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Background: Adverse consequences, including non-fatal overdose and death, are prevalent in adolescents and young adults with opioid use disorder (OUD). Barriers toward medication for opioid use disorder (MOUD) have been identified in adult populations but are poorly understood in youth. Objective: This exploratory multi-mixed methods study examines beliefs and attitudes of addiction treatment program staff about the use of MOUD in youth. Methods: A 40-item survey was distributed electronically to 299 addiction treatment programs in Georgia from May 2020 to January 2021. Participant (N = 215; 74% female) attitudes regarding the use of MOUD in three age groups (adolescents (aged 16–17), young adults (aged 18–25), and adults (aged 26+) on a 6-point Likert scale were compared using paired samples t-tests. A series of one-way ANOVA analyses examined differences in attitudes and beliefs across participant characteristics. Verbatim responses to qualitative survey questions were analyzed using a coding reliability approach to thematic analysis. Results: Participants were less likely to support MOUD in adolescents (M = 3.68, SD 1.5) compared with young (M = 4.38, SD 1.36, t = 8.19, p < .001, d = .51) and older adults (M = 4.64, SD 1.3, t = 9.83, p < .001 d = .74). Participants endorsed higher response rates for the use of both naltrexone and buprenorphine over methadone in young adults. A total of 1,412 text responses were reviewed. Participants highlighted barriers to acceptance and use of MOUD in adolescents including safety concerns and impact on brain development. Conclusions: The results support a comprehensive approach to reducing the barriers to using medications to treat OUDs in adolescent populations. Formal and focused continuing education to correct attitudes and beliefs about MOUD treatment for adolescents is necessary.

Self-injurious thoughts and behaviors (SITB) are of increasing concern among adolescents, especially those who use substances. Some evidence suggests that existing evidence-based substance use treatments (EBTs) could impact not only their intended substance use targets but also SITB. However, which types of substance use treatments may have the greatest impact on youth SITB is not yet clear. Based on prior literature showing that family support and connection may buffer youth from SITB, we initially hypothesized that family-based EBTs would show greater improvement in SITB compared to those receiving individually focused EBTs and that the size of the effects would be small given the comparison between two active, evidence-based interventions, and base rates of SITB.In a sample of 2893 youth in substance use treatment, we compared the effectiveness of individually and family-based EBTs in reducing SITBs. The study used entropy balancing and regression modeling to balance the groups on pre-treatment characteristics and examine change in outcomes over a one-year follow-up period.Both groups improved in self-injury and suicide attempts over the one-year study period, but only youth in individual treatment improved in suicidal ideation. However, the study found no significant difference between the changes over time in the two groups for any outcome. As expected, effect sizes were small and power was constrained in this study given the rarity of the outcomes, but effect sizes are similar to those observed with substance use outcomes.The results provide important exploratory evidence on the potential relative effectiveness of these two treatments for SITBs. This study supports prior findings that EBTs for youth substance use may help to improve SITB and suggests that different treatment formats (individual or family-based) could result in different benefits for SITB outcomes.

Treatment retention and engagement of emerging adults with opioid use disorders can be particularly challenging. This study compares treatment outcomes of young adults with primary opioid use (OU) to those with primary marijuana or alcohol use (MAU), who received the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based therapy for the treatment of substance use. The MAU and OU groups were comprised of an outcome sample of 419 young adults ages 18-25. Groups were compared on intake demographics, clinical characteristics, and measures of treatment retention and other associated factors, including treatment initiation and engagement. Outcome measures were administered at A-CRA intake and at 3, 6, and 12 months post-intake. Both groups were similar in treatment retention, initiation, and engagement. Both groups showed a similar decrease in alcohol (p < .001) and marijuana use (p < .001). The OU group had significantly less opioid use at 3 months (p < .001) and maintained this decrease, but did not improve to the level observed in the MAU group at the 12-month follow-up. The Adolescent Community Reinforcement Approach merits further study as a behavioral treatment for young adults with opioid use.

