No state in the United States offers adolescent-specific provider certification and only five states require adolescent-specific knowledge for licensure (Northwest Fronteir Addiction Technology Transfer Center, 2000; Pollio, 2002). At the national level, the National Association of Alcoholism and Drug Abuse Counselors (NAADAC) certification program employs a competency-based tiered system of national-level credentials: national certified addictions counselor, level I, national certified addictions counselor, level II, and master addictions counselor. There are no adolescent-specific knowledge requirements for any level, including the highest level (NAADAC, 2003). Since knowledge of adolescent development and skill and interest in treating youth are of paramount importance to treatment of adolescents (Deas et al., 2000; Winters et al., 2000), questions arise as to (1) whether the few staff

who do treat adolescents are sufficiently skilled to do so, and (2) why state and national credentialing processes do not require adolescent-specific knowledge. This is particularly perplexing given that the NAADAC recently added a national tobacco addiction specialist certification program. Judging from the scientific literature, a national certification program for adolescent addiction specialist appears to be equally important. At the very least, incorporation of adolescent-specific knowledge requirements into all certification programs should result in a more informed group of providers.

Compounding the paucity of properly credentialed adolescent services is the failure of programs to accept an array of insurance types: less than 50% of adolescent AOD programs accept Medicaid; less than two thirds accept private insurance; and less than two thirds have a sliding fee scale (SAMHSA, 2001a). Even when insurance is accepted, adolescents are the most uninsured group in this country, rendering many of them unable to finance their treatment (Ford et al., 1999; Klein et al., 1999). As stated earlier, approximately 4 million youth in this country are without any form of health insurance, with many more having insurance that does not cover behavioral health treatment (Center for Adolescent Health and the Law, 2000). Inadequate financing mechanisms and lack of insurance coverage, coupled with the insufficient number of adolescent programs, further reduces the already limited odds of gaining access to treatment once identified.

Improvement in early problem identification is only the beginning to a very large and complex problem. If the system is to meet the needs of identified youth, other service system inadequacies will need to be addressed simultaneously: (1) the demand for adolescent substance abuse treatment—current demand already exceeds the system's capacity to intervene; and (2) inade quate financing mechanisms—too few dollars and too few funding mechanisms render it difficult to support a treatment episode.

Despite research advances in adolescent assessment practices (Winters & Stinchfield, 1995), the standard clinical intake does not identify the full range of problems and strengths brought to a substance abuse treatment program by an individual youth, nor does it assess youth within a developmental context of measurement (Weinberg et al., 1998). In a typical program, an unstructured interview (generally with program-

developed forms) is conducted to obtain an in-depth drug use history, a psychiatric review, and a physical examination. These components are the mainstay for treatment planning (Weinberg et al., 1998). As we and others have shown, adolescents with SUD are characterized by interconnected, complex problems (Hawkins et al., 1992; Fleming, Leventhal, Glynn, & Ershley, 1989; Helzer, 1981; Hirschi, Hindelang, & Weis, 1980; Meyers et al., 1999; Morrison, McCusker, Stoddard, & Bigelow, 1995; Prout & Chuzik, 1988; Winters & Stinchfield, 1995).

In a recent study of 205 youth in drug treatment (Meyers, Hagan, & McDermott et al., under review), many individuals had an array of problem behaviors, with typical onset occurring in early or middle childhood. Excluding tobacco, alcohol and other drugs were tried at approximately 11 years of age on average (11.3; SD = 2.5), with at least weekly use starting by the age of 13 (12.9; SD = 1.8). Alcohol, marijuana, hallucinogens, heroin, and cocaine tended to be the most predominant substances of abuse; 89% of the youth were daily cigarette smokers. With respect to mental health issues, 93% of youth had at least three symptoms of a mental health disorder at treatment admission, with 82% meeting criteria for an Axis I nondrug diagnosis by the age of 12 years. Family problems were prevalent in that 50% of the youth lived with active substance abusers, 53% had run away from home, 53% reported transient living arrangements, and 31% reported police or child welfare involvement with their family. Inconsistent discipline practices (46%), harsh discipline practices (35%), and a lack of supervision (46%) were also reported. In 21% of cases, youth assumed the adult or parental role within the household. Educational deficits were the norm, with 77% reporting a history of academic problems, 74% reporting attendance problems, and 80% reporting discipline problems. It is therefore not surprising that 57% of these teens had dropped out of school by the age of 15. Further, 75% had been or were currently involved with the justice system, 55% actively carried guns, and 43% had witnessed a murder or an attempted murder in their community. Eighty-three percent of the youth were sexually active; all (100%) reported hanging out with peers who either had AOD problems or were involved in the juvenile justice system.

