DOCUMENT RESUME CG 030 098 ED 443 038 Treatment of Adolescents with Substance Use Disorders. TITLE Treatment Improvement Protocol (TIP) Series 32. Substance Abuse and Mental Health Services Administration INSTITUTION (DHHS/PHS), Rockville, MD. Center for Substance Abuse Treatment.; CDM Group, Inc. SMA-99-3345 REPORT NO 1999-00-00 PUB DATE 163p.; For other documents in the TIP Series, see CG 030 NOTE 099-103 and CG 030 130-134. 270-95-0013 CONTRACT National Clearinghouse for Alcohol and Drug Information, AVAILABLE FROM P.O. Box 2345, Rockville, MD 20847-2345. Tel: 800-729-6686 (Toll Free). Non-Classroom (055) Guides PUB TYPE MF01/PC07 Plus Postage. EDRS PRICE Adolescent Development; *Adolescents; Counselor Training; DESCRIPTORS *Drug Rehabilitation; Emotional Adjustment; Ethics; Family Counseling; Family Role; Illegal Drug Use; *Intervention; *Outcomes of Treatment; Program Development; *Substance Abuse ABSTRACT This TIP on the best practice guidelines for treatment of substance abuse aims to help teach treatment providers about the latest information available to design and deliver better services to adolescent clients with substance use disorders. This publication represents advances in the understanding of the immediate and long-term physiologic, behavioral, and social consequences of use, abuse, and dependency. Adolescent substance users differ from adults in many ways, and this TIP explains how knowledge about these differences will help treatment providers grasp why adolescents use substances and how substance use may become an integral part of their identity. A discussion on program design, policies and procedures, and evaluation, as part of program development for treatment, is provided. Other treatment approaches such as therapeutic communities and 12-Step-Based Programs are detailed. It includes a discussion on contemporary family therapy as another effective form of treatment. Youth with distinctive treatment needs are considered in detail, including those in the juvenile justice system; homeless youth; those with nonheterosexual identity; and those with coexisting physical, behavioral, and psychiatric disorders. It concludes with a discussion of the legal and ethical issues of providing treatment to adolescents. The following appendixes are included: "Bibliography," "Medical Management of Drug Intoxication and Withdrawal," and "Field Reviewers." (Contains 11 figures and 173 references.) (JDM) Reproductions supplied by EDRS are the best that can be made from the original document. Substance Abuse and Mental Health Services Administration U.S. DEPARTMENT si.vIcts., OF HEALTH AND HUMAN SERVICES .4.$) Public Health Service Center for Substance Abuse Treatment Substance Abuse and Mental Health Services a Administration Treatment of Adolescents With Substance Use Disorders Treatment Improvement Protocol (TIP) Series 32 BEST COPY AVAILABLY iNI NNW MMINIm affIMN I III I I I I I MililaiNs MININIMINIEMI B11111111111111 111111111111111 1.1.144.1t: U.S. DEPARTMENT OF EDUCATION Improvement Office of Educational Research and EDUCATIONAL RESOURCES INFORMATION CENTER (ERIC) This document has been reproduced as received from the person or organization 4212 originating it. Minor changes have been made to improve reproduction quality. Points of view or opinions Stated in this document do not necessarily represent official OERI position or policy. 2 res) l a t n e m D B C E E E E n , , , A A A o r i v n E l a n s J o H r e , s K E C B I F r , d G , e , , , F , , r A E E A A p o , , r F E s e i t D n I e s U l e a c n J n K L o C E I F , a s I , , t , , , H , r H D D H , B s e H b a p , , , , , , G i B G B u A , a G r G e r S t t n i h r I C t i W t n e s m n s t r s n e s c e e n D c G K s o s s E I L , C A , e , C A F , J , H , l D J , o l , t , G a E B n d c e A i i d l C e f M o t n e m n r 3 t e a t C C D D C C t e a A r , , P , , , , B B T B B B B e : s 2 U 3 ) P I T l a ( i t c n l t l d o o n e l a t a e s d c m i n e t o t t i r e o n e m r n t o h t n g a i t e a e t t c o p t e a i i e i a a y n t n n t d r r p a t a e s o P T o a i n t p p p r s m m u i e t e n n t f t o m l a n r o t i i a y y z n t t e i e e e t e e l n l i n t e a v v l m v l l v n p e e a a e i a i i i i e t y m m c c r t s s s s e a d i t T i i n n n n p v d d t t i y t e e e e e a a s s o e e u a r t t e t t e e o M M n n a n r n O D R r r h p c I I i i t t m I g t - e n n n s d o e e , i e t s s l s n s m h r t u n n u d n i r e t t o o v r e - s n m e t e e s e h i v n o a a m t h s d c c s e e e m p e e n t n n l c s r o r s a s d o a s r a a T a e s e n o e n t c e l a h e h s t r p s f c a n r e b T t l t s o i a a y e a t u A , v n e t A n c l e i s g r o a n g t i d i k e a d t n n S i n f e e n d s m p o e o i e i s C h e e w t k m d h s u r u i t t s a r n l e a T o e o o C e e m t c , a l i n e p b t l t o . f o i t d t e r r e o l l n n n n e e f h a v s o e e e t a t l e T e i t i n e h m m t c s a r . h v e i p w n s p . l l t T t s l e a r , e o a a a b l r o e l l d d t