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What Research Tells Us About the Treatment of Adolescent Substance Use Disorders

 
Janet C. Titus, Ph.D. and Mark D. Godley, Ph.D.; Governor’s Conference on Substance Abuse Prevention, Intervention, and Treatment for Youth; 1999-08-30
[Identifier: http://www.doctordeluca.com/Library/WOD/ResearchAdolSubAbuse99.htm]
[Related resources: http://www.doctordeluca.com/Library/LibPages/AbsHR-Journalism-lib.htm]
[Source: http://www.chestnut.org/LI/cyt/findings/Gov Summit.pdf]
 
See also:
The Challenge of Prescription Drug Misuse:
A Review and Commentary” - William Hurwitz, M.D.; Pain Medicine; 6(2); 152-161; March 2005
 

[ENTIRE 56 page Report in PDF print format]
NOTE: The introductory sections of this paper (the first 11 pages) are reproduced in HTML on this webpage. The entire 56 page report is available in PDF format from the above link.

How this Report is Organized:
Pages 2 – 11 of this report briefly overview the prevalence of substance abuse in Illinois and the nation as well as the multiple problems among youth who come to treatment. This section also provides an overview of the major treatment approaches that have been studied to date. If your reading time is greatly limited we recommend reading the first 12 pages of this report. It will provide you with a good overview of what research tells us about treatment for adolescent substance use disorders.

This bulk of this briefing report is devoted to summaries of adolescent treatment effectiveness studies. In preparing to write this report we surveyed the peer-reviewed journals in substance abuse to find these studies and subsequently reduced each one to an easy-to-read two or three page summary. Each of the 16 summaries uses a standardized format that includes:

1) Contact information for the Principal Investigator;
 
2) Program objectives;
 
3) Description of the treatment program;
 
4) Study participant description;
 
5) Research design;
 
6) Outcomes; and,
 
7) References.

These studies start on page 12 [See: Full Text of this report in PDF format].

Authors’ Notes: [See: Full Text of this report in PDF format]

Introduction
America’s concern with its youth and substance abuse is by no means a modern day
problem. In the mid-19th century, adolescent alcohol, tobacco, and other drug use came to be
identified as a problem. In his book, Slaying the Dragon: The History of Addiction Treatment in
America, William White points out that this national concern led to the development of
minimum drinking age laws, mandatory school temperance education laws, youth temperance
literature, and the inclusion of young people in several sobriety-based support groups and
“inebriate homes and asylums.” In addition, special efforts were made to prevent abuse by
enrolling school-aged youth in groups like the “Children’s Crusade,” a popular grassroots
movement which persuaded youth to sign a pledge to be abstinent. For the most part these
concerns were limited to alcohol abuse. Few instances of youth treated for marijuana or “hard”
drugs can be found in the literature until the late 1960’s. Since then a virtual explosion of
concern over adolescent drug abuse has been witnessed in the United States.

The overall purpose of this paper is to summarize research from substance abuse journals
to provide an understanding of what treatment approaches have been studied and their relative
effectiveness. This paper is organized in six sections designed to give the reader a brief
overview of: 1) the prevalence of substance abuse in our nation and state; 2) complicating
conditions that adolescents with substance use disorders have when they come to treatment; 3) an
overview of promising approaches in the literature; 4) a brief report of what we know about the
effectiveness of treatment for adolescent substance use disorders; 5) some conclusions and
thoughts on future directions; and 6) summaries of promising programs.

Prevalence of Substance Abuse In the Nation and Illinois
There is an abundance of information on contemporary drug abuse by adolescents (age 18
and under). Many states, including Illinois, survey youth as do several national studies. Of the
national studies, those funded by the National Institutes of Health (Monitoring the Future Study)
and the Substance Abuse and Mental Health Administration (National Household Survey on
Drug Abuse) are the most authoritative. A brief synopsis of important facts from these surveys
follows:

* After drug use peaked for adolescents in 1979/1980, the country experienced a decade of
declining drug use among youth until the early 1990’s.

* Adolescent drug use started increasing in the early 1990’s and continued to do so until 1997.
During this time, adolescents perceived lower risk of harm from drug use. This trend was
true in Illinois and nationally.