In addition to these descriptive data illustrating the clinical complexities of substance-abusing youth, we empirically identified seven treatment-oriented youth prototypes (Meyers, McDermott, Webb, & Hagan, in press).

These typologies suggest that adolescents in substance abuse treatment programs are a very diverse group of youth. While it is clear that effective treatment needs to address these multiple problems, neither the simple availability of multiple services nor even the broad, undifferentiated provision of multiple services appears to be appropriate for producing treatment gains. Instead, gains are most likely to be obtained when the facets of treatment relate directly (i.e., are matched) to the life areas of the teen that are in need of remediation (Meyers et al., 1999). Given the degradation of services available within many service programs (Delany et al., 2001; Etheridge, Smith, Rounds-Bryant, & Hubbard, 2001; SAMHSA, 2001b), service coordination between programs and systems will be necessary if treatment matching is to become a reality.

When limited assessments are conducted, there is a risk that services will focus on just a few issues or provide services that are irrelevant

to a youth's profile. These scenarios are rarely associated with significant clinical benefits (Henggeler, Schoenwald, Pickrel, Rowland, & Santos, 1994; Kiestenbaum, 1985). Limited assessments can result in a cascading effect of inadequate treatment plans, incomplete treatment matching, limited service coordination, poor treatment engagement and retention, and poor utilization of scarce resources. In turn, this can lead the youth and the family to conclude that “treatment doesn't work.” Hence, once youth are identified and find access to substance abuse treatment, there is a strong need for the use of standardized multidimensional assessment tools.

Even if comprehensive assessments leading to prioritized but multifocused treatment planning can become standard clinical practice, another barrier will become even more apparent. Few if any programs are able to deliver even a minimal constellation of developmentally sensitive educational, social, or health services. Within the last few years, there has been a severe decline in the number and types of on-site services provided by adolescent substance abuse treatment programs in the United States (Etheridge et al., 2001). This occurs at a time when it is widely recognized that (1) treatment decisions for adolescents are better informed by pretreatment psychosocial factors than by drug use severity (Latimer, Newcomb, Winters, & Stinchfield, 2000), and (2) treatment effectiveness is contingent upon treatment for the array of comorbid dysfunctions within clinical samples (Kazdin & Weisz, 1998; Williams & Chang, 2000).

As a result of limited assessment and service decline, adolescents who are fortunate enough to obtain substance abuse treatment will probably not receive the type or amount of services required to minimally address their needs (Delany et al., 2001; Etheridge et al., 2001; SAMHSA, 2001b). Even adolescents are aware of service deficiencies: many of those who had received substance abuse treatment reported that their needs were not met by the services they received (Eth ridge et al., 2001), with family and psychiatric needs most often going unmet (40%–50%). Since these are perhaps the two domains most comorbid with adolescent substance abuse, it is likely that these unmet needs may particularly compromise the effects of the services (typically drug counseling) that can be provided.

The effects of provided services can also be compromised if they are not developmentally focused. Adolescents are a unique client group in that (1) they are in a continuous state of social, biological, cognitive, and emotional development; and (2) risk taking and experimentation characterize normal development (Deas et al., 2000; Eccles et al., 1993; Gottlieb, Wahisten, & Licklieter, 1998; Greene, 1993). Consequently, evidence continues to mount demonstrating the effectiveness of interventions that address the developmental processes of social-identity development, peer group influences, self-regulation, moral and cognitive development (e.g., perspective-taking), and autonomy seeking (i.e., separation from the family [classic view] or movement toward family interdependence [contemporary view]; Deas et al., 2000; Wagner & Waldron, 2001). To obtain optimal effects, ecologically framed interventions that address individual and proximal factors are necessary (Bronfenbrenner, 1986, 1989; Liddle & Hogue, 2001). Because the family or household is a principle ecological context for child and adolescent development, targeted interventions with the family as a unit that address limit setting, monitoring and supervision, consistent discipline practices, and communication patterns are required to compliment individually based services. When there is limited availability of these core components, treatment delivery falls short of meeting individual needs. This has a negative impact on retention, one of the most consistent predictors of treatment outcome (Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997; Simpson, Joe, & Brown, 1997; Simpson, Joe, Broome et al., 1997). When the treatment landscape has been compromised by service deterioration and nondevelopmentally focused care, it is not surprising that few adolescents complete treatment, thus reducing their chances of having a good outcome (Battjes, Onken, & Delany, 1999; Williams & Chang, 2000; Winters, 1999).