Volunteer Recovery Support for Adolescents (VRSA) is a novel recovery monitoring and support service for youth after discharge from residential treatment for substance use disorders. Study methods and results of a randomized controlled study are presented in a companion paper and provide evidence that VRSA improves pro recovery peer and activity involvement, decreases substance use and related problems, and increases early full remission (Godley et al., under review). This paper describes the VRSA model, how fidelity was monitored, methods used to recruit, retain, train, and supervise volunteers, how well volunteers were able to implement the model, and how adolescents responded to VRSA. As evidenced by successful recruitment of volunteers to cover caseload needs, positive rates of volunteer retention, and favorable recovery support session completion rates, VRSA is a flexible, potentially low-cost model for providing extended recovery support services that is both feasible and acceptable to adolescents. Future research is needed to identify variables that predict volunteer commitment and to investigate if matching gender, race/ethnicity, or other variables affect results.

BACKGROUND: Treatment of opioid use disorder (OUD) in adolescents and young adults is imperative to reduce the risk of overdose and other opioid-related harms. Limited information has been published about national trends in health disparities including utilization, access to medication for opioid use disorder (MOUD), and treatment retention of adolescents and young adults with OUD. METHODS: This secondary data analysis tested for trends and age-related disparities in national OUD treatment admissions, as well as length of stay (defined as continuous enrollment in some form of treatment at a program) and planned use of MOUD for adolescents (age 12–17) and young adults (age 18–24) using the Treatment Episode Data Set from 2008 to 2017. The study also used data from the National Survey on Drug Use and Health to identify population prevalence of OUD and presentation to OUD treatment in adolescents and young adults compared to older adults (age 25+). RESULTS: OUD treatment admissions significantly decreased over the decade by 63% (z = 2.61, p

Background In a recently published randomized controlled trial (RCT) of Volunteer Recovery Support for Adolescents (VRSA), a secondary finding indicated that better adherence to planned VRSA telephone session frequency resulted in significantly higher remission rates relative to lower session adherence. However, interpretation of this dose-response relationship may have been confounded by participant characteristics such as baseline levels of substance use and mental health problems. Methods The present study used statistical methods designed to approximate RCTs when comparing more than two nonequivalent groups that include an assessment of the potential impact of omitted variables. Classification and Regression Tree (CRT) analysis was used to establish the cut-point between high (H) and low (L) VRSA dosage groups. Because we were interested in generalizing to youth with poor attendance, the L-VRSA group served as the reference group. Balancing weights for H-VRSA and a services as usual (SAU) control group were calculated to ensure similarity of baseline pretreatment characteristics to the reference group, and sensitivity of findings to unobserved confounding variables was assessed. Results Findings suggested that superior remission rates at the end of the intervention phase were the result of high adherence to planned VRSA session frequency. Recommendations to achieve high VRSA participation among a larger segment of youth and to test whether longer VRSA duration improves the stability of recovery outcomes are provided. Conclusion Few published dose-response studies have adequately controlled for selection confounds from both observed and unobserved confounding. As such, the present study aims to both assess the impact of different dosage levels of VRSA and provide a template for how to apply state-of-the-art statistical methods designed to approximate randomized controlled trials to such studies.

The current study seeks to advance understanding about how to address substance use and co-occurring mental health problems in adolescents. Specifically, we compared the effectiveness of two evidence-based treatment programs (Motivational Enhancement Treatment/Cognitive Behavior Therapy, 5 Sessions [MET/CBT5] and Adolescent Community Reinforcement Approach [A-CRA]) for both substance use and mental health outcomes (i.e., crossover effects). We used statistical methods designed to approximate randomized controlled trials when comparing nonequivalent groups using observational study data. Our methods also included an assessment of the potential impact of omitted variables. We found that after applying balancing weighting to ensure similarity of the baseline samples (given the nonrandomized study design), both groups significantly improved on the two substance use outcomes (days abstinent and percent of youth in recovery) and on the two mental health outcomes (post-traumatic stress disorder (PTSD) symptoms and general emotional problems). Youth in A-CRA were significantly more likely to be in recovery at the 3-month follow-up compared to youth in MET/CBT5, but the size of this effect was very small. Youth receiving MET/CBT5 appeared to show significantly more improvement in the two mental health measures compared to youth in A-CRA, though these effect sizes were also very small. The findings indicate that adolescents with co-occurring substance use and mental health problems improve on both substance use and mental health outcomes with both treatments even though they are not specifically targeting mental health problems.