* When we speak about drug use among adolescents, we are primarily talking about tobacco,
alcohol, and marijuana – these drugs are known as the “gateway” drugs and account for the
vast majority of adolescent drug use.

* Of the small percentage of youth who abuse “hard drugs,” such as Cocaine, Heroin, and
amphetamines, virtually all of them started with the gateway drugs.

* Close to half of youth in grades 10 – 12 have used marijuana at least once in their lives.

* More than 1 out of 3 youth in grades 10 – 12 have used marijuana in the past year.

* Within the past two years, gateway drug use (tobacco, alcohol, and marijuana) among
adolescents has begun to decline, although still remains disturbingly high. Illinois students
reported “past 30 day use” at the time of a 1998 survey as follows:

Tobacco – 28% (Nearly 3 out of 10 students)
Alcohol – 41% (Over 4 out of 10 students)
Marijuana – 20% (2 out of 10 students)

* For grades 8 – 10, Illinois students’ drug use was higher than the national average.
 
* Among adolescents entering substance abuse treatment, marijuana is the primary drug of
abuse.
 
* The age of first marijuana use has decreased from over 18 in the 1960’s to 15 – 17 years of
age in the late 1970’s and 1980’s to under 15 in the late 1980’s and 1990’s. We should all be
concerned about this disturbing trend because the odds of having marijuana dependence as an
adult are six times higher for those who start using marijuana before the age of 15 than for
those starting after age 18.
 
* Despite the rise in substance use and the potential for long-term consequences, fewer than
10% of adolescents reporting substance use disorder symptoms in the past year have ever
received treatment.

Co-occurring Problems and Treatment Placement
Adolescents presenting for substance abuse treatment almost never enter as a “selfreferral.”
Instead, they are typically referred by a parent, juvenile justice system official (judge,
probation or parole officer), school official, child welfare worker, or representative of some other
community institution. Accordingly, they may enter treatment with multiple problems (legal,
mental health, etc.) Depending on the severity of the substance use disorder and related
problems, counselors will make a determination as to which level of treatment the client should
be placed. In Illinois, treatment organizations are required to follow the patient placement
guidelines set forth by the American Society of Addiction Medicine (ASAM Patient Placement
Criteria II, 1996). Briefly, these guidelines require that clients who enter outpatient treatment
(usually 1-3 hours per week of treatment) have fewer symptoms of dependence and other
problems than those who enter intensive outpatient treatment (16 hours per week of treatment or
more). Likewise, clients entering intensive outpatient treatment have less severe and fewer
problems than those entering residential treatment. Thus, the ASAM criteria require counselors
to follow the principle of providing the least restrictive care needed to assist the client.
In a recent study of two adolescent treatment providers in Illinois, it was found that
nearly 3 out of 4 (73%) outpatient and residential clients were involved with the criminal justice
system. Most similarities between the outpatient and residential clients ended, however, with
criminal justice involvement. The statistics reported below illustrate two important points: 1)
adolescents with substance use disorders have additional problems; and 2) counselors do indeed
select the type of treatment based on the severity of these problems.

Adolescents age 12 –18
Symptoms of Severity

Outpatient
N=54

Residential
N=217

Prior Substance Abuse Treatment Episodes

None

59.3%

24.0%

One

24.1%

32.3%

2+episodes

16.7%

43.8%

Drug Use (Past 90 days)

Weekly Alcohol Use

3.7%

32.7%

Weekly Marijuana Use

40.7%

63.6%

Weekly Crack/Cocaine Use

1.9%

11.1%

Weekly Heroin/Opiod Use

1.9%

5.1%

Weekly Other Drug Use

5.6%

16.1%

Alcohol Severity

No Use

1.9%

1.4%

Use

31.5%

18.9%

Abuse

51.9%

35.5%

Dependence

0.0%

6.0%

Physiological Dependence

14.8%

38.2%

Drug Use Severity

No Use

0.0%

0.9%

Use

24.1%

3.7%

Abuse

33.3%

23.5%

Dependence

3.7%

7.8%

Physiological Dependence

38.9%

64.1%

Mental Health

General Mental Distress

27.8%

48.8%

Post Traumatic Stress Disorder

42.6%

54.1%

Attention Deficit Hyperactivity Disorder

66.7%

76.4%

Conduct Disorder

42.6%

70.7%

Sexual Risk (Past 90 days)

No Sexual Partners

38.9%

27.2%

One Sexual Partner

35.2%

32.7%

Multiple Sexual Partners

25.9%

40.1%

Unprotected Sex

40.7%

47.0%

These statistics reveal a disturbing and challenging fact: adolescents with substance use
disorders presenting for treatment are typically involved with the criminal justice system and
often have co-occurring emotional and other problems. It is important for treatment programs to
assess the extent of such problems and provide or arrange for additional counseling to address
them. It is equally important to coordinate services with other organizations (e.g., Probation
Department) involved in the client’s life in order to achieve coordination of services and care.

