and local laws and regulations and forrequirements for contract compliance. Statelicensing requirements may also includeobligatory standards about what goes in a policyand procedures manual. Both the program staffand clients are protected by these regulations,which may include the following:

A program mission statement identifyingunderlying program principles, including theprogram's commitment to a drug-freeworkplace

a Confidentiality procedures for clients as wellas the staff

em Documentation guidelines and requirementsfor client charts, including reportingrequirements for sexual and physical abuseand suicidal and violent behavior

m Personnel policies that describeHiring, firing, and disciplinaryprocedures, including the hiring of staffwith histories of certain categories offelonies and misdemeanorsUse of staff members who are in recovery

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28

Substance use regulations for staffmembersProfessional standards and behaviorEmployee benefits and grievanceproceduresDrug testing and fingerprintingproceduresRules governing relationships withcurrent or former clientsEmployee assistance programsRole of employee unions or boards ofdirectorsMalpractice coverage

Policies concerning critical incidents, such asinvoluntary commitment, emergencyprocedures (e.g., suicide, violence), andinappropriate behavior (e.g., drug use)during treatment

In addition, HIV guidelines and staff trainingshould describe the universal precautionsrecommended by the Centers for DiseaseControl and Prevention, specify who shouldknow the HIV status of clients and familymembers, and outline the policies andprocedures for HIV testing of clients and staffmembers. Programs may wish to designate astaff person as the AIDS trainer. This traininghelps to raise awareness of the HIV- related

needs and concerns of adolescents. Also,guidelines should address precautions abouthepatitis B and C and tuberculosis. Some strainsof hepatitis are easily transmitted and may bemore prevalent than HIV in certaincommunities. Hepatitis B vaccinations may beconsidered for at-risk staff members withsignificant client contact.

StaffingStaffing decisions are best made with attentionto program needs, job descriptions, andeducational and experiential requirements foreach position. It also must be determined which

53

services will be provided on site by programpersonnel and which are to be provided byarrangement with an external agency, program,or professional. If volunteers or interns are to bean integral part of the program, specific policiesmust be established regarding their supervision,training, and responsibilities.

Staff-members should represent the culturaldiversity of the program's client population. Inaddition, the facility's forms, books, videos, andother materials should reflect the culture andlanguage of the clientele. Innovative andintensive continuing education, staffdevelopment, and outreach efforts during staffrecruitment may be needed to improve culturalcompetence among staff. If a significant part ofthe client population is non-English-speaking, atleast one staff member should be bilingual andbicultural. Cultural differences should beaddressed in clinical staff meetings, throughinteragency collaborations, and at all levels ofthe organization, with the goal of enhancingcultural sensitivity and cultural competence. Forindividuals with disabilities, the AmericansWith Disabilities Act of 1990 requires treatmentfacilities to be accessible to all clients, which maymean having a sign language interpreter andother specially trained personnel on staff. Formore information on treating people withdisabilities and coexisting disorders, see TIP 29,Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities (CSAT, 1998).

Core StaffThe type of program and the range of servicesoffered within a program determine treatmentstaffing patterns. The following positionsshould comprise a core staff:

Program or clinical supervisorSubstance use disorder counselors

m Therapists (preferably at a master's levelwith a certification in substance abusetreatment)

The essential roles of core staff include

m Intakem Screeningm Assessment (including a cultural assessment)El Case management, including treatment

planning and crisis interventionSubstance use disorder treatment(individual, group, family)

m Providing specialized education on topicssuch as understanding substance use, HIVinfection and AIDS, and other sexuallytransmitted diseases (STDs)

m Planning continuing care and treatmentm Record keeping and report writing

Optional StaffAs the intensity of the treatment increases,programs may require additional personnel.These professionals may be hired as part-timestaff members or as consultants, or they may beprovided by contract or through referral. Theyinclude:

PsychiatristsPediatricians, adolescent medicinespecialists, internal medicine specialists,and/or family practitionersPsychologists

Nursesm Recreational therapists (leading activities in

art, music, drama, wilderness outings, etc.)Occupational therapistsDisabilities specialists, including signlanguage interpretersOutreach workers

m Home intervention workersm Continuing care workers

Cultural advisors or spiritual leadersStudents, interns, and fellows (from localcolleges and universities)

® Vocational specialistsm Case managers

General Program Characteristics

Skills DevelopmentThe complexities of an adolescent's needs andconcerns require that the clinical staff besupervised. However, high-level skill orexpertise may not be necessary for"all staffmembers in all areas. Most important isregularly scheduled training that occursperiodically throughout the year. This is greatlypreferable to ad hoc training presented toaddress crises or acute situations. Training onspecialty topics should be available in thefollowing areas:

Changes in diagnostic criteria for substanceuse disorders (e.g., DSM-IV criteria)

New substance use disorder treatmentapproaches specific to adolescents and theirfamiliesFamily dynamics and family therapyAdolescent growth and developmentSexual and physical abuseGender issues, including gender and sexualidentities (e.g., gay, lesbian, transgender)Mental health problems (particularlydepression, anxiety disorders, and conductdisorders)Awareness of different cultural and ethnicvaluesRecreational and prosocial activitiesPsychopharmacologyGroup dynamics and group therapySuicidal behaviorGrief and lossReferral and community resourcesManagement of oppositional and violentbehaviorsCognitive impairments (learning disabilities,cognitive disorders, and organic mentaldisorders)Legal matters (custody and juvenile justiceconcerns, child abuse and neglect reportingrequirements, and duty-to-warn issues)

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Chapter 3

Treatment planning and documentationHIV/AIDSOther health matters (STDs, tuberculosis,hepatitis, nutrition)GangsDrug dealing

Staff Members in RecoveryTreatment programs often use recoveringsubstance abusers as staff members. Staffmembers who are themselves in recovery canoffer unique hope, role modeling, and insightinto dependency, addiction, and recovery.When recovering individuals are hired, theyshould have the same level of expertise andtraining required of other staff members in thesame position. Recovering individuals musthave clear evidence of at least 2 to 5 years ofrecovery demonstrated by regular attendance at12-Step meetings, a current sponsor, andcontinuous abstinence from substances otherthan those prescribed by a physician.

Certification and CredentialsEach State has different requirements for thecertification of substance abuse counselors.Certification is available in many disciplines; forexample, a nurse can be certified in chemicaldependency, and a physician can become acertified addictions specialist. Recordsdocumenting these credentials are necessary.Programs should encourage all staff members tobecome certified and support their continuingeducation efforts to enhance their clinicalcompetence in their specialty.

Supervision and EvaluationA supervisory review of each staff member'sperformance should be conducted on a regularbasis. Opportunities for self-evaluation andfeedback from other staff and team members canbe included in the evaluation process. Theprogram's manual on policies and proceduresshould specify how the program deals with staff

30

turnover, burnout, relapse, and related staffproblems, as well as specific procedures for staffreviews.

Supervision should include training staff onprogram procedures and policies, developingclinical skills, monitoring performance andproviding feedback, identifying clinicallimitations, addressing transference andcountertransference (such as relationships andidentification between the adolescent andtreatment personnel), and dealing with staffconcerns.

Perspectives onCounseling YouthUnderstanding how adolescents perceive andreact to treatment is crucial in developingappropriate counseling techniques to addresstheir substance use. Treating an adolescent likean adult will likely result in failurecounselingadolescents requires sensitive yet firmapproaches. An adolescent treatment programshould have explicit and impartiallyadministered standards for behavior. It shouldemphasize treatment of every participant in apersonal, respectful, and hopeful manner. Theprogram staff should maintain an optimistictone and be dedicated to serving and helping itsclients, while exercising authority withoutseeming authoritarian. The staff should alsoensure that every participant is protected frompossible harassment, such as teasing and hazing,by other program clients. When youths do notabide by the treatment program guidelines, theymust be held responsible for their conduct, butin a manner that avoids a confrontational styleor indicators of mistrust. It is also importantthat youth be helped in fulfilling theirresponsibilities in a way that would typically beinappropriate for adults. For example, if anadolescent does not show up on time for anoutpatient program, he should be calledimmediately and reminded to attend.

61

Program ComponentsMany adolescent treatment programs,regardless of their therapeutic orientation,include significant shared components, some ofwhich are described below. The level ofintensity of these components will varyconsiderably in outpatient and residentialtreatment.

OrientationThis initial stage in treatment is very importantto the adolescent. Many new activities may bethreatening to the adolescent, and coming intotreatment can intensify feelings of fear and self-

consciousness. Moreover, adolescentsfrequently have incomplete and inaccurateinformation about the nature of substance usedisorders and treatment programs. The clientmay have heard that very negative thingshappen in treatment and that "people really geton your case." The awkwardness experiencedby adolescents may also be intensified. Duringadolescence, many situations can increase ayoung person's anxiety level. Anxiety can beacted out in many negative ways, includingleaving or running away from the program.Sometimes, the acting-out behavior is sodisruptive that the client may have to bedischarged by the staff. Thus, it is importantthat the orientation to treatment be structured toprovide relief from anxiety.

One main component of orientation isexplaining to adolescents what treatment is, as

well as what it is not, in a nonconfrontationalstyle and tone. If the youth has a mistakennotion about the nature of treatment, thechances for treatment success may be lowered.Young people come into treatment with manydifferent expectations. It will help theadolescent to know the meanings of such termsas chemical dependency, expectations, and

unmanageableness. But definitions must be clear

and not too abstract, given that some


adolescents may be unable to grasp complex

concepts.Orientation also provides an opportunity to

clarify the adolescent's role. Videos of activitiesto be experienced in treatment can be shown.Orientation should include the concept ofprogram expectations. This term is preferable tothe term rules, which implies staff dictates orcommands (Winters and Schiks, 1989). Havingexpectations implies ownership by the client andpromotes responsibility from him.Communication of essential principles andexpectations can start during orientation andcontinue throughout the treatment process.

Daily Scheduled ActivitiesMost adolescents who require treatment forsubstance use disorders have been preoccupiedwith the use of substances to the exclusion ofparticipation in positive recreational activitiesand the development of basic living skills.When the substance use is removed, they maynot know how to use their time appropriately.A prescribed daily schedule of school, chores,homework, and especially recreation cansignificantly help with this relearning process.In outpatient programs, staff members can workwith adolescents and their families to scheduleactivities for the client during the hours awayfrom treatment; in residential programs,scheduling can be more elaborate. A fullschedule with many different group activitieshas been shown to work well with adolescents(Winters and Schiks, 1989).

Adolescents who have centered their leisuretime on the use of substances may resist learningnew skills and often equate staying clean withboredom. Youths who engage in thrill-seeking

behaviors by using rock cocaine seem especiallysusceptible to anhedonia, an inability toexperience pleasure, because of the boredomthat sets in afterward. Encouraging theadolescent client to take advantage ofcommunity recreational resources and to

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Chapter 3

develop socially appropriate recreational habitswill help ensure that she remains soberfollowing treatment. Adolescent treatmentprograms can provide many recreationalopportunities to their clients with relatively littleexpense. For example, a program mightestablish an athletic period during which it takesgroups of youths to the local "Y" to playbasketball. Chess, ping pong, computer games,and other sports and games can be provided atthe treatment site.

Peer MonitoringGiven the important influence of peers on anadolescent's behavior and attitudes, it stands toreason that pressure from peers often keeps theclient from achieving treatment goals. Althoughthis pressure occurs in social times rather thanwithin structured program activities, it must beaddressed during treatment. Group therapy canhelp the client build the strength needed tooverride peer pressure and harness the influenceof the peer group in a positive manner. In aprocess guided by the clinician, clients canreceive constructive feedback about theirprogress from their peers. The group can serveas an important source for addressing theclient's denial about his substance use disorder,as well as promote positive behavioral changes.In addition, peers can indirectly influencechange by way of clients' learning vicariouslythrough others' stories and interactions(Stinchfield et al., 1994). When denial is strong,peer monitoring can be a relativelynonthreatening form of confrontation.

Conflict ResolutionConflicts often arise among young clients orbetween clients and staff members. Thetreatment staff should take a proactive stance toresolve such conflicts. This may entail havingextra staff meetings or addressing these issuesdirectly in team meetings. How the conflict isdealt with is critical. If staff members take an

32

authoritarian approach, the conflicts mayescalate, resulting in damaged rapport and aretreat from the treatment process.

Power struggles between a youth and acounselor can arise from the client's inability orunwillingness to meet program expectations.They also often arise when the staff is nottrained in how to work with adolescents. Whena youth is unable to meet program expectations,modifications in the treatment plan to better suitthe client's abilities are desirable. It is importantin power struggles to keep the focus on what theclient can reasonably achieve rather than on staffpolicies. If it appears that numerous programexpectations have to be modified for the client,this may signify that the program is notappropriate for that individual. In such cases,the client may have to be referred to a differentlevel of care or to another treatment program.

For cases in which the client seems able to

meet the program's expectations but does not doso, the clinician should directly address what isimpeding the client's participation. It is mostuseful to encourage a resistant adolescent bytelling her that she has the capabilities but is notworking up to her level. This positive approachmay help avoid unnecessary power struggles.An unwilling client may need the attention ofstaff members who are skilled in implementingmotivational techniques such as buildingtherapeutic rapport and in identifying andaddressing specific sources of poor motivation,such as the client's having a learning problem,feeling shame or guilt about having his

problems with substances come to light, andexperiencing social discomfort by virtue of beingin a new environment.

Client ContractsEntering into a behavioral contract, including a

substance-free contract, with an adolescent is acounseling tool that can help a provider identifythe current level of the adolescent's functioningand developmental markers, providing a

baseline from which to periodically monitorchange. Contracts should include the following:

Specific treatment goals organized aroundspecific client target behaviors

Ea Concrete descriptions of the consequences tothe client if the contract is not followed andthe rewards if the contract is followedSpecific outlining of situations to which the

contract appliesThe time frame during which the contract is

activeOptions regarding contract revisionsA written reminder of boundaries andexpectations

The contract should be composed and signedby both the client and the primary counselor andcopies distributed to both parties. By involvingthe client in the process, the importance of thegoals is emphasized, and a commitment to theplan is asked of the client and the therapist.Contracting provides a clear and concrete set ofexpectations that are mutually acceptable toboth the client and counselor. It helps hold theclient accountable for her behavior andundercuts manipulation. Some counselors alsohave the adolescent's family sign the contract,which communicates to the client that her family

is also committed to the treatment process.Contracts are especially useful to adolescents

because they give them a sense of control ingoing through treatment and a degree ofpersonal investment in their well-being, both ofwhich are important to teenagers who havedifficulties with authority or who are strugglingto establish an identity. Moreover, contractsmay represent the first time an adult has takenreal interest in them. A successfully completedcontract can give an adolescent a sense of self-fulfillment and responsibility that will bevaluable after treatment is finished.

It is important to avoid written contracts thatare inflexible and that pose unreasonableexpectations for teenagers whom staff members


would like to exclude from treatment programs.Clients who enter into a contract too quicklymay come to believe that it is a form of coercion

on the part of the counselor. Contracts shouldbe made in the context of collaboration betweenthe adolescent and counselor, in which clientshave a role in defining problems, goals, andapproaches that will be the focus of their

individual treatment.

SchoolingSome States mandate that adolescents receiveseveral hours of classroom schooling while intreatment, particularly if they are receivingresidential care or day-long outpatient care.Helping adolescents have a successfulexperience in the classroom is one of the most

important factors in their recovery. Regardlessof whether the schooling is provided on site (by

the program or through homebound publicteachers) or off site (in public settings), theeducational program must be fully integratedinto the adolescent's clinical program. This isbest accomplished when the teaching staffmembers are considered part of the treatmentstaff and when the behavioral program isextended into the classroom, as occurs in manyresidential programs. If adolescents attend localpublic schools, it is desirable to have a dedicatedliaison at the school who can attend treatmentteam meetings at the program.

Educational activities generally focus onsubstance use disorders and recovery, as well as

on basic school subjects. Conductingeducational activities with this age group can be

challenging. It is a common observation amongtreatment providers that many adolescentssuffer from learning disabilities. Staff membersmust be able to deal with reading and attentionspan problems by modifying traditionaleducation strategies and techniques. Forexample, group exercises in which the clients arerequired to read aloud may not be veryproductive. An alternative is to play an

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34

audiotape while adolescents follow along in abook; another is to assign reading to a

designated reader group composed of clientswho enjoy reading and can read well aloud.

Testing can be done to determine the client'sreading ability and to rule out learningdisabilities. Testing should also include an eyeexam and an evaluation for blurred vision as aside effect of medications, because poor visioncan confound test results. Special readingmaterials should be available for clients withreading and attention span problems. Anotherapproach is to give lectures that allow forinteraction among the clients in a group. Thepower of the personal story can also be apowerful teaching tool, particularly when anexperienced patient recounts her experiences.

Questions to consider in developing a schoolprogram include the following:

What are reasonable academic expectationsfor the adolescent client? By obtaining theclient's school records, staff members cangauge appropriate educational goals.What criteria and procedures will be used todetermine whether a client has specialeducational needs?To whom should the client be referred forspecialized educational testing?What liaisons with the client's school can bedeveloped? Issues that can be discussedinclude receiving appropriate academiccredit for class work taken as part of thetreatment program and re-enrollmentplanning.

How are the client's treatment andeducational needs coordinated, and ifnecessary, how will these needs becoordinated with juvenile justice and childwelfare systems?

It is important to emphasize that schools are

mandated to identify youngsters with learning

6'7

disabilities and to develop an individualizededucation plan for each student with disabilities.All staff members working with adolescentsmust be sensitive to their educational needs.

Staff members should advocate for their clients'continued participation in school.

Vocational TrainingCareer planningthat is, education aboutdifferent career possibilitiesis an importantintervention for adolescents and should be apart of a treatment program's clinical plan. Forexample, having people in various professionscome to a program and talk about their workand their careers is often of interest to adolescent

clients. Other appropriate interventions includeprevocational training (e.g., a program thatemphasizes coming to work on time, theappropriate etiquette for interacting with a bossor supervisor, acting in the interest of anemployer when on the job) and teaching job-finding skills (e.g., how to find a job, how to

prepare a résumé, how to speak at an interview).Without these skills, many youths may be morelikely to support themselves through illegalactivities and would be more prone to relapse.

Because many outpatient programs cannotdirectly address the vocational needs of theirclientsoften because they lack vocationaltraining resources and specialistsit isimportant to attempt to develop collaborativeagreements with local vocational programs.

Treatment PlanningA treatment plan should be developed by theprimary therapists or treatment team in concertwith the client, family, family collaterals, and,

when possible, representatives of the referringagency. Engaging both the client and family inthe treatment process can promote theirwillingness to participate in the actual

intervention. All of these parties must obey theFederal confidentiality regulations (see Chapter

8). The treatment plan should becomprehensive, specific, and objective so thatprogress can be measured. Naturally, the planshould address the environmental factors thatmay have contributed to the youth's substanceuse disorder and that could be a hindrance torecovery. At a minimum, a treatment planshould identify the following:

Target problems of the client and the family,

including substance use and psychosocial,medical, and possible psychiatric disordersGoals that help clients recognize theirinvolvement with substances andacknowledge responsibility for the problemsresulting from substance use and that takeinto account what the adolescent wants to

accomplishin Objectives that are realistic and measurable

steps for achieving each goalTime frames for the achievement of the

stated objectivesAppropriate interventions, that is, treatmentstrategies and services that are needed toachieve the objectivesAssessment methods for measuring theextent to which goals, objectives, and

interventions are fulfilledal Educational, legal, and external support

systems

The specified treatment strategies andservices should include the identification of thepersons who will be providing treatment, anexpected timetable for achieving the objectives,the date the treatment plan will be reviewed,and where treatment is to take place (Beck et al.,1993; Berg, 1991). The treatment plan should be

subject to frequent reassessments to determinewhether the client is making therapeuticprogress. If progress is not being made, theclient, family, therapist, and key interested


players should examine whether the therapist'sgoals and the client's goals match.

Linkages to the CommunityTreatment programs must work closely with theother entities that are involved in the treatmentof adolescents. Programs whose clients are ofteninvolved in multiple agencies (especially schoolsystems, child welfare, and juvenile justiceagencies) should write interagency agreements,also called memoranda of understanding, withother involved agencies. The agreements shoulddescribe payment policies, funding problems,mutual goals for clients, and intra- andinteragency contracts. Moreover, guidelines forconfidentiality must be established, anddiscussions should focus on potential problemsor key concerns for which different agenciesmay have different policies (such as protocolsfor a student who is found to be carrying drugs).In addition to interagency memoranda ofunderstanding, it is important to have anestablished practice of exchanging signedreleases of information from each shared client,insofar as the client is willing to agree to shareinformation and sign releases, so that theinvolved staff members can more freelyexchange confidential information about theclient's progress and difficulties (see Chapter 8).

Program managers should encourage andsupport staff members' involvement incommunity activities, a task that often goes"above and beyond" a person's official jobdescription or title. Outpatient programs oftenmust rely on staff members from othercommunity programs to complement theirservices or to provide staff training. Communityinvolvement by the program staff can empowerthe community to address local problems suchas gangs or territorial issues.

Recovering individuals in the community canserve as valuable role models and mentors foradolescents in treatment. Adolescents

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Chapter 3

particularly need adults to whom they can relateand with whom they can identify. These may beyoung recovering adults who have achieved orare working toward their educational goals; whoare doing well in their profession oremployment, perhaps owning their ownbusiness; and who have generally been able tosucceed despite their history of substance use.

These individuals can offer advice, assistance,and support in tasks such as preparing résumés,helping with schoolwork, or selecting andapplying to colleges.

Also key are networking with communityservices, understanding the community'sreaction to the program's presence, and

establishing a community advisory board. It isadvisable to include recovering adolescentclients on the advisory board. Building a broadcommunity base can enhance the program'sopportunity to provide effective treatment foryouth in the community. It cannot be overstatedthat a commitment by the program tocommunity involvement is vital for the successof an adolescent outpatient treatment program.

Program EvaluationIn recent years, there has been modest progressin addressing the question of whetheradolescents improve after substance usedisorder treatment (Catalano et al., 1990-1991;Friedman et al., 1986, 1994; Hoffmann et al.,

1987, 1993). Continuing assessment of programefficacy can provide valuable information onwhich areas of a treatment program are

functioning smoothly and which areas requiremodification. External licensing, accreditation,and funding agencies may carry out such anevaluation, often for the purpose of monitoringcompliance with Federal, State, and privateagency regulations. Alternatively, evaluationmay be carried out internally by staff andclients. The value of such assessment depends

36

67

more on the measures used than on whether it isaccomplished externally or internally.

All too frequently, program evaluation isbased on the number of clients seen, themaintenance of a desired census level, oradherence to regulations or protocols withoutregard to outcome measures. Many programs ofhigh quality do not document their effectivenessin terms of client retention, posttreatmentfunctioning, and use of aftercare services, for

example. Although the cost of care, efficiency intreatment, provision of categorical services, andadherence to regulations are certainly important,the true worth of a treatment program must bemeasured by the success of its clients.

When evaluations involve makingcomparisons between programs, differencesamong clients must be considered. For example,some programs will not accept clients withcoexisting disorders and will inevitably producebetter "outcomes" than programs that admitregardless of coexisting disorders.

Evaluation of success must be ongoing andmust apply both to adolescent clients who

complete treatment and to those who left careprior to discharge. It is the obligation of thetreatment program to provide for the continuingassessment of each client's progress, althoughobtaining accurate information on anadolescent's maintenance of abstinence andsuccess in other life skills may be difficult,expensive, and time consuming. Suchdifficulties are pervasive within the field ofsubstance use disorder treatment and remain anobstacle to assessing the efficacy of a specificprogram and to comparing the effectiveness ofdifferent treatment approaches. Nevertheless,each program has an obligation to monitorprogress of the client during treatment andattempt to characterize the long-term success orfailure of adolescents discharged from its care.The knowledge gained through these processes

should be used to refine the treatment program.Monitoring the adolescent's progress duringtreatment typically includes receiving feedbackfrom members of the treatment team, obtainingreports directly from the adolescent, and gettingreports and feedback from family, school, andemployers. Some evaluations include use of


urinalysis and BreathalyzerTM results to provide

a validity check against self-reports. For acomplete discussion of the measurement ofposttreatment outcomes, readers should refer toTIP 14, Developing State Outcomes Monitoring

Systems for Alcohol and Other Drug Abuse

Treatment (CSAT, 1995a).

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4 Twelv Step-

In the United States, many public and privatesubstance use disorder treatment programs,including those for adolescents, subscribe to

the 12-Step-based approach organized aroundthe philosophy of Alcoholics Anonymous (AA)(Bukstein, 1994; Institute of Medicine [IOW1990). AA is an organization that began as afellowship devoted to helping those who wish tostop drinking. From its original two members in1935Bill W., a stockbroker, and Dr. Bob, asurgeonit has become an internationalorganization consisting of more than 73,000

groups worldwide, with an estimatedmembership in the United States and Canada ofapproximately 800,000 (TOM, 1990). Certainly,

any discussion of contemporary treatments foradolescents with substance use disorders mustinclude a review of 12-Step models because of

their great influence on substance use disordertreatment.

Interestingly, there is a notable lack ofresearch on 12-Step-based programs, whichhave for nearly three decades been the mostprevalent model of treatment (Bukstein, 1994).Yet family-based models, which are relativelynew, have been impressively evaluated withcontrolled studies (see Chapters 5 and 6). This ispartly because most 12-Step-based programs donot have a research tradition due to theiremphasis on preserving the anonymity of theirmembers.

Although AA does not view itself as atreatment modality (Laundergan, 1982), it playsa prominent role in the design and

D as Pro IP41,ra

implementation of 12-Step-based programs intwo important ways: (1) It fosters relationshipswith the local treatment facilities, and (2) itsphilosophy, methods, and materials are formallyintegrated into the treatment activities (Gallant,1988). Practically speaking, some 12-Step-basedtreatment programs are headed by privatephysicians or affiliated with a hospital, whereasothers, often led by mental health professionals,are "self-standing." Although generallycharacterized as aftercare, 12-Step-basedprograms are sufficient treatment for millions of

people, young and old, around the world.

The 12 StepsThe 12 Steps were written in 1938 by thefounders of the fledgling AA and originallyappeared in what is known to legions ofrecovering adults as the Big Book (AA, 1976). In

AA, sobriety is maintained by carefully applyingthis 12-Step philosophy and by sharingexperiences with others who have sufferedsimilar problems. Many clients who areinvolved with AA find another AA memberwho will serve as a sponsor and provideguidance and help in times of crisis when thereturn to substance use becomes overwhelming.This sharing and group support approach hasspawned a number of self-help programs, suchas Al-Anon (for families and friends of thealcoholic) and Narcotics Anonymous (NA) (forpersons addicted to substances other than or inaddition to alcohol). Learning and practicing

6939

Chapter 4

the 12 Steps, which are listed below, is the mainfocus of AA and NA. NA programs change

some wording in the first and last steps to makethem appropriate to users of illicit drugs andother substances; these appear in parentheses.