Research on continuing care treatment for adolescents following discharge from primary treatment has demonstrated benefit, yet treatment providers encounter multiple barriers in its implementation. Less formal recovery support following treatment is promising, but controlled trials of effectiveness are lacking. This study reports results of a randomized trial of recovery support provided by student volunteers via telephone to youth discharged from residential treatment. Both direct and indirect effects were predicted for proximal (pro-recovery peers, recovery management activities) and distal (AOD use and problems, AOD remission) outcomes. Method Prior to treatment discharge, participants were randomized to either 9 months of post-treatment Volunteer Recovery Support for Adolescents (VRSA; n = 201) or continuing care services as usual (SAU; n = 201) and assessed over 12 months post- discharge. Results There were significant direct effects for VRSA to have more involvement with pro-recovery peers and recovery management activities than SAU. VRSA also had significant indirect effects on reducing AOD use and problems and increasing remission via increases in pro-recovery peers and recovery management activities at 9- and 12-month assessments. Dose-response analyses demonstrated significant increments of improvement in proximal and distal outcomes as VRSA session completion rate increased, but effectiveness attenuated at the post-VRSA (12- month) follow-up assessment. Conclusion Findings suggest that VRSA is a promising option for post-treatment recovery support, especially in the higher dose range. Additional research is needed to test the feasibility of providing VRSA in the higher dose range to a larger proportion of intent to treat samples and extending VRSA duration.

Emerging adulthood is the period of greatest risk for problematic substance use. The primary aim of the current study was to examine the relationship between a broad measure of child maltreatment and several key outcomes for a large clinical sample of emerging adults ( n = 858) and adolescents ( n = 2,697). The secondary aim was to examine the extent to which the relationship between child maltreatment and treatment outcomes differed between emerging adults and adolescents. Multilevel latent growth curve analyses revealed emerging adults and adolescents who experienced child maltreatment reported significantly greater reductions over time on several treatment outcomes (e.g., substance use, substance-related problems, and emotional problems). Overall, analyses did not support differential relationships between child maltreatment and changes over time in these substance use disorder treatment outcomes for emerging adults and adolescents. The one exception was that although emerging adults with child maltreatment did reduce their HIV risk over time, their improvements were not as great as were the improvements in HIV risk reported by adolescents who had experienced child maltreatment.

This study investigates the feasibility of adapting empirically-supported family treatments for emerging adult peer dyads. Data were collected (n=84) from emerging adults and their peers. Peers completed measures of substance use, willingness to participate in their friends' treatments, and an adapted version of the Significant Other Behavior Questionnaire (SBQ), which measures concerned significant others' (CSO) responses to another's use such a punishing, supporting, or withdrawing from the user. Peers were more likely to support sobriety or enable use, versus punishing use or withdrawing from their friends. Overall, peers were quite willing to assist in treatment, but heavily using peers were less enthusiastic. For some emerging adults, their current peers may represent untapped resources to integrate into treatment, and providing peer-enhanced treatments may expand the reach of services to non-treatment seeking populations.

Specific treatments targeting adolescents with substance use disorders (SUDs) have been developed over the last couple of decades. Despite these developmentally tailored treatments, long-term abstinence rates remain relatively low among adolescents receiving care. Research over the last decade has increasingly focused on adolescents with comorbid substance use and psychiatric disorders, in recognition of the barriers caused by inadequate treatment of co-occurring psychiatric disorders. Treatments targeting dually diagnosed youth are now regarded as essential to improving SUD treatment outcomes, but remain underutilized. A variety of treatment modalities such as behavioral therapy, family therapy, 12-step groups, motivational interviewing, contingency management, and combinations of these interventions have been modified for adolescents. In this article, we review the research on these treatments, as they apply to dually diagnosed youth. Furthermore, we explore the evidence for various treatments targeting comorbid SUD, specific to the presence of externalizing or internalizing disorders. The current evidence base supports the importance of integrated treatment targeting both SUD and psychiatric disorders simultaneously. High-quality treatment programs offering combinations of behavioral and family therapy, particularly with motivational interviewing and contingency management, are particularly well supported. In addition, we review various psychotropic medication treatments that have also been studied in conjunction with adolescent SUD treatment. Finally, we review research on post-treatment, supportive care that has been shown to improve long-term SUD outcomes. Recently conceptualized modular treatments, which offer personalized combinations of evidence-based treatments for specific disorders, have been proposed as a means of improving outcomes. Future research on modular programs must test the efficacy of individualized treatments when applied to combinations of psychiatric and SUDs in adolescents.