What are Current Adolescent Treatment Approaches?
Current approaches to the treatment of adolescent drug use fall into four main modalities:
12-Step, Behavioral, Family-Based, and Therapeutic Communities. Each views the problem of
adolescent substance use -- its etiology, maintenance, and resolution -- from a slightly different
angle (Bukstein, 1995; Winters, Latimer, & Stinchfield, 1999).

The 12-Step approach -- also known as the Minnesota Model or the Alcoholics
Anonymous(AA)/Narcotics Anonymous(NA) approach -- is the most widely used model in the
treatment of adolescent drug abusers. Based on the tenets of AA and basic psychotherapy, the
12-Step model views “chemical dependency” as a disease that must be managed throughout
one’s life, with abstinence as a goal. The backbone of 12-Step treatment is “step work”, a series
of treatment and lifestyle goals that are worked in groups and individually. The first three steps
help the adolescent to be more honest, decide to stop using drugs and alcohol, and choose a new
lifestyle. Steps four through nine, the “action steps”, help adolescents continue to be honest,
develop and implement an action plan for a changed lifestyle, and correct past wrongs where
possible. Steps ten through twelve are the “growth steps” and encourage adolescents to continue
to work a recovery program throughout their lives. Typically the first five steps are covered in
the treatment program, while steps 6 through 12 are addressed in aftercare and ongoing
involvement in community self-help groups. Step work provides the basic structure for
treatment and recovery.

Other components of 12-Step programs include group therapy (the primary mode of
treatment delivery in 12-Step programs), individual counseling, lectures and psychoeducation,
family counseling, written assignments (including step work), recreational activities,
participation in aftercare, and attendance at AA/NA meetings in the community. Counselors in
12-Step programs are often recovering substance users and serve as powerful role models for
living a drug-free life. Although once available only in residential settings, 12-Step treatment is
now widely offered in both residential and outpatient settings.

Behavioral approaches focus on the underlying cognitive processes, beliefs, and
environmental cues associated with the adolescent's use of drugs and alcohol and teach
adolescents coping skills to help them remain drug-free. Whether called Behavior Therapy,
Cognitive Therapy, or Cognitive-Behavioral Therapy, all behavioral approaches view substance
abuse as a learned behavior rooted in the adolescent's cultural context (family, peers, social
institutions, etc.) that defines drug-related beliefs and behaviors. The goal of behavioral
approaches is to teach adolescents to "unlearn" the use of drugs and to learn alternative, prosocial
ways to cope with their lives. In particular, given behavior is mediated by thoughts and beliefs,
cognitive-behavioral techniques attempt to alter thinking as a way to change behavior.
Behavioral techniques are used in residential and outpatient settings as part of group or
individual therapies.

A commonly used behavioral intervention focuses on the development of coping skills.
Particular skills to be taught are introduced and modeled. Using examples from the adolescents'
lives is crucial to help engage them and convince them of their practical utility. Specific skills
vary by program but may include drug and alcohol refusal skills, resisting peer pressure to use
drugs and alcohol, communication skills (nonverbal communication, assertiveness training,
negotiation and conflict resolution skills), problem-solving skills, anger management, relaxation
training, social network development, and leisure-time management. New behaviors are tried
out in low-risk situations (e.g. during group therapy role plays, individually with a counselor)
and eventually are applied in more difficult, "real-life" situations. Homework assignments are
common, such as trying out a new behavior or collecting problem situations to discuss during
therapy. Staff and parents should provide positive reinforcement for the use of new behaviors.
"Behavioral contracting" is another technique used in behavioral approaches. The adolescent
and counselor agree on a set of behaviors to be changed and develop weekly incremental goals
for the adolescent. As each goal is reached, the adolescent is highly praised or otherwise
reinforced. Behaviors are explicitly defined on the contract, with criteria and time limitations
noted.

