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Book Title: Treating and Preventing Adolescent Mental Health Disorders  > pp. [425]-[429]
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end p.425
ing this challenge lies in universal, community-based innovations (e.g., Holder, 2001).
Holder (2001, 2002) notes that there have been two different approaches to addressing substance-related public health goals—namely, the catchment and community-system approaches. In the catchment approach to prevention of substance-related problems, a community is viewed as a collection of target groups with adverse behaviors and correlated risks. Operationally this involves locating persons at risk, identifying their risk factors, and implementing interventions to reduce risk factors, often entailing education-based programs. Notably, there is little attention to social dynamics or organiza-tional-and systems-level factors influencing individual target group behaviors. Consistent with the emphasis on environmental influences and potential supports for youth development is the focus of the community-systems approach on the community at large, defined as a set of persons “engaged in shared, social, cultural, political, and economic processes” (Holder, 2002, p. 906). Thus a wide range of problems is collectively considered and the focus is on interventions that address a variety of aspects of the shared behavioral environment in a community. This focus is consistent with the idea of a comprehensive youth strategy recommended by Jamieson and Romer (2003) and others (e.g., Flay, 2002; Roth & Brooks-Gunn, 2002).
A recurring theme in the literature on community partnerships, particularly that concerning diffusion of evidence-based interventions, is the need for community intervention capacity-building, as a way to sustain quality imple-mentation of preventive and developmental competency-building interventions (e.g., Altman, 1995; Lerner, 1995; Morrisey et al., 1997). In this case, capacity building can be defined as efforts designed to enhance and coordinate human, technical and scientific, financial, and other organizational resources directed toward quality implementation of evidence-based, developmentally oriented, preventive interventions for youth (see Spoth et al., 2004). A lack of capacity for sustained intervention implementation is frequently cited as a primary reason for failures in community-based dissemination of interventions (e.g., Arthur, Ayers, Graham, & Hawkins, 2003; Feinberg, Greenberg, Osgood, Anderson, & Babinski, 2002; Goodman, 2000). This is particularly true in the case of school-based interventions (Gottfredson & Wilson, 2003; Hallfors, 2001). Especially problematic is the fact that efficacious school-based interventions are frequently unable to survive the withdrawal of grant funding (Adelman & Taylor, 2003).
FUTURE CHALLENGES
It is fitting to close this chapter on prevention by highlighting the challenge of the necessary bridge building for an improved youth development strategy. Just as there must be a construction plan for building a viable bridge across a chasm or gorge, requiring careful integration of input from a diverse group of designers, planning for a comprehensive strategy to foster positive youth development and prevent youth substance-related problems necessitates a sustained, well-organized effort, with input from a range of community interventionists, scientists, and policymakers at the state and federal levels. One potential contribution to this larger planning effort is a design for universities and communities to partner together to foster a higher prevalence of capable and problem-free youth. However, the wide range of tasks for those involved in community–university partnerships, the many barriers to task accomplishment, and the limited resources available highlight the challenges to design implementation that lie ahead. The single most salient feature of this particular challenge is the apparent gap between necessary human, technical and scientific, and funding resources on the one hand and the limited resource availability on the other. Nonetheless, the salience of the resource gap underscores the potential benefits of efficient and effective capacity building, particularly that which is based in existing community, state, and national infrastructures for coordinated activities supportive of youth.
end p.426
CHAPTER 20 Research Agenda for Substance Use Disorders
end p.427
For a variety of reasons, little research has been conducted among adolescents with substance abuse problems. We operate as though data obtained from studies in adults applies to adolescents, but we know that there are critical differences. Thus assumptions about adolescents must be empirically tested. The following are a series of questions compiled by the Commission on Abuse of Alcohol and Other Drugs that we believe should be given high priority.
What We Know
•  
Substance abuse will often progress to addiction and become a lifelong illness, if not treated.
•  
Long-term treatment is usually required to arrest addiction.
•  
Motivation is an important ingredient for successful treatment.
 
Changes in lifestyle are required.
 
Drug use is a pleasure-reinforced compulsion.
 
Drug craving may lead to relapse.
•  
Adolescents are different from adults.
 
There are differences in brain development and plasticity.
 
Specialized treatment approaches are necessary, including:
 
Age-appropriate interventions
 
More focus on family treatment
 
Longitudinal continuation of treatment.
•  
Heredity affects the vulnerability to addiction.
•  
Availability of drugs is a key variable in developing drug abuse.
What We Do Not Know
•  
Which psychosocial treatments are most effective? All of the following show some promise:
 
Individual therapy (cognitive-behavioral therapy, maturation enhancement therapy)
 
Family therapy
 
Group therapy
 
Twelve-Step rehabilitation
•  
Is group therapy an effective modality for adolescents?
 
If so, how should it be structured?
 
Should adolescents always be segregated from adults in group treatment?
•  
What is the neurobiology of adolescent addiction?
 
Initiation of addictive patterns
 
Progression of addiction
 
Vulnerability to specific agents
•  
Is it necessary to require complete abstinence in adolescents attempting recovery?
 
Does this mean ceasing use of all addicting drugs?
 
Does nicotine use impede recovery?
•  
How can we enhance perceived risk for experimenting with drugs?
•  
How can we best match patients with treatments?
 
Matching problems to treatments has been found effective in small studies, but rarely used in practice.
•  
How can the judicial system positively influence outcome?
What We Urgently Need to Know—The Priorities
•  
Prevention programs: which ones are most effective or ineffective?
 
Mass media campaigns?
 
Drug Abuse Resistance Education (DARE)?
 
Urine testing?
 
Other approaches?
•  
Which specialized treatments for adolescent addiction provide the best outcomes?
•  
Which specialized programs can prevent binge drinking in college?
•  
Which pharmacological treatments work best for adolescents with substance use disorders?
 
Pharmaceutical companies have shown little interest in developing medications for adult addictions and none for substance abuse in adolescence. How can we recruit the pharmaceutical industry into the area of prevention and treatment?
•  
What are the best means of identifying adolescents at risk for addiction?
end p.428
•  
How can we recruit scientists into the area of addiction research?
How Can We Improve the Treatment System?
•  
How can we obtain adequate reimbursement for treatment providers?
 
Adolescent treatment programs are scarce and underfunded.
•  
How can we provide an accessible continuum of care with age-appropriate expertise?
 
Medical and psychiatric evaluation capability
 
Inpatient facilities
 
Partial hospitalization and intensive outpatient programs
 
Outpatient treatment with long-term capability
•  
How can we integrate substance abuse treatment with other mental health treatment?
 
Comorbidity of substance abuse with other mental disorders is very common.
 
Few treatment programs are equipped to treat dual diagnosis.
•  
How can we disseminate scientific evidence supporting the disease concept of addic-ion?
•  
How can political initiatives secure appropriate resource allocation?
end p.429
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