1. We admitted we were powerless over alcohol(our addiction)that our lives had becomeunmanageable.

2. We came to believe that a Power greater thanourselves could restore us to sanity.

3. We made a decision to turn our will and ourlives over to the care of God as weunderstood Him.

4. We made a searching and fearless moralinventory of ourselves.

5. We admitted to God, to ourselves, and toanother human being the exact nature of ourwrongs.

6. We were entirely ready to have God removeall these defects of character.

7. We humbly asked Him to remove ourshortcomings.

8. We made a list of all persons we had harmedand became willing to make amends to themall.

9. We made direct amends to such peoplewherever possible, except when to do sowould injure them or others.

10. We continued to take a personal inventoryand when we were wrong promptlyadmitted it.

11. We sought through prayer and meditation toimprove our conscious contact with God aswe understood Him, praying only forknowledge of His will for us and the powerto carry that out.

12. Having had a spiritual awakening as the

result of these steps, we tried to carry thismessage to alcoholics (addicts) and topractice these principles in all our affairs.

Treatment effectiveness is believed to bemaximized the more a client is able to

40

personalize the concepts expressed by the stepsinto her own life.

From AA to theMinnesota ModelDifferent ways of incorporating the 12 Steps intotreatment have evolved over the years. A majoradaptation of the model initially developed atWillmar State Hospital in Minnesota has become

known as the Minnesota model. By the 1980s, itwas the linchpin of almost all programs treatingalcoholic and other substance-dependentpatients. The goals of the Minnesota modelinclude moving away from the simple custodialcare of alcoholics, clarifying the distinction

between detoxification and treatment, andidentifying a variety of elements of care withinone program. The continuum of carecomponents generally includes a diagnostic andreferral center, a primary residentialrehabilitation program, an extended careprogram, residential intermediate care (e.g.,halfway houses), outpatient care (diagnostic,primary, and extended), aftercare, and a familyprogram.

The Hazelden Foundation further modifiedthis model of care, which preceded enrollmentin a primary care program with several days ofdetoxification in a separate facility. TheMinnesota model tried to develop anenvironment of recovery in a setting removedfrom daily life, often in the country, for a fewmonths.

The approach that evolved was highlystructured and included detoxification,psychological evaluation, general andindividualized treatment tracks, groupmeetings, lectures, and counseling, as well asreferral to medical, psychiatric, and socialservices, as needed. Group counseling wasconsidered the main therapeutic technique.Emphasis was on using older, more advanced

residents to share experiences and to pass onknowledge and values to patients. The 12 Stepswere carefully studied, and AA meetings wereheld within the treatment framework. Theprimary care program was intended to last up to60 days in a residential setting in the hope that acaring and low-stress environment removedfrom traditional daily life would facilitate the

recovery process.In the early 1960s, Hazelden developed a 21-

day version; insurance companies then set 28days as a reimbursement guideline in order toensure sufficient coverage. This abbreviatedversion viewed intensive treatment as a-multidisciplinary endeavor, in which thephysician, nurse, psychiatrist, psychologist,counselor, and administrators were involved ina hospital setting. Rehabilitation was providedafter intensive treatment by nonmedical staffand coordinated by the counselor. Participationin AA for patients and in Al-Anon for familymembers got started during treatment andideally continued for 2 years after treatment.More specifically, treatment componentsincluded

Strong AA orientationSkilled alcoholism counselors as primary

therapistsPsychological testing and psychosocial

evaluationMedical and psychiatric support forcoexisting disordersTherapists trained in systematized methodsof treatment including Gestalt, psychodrama,reality therapy, transactional analysis,behavior therapy, activity therapy, and stressmanagementUse of therapeutic milieu and crisisinterventionSystems therapy, especially with employers,

and later including a family component

Twelve-Step-Based Programs

Family- and peer-oriented aftercare (Stuckeyand Harrison, 1982)

For many years, some in the treatment fieldconsidered the Minnesota model the only"workable" method of treatment for substanceuse disorders. Then, as the nation's attention inthe 1970s and 1980s focused on the use of illicit

drugs (e.g., cocaine), three trends in servicedelivery occurred. First, treatment programsexpanded their curriculum to addresssubstances other than alcohol. Second, newprograms were developed that specificallyaddressed individuals with nonalcoholsubstance use disorders. Third, both types ofprograms eventually discovered that alcoholismand substance use disorders overlapped, andthus most programs oriented themselves to thetreatment of both.

As the years passed, additional types oftreatment approaches emerged, including socialmodel programs and programs based inpsychology, such as family-based therapy in itsmany forms. Parts of the 12-Step-basedapproach were incorporated into these treatmentprograms. Since the advent of managed care,outpatient programs of all approaches arebecoming the norm. Residential programswithin the public or private sector have becomeless common and often have diminished lengthsof stay. Those that remain are often locatedwithin institutions, such as correctionalinstitutions or hospital-based psychiatric units.

Incorporating the12-Step-Based ApproachAlthough the Big Book contains stories of thedrinking experiences and recovery of middle-aged adult alcoholics living in a very differenttime from today, its principles are relevant toadolescents (Winters and Schiks, 1989).Providers treating adolescents in a 12-Step-

41

Chapter 4

based program should bear the following inmind:

Substance use disorders are primary,multifaceted illnesses that exist in people ofall ages, including adolescents.

® Persons with substance use disorders areindividuals with unique and separate needswho share a common problem and thereforeshould be treated with respect and dignity.Once substance-abusing and substance-dependent adolescents are given informationabout their disorder(s) in an understandableway, they are capable of helping others, aslong as they receive some guidance.Use of group therapy is well suited toadolescents, who tend to rely heavily on peerexamples and approval. Thus, mutualsharing in a peer group setting is vital to therehabilitation process.

® The principles of recovery outlined by AAprovide effective and proactive tools forcontinuing one's recovery from druginvolvement.

111 Once a person has lost control over his use ofsubstances as an adolescent, returning toresponsible and legal use as an adult may

require additional help and support.

12-Step Principles in TreatmentMost 12-Step-based programs concentrate onthe first five steps during primary treatment,whereas the remaining ones are attended toduring aftercare. Below are ways to present thefirst five steps to adolescents so that theirspecialized developmental needs can beaddressed (Winters and Schiks, 1989).

Step 1: We admitted we were powerless over

alcoholthat our lives had become

unmanageable. With adolescents, the primary

goal of this step is to assist them in reviewing

their substance use history and to have themassociate it with harmful consequences. It

42

helps them understand their need forsupport in not using.

ca Step 2: We came to believe that a Power greater

than ourselves could restore us to sanity. At a

practical level, this step can be simplified to"There is hope if you let yourself be helped." A

powerful way to convey this messageinvolves allowing new clients to interact withthose who have been successful and areleaving the program. The "goodbye" orgraduation ritual for successful clients helpsto instill hope in others. Providers must helpadolescents with coexisting mental disordersor cognitive disabilities to understand thatStep 2 refers to obtaining help to stopsubstance seeking and use and not "curing"their mental disorder. Providers should alsospell out that depression or anhedonia afterabstinence is common and can get better.Step 3: We made a decision to turn our will and

our lives over to the care of God as we understood

Him. This step can be simplified as well:"Try making decisions in a different way; take

others' suggestions; permit others to help you."

Using the phrase "Helping Power" instead of"Higher Power" can benefit some.Step 4: We made a searching and fearless moral

inventory of ourselves; Step 5: We admitted to

God, to ourselves, and to another human being

the exact nature of our wrongs. Steps 4 and 5

provide an opportunity to be accepted byanother person in spite of one's pastbehaviors and to take a "personal inventory"of those past behaviors. These steps enableclients to put some of their past unpleasantsubstance use experiences behind them.

Some other aspects of the 12-Step model may

also have to be modified for adolescents. Forexample, the tenet that newly abstinentmembers should have no major life changes for1 year in order to concentrate solely on theirrecovery may be difficult for adolescents to

internalize. A year has a different meaning intheir world, and many changes are an inevitableaspect of adolescence. An advantage of using a12-Step-based program and having a sponsor isthat help is available 24 hours a day, not onlywhen the staff is on duty. It is an empoweringidea to know that help is "only a phone callaway."

Obviously, an important goal of 12-Step-based programs is to build an affinity betweenthe client and AA meetings. The goal is to teachthe young client that continuing participation inthese group meetings after treatment isimportant to his recovery. Young people areincreasingly joining AA and NA groups; in somecities, regular AA and NA meetings exist thatare attended by teenagers and young adults andthat are supervised by an appropriate adult.This continuing support network is believed tobe invaluable to the ongoing recovery process.

Individual Treatment PlanningAll teenagers in treatment have some problemsin common, and these can be addressed ingroups. Clearly, group work is a hallmark of12-Step-based treatment. However, many needsof individuals in this age group are bestaddressed in one-on-one or other specificallyplanned interventions in individualizedtreatment plans. For example, in 12-Step-basedprograms, such individualized planning oftenrevolves around work on one or more of thesteps, and many 12-Step plans address lifeproblems and how the concepts of AA can beused as problem-solving strategies. Also, giventhat family is a core treatment component, it iscommon for the client's specialized plan toaddress family issues such as substance usenorms in the family, familial abuse, and siblingrelationships.

It is also common for individualizedtreatment plans to address the teenager's socialanxiety. For example, patients with difficultyspeaking in a group setting should meet with a

Twelve-Step-Based Programs

counselor and work on strategies to address thesource of the problem. The counselor and theclient can discuss ways of setting ground ruleswith peers who use substances when socialcircumstances arise in the future. Also, someclients will want to discuss how to best developa future relationship with an appropriatesponsor.

Research StudiesIn recent years, there has been modest progressin addressing the question of whetheradolescents improve after treatment ofsubstance use disorders (e.g., Catalano et al.,1990-1991; Friedman et al., 1986, 1994;

Hoffmann et al., 1987, 1993). It is perhaps ironicthat the widely used Minnesota model approachhas received relatively minimal researchattention. When large-scale studies have beenconducted, they have suffered from poorfollowup contact rates and usually do notinclude comparison groups. Hazelden's Youthand Family Center in Minnesota conducted atreatment outcome study of 480 clients whocompleted treatment in the mid-1980s.However, only 53 percent of the sample werecontacted at 1 year after treatment. Almost half(46 percent) of those contacted reported no useof alcohol, and over two-thirds (68 percent)indicated no use of other substances during thefollowup period (Keskinen, 1986).

Harrison and Hoffmann reported outcomeresults from several residential treatmentprograms, many of which were based on theMinnesota model (Harrison and Hoffman, 1989).Data from 924 adolescents (49 percent of theeligible followup sample) were collected; 42

percent reported total abstinence during thefollowup period, and another 23 percent hadused substances less than monthly. There aresmaller scale evaluations of 12-Step-basedprograms that have better followup rates (e.g.,Alford et al., 1991; Brown et al., 1989; Knapp et

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Chapter 4

al., 1991; Richter et al., 1991); these studies

report abstinence rates in the range of about 50to 60 percent.

In a recent evaluation of a 12-Step-basedapproach, some of the methodologicalweaknesses of previous studies were addressed,namely, a high contact rate at followup wasachieved and meaningful comparison groupswere included (residential vs. outpatient, and notreatment vs. treatment) (Winters et al., in press).

Six- and 12-month substance use outcomes weremeasured among 245 drug clinic-referredadolescents, 179 of whom received complete orincomplete treatment and 66 of whom weredeemed to need treatment but did not receiveany. The intent-to-treat adolescents showedsignificant reductions in substance usefrequency when preintake levels were comparedwith followup levels. Fifty-three percent ofthem reported either abstinence or minor lapses(substance use only once or twice) during the 6months following treatment, while 44 percentreported this status for the full year followingtreatment. Absolute and relative outcomemeasures indicated that completing treatmentwas associated with far superior outcomes when

44

compared with those who did not completetreatment or received no treatment at all. Thepercentage of those completing treatment whoreported either abstinence or minor relapses forthe 12 months following treatment was 53percent, compared with 15 percent and 27percent for those who did not completetreatment or who did not receive treatment,respectively. There were no outcome differencesbetween residential and outpatient groups, yetfemales tended to report better outcomescompared with males. Among the intent-to-treat subjects who relapsed, alcohol was themost commonly used substance during thefollowup period, despite marijuana being thepreferred substance at intake. Until morerigorous research designs are applied, the mostconclusive statements that can be made aboutthe effectiveness of the 12-Step-based approachfor adolescents is that many youths areimproved after receiving this form of care.Although some preliminary data indicate thatthe 12-Step-based method yields outcomes thatare superior to no treatment at all, there is agreat need for controlled studies in this field.

'74

T er utic Co

The therapeutic community (TC) is an

intensive and comprehensive treatmentmodel developed for use with adults that

has been modified successfully to treatadolescents with substance use disorders. TCsfor the treatment of addiction originated in 1958,a time when other systems of therapy, such aspsychiatry and general medicine, were notsuccessful in treating alcohol or substance usedisorders. The first TC for substance users(Synanon) was founded in California by ChuckDederich, one of the earliest members ofAlcoholics Anonymous (AA), who wanted toprovide a controlled (substance-free)environment in which alcohol and substanceusers could rebuild their lives, using theprinciples of AA along with a social learning

model (De Leon, 1995a).

The core goal of TCs has always been topromote a more holistic lifestyle and to identifyareas for change such as negative personalbehaviorssocial, psychological, andemotionalthat can lead to substance use.Residents make these changes by learning fromfellow residents, staff members, and otherfigures of authority. In the earliest TCs,punishments, contracts, and extreme peerpressure were commonly used. Partly becauseof these methods, TCs had difficulty winningacceptance by professional communities. Theyare now an accepted modality in the mainstreamtreatment community. The use of punishments,contracts, and similar tools have been greatly

u aides

modified, although peer pressure has remainedan integral and important therapeutic technique.

Originally, the large majority of residentsserved by TCs were male heroin addicts whoentered 18- to 24-month residential programs.By the mid-1970s, a more diverse clientele wasentering treatment; 45 percent used heroin aloneor in combination with other substances, andmost were primarily involved with a range ofsubstances other than heroin, such asamphetamines, marijuana, PCP, sedatives, andhallucinogens. By the 1980s, the large majorityof those entering treatment in TCs had primarilycrack or cocaine problems. The percentage ofwomen entering treatment grew, and theypresented with different problems, includingextremely dysfunctional lives and morepsychopathology. Although several adolescentTCs have been in operation since the late 1960s,increasing numbers of younger people soughttreatment during the 1980s, and manypreviously all-adult communities beganadmitting adolescents. With the inclusion ofyouths in these adult TCs, education and familyservices were added as important programcomponents.

The TC model has been modified over timeto include a variety of additional services notprovided in the early years, including varioustypes of medical and mental health services,family therapy and education, and educationaland vocational services. In the beginning, nearlyall staff members were paraprofessionalsrecovering from addiction; over the years,

7';45

Chapter 5

increasing numbers and types of professionallytrained specialists have been employed by TCsand are now serving in staff or consultantpositions.

The Generic TC ModelAs a socialpsychological form of treatment foraddictions and related problems, the TC hasbeen typically used in the United States to treatyouth with the severest problems and for whomlong-term care is indicated. TCs have twounique characteristics:

The use of the community itself as therapistand teacher in the treatment processA highly structured, well-defined, andcontinuous process of self-reliant programoperation

The community includes the social environment,peers, and staff role models. Treatment isguided by the substance use disorder, the person,

recovery, and right living (De Leon 1995a).

Right living emphasizes living in the present,

with explicit values that guide individuals inrelating to themselves, peers, significant others,and the larger society. Recovery is seen as

changing negative patterns of behavior,thinking, and feeling that predispose one tosubstance use and developing a responsiblesubstance-free lifestyle. It is a developmentalprocess in which residents develop themotivation and know-how to change theirbehavior through self-help, mutual self-help,and social learning.

The theoretical framework for the TC model

considers substance use a symptom of muchbroader problems and, in a residential setting,uses a holistic treatment approach that has animpact on every aspect of a resident's life.Residents are distinguished along dimensions ofpsychological dysfunction and social deficits.The community provides habilitation, in which

some TC residents develop socially productivelifestyles for the first time in their lives, and

46

rehabilitation, in which other residents are helped

to return to a previously known and practiced orrejected healthy lifestyle (De Leon, 1994). Aprimary distinction between the TC approachand 12Step-based programs is the belief thatthe individual is responsible both for hisaddiction and for his recovery. Where AA says"let go, let God," TCs take the view that "yougot yourself here, now you have to get yourselfout with the help of others."

Traditionally in the TC, job functions, chores,

and other facility management responsibilitiesthat help maintain the daily operations of the TChave been used as a vehicle for teaching self-development. Remaining physically separatedfrom external influences strengthens the sense ofcommunity that is integral to the residentialsetting. Activities are performed collectively,except for individual counseling. Peers are rolemodels, and staff members are rationalauthorities, facilitators, and guides in the self-help method. The day is highly structured, withtime allocated for chores and otherresponsibilities, group activities, seminars,meals, and formal and informal interaction withpeers and staff members. The use of thecommunity as therapist and teacher results inmultiple interventions that occur in all theseactivities.

Treatment is ordinarily provided within a 24-hour, 7-days-per-week highly structured plan ofactivities and responsibilities. Althoughrecommended treatment tenures have generallyshortened in recent years, averaging around 1year, they may last as long as 18 months. Thefull-time approach is part of the ecological pointof view held by proponents and leaders of TCs.The program is conducted in three stages:induction, primary treatment, and preparationfor separation from the TC (De Leon, 1994).

Like many other substance use disordertreatment providers in today's health caremarket, TC personnel are committed toproviding services to residents in shorter

periods of time and with decreased resourcesthan was the case in previous years.Modifications of the traditional residentialmodel and its adaptation for special populationsand settings are redefining the TC modalitywithin mainstream and mental health services.Two new strategies have recently beensuggested: focusing goals on moving theresident to the next stage of recovery in another,less expensive setting, or expanding aftercareopportunities in residential and day treatmentprograms following TC treatment (De Leon1995a, 1995b; Rosenthal et al., 1971).

Adollescents Iln TCsJainchill and others have pointed out that onlyrecently has cross-site information describingadolescents who enter TCs been compiled(Jainchill, 1997). One exception was the DrugAbuse Reporting Program (DARP), which in the

1960s and 1970s found that almost one-third ofthe TC sample was younger than 20 years old.(DARP was the nation's first comprehensivemultimodality study of the treatment industry.)Those teenage TC residents typically were whitemales who used opioids (Rush, 1979). Data aresparse after the 1970s. However, new datareveal that adolescents make up 20 to 25 percentof the residents in TCs. Some 80,000 clients were

admitted to TCs in 1994 (De Leon, 1995b).

Resident CharacteristicsAdolescents who enter TCs tend to have serioussubstance use and behavioral problems thatrender them dysfunctional in many arenas(Jainchill, 1997). Common problems are truancy,conduct disorders, poor school performance,attention deficit/hyperactivity disorder(AD/HD), learning disabilities, and problemsrelating to authority figures. In terms ofsubstance use history, adolescents entering TCshave begun substance use at an earlier age andhave greater involvement with alcohol and

Therapeutic Communities

marijuana and less use of opiates compared withadults.

A majority of youths in TCs have beenreferred by the juvenile justice system, familycourt, or child welfare (social service) systemsand reflect an early involvement with illegalactivities and family dysfunction. Conductdisorders and juvenile delinquency are common.In fact, some TCs are operated by criminaljustice institutions, such as correctional agencies,and may be structured as minimum-securitycorrectional facilities.

Less frequently, adolescents enter the TCunder parental pressure. Thus, extrinsicpressures are usually required to coerce theadolescent into treatment and to keep her there.It is not uncommon for such residents to havelittle motivation to change their behavior.

Most adolescent residents are malesmandated by the court, and problems of socialdeviance are commonplace. Because adolescentfemales commit fewer crimes and less violentones than do adolescent males (Jainchill et al.,1995), they are not often mandated to a TC,although they may be brought to treatment by afamily court. However, even those adolescentfemales with the same range and type ofproblems as the males generally do not enterTCs. One of the questions facing the TCmovement is how to create and conduct effectiveoutreach for adolescent females who needtreatment. Very often, when females do enterTCs, their problems are found to be more severethan the problems of most of the males. Whenfemales are enrolled in the TC, sleeping quartersare separate but activities are very often coed(Jainchill et al., 1995).

Both adults and adolescents in TCs sharemany problems. There is little differencebetween the social histories of adult andadolescent users in residential treatmentconcerning onset and pattern of substance use,academic performance, and juveniledelinquency (De Leon, 1988).

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Chapter 5

TCs With AdolescentsA core feature of TC treatment for adults andadolescents alike is that the community serves asthe primary therapisttreatment is acommunity process, and it is not possible toidentify a single individual as therapist.Although adolescents often have a primarycounselor with whom they work individually,everyone in the community, including theadolescents themselves, has responsibility as atherapist and teacher. Peer-group meetings ledby an adolescent with a staff facilitator arecommon.

The community's role is critical to the client'shabilitation and rehabilitation. For theadolescent, the community may be even morecrucial than for adults because the TC functionsas the family. This is a significant function

because many youths in TCs come fromdysfunctional families. Being a member of theTC community gives them an opportunity toexperience and learn how to have and maintainpositive relationships with authorities, parents,siblings, and peers. Nearly all activities, evenhousekeeping responsibilities, are consideredpart of the therapeutic process. It is preciselybecause adolescent residents usually come fromenvironments without structure, routine, rules,or regulations that the TC is ideally suited toproviding their treatment.

Modifications that are generally made in theTC model for treatment of adolescents aresummarized as follows:

The duration of stay is shorter than foradults.

Treatment stages reflect progress alongbehavioral, emotional, and developmentaldimensions.Adolescent programs are generally lessconfrontational than adult programs.Adolescents have less say in themanagement of the program.

48

Staff members provide more supervisionand evaluation than they do in adultprograms.Neurological impairments, particularlylearning disabilities and related disorders(e.g., AD/HD), are assessed.There is less emphasis on work and moreemphasis on education, including actualschoolwork, in the adolescent program.Family involvement is enhanced and ideallyshould be staged, beginning with orientationand education, then moving to supportgroups, therapy groups, and therapy withthe adolescent. When parental support isnonexistent, probation officers, socialworkers, or other supportive adults in theyouth's life can participate in therapy.

Additional modifications are madedepending on the specific needs of theprogram's referral and funding sources(Rockholz, 1989). For example, some programs

primarily serve protective services cases (e.g.,abuse and neglect, homelessness) involvingadolescents who often present with psychiatricneeds that require medication. Others servejuvenile and criminal justice system-involvedyouths with behavioral disorders, who requireanger management programming and whorespond better to more traditional confrontationtechniques. Still others operate collegepreparatory TCs, without the use ofpsychotropic medications, for emotionallytroubled, upper-middle class youths.

Duration of StayIn the past, TCs for adolescents were entirelyresidential programs lasting 18 months to 2

yearsthe time required for behavior change tobe internalized and practiced by the adolescent.The conservative funding policies that typify the1990s have introduced complex issues forresidential TCs because success in treatment iscorrelated positively with extended stay in theprogram. As with so many other issues in

73

substance use disorder treatment today, finaldecisions often have to be based more onfinancial considerations than on therapeuticneed, with the result that most programs canplan only for a course of treatment that lasts 6 to12 months. A few programs are attempting toprovide TC treatment in 6 months; this is aradical move. Clinical wisdom suggests that theideal duration of treatment for adolescents in aTC is 12 to 18 months and that adolescents withvery deep and complicated disorders cannot betreated effectively in 28 days. However, noresearch is available to compare treatmentsuccess in 28-day programs with treatment inthe longer stay programs.

StaffingOriginally, only persons in recovery staffed TCs,and TC directors and staff were opposed totherapy by psychologists, psychiatrists, andother mental health personnel such as socialworkers or family counselors. TCs are nowintegrating the services of professionals withtraining in some area of mental health, and thereis recognition that individual counseling cancomplement the group approach, which was themainstay of treatment during the first twodecades of TCs.

TC staffs today are a mixture of nondegreedfrontline counselors and degreed professionals.The counselors who do not have degreestypically facilitate the daily TC activities andserve as role models for successful recovery; the

degreed staff includes vocational counselors,nurses, psychologists, social workers, andsubstance abuse counselors.

Having an on-site nursing staff is importantto monitor medications, provide healtheducation, and provide cross-training for thecounselors, particularly regarding thesymptomatology of addiction. Teachers in a TCprogram for adolescents must understandsubstance use disorders among youths fromdisadvantaged families with severe dysfunction.


Cross-training for the teachers is also important.It is essential that the counselor meet at least

weekly with the teacher(s) to integrate schoolinginto the program. Psychiatrists are ofteninvolved because of the common presence ofdisorders such as depression or AD/HD.Pharmacological agents for coexisting disordersare now permitted and are used widely by someTCs serving adolescents with coexisting mental

disorders.Depending on the size and staffing of the TC,

there will be some combination ofadministrative, legal, dietary, and maintenancestaff. The people in these categories are oftenconsidered integral to the clinical process. Forexample, office personnel may actually havesome clinical input in terms of hands-onmanagement of a resident who has a jobfunction under their supervision. It is essentialthat all employees who have any direct orindirect dealings with residents receive trainingthat gives them a thorough understanding of theTC concept and its bearing on their specific

duties.

ProtocolMost programs are designed so residents canprogress through phases as they advancethrough treatment. Tied to the phases areincreased responsibilities and privileges. Onecannot advance to the next higher level until hedemonstrates responsibility, self-awareness, andconsideration for others (De Leon, 1995a). Bymoving through these structured phases, theadolescent acquires and benefits frompsychological and social learning beforeproceeding to the next stage. Each stageprepares the resident for the next. Afterbecoming a responsible member of the treatmentcommunity, the adolescent can move on to theoutside community. In adult TCs, residentsadvance through developmental stages to a levelof authority in which they become responsiblefor the TC's operation. However, this is not

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Chapter 5

appropriate for adolescents, for whom the staffplays the role of effective parents.