Family-based approaches acknowledge the critical influence of the adolescent's family
system in the development and maintenance of substance abuse problems. Most techniques are
based on four family therapy models - Structural, Strategic, Functional, and Behavioral - alone or
by combining effective parts of a number of models.

From the family therapy perspective, adolescent substance abuse is a symptom of
maladaptive family relationships, interactions, and expectations. The family is viewed as a
collection of sub-systems (e.g., parents, kids, etc.), each with a variety of roles. Ideally,
boundaries between sub-systems are permeable enough for, say, an adolescent to feel
comfortable seeking input from a parent on an important issue, but not so permeable that the
boundaries between parent and child (e.g. who is the parent, who is the kid) are blurred.
Problems arise when boundaries and roles are not clear or are inappropriate for a given family
sub-system.

Techniques used by family therapists include observing the interactive patterns between
members by encouraging them to speak directly to each other, pinpointing problems in
interactions and their underlying relationship problems, and helping families improve their
relationships. Techniques to clarify family roles and boundaries help families change
maladaptive interaction patterns. The therapist's use of "reframing" or "relabeling" problem
behavior - defining problem behavior in a new way - leads to new insights and opportunities to
mend or develop relationships. Given the importance of day-to-day communication patterns
between members, most family models stress the importance of having the entire family present
for therapy.

Therapeutic communities (TCs) are long-term residential programs reserved for adolescents
with the most severe substance abuse and related problems. The traditional duration of stay is at
least 15 months, although some TCs have adopted shorter lengths of stay based on progress (6-
12 months). The philosophy behind the TC is that substance abuse is a disorder of the entire
person resulting from an interruption in normal personality development and deficits in
interpersonal skills and goal-attainment. Thus, in order for an adolescent to learn to change, he
is steeped in a drug-free lifestyle that integrates the behaviors, affect, values, and life choices of
that lifestyle. The social organization of the TC serves as a family surrogate for the adolescent
and provides a therapeutic, supportive environment for the adolescent to mature and grow.

Life in a TC is highly structured, with days scheduled from early morning through the
evening. Days are filled with school classes and tutoring, peer group and individual therapy,
recreation, jobs, and occupational training. Management of the TC is the responsibility of the
residents, and all adolescents are assigned a job. Through progress and productivity, adolescents
rise through the job hierarchy to positions of management or coordination. Participation by a
family member is often a part of the TC experience. As in 12-Step programs, counselors and
primary staff at TCs are often ex-clients who have been successfully rehabilitated in TCs.
Is Adolescent Treatment Effective?

Research on the effectiveness of adolescent treatment is in its infancy. Few rigorous
evaluations of effectiveness have been done, and of those studies that do exist, many have
methodological problems that make definitive conclusions difficult if not impossible. The
earliest studies of treatment effectiveness were large-scale national efforts that included
adolescent samples (Sells & Simpson, 1979; Hubbard, et al, 1985), but it has only been within
the past 10 to 15 years that treatment effectiveness research has focused exclusively on outcomes
for adolescents.

Despite the problems of early efforts in adolescent treatment research, a few very broad
statements on outcomes are possible.

First, treatment works. Across all studies, decreases in
adolescent drug use and associated problems have been observed following treatment. Studies
comparing outcomes for adolescents who attend and complete treatment versus those who do not
attend or fail to complete treatment typically show positive outcomes for the
attendees /completers and less positive outcomes or no change for those who do not. However,
no single treatment modality stands out as reliably superior to another - most have demonstrated
positive outcomes, and it is unknown which modality or combination of modalities will work
best for given individuals.

A second broad outcome of adolescent treatment research is that relapse rates for adolescents
following treatment are high. Social pressure to use drugs is strong in adolescent culture, and
few treatment programs offer ongoing aftercare or support to buffer the effects of returning to the
"real world". It is possible that the positive outcomes observed in treatment would be sustained
if post-treatment recovery maintenance services or booster sessions were a normal part of
treatment. While the idea of periodic “booster sessions” is appealing, the practicality of getting
adolescent clients to reliably attend such services is not yet known. Additionally, maintenance or
booster sessions may not be reimbursable under several managed care and other insurance plans.

