What are the critical components for developing effective adolescent treatment programs?

The field of research-based youth treatment services is young, but growing fast. The knowledge base is rapidly expanding with the continued grant opportunities from t he Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health, Robert Wood Johnson Foundation, and others. Any new program development for youth substance abuse should now incorporate research findings from clinical trials within the last 5 years. These findings point to specific differences, not only in the design of treatment protocols, but also in medication regimens, continued care, and the role of self-help. For instance, critical to effective youth treatment is the linkage of multiple service environments with the family or guardians involved. Additionally, a "youth" program needs to describe how to conduct parent training classes, set up supervised free time, provide pro-social activities, manage interagency teams, ensure appropriate educational services, involve juvenile justice/drug courts, and so on.

The following list of essential components can act as a guide to developing appropriate services for youth. These principles are in resources such as Drug Strategies: Treating Teens Guide < www.drugstrategies.org > and the Physicians Leadership on National Drug Policy: Adolescent Substance Abuse Primer< www.plndp.org >. In addition, the new book Adolescent Treatment in the United States by Stevens and Morral describes 11 exemplary substance abuse youth treatment programs that have now been "manualized." These manuals, including the Center for Substance Abuse Treatment (CSAT) cannabis youth treatment manuals, are available at the www.chestnut.org Web site.

The list of principles can be categorized into two general parts: direct service and program structures.

In this FAQ, I will describe the initial direct service components, including assessment and comprehensive adolescent based treatment. In the next FAQ, I will focus on the continued care and recovery check up aspect of direct service. To conclude the FAQ program development series, I will describe programmatic structures needed to ensure effective practice.

Essential front-line components of effective treatment include the following :

Progressive Assessment- human service workers need an understanding of the stages of use, the areas of life that are affected by substances, and the way to assess when it becomes a problem. Many states have adopted the CRAFFT (a short, 6-question substance-abuse screen) and Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) (a 52-question co-occurring screening tool). The Center for Substance Abuse Treatment (CSAT) is also encouraging youth treatment programs to use the Global Appraisal of Individual Needs (GAIN) series of assessment tools (GAIN, GAIN-Q, GAIN-M90), which are not only comprehensive but are compliant with the Government Performance Act (GPRA) and the Health Insurance Portability and Accountability Act (HIPPA).

Providing Comprehensive Services- programs must consider the individuality and co-occurring or co-existing mental health needs of youth with substance disorders. There is little evidence that one modality of treatment or session format (individual, group, and family) is appropriate for all clients; thus flexibility, availability and treatment matching a client's needs to available services is the most effective approach. Evidence-based practices for youth include protocols that are motivational, that are cognitive behavioral and behavioral, that involve family, and that use 12-step strategies.

Orientation- programs should make the orientation process inviting and easy to understand. Materials that explain the process of treatment (the consent for treatment, confidentiality, available options) should also describe to the family what is to be expected of the participants and the clinicians. This vital component of service is often brushed over, but it is essential to engaging families.

Adolescent-Focused Treatment- services must be engaging (i.e., dynamic and active, "meet them on their own turf"), clinically and developmentally appropriate, and strength based. Evidence-based treatment manuals address developmental factors, including adapting situations, triggers, and consequences for youth. These manuals offer treatments that use motivational philosophies to engage the mandated population, use concrete versus abstract concepts, deal with loss of control issues, support recovery environments, and support continued care. Additionally, these adolescent practices include targeted sessions for victimization/trauma, anger management, depression, and gender and cultural issues. Treatment needs to be habilitative rather than re-habilitative; programs need to emphasize the acquisition of new capacities rather than the restoration of old ones. Additionally, programs should include ongoing psychiatric services with continued assessment, medication management, and family involvement (assessment, parent education, multifamily groups, family counseling, parent behavior training, and home visits). Of equal importance is linkage to education services (on-site if residential), wrap-around services (transportation, case management, and coordination of care), healthcare (contraception, sexually transmitted diseases, and asthma/respiratory problems), recreational activity (room for gross motor activities), and exposure to non-using activities.

Availability of a Continuum of Care- a continuum of care must respond to the full range of service needs: prevention, screening, assessment, intervention, a menu of treatment options, case management/specializedrehabilitation, and continued care.

Gender and Cultural Competence- Gender competence and cultural competence are essential in developing a successful therapeutic alliance between a youth and his or her counselor. Recent research points to significant differences between male and female adolescent drug users. "Gender responsiveness is creating an environment through site selection, staff selection, program development, content and material that reflects an understanding of the realities of women's lives, and is responsive to the issues of the participants" (Stephanie Covington, Ph.D., Institute for Relational Development Center for Gender & Justice, see new SAMHSA-TIP on treating women). The same type of program responsiveness is critical for working with youth and families of mixed racial and cultural identities. Sensitivity to others and factors that help build trust are especially important for gay and lesbian youth who might not otherwise be willing or able to address key aspects of their identity.