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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [390]-[394]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [390]-[394]
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PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved
CHAPTER 18 Treatment of Substance Use Disorders
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The high rate of adolescent substance abuse in the United States (Johnsten, O'Malley, & Bachman, 1998) makes the identification of effective treatment approaches a significant priority. Effective early intervention is crucial. Adolescents who initiate alcohol use by age 14 are significantly more likely to develop alcohol dependence as adults than those who initiate use by age 20, with significant reductions in the odds of developing dependence for each year of delayed initiation (Grant & Dawson, 1997). Effective early intervention is also crucial with substance-abusing adolescents because it can play a preventive role in later years (Borduin et al., 1995; Kazdin, 1991, 1993; Santisteban et al., 2003). While alcohol remains the most commonly used substance (illegal among adolescents; Kandel, & Faust, 1975; Kandel & Yamaguchi, 1993), a marked trend in recent years is the increased use of cannabis among adolescents, which has led to an increased demand for cannabis treatment. From 1992 to 1998, the number of adolescents with primary, secondary, or tertiary problems related to cannabis who presented to the U.S. public treatment system grew from 51,081 to 109,875 (a 115% increase) (Dennis et al., 2002). In 1998, over 80% of these adolescents received treatment in an outpatient setting. The bulk of treatment evaluation studies and clinical trials report the most prevalent types of substance use in clinical populations are alcohol and marijuana, with some cocaine, heroin, methamphetamine, hallucinogen, and polysubstance use as well, based on setting and sample. Treatment of substance-abusing adolescents is complicated by a number of factors that appear to be particularly prevalent or problematic among adolescents (although they complicate treatment for adults as well). First, as noted previously, adolescents in treatment samples usually use multiple substances, typically alcohol and marijuana with occasional cocaine use (Henggeler, Pickrel, Brondino, & Crouch, 1996; Kaminer, Burleson, & Goldberger, 2002; Winters, Stinchfield, Opland, Weller, & Latimer, 2000) and, increasingly, heroin as well. Second, as highlighted at several points throughout this volume, substance-using adolescents have very high rates of comorbid psychi
atric disorders, which can greatly complicate treatment delivery and outcome. For example, Henggeler et al. ( 1996) reported that 35% of participants in a clinical trial of family approaches (described in more detail below) met criteria for conduct disorder, 19% for social phobia, 12% for oppositional defiant disorder, and 9% for major depression. In Waldron, Slesnick, Brody, Turner, and Peterson's ( 2001) sample, 89.8% had a history of significant delinquent behavior, 29.7% met criteria for anxiety and depressive disorders, and 27.3% had attention problems. Kaminer and colleagues ( 2002) reported that 55% met criteria for an externalizing disorder, 39% for conduct disorder, 18% for attention-deficit hyperactivity disorder (ADHD), 22% for depression, and 26% for an anxiety disorder. As discussed in more detail below, the presence of a comorbid disorder often indicates the need for evaluation for pharmacotherapy as well and for close monitoring of treatment adherence and response. The presence of conduct disorder is particularly significant among substance-abusing adolescents as it is often associated with poor long-term treatment outcome and persistence of antisocial behavior in this population (Myers, Stewart, & Brown, 1998). Moreover, in some circumstances (e.g., deviant adolescents assigned to interactional groups), inclusion of a high proportion of adolescents with conduct disorders in some types of unstructured groups may lead to generally poor outcomes (Arnold & Hughes, 1999; Dishion, McCord, & Poulin, 1999). Treatment of substance-abusing adolescents is also complicated by high rates of substance abuse in their immediate families. Henggeler et al. ( 1996) reported that a substance abuse problem was present in 18% of birth mothers and 56% of the fathers of youth in their treatment sample. Winters et al. ( 2000) reported that 66% of participants had at least one parent with substance use disorder. This complication is significant because parental substance use is associated with poor parenting practices and low levels of parent monitoring, which can further exacerbate adolescent substance use (Chilcoat, Dishion, & Anthony, 1995). Furthermore, exposure to drug use and drug-related cues within the household is likely to provoke craving in established, adolescent substance abusers.
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© Copyright Oxford University Press, 2006. All Rights Reserved
Another obstacle to treatment for adolescents is that adolescents rarely seek treatment voluntarily but are usually coerced at some level after experiencing school, legal, or medical problems (Brown, 1993). Treatment is also complicated by their involvement in the multiple systems in which their legal, school, and medical problems are being addressed, as these problems may be identified prior to recognition of the presence of a substance use disorder (Henggeler, Borduin, & Melton, 1991). Finally, high attrition from treatment is a particular problem among adolescents, with treatment completion rates for adolescents in therapeutic communities estimated at less than 20%. Completion rates for outpatient programs are generally estimated at 50% (Henggeler et al., 1996).