Creating a Safe EnvironmentPart of the ecological approach to treatment inthe TC is the creation of a safe and nurturingenvironment, within which adolescents canbegin to experience healthy living. It isimportant for the staff of the TC to understandwhat type of home, neighborhood, and socialenvironment from which each adolescent comes.Many adolescents enrolled in the TC come fromunsafe physical and psychological

environments; the characteristics of the homeand neighborhood do not facilitate healthyliving, and many risk factors may be

environmental. For example, many of theseadolescents are third-generation substance userswho have grown up in an environment wheresubstance use is an everyday activity. Often,physical or psychological violence accompanies

the addictive practices, and children andadolescents may be physically andpsychologically damaged.

Essential to creating a safe environment is theTC's strict adherence to "cardinal rules" that, ata minimum, prohibit substance use orpossession, physical threats or violence, orsexual contact. It is also essential that theenvironment be psychologically safe byensuring, for example, that adolescents are notverbally attacked and that they feel comfortableenough to disclose even the most sensitive of

events (and associated feelings), such as sexualabuse.

Groups in the TC for AdolescentsVarious types of counseling groups are providedin the TC. Groups constitute an importanttherapeutic technique, as they have since theearliest TCs were established. Typically,

everyone attends at least one group session aday.

50

Today's TCs generally do not use thegrueling encounter groups and all-night"marathons" of their earlier counterparts, butmodified encounter groups still are common.Some programs have begun to move away fromencounter groups and have included 12-Stepwork, as in the 12-Step model of treatment.

Techniques such as confrontation, designed tohelp adolescents recognize and acknowledgetheir feelings and learn to accept personal andsocial responsibility, can be counterproductiveby raising clients' defensiveness. Groupmeetings at advanced stages of the program arecomposed of peers, whereas other groups foradolescents are led by qualified counselors ortherapists. Many of the TC programs foradolescents use a cognitive restructuringapproach to change adolescents' thinking and toredirect the focus of their attention to healthierbehavior.

There are various types of groups that dealwith physical and sexual abuse, although it isvery difficult to get adolescents to acknowledge

that they have experienced abuse. Skill groupsalso exist in adolescent TCs to enhance existingskills or build new ones.

EducationEnabling residents to receive a good educationand at least complete high school are critical

goals for adolescent TCs. Comprehensive TCsprovide their own schools, licensed as required,with full-time, salaried, or local educational

agency-provided teachers. Others have ateacher who comes in part time to conductclasses. All teachers must be State-certified toprovide special education or education in theirspecific subject area. Residents must receive aminimum of 5 hours of academic instruction perschool day. It is critical that educational services

be fully integrated into the TC program and thatthey be consistent with the TC process.Teaching staff should be active in the treatmentplanning process, and behavioral management

o

programming should be integrated into the

"house" procedures.Because schooling replaces most of the work

responsibilities common in adult TCs, theadolescent's workload is not as heavy as that of

the adult. Each resident has assigned jobresponsibilities in the evening and on weekends,such as preparing dinner, washing dishes,mopping, dustingthe important tedium ofsober life. After dinner, there is study time anda group meeting. Lights-out is monitored at aspecific time, such as 10:30 p.m.

RecreationRecreational activities are important forteenagers in TCs who need help in learning toenjoy themselves and others without usingsubstances. These activities help overcomeboredom, a key problem with adolescents.Physical activities, such as outdoor sports, arenecessary but difficult to provide in winter,particularly in programs that are housed in alimited amount of space. Some TCs haveincorporated relationships with local public

facilities or programs such as Outward Bound.

AftercareDuring the first two decades of the TC, residentsspent 18 to 24 months in treatment and wereessentially considered to be "cured" and not in

need of formal aftercare services. As theaverage length of stay decreased, however, itbecame necessary to return adolescents to theirfamilies or independent living situations withcontinuing treatment needs. Others requiredhalfway houses, which were, and continue to be,

scarce. In most cases today, adolescents arereferred to outpatient programs, especially forcontinued family therapy. Some are servedthrough alumni or other affiliated aftercareresources of TC agencies. Although AlcoholicsAnonymous (AA) and Narcotics Anonymous(NA) are minimally included in manyadolescent and adult TCs, most programs have

s


experienced significant improvements intreatment outcomes when they introduceresidents to AA/NA during the reentry phase oftreatment and strongly encourage them to usethese 12-Step programs as valuable and effectiveaftercare supports. Evaluative workdocumenting significant reductions inrecidivism, substance use, and antisocialbehavior through the use of dedicated TCresidents in the community for aftercare is justbeginning to emerge, primarily from researchersdealing with adult prison populations (Inciardiet al., 1997). Ideally, sophisticated satelliteaftercare programs should be provided in thecommunities where the residents live. Foradolescents, aftercare programs should include afamily therapy component.

Involvement of theAdolescent's FamilyIn the early days of the adolescent TC, familieswere often viewed as the cause of theadolescent's problems and were kept away fromthe adolescent. Families were usually onlyinvolved with occasional parent support groupsor Al-Anon and thus were kept away from theirchildren. For cases in which the adolescentplanned to return home, parents were usuallybrought in for a conference or two shortly beforethe adolescent left residence in the TC. In many

cases, adolescents were older and tended to

move out to independent living in thecommunity near the TC programoften withlittle or no family counseling.

Today, TCs often provide comprehensivefamily services programs, including suchcomponents as family assessments, family

counseling and therapy including multifamilygroups, parent support groups, and familyeducation programs. Some TCs have well-established parent groups that provide programfundraising and scholarship assistanceinitiatives. Regular visitation remains limited in

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52

most TCs to weekly or monthly open houses andspecial events such as graduations.

The issues of accessibility and limited familysupports are challenging to TCs, especially whenthey are located away from families. Manyfamilies lack the transportation or interest to beinvolved in regular family programming. Insome cases, adolescents have no living parentsor have a parent who is incarcerated. In casessuch as these, teleconferencing and familycounseling with the individual are necessaryalternatives. Some programs developagreements with other service providers wherethe family resides. These programs can helpwith parenting skills training and can providesupport and guidance on how to help the youthmaintain his recovery. The TC tends to providea surrogate extended family for residents, whichcan provide a corrective experience resulting in

more positive self-identity. Ideally, staffmembers and the community as a wholeprovide effective reparenting through a balanceof discipline without punishment or shaming,along with love and concern without enabling.

Related to this is the issue of rural programsversus urban programs that are located closer tothe homes of TC residents. Proponents of cityprograms argue that it is unfair to takeadolescents away from their families for theduration of treatment. On the other hand, if thefamily is really dysfunctional, it is better to keepadolescents away from their family. Locatingthe adolescent in a rural area away from theenvironment in which she was involved withsubstances and away from her peers in thatenvironment may strengthen the adolescent'sresistance upon return to that environment.There is disagreement on this matter, however;some authorities believe there is no value inmoving the adolescent to a rural area. Otherstake a middle ground by placing the adolescentin a rural TC initially and then returning theyouth to treatment in her original environment.

'8 2

Special Issues of theAdolescent TC ResidentTC staff members must be prepared to deal withmany special issues of adolescents that willcome to the fore in the treatment process. Threeare particularly common and important: self-image, guilt, and sexuality (De Leon, 1988;Jainchill, 1997).

Self-imageAdolescents are struggling to develop anidentity, which is a critical and sometimesdifficult task, even for those leading ordinarylives without the types of problems experiencedby an adolescent in the TC. They often selectimages they want to assume, body postures, andan affected manner of speaking that may beinappropriate. Their images may be embeddedin street culture and gang affiliation. Staffmembers can work with them and help them seehow a healthy identity develops and ismaintained; they are in a position to help theadolescent avoid the acquisition of a negativeself-image that can be destructive. Once thisstage of understanding has been reached, staffmembers can help adolescents develop self-monitoring methods to assess their own imagesas well as images of others and to suggestchanges in behaviors, dress, speech, or evenposture, when appropriate.

GuiltMany experienced TC professionals view guiltas the fundamental feeling associated with self-defeating behavior, including substance use andacting out against others (such as by stealing).They frequently say to adolescents, "Guilt kills,"which expresses their understanding thatnegative behavior produces guilt, which in turn,results in more negative behavior to escapeguilty feelings. Adolescents can benefit fromhelp with self-guilt (e.g., how their actions havehurt other people) and community guilt (e.g.,breaking house rules or not confronting negative

behavior and attitudes of other residents).

TC staff members regularly address guilt inencounter groups, seminars, counseling, andeven in special guilt sessions, in whichconfession is the first step in counteracting thefeeling of guilt. While it is necessary to disclose

the act itself, the root issue in these sessions is

the concealment of that act, which the adolescentmust confess. Discussion of guilt is valuable forall adolescents, whether they are undergoinggroup, community, or individual therapy(DeLeon, 1995a). It is of critical importance that

the residents understand the relationshipbetween guilt and self-destructive behavior.Recognition and acceptance of the pain

associated with guilt is the first step to anexperiential basis for new social learning.Finally, it is hoped that the resident willunderstand that acknowledging past misdeedscan be a springboard for commitment to achanged future.

SexualitySexuality, social behavior, and personal identityare interrelated in all human beings, butproblems in these areas are intensified duringadolescence. Staff members will encounterproblems related to sexual feelings, sex roles,values, attitudes, and interpersonal relationshipsbetween the sexes. Some residents may betrying to cope with feelings related to sexualabuse. The adolescent must learn to managestrong sexual impulses. Sexual adjustment ofadolescents with substance use disorders iscomplicated by other problems such as the lackof sex education at home or school or havingpoor role models. Altogether, there is a risk thatthe adolescent will develop distortions inattitude, values, and self-perceptions regardingsex.

TC professionals can best deal with theseproblems through management and rules (e.g.,rules against sexual contact) and throughproviding sex education in seminars as well asdealing with sexual issues during encountergroups, one-on-one counseling, and special


sessions that are focused on problem solving.Boys' and girls' living spaces should beseparated. The longer term stay and increasedcontact make TCs a good environment forcounseling and education on HIV infection,AIDS, and safe sex; the TC can make a real

contribution to the young person's life byhelping her understand and practice safe sex.

Research StudiesThere is no consensus definition of successfultreatment outcomes for adolescent TC programs.Some TCs believe they have been successful if,after treatment, the adolescent uses onlymarijuana. Others measure treatment success byreductions in the amount of substance use andin criminal and delinquent behavior. For some,the standard of abstinence from all substancesand complete cessation of all delinquentbehavior following treatment is the ultimategoal. Still others have looked at indicators suchas improvements in the adolescent's self-esteem,quality of relationships with others, andimprovement in academic performance andattendance (Rockholz, 1978).

Data on the TC approach to adolescent carecome from recent reviews of the literature (e.g.,Jainchill et al., 1995; Pompi, 1994) and current

adolescent studies by Jainchill and associates atthe Center for Therapeutic Community Research(CTCR) (Jainchill, in press). Other sources of

information are earlier multimodality studiesinvolving adolescents in TCs, funded by theNational Institute on Drug Abuse (Hubbard etal., 1989) and large multiprogram studies of TC

programs in Therapeutic Communities ofAmerica (De Leon, 1985).

Using data from these sources, it is possibleto hypothesize that retention rates and post-treatment outcomes are similar to those amongadults, with adolescents showing positivechanges in the use of cocaine, opiates, andmethamphetamine and reductions in criminal

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activity. The majority of adolescents admitted toTCs who drop out do so within the first 30 days.Dropout rates diminish after that time.Retention rates vary considerably amongprograms. The highest retention rates are foundamong adolescents who are legally mandated totreatment, probably because fulfilling the courtrequirement supports the adolescent while heundergoes compliance, which lays thegroundwork for the retraining stages that occurin later therapy. Thus, a legal mandate can be avaluable tool in increasing adherence to andefficacy of treatment (De Leon, 1995b).

There has been a long-held clinical

impression that younger clients are lessmotivated than adults to be in treatment, andthis impression has recently been confirmed byempirical data from CTCR, although youngerclients are likely to remain in treatment longer ifthey are highly motivated to be there. Ifmotivation and readiness can be assessed atintake, treatment providers may be able toidentify those youths who are at high risk fordropping out. Such information could guide thedevelopment of intervention strategies toenhance motivation and retention in treatment.

Outcome StudiesThe relatively few studies that have reported onthe effectiveness of long-term residentialtreatment indicate that residential treatment isgenerally more effective than outpatientmodalities, that a client's length of stay intreatment is a critical factor, and that adolescentsrequire a longer treatment tenure than adults(e.g., De Leon, 1985; Hubbard et al., 1985; Sells

and Simpson, 1979). Among these studies the

54

most consistent improvements were seen onmeasures of criminal involvement withmarijuana, and there has been a notable lack ofmarijuana-specific treatment studies.

Jainchill and colleagues recently completed a1-year posttreatment followup study ofadolescents who were in residential therapeuticcommunities (Jainchill et al., in preparation).The majority (46 percent) indicated thatmarijuana was their primary drug of abuse.Followup interviews were completed on 485adolescents of whom 31 percent graduated orcompleted the residential phase of treatment, 52percent dropped out, and the remainder wereterminated for a variety of other reasons. Therewere significant reductions in substance use,both in the percentage of adolescents reportinguse of specific substances and in the extent orfrequency of use. Those who completedtreatment showed more positive outcomes thanthose who did not complete treatment. Therewere similar improvements obtained in the levelof criminal activity. For both those whocompleted treatment and those who did notcomplete treatment, there were significantreductions in all areas of criminal activity(e.g., violent crimes, drug sales, propertycrimes); however, the reductions were greaterfor those who completed treatment. Continuedresearch supported by the National Institute onDrug Abuse is investigating long-term outcomes(5 and 7 years after treatment) for those

adolescents. The need for further studies iscritical, particularly for those that address theissue of treatment duration and tenure inrelation to outcome.

84

6 Family Thera

he interconnected relationships within afamily are widely recognized as crucialelements of substance use disorders and

their treatment. Clinicians and researchers agreethat interactions among family members canaffect the emotional health of individualmembers and thus fail to prevent thedevelopment of substance use disorders.Although family factors have been implicated in

the etiology of adolescent substance use, it isimportant to recognize that individual,environmental, and contextual factors also

contribute to adolescent substance usebehaviors. With that in mind, adolescentsubstance use disorders are commonly referredto as multidimensional disorders.

Through the years, many substance usedisorder treatment programs have worked withfamily members in a component called family-

based therapy, family-centered therapy, or simply

family therapy. Just as these names differ, sohave the services differed from one treatmentprogram to another. They reflect that family-based interventions work at the level of familychange (e.g., parenting practices, familyenvironment, problem solving) and also aim to

take into account the psychosocial environmentsin which the adolescent lives. In one situation,family therapy might refer to an educationalsession or a discussion of family problems with asubstance abuse counselor. In others, it mightconsist of a few family conferences with

members of the treatment team present toexplore what family members can do to help the

patient. Some programs may have very effectivefamily counseling sessions, referred to as family

therapy.The distinctions among family-based

therapy, family-centered therapy, and familytherapy are not unimportant. They reflectdifferent versions of family-based intervention.Some family-focused interventions assume thatinformation about the 12-Step philosophy,delivered in the context of family treatment, issufficient to affect the substance-using behaviorsof the adolescent. Other approaches, as well asmost family-based therapies, assume that theinteraction within the family and betweenimportant family members and otherextrafamilial individuals is critical to making

change. Data support the link between changesin central aspects of family functioning andchanges in the substance-using and problembehaviors of the adolescent (Schmidt et al.,

1996).

Too often, however, the phrase "familytherapy" is a "catch-all" name for any activitythat brings family members together fordiscussion. Unfortunately, much of what haspassed for family therapy throughout thedevelopment and history of substance usedisorder treatment has not been the provision ofservices using a carefully learned anddisciplined therapeutic approach. Nor has itbeen designed with a solid understanding offamily dynamics or led by well-trained andexperienced family therapists.

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Fortunately, these old approaches have allbut disappeared from treatment programs. It isnow recognized throughout the substance usedisorder treatment field that working withfamilies is a huge responsibility that requires aclinical understanding of family interactions andpathologies. It is notable that one of today'sleading texts on family therapy has concludedthat much of the cutting edge research in thefield at large is done in the context of asubstance use disorders (Nichols and Schwartz,1998).

Over the past two decades, much has beenlearned in carefully constructed and controlledresearch studies to indicate how a familytherapist, working in conjunction with othermembers of the treatment staff or alone, canintervene constructively to help a family changebehaviors (Stanton and Todd, 1979; Stanton andShadish, 1997; Gurman et al., 1986; Liddle,

1992). These studies have been conducted inresearch-based settings, not within existingcommunity-based programs. However,sufficient outcome data and experience nowexist to transfer the research models to

naturalized treatment settings. Family therapyprograms may also be suitable sites of effectiveresearch on adolescents who have substance usedisorders.

Family Therapy as aRecent Approach

Integrating Family TherapySubstance use disorder treatment programs canuse family therapists to apply therapeuticapproaches that have been proven effective withadolescents and their families. Preparing forand integrating a therapist who will providefamily therapy in a treatment program requiresa considerable amount of time. Furthermore, atherapist who practices a family-based approachshould have formal, professional training in this

56

method. Family therapy fits well into theregimen of treatment in which case managementis used; it has also been shown effective inhome-based treatment (Comfort and Shirley,1990; Thompson et al., 1984).

What Is Family Therapy?Three approaches of family therapy are beingapplied in treatment settings today:

1. The old-style paradigm believes that something

wrong in the family produced the substanceuse disorder. In other words, the familycaused it. This view has been recentlyrevised to reflect an increased understandingof family dynamics.

2. The second paradigm focuses on risk and

protective factors by working with families toreduce the risk factors and increase theprotective factors. It is commonly used inadolescent substance use preventionprograms as well as treatment.

3. The third paradigm of family therapy, which is

the concern of this chapter, takes amultisystemic or multidimensionalperspective in the therapeutic process.Therapy includes all family members, and insome cases, peers (although theirinvolvement would be limited to when thetherapist believes their participation wouldbe helpful). In effect, the family or the groupis the patient. The justification for the

multidimensional approach is that the twomost important influences on the adolescentare his family and members of his peergroup.

Multidimensional family therapy startedsometime in the 1930s when social scientists

began to understand that family members areinterconnected and interdependent parts of asystem. They constantly interact with and affecteach other. When there is a change in anyindividual member of the family, others in thefamily system are affected. From a systems

3 6

perspective, families are seen as organisms thatcontinuously change and reconstitutethemselves (Gladding, 1995). One studysummarized family systems as a powerful andinfluential series of interconnected relationshipsamong family members that provide for humanbehavior, emotion, values, and attitudes (Fig ley

and Nelson, 1990).Contemporary family therapy approaches

understand the importance of treatingindividuals as subsystems within the familysystem and as units of assessment andintervention; in other words, each member of thefamily is capable of being assessed and can act

as a unit of interventionfor example, bychanging her interactional patterns. The criticalpoint is that family-based treatments work withmultiple units, including individual parents,adolescents, parent-adolescent combinations,and whole families, as well as family membersvis-à-vis other systems. It is the multiplesystems approach that distinguishes currentfamily-based therapies from older family

therapy approaches (Liddle, 1995).Applied appropriately, family therapy often

can quickly cut through to the reality of asituation. This makes it an effective tool intreatment. When used with all of the membersof the family, it can open and improvecommunications, often eliminating the family

secrets that have enabled the client to continuepracticing his addiction. It is important to notethat some families with an adolescent with asubstance use disoider do not need familytherapy. These families function well andshould not change in any substantive way. Ifthe family system is effective overall, individualor group therapy for the member with thesubstance use disorder may be the focus of thetherapy, with occasional family meetings toconvey information, to help the family providesupport to the substance-using member, and tointegrate the family into the long-term goal ofrelapse prevention.

Family Therapy

Elaborations of theFamily Systems PerspectiveWithin the systems approach, several types offamily therapy strategies have been applied andstudied with adolescents who have substanceuse disorders. These include

El Functional family therapyo Structural ecosystems therapy

Multisystemic family therapyo Multidimensional family therapyo Problem-based therapy

All of these are considered integrative familytherapies, meaning that they draw from and

build on a number of structural, strategic, andbehavioral models of family therapy that haveemphasized families as systems.

Engagement in TreatmentEngaging adolescent substance users intreatment is notoriously difficult (Szapoczniket al., 1988). Youths in these circumstancestypically do not believe their substance use is aproblem and rarely seek treatment. Instead theyare brought into treatment by their parents orcoerced into treatment by the criminal justicesystem. Thus, family therapy modelsspecializing in engagement interventions weredeveloped. Such specialized engagementinterventions allow therapists to diagnose, join,and restructure a family from the first contact tothe first family therapy session (Szapocznik etal., 1988).

Using the principles of family therapy towork with the family to engage them intreatment is a well-established component offamily treatment of substance use disorders.The therapist uses the usual therapeutic tools offamily therapy but uses them to deal first withthe problem of engagement until resistance toparticipation is overcome. Henggeler furtherdeveloped these ideas by emphasizing thattherapists, along with the treatment team, muststrive to engage the family in treatment and to

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reach treatment goals; if obstacles develop, thetherapist should devise alternative strategies toattain desired outcomes (Henggeler et al., 1986).

Changing Interactions AmongFamily MembersThe therapist's intervention aims to bring aboutchange in the way family members relate to eachother by examining the underlying causes ofdysfunctional interactions and by encouragingnew (and presumably healthier) ones. Bycreating a context in which families focus onrevitalizing interpersonal bonds and acting inmore adaptive ways within the family, theprocess helps members of the family changenegative emotional and attributionalcomponents (especially blaming) of theirinteraction.

In doing so, the therapist helps familymembers appreciate how the values andperspectives of each family member may differfrom their own, but that differences do not haveto be a source of conflict. Helping familymembers solve problems together in thetherapeutic setting enables them to learnstrategies that can be applied with theadolescent in the home. Such maneuvers intherapy decrease family conflicts and improvethe effectiveness of communication. Familymembers, both parents and youth, learn how tolisten to one another and solve problemsthrough negotiation and compromise.

For example, in family therapy sessions, thetherapist may help the adolescent understandthe origins of expressions of hostility towardhim by family members. Take the situation inwhich the parents are upset about the teenageson playing the stereo in the family's apartmentlate at night and keeping other family membersfrom sleeping. The therapist might ask theparents if they ever played their radio too loudlywhen they were teenagers, thus helping them toidentify with their son. This softening on thepart of the parents may help the adolescent

58

accept the fact that he will still be able to hear hisfavorite music even if he lowers the volume ofthe stereo. Then, an agreement may benegotiated in which the adolescent agrees todecrease the volume or use headphones after9:30 p.m. or when others are watchingtelevision. This is a more productive resolutionof the problem than having the teenager leavethe family's apartment at night so he can playhis stereo the way he really likes to.

Another method of improvingcommunication between family members is tointroduce the concept of "I" statements. "I"statements focus on the effect of an action on thespeaker rather than on the action itself. Insteadof saying "you always do (blank)..." a familymember would say, "I feel (blank) when you(blank) because (blank)." These statements areoften effective because people can disagreeabout what they "always" do, but it is moredifficult for them to dispute what someone saysshe feels. Further expansion on this techniquewould involve a listening skills exercise. Onemember would paraphrase what she heard theother person say until the first speaker statesthat she got it exactly right.

Another goal in the family treatment of

substance use disorders is to equip parents withthe skills and resources needed to address theinevitable difficulties that arise in raisingadolescents. Parents of youths who usesubstances typically aggravate small conflictsbecause their parenting practices are too extreme(e.g., too permissive, authoritarian, orinconsistent). Moreover, by the time parentsseek therapy for their child they have "triedeverything" and feel quite hopeless about beingable to improve the situation. It is the familytherapist's job to help parents regain theiroptimism and motivate them to continue to helptheir child. Family therapists, then, bolster theparents' self-confidence as parents and at thesame time help them improve their parentingskills. Parents are taught how to provide age-

88

appropriate monitoring of their child (e.g., to

know their friends, to know how they spendtheir time), set limits (e.g., negotiate with theyouth about reasonable curfews, schedules, andfamily obligations), establish a system of

positive and negative consequences, rebuildemotional attachments, and take part inactivities with the child outside the home.

The special case of multidimensional familytherapy includes several core targets ofassessment and change: the individualadolescent, the parent(s), the family interaction(parent-adolescent interactional patterns), andfamily members vis-à-vis extrafamilial personsand systems. Interventions within each of thesecore targets occur in a particular sequence. Thetheoretical framework underpinning thesequence of the interventions within eachsubsystem includes developmental theory andresearch, including attachment relations, familysystems, and family therapy. Process studies onmultidimensional family therapy indicate thatcertain aspects of behavior (proximal targets)must be changed before other target behaviorscan change (more distal behaviors). In a sense, itis a moderator approach to change. Forexample, some aspects of a parent's behaviorchange before others (attachment increasesbefore parenting practices can change) (Schmidtet al., 1996). In the therapeutic alliance with theadolescent, focusing on the client's lifeexperiences and the capacity to tell his story in atherapeutic context to a therapist who will helphim tell it to others (including his family, in thecontext of other parallel work with the parentand extrafamilial others), often facilitatesimprovements in initially poor therapist-adolescent alliances (Diamond and Liddle,1996). Furthermore, interactional impasseswithin the context of family therapy sessions canbe resolved if the interaction can be facilitatedthrough certain stages (i.e., resist problemsolving in enactments too early, focus on

slowing down the pace of the communication,

Family Therapy

help the parent and adolescent share theirexperience of their situation) (Diamond and

Liddle, 1996).

Beyond the FamilyContemporary family systems approaches haveevolved to the point at which numeroussystems, in addition to the youth and family, aretargets of the intervention. These extendedsystemsmost notably peers, school, andneighborhoodare believed to help maintaindysfunctional interactions in families and thusare important targets. For example, the therapistmight focus on the system composed ofinteractions between the adolescent and herpeers who engage in delinquent acts, or focus onthe system consisting of interactions between theadolescent and an institution, such as school,that keep her from becoming engaged inschoolwork. The aim of family treatment, then,is to change the dysfunctional systems withinthe core systemsthe familyand between thefamily and social systems such as the peer group

or the school.These approaches may direct family

members to join groups such as a church or civicgroup. In the area of peer relationships,therapists may discourage association withdeviant peers and help establish parentalsanctions for contact with these bad influences.In the forms of family therapy known asmultisystemic therapy and structural ecosystemstherapy, for example, the parents are supportedby the counselor to implement effectiveparenting to address the problem of associationswith deviant peers. The counselor also helps theparents develop strategies for monitoring andsupporting the youth's school performance orvocational functioning.