Third, retention in treatment programs is problematic, with drop-out rates ranging from 20-
50+% across studies. Given outcomes for treatment completers are typically better than those
for non-completers, efforts at treatment engagement and retention need more attention. There is
some evidence that family-based treatments can yield high treatment engagement and retention
rates (Liddle & Dakof, 1992), but there have been no direct comparisons of treatment
engagement and retention across modalities and no single modality stands out as superior.
Treatment completers and non-completers may vary on important psychological dimensions
(Kaminer et al., 1992), but even studies that have followed completers and non-completers show
that non-completers can reduce their use, although typically not to the same degree as completers
(Alford et al, 1991; Winters et al., 1999).

Fourth, long-term outcomes for adolescents who complete treatment are unknown. Although
a handful of studies have follow-up periods of up to two years, typical follow-up extends no
longer than twelve months after treatment.

Adolescent substance abuse is a complex problem with multiple causes, leading many to
believe that the most effective treatments will be those that combine aspects of all treatment
modalities to fit the individual needs of an adolescent and his life situation. Unfortunately,
current health care management practices and downsizing of services pose a threat to matching
the most appropriate care to the needs of clients. For example, clients with high problem
severity and a poor recovery environment may be denied access to residential care or approved
only for sub-therapeutic lengths of stay. In a recent study of a residential versus outpatient 12-
Step program, Winters, et al. (1999) found no difference in outcomes between adolescents
treated in residential versus outpatient settings. However, severity of the adolescents' drug
problems had nothing to do with their placement in these settings. Rather, placement was
dictated by what a given adolescent's insurance company policy would support, leading to
inappropriate placements for many adolescents and no average difference in severity between the
inpatient and outpatient groups. Fortunately for citizens of Illinois, treatment programs are
required to follow the placement criteria of the American Society of Addictive Medicine (1996),
which matches the intensity of treatment to the severity of the adolescent's drug use and related
problems.

Adolescent Research Studies Currently Underway in Illinois
One of the reasons it is impossible to say which treatment modality works better than another
is that until very recently, there have been no large-scale efforts to experimentally compare more
than two or three treatment approaches against each other. In the near future, however, the field
will be in a position to make such statements, owing largely to a national study currently
underway and led by researchers at Chestnut Health Systems. The Cannabis Youth Treatment
(CYT) project (Dennis, Babor, Diamond, Donaldson, S.Godley, Tims, et al., 1998), funded by
the Center for Substance Abuse Treatment (CSAT), is the largest multi-site randomized field
experiment of adolescent treatment ever undertaken -- largest in terms of the number of
adolescents treated and the variety of treatments being tested. The purpose of the study is
twofold: (1) to determine the overall clinical effectiveness, cost, and cost-effectiveness of five
promising adolescent treatment approaches targeted at reducing/eliminating marijuana use and
associated problems in adolescents, and (2) to provide validated models of these approaches to
the treatment field. Researchers from four well-respected treatment and academic institutions
(Chestnut Health Systems in Bloomington and Madison County, Illinois; Operation PAR in St.
Petersburg, Florida; the Addiction Research Center at the University of Connecticut in
Farmington, Connecticut; and the Child Guidance Center of the Children's Hospital of
Philadelphia (University of Pennsylvania) in Philadelphia, Pennsylvania) are collaborating on the
treatment and management phases of the project, while economists from the University of Miami
in Miami, Florida are leading the study of costs and cost-effectiveness. To date, no studies on
the costs and cost-effectiveness of adolescent treatment have been done.

The CYT study focuses on five experimental treatments organized under two research arms,
both comparing a strong five-session brief intervention with two more intensive interventions. In
the “incremental arm”, each subsequent intervention builds upon the features of the previous
intervention. Treatments in the incremental arm include: a brief five-session treatment (MCB5;
Sampl & Kadden, 1998); a second intervention in which additional group sessions are added to
the five-sessions (MC12; Webb, Scudder, & Kaminer, 1998); and a third intervention in which
family sessions are added to the second intervention, thereby creating a longer-term group
intervention with family support (FSN; Bunch, Hamilton, Tims, Angelovich, & McDougall,
1998). In the “alternative arm”, the same brief five-session intervention is compared with: a
longer individualized approach for the second condition (ACRA; Meyers, Smith, S. Godley, M.
Godley, & Karvinen, 1998); and an individualized family therapy approach for the third (MDFT;
Liddle, 1998). While both of the latter involve more exposure/resources, they also involve
different approaches. To date, nearly 500 adolescents have been randomly assigned to one of the
five treatments, treatment completion rates are in the 80% range, and follow-up interview rates
through 9 months post-treatment exceed 95%. CYT is awaiting word on further funding to
continue longer-term follow-up. Results from this initial phase of the study are expected in
September, 2000.