[Correction Notice: An Erratum for this article was reported in Vol 31(1) of Psychology of Addictive Behaviors (see record 2016-59284-001). In the article, the disclosed interest for Mark D. Godley in the author note is misrepresented. The accurate representation is that the organization employing Mark D. Godley, Chestnut Health Systems, receives fees for A-CRA training. In addition, the disclosed interest statement for Jane Ellen Smith and Robert J. Meyers should read Jane Ellen Smith and Robert J. Meyers each have private consulting businesses that conduct workshops on CRA or A-CRA; they also receive royalties on the CRA book. All versions of this article have been corrected.] Central to the debate over the implementation of empirically supported treatments is whether therapist skill has a measurable, positive relationship with client outcome. The fidelity and skill with which therapists deliver treatments have been studied under the constructs of adherence and competence. Evidence for a relationship between adherence and competence and client outcomes has been mixed, possibly due to small sample sizes, potentially inadequate measures for rating therapists' skill, and limited statistical methods. The current study used a data set in which 91 therapists provided services to 384 clients from the Assertive Adolescent and Family Treatment project. Therapists trained to deliver the Adolescent Community Reinforcement Approach (A-CRA) submitted audiorecorded sessions to independent raters during their training process. Measures of adherence and competence derived from session ratings were examined in a multilevel model for associations with client substance use outcomes at 3-, 6-, and 12-month follow-ups. Therapist competence was significantly predictive of decreases in clients' days of substance use. Therapist adherence was not predictive of client substance use outcomes in the full sample; however, when only those clients who completed the 12-month follow-up were included, between-therapists adherence was found to be predictive of a decrease in client substance use. This study adds to the evidence that competence in the delivery of treatment is associated with better client treatment outcomes. Adherence may be associated with better treatment outcomes as it was in follow-up completers. Future research should investigate the nature of the relationship between protocol-specific adherence and competence and client outcomes. (PsycINFO Database Record

Research shows that many adolescents who enter treatment for substance use do not complete the recommended program, and after discharge, do not connect with continuing care services. Furthermore, the majority of adolescents will return to some level of substance use either during or after participation in treatment. Our review found 10 outcome studies of continuing care treatment for adolescents. Five of six studies with randomized designs resulted in significant clinical improvement for youth receiving the experimental continuing care approaches. Key findings of these trials are that more assertive approaches can increase continuing care initiation rates and that rapid initiation of continuing care made a difference in reducing substance use. Findings suggest that continuing care is not only appropriate for those who successfully complete treatment but also for many individuals who do not. Although there are no randomized controlled studies of adolescent participation in mutual aid groups, evidence is accumulating suggesting that matching adolescents to age-appropriate 12-step and other mutual aid groups can support recovery. Research employing adaptive treatment designs holds promise for establishing decision rules as to which adolescents need low-intensity continuing care services and which need more intensive care.

This study examined client and program factors predicting initiation and engagement for 2,191 adolescents at 28 outpatient substance abuse treatment sites implementing evidence-based treatments. Using Washington Circle criteria for treatment initiation and engagement, 76% of the sample initiated, with 59% engaging in treatment. Analyses used a 2-stage Heckman probit regression, accounting for within-site clustering, to identify factors predictive of initiation and engagement. Adolescents treated in a pay-for-performance (P4P) group were more likely to initiate, whereas adolescents in the race/ethnicity category labeled other (Native American, Asian, Pacific Islander, Native Alaskan, Native Hawaiian, mixed race/ethnicity), or who reported high truancy, were less likely to initiate. Race/ethnicity groups other than Latinos were equally likely to engage. Among White adolescents, each additional day from first treatment to next treatment reduced likelihood of engagement. Although relatively high initiation and engagement rates were achieved, the results suggest that attention to program and client factors may further improve compliance with these performance indicators.