As another example, the therapist within themultidimensional family therapy approachwould identify and assess the negativeconsequences associated with taking part inthese extrafamilial systemssuch as skipping an

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Chapter 6

appointment with a probation officer or hangingout with peers late at night on unsafe streetcorners where illicit drugs are bought and sold.The therapist might meet with the probationofficer or ask the adolescent to bring a peer to a

session to review the problem from the youth'sperspective.

The therapist then helps the adolescent andhis family become aware of these consequencesby identifying their long-term significance, suchas the potential legal problems of missingappointments with the probation officer or beingblamed for participating in drug deals.Conducting this type of session requires greatskill to ensure that the participants in thediscussion do not feel blamed for the problem orbecome defensive about their actions. Whensessions are led skillfully by a therapist who hasestablished a therapeutic alliance with theadolescent, the adolescent will ideally reachrational alternatives to his behavior.

Like other systemic therapies, these therapiesare based on knowledge of the developmentalaspects of families, primarily of adolescents, andthe ecological environment in which they live.The therapist draws from this base of knowledgeto assess and intervene with the adolescent, thefamily, or the community institutions withwhich the adolescent is involved, including suchinstitutions as the juvenile justice system, a gang,a youth organization, or a public health clinic, aswell as the school. These systems are assessed interms of their past and present actions thatcontribute to family dysfunction.

The Therapeutic AllianceEven with a systems perspective, family therapymodels consider the therapeutic alliancebetween therapist and adolescent as the crucialcomponent. It is important for the therapist towork hard to establish a therapeutic relationshipwith the adolescent. This relationship supportsthe adolescent in developing a personal agenda,such as ensuring that the family system of

60

discipline does not deny the adolescent theopportunity to participate in social activities orimpede personal growth. This qualifies thesense in which therapy is conducted with thewhole family. It is also a chief task for thetherapist to clarify to the client and other familymembers that the purpose of the whole exerciseis to help the client. This often conflicts with thefamily's tendency to scapegoat the member whohas been in trouble or to ignore the personalneeds of the client.

What Should theProgram Staff Know?At a practical level, the duration of family-basedtreatment typically ranges from 2 to 6 months,decreasing in intensity toward the end of theperiod of treatment. This may translate intoapproximately 5 to 20 therapy sessions.Naturally, more difficult cases take longer.Henggeler and colleagues, using a familypreservation model, reported a caseload size percounselor of 4 to 6 families (Henggeler et al.,1992). Other approaches have caseloads of 4 to10 cases per counselor. Different groups offamily members may attend different therapysessions; for example, if the therapist isdiscussing poor parenting, the youth will not beincluded because the youth's presence mightserve to undermine parental authority.Treatment can be relatively intense, withmultiple sessions during a single week. It alsocan be intense in terms of explicit goal settingand extensive homework assignments. Also, thesetting does not have to be conventional and canoccur in either home or community settings.

Family therapists should be acutely aware ofthe complex of behaviors and systemicinteractions associated with recovering from asubstance use disorder. They also should beaware of cultural differences in family patternsand typical attitudes toward therapy(McGoldrick et al., 1982). Adolescent substance

90

involvement should be considered within thecontext of other problem behaviors such asdelinquency and school problems, necessitatingnew frameworks of diagnosis and assessment, aswell as treatment. Liddle and Dakof wrote thatfamilial attitudes and behavior, familyemotional environment, and parenting practicesare dimensions consistently targeted by family-based interventions (e.g., parental substance use,parent-adolescent conflict, emotionaldisengagement) (Liddle and Dakof, 1995a).

Adolescent clients will benefit when thetreatment team, including counselors, nurses,and doctors, working in conjunction with familytherapists, has a general understanding offamily therapy within the substance usedisorder treatment setting. When they have thisunderstanding, the treatment team can bestsupport the efforts of the therapist andcoordinate their components of treatment withfamily therapy. For example, when substanceuse disorder counselors know that theadolescent is going through an intense time infamily therapy, they can reduce the intensity ofsubstance use education with the adolescent.Likewise, the physician can include theprovision of family therapy as a factor in herdecisions about medication.

Research StudiesIncreasing numbers of research-based trials areclearly defining and studying the use of family-based therapy among adolescents in treatmentfor substance use disorders. In 1980, theNational Institute on Drug Abuse (NIDA) beganto address adolescent substance use disorderssystematically to find out if effective family-

based therapy models could be applied toadolescents (Liddle et al., 1992). The role of

family relationships in the creation andmaintenance of substance use disorders has beenunderstood for some time. The pioneeringstudy on family therapy with adults with

Family Therapy

substance use disorders was a NIDA project(Stanton and Todd, 1979). Szapocznik andcolleagues were the first to establish theeffectiveness of family therapy in treatingadolescent substance use disorders (Szapoczniket al., 1983, 1990). In subsequent researchfunded primarily by NIDA, and to a lesserdegree by the National Institute on AlcoholAbuse and Alcoholism and other sources, greatstrides have been made in understanding anddefining the types of family therapy that workbest with adolescents with substance usedisorders.

The great importance of these models to thesubstance use disorder treatment field is that asthey have been carefully tested and documentedover time in many different settings, includingthe home and outpatient programs, revisionshave been incorporated as needed, therebyimproving the effectiveness of the models.Thus, a program that applies one of thedocumented family therapy models canimplement family therapy with some certaintythat successful treatment of adolescents willresult. In the public arena, State directors ofalcohol and drug treatment agencies, as well asindividual program directors, can be assuredthat funds invested in family therapy are wiselyspent.

Driven largely by current efforts to reducethe costs of health care and provide documentedevidence of the effectiveness of the care, theprimary setting for adolescent substance usedisorder treatment today is the outpatientprogram. For the first time, conclusions can nowbe drawn about some particular forms of familytherapy that work effectively in this setting.

The documentation of family therapies inadolescent programs is particularly interestingbecause they have been used successfully amongadolescents who are difficult to treat (Liddle andDakof, 1995b; Stanton and Shadish, 1997;

Henggeler et al., 1986). One of the most excitingaspects of this accumulating research and

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Chapter 6

62

treatment evaluation is that the family therapies clients from the most disadvantagedapplied in these research settings have been backgrounds and with very severe substance useshown to be especially effective with adolescent disorders.

9 L. "'

7 )(outeaymen ": Needs

any adolescents who acutely needtreatment for substance use disordersmay be in circumstances that make

early identification and treatment particularlydifficult. Sometimes, legal, social, or healthcircumstances in a young person's life createunique problems that require attention. Youthsin the child welfare and juvenile justice systemsare at particularly high risk for developing asubstance use disorder. More often than not,they have more risk factors than other childrenand fewer protective factors. For example,adolescents who have come into contact with thejuvenile justice system can be expected todisplay severe problems surrounding family andsocial relationships, as well as coexisting mental,emotional, or physical difficulties (Dembo et al.,

1991). Screening and intervention policies inprimary care settings will help uncover both thesubstance use disorders and the problems thatoften accompany them: illegal activity,homelessness, shame surrounding sexualidentity, and coexisting mental disorders.

Treatment in lie Juvenilejustice SystemMany young people who enter the juvenilejustice system for relatively minor offenses, suchas problems in school or at home, enter a cycle offailure reinforced by repeated instances of these

problems. Most of the adolescents who come

into contact with the juvenile justice system havealready developed a number of functionalproblems. Many of these youths have hadsubstance use disorders and other psychosocialconcerns for some time, and many come fromfractured or dysfunctional families. By the timethese adolescents enter the juvenile justicesystem, they have developed serious substanceuse disorders and attendant psychosocialdysfunction.

For these reasons, early intervention iscritical in working with adolescents who havehad contact with the juvenile justice system.Every young person involved in the juvenilejustice system, regardless of his charge, shouldundergo thorough screening and assessment forsubstance use disorders, physical healthproblems, psychiatric disorders, history ofphysical or sexual abuse, learning disabilities,and other coexisting conditions. Juvenileprobation officers can be helpful partners in thesystem of care. For their part, treatment serviceproviders should educate the local juvenilejustice system about the importance of earlyintervention and what resources are available tothem. Juvenile justice professionals should berequired to have training in identifying andappropriately intervening with substance use intheir clients. Having court-ordered treatmentand monitoring may be the most effectiveapproach to getting substance use disorderservices to many adolescents. It is almost

9%)

63

Chapter 7

impossible to intervene unless the youth isremoved from the environment that brought herinto conflict with the juvenile justice system inthe first placethat is, the home neighborhood.

Diversion ProgramsBecause the justice system is overwhelmed witha high case volume and limited resourcesajudge in juvenile justice may handle thousandsof cases a yearincreased emphasis has beenplaced on diversion programs (sometimes calleddispositional alternatives) for juvenile offenders.These alternatives have been shown to be highlyeffective in relation to the minimal resourcesinvested in them. Juvenile detention facilitiesare designed to provide short-term care forjuveniles awaiting adjudication or disposition.However, juveniles placed in detention facilitiesare unlikely to receive the special programsnecessary for treatment or reintegration intosociety. For these reasons, alternatives toplacing juvenile offenders in secure facilitieshave increased dramatically in recent years. Therange of transitional programs that help toprepare youths to return to their communitieshas widened as well. The use of alternativeplacement resources will likely involve multipleagencies. Therefore, it is vital to have a singlecase manager to coordinate services and be thecentral monitoring and tracking source for eachadolescent. It is important for juvenile programadministrators to be aware of the pros and consof each program and to place youths in theprograms that are likely to be of most benefit tothem. A number of approaches and types ofsettings are now being used, and the manyoptions that are available make it possible toselect the setting most conducive to a juvenile'streatment needs. Some of the availablealternatives are described below.

E Intensive community supervision. Under

intensive community supervision, a youthremains in the community and mustregularly report to an assigned probation

64

counselor. This arrangement allows theadolescent to attend school and to maintainfamily relationships with minimalinterruption. The planned frequency of therequired contacts with the probationcounselor may vary from several times a dayto twice a week; less than twice a week is notconsidered intensive supervision. Telephonecontact alone is not enough, although it maybe used to supplement personal meetings.

E Day reporting centers. As part of communitysupervision programs, reporting centers canbe set up in accessible locations in the

community, such as schools and shoppingcenters. Youths then report regularly tothese stations according to their case plans.Some centers provide education, recreation,or social services.

El Day treatment. Specialized day programs thatinclude education and social services helpyouths develop social skills. They alsoprovide supervision and control in a familiarsetting. In many day treatment programs,youths take classes in the morning,participate in a group activity (such asplaying sports) in the afternoon, and returnhome at night.

Evening and weekend programs. Direct

supervision and programming similar to daytreatment are also offered during eveningand weekend hours. Tutoring, recreation,employment, and treatment services can beprovided to supplement an adolescent'sregular educational or work programs. Likeday treatment programs, evening andweekend programs provide supervision inaddition to education and social skillsdevelopment.

Tracking. Tracking programs hire staff

(usually part-time) to monitor youths and toreport their compliance with specificrequirements in areas such as schoolattendance, participation in counseling, andjob performance. Whether working with

other service providers or independently,trackers report regularly to the agency thathas jurisdiction over the adolescent.

m Electronic monitoring. Some youths are now

released under the condition that they wearan electronic device that monitors theirmovements. The efficacy of such systems isdebated by professionals and technicians inthe juvenile justice system, but all agree thatelectronic monitoring alone is insufficientand that, to be successful, such tracking mustbe part of a multifaceted effort.

m Home detention. Adolescents under homedetention are supervised by their parents intheir homes and are allowed to leave only togo to school or work. This type of treatmentis well-suited for youths who do not requireinstitutional security but need adultsupervision and structure. Home detentionis generally a short-term arrangement that isused until a detailed, long-range plan isdeveloped.Home tutoring. Supplementing regulareducational programs with home tutoringhelps to remedy adolescents' educationaldeficiencies, establishes contact with an adult

role model, and provides supervision.Mentor tutoring. Providing a trained

adolescent tutor for a troubled youth can beextremely beneficial. In addition toeducational tutoring, a mentor can offeradvice, emotional support, and a respectful,

caring relationship.m Work and apprenticeship. Some local

businesses provide jobs or apprenticeshipsfor juvenile offenders, generally inconjunction with an educational program.Such programs instill a work ethic, a sense ofresponsibility, and a feeling ofaccomplishment while enhancing communityrelations.

m Restitution. Under court order, juveniles maybe asked to try to rectify the damage theyhave caused their victims. Restitution may

Youths With Distinctive Treatment Needs

be in cash or in services amounting to aspecific dollar value. Most frequentlyordered in property crimes, restitutionprovides an alternative to incarceration,thereby reducing public costs whilecompensating victims.

B Community service. Some offenders are

required to provide services that benefit theentire community, such as cleaning up parksor working in nursing homes. This is a formof restitution that allows juveniles tocontribute routine but worthwhile services.Community service projects must be clearlyidentified, and the juveniles in theseprograms must be properly supervised.

m Volunteer programs. Volunteers are oftenavailable to tutor youths and to supervisework and recreational activities. They mayalso provide an additional service to youthsas friends, role models, and listeners. Likeregular employees, volunteers requiretraining, specific job descriptions, and

supervision.

For more information on alternatives foradolescents involved in the juvenile justicesystem, refer to TIP 21, Combining Alcohol and

Other Drug Abuse Treatment With Diversion for

Juveniles in the Justice System (CSAT, 1995d).

Juvenile Drug CourtsThe caseloads of most juvenile courts in this

nation have changed dramatically during thepast decade. The increasingly complex nature ofboth delinquency among juveniles andsubstance use disorders has contributed to moreserious and violent criminal activity andescalating degrees of substance use. Juvenilejustice professionals recognize that the problemsthat bring a juvenile under the court'sjurisdiction are affected by family factors,community factors, peer issues, and otherindividual and environmental variables.

The juvenile court traditionally has beenconsidered an institution specifically established

65

Chapter 7

to address multiple needs of the juvenile.However, it is becoming clearer among juvenilejustice practitioners that conventional practicesare ineffective when applied to the problems ofjuveniles with substance use disorders. Duringthe past 2 years, a number of jurisdictions haveexamined the experiences of adult drug courts toexplore the possibility of adapting such systemsfor juvenile courts in the hopes of moreeffectively dealing with an increasing substance-using juvenile population. Interest in juveniledrug courts is developing rapidly across thecountry, with a number already operational orin the planning stage. The States of California,Florida, and Nevada have the greatest activity,but according to a recent report, 59 programs areunderway or planned across 30 States (DrugCourt Clearinghouse and Technical AssistanceProject , 1997). See Figures 7-1 and 7-2.

ChallengesThe process of developing and implementingjuvenile drug courts must address severalchallenges, including

Counteracting the negative influences ofmultiple risk factors, most notably thepresence of coexisting psychiatric disorders,peer deviance, and poor family dynamics

® Addressing the needs of the family,especially families with substance usedisorders and poor parenting practices

111 Complying with confidentiality requirementsfor juvenile proceedings while at the sametime obtaining necessary information toadequately assess and refer the substance-using juvenile

El Overcoming the typical lack of motivation toengage in the recovery process (since mostyouthful substance users have rarely hitbottom like long-term adult substanceusers)along with those traits that typify theconduct-disordered juvenile offender,including a sense of invulnerability, lack ofconcern for one's future, and disinterest in

66

conventional values, all of which complicatethis motivational hurdle

is Responding to numerous developmentalchanges that may occur in the adolescentduring the course of extended supervisionwhile under the court's jurisdiction

CharacteristicsAlthough the importance of flexibility ofjuvenile court operations has been emphasized,several characteristics common to existingjuvenile courts have been identified (Drug CourtClearinghouse and Technical Assistance Project,1997):

Early and comprehensive intake assessments,with an emphasis on the functioning of theadolescent's family and the adolescentthroughout the court process

is A heavy emphasis on responding to theneeds of the adolescent by coordinating theactions of the court, the school system, thetreatment service provider, and othercommunity agenciesUse of the case management approach, inwhich active and continuous supervision ofthe adolescent occurs throughout theassessment, referral, and treatment processes

m Immediate use of both sanctions applied fornoncompliance and incentives to recognizeprogress by the adolescent and the family

Homeless andPrecariously HousedYouthsAn estimated 750,000 to 1.3 million youths runaway from their homes each year, and one-thirdof these are believed to become chronicallyhomeless. A growing body of literature suggeststhat these young "street" people are at high riskfor a wide range of problems, particularlysubstance use (Kipke et al., 1995, 1997).

Research among homeless youth in inner-cities indicates that most of these young people

90


Figure 7-1

Status of IDru,g Courts in the,,UnitedStates

Estimated total number ofindividuals who have enrolled

Avera:e retention rates

Adolescent Pro:rams

850'

96 iercent`

Adult Pro:rams45,000b

70 percent'

'Based on 13 active programs'Based on 99 active programs`Based on number of graduates and active participants in comparison with total participants enrolled

use multiple substances, although the types ofsubstances used were found to vary amonggeographical areas of the country (Kipke et al.,1996). On the East Coast, for example, commonsubstances of use were heroin and crack cocaine,whereas on the West Coast, the use of LSD,ecstasy, and methamphetamine was morecommon (Kipke et al., 1997). Substance use,defined according to DSM -1V criteria, has been

found to be a pervasive problem among theseyouths. For example, 71 percent of inner-cityhomeless youths in Los Angeles were classifiedas having an alcohol and/or illicit substance usedisorder (Kipke et al., 1997). In addition, as

many as 30 percent of them reportedintravenous drug use, and of these, 59 percentreported having shared needles and equipmenton at least one occasion. Added to the risk ofHIV posed by this practice are the additionalrisks associated with "survival sex"the tradingof sex for food, shelter, or drug money. Asmany as 40 percent of street youths areestimated to engage in this activity (Kipke et al.,1995).

Most street youths also have a long history of

abuse and neglect: Over 50 percent of homelessadolescents report having experienced physical,sexual, and/or emotional abuse and neglect(Sibthorpe et al., 1995). Not surprisingly, manyhomeless youth turn to substance use in aneffort to numb their emotional pain and copewith the uncertainty and instability of their lives.

Effective treatment of substance use

disorders in this population hinges on thenecessity of recognizing the importance of theseyoung people's readiness for treatment. Also,entering a substance use disorder treatmentsystem is a complicated process, and displacedyouths are likely to require help in gainingaccess to services. Outreach programs shouldhave in place a "step-up" for homeless or inner-city youths to enter these programs, assistingthem in negotiating the various obstacles thatmay be potential barriers to services. Theseadolescents may require several street contactsbefore they are willing to trust anyone. Streetoutreach workers should focus on developingtrusting relationships with youths that, overtime, can influence a young person to access

substance use disorder treatment services. Awide array of services should be readilyavailable, especially emergency shelter services,residential treatment services, or transitionalliving services, depending on the individual'sneeds. Furthermore, most of these youths donot believe that their primary problems arerelated to their substance use. For adolescentswho may or may not be receiving services butwho are living on the streets, outreach becomesa primary intervention strategy. Serviceproviders must meet with, talk to, and developrelationships with young people on the street toengage them in treatment (see the Levels ofTreatment subsection in Chapter 2).

9`Q

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Chapter 7

Figure 7-2

Number of Drug Court Programs Underway/Planned

Once a homeless youth has entered thesystem, the next step is establishing a casemanagement plan that is based on a thoroughassessment of her needs. Possible services mayinclude finding housing, dealing with familyproblems, entering substance use or HIV-relatedtreatment, and providing job training, schooling,and sexual and reproductive health care. It maybe necessary to prioritize the needs for servicesaccording to the individual's severity ofproblems.

Returning homeless or runaway youths totheir homes after treatment is not always in theirbest interest because less than optimalconditions may exist in these homes. Many ofthese youths have parents with serioussubstance use disorders who may have been thefirst to expose their children to intravenousdrugs. Treatment providers must make effortsto assess whether family reunification isappropriate for these youths. Returning them toa chaotic home environment after treatment isfrequently not an appropriate discharge option.In these cases, treatment providers should

68

collaborate with child welfare professionals to

explore the possibility of other transitional livingoptions for homeless youths.

Homosexual, Bisexual,and TransgenderedYouthsDuring the adolescent years, some young peopleexplore a variety of sexual relationships withboth the same and opposite sexes. It is duringthis time of experimentation that they begin todevelop a sexual identity, including whetherthey see themselves as heterosexual,homosexual, bisexual, or transgendered (that is,biologically of one sex but identifying primarily

with the opposite sex). Youths who begin todevelop a nonheterosexual identity have a highrisk of being ostracized by family and friends,leading many to become integrated into adultgay cultures in which substance use is greater(Cabaj, 1989; Myers et al., 1992). Rates of

depression, anxiety, and suicidal ideation and

attempts are high in these groups (Remafedi etal., 1991). Others may turn to substance use inresponse to having experienced physical orsexual abuse or as a result of homelessness.

Whatever scenario led to their currentcircumstances, these youths are at high risk fordeveloping serious substance use disorders. It isoften the case that these youths do not bringtheir problems and concerns to the attention ofhealth care providers because it would meandisclosing their sexual identity and riskingfurther alienation. Many of these youths haveno one in whom they can confide, and mostcommunities lack gay-identified services. Suchservices can be important in these situationsbecause of issues of protecting client identity.Also, gay-specific services are likely to be more

sensitive to the importance of not divorcing theissues of sexual identity from substance usedisorders during the treatment process.Effective treatment for these youths incorporateshelping them to feel comfortable with, and totake pride in, their sexual identity.

Yo the ith Coexistingisorders

Substance-abusing and substance-dependentadolescents often have coexisting physical,behavioral, and psychiatric disorders.Traditional treatment for substance usedisorders may not be effective in addressing thespecific problems associated with thesecoexisting disorders. The following sectiondiscusses specialized and adjunctive servicesthat may be needed for coexisting disorders.

Physical Health ProblemsAdolescents with chronic physical illnesses areat high risk for substance use disorders. This isparticularly the case for those with pain-relatedsyndromes, such as sickle cell anemia, migraineheadaches, and arthritis, for which treatmentwith opioid analgesics is often required. Other


illnesses that require long-term, intensivemedical intervention, such as cystic fibrosis andchronic renal failure, take a toll on both physicaland emotional health. Clinicians shouldconsider that this may, in turn, increase the riskfor misuse of psychoactive substances. Chronicillness may also put teenagers at risk forsubstance use disorders because they may feelthat using substances is the only way that they

can relate to a peer group.Distinguishing between appropriate

treatment for pain and an individual's abuse ofanalgesic drugs is often difficult, particularlywhen individuals develop symptoms oftolerance to large doses of narcotics that areused as part of treatment. It is important toremember that addiction is defined as the use ofsubstances despite adverse consequences,preoccupation with use, and the development oftolerance or withdrawal, and not tolerance orwithdrawal alone. Many individualsundergoing treatment for chronic pain developphysiological tolerance to opioid medicationsand will suffer withdrawal if the medication isabruptly discontinued. This does not necessarilymean, however, that they are addicted.Clinicians must determine whether the narcotictreatment is improving or worsening thepatient's quality of life and whether the patientis developing a preoccupation with obtainingand using the substance.

When this question does arise, however,frequent and open communication among alltreatment professionals is essential. Onephysician should be assigned to write allprescriptions, and patients may be asked to signa contract to this effect. In acute situationswhere a patient appears to be in pain and isrequesting medication, it is best to err on theside of giving treatment. That is, administer therequested medication under controlledconditions (e.g., admit to the hospital ortreatment facility) and then consult with aphysician who is specially trained in the

99 69

Chapter 7

treatment of pain and addiction. This approachprevents sudden, dangerous withdrawal andhelps to build the patient's sense of trust. If apatient is exaggerating symptoms or reporting afictitious illness, there will be ample time later toaddress these problems.

Whenever there is a suspicion of a coexistingsubstance use disorder and a medical illness, thetreatment team must simultaneously assess andtreat both problems. There may be a tendencyfor treatment professionals to focus on only oneof the coexisting disorders; in other words,either the patient has a real pain syndrome or hehas a substance use disorder. The treatmentprovider should recognize when the patient hasa coexisting disorder and address both the realchronic pain or distress and the substance usedisorder. When an individual is admitted totreatment, a complete physical assessmentshould be conducted; when new or recurrentphysical complaints arise, a completereassessment should be performed. See TIP 29,Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities, for further

discussion on this topic (CSAT, 1998)Patients with severe or life-threatening

illnesses, particularly HIV infection and AIDS,may require hospitalization and ongoingpsychotherapy to deal with the physical andemotional effects of these conditions. HIV-infected patients who develop AIDS mayescalate their substance use, with therationalization that they now have nothing tolose. It helps to make these patients understandthat their substance use is likely only to hastenthe progress of their disease and that AIDS isbeing increasingly managed as a chronic ratherthan a fatal illness. (Refer to the forthcomingrevised TIP, Treatment of Persons with HIV/AIDS

and Substance Use Disorders [CSAT, in press].)

Emotional and Mental DisordersThe coexistence of adolescent substance use andmental or behavioral disorders is relatively

70

common (Bukstein, 1997). Because these twosets of problems are integrally related and oftendifficult to disentangle, it is probably best totreat the cluster of disorders together. Attentionto the treatment of only the substance use oronly the other disorder may not result in optimaloutcomes. Treatment providers and mentalhealth authorities should develop programstogether to treat youths with coexistingdisorders. Crosstraining can help staff of bothprograms develop the sensitivity and the clinicalskills to understand the dual diagnosis and toidentify the presence of either problem or both.

Substance use by adolescents with coexistingand behavioral disorders has receivedconsiderable discussion in the adolescentliterature. Whereas the prevalence ofdiagnosable behavioral disorders among clinicaladolescent populations has a solid empiricalbase (Kaminer, 1994), there are still questions

about the extent to which the coexistingdisorders are the cause or the effect of thesubstance use and how one may alter the courseof the other (Meyer, 1986). However, studiesamong adolescents being treated for substanceuse disorders reveal a high prevalence ofcoexisting disorders, primarily mood disorders(particularly depression), conduct/oppositionaldefiant disorder, and attention deficit/hyperactivity disorder. In a recent review of thisliterature, Kaminer reported quite variablecoexisting psychiatric rates among adolescentshaving substance use disorders, althoughvarious studies indicate a trend of over half ofthe subjects having at least one psychiatricdisorder, with conduct disorder being the mostprevalent (Kaminer, 1994).