Treatment Evaluation Studies
There are few rigorous evaluations of the effectiveness of standard treatment approaches for adolescents. As of 2001, two major reviews identified between 32 and 53 published studies (Dennis & White, 2003; Williams et al., 2000), 21 of which were published in the last 5 years. Overall, most of these were program evaluation studies of inpatient services, and only about 15 were randomized clinical trials in outpatient settings. The older studies tend to suffer from a range of methodological problems. A number of newer studies have been recently published or are under way. These studies are more likely to have high inclusion rates (over 80%), experimental designs, manualized protocols, standardized measures, validation substudies, repeated measures, long-term follow-up (e.g., 12 or more months), and high follow-up rates (80% to 90% or more). They also include economic analysis of the cost and benefits to society (Dennis & White, 2003). The existing program evaluation research has focused primarily on four types of programs. First, the bulk of studies have focused on the “Minnesota model,” generally a 4-to 6-week in
patient program that offers a range of services (i.e., individual, group, and family counseling, and school and recreational activities). Many of these programs are guided by an Alcoholics Anonymous or Narcotics Anonymous Twelve-Step orientation. A second major class of treatment delivery is outpatient drug-free programs. These usually consist of individual and group counseling, often with some family involvement. A third, less commonly studied treatment approach for adolescents is the “therapeutic community.” Based on adult therapeutic community approaches, these programs are typically highly disciplined, 6-to 12-month residential programs that tend to offer a Twelve-Step orientation. The final form of treatment that has been investigated is the Outward Bound or life skills training programs. These wilderness programs typically last 3 to 4 weeks and use the challenges of survival and group interdependency as the key therapeutic ingredients. Until recently, the three more intensive programs (inpatient, residential, and Outward Bound) had received the most attention from investigators. Roughly 30 to 40 studies exist, which involved primarily uncontrolled evaluations of a single treatment program (Williams et al., 2000). In these studies, it is difficult to determine the relative effectiveness of the approach because few included any type of comparison or control group; however, in some studies, patients who dropped out of treatment served as a quasi-experimental control group (although this is clearly not an ideal comparison because of the possibility of selection bias). The primary outcome measures used in these studies are typically abstinence, drug use reduction, and treatment retention, although different studies tend to define these differently. Outcomes are almost always measured by self-report and often taken from clinical records, rather than assessed by an independent evaluator. The use of validated outcome measures or biologic indicators of substance use is rare. Thus, the highly positive outcomes typically reported by these studies should be tempered by an understanding of the substantial limitations of their designs. On average about 50% of patients reported significant decreases in substance use, typically measured as days of any drug use (Williams et al., 2000).
end p.393
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© Copyright Oxford University Press, 2006. All Rights Reserved
Given that most of these programs emphasized complete abstinence, on average only 38% of those followed reported complete abstinence at 6 months.
Evaluation of Outpatient Approaches
Although residential and inpatient treatment warrants more research, focus on improving the effectiveness of outpatient services seems the most promising, given that nearly 80% of adolescents with substance abuse at least initially receive outpatient treatment. In addition, outpatient services have many benefits (e.g., ability to characterize or dictate specific treatments, potential use of randomized designs, larger sample size, etc.). Although few well-designed treatment evaluations of outpatient services exist, there are some important large-scale studies that involve primarily cannabis use, and these are summarized here. These multisite studies of existing practice generally defined minimal or no treatment as less than 90 days (13 weeks) of outpatient service, even though nearly 80% met that criteria. Changes in days of marijuana use were assessed in most of these studies, allowing some cross-study comparison. Among the 111 to 158 youths (under age 21) followed through the Drug Abuse Reporting Program (DARP; Simpson, Savage, & Sells, 1978; Sells & Simpson, 1979) in the early 1970s, cannabis use rose from 3% to 10% in the 3 years following their discharge. Among the 87 adolescents receiving outpatient treatment in the Treatment Outcome Prospective Study (TOPS; Hubbard, Cavanaugh, Craddock, & Rachel, 1985) in the early 1980s, the change in daily cannabis use from the year before to the year after treatment varied from a decrease of 42% (for those with less than 3 months of treatment) to an increase of 13% (for those with 3 or more months of treatment). Among the 156 adolescents receiving treatment (predominantly outpatient) in the Services Research Outcome Study (SROS) during the late 1980s to early 1990s (Office of Applied Studies, 2000), cannabis use rose 2% to 9% between the year before and 5 years after treatment. Among the 236 adolescents in the National Treatment Improvement
Evaluation Study (NTIES; Center for Substance Abuse Treatment [CSAT], 1999; Gerstein & Johnson, 1999) during the early 1990s, there was a 10% to 18% reduction in use between the year before and year after treatment. Among the 445 adolescents followed up after outpatient treatment in the Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A; Grella, Hser, Joshi, Rounds-Bryant, 2001; Hser et al., 2001) in the mid-to late 1990s, there was a 21% to 25% reduction in cannabis use between the years before and after treatment.
The Effectiveness of Specific Approaches: Randomized Clinical Trials
Randomized clinical trials are the gold standard for establishing the efficacy of a given approach, as they are the most rigorous approach that clinical investigators have for evaluating the effectiveness of a given treatment in comparison with a well-defined control treatment and while controlling for multiple threats to internal validity. Although the number of well-designed controlled clinical trials of well-defined treatment approaches for substance-abusing adolescents is steadily increasing, the knowledge base regarding effective treatments continues to lag well behind that for adult substance use disorders. Drawing firm conclusions about treatment outcome and the relative benefits of different approaches is difficult, as there remain only a few controlled clinical trials that meet the rigorous standards required for determining that a treatment be called “empirically supported” (Chambless & Hollon, 1998). Many of the studies reviewed here are characterized by several threats to internal validity, including differential attrition, lack of validated independent outcome measures with objective evaluation of drug use, small sample sizes, lack of specification and evaluation of treatment fidelity and quality, dilution of interventions, and limited follow-up (Cottrell & Boston, 2002; Deas & Thomas, 2001; Kaminer et al., 2002; Waldron, 1997). Thus, with only a few exceptions, caution must be used in making conclusions about the effectiveness of these approaches.
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doi:10.1093/9780195173642.003.0019
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