This article addresses less developed areas of clinical research that are of great importance for better understanding the therapeutic process along the continuum of care in youth with alcohol and other substance use disorders (AOSUD). These include the rationale, design, mechanisms of behavior change (MBCs), implementation, monitoring, and outcome-based modification of treatment continuum for youth with AOSUD. The specific objectives are: (1) present current knowledge pertaining to the pretreatment phase including the effect of baseline assessment on treatment outcome; (2) address potential MBCs in treatment; (3) discuss the importance of aftercare, also known as continued care, to prevent postintervention relapse; (4) consider how reconceptualization of therapeutic paradigms might advance the field, in particular treatment algorithm or adaptive treatment strategies addressing poor response to treatment.

The American Society on Addiction Medicine's Patient Placement criteria are commonly used in adolescent treatment. However, the use of these criteria and how they affect the course of treatment and interact with adolescent change has not been examined. Twelve-month treatment patterns were examined for 176 adolescents who entered their first ever episode in a treatment system using these criteria. Forty-one percent of the adolescents received additional treatment after their initial outpatient episode with over 30 unique treatment sequences (i.e., various combinations of outpatient, intensive outpatient, and residential treatment). Significant differences in treatment patterns were found between the change trajectory groups. For example, adolescents who participated in only one outpatient treatment episode were more likely to be in the low alcohol and drug use (AOD) group and less likely to have high rates of time in a controlled environment or to report moderate AOD use. Over one-third of the adolescents participated in additional treatment and almost one-quarter of those who only participated in outpatient treatment had problematic use. These findings suggest the need for clinical monitoring protocols that can be used to identify adolescents needing additional treatment or recovery services.

The effectiveness of adolescent treatment to reduce substance use has been demonstrated by a number of different literature reviews, yet longer term outcome studies have suggested that continued alcohol and other drug use is common. Participation in continuing care services and reductions in environmental risk factors (e.g., peer substance use or alcohol or drug use in the home) have both been found to be associated with improved posttreatment substance use. The authors conducted Path analysis to examine the experimental direct effect of the Assertive Continuing Care Protocol (S. H. Godley, M. D. Godley, & M. L. Dennis, 2001) on general continuing care adherence following residential treatment and the protocol's indirect effect (via general continuing care adherence) on social and environmental risk factors, as well as subsequent substance use and substance-related problems. Supporting previous findings, the final model indicates that greater adherence to continuing care is associated with reductions in environmental risk, which in turn is associated with reduced adolescent substance use and substance-related problems 9 months after discharge from residential treatment.

Aims This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1–3) and longer-term (months 4–9) abstinence. Design Two-group randomized design. Setting Eleven counties surrounding a community-based residential treatment program in the Midwestern section of the United States. Participants A total of 183 adolescents, ages 12–17 years, with one or more Diagnostic and Statistical Manual version IV (DSM-IV) substance use dependence disorder and met American Society for Addiction Medicine (ASAM) placement criteria for non-medical residential treatment. Intervention Prior to discharge from residential treatment, participants were assigned randomly to receive either UCC, available at outpatient clinics in the 11-county study area, or ACC via home visits. Measurements Self-reported interview data were collected at intake, 3, 6 and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months. Findings ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence. Conclusions ACC appears to be an effective alternative to UCC for linking, retaining and increasing adherence to continuing care. Replication with larger samples is needed to investigate further the direct and indirect effects of ACC found in this study.

Because alcohol or other drug use following adolescent substance abuse treatment is common, understanding mediators of posttreatment outcome could help improve treatment interventions. The authors conducted path analyses based on data from 552 adolescents (aged 12-18; 82% male) with cannabis abuse or dependence who participated in outpatient treatment. The analysis used the Family Conflict and Cohesion subscales, from the Family Environment Scale, and several scales and indices from the Global Appraisal of Individual Needs. Family conflict, family cohesion, and social support indirectly predicted substance use and substance-related problems as mediated by recovery environment and social risk. This model replicated across 4 follow-up waves (3, 6, 9, and 12 months postintake). These results support the idea of targeting environmental factors during continuing care as a way to improve treatment outcomes for adolescents with cannabis disorders.