Once a youth with a mental or behavioraldisorder begins to use substances, bothproblems tend to worsen. Because it is believedthat a major reason for substance use amongemotionally disordered youths is to cope withnegative affects (such as anxiety or depression),there may be a rebound effect on the coexisting

100

disorder if the substance use is discontinued.For example, a youth who drinks heavily to self-medicate anxiety may become even more

anxious when she reduces or quits drinking.The Panel recommends that any adolescent whois being treated for a substance use disorder andis also taking psychoactive medications for acoexisting mental or emotional disorder shouldhave routine urine testing as a part of hertreatment plan. For more information oncoexisting psychiatric conditions and substanceuse disorders, refer to TIP 9, Assessment and

Treatment of Patients With Coexisting Mental

Illness and Alcohol and Other Drug Abuse (CSAT,

1994).

Attention Deficit/Hyperactivityisorder: A Special Case

Attention deficit/hyperactivity disorder(AD/HD) has been diagnosed with increasingfrequency over the past decade, perhaps owingpartly to an increased awareness of the disorder.A growing body of literature indicates thatyouths with AD/HD are at high risk to developa substance use disorder, particularly if AD/HDcoexists with conduct disorder (e.g., Wilens etal., 1994; Windle and Windle, 1993). In addition,

the persistence of AD/HD symptoms has beenassociated with elevated risk for substance usedisorder in late adolescence and early adulthood(Biederman et al., 1995). Young people withAD/HD are impulsive and inattentive and somay require adjustment in the treatmentregimen in order to address these problems. Asignificant percentage of adolescents withAD/HD also have specific learning disorders.Such information-processing problems canimpair their ability to understand adequately thecomponents of treatment that require listening


and verbal skills. For example, such deficitsmay make group therapy a difficult and evenpainful process for AD/HD-afflicted youths.

AD/HD complicates the treatment ofsubstance use disorders. Dextroamphetamineand methylphenidate, both of which arepotential drugs of abuse, are currently themedications of choice and are sometimes thetherapeutic approach of choice for treatingchildhood AD/HD. The increasing frequencywith which AD/HD has been diagnosed overthe last decade has brought with it concern overthe increased potential for abuse of the AD/HDmedications (Cantwell, 1996). The small body ofliterature that has focused on this issue hasyielded mixed results, with some studiesreporting both worsening of risk for substanceuse disorders and improvement in risk,depending on the variable and substanceassessed (Weiss and Hechtman, 1993). There areanecdotal reports that a black market in schoolshas developed in which youths sell stimulants totheir peers. Methylphenidate can be ground upand insufflated like cocaine, and in this form it

can cause sudden cardiac arrest.Any adolescent who is being treated for a

substance use disorder and is also takingpsychoactive medications for a coexistingpsychiatric disorder should have routine urinetesting as part of his treatment plan. Closescrutiny of the psychopharmacologicalmanagement of AD/HD is particularlyimportant in such youths who are receivingtreatment for substance use disorders. Thebottom line is that psychoactive agents oftenhave a high potential for abuse, and they shouldbe used with extreme caution in adolescentswith substance use disorders.

101 71

Le al and Et

by Margaret K. Brooks, Esq.1

providers of adolescent treatment forsubstance use disorders must sometimesgrapple with these two questions:

1. Can the provider admit an adolescent intothe treatment program without obtaining theconsent of a parent, guardian, or other legallyresponsible person?

2. How can substance use disorder treatmentprograms communicate with othersconcerned about an adolescent's welfarewithout violating the stringent Federalregulations protecting confidentiality ofinformation about clients?

The answers to these questions are especiallycomplex for those who treat adolescents forsubstance use disorders because a mix of Federaland State laws govern these areas;"adolescence" spans a range of ages andcompetencies; and the answer to each questionmay require consideration of a matrix of clinical

as well as legal issues.This chapter will examine the factors

treatment service providers should consider indeciding whether a particular adolescent mayconsent to treatment in the absence of parentalconsent or notification and how communicationswith other systems can be accomplished withoutviolating the adolescent's right to privacy. Thefirst section discusses the consent issue in thecontext of the legal constraints imposed by

local Issues

Federal and State law and the clinical issues thatmay have an impact on the decision.

The second section discusses how providerscan communicate with others concerned aboutthe adolescent's welfare without violating eitherthe Federal confidentiality rules or theadolescent's heightened sense of privacy.

Consent to TreatmentAmericans attach great importance to being leftalone. They pride themselves on havingperfected a social and political system that limitshow far government and others can control whatthey do. The principle of autonomy is enshrinedin the Constitution, and U.S. courts haverepeatedly confirmed Americans' right to makedecisions for themselves. This tradition isparticularly strong in the area of medicaldecisionmaking: An adult with "decisionalcapacity"' has the unquestioned right to decidewhich treatment he will accept or to refusetreatment altogether, even if that refusal may

result in death.The situation is somewhat different for

adolescents because they do not have the legalstatus of full-fledged adults. There are certaindecisions that society will not allow them tomake: Below a certain age (which varies by Stateand by issue), adolescents must attend school,may not marry without parental consent, maynot drive, and cannot sign binding contracts.

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Chapter 8

Adolescents' right to consent to medicaltreatment or to refuse treatment also differsfrom adults'. Whether a substance use disordertreatment program may admit an adolescentwithout parental consent depends on Statestatutes governing consent and parentalnotification in the context of substance usedisorder treatment and a number of fact-basedvariables, including the adolescent's age andstage of cognitive, emotional, and socialdevelopment. Although it may make clinicalsense to obtain consent for treatment from anunderage adolescent, it is relevant to considerthe wide range of factors that contribute to aprogram's decision to admit an adolescent fortreatment without parental consent.

State LawsMore than half the States, by law, permitadolescents less than 18 years of age to consentto substance use disorder treatment withoutparental consent. In these States, providers mayadmit adolescents on their own signature. (Theimportant question of whether the provider canor should inform the parents is discussedbelow.)

In States that do require parental consent ornotification, a provider may admit an adolescentwhen there is parental consent or (in those Statesrequiring notification) when the adolescent iswilling to have the program communicate with aparent. Presumably, a parent whose child seekstreatment will consent. (A parent or guardianwho refuses to consent to treatment that a healthcare professional believes necessary for theadolescent's well-being may face charges ofchild neglect.)

The difficulty arises when the adolescentapplying for admission refuses to permitcommunication with a parent or guardian. As isexplained more fully below, with one verylimited exception, the Federal confidentialityregulations prohibit a program fromcommunicating with anyone in this situation,

74

including a parent, unless the adolescentconsents. The sole exception allows a programdirector to communicate "facts relevant toreducing a threat to the life or physical well-being of the applicant or any other individual tothe minor's parent, guardian, or other personauthorized under State law to act in the minor'sbehalf," when

® The program director believes that theadolescent, because of extreme youth ormental or physical condition, lacks thecapacity to decide rationally whether toconsent to the notification of her parent orguardianThe program director believes the disclosureto a parent or guardian is necessary to copewith a substantial threat to the life orphysical well-being of the adolescentapplicant or someone else. §§2.14(c) and (d)

Note that §2.14(d) applies only to applicantsfor services. It does not apply to minors who arealready clients. Thus, programs cannot contactparents of adolescents who are already clientswithout the adolescent's consent even ifcounselors are concerned about adolescent'sbehavior.

This is the point at which things becomemore complicated. If the adolescent refuses toconsent to communication with a parent in aState that requires parental consent ornotification, and the situation does not fit withinthe exception in §§2.14(c) and (d), the program

has two clear choices: It can refuse to admit theadolescent,3 or it can admit the adolescentdespite what the law seems to require. Inmaking this decision, the program shouldconsider the following factors (see Figure 8-1).

Other VariablesThe adolescent's age. Society accords adolescents

increased autonomy as they get older. Althoughthe details of the rules vary from State to State,

adolescents in the middle age range may obtain

1 0 3

Legal and Ethical Issues

Figure 8-1

Decision Tr,ee

Should a program admit an adolescent to treatmentwithout parental consent/notification?

Does State law requireparental consent ornotification?

YES

IL

f> NO

Factors to consider:

® Chronological age

® Emotional, social, and cognitivematurity

® Family circumstances

® Need for treatment

Clinical appropriateness ofadmission to this program

to Intensity of treatment

® State law governing refusal toadmit

® Program's financial capacity toprovide treatment withoutreimbursement

® Possible liability if programadmits the adolescent

1Are family circumstances a threat tothe adolescent's well-being?

1> Admit if program meetstreatment needs

OPTIONS

1. Admit adolescent

Admit adolescent without reservation

Admit adolescent for a limitedperiod for moderate treatment andrevisit consent issue later

2. Refuse to admit

Refuse admission due toadolescent's age and maturity

Refuse admission becausetreatment is not needed

Refuse admission because treatment is notappropriate and refer adolescent to anothertype of counseling service or anothersubstance use disorder treatment program

0,- YESMake a report to childwelfare authorities

1 0 475

Chapter 8

a driver's license, often with limitations, andmay work during their high school years, if theyobtain work permits. It follows that a treatmentprovider that might refuse to admit a 14-year-old without parental consent in a State requiringit might have little concern admitting an 18-year-old in similar circumstances.

The adolescent's maturity. Chronological age is

clearly not the only concern. There are 14-year-olds who have maturity beyond their years, andthere are emotionally immature 18-year-oldswith poor social skills and reasoning ability.Thus, a provider pondering whether to admit anadolescent without parental consent in a Staterequiring it should assess the adolescent'smaturity as well as her chronological age.

The adolescent's family situation. This TIP has

emphasized the importance of familyinvolvement in treatment. However, involvingan adolescent's parents or notifying them toobtain their consent may be impractical andclinically unwise in some cases. Adolescentswho refuse to permit parental notification mayhave good reasons; requiring them to do so maynot be ethical or very good clinical practice.Reconciliation with the family may be vital to anadolescent's recovery, but circumstances maydictate that it be abandoned or postponed until alater stage of treatment.

The kind of treatment to be provided. The more

intrusive and intensive the proposed treatmentwould be, the more risk the program assumes inadmitting the adolescent without parentalconsent. An outpatient program is on firmerground admitting an adolescent withoutparental consent than an intensive outpatient ora residential program would be.

Federal confidentiality restrictions. As has

already been mentioned, the Federalconfidentiality regulations require substance usedisorder treatment programs that wish tocommunicate with an adolescent's parents toobtain the adolescent's written consent.

76

The program's possible liability for refusing

admission. State law may impose a duty on aprogram to treat clients in need.

The program's possible liability for treating the

adolescent without parental consent. It is

theoretically possible that a provider could besued for treating an adolescent withoutobtaining parental consent in a State thatrequires it. It is, however, unlikely. If thetreatment provided is uncontroversial andrelatively nonintrusive, does not put theadolescent at risk, and is carried out in aresponsible, nonnegligent manner, it would behard for a parent to show that any harm wasdone. This is particularly so if the providermade a reasoned decision (relying on the factorsdiscussed here) and acted in good faith and outof concern for the adolescent.

Of course, there is a slim possibility that aparent might sue a provider, claiming thattreatment harmed the youngster or turned theadolescent away from the family. However,success in such a case would require proof thattreatment harmed the adolescent or that familyrelationships were good prior to treatment andtreatment caused the adolescent's alienation.These are extraordinarily difficult things toprove. Despite popular belief, most lawyers donot chase after cases that are complex, time-consuming, expensive, and difficult to win.Convincing an attorney to take on such a casewould not be easy.

The program's financial condition. If the

program admits an adolescent without parentalconsent, it may not be paid for its treatmentservices. Any effort to bill the parent over theobjections of the adolescent would violate theFederal confidentiality regulations. If a programis publicly funded, support for services foradolescents who do not want their parentsnotified may not be a problem.

Because of the complexity of this issue,

programs in States with laws that do not clearlyallow admission of adolescents without parental

105

consent or notification should develop anadmissions policy. The policy should be basedon the variables discussed above, vis-à-vis:

State law regarding treatment of adolescents(i.e., is parental consent and/or notificationrequired?)State law regarding program liability ifadolescent clients in need are turned awayThe family circumstances as related by theadolescentverifying the adolescent's viewof his family, with his consent, by contactingan adult who knows the family wellThe adolescent's age and emotional,cognitive, and social maturity

m The nature, severity, and complexity ofpresenting problems, and the kind oftreatment the program providesThe program's financial capacity to providetreatment without reimbursement from thefamily

Potential for exposure to a lawsuit should theprogram admit the adolescentWith the above factors in mind, anassessment of the potential liability of theprogram if the adolescent is admitted

The admission policy need not be rigid. Forexample, a provider could develop a policypermitting treatment of limited duration foradolescents of sufficient maturity who are inneed of treatment and who refuse to consent toparental notification. During that period oftime, the program would provide treatment oflight or moderate intensity and, at the sametime, work with the adolescent on thenotification issue. If the adolescent consents toparental notification after a period of time, theproblem may be resolved. If the adolescentremains adamantly opposed to communicationwith her parents and if the program is convincedthere is ample justification, it could assist theadolescent in finding another adult relative tobring into the picture or help find legalassistance that would permit the adolescent to


gain "emancipated minor" status or simplycontinue treatment.

If an adolescent's family situation poses areal threat to her well-being, it may beappropriate for the program to report that fact tochild welfare officials.' This option is alsoavailable to the provider who determines that itis inappropriate to admit an adolescent totreatment without parental consent because ofthe youngster's age or maturity.' The entiredecisionmaking process, including reasons forexceptions to the policy, should be noted in theclient's medical records.

Privacy andConfidentialityThose who treat adolescents with substance usedisorders are naturally concerned about theirclients' privacy and confidentiality. For anadolescent, disclosure of a substance usedisorder may contribute to negative stigma.Disclosures of information about an adolescent'ssubstance use disorder might result in hishaving to deal with inquisitive peers, who mayfeel uncomfortable around him or subject him toridicule. Adolescents in recovery have much toovercome, without having to face their peersbefore they are ready.

Given the importance of respectingadolescent clients' privacy, how can a programthat assesses and treats adolescents approachfamily, school, and other sources that haveinformation it may need? Can the programcontact a parent or guardian without anadolescent's consent? If an adolescent tells aprogram staff member that she has been abused,can the program report it? If the adolescent tellsa counselor she has committed a crime, shouldthe counselor notify the police? If the adolescentis threatening harm to herself or another, can theprogram call the authorities? Are there specialrules regarding confidentiality for programs

.106

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operating in the juvenile justice system or forchild welfare programs?

This section attempts to answer these andrelated questions. It has five parts. First, there isan overview of the Federal law protecting ayouth's right to privacy when seeking orreceiving treatment services. Next is a detaileddiscussion of the rules regarding the use ofconsent forms to get an adolescent's permissionto release information about his seeking orreceiving substance abuse services. The thirdreviews the rules for communicating with othersabout various issues concerning a youth who isin treatment for a substance use disorder(including rules for communicating withparents, guardians, and other sources; reportingchild abuse; warning others of an adolescent'sthreats to harm herself or another; and specialrules for use within the criminal and juvenilejustice systems). The next part discusses anumber of exceptions to the general rule barringdisclosure such as medical emergencies. Thissection ends with a few additional pointsconcerning a youth's right to confidentialservices and the need for programs to obtainlegal assistance.

Federal Law Protects Adolescents'Right to PrivacyConcerned about the adverse effects socialstigma and discrimination have on clients inrecovery and how that stigma anddiscrimination might deter people from enteringtreatment, Congress passed legislation, and theDepartment of Health and Human Servicesissued a set of regulations to protect informationabout clients' substance use disorder treatment.The law is codified at 42 U.S.C. §290dd-2. The

implementing Federal regulations, Confidentiality

of Alcohol and Drug Abuse Client Records, are

contained in 42 C.F.R. Part 2 (Vol. 42 of the Code

of Federal Regulations, Part 2).

The Federal law and regulations severelyrestrict communications about identifiable

78

clients by "programs" providing substanceuse/abuse diagnosis, treatment, or referral fortreatment (42 CFR §2.11). The purpose of thelaw and regulations is to decrease the risk thatinformation about individuals in recovery willbe disseminated and that they will be ostracizedor subjected to discrimination.

The regulations restrict communicationsmore tightly in many instances than, forexample, either the doctorclient or theattorneyclient privilege. Violating theregulations is punishable by a fine of up to $500for a first offense and up to $5,000 for eachsubsequent offense (§2.4).6 Some may view

these Federal regulations governingcommunication about the adolescent andprotecting privacy rights as an irritation or abarrier to achieving program goals. However,most of the nettlesome problems that may cropup under the regulations can easily be avoidedthrough planning ahead. Familiarity with theregulations' requirements will assistcommunication. It can also reduceconfidentiality-related conflicts among theprogram, adolescent client, parent, and outsideagencies so that they occur only in a fewrelatively rare situations.

What Types of Programs AreGoverned by the Regulations?Any program that specializes, in whole or inpart, in providing treatment, counseling, and/orassessment and referral services for adolescentswith substance use disorders must comply withthe Federal confidentiality regulations (42 C.F.R.

§2.12(e)). Although the Federal regulationsapply only to programs that receive Federalassistance, this includes indirect forms ofFederal aid such as tax-exempt status or State orlocal government funding coming (in whole orin part) from the Federal Government.

Coverage under the Federal regulations doesnot depend on how a program labels its services.Calling itself a "prevention program" does not

for

excuse a program from adhering to theconfidentiality rules. It is the kind of services,not the label, that will determine whether theprogram must comply with the Federal law.

The General Rule: Overview ofFederal Confidentiality LawsThe Federal confidentiality laws and regulationsprotect any information about an adolescentwho has applied for or received any substanceuse/abuse-related assessment, treatment, orreferral services from a program that is coveredunder the law. Services applied for or receivedcan include assessment, diagnosis, individualcounseling, group counseling, treatment, orreferral for treatment.' The restrictions ondisclosure (the act of making information knownto another) apply to any information that wouldidentify the adolescent as having a substance usedisorder either directly or by implication. Thegeneral rule applies from the time the adolescentmakes an appointment. It also applies to formerclients. The rule applies whether or not theperson making an inquiry already has theinformation, has other ways of getting it, hassome form of official status, is authorized byState law, or comes armed with a subpoena orsearch warrant.

When May Confidentialinformation Be Shared WithOthers?Information that is protected by the Federalconfidentiality regulations may always bedisclosed after the adolescent has signed aproper consent form. (As will soon becomeclear, parental consent must also be obtained insome States.) The regulations also permitdisclosure without the adolescent's consent inseveral situations, including medicalemergencies, reporting child abuse, andcommunications among program staff.Nevertheless, obtaining the adolescent's consentis the most commonly used exception to the


general rule prohibiting disclosure. Theregulations' requirements regarding consent arestrict and somewhat unusual and must becarefully followed.

Consent: Rules about obtainingadolescent consent to disclosetreatment informationMost disclosures are permissible if an adolescenthas signed a valid consent form that has notexpired or been revoked (§2.31).8 A properconsent form must be in writing and mustcontain each of the items specified in §2.31:

in The name or general description of theprogram(s) making the disclosure

ts The name or title of the individual ororganization that will receive the disclosure

g The name of the adolescent who is the subjectof the disclosure

s The purpose or need for the disclosureg How much and what kind of information

will be disclosedA statement that the adolescent may revoke(take back) the consent at any time, except tothe extent that the program has already actedon it

E The date, event, or condition upon which theconsent will expire if not previously revoked

g The signature of the adolescent (and, in someStates, her parent)The date on which the consent is signed(§2.31(a))

A general medical release form or anyconsent form that does not contain all of theelements listed above is not acceptable. (Seesample consent form in Figure 8-2.) A numberof items on this list deserve further explanationand are discussed under the followingsubheadings:

En The purpose of the disclosure and how muchand what kind of information will bedisclosed

g The adolescent's right to revoke his consent

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80

Figure 8-2

Sample Consent Form

Consent for the Release of Confidential Information

, authorize XYZ Clinic to receive

(name of client or participant)

from/disclose to

(name of person and organization)

for the purpose of

(need for disclosure)

the following information

(nature of the disclosure)

I understand that my records are protected under the Federal and State Confidentiality Regulations

and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I also understand that I may revoke this consent at any time except to the extent that action has

been taken in reliance on it and that in any event this consent expires automatically on

unless otherwise specified below.

(date, condition, or event)

Other expiration specifications:

Date executed

Signature of client

Signature of parent or guardian, where required

109

o Expiration of the consent formThe adolescent's signature and parentalconsent

O The required notice against re-releasinginformation

These topics are followed by a note aboutagency use of the consent forms.

The purpose of the disclosure andhow much and what kind ofinformation will be disclosedThese two items are closely related. Alldisclosures, and especially those made pursuantto a consent form, must be limited toinformation that is necessary to accomplish theneed or purpose for the disclosure (§2.13(a)). Itwould be improper to disclose everything in anadolescent's file if the recipient of theinformation needs only one specific piece ofinformation.

The purpose or need for the communicationof information must be specified on the consentform. Once the purpose or need has beenidentified, it is easier to determine how muchand what kind of information will be disclosed,tailoring it to what is essential to accomplish thespecified need or purpose. That, too, must bewritten into the consent form.

As an illustration, if an adolescent needs tohave her participation in counseling verified inorder to be excused from school early, thepurpose of the disclosure would be "to verifytreatment status so that the school will permitearly release," and the amount and kind ofinformation to be disclosed would be "time anddates of appointments." The disclosure wouldthen be limited to a statement that "Susan Jones(the client) is receiving counseling at XYZ

Program on Tuesday afternoons at 2 p.m."

The adolescent's rightto revoke consentThe adolescent may revoke consent at any time,and the consent form must include a statementto this effect. Revocation need not be in writing,


but the standard of practice is to document averbal revocation with a dated note in thetreatment record. If a program has alreadymade a disclosure prior to the revocation, actingin reliance on the adolescent's signed consent, itis not required to try to retrieve the informationit has already disclosed.

The regulations also provide that "acting inreliance" includes the provision of services whilerelying on a consent form permitting disclosuresto a third-party payor. (Third-party payors arehealth insurance companies, Medicaid, or anyparty that pays the bills other than theadolescent's family.) Thus, a program can billthe third-party payor for services providedbefore the consent was revoked. However, aprogram that continues to provide services aftera client has revoked a consent authorizingdisclosure to a third-party payor does so at itsown financial risk.

Expiration of consent formThe form must also contain a date, event, orcondition on which it will expire if notpreviously revoked. A consent must last "nolonger than reasonably necessary to serve thepurpose for which it is given" (§2.31(a)(9)).

Depending on the purpose of the consenteddisclosure, the consent form may expire in 5days, 6 months, or longer. Sound practice callsfor adjusting the expiration date in this way,rather than imposing a set time period, say 60 to

90 days. When providers use uniformexpiration dates, they can find themselves in asituation for which there is a need for disclosure,but the adolescent's consent form has expired.This means at the least that the client must cometo the agency again to sign a consent form. Atworst, the client has left or is unavailable, andthe agency will not be able to make thedisclosure.

The consent form does not have to contain aspecific expiration date but may instead specifyan event or condition. For example, if anadolescent has been placed on probation at

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school on the condition that he attendcounseling at the program, the consent form canbe drafted to expire at the completion of theprobationary period. Or, if an adolescent isbeing referred to a specialist for a singleappointment, the consent form should stipulatethat consent will expire after he has seen"Dr. X."

The signature of the adolescent (andthe issue of parental consent)The adolescent must always sign the consentform in order for a program to releaseinformation even to her parent or guardian. Theprogram must get the signature of a parent,guardian, or other person legally responsible forthe adolescent in addition to the adolescent'ssignature only if the program is required byState law to obtain parental permission beforeproviding treatment to the adolescent (§2.14).

In other words, if State law does not requirethe program to get parental consent in order toprovide services to the adolescent, then parentalconsent is not required to make disclosures(§2.14(b)). If State law requires parental consentto provide services to the adolescent, thenparental consent is required to make anydisclosures. Note that the program must alwaysobtain the adolescent's consent for disclosuresand cannot rely on the parent's signature alone.

Required notice against redisclosinginformationOnce the consent form has been properlycompleted, there remains one last formalrequirement. Any disclosure made with clientconsent must be accompanied by a writtenstatement that the information disclosed isprotected by Federal law and that the recipientcannot further disclose or release suchinformation unless permitted by the regulations(§2.32). This statement, not the consent formitself, should be delivered and explained to therecipient of the information at the time ofdisclosure or earlier. (Of course, an adolescent

82

may sign a consent form authorizing aredisclosure.)

Note on agency use of consent formsThe fact that an adolescent has signed a properconsent form authorizing the release ofinformation does not force a program to makethe proposed disclosure, unless the program hasalso received a subpoena or court order(§§2.3(b)(1); 2.61(a)(b)). In most cases, the

decision whether to make a disclosureauthorized by a client's signed consent is up tothe program, unless State law requires orprohibits a particular disclosure once consent isgiven. The program's only obligation under theFederal regulations is to refuse to honor aconsent that is expired, deficient, or otherwiseknown to be revoked, false, or incorrect(§2.31(c)).

In general, it is best to follow this rule:Disclose only what is necessary, for only as long

as is necessary, keeping in mind the purpose fordisclosing the information.

Rules for Communicating WithOthers About Adolescents:Common IssuesNow that the rules regarding consent are clear,attention can turn to the questions that wereintroduced at the beginning of this section.

How can a program seek information fromcollateral sources about an adolescent,coordinate care with other agencies servingthe adolescent, and make referrals for theadolescent?How can programs communicate withparents?

PE Are there special rules for adolescents whoare involved in the juvenile or criminaljustice systems?

1 Do programs have a duty to warn potentialvictims or law enforcement agencies ofthreats by adolescents, and if so, how do theycommunicate the warning?

11 1

O What should a program do if an adolescentconfesses to committing a crime?

O How should programs deal with adolescents'risk-taking behavior?Can programs report child abuse?

Seeking Information FromCollateral Sources, CoordinatingCare, and Making ReferralsMaking inquiries of schools, doctors, and otherhealth care providers might, at first glance, seemto pose no risk to an adolescent's right toconfidentiality. But it does.

When a program that screens, assesses, ortreats adolescents asks a school, doctor, orparent to verify information it has obtained fromthe adolescent, it is making a disclosure that thenamed adolescent has sought help for asubstance use disorder. The Federal regulationsgenerally prohibit this kind of disclosure unlessthe adolescent consents.

How then is a program to proceed? Theeasiest way is to get the adolescent's consent tocontact the school, health care facility, and so on.

In fact, the program can ask the client to sign aconsent form that permits it to make this kind oflimited disclosure in order to gather informationfrom any one of a number of entities or personslisted on the consent form. Note that thiscombination form must still include "the nameor title of the individual or name of theorganization" for each collateral source theprogram may contact. The program must alsoinform the party at the other end of the inquiryabout the prohibition on redisclosure, orally atfirst if the communication is via telephone.