e a p e o a . f n s t s e r o n e r s t t c u s t e t c t t t e m o a n g i a a m f a r t h : s f e i n o u n n f r r t e n a c s i l e o e p l w s f b i a s u o a i p i r o o l e v t o r s t e e o t a a r l i n i e s e i t v p l o v r p c r i e u l d t e r p d e a n e o n n m m C i L b v d a a e f s i i Use Pattern A. Problem(s) resulting from use or low-to-moderate current use B. Problem(s) resulting from use C. Moderate-to-heavy recent use D. No recent moderate-to-heavy use Medical Concerns A. Low-to-moderate use without anticipated with- drawal B. Subacute toxicity C. Social support for detoxification D. Compliance regimen E. Premorbid/subacute toxicity Toxicity requires 24-hour medical monitoring F. G. Other medical concerns that outpatient treatment cannot handle H. Morbid, acute toxicity (overdose) that may require life support All medically complicating conditions, including I. those requiring life support/intensive care No detoxification required J. K. Medical conditions that do not require life support/ intensive treatment services L. No special medical services required on site Intrapersonal A. Less effective coping skills B. Less competent emotional/cognitive functioning C. Still able to function in a nonstructured setting D. Ineffective but functional coping skills E. Requires marginally structured setting Requires moderately structured setting F. G. Dysfunctional coping skills H. Emotional/cognitive/psychiatric impairment Requires 24-hour structured setting I. Continuous psychiatric monitoring J. K. Requires long-term residential treatment, including psychiatric and activities of daily living (ADL) services L. Requires supervision in structured setting, ADL, and other psychosocial rehabilitation Interpersonal A. Identified deficiencies in relationships with signifi- cant others and history of substance use and/or other risk-related behaviors that increase the potential for developing a psychoactive substance use disorder B. Able to function in a nonstructured setting C. Requires marginally structured setting D. Requires moderately structured setting E. Dysfunctional relationships and behaviors that do not pose an immediate threat to self or others F. Behavior requires 24-hour structured care G. Dysfunctional relationships and behaviors that may pose an immediate threat to self or others H. Behavior requires psychiatric management Behavior requires ADL services and possibly I. psychiatric services Behavior manageable within a structured setting J. K. Requires behavior management within a structured setting which provides supervision, ADL, and other psychosocial. rehabilitation Environmental A. Environmental/contextual factors affect the indi- vidual but do not warrant removal from current living situation B. Needs to be supported by minimal treatment C. Needs to be supported by moderate treatment D. Needs to be supported by intensive treatment E. Environmental/contextual factors dictate individual must be removed from adverse influences of the current living situation 4 Treatment of Adolescents With Substance Use Disorders Treatment Improvement Protocol (TIP) Series 32 Ken C. Winters, Ph.D. Revision Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 This publication is part of the Substance Mary Smolenski, Ed.D., C.R.N.P., former Abuse Prevention and Treatment Block Grant project director, and Mary Lou Leonard, technical assistance program. All material former project manager. appearing in this volume except that taken directly from copyrighted sources is in the The opinions expressed herein are the views public domain and may be reproduced or of the Consensus Panel members and do not copied without permission from the Substance reflect the official position of CSAT, Abuse and Mental Health Services SAMHSA, or the U.S. Department of Health Administration's (SAMHSA) Center for and Human Services (DHHS). No official Substance Abuse Treatment (CS AT) or the support or endorsement of CSAT, SAMHSA, authors. Citation of the source is appreciated. or DHHS for these opinions or for particular instruments or software that may be described This publication was written under contract in this document is intended or should be number 270-95-0013 with The CDM Group, inferred. The guidelines proffered in this Inc. (CDM). Sandra Clunies, M.S., document should not be considered as I.C.A.D.C., served as the CSAT Government substitutes for individualized client care and project officer. Rose M. Urban, M.S.W., J.D., treatment decisions. C.S.A.C., served as the CDM TIPs project director. Other CDM TIPs personnel included Y-Lang Nguyen, production/copy editor, Raquel Ingraham, M.S., project manager, DHHS Publication No. (SMA) 99-3345 Virginia Vitzthum, former managing editor, Reprinted 1999 6 Contents vii What Is a TIP? Editorial Advisory Board ix Consensus Panel xi Foreword xiii Executive Summary and Recommendations xv Substance Use Disorder Treatment and Adolescents xvi Tailoring Treatment to the Adolescent xvii General Program Characteristics xviii 12-Step-Based