Aims To examine the comparability, reliability and predictive validity of two instruments used to assess alcohol use and dependence: the Global Appraisal of Individual Needs (GAIN) and the Form 90 Timeline Followback (TLFB) method. Design, setting and participants Adolescents (n = 101) admitted to a residential treatment program in the United States were interviewed at intake with the GAIN, and again within a week with a variation of TLFB, called Form 90. Alcohol and cannabis measures were compared and used to predict the number of past-month substance abuse and dependence symptoms. Measurement Self-report measures of days of alcohol and cannabis use in the 90 days prior to intake, peak number of drinks/joints used, peak blood alcohol content (BAC) and alcohol and cannabis abuse and dependence symptom counts. Findings Results revealed that the measures had: (a) excellent comparability (r = 0.7–0.8) across the two instruments; (b) deteriorating reliability after reported peak BAC levels exceeded 0.50 and peak joints exceeding 19; and (c) similar and strong relationships between use measures and the number of abuse/dependence symptoms across measures and instruments. Conclusions In a sample of 101 adolescents who were admitted to residential treatment for alcohol or drug dependence, the corresponding measures from the two instruments produced comparable results. If the cross-validation of these two measures generalizes to adolescents treated in out-patient settings and other adolescent treatment populations, the GAIN and Form 90 may provide useful core alcohol measures for meta-analyses.

Adolescents with the most severe alcohol and other drug (AOD) use disorders are typically admitted to residential treatment. Of the more than 21,000 U.S. adolescents admitted to residential treatment supported by public funds in 2009, 53% received an unfavorable discharge and 76% failed to complete 90 days of treatment (United States Department of Health and Human Services, 2009), the length of stay threshold associated with better outcomes (Hser et al., 2001). Additional research has shown that 60–70% of adolescents relapse within 90 days after residential treatment (Brown, Vik, & Creamer, 1989; Godley, Godley, Dennis, Funk, & Passetti, 2002). Providing continuing care following addiction treatment can improve clinical outcomes (Dennis & Scott, 2007; Godley, Godley, Dennis, Funk, & Passetti, 2007; Kaminer, Burleson, & Burke, 2008; Kim et al., 2011; McKay, 2009; Saitz, Larson, LaBelle, Richardson, & Samet, 2008; Winters, Stinchfield, Latimer, & Lee, 2007), but relatively few adult and adolescent patients attend even one continuing care session following discharge from residential treatment (Donovan, 1998; Godley & Godley, 2011). Although some adolescent patients lack motivation to follow through with continuing care referrals, structural barriers exist as well. Residential treatment programs receiving state and/or Medicaid reimbursement typically serve large geographical areas, requiring referral to treatment organizations closer to the patient’s home after residential treatment. A recent study showed that continuing care was initiated about half the time for those with planned residential discharges and less than 10% of the time for those with unplanned discharges (Godley & Godley, 2012). Only one randomized trial of continuing care for youth discharged from residential treatment has been published, and that study examined the effects of Assertive Continuing Care (ACC; Godley et al., 2007). This intervention was developed to overcome barriers to continuing care participation by sending clinicians trained in the Adolescent Community Reinforcement Approach (A-CRA) and case management (Godley, Godley, & Dennis, 2001) to meet with youth in their school, home, or other community location within two weeks of discharge. In this experiment, adolescents assigned to ACC after residential treatment were significantly more likely than those receiving Usual Continuing Care (UCC) to receive continuing care (94% vs. 54%) and attend more sessions. Main effects of ACC were found for abstinence from their primary drug, marijuana, over a 9-month follow-up (d=.32). Decreases for alcohol and other drugs were all in the predicted direction but not significant (Godley et al., 2007). The effects of ACC may be due to the combination of (a) case management services designed to increase adherence to the requirements of school and/or juvenile justice – two common social systems in which