Note, however, if the information beingdisclosed is not about the adolescent's substanceuse disorder, then the answer may be different.For example, 14-year-olds may be able toauthorize release of information about substanceuse disorder treatment, but a client may have tobe 16 years old to consent to release a psychiatricrecord, and, in most jurisdictions, school systems


will not release educational records if the clientis less than 18 years old. Many programs haveboth child and parent sign to indicate that, evenif only one signature is required by law, allparties involved agree to the release of theinformation.

Communications AmongAgenciesMaking Periodic Reportsor Coordinating CarePrograms serving adolescents may have toconfer on an ongoing basis with other agencies,such as mental health or child welfare programs.Again, the best way to proceed is to get theadolescent's consent (as well as parental consentwhen State law so requires). Care should betaken in wording the consent form to permit thekinds of communications necessary. Forexample, if the program needs ongoingcommunications with a mental health provider,the "purpose of the disclosure" would be"coordination of care for Hector Velez" and"how much and what kind of information willbe disclosed" might be "treatment status,treatment issues, and progress in treatment." Ifthe program is treating a client who is onprobation at school and whose future schoolattendance is contingent on treatment, the"purpose of disclosure" might be "to assist theclient to comply with the school district'smandates" or to "supply periodic reports aboutattendance" and "how much and what kind ofinformation will be disclosed" might be"attendance" or "progress in treatment." Notethat the kinds of information that will bedisclosed in these two examples are quitedifferent. The program might well sharedetailed clinical information about a client witha mental health provider if that would assist incoordinating care. Disclosure to a school shouldbe limited to a brief statement about the client'sattendance or progress in treatment. Disclosureof detailed clinical information to the schoolwould, in most circumstances, be inappropriate.

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The program should also give considerablethought to the expiration date or event theconsent form should contain. For coordinatingcare with a mental health program, it might beappropriate to have the consent form expirewhen treatment by either agency ends. Aconsent form permitting disclosures to a schoolmight expire when the adolescent'sprobationary period ends.

Programs treating adolescents often referclients to other health care or social serviceagencies. Giving an adolescent the name andtelephone number of an outside gynecologist,tutoring service, or training program might notbe effective unless the adolescent's treatmentcounselor calls to set up the appointment for theadolescent. However, such a call is a disclosureof confidential information that the adolescenthas a substance use disorder and requires thecounselor to get the client's consent in writing(as well as parental consent in States requiringit).

Communicating WithParents or GuardiansAs has been noted above, programs may notcommunicate with the parents of an adolescentunless they get the adolescent's written consent.When the adolescent is willing to consent to adisclosure to her parents, the program shouldtake the opportunity to discuss with theadolescent whether she (and the program) wantcommunications between the program and hisparent or guardian to occur just once or on aregular basis. This decision will affect how theprogram fills out the consent form.

If a program counselor and the adolescentjointly decide they want the counselor to conferwith the parent or guardian only once, in orderto obtain the parent's consent to treatment or togather additional information, the purpose ofthe disclosure (which must be stated on theconsent form) would be "to notify Mary's

parents" or "to obtain information from Mary's

84

parents in order to assist in the assessmentprocess." The "kind of information" to bedisclosed (in either of these instances) would be"Mary's application for services." Theexpiration date should be keyed to the date ofparental notification or the date by which thecounselor thinks the assessment process will becompleted.

If the program and Mary decide they wantthe program's counselor to be free to talk toMary's parent or guardian over a longer periodof time, the program would fill out the consentform differently. The purpose of the disclosuremight then be "to provide periodic reports toMary's parents" and the kind of information tobe disclosed would be "Mary's progress intreatment." Or, the purpose might be "toprovide family counseling to Mary and herfamily" and the kind of information to bedisclosed would be "Mary's treatment." Theexpiration of this kind of open-ended consentform might be set at the date the program andMary foresee counseling ending or even "whenMary's participation in the program ends."(However, Mary can revoke the consent anytime she wishes.)

What if Mary refuses to consent? Because theFederal confidentiality regulations forbiddisclosures without Mary's consent, the programcannot confer with her parents. This issue wasdiscussed above.

Special Consent Rules forAdolescents Involved in theCriminal or Juvenile JusticeSystemsPrograms assessing or treating adolescents whoare involved in the criminal justice system (CJS)

or juvenile justice system (JJS) (i.e., juvenile

court) must also follow the Federalconfidentiality rules. However, some specialrules apply when an adolescent comes forassessment or treatment as an official conditionof probation, sentence, dismissal of charges,

1 3

release from detention, or other disposition of acriminal or juvenile justice proceeding.'

A consent form (or court order) is stillrequired before a program can discloseinformation about an adolescent who is thesubject of CJS or JJS referral. However, the rules

concerning the length of time that a consent isvalid and the process for revoking the consentare different (§2.35). Specifically, the regulationsrequire that the following factors be consideredin determining how long a CJS or JJS consentwill remain in effect:

m The anticipated duration of treatmentEl The type of juvenile or criminal proceedingm The need for treatment information in

dealing with the proceedingm When the final disposition will occur® Anything else the adolescent, program, or

justice agency believes is relevant

These rules allow programs to draft theconsent form to expire "when there is asubstantial change in the adolescent's justicesystem status." A substantial change in justicestatus occurs whenever the adolescent movesfrom one phase of the JJS or CJS to the next. Forexample, for an adolescent on probation, achange in JJS or CJS status would occur when

the probation ends, either by successfulcompletion or revocation. Thus, the programcould provide an assessment and periodicreports to the adolescent's probation officer andcould even testify at a probation revocationhearing if it so desired, because no change instatus would occur until after that hearing.

Moreover, the Federal regulations permit theprogram to draft the consent form so that itcannot be revoked until a certain specified dateor condition occurs. The regulations permit theJJS or CJS consent form to be irrevocable so that

an adolescent who has agreed to enter treatmentin lieu of prosecution or punishment cannot thenprevent the court, probation department, orother agency from monitoring his progress.


Note that although a JJS or CJS consent may bemade irrevocable for a specified period of time,that time period must end no later than the finaldisposition of the juvenile or criminal justiceproceeding. Thereafter, the adolescent mayfreely revoke consent. A sample criminal justiceconsent form appears in Figure 8-3.

Duty to WarnFor most treatment professionals, the issue ofreporting a client's threat to harm another orcommit a crime is a troubling one. Manyprofessionals believe that they have an ethical,professional, or moral obligation to prevent acrime when they are in a position to do so,particularly when the crime is a serious one.

There has been a developing trend in the lawto require psychiatrists and other therapists totake "reasonable steps" to protect an intendedvictim when they learn that a client presents a"serious danger of violence to another." Thistrend started with the case of Tarasoff v. Regents

of the University of California, 17 Ca1.3d 425

(1976). In that case, the California SupremeCourt held a psychologist liable for monetarydamages because he failed to warn a potentialvictim that his client threatened to kill thatperson and then did so. The court ruled that if apsychologist knows that a client poses a seriousrisk of violence to a particular person, thepsychologist has a duty "to warn the intendedvictim or others likely to apprise the victim ofthe danger, to notify the police, or to takewhatever other steps are reasonably necessaryunder the circumstances."

Although the Tarasoff ruling, strictlyspeaking, applies only in California, courts andlegislatures in other States have adoptedTarasoff's reasoning to hold therapists liable for

monetary damages when they have failed towarn someone threatened by a client. In mostinstances, liability is limited to situations inwhich a client threatens violence to a specificidentifiable victim; liability does not usually

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Figure 8-3

Consent Form: Criminal Justice System leferral

Consent for the Release of Confidential Information

, hereby consent to communication

(name of defendant)

between and

(treatment program)

(court, probation, parole, and/or other referring agency)

the following information

(nature of the information, as limited as possible)

The purpose of and need for the disclosure is to inform the criminal justice agency(ies) listed above

of my attendance and progress in treatment. The extent of information to be disclosed is my

diagnosis, information about my attendance or lack of attendance at treatment sessions, my

cooperation with the treatment program prognosis, and

I understand that this consent will remain in effect and cannot be revoked by me until:

There has been a formal and effective termination or revocation of my release from

confinement, probation, or parole, or other proceeding under which I was mandated into

treatment or

(other time when consent can be revoked and/or expires)

I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal

Regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records and that recipients of

this information may redisclose it only in connection with their official duties.

(Date) (Signature of defendant/patient)

(Signature of parent, guardian, or

authorized representative if required)

86

apply when a client makes a general threatwithout identifying the intended target.

If an adolescent's counselor thinks the youthposes a serious risk of violence to someone, thereare at least twoand sometimes threequestions that must be answered:

1. Does a State statute or court decision imposea duty to warn in this particular situation?

2. Even if there is no State legal requirementthat the program warn an intended victim orthe police, does the counselor feel a moralobligation to warn someone?

The first question can only be answered byan attorney familiar with the law in the State inwhich the program operates. If the answer tothe first question is "no," then it is advisable todiscuss the second question with a knowledge-able lawyer, too.

If the answer to question 1 or 2 is "yes," thenhow can the program warn the victim orsomeone able to take preventive action withoutviolating the Federal confidentiality regulations?

The problem is that there is a conflictbetween the Federal confidentialityrequirements and the duty to warn imposed byStates that have adopted the Tarasoff rule.

Simply put, the Federal confidentiality law andregulations appear to prohibit the type ofdisclosure that the Tarasoff rule requires.

Moreover, the Federal regulations make it clearthat Federal law overrides any State law thatconflicts with the regulations (§2.20). In the onlycase, as of this writing, that addresses thisconflict between Federal and State law (Hansenie

v. United States, 541 F.Supp. 999 (D. Md. 1982)),

the court ruled that the Federal confidentialitylaw prohibited any report.

When an adolescent makes a threat to harmhimself or another and the program isconfronted with conflicting moral and legalobligations, it can proceed in one of thefollowing ways:


o The program can go to court and request acourt order authorizing the disclosure. Theprogram must take care that the court abidesby the requirements of the Federalconfidentiality regulations (which arediscussed below in detail).The program can make a disclosure that doesnot identify the adolescent who hasthreatened to harm another as a client. Thiscan be accomplished either by making ananonymous report orfor a program that ispart of a larger nonsubstance use disordertreatment facilityby making the report inthe larger facility's name. For example, acounselor employed by a substance abuseprogram that is part of a mental healthfacility could phone the police or thepotential target of an attack, identify herselfas "a counselor at the New City MentalHealth Clinic," and explain the risk. Thiswould convey the vital information withoutidentifying the adolescent as someone insubstance use disorder treatment.Counselors at freestanding treatmentprograms cannot give the name of theprogram. (The "nonclient-identifyingdisclosure" exception is discussed more fullybelow.)

o If the adolescent has been mandated intotreatment by the CJS or JJS, the program canmake a report to the mandating CJS or JJSagency, so long as it has a CJS consent formsigned by the adolescent that has beenworded broadly enough to allow this sort ofinformation to be disclosed. The CJS or JJS

agency can then act on the information toavert harm to the adolescent or the potentialvictim. However, the regulations limit whatthe justice agency can do with theinformation. Section 2.35(d) states thatanyone receiving information pursuant to aCJS consent may redisclose and use it only tocarry out that person's official duties withregard to the client's conditional release or

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other action in connection with which theconsent was given. Thus, the referring justiceagency can use the disclosure to revoke theadolescent's conditional release or probationor parole. If the justice agency wants to warnthe victim or to notify another lawenforcement agency of the threat, it must becareful that it does not mention that thesource of the tip was someone at a substanceuse disorder treatment program or that theadolescent making the threat is in treatmentfor a substance use disorder. However, thedisclosure most likely cannot be used toprosecute the adolescent for a separateoffense (such as making the threat). The onlyway to prosecute an adolescent based oninformation obtained from a program is toobtain a special court order in accordancewith §2.65 of the regulations (which is

discussed below).o The program can make a report to medical

personnel if the threat presents a medicalemergency that poses an immediate threat tothe health of any individual and requiresmedical intervention. (See the dikussion ofthe medical emergency exception below.)

o The program can obtain the client's consent.

If none of these options is practical and if acounselor believes there is a clear and imminentdanger to an adolescent client or anotheridentified person, then it is probably wiser to erron the side of making an effective report aboutthe danger to the authorities or to the threatenedindividual.

Although each case presents differentquestions, it is doubtful that any prosecution (orsuccessful civil lawsuit) under theconfidentiality regulations would be broughtagainst a counselor who warned about potentialviolence when he believed in good faith thatthere was real danger to a particular individual.On the other hand, a civil lawsuit for failure towarn may well result if the threat is actuallycarried out. In any event, the counselor should

88

at least try to make the warning in a manner thatdoes not identify the individual as having asubstance use disorder.

Duty-to-warn issues represent an area inwhich staff training, as well as a staff reviewprocess, may be helpful. For example, atroubled youth may engage in verbal threats as away of "blowing off steam." Such threats maybe the adolescent's cry for additional supportservices. Program training and discussions canassist staff in sorting out what should be done ineach particular situation.

Is There a Duty to Warn of an HIV-Infected Adolescent's Threat toOthers?One more duty-to-warn issue needs to bediscussed. Do providers have a duty to warnothers when they know that an adolescent theyare treating is infected with HIV? When wouldthat duty arise? Even where no duty exists,should providers warn others at risk about anadolescent's HIV status? Finally, how can othersbe warned without violating the Federalconfidentiality regulations and Stateconfidentiality laws?

Is there a duty?The answer to the first question is a matter ofState law. Courts in some States have held thathealth care providers have a duty to warn thirdparties of the behavior of persons under theircare if it poses a potential danger to others. Inaddition to these court decisions, some Stateshave enacted laws that either permit or requirehealth care providers to warn certain thirdparties. These persons may include sex partnersat risk. Usually, these State laws prohibitdisclosure of the infected person's identity,while allowing the provider to tell the person atrisk that he may have been exposed. It isimportant that providers consult with anattorney familiar with State law to learn whetherthe law imposes a duty to warn, as well aswhether State law prescribes the ways in which

11"

a provider can notify the person at risk. (Forexample, is the provider prohibited fromdisclosing the adolescent's name? Must theadolescent consent?) Because the law in thisarea is still developing, it is also important tokeep abreast of changes.

When does the duty arise?Two behaviors of infected persons can putothers at risk of infection: unprotected sexinvolving the exchange of bodily fluids andneedle-sharing. Because HIV is not transmittedby casual contact, the simple fact that anadolescent is infected would not give rise to aduty to warn the adolescent's family oracquaintances who are not engaged in sex orneedle-sharing with the adolescent.

This still leaves open the question of when aduty arises. Would it be when an adolescenttells a counselor that he wants or plans to infectothers? Or would it arise when an adolescenttells the counselor that he has already exposedothers to HIV? These are two differentquestions.

The threat to expose othersA counselor whose adolescent client threatens toinfect others should consider three questions indetermining whether there is a duty to warn:

Is the adolescent making a threat or "blowing off

steam"? Sometimes, wild threats are a way ofexpressing anger. Such threats may be theadolescent's cry for additional support services.However, if the adolescent has a history ofviolence or of sexually abusing others, the threatshould probably be taken seriously.

Is there an identifiable potential victim? Most

States that impose a duty to warn do so onlywhen there is an identifiable victim or class of

victims. Without an identifiable victim, it isdifficult to warn anyone; and, unless publichealth authorities have the power to detainsomeone in these circumstances, there is littlereason to inform them.


Does a State statute or court decision impose a

duty to warn in this particular situation? Even if

there is no State legal requirement that theprogram warn an intended victim or the police,does the counselor feel a moral obligation towarn someone?

Clearly, there are no definitive answers inthis area. As with other duty-to-warn issues,each case depends on the particular fact patternpresented and on State law. If a providerbelieves that she has a duty to warn under Statelaw or that there is real danger to a particularindividual giving rise to a moral or ethical dutyto warn that individual, she should do so in away that complies with both the Federalconfidentiality regulations and any State law orregulation regarding disclosure of medical orHIV-related information. Because a client isunlikely to consent to a disclosure to thepotential victim, in an effort to comply with theFederal regulations, a provider could

o Seek a court order authorizing the disclosure.The provider should consult State law todetermine whether it imposes requirementsin addition to those imposed by the Federalregulations.

o Make an "anonymous" warningthat is, awarning that does not disclose theadolescent's status as having a substance usedisorder. The provider should also limit theway it issues the warning so as to expose theadolescent's identity as HIV-positive to asfew people as possible.

Reporting an exposureSuppose an HIV-infected adolescent tells hiscounselor that he has had unprotected sex orshared needles with someone? If the counselorknows who the person is, does she have a dutyto warn the person (or law enforcement)?

This is not a true duty-to-warn case becausethe exposure has already occurred. The purposeof the "warning" is not to prevent a criminal act,

1 8 89

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but to notify an individual so that he can takesteps to monitor health status or begin drugtherapy. Thus, it is probably not helpful to call alaw enforcement agency. Rather, the counselormight want to let the public health authoritiesknow, particularly in States with mandatorypartner notification laws. Public health officialscan then find the person at risk and provideappropriate counseling.

How can programs notify the public healthdepartment without violating the confidentialityregulations? In some areas of the country,programs have signed qualified serviceorganization agreements (QS0As) with publichealth departments that provide services to theprogram (for more information on QSOAs, seethe subsection, Sharing Information With anOutside Agency That Provides Services to thePrograms, below). This enables providers toreport exposures to the department in situationslike these. The public health department canthen help not only the person the counselorbelieves was exposed, but can also trace othercontacts the adolescent may have exposed. Indoing so, the public health department oftendoes not identify the person who has put hiscontacts at risk. Certainly, the public healthdepartment would not have to tell the contactthat the person is in treatment for a substanceuse disorder, and the QSOA would prohibit itfrom doing so. (A treatment program must alsomake sure that reporting an exposure by a clientthrough a QSOA complies with any State lawprotecting medical or HIV-related information.)

Notifying others withoutviolating the lawIf the provider does not have a QSOA with thepublic health department, it might try one of thefollowing:

o Consent. The provider could inform thehealth department with the adolescent'sconsent. The consent form must comply withboth the Federal confidentiality regulations

90

and any State requirements governing clientconsent to release of HIV/AIDS information,as well as any State law governing consent byadolescents (i.e., whether a parent must also

consent).la "Anonymous" notification. If the program

notifies the public health department in away that does not identify the adolescent ashaving a substance use disorder it would becomplying with the Federal regulations.

Ea Court order. Again, State law must be

consulted to determine whether it imposesrequirements in addition to those imposed bythe Federal regulations.

One of these methods should enable theprovider to alert the public health department,which is the most effective way to notifysomeone who may have been exposed.

The provider should document the factorsthat impelled the decision to warn an individualof impending danger of exposure or to report anexposure to the public health department. If thedecision is later questioned, then notes made atthe time the decision was made could proveinvaluable.

Finally, the provider should remember thatany time a program warns someone of a threatan adolescent makes without the adolescent'sconsent, the program may be undermining thetrust of other adolescents and thus itseffectiveness. This may be particularly true for aprogram serving HIV-positive adolescents.Other clients may learn of the disclosure, andthe trust that the program worked so hard tobuild may be weakened. This is not to say that adisclosure should not be madeparticularlywhen the law requires it. It is to say that a

disclosure should not be made without carefulthought.

The circumstances in which a duty to warnor notify arises may change over time asscientists learn more about the virus and itstransmission and as better treatments aredeveloped. There is little doubt that the law will

119

also change as States adopt new statutes andtheir courts apply statutes to new situations.

Programs should develop a protocol aboutduty-to-warn cases, so that staff members arenot left to make decisions on their own aboutwhen and how to report threats of violence andthreats or reports of HIV transmission. Ongoingtraining and discussions can also assist staffmembers in sorting out what should be done inany particular situation.

Reporting Criminal ActivityWhat should a program do when an adolescenttells a counselor that she intends to goshoplifting at the mall, something the counselorknows he has done before. Does the programhave a duty to tell the police? Does a programhave a responsibility to call the police when anadolescent discloses to a counselor that heparticipated in a serious crime some time in thepast? What can a program do when a clientcommits a crime at the program or against anemployee of the program? These are three verydifferent questions that require separateanalysis.

Reporting threatenedcriminal activityBy this time, the reader should know the answerto the first question: A program generally doesnot have a duty to warn another person or thepolice about an adolescent's intended actionsunless the client presents a serious danger ofviolence to an identifiable individual.

Shoplifting rarely involves violence, and thecounselor may not know which stores are to bevictimized. Petty crime like shoplifting is animportant issue that should be dealt withtherapeutically. It is not something a programshould necessarily report to the police.

Reporting past criminal activitySuppose, however, that an adolescent clientadmits during a counseling session that he killedsomeone 3 months ago. Here the program is not


warning anyone of a threat, but serious harmdid come to another person. Does the programhave a responsibility to report that?

In a situation in which a program thinks itmight have to report a past crime, there aregenerally three questions to consider:

1. Is there a legal duty to report the pastcriminal activity to the police under Statelaw?

Generally, the answer to this question is no.In most States, there is no duty to tell the policeabout a crime committed in the past. Even thoseStates that impose a duty to report rarelyprosecute violations of the law.

2. Does State law permit a counselor to reportthe crime to law enforcement authorities ifshe wants to?

Whether or not citizens have a legalobligation to report past crimes to the police,State law may protect conversations betweencounselors of substance use disorder treatmentprograms and their clients and exemptcounselors from any requirement to report pastcriminal activity by clients. State laws varywidely on the protection they accordcommunications between clients and counselors.In some States, admissions of past crimes maybe considered privileged, and counselors may beprohibited from reporting them; in others,admissions may not be privileged. Moreover,each State defines the kinds of relationshipsprotected differently. Whether a communicationabout past criminal activity is privileged (andtherefore cannot be reported) may depend onthe type of professional the counselor is andwhether she is licensed or certified by the State.

Any program that is especially concernedabout this issue should ask a local attorney foran opinion letter about whether there is a dutyto report and whether any counselorclientprivilege exempts counselors from that duty.

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3. If State law requires a report (or permits oneand the program decides to make a report),how can the program comply with theFederal confidentiality regulations and Statelaw?

Any program that decides to make a reportto law enforcement authorities about a client'sprior criminal activity must do so withoutviolating either the Federal confidentialityregulations or State laws. A program thatdecides to report a client's crime can complywith the Federal regulations by following one ofthe first three methods described above in thediscussion of duty to warn:

ga It can make a report in a way that does notidentify the adolescent as a client insubstance use disorder treatment.

m It can obtain a court order permitting it tomake a report if the crime is "extremelyserious" (§2.65(d)).If the adolescent is an offender who has beenmandated into treatment by a criminal justiceor juvenile justice agency, the program canmake a report to that justice agency, if it has aCJS consent form signed by the adolescentthat is worded broadly enough to allow thissort of information to be disclosed. (Note,however, that the regulations limit theactions law enforcement officials may take

once they have received the information.)

Because of the complicated nature of thisissue, any program considering reporting anadolescent's admission of criminal activityshould seek the advice of a lawyer familiar withlocal law as well as the Federal regulations.Because past criminal activity may not indicatean emergency, the counselors do not have todecide immediately whether to report it. Thisissue can be addressed with the client as atreatment issue. With the support of a programand proper legal advice, the adolescent mayreport the crime himself.

92

Reporting crimes on programpremises or against programpersonnelThe answer is more straightforward when anadolescent client has committed or threatens tocommit a crime on program premises or againstprogram personnel. In this situation, theregulations permit the program to report thecrime to a law enforcement agency or to seek itsassistance. In such a situation, without anyspecial authorization, the program can disclosethe circumstances of the incident, including thesuspect's name, address, last known where-abouts, and status as a client at the program(§2.12(c)(5)).

One crime that an adolescent might wellcommit on program premises is drugpossessionbringing drugs into the programeither on her person or (if the program isresidential) in her luggage. When a programfinds drugs on a client or in a client's personalproperty, what should it do? Should theprogram call the police? What should it do withthe drugs?

The answer to the first question has alreadybeen discussed above in the section dealing withreporting criminal activity. Generally, State lawdoes not require programs to make such areport. As for the second question, Stateregulations often govern how a program maydispose of drugs, sometimes requiring that theybe flushed down a toilet. Programs shouldcheck with their State substance abuse agency ifthey are unsure about State mandates.

Dealing With Adolescents'Risk-Taking BehaviorAdolescents in treatment for a substance usedisorder may engage in risky activities such asrenewed drug-taking, criminal behavior, riskysexual conduct, or other activity dangerous tothemselves or others. If a counselor believes that

1 2

the adolescent's conduct is dangerous andcounseling seems not to be productive inreducing that behavior, what should he do?

This chapter has already examined what thecounselor cannot do: He cannot call theadolescent's parents without the adolescent'sconsent and, unless there are unusualcircumstances, he most likely cannot call law

enforcement authorities. There are, however,some things he can do:

o If the adolescent has relapsed into substanceuse and the relapse has reached the pointwhere it threatens her health and requiresimmediate medical intervention, thecounselor could call the adolescent's familydoctor under the "medical emergency"exception. Note that the situation must be areal medical emergency. The medicalpersonnel that the counselor calls must "havea need for the information...for the purposeof treating" the adolescent's condition(§2.51). (For the other requirements of thissection, see below.)

Alternatively, the program could apply for acourt order that would authorize it to informthe adolescent's parents or other responsibleadults.

Neither of these alternatives is very

satisfactory. A program can use the "medicalemergency" exception only in very limitedcircumstances, and obtaining a court order istime-consuming and expensive.

There is a more satisfactory option: When a

program admits an adolescent who has a historyof risk-taking behavior, the program could askthe adolescent to sign a consent form thatauthorizes the program to tell an adult theadolescent trusts if the adolescent's behaviortakes a dangerous turn. The adult named couldbe a parent or other relative, a minister or youthcounselor, or anyone else with whom theadolescent has rapport. An adolescent enteringtreatment might consent to this arrangement


because she may believe, as do many peopleentering treatment, that she will not suffer arelapse. An added benefit of this kind of requestis that it demonstrates to the adolescent that theprogram respects her feelings and preferences,takes confidentiality seriously, and will notdisclose information to others without theadolescent's consent.

Note that if a counselor notifies the personnamed in the consent form, that person is boundby the regulations not to disclose theinformation further without the adolescent'sconsent, unless he can do so without revealingthe fact that the adolescent is in treatment for asubstance use disorder. The adolescent canrevoke her consent at any time.

Reporting Child Abuse and NeglectAll 50 States and the District of Columbia have

statutes requiring reporting when there isreasonable cause to believe or suspect that childabuse or neglect is occurring. Although manyState statutes are similar, each has different rulesabout what kinds of conditions must bereported, who must report, and when and howreports must be made.