Another research project currently underway at Chestnut Health Systems addresses the need
for research on the effects of providing concentrated aftercare services for adolescents
discharged from residential treatment. The Assertive Aftercare Project (AAP) is a five year
randomized field experiment funded by the National Institute on Alcoholism and Alcohol Abuse
(Godley, Godley, & Dennis, in press). The purpose of this study is to learn whether an assertive
approach to aftercare (home-based intervention and case management services) is more likely
than standard aftercare to 1) link clients to needed aftercare services in their community; and 2)
decrease drug use and related problems. This study will examine the extent to which the AAP
and Standard Aftercare conditions achieve these outcomes at three, six, and nine months after
discharge from residential care.

The AAP model is a combination of a behavioral intervention based on the Adolescent
Community Reinforcement Approach (ACRA) and case management procedures. The ACRA
model seeks to replace drug using behaviors with prosocial alternative behaviors. It also uses
communication skills training, problem solving, relapse prevention skills, access to recreational
and other prosocial activities, and job-finding procedures to help the client maintain recovery.
The case management component provides transportation, advocacy, linkage, and monitoring to
assist the client in obtaining needed services in the community.

To date the project has enrolled 72 clients across both conditions; of these, 53 have
completed participation. The follow-up rate for these clients at three, six, and nine months post
discharge is well over 90% across all intervals. The AAP project is funded through May, 2002
and outcome results are anticipated closer to that time.

Research Studies with Adolescents in other States
As this paper is being written there are several research studies in progress in other states. At
the University of New Mexico in Albuquerque, Dr. Holly Waldron is comparing the
effectiveness of brief Functional Family Therapy to Cognitive Behavior Therapy. At the
University of South Carolina, Dr. Scott Hennggeler is starting a new study of Multisystemic
Therapy enhanced with elements from the community reinforcement approach aimed at juvenile
drug court clients. At the University of Miami, Dr. Howard Liddle continues to evaluate the
effectiveness of Multi-Dimensional Family Therapy with adolescent substance abusers and their
families. In a major new initiative started last year, the Center for Substance Abuse Treatment
(CSAT) is studying five existing exemplary adolescent treatment programs using quasi10
experimental research designs. Five residential treatment programs were selected: 1) La Canada
Program, Tucson, AZ; 2)Thunder Road, Inc, Oakland, CA; 3) Phoenix Academy, Los Angeles,
CA; 4) Mountain Manor Treatment Center, Baltimore, MD; and 5) Dynamic Youth, Brooklyn,
NY. Each of these programs is paired with a program evaluation team to study treatment process
and outcome over a three year period. In addition to these five programs, CSAT plans to add
several additional adolescent treatment programs around the country to this study group in FY-
2000.

The final section of this document outlines the majority of research efforts to date on the
effectiveness of adolescent treatment. The study summaries are arranged by the primary
modality being showcased: 12-Step, Behavioral, Family-Based, and Therapeutic Communities.
These studies represent the bulk of research-validated knowledge on adolescent treatment
effectiveness.

[ENTIRE 56 page Report in PDF print format]


References

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American Society of Addictive Medicine (1996). Patient placement criteria for the
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Bunch, L., Hamilton, N., Tims, F., Angelovich, N. &, McDougall, B. (1998). CYT: A
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Webb, C., Scudder, M. & Kaminer, Y. (Eds.) (1998). The MCBT5 Supplement: 7
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Winters, K.C., Latimer, W.L., & Stinchfield, R.D. (1999). Adolescent Treatment. In P.J.
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[ENTIRE 56 page Report in PDF print format]
 

 

Dr. DeLuca's Addiction, Pain, and Public Health Website

Alexander DeLuca, M.D., MPH

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Originally posted: 2005-10-10

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