youth are involved; (b) A-CRA for the adolescent, which uses both operant learning and cognitive behavior therapy procedures to identify and increase reinforcing pro-social activities and facilitates the development of improved communication, relapse prevention, and other skills; (c) A-CRA sessions for both the adolescent and caregiver; and (d) homework assigned after each session to practice a new skill and engage in a new or recurring pro-social activity. Despite the durable success of ACC in the initial trial relative to UCC, effect sizes for both marijuana and alcohol were small, suggesting that additional improvements to the model should be considered. Contingency Management (CM) interventions have been successfully added to the Community Reinforcement Approach and Cognitive Behavior Therapy in trials with adults to further improve substance use outcomes (Higgins, Silverman, & Heil, 2007). The effectiveness of CM in addiction treatment is rapid and reliable through the active phase by providing contingent reinforcement for drug abstinence and, in some studies, treatment attendance or verifiable activities. Only a few controlled studies combining CM with other treatments have been conducted for adolescents with AOD use disorders, and none were continuing care studies. Compared to a family court condition, a juvenile drug court intervention enhanced with Multi-Systemic Therapy plus CM evidenced large effects in decreasing substance use (ESs = 0.0.38 to 2.48) and criminal behavior (ESs = −0.04 to 1.88; Henggeler et al., 2006), and CM combined with parent training and Motivational Enhancement/Cognitive Behavior Therapy (MET/CBT) was more effective for adolescents than MET/CBT alone in increasing continuous abstinence from marijuana during the 3-month treatment phase (d=0.48) but less so over extended follow-up (Stanger, Budney, Kamon, & Thostensen, 2009). In studies by Azrin and colleagues (Azrin et al., 1994, 2001), a multi-component Family Behavior Therapy intervention including parent-mediated CM for abstinence and pro-social activities significantly reduced drug use compared to supportive counseling (Azrin et al., 1994) but in a second study, did not reduce drug use more than a cognitive behavioral problem-solving condition (Azrin et al., 2001). The available evidence suggests that adding CM to cognitive behavioral therapies is a promising strategy to improve adolescents’ drug use outcomes. Although several studies with adults found CM combined with CBT interventions to be more effective than either CM or CBT alone (Higgins et al., 2007; Kadden, Litt, Kabela-Cormier, & Petry, 2007), other studies found that CM alone was as effective (Rawson et al., 2002) or more effective than CM and CBT combined (Carroll et al., 2012). Because CM alone has demonstrated effectiveness with adults and is relatively straightforward to implement, it merits testing with adolescents as a post-treatment continuing care intervention. In summary, CM has demonstrated efficacy in producing abstinence for adults and, in combination with other interventions, for adolescents. In addition, ACC has shown promise in a single trial sustaining abstinence for significantly more youth than UCC, but the effects were relatively small. For the present study, it was expected that the immediate contingent reinforcement offered through CM would improve engagement in pro-social activities and lead to greater improvement in abstinence outcomes, but because the ACC intervention is designed to increase abstinence (through increasing pro-social activities, social skills, relationship with parents, and better adherence to education and juvenile justice requirements), it was unclear whether this would exceed ACC alone. The combination of CM and ACC might provide additional sustained benefit by rapid contingent reinforcement of abstinence and pro-social activities via CM with skills training and case management provided through ACC; however, this has never been tested. The present study reports the results of a randomized trial to assess the degree to which three experimental approaches were more successful at engaging youth in post-residential continuing care and maintaining AOD abstinence during the 12 months following residential discharge relative to a UCC alone condition: (a) CM, a well-established, replicable evidence-based intervention; (b) ACC, a multi-component intervention with behavioral, CBT, and case management elements; and (c) CM +ACC, a combination of both approaches.