When a program makes such a report, itshould generally notify the family, unless thenotification would place the child in furtherdanger. The program should also endeavor tocontinue to work with the family as the Stateinvestigates the complaint and the childprotective process unfolds. Families shouldnever be abandoned because of suspected abuseor neglect, and health care providers should bewary of making judgments until a comprehen-sive assessment has been completed by Stateauthorities.

Most States now require not only physiciansbut also educators and social service workers toreport child abuse. Most States require animmediate oral (spoken) report, and many nowhave toll-free numbers to facilitate reporting.(Half of the States require that both oral and

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written reports be made.) All States extendimmunity from prosecution to persons reportingchild abuse and neglect. Most States providepenalties for failure to report.

Program staff will often need some form oftraining to review the State's child abuse andneglect laws and to clearly explain what theterms abuse and neglect really mean according to

the law. A lay person'sor a professional'sidea of child neglect may differ greatly from thelegal definition. For example, in some States, achild living with a parent involved in extensivesubstance abuse, perhaps surrounded by aculture of drugs and alcohol, is not considered tobe abused or neglected unless certain otherconditions are met. Such legal definitions maygo against the grain of what some staff membersconsider to be in the best interest of the child,but these are safeguards that have developedover time to protect the child, the parent, andthe family unit. A forthcoming TIP entitledResponding to Child Abuse and Neglect Issues of

Adult Survivors in Substance Use Disorder

Treatment (CSAT, in press) provides more

information on this issue.Because of the variation in State law,

programs should consult an attorney familiarwith State law to ensure that their reportingpractices are in compliance.1° Because manyState statutes require that staff members reportinstances of abuse to administrators, who arethen required to make an official report,programs should establish reporting protocols tobring suspected child abuse to the attention ofprogram administrators. Administrators, inturn, should shoulder the responsibility to makethe required reports.

The Federal confidentiality regulationspermit programs to comply with State laws thatrequire the reporting of child abuse and neglect.However, this exception to the general ruleprohibiting disclosure of any information abouta client applies only to initial reports of childabuse or neglect. Programs may not respond to

94

followup requests for information or tosubpoenas for additional information, even ifthe records are sought for use in civil or criminalproceedings resulting from the program's initialreport. The only situation in which a programmay respond to requests for followupinformation is when the adolescent consents orthe appropriate court issues an order undersubpart E of the regulations.

Other Exceptions toThe General RuleReference has been made to other exceptions tothe general rule prohibiting disclosure regardingan adolescent who seeks or receives substanceuse disorder treatment services.

In the subsections that follow, six exceptionsto the Federal confidentiality rules are examinedin greater detail:

o Disclosures that do not reveal that the clientas having a substance use disorder

o Disclosures authorized by court orderDisclosures during medical emergencies

o Disclosures to an outside agency thatprovides a service to the program

o Disclosures of information within theprogramDisclosures of information to researchers,auditors, and evaluators

Communications That Do NotDisclose "Client-Identifying"InformationFederal regulations permit substance usedisorder treatment programs to discloseinformation about an adolescent if the programreveals no client-identifying information."Client-identifying" information is informationthat identifies someone as having a substanceuse disorder. Thus, a program may discloseinformation about an adolescent if thatinformation does not identify him as having asubstance use disorder or support anyone else's

identification of the adolescent as having asubstance use disorder.

There are two basic ways a program maymake a disclosure that does not identify a client.The first way is obvious: A program can reportaggregate data about its population (summingup information that gives an overview of theclients served in the program) or some portionof its population. Thus, for example, a programcould tell the newspaper that, in the last 6months, it screened 43 adolescent clients-10female and 33 male.

The second way has already been discussed:A program can communicate information abouta specifically named adolescent in a way thatdoes not reveal the adolescent's status as asubstance use disorder treatment client(§2.12(a)(i)). Thus, a program that providesservices to adolescents with other problems orillnesses as well as substance use disorders maydisclose information about a particular client(e.g., in order to make a referral) as long as itdoes not reveal the fact that the client has asubstance use disorder or is receiving treatment.A counselor employed by a program that is partof a general hospital could call the police about athreat an adolescent made, so long as thecounselor did not disclose that the adolescenthas a substance use disorder or is a client of thetreatment program.

Programs that provide only substance usedisorder services cannot disclose informationthat identifies a client under this exception,because letting someone know a counselor iscalling from the "XYZ Treatment Program" willautomatically identify the adolescent assomeone in the program. However, a free-standing program can sometimes make"anonymous" disclosures, that is, disclosuresthat do not mention the name of the program orotherwise reveal the adolescent's status ashaving a substance use disorder. Note that withthe widespread use of caller identification,"anonymous" communications may not be so


anonymous. Soon, it may no longer be possiblefor a freestanding program to use this kind ofanonymous communication.

Court-Ordered DisclosuresA State or Federal court may issue an order thatwill permit a program to make a disclosureabout an adolescent that would otherwise beforbidden. A court may issue one of theseauthorizing orders, however, only after itfollows certain special procedures and makesparticular determinations required by theregulations. A subpoena, search warrant, orarrest warrant, even when signed by a judge, isnot sufficient, standing alone, to require or even

to permit a program to disclose information(§2.61)."

Before a court can issue an order authorizinga disclosure about an adolescent that isotherwise forbidden, the program and theadolescent whose records are sought must begiven notice of the application for the order andsome opportunity to make an oral or writtenstatement to the court.'2 Generally, theapplication and any court order must usefictitious (made-up) names for any knownadolescent, not the real name of a particularclient. All court proceedings in connection withthe application must remain confidential unlessthe adolescent requests otherwise (§§2.64(a), (b),

2.65, 2.66).

Before issuing an authorizing order, the courtmust find that there is "good cause" for thedisclosure. A court can find "good cause" onlyif it determines that the public interest and theneed for disclosure outweigh any negative effectthat the disclosure will have on the client or thedoctor-client or counselor-client relationshipand the effectiveness of the program's treatmentservices. Before it may issue an order, the courtmust also find that other ways of obtaining theinformation are not available or would beineffective (§2.64(d))." The judge may examinethe records before making a decision (§2.64(c)).

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There are also limits on the scope of thedisclosure that a court may authorize, evenwhen it finds good cause. The disclosure mustbe limited to information essential to fulfill thepurpose of the order, and it must be restricted tothose persons who need the information for thatpurpose. The court should also take any othersteps that are necessary to protect theadolescent's confidentiality, including sealingcourt records from public scrutiny (§2.64(e)).

The court may order disclosure of"confidential communications" by an adolescentto the program only if the disclosure

Is necessary to protect against a threat to lifeor of serious bodily injury

E Is necessary to investigate or prosecute anextremely serious crime (including childabuse)Is in connection with a proceeding at whichthe adolescent has already presentedevidence concerning confidentialcommunications (e.g., "I told my

counselor ...") (§2.63)

If the purpose of seeking the court order is toobtain authorization to disclose information tolaw enforcement authorities so that they caninvestigate or prosecute a client for a crime, thecourt must also find that (1) the crime involvedis extremely serious, such as an act causing orthreatening to cause death or serious injury;(2) the records sought are likely to containinformation of significance to the investigationor prosecution; (3) there is no other practicalway to obtain the information; and (4) the publicinterest in disclosure outweighs any actual orpotential harm to the client, the doctorclientrelationship, and the ability of the program toprovide services to other clients. When lawenforcement personnel seek the order, the courtmust also find that the program had anopportunity to be represented by independentcounsel. If the program is a government entity,it must be represented by counsel (§2.65(d)).

96

Medical EmergenciesA program may make disclosures to public orprivate medical personnel "who have a need forinformation about [an adolescent] for thepurpose of treating a condition which poses animmediate threat to the health" of the adolescentor any other individual. The regulations define"medical emergency" as a situation that posesan immediate threat to health and requiresimmediate medical intervention (§2.51).

The medical emergency exception permitsdisclosure only to medical personnel. Thismeans that the exception cannot be used as thebasis for a disclosure to the police or othernonmedical personnel, including parents.Under this exception, however, a program couldnotify a private physician or school nurse abouta suicidal adolescent so that medicalintervention can be arranged. The physician ornurse could, in turn, notify the adolescent'sparents, so long as no mention is made of theadolescent's substance use disorder.

Whenever a disclosure is made to cope witha medical emergency, the program mustdocument the following information in theadolescent's records:

The name and affiliation of the recipient ofthe informationThe name of the individual making thedisclosureThe date and time of the disclosureThe nature of the emergency

Sharing Information With anOutside Agency That ProvidesServices to the ProgramIf a program routinely needs to share certaininformation with an outside agency thatprovides services to it, then it can enter intowhat is known as a QSOA. (A sample QSOA isprovided in Figure 8-4.)

A QSOA is a written agreement between aprogram and a person (or agency) providing

1e'5


Figure 8-4

Qualified Service Organization Agreement

XYZ Service Center ("the Center") and the

(name of the program)

("the Program") hereby enter into a qualified service organization agreement, whereby the Center

agrees to provide

(nature of services to be provided)

Furthermore, the Center:

(1) acknowledges that in receiving, storing, processing, or otherwise dealing with any

information from the Program about the clients in the Program, it is fully bound by the provisions of

the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Client Records, 42

C.F.R. Part 2; and

(2) undertakes to resist in judicial proceedings any effort to obtain access to information pertaining

to clients otherwise than as expressly provided for in the Federal Confidentiality Regulations, 42 C.F.R.

Part 2.

Executed this day of , 199

President

XYZ Service Center

[address]

Program Director

[name of the program]

[address]

services to the program, in which that person (oragency):

Acknowledges that in receiving, storing,processing, or otherwise dealing with anyclient records from the program, she is fullybound by (the Federal confidentiality)regulationsPromises that, if necessary, she will resist injudicial proceedings any efforts to obtain

access to client records except as permittedby these regulations (§§2.11, 2.12(c)(4))

A QSOA should be used only when anagency or official outside the program isproviding a service to the program itself. Anexample is when laboratory analyses or dataprocessing are performed for the program by anoutside agency.

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A QSOA is not a substitute for individualconsent in other situations. Disclosures under aQSOA must be limited to information that isneeded by others so that the program canfunction effectively. A QSOA may not be usedbetween different programs providing substanceuse disorder treatment and other services.

Internal Program CommunicationsThe Federal regulations permit someinformation to be disclosed to staff memberswithin the same program. The restrictions ondisclosure in these regulations do not apply tocommunications of information between oramong personnel having a need for theinformation in connection with their duties thatarise out of the provision of diagnosis,treatment, or referral for treatment of substanceuse disorders if the communications are(1) within a program or (2) between a programand an entity that has direct administrativecontrol over that program (§2.12(c)(3)).

In other words, staff who have access toclient records because they work for oradministratively direct the programincludingfull- or part-time employees and unpaidvolunteersmay consult among themselves orotherwise share information if their substanceuse work so requires (§2.12(c)(3)).

A question that frequently arises is whetherthis exception allows a program that treatsadolescents and that is part of a larger entity,such as a school, to share confidentialinformation with others who are not part of theassessment or treatment unit itself. The answerto this question is among the most complicatedin this area. In brief, there are circumstancesunder which the substance use disordertreatment unit can share information with otherunits. However, before such an internalcommunication system is set up within a largeinstitution, it is essential that an expert in thearea be consulted for assistance.

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Research, Audit, or EvaluationThe confidentiality regulations also permitprograms to disclose client-identifyinginformation to researchers, auditors, andevaluators without client consent, providedcertain safeguards are met (§§2.52, 2.53)."

Other Rules About Adolescents'Right to Confidentiality

Client notice and access to recordsThe Federal confidentiality regulations requireprograms to notify clients of their right toconfidentiality and to give them a writtensummary of the regulations' requirements. Thenotice and summary should be handed toadolescents when they begin participating in theprogram or soon thereafter (§2.22(a)). Theregulations contain a sample notice. Programscan use their own judgment to decide when topermit adolescents to view or obtain copies oftheir records, unless State law allows clients orstudents the right of access to records. TheFederal regulations do not require programs toobtain written consent from clients beforepermitting them to see their own records.

Security of recordsThe Federal regulations require programs tokeep written records in a secure room, a lockedfile cabinet, a safe, or other similar container."Programs should establish written proceduresthat regulate access to and use of adolescents'records. Either the program director or a singlestaff person should be designated to processinquiries and requests for information (§2.16).

A Final NoteSubstance use disorder treatment programsshould try to find a lawyer who is familiar withlocal laws affecting their problems. As hasalready been mentioned, State law governsmany concerns relating to treatment of

1 7

adolescents. A practicing lawyer with anexpertise in adolescent substance use concerns isthe best source for advice on such issues.Moreover, when it comes to certain issues, thelaw is still developing. For example, programs'duty to warn of clients' threats to harm others isconstantly changing as courts in different Statesconsider cases brought against a variety ofdifferent kinds of care providers. Programstrying to decide how to handle such a situationneed up-to-the minute advice on their legalresponsibilities.

Endnotes1. This chapter was written for the Revision

Panel by Margaret K. Brooks, Esq., Montclair,

New Jersey.2. An adult with "decisional capacity" is one

who is able to understand an explanation ofher diagnosis, prognosis, and choices oftreatment, as well as their risks and benefits,and likely outcome should treatment berefused.

3. In States where parental consent is notrequired for treatment, the Federalconfidentiality regulations permit a programto withhold services if the minor will notauthorize a disclosure that the programneeds in order to obtain financialreimbursement for that minor's treatment.The regulations add a warning, however,that such action might violate a State or locallaw (§2.14(b)).

4. Program staff may need training about whatthe State's child abuse and neglect lawsrequire, including what conditions areconsidered reportable. See the discussion ofchild abuse reporting.

5. Of course, a provider may turn an adolescentaway for clinical reasons, that is, because ithas determined that no treatment is neededor that the treatment it offers is inappropriatefor the particular adolescent. In this case, the


program might want to make a referral toanother type of counseling service or toanother substance use disorder treatmentprogram. The procedure for making areferral is discussed in section 2.

6. Citations in the form "§2..." refer to specificsections of 42 Code of Federal Regulations

(C.F.R.) Part 2.

7. Only adolescents who have "applied for orreceived" services from a program areprotected. If an adolescent has not yet beenevaluated or counseled by a program and hasnot himself sought help from the program,the program is free to discuss theadolescent's substance use disorders withothers, although it would not be wise to doso. But, from the time the adolescent appliesfor services or the program first conducts anevaluation or begins to counsel the youth, theFederal regulations govern.

8. Note, however, that no information that isobtained from a program (even if the clientconsents) may be used in a criminalinvestigation or prosecution of a client unlessa court order has been issued under thespecial circumstances set forth in §2.65. 42U.S.C. §290dd-2(c); 42 C.F.R. §2.12(a),(d).

9. Although the rules concerning CJS consentprobably apply to proceedings in juvenilecourt involving acts that, if committed by anadult, would be a crime, there appear to beno cases on point. It is less likely that thespecial CJS consent rules would apply whenan adolescent is adjudicated (found to be) inneed of special supervision (e.g., "persons inneed of supervision"), but not guilty of acriminal act.

10. If an attorney is not immediately available,and someone wants information about childabuse and neglect rules within a particularState, contact the social service or childwelfare agency for that area. Nationally, theChild Welfare League of America can also becalled at 202-638-2952. Definitions of terms

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can also be accessed on the Internet. Statestatute definitions are located athttp: / iwww.calib.cominccanchistatutes.htm. Federal definitions, which appear in theChild Abuse Prevention and Treatment Act(CAPTA), 42 U.S.C. §5106g, are available on

the Internet at http: /www.calib.cominccanch/pubs/whatis.htm

11. For information about how to deal withcommunications with lawyers, lawenforcement officials and subpoenas, see TIP24, A Guide to Substance Abuse Services for

Primary Care Clinicians, (CSAT, 1997), pp.

111-112. For information about dealing withsearch and arrest warrants, see TIP 19,Detoxification from Alcohol and Other Drugs

(CSAT, 1995c), pp. 83-84. Additionalinformation about dealing with subpoenasappears in Confidentiality: A Guide to the

Federal Laws and Regulations, (New York:

Legal Action Center, 1995 ed.).12. However, if the information is being sought

to investigate or prosecute a client for a

100

crime, only the program need be notified(§2.65); and if the information is sought to

investigate or prosecute the program, noprior notice at all is required (§2.66).

13. Outcome evaluation that assesses clients'behavior at set times after completion oftreatment (the importance of which ismentioned in Chapter 2) poses particularproblems under the Federal regulations. Fora discussion of this issue and a morecomplete explanation of the requirements of§§2.52 and 2.53, see TIP 14, Developing State

Outcomes Monitoring Systems for Alcohol and

Other Drug Abuse Treatment (CSAT, 1995a),

pp. 58-59.14. Computerization of records greatly

complicates efforts to ensure security. For abrief discussion of some of the issuescomputerization raises, see TIP 23, Treatment

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1 2 9

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1 4 0

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111

Appendix A

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112

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Winters, K.C.; Latimer, W.W.; and Stinchfield, R.

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Substance Abuse, in press.

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Weller, C.; and Latimer, W.W.

Characterizing the effectiveness of theMinnesota Model approach in the treatmentof adolescent drug abusers. Submitted forpublication, 1998.

Appendix BMedical Management of DrugIntoxication and Withdrawal

The following table was created by Dr. John Knight and reprinted with his permission. It will appear inthe forthcoming publication, Knight, J.R. Substance use, abuse, and dependence. In: Levine, M.D.; Carey,W.B.; and Crocker, A.C., eds. DevelopmentalBehavioral Pediatrics, 3rd edition. Philadelphia: W.B.

Saunders, in press.

142113

Med

ical

Man

agem

ent o

f D

rug

Into

xica

tion

and

With

draw

alA

. Alc

ohol

Nam

es/P

repa

ratio

nsIn

toxi

catio

nW

ithdr

awal

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Bee

rM

ild -

Mod

:. l,

leve

l of

Obs

erva

tion

and

supp

ortiv

eM

ild-M

od: r

estle

ssne

ss,

Thi

amin

e 10

0 m

g. I

M,

Win

eco

nsci

ousn

ess,

poo

rca

re, p

rote

ct a

irw

ay, p

ositi

onag

itatio

n, c

oars

e tr

emor

,B

enzo

diaz

epin

e ta

per

Har

d L

iquo

rco

ordi

natio

n, a

taxi

a,ny

stag

mus

, con

junc

tival

inje

ctio

n, s

lurr

ed s

peec

h,

stup

or, G

I bl

eed,

orth

osta

tic h

ypot

ensi

on

on s

ide

to a

void

asp

irat

ion

r se

nsiti

vity

to s

enso

ry in

put,

naus

ea, v

omiti

ng, a

nore

xia,

auto

nom

ic h

yper

activ

ity

(tac

hyca

rdia

, hyp

erte

nsio

n,hy

pert

herm

ia),

anxi

ety/

depr

essi

on,

head

ache

, ins

omni

a

(chl

ordi

azep

oxid

e 25

-50

mg.

q6h

X 2

4 hr

s., t

hen

25 m

g. q

6h

X 4

8 hr

s.; o

r di

azep

am,

clon

azep

am, o

xaze

pam

),

Mul

tivita

min

s

Seve

re: R

espi

rato

ryde

pres

sion

, com

a, d

eath

.

(Chr

onic

: pan

crea

titis

,ci

rrho

sis,

are

rar

e in

adol

esce

nts)

Ven

tilat

ory

supp

ort,

inte

nsiv

e

care

Seve

re: s

eizu

res,

hallu

cina

tions

, del

iriu

m,

deat

h

Seiz

ures

: ben

zodi

azep

ines

(dia

zepa

m 0

.2-0

.5 m

g/kg

/dos

eIV

., M

ax. d

ose=

10 m

g.,

or 0

.5 m

g/kg

/dos

e PR

)H

allu

cina

tions

: Hal

oper

idol

Path

olog

ical

: bel

liger

ent,

exci

ted,

com

bativ

e,

psyc

hotic

sta

te (

even

aft

ersm

all a

mou

nt in

susc

eptib

le p

erso

n)

Phys

ical

res

trai

nt,

low

dos

e be

nzod

iaze

pine

(lor

azep

am 1

-5 m

g. P

O a

s

need

ed),

or

halo

peri

dol 1

-5 m

g. q

4-8

hrs.

IM o

r 1-

15 m

g/do

se P

O

Mis

cella

neou

s In

form

atio

n: A

lcoh

ol is

hig

hly

addi

ctiv

e, a

nd w

ithdr

awal

fro

m it

is a

ssoc

iate

d w

ith s

erio

us, p

oten

tially

leth

al, s

ide

effe

cts

whi

ch b

egin

A -

)6-

24 h

ours

aft

er th

e la

st d

rink

. Alc

ohol

dep

ende

ncy

is r

are

in a

dole

scen

ts, h

owev

er, b

ut a

lcoh

ol-r

elat

ed d

eath

s ar

e no

t. A

dole

scen

ts te

nd to

be

bing

e1

'dr

inke

rs a

nd a

re a

t hig

h ri

sk f

or a

lcoh

ol-r

elat

ed a

ccid

ents

and

acu

te a

lcoh

ol p

oiso

ning

.4

B. C

anna

bis

Nam

es/P

repa

ratio

nsIn

toxi

catio

nW

ithdr

awal

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Mar

ijuan

a

Pot,

herb

, gra

ss, w

eed,

reef

er, d

ope,

Bud

s,

sins

emill

a, T

hai s

ticks

TH

C c

apsu

les

Has

hish

Has

hish

Oil

Acu

te: E

upho

ria,

sen

sory

stim

ulat

ion,

pup

illar

yco

nstr

ictio

n, c

onju

nctiv

al

inje

ctio

n, p

hoto

phob

ia,

nyst

agm

us, d

iplo

pia,

T a

ppet

ite, a

uton

omic

dysf

unct

ion

(tac

hyca

rdia

,hy

pert

ensi

on, o

rtho

stat

ichy

pote

nsio

n) te

mpo

rary

bron

chod

ilata

tion

Rea

ssur

ance

and

obs

erva

tion

Chr

onic

: gyn

ecom

astia

,re

activ

e ai

rway

dis

ease

,1

sper

m c

ount

, wei

ght

gain

, let

harg

y,

amot

ivat

iona

l syn

drom

e

Dis

cont

inua

tion

of u

se,

sym

ptom

atic

trea

tmen

t/car

e(b

ronc

hodi

lato

rs f

orw

heez

ing)

Chr

onic

use

rs: m

ildir

rita

bilit

y, a

gita

tion,

inso

mni

a, E

EG

cha

nges

.

Rea

ssur

ance

; sym

ptom

sdi

sapp

ear

in 3

-4 d

ays

Path

olog

ical

: pan

ic,

delir

ium

, psy

chos

is,

flas

hbac

ks

Psyc

hosi

s: N

euro

lept

icm

edic

atio

n

Mis

cella

neou

s In

form

atio

n: C

anna

bis

deri

vativ

es h

ave

rela

tivel

y lo

w a

ddic

tive

pote

ntia

l. T

hese

dru

gs a

re c

omm

only

use

d by

ado

lesc

ents

, how

ever

,an

d ar

e as

soci

ated

with

adv

erse

psy

chol

ogic

al e

ffec

ts. T

he p

oten

cy o

f m

ariju

ana

has

trip

led

over

the

past

25

year

s.

BE

ST

CO

PY

AV

AIL

AB

LE14

514d

C. H

allu

cino

ens

Nam

es/P

repa

ratio

nsIn

toxi

catio

nW

ithdr

awal

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Phen

cycl

idin

e (P

CP)

ange

l dus

t, su

per

gras

s,

peac

e w

eed

Lys

ergi

c ac

id

Acu

te: P

erce

ptua

l (vi

sual

,au

dito

ry)

dist

ortio

n an

dha

lluci

natio

ns, n

ysta

gmus

,

feel

ings

of

depe

rson

aliz

a-

Rea

ssur

ance

and

obs

erva

tion

(For

ant

icho

liner

gics

, i.e

.,

jimso

n w

eed,

nig

htsh

ade,

sym

ptom

s ar

e m

ore

seve

re

Psyc

holo

gica

lR

eass

uran

ce

diet

hyla

mid

e (L

SD)

Aci

d, b

lotte

rs, o

rang

e

suns

hine

, blu

e he

aven

,

mic

rodo

t, su

gar

cube

s

tion,

mild

nau

sea,

trem

ors,

tach

ycar

dia,

hyp

erte

nsio

n,

hype

rref

lexi

a

and

may

req

uire

gas

tric

lava

ge, b

enzo

diaz

epin

e

seda

tion,

and

hosp

italiz

atio

n.)

Mes

calin

em

esc

Chr

onic

: fla

shba

cks

Dis

cont

inua

tion

of u

se

Peyo

tebu

ttons

, cac

tus

Psilo

cybi

n

mag

ic m

ushr

oom

s,

'shr

oom

s

Path

olog

ical

: pan

ic,

para

noia

, psy

chos

isPs

ycho

sis:

clo

se o

bser

vatio

nin

a q

uiet

roo

m.

benz

odia

zepi

nes

(Lor

azep

am 1

-5 m

g. P

O).

Jim

son

wee

dlo

cow

eed

Use

of

neur

olep

tic

med

icat

ion

is c

ontr

over

sial

.

Nig

htsh

ade

Mis

cella

neou

s In

form

atio

n: P

CP

may

be

spri

nkle

d on

mar

ijuan

a an

d sm

oked

. Exp

osur

e ca

n th

us o

ccur

with

out t

he u

ser's

kno

wle

dge.

1-1

1.4

D. I

nhal

ants

Nam

es/P

repa

ratio

nsIn

toxi

catio

nW

ithdr

awal

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Nitr

ous

Oxi

de,

laug

hing

gas

, whi

ppet

s

Am

yl N

itrite

,

popp

ers,

sna

pper

s

But

yl N

itrat

e,

rush

, bul

let,

clim

ax

Chl

oroh

ydro

carb

ons

aero

sol s

pray

can

s

Acu

te: e

upho

ria,

diso

rien

tatio

n, s

edat

ion,

conj

unct

ival

inje

ctio

n,

acut

e to

xici

ty to

CN

S,

liver

, kid

neys

Nitr

ates

: sud

den

hypo

xem

ia, h

ypot

ensi

on

Sym

ptom

atic

med

ical

trea

tmen

ts

Psyc

holo

gica

l

Phys

iolo

gica

lunk

now

nR

eass

uran

ce, s

uppo

rt

Hyd

roca

rbon

s,

gaso

line,

glu

e,

solv

ents

, Whi

te-o

ut

Chr

onic

: per

iphe

ral n

erve

,

CN

S, li

ver,

and

kid

ney

dam

age

Dis

cont

inua

tion

of u

se,

supp

ortiv

e th

erap

ies

(dia

lysi

s, e

tc.)

