It does little good to know what treatments are effective if those treatments cannot reach the children and families who need them. Likewise, it does little good to have effective treatment protocols sitting idly on academic shelves.

Significant state and national policy initiatives are currently focused on more closely aligning science and practice. These initiatives present unique opportunities for linking scientific developments on effective clinical care to organizational system and policy reform. The availability of a growing research base on effective clinical treatments and practices offers an opportunity to tap into a reservoir of scientifically based strategies. Testing their applicability within locally based service systems is the key question for the next generation of services research. However, limitations in the evidence base as well as limitations in understanding the fit of EBPs to service contexts pose considerable challenges to treatment developers, policymakers, administrators, clinicians, and families. New models for crossing the boundaries between research and practice and accelerating delivery of quality care need to be applied. Creating family-driven and empirically based services and supporting these services through policies that provide fiscal incentives for delivery of outcome-based practices requires commitment to empirical inquiry and to the “obstinate questioning” (Wordsworth, Intimations of Immortality: An Ode, 1819) that alone sustains creative change.

Adolescents with varying degrees of substance use can be found throughout U.S. communities, coming into contact with a variety of settings and service systems. Identification of these teens, regardless of their level of use, is important so that targeted, developmentally focused interventions can be delivered (e.g., brief interventions, outpatient treatment, long-term residential treatment, all followed by the appropriate form of reintervention, step-down, or continuing care services). Such identification has the potential to reduce the morbidity and mortality related to this condition.

The settings within a community can be categorized into two tiers: (1) first-gate generalist settings, and (2) more specialized, problem-focused systems of care (e.g., mental health, child welfare). Generalist settings (e.g., health-care settings, schools) are settings where many adolescents can be found, and they have the opportunity to provide the “first gate” into needed behavioral health and social services. Specialized, problem-focused systems of care, by con

trast, center on adolescents with more serious and specific problems (e.g., the mental health system, the juvenile justice system, the child welfare system, the drug treatment system). In a well-structured system, the general settings and the problem-focused systems would have the training and ability to screen and refer adolescents with presumptive evidence of substance use (or any other specific problem) (a) for a more in-depth assessment; or (b) to problem-focused agencies for intervention (e.g., mental health clinic, substance abuse program). Moreover, an optimized system would have interagency working arrangements in place to assure multidimensional service provision and continuity of care without unnecessary overlap of services.

With respect to early identification, it is important for early screening efforts to differentiate substance use from substance abuse or dependence. This is important for both the efficiency of system operation (i.e., conservation of more intensive services for those with more severe problems) and because these different stages of substance use require qualitatively different types of interventions (Wagner & Waldron, 2001; Winters, 1999).

An appropriate clinical response to identified substance use is likely to be one of a variety of recently developed brief interventions designed to prevent escalation of use into abuse or dependence and the associated penetration into the juvenile justice and social service systems that typically is associated with more severe use (Bilchik, 1995; Greenwood, Model, Rydell, & Chiesa, 1998; RAND, 1996; Wagner & Waldron, 2001; Winters, 1999). Because the effects of brief interventions may weaken after 12 months, the delivery of a brief reintervention is critical if prevention of escalation is to be maintained (Conners, Tarbox, & Faillace, 1992; Connors & Walitzer, 2001; Stanton & Burns, 2003; U.S. Department of Health and Human Services, 1993). In contrast to the appropriate clinical response to substance use, the appropriate clinical response to an identified case of abuse or dependence is likely to be much more intensive, structured, and long-lasting (Wagner & Waldron, 2001; Winters, 1999), designed to change (or slow) the trajectory of a long-term drug-using career. Thus, for both clinical and cost-effectiveness reasons, it is critical for both systems to be able to identify use, to differentiate use from abuse or dependence, to appropriately refer for a comprehensive assessment based on identification, and to provide rapid linkage to the appropriate level of clinical intervention for each type of case. As will be described below, we have found that both service tiers are deficient in these important skills.