This study examined the relationship between Adolescent Community Reinforcement Approach (A-CRA) participation with treatment engagement, retention, and satisfaction, and with substance use and emotional problem outcomes. Participants had substance use disorders (SUD) only or co-occurring substance use and psychiatric problems. Those with co-occurring problems reported more days of substance use and emotional problems at intake to treatment than those with SUD only. All groups received equivalent exposure to A-CRA during treatment implementation. At the 12-month follow-up, adolescents classified as externalizers (n = 468) or those with both externalizing and internalizing problems (n = 674) had significantly greater improvement in their days of abstinence and substance problems relative to adolescents with substance use disorders only (n = 666). Additionally, adolescents reporting symptoms of internalizing (n = 154), externalizing, or both externalizing and internalizing disorders had significantly greater improvements in days of emotional problems relative to adolescents with SUD only.

Within the context of an initiative to implement evidence-based practices (EBPs) for adolescents with substance use disorders, this study examined the extent to which staff factors measured at an initial EBP training workshop were predictive of EBP competence and turnover status of staff (N = 121) measured 6, 9, and 12 months posttraining. By the final assessment point, 52.3% of staff transitioned to the employed/EBP-competent category, 26.6% transitioned to the not employed/not EBP-competent category, 4.6% transitioned to the not employed/EBP-competent category, and 16.5% had not transitioned out of the initial category. Multilevel multinomial regression analysis identified several measures that were significant predictors of staff transitions to the not employed/not EBP-competent category (e.g., program needs, job satisfaction, burnout) and transitions to the employed/EBP-competent category (e.g., months in position, pressures for change, influence). Findings have implications for the development and testing of strategies to train and retain staff to deliver EBPs in practice settings.

For adolescents, substance use disorder (SUD) treatment outcomes (e.g., abstinence, problematic behaviors) often cannot be measured soon enough to influence treatment trajectory. Although process measures (e.g., treatment engagement) can play an important role, it is essential to demonstrate their association with outcomes. This study explored the extent to which engagement in outpatient treatment was associated with outcomes and whether demographic/clinical characteristics moderated these relationships.This is a prospective study of adolescents (N=1491) who received outpatient treatment for SUDs at one of 28 treatment sites taking part in a national evidence-based practice implementation initiative. Information from the Global Appraisal of Individual Needs interviews at intake and six-month follow-up, as well as encounter data, were used. Adjusted hierarchical logistic models were used to estimate effects of engagement on six-month outcomes.Sixty-one percent of adolescents engaged in outpatient treatment. Adolescents engaging in treatment had significantly lower likelihoods of reporting any substance use (OR 0.60, 95% CI 0.41, 0.87), alcohol use (OR 0.63, 95% CI 0.45, 0.87), heavy alcohol use (OR 0.53, 95% CI 0.33, 0.86), and marijuana use (OR 0.64, 95% CI 0.45, 0.93). This association of engagement with abstinence outcomes was not limited to any particular group. Treatment engagement, however, was not associated with adolescents' self-report of illegal activity or trouble controlling behavior at follow-up.At the individual level, the Washington Circle engagement measure was a predictor of some positive outcomes for adolescents in outpatient treatment. Efforts to better engage adolescents in treatment could improve quality of care.

One fifth of all public treatment admissions are emerging adults, and few studies have considered whether treatments are developmentally appropriate. This study compares outcomes between adolescents and emerging adults with substance use disorders who received the Adolescent Community Reinforcement Approach (A-CRA). Propensity score matching was used to create a weighted comparison group of adolescents (n = 151) who had similar demographic characteristics, clinical severity, and treatment retention as the group of emerging adults (n = 152). We examined age differences in abstinence and other psychosocial outcomes at the last available follow-up. Emerging adults and adolescents both reduced their substance use at follow-up. However, emerging adults were less likely to be abstinent and in remission and had more days of alcohol use when compared with adolescents. This study's findings are consistent with prior work on emerging adults. Additional research should examine features of interventions that are most effective in addressing the developmental needs of emerging adults.

The current study examined the predictive validity of the Washington Circle (WC) continuity of care after long-term residential treatment performance measure, as well as the impact of assertive continuing care interventions on achieving continuity of care. This measure is a process measure that focuses on timely delivery of a minimal floor of services that are necessary to provide sufficient quality of treatment but should not be construed to be the optimal continuity of care after residential treatment for any specific adolescent. Participants included 342 adolescents who were admitted to long-term residential treatment and randomly assigned to either standard continuing care or an assertive continuing care condition. Overall, results provide initial support for the WC continuity of care after residential treatment performance measure as a useful predictor of 3-month recovery status. Additionally, assignment to an assertive continuing care condition was found to significantly increase the likelihood of achieving continuity of care.

Data from 399 adolescents, who participated in one of four randomly controlled trials of the Adolescent Community Reinforcement Approach (A-CRA) intervention, were used to examine the extent to which exposure to A-CRA procedures mediated the relationship between treatment retention and outcomes. Although zero-order correlations indicated that retention in treatment was a significant predictor of alcohol and other drug (AOD) use (r = -0.18, p < .001), this relationship was reduced to nonsignificance (p = .39) when exposure to A-CRA procedures was included in the model. Overall, the final model evidenced a very good fit (root mean square error of approximation = .00; comparative fit index = 1.00) and explained 29% and 43% of the variance in adolescents' posttreatment AOD use and AOD-related problems, respectively. In addition, Chi-Squared Automatic Interaction Detection analysis was