(typ

ewri

ter

corr

ectio

n fl

uid)

Plum

bism

: Che

latio

nth

erap

yL

eade

d G

asol

ine

(not

Path

olog

ical

: car

diac

in U

S)ar

rhyt

hmia

and

arr

est

Res

usci

tatio

n, h

ospi

taliz

atio

n

Mis

cella

neou

s In

form

atio

n: N

itrou

s ox

ide

is s

omet

imes

sol

d at

roc

k co

ncer

ts in

side

bal

loon

s. N

itrat

e co

mpo

unds

hav

e be

en m

ost p

opul

ar a

mon

gga

y m

en, a

llege

dly

to e

nhan

ce s

exua

l exp

erie

nces

. The

vol

atile

hyd

roca

rbon

com

poun

ds a

re f

avor

ed b

y yo

unge

r ad

oles

cent

s an

d po

pula

r in

som

eL

atin

-Am

eric

an c

ount

ries

, on

Nat

ive

Am

eric

an r

eser

vatio

ns, a

nd in

Lat

ino

com

mun

ities

with

in th

e U

nite

d St

ates

.

14 9

BE

STC

OPY

AV

AIL

AB

LE

150

151

E. S

timul

ants

Nam

es/P

repa

ratio

nsIn

toxi

catio

nW

ithdr

awal

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Coc

aine

Cok

e, S

now

, Fla

ke,

Blo

w, N

ose

Can

dy

Cra

ck

Free

base

, Roc

ks

Am

phet

amin

es

Acu

te: e

xhila

ratio

n,

euph

oria

, res

tless

ness

,ir

rita

bilit

y, in

som

nia,

pupi

llary

dila

tatio

n,ta

chyc

ardi

a, a

rrhy

thm

ia,

ches

t pai

n, h

yper

tens

ion,

Rea

ssur

ance

and

obs

erva

tion

Sym

ptom

atic

car

eA

gita

tion:

hig

h do

sebe

nzod

iaze

pine

s (D

iaze

pam

10-2

5 m

g)

Tac

hyca

rdia

, I-I

TN

:

Spee

d, B

lack

Bea

utie

s

Met

ham

phet

amin

eC

rank

, Cry

stal

Met

h,

anor

exia

, hyp

erpy

rexi

a,hy

perr

efle

xia

(con

trov

ersi

al, s

ee b

elow

)

Hyp

erth

erm

ia: e

xter

nal

cool

ing

Ice

Met

hylp

heni

date

Chr

onic

: (if

sno

rtin

g:D

isco

ntin

uatio

n of

use

,C

hron

ic u

sers

: sev

ere

Clo

se o

bser

vatio

n, r

eass

uran

ce;

Rita

lin

infl

amed

nas

al m

ucos

a,sy

mpt

omat

ic tr

eatm

ent/c

are.

depr

essi

on w

ithsy

mpt

oms

disa

ppea

r in

3-4

Pem

olin

e

Cyl

ert

Rx

Die

t Pill

s

Did

rex,

Ten

uate

,

lona

min

, San

orex

, etc

.

sept

al e

rosi

on o

r

perf

orat

ion)

con

fusi

on,

sens

ory

hallu

cina

tions

,

para

noia

, dep

ress

ion

Psyc

hosi

s: N

euro

lept

icm

edic

atio

nsu

icid

al/h

omic

idal

idea

tion,

exha

ustio

n, p

rolo

nged

sle

ep,

vora

ciou

s ap

petit

e

days

"Leg

al s

peed

"Pa

thol

ogic

al: s

udde

nR

esus

cita

tion,

hos

pita

lizat

ion

OT

C d

iet o

r st

ay a

wak

e

pills

card

iac

arre

st,

hype

rten

sive

cri

sis,

seiz

ures

HT

N c

risi

s: b

eta-

bloc

kers

,

Phen

tola

min

e, N

itrop

russ

ide

Seiz

ures

: IV

Dia

zepa

m, (

see

alco

hol s

ectio

n ab

ove)

, or

Phen

ytoi

n 15

-20

mg/

kg s

low

IV p

ush

with

car

diac

mon

itor

Mis

cella

neou

s In

form

atio

n: W

hile

use

of

coca

ine

and

crac

k ha

s de

clin

ed s

omew

hat i

n re

cent

yea

rs, a

mph

etam

ines

hav

e be

com

e m

ore

popu

lar.

Met

ham

phet

amin

e is

mor

e co

mm

only

ava

ilabl

e in

Cal

ifor

nia,

the

Wes

t, an

d So

uthw

est.

With

the

incr

ease

d pu

blic

aw

aren

ess

of A

D/H

D a

nd th

epo

pula

rity

of

stim

ulan

t med

icat

ions

to tr

eat i

t, R

ita li

n ha

s no

w b

ecom

e a

drug

of

abus

e am

ong

som

e ad

oles

cent

s. I

t can

be

grou

nd u

p an

d"s

nort

ed,"

and

has

been

impl

icat

ed in

sev

eral

rep

orts

of

sudd

en c

ardi

ac a

rres

t and

dea

th. S

o-ca

lled

"leg

al s

peed

," O

TC

pre

para

tions

whi

ch a

re a

vaila

ble

inph

arm

acie

s an

d th

roug

h m

ail o

rder

hou

ses,

can

cau

se to

xici

ty s

imila

r to

mor

e po

tent

stim

ulan

ts w

hen

take

n in

hig

h do

ses.

15=

'

F. D

epre

ssan

tsN

ames

/Pre

para

tions

Into

xica

tion

With

draw

alSi

gns

and

Sym

ptom

sT

reat

men

tSi

gns

and

Sym

ptom

sT

reat

men

tB

enzo

diap

ines

:M

ild-M

od: C

NS

Obs

erva

tion

and

supp

ortiv

eM

ild-M

od: r

estle

ssne

ss,

Gra

dual

red

uctio

n of

the

drug

Val

ium

, "V

's,"

seda

tion,

pup

illar

yca

re, p

rote

ct a

irw

ay, p

ositi

onan

xiet

y, a

gita

tion,

trem

or,

of d

epen

denc

y, o

r

Lib

rium

, Ser

ax,

Klo

nopi

n, T

ranx

ene,

Xan

ax, H

alci

on,

Roh

ypno

l, "R

uffl

es"

Bar

bitu

rate

s:N

embu

tal,

Seco

nal,

Am

ytal

, Tui

nal,

dow

ners

, bar

bs, b

lue

devi

ls, r

ed d

evils

,

yello

ws,

yel

low

jack

ets

Met

haqu

alon

e:

cons

tric

tion,

diso

rien

tatio

n, s

lurr

ed

spee

ch, s

tagg

erin

g ga

it

Seve

re: R

espi

rato

ryde

pres

sion

, hyp

othe

rmia

,co

ma,

dea

th

on s

ide

to a

void

asp

irat

ion

Acu

te O

D: G

astr

ic la

vage

.Su

ppor

tive:

ven

tilat

or,

war

min

g bl

anke

t, IC

U c

are

abdo

min

al c

ram

ps, n

ause

a,vo

miti

ng, h

yper

refl

exia

,

hype

rten

sion

, hea

dach

e,

inso

mni

a

Seve

re: s

eizu

res,

del

iriu

m,

hype

rpyr

exia

, hal

luci

natio

ns,

deat

h

Phen

obar

bita

l sub

stitu

tion

(cal

cula

te p

heno

barb

ital

equi

vale

nt o

f da

ily d

ose,

or

give

3-4

mg/

kg/d

ay ÷

q8h

)w

ith g

radu

al ta

per.

Or

chan

gesh

ort-

actin

g be

nzod

iaze

pine

tolo

nger

-act

ing

benz

odia

zepi

ne

and

then

tape

r

Seiz

ures

: Dia

zepa

mH

allu

cina

tions

: Hal

oper

idol

(see

alc

ohol

sec

tion

abov

e fo

r

dose

s)

Qua

alud

es, l

udes

,

sopo

rs

Path

olog

ical

: par

adox

ical

disi

nhib

ition

,

hype

rexc

itabi

lity

Sym

ptom

s pa

ss in

a m

atte

r of

hour

s; p

hysi

cal r

estr

aint

, low

dose

ben

zodi

azep

ine

rare

lyne

eded

Mis

cella

neou

s In

form

atio

n: T

hese

com

poun

ds a

re a

ll si

mila

r to

alc

ohol

in e

ffec

t and

hig

hly

addi

ctiv

e. W

ithdr

awal

sym

ptom

s ar

e se

vere

and

may

begi

n 12

-16

hour

s af

ter

last

dos

e or

may

be

dela

yed

for

up to

a w

eek.

153

15,4

O

G. N

arco

tics

Nam

es/P

repa

ratio

nsIn

toxi

catio

nW

ithdr

awal

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Her

oin,

smac

k, h

orse

, jun

k,

brow

n su

gar,

Big

H,

mud

Opi

umR

x N

arco

tics

Mor

phin

e, M

eper

idin

e

Fent

anyl

, Oxy

codo

ne,

Hyd

roco

done

, Cod

eine

Dar

von,

etc

.

Acu

te: E

upho

ria,

pupi

llary

con

stri

ctio

n,

depr

essi

on o

f re

spir

atio

nsan

d ga

g re

flex

,

brad

ycar

dia,

hyp

oten

sion

,co

nstip

atio

n

Chr

onic

: com

plic

atio

ns o

fIV

use

incl

ude

Hep

atiti

s B

,

HIV

/AID

S, S

BE

, bra

in

absc

esse

s

Path

olog

ical

: Acu

te O

Dm

ay c

ause

res

pira

tory

arre

st a

nd d

eath

Air

way

pro

tect

ion,

judi

ciou

s

use

of n

alox

one

Dis

cont

inua

tion

of u

se,

targ

eted

med

ical

car

e fo

r

infe

ctio

us c

ompl

icat

ions

Intu

batio

n an

d ve

ntila

tion,

nalo

xone

(IV

, IM

, SC

, ET

T):

child

ren

< 2

0 kg

:

0.1

mg/

kg/d

ose

q2-3

hrs

.ch

ildre

n >

20

kg:

2-5

mg/

dose

Chr

onic

use

rs: r

estle

ssne

ss,

lacr

imat

ion,

yaw

ning

,pu

pilla

ry d

ilata

tion,

rhin

orrh

ea, s

niff

ing,

sne

ezin

g,

swea

ting,

flu

shin

g,ta

chyc

ardi

a, h

yper

tens

ion,

mus

cle

cram

ps, a

bdom

inal

cram

ps, n

ause

a, v

omiti

ng,

diar

rhea

Acu

te d

etox

ific

atio

n:M

etha

done

(PO

)

Chi

ldre

n: 0

.7 m

g/kg

/day

q4-6

hrs

., or

adu

lt 30

-40

mg.

/

day

in 3

-4 d

ivid

ed d

oses

, with

5 m

g/da

y ta

per.

Clo

nidi

ne (

PO)

Chi

ldre

n: 5

-7 m

cg/k

g/da

yq6

-12

hrs.

(m

ax =

0.9

mg/

day)

Adu

lt: 0

.1 m

g. te

st d

ose,

che

ck

post

ural

BPs

. If

stab

le, 0

.1-0

.2m

g PO

q4-

6 hr

s.

Lon

g-te

rm tr

eatm

ent:

Lon

g-te

rm th

erap

eutic

supp

ort.

Met

hado

ne o

r L

AA

M

mai

nten

ance

(sp

ecia

lized

clin

ics

only

)

Mis

cella

neou

s In

form

atio

n: I

ndiv

idua

ls w

ho a

buse

nar

cotic

s se

ldom

see

k tr

eatm

ent f

or in

toxi

catio

n. T

hey

are

mor

e of

ten

foun

d se

mi-

com

atos

e an

dbr

ough

t to

the

hosp

ital b

y fr

iend

s or

the

EM

S fo

r tr

eatm

ent.

Whe

n tr

eatin

g an

ove

rdos

e, r

emem

ber

that

nal

oxon

e ha

s a

shor

ter

dura

tion

of a

ctio

n th

anm

ost n

arco

tic d

rugs

, and

dos

es th

eref

ore

shou

ld b

e re

peat

ed a

t fai

rly

freq

uent

inte

rval

s. T

hese

pat

ient

s re

quir

e le

ngth

y (1

2-24

hou

rs)

peri

ods

ofob

serv

atio

n in

hos

pita

l.

155

156

H. D

esig

ner

Dru

gs

Nam

es/P

repa

ratio

nsIn

toxi

catio

nW

ithdr

awal

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Sign

s an

d Sy

mpt

oms

Tre

atm

ent

Fent

anyl

ana

logs

Synt

hetic

her

oin,

Chi

na

Whi

te

Mep

erid

ine

anal

ogs

MPP

P, M

PTP

Sim

ilar

to n

arco

tics

(abo

ve)

Sim

ilar

to n

arco

tics

(abo

ve)

Sim

ilar

to n

arco

tics

(abo

ve)

Sim

ilar

to n

arco

tics

(abo

ve)

Am

phet

amin

ean

alog

s

MD

MA

, Ecs

tasy

,

Ada

m, E

VE

, ST

P,

PMA

, TM

A, D

OM

,

DO

B, e

tc.

Sim

ilar

to a

mph

etam

ines

(abo

ve)

Sim

ilar

to a

mph

etam

ines

(abo

ve)

Sim

ilar

to a

mph

etam

ines

(abo

ve)

Sim

ilar

to a

mph

etam

ines

(abo

ve)

PCP

Ana

logs

PCPy

, PC

E

Sim

ilar

to P

CP

(abo

ve)

Sim

ilar

to P

CP

(abo

ve)

Sim

ilar

to P

CP

(abo

ve)

Sim

ilar

to P

CP

(abo

ve)

Mis

cella

neou

s In

form

atio

n: M

ore

popu

lar

on th

e W

est C

oast

, des

igne

r dr

ugs

can

be b

oth

stro

nger

and

che

aper

than

the

pare

nt c

ompo

und.

Qua

lity

is n

ot c

ontr

olle

d du

ring

illic

it m

anuf

actu

ring

, pos

ing

grea

t dan

ger

to u

sers

. For

exa

mpl

e: M

PTP,

a c

onta

min

ant o

f th

e M

eper

idin

e an

alog

MPP

P,ca

uses

irre

vers

ible

Par

kins

on's

Dis

ease

.

Sour

ce:

Kni

ght J

.R.,

Subs

tanc

e us

e, a

buse

, and

dep

ende

nce.

In:

Lev

ine,

M.D

.; C

arey

, W.B

.; C

rock

er, A

.C. e

ds.,

Dev

elop

men

tal-

Beh

avio

ral P

edia

tric

s, 3

rd e

d.

Phila

delp

hia:

W.B

. Sau

nder

s C

o., i

n pr

ess.

Ref

eren

ces:

Cha

ng G

., K

oste

n T

.R. E

mer

genc

y m

anag

emen

t of

acut

e dr

ug in

toxi

catio

n. I

n: L

owin

son,

J.H

., R

uiz,

P.,

Mill

man

, R.B

., ed

s., S

ubst

ance

Abu

se: A

Com

preh

ensi

ve T

extb

ook.

Bal

timor

e: W

illia

ms

& W

ilkin

s, 1

992.

Cen

ter

for

Subs

tanc

e A

buse

Tre

atm

ent.

Gui

delin

es f

or th

e T

reat

men

t of

Alc

ohol

- an

d O

ther

Dru

g-A

busi

ng A

dole

scen

ts. T

reat

men

t Im

prov

emen

t Pro

toco

l

(TIP

) Se

ries

4. D

HH

S Pu

b. N

o. 9

3-20

10. W

ashi

ngto

n, D

C: U

.S. G

over

nmen

t Pri

ntin

g O

ffic

e, 1

993.

Cen

ter

for

Subs

tanc

e A

buse

Tre

atm

ent.

Det

oxif

icat

ion

for

Alc

ohol

and

Oth

er D

rugs

. Tre

atm

ent I

mpr

ovem

ent P

roto

col (

TIP

) Se

ries

19.

DH

HS

Pub.

No.

93-

2010

. Was

hing

ton,

DC

: U.S

. Gov

ernm

ent P

rint

ing

Off

ice,

199

5.B

aron

e, M

.A.,

ed. T

he H

arri

et L

ane

Han

dboo

k, 1

4th

ed. S

t. L

ouis

: Mos

by, 1

996.

Ack

now

ledg

men

t: M

icha

el S

hann

on, M

.D.,

M.P

.H. (

Tox

icol

ogy

Prog

ram

) an

d B

rigi

d V

augh

an, M

.D. (

Dep

artm

ent o

f Ps

ychi

atry

) at

Chi

ldre

n's

Hos

pita

l, B

osto

n, a

ssis

ted

with

pre

para

tion

of th

is ta

ble.

157

158

Appendix CField Reviewers

jack Araza, Ph.D., C.A.D.C.

Carson City, Nevada

Michael Beard

Deputy DirectorLassen County Alcohol and Drug Abuse

DepartmentSusanville, California

Helen Bergman, M.S.W., L.I.C.S.W.

Co-DirectorCommunity ConnectionsWashington, D.C.

Robert Bick, M.A., S.A.C.

DirectorChamplain Drug and Alcohol ServicesHoward Center for Human ServicesSouth Burlington, Vermont

Saroja A. Boaz, M.S., A.C.C.

Executive Director

Intake Assessment and Referral CenterFlint, Michigan

Patricia Bradford, L.I.S.W., L.M.F.T., C.T.S.

P.A. Bradford and AssociatesColumbia, South Carolina

Deborah Briseno, M.S.Ed., C.A.D.C.

Program DirectorCentral East Alcoholism and Drug CouncilMattoon, Illinois

Margaret K. Brooks, Esq.

ConsultantMontclair, New Jersey

Richard Conlon, M.P.A.

Assistant ChiefBehavioral Interventions and Research

Branch

Division of STD Prevention

Centers for Disease Control and PreventionAtlanta, Georgia

Patricia Cummings, M.S.S.W., L.C.S.W.

Prevention Director/Planning OfficerSeven Counties Services, Inc.Louisville, Kentucky

Richard Dembo, Ph.D.

Professor of CriminologyUniversity of South FloridaTampa, Florida

John de Miranda, Ed.M.Executive Director

National Association on Alcohol, Drugs, andDisability, Inc.

San Mateo, California

Jean Anne Donaldson, M.A.Public Health AdvisorCenter for Substance Abuse TreatmentRockville, Maryland

159123

Appendix C

Janice M. Dyehouse, R.N., M.S.N., Ph.D.

Professor

College of NursingUniversity of CincinnatiCincinnati, Ohio

Bryan R. Ellis, M.A., C.S.W.

PresidentADE IncorporatedClarkston, Michigan

Janice Embree-Bever, M.A., C.A.C.III

Planning/Grants Officer IIIAlcohol and Drug Abuse DivisionColorado Department of Human ServicesDenver, Colorado

Jill Shepard Erickson, M.S.W.

Public Health AdvisorChild and Family BranchCenter for Mental Health ServicesSubstance Abuse and Mental Health Services

AdministrationRockville, Maryland

David L. Favreau, L.M.H.C., C.A.S.

Assertive CommunicationsDracut, Massachusetts

Jerry P. Flanzer, D.S.W.

Director

Recovery and Family Treatment, Inc.Alexandria, Virginia

Luis E. Flores, M.A.

Associate AdministratorStop Child Abuse and Neglect, Inc.Laredo, Texas

Lawrence S. Friedman, M.D.

Chief

Division of Primary Care Pediatrics andAdolescent Medicine

University of California at San DiegoSan Diego, California

124

Michael F. Goodnow, C.A.D.A.C., I.C.A.D.A.C.

Social Science Program Specialist

Training & Technical Assistance Division

Office of Juvenile Justice and DelinquencyPrevention

Department of JusticeWashington, D.C.

Don M. Hashimoto, Psy.D.

Clinical Director

Ohana Counseling Services, Inc.Hilo, Hawaii

Martin HernandezVentura County Behavioral Health

DepartmentVentura, California

James Herrera, M.A., L.P.C.C.

Center on Alcoholism, Substance Abuse, andAddictions

University of New MexicoAlbuquerque, New Mexico

Norman G. Hoffmann, Ph.D.Director, Policy ProgramCenter for Alcohol and Addiction StudiesDepartment of Community HealthBrown UniversityProvidence, Rhode Island

Lewis Jay Lester, M.S.W., L.C.S.W.

Eureka, California

Victor Lidz, Ph.D.

Assistant ProfessorInstitute for Addictive DisordersAllegheny University of Health SciencesPhiladelphia, Pennsylvania

Colleen R. McLaughlin, Ph.D.

Senior Research AnalystDepartment of SurgeryMedical College of Virginia

Richmond, Virginia

Thomas J. McMahon, Ph.D.

Assistant Professor of PsychologyYale School of Medicine

Substance Abuse CenterNew Haven, Connecticut

Lisa A. Melchior, Ph.D.

Vice President for EvaluationThe Measurement GroupCulver City, California

D. Paul Moberg, Ph.D.

Center for Health Policy and ProgramEvaluation

University of Wisconsin at MadisonMadison, Wisconsin

Andrew MorralRAND

Santa Monica, California

David F. O'Connell, Ph.D.

Corporate Clinical DirectorAdolescent Treatment Services

Caron FoundationWernersville, Pennsylvania

Nancy Petry, Ph.D.

Assistant Professor

Department of PsychiatryUniversity of Connecticut Health CenterFarmington, Connecticut

Elizabeth Randert, Ph.D.

Research PsychologistTreatment Research BranchDivision of Clinical and Services Research

National Institute on Drug AbuseNational Institutes of HealthRockville, Maryland

Scott M. Reiner, M.S., C.A.C., C.C.S.

Substance Abuse Program SupervisorSubstance Abuse Services UnitVirginia Department of Juvenile JusticeRichmond, Virginia

Field Reviewers

Jeanine Ricchetti, M.S., L.P.C., C.C.A.S.

Clinician/Clinical SupervisorWayne County Mental HealthGoldsboro, North Carolina

Steve Riedel, M.S.Ed.

Associate Director

Our Home, Inc.Huron, South Dakota

D. Paul Robinson, M.D.

Division of Adolescent MedicineChildren's Hospital of MissouriColumbia, Missouri

Peter B. Rockholz, M.S.S.W.

DirectorResidential Services

APT Foundation, Inc.

Newtown, Connecticut

Sarah E. Shapleigh, M.S.W., C.A.P.C.

CounselorChemical Dependency Services DepartmentGrasmere Intermediate Care Facility for the

Mentally Ill

Chicago, Illinois

Peg J. Shea, M.S.S.W., L.C.S.W., C.C.D.C.

Program DirectorTurning Point Addiction ServicesMissoula, Montana

Lawrence M. Sideman, Ph.D.

Clinical Director/Assistant DirectorTreatment Assessment Screening Center, Inc.Phoenix, Arizona

Richard T. Suchinsky, M.D.

Associate Director for Addictive Disordersand Psychiatric Rehabilitation

Mental Health and Behavioral SciencesServices

Department of Veterans AffairsWashington, D.C.

BESTCOPYAVAILABLE

125

Appendix C

James Taylor, M.A., C.A.D.C. II

Alcohol and Drug Treatment CoordinatorHillcrest Youth Correctional Facility

Salem, Oregon

Sally Towns, M.Ed., M.S.W.

Mental Health SpecialistLouisiana Office of Mental Health

Baton Rouge, Louisiana

William L. White

Senior Research ConsultantLighthouse InstituteChestnut Health Systems, Inc.Bloomington, Illinois

126

Raymond E. Wilson, M.A., C.A.D.C., M.S.

Senior Counselor, M.H.S.-IIDrug Treatment ProgramsMarion County Health DepartmentSalem, Oregon

Katherine Wingfield, M.S.W.

Program ManagerChemical Dependency InitiativeChild Welfare League of America

Washington, D.C.

The TIPs SeriesTIP 1TIP 2TIP 3TIP 4TIP 5TIP 6TIP 7

TIP 8TIP 9

TIP 10TIP 11

TIP 12

TIP 13

TIP 14

TIP 15TIP 16TIP 17

TIP 18

TIP 19TIP 20TIP 21

TIP 22TIP 23

TIP 24TIP 25TIP 26TIP 27TIP 28TIP 29

TIP 30

TIP 31TIP 32TIP 33

V

State Methadone Treatment Guidelines BKD98Pregnant, Substance-Using Women BKD107Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents BKD108Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents BKD109Improving Treatment for Drug-Exposed Infants BKD110Screening for Infectious Diseases Among Substance Abusers BKD131Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in theCriminal Justice System BKD138Intensive Outpatient Treatment for Alcohol and Other Drug Abuse BKD139Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other DrugAbuse BKD134Assessment and Treatment of Cocaine-Abusing Methadone-Maintained Patients BKD157Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and InfectiousDiseases BKD143Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the CriminalJustice System BKD144The Role and Current Status of Patient Placement Criteria in the Treatment of SubstanceUse Disorders BKD161Developing State Outcomes Monitoring Systems for Alcohol and Other Drug AbuseTreatment BKD162Treatment for HIV-Infected Alcohol and Other Drug Abusers BKD163Alcohol and Other Drug Screening of Hospitalized Trauma Patients BKD164Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal JusticeSystem BKD165The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse TreatmentProviders BKD173Detoxification from Alcohol. and Other Drugs BKD172Matching Treatment to Patient Needs in Opioid Substitution Therapy BKD168Combining Alcohol and Other Drug Abuse Treatment With Diversion

for Juveniles in the Justice System BKD169LAAM in the Treatment of Opiate Addiction BKD170Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal CaseProcessing BKD205A Guide to Substance Abuse Services for Primary Care Clinicians BKD234Substance Abuse Treatment and Domestic Violence BKD239Substance Abuse Among Older Adults BKD250Comprehensive Case Management for Substance Abuse Treatment BKD251Naltrexone and Alcoholism Treatment BKD268Substance Use Disorder Treatment for People With Physical andCognitive Disabilities BKD288Continuity of Offender Treatment for Substance Use Disorders From Institution toCommunity BKD304Screening and Assessing Adolescents for Substance Use Disorders BKD306Treatment of Adolescents With Substance Use Disorders BKD307Treatment for Stimulant Use Disorders BKD289

Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information(NCADI), (800) 729 -6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.

DHHS Publication No. (SMA) 99-3345Substance Abuse and Mental Health Services AdministrationReprinted 1999

1 6

SAMHSA

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