Programs xx Therapeutic Communities xxi Family Therapy xxii Youths With Distinctive Treatment Needs xxiii Legal and Ethical Issues xxv Chapter 1Substance Use Among Adolescents 1 The Consequences 2 Treatment Needs 5 Chapter 2Tailoring Treatment to the Adolescent's Problem 9 Understanding the Problem 9 Factors Affecting Treatment Placement 10 The Continuum of Treatment 15 Chapter 3General Program Characteristics 27 Scope and Approach 27 Staffing 28 Perspectives on Counseling Youth 30 Program Components 31 Treatment Planning 34 Program Evaluation 36 iii Contents Chapter 4Twelve-Step-Based Programs 39 The 12 Steps 39 From AA to the Minnesota Model 40 Incorporating the 12-Step-Based Approach 41 Research Studies 43 Chapter 5Therapeutic Communities 45 The Generic TC Model 46 Adolescents in TCs 47 TCs With Adolescents 48 Research Studies 53 Chapter 6Family Therapy 55 Family Therapy as a Recent Approach 56 What Should the Program Staff Know? 60 Research Studies 61 Chapter 7Youths With Distinctive Treatment Needs 63 Treatment in the Juvenile Justice System 63 Homeless and Precariously Housed Youths 66 Homosexual, Bisexual, and Transgendered Youths 68 Youths With Coexisting Disorders 69 Chapter 8Legal and Ethical Issues 73 Consent to Treatment 73 Privacy and Confidentiality 77 A Final Note 98 Endnotes 99 Appendix ABibliography 101 Appendix BMedical Management of Drug Intoxication and Withdrawal 113 Appendix CField Reviewers 123 Figures 1-1: Perceived Risk of Harm From and Use of Marijuana Among High School Students, 1991 and 1995 2 1-2: Contrasts Between Confrontation of Denial and Motivational Interviewing 7 2-1: Treatment Stages and the Problem Severity Continuum 10 2-2: Adolescent Development: General Features of Early and Later Stages 11 2-3: Client Assessment Criteria 16 8 iv Contents 7-1: Status of Drug Courts in the United States 67 7-2: Number of Drug Court Programs Underway/Planned 68 75 8-1: Decision Tree 8-2: Sample Consent Form 80 8-3: Consent Form: Criminal Justice System Referral 86 97 8-4: Qualified Service Organization Agreement WI"'at Is a TF-3? by their peers. This Panel participates in a series Treatment Improvement Protocols (TIPS) of discussions; the information and are best practice guidelines for the recommendations on which they reach treatment of substance use disorders, consensus form the foundation of the TIP. The provided as a service of the Substance Abuse members of each Consensus Panel represent and Mental Health Services Administration's treatment programs for substance use disorders, (SAMHSA) Center for Substance Abuse hospitals, community health centers, counseling Treatment (CSAT). CSAT's Office of Evaluation, programs, criminal justice and child welfare Scientific Analysis and Synthesis draws on the agencies, and private practitioners. A Panel experience and knowledge of clinical, research, Chair (or Co-Chairs) ensures that the guidelines and administrative experts to produce the TIPs, mirror the results of the group's collaboration. which are distributed to a growing number of A large and diverse group of experts closely facilities and individuals across the country. reviews the draft document. Once the changes The audience for the TIPs is expanding beyond recommended by these field reviewers have public and private treatment facilities for been incorporated, the TIP is prepared for substance use disorders as substance use publication, in print and online. The TIPs can be disorders are increasingly recognized as a major accessed via the Internet on the National Library problem. of Medicine's home page at the URL: The TIPs Editorial Advisory Board, a http: / /text.nlm.nih.gov. The move to electronic distinguished group of substance use disorder media also means that the TIPs can be updated experts and professionals in such related fields more easily so that they continue to provide the as primary care, mental health, and social field with state-of-the-art information. services, works with the State alcohol and drug Although each TIP strives to include an abuse directors to generate topics for the TIPs evidence base for the practices it recommends, based on the field's current needs for CSAT recognizes that the field of substance use information and guidance. disorder treatment is evolving, and published After selecting a topic, CSAT invites staff research frequently lags behind the innovations from pertinent Federal agencies and national pioneered in the field. A major goal of each TIP organizations to a Resource Panel that is to convey "front-line" information quickly but recommends specific areas of focus as well as responsibly. For this reason, recommendations resources that should be considered in proffered in the TIP are attributed to either developing the content of the TIP. Then Panelists' clinical experience or the literature. If recommendations are communicated to a there is research to support a particular Consensus Panel composed of non-Federal approach, citations are provided. experts on the topic who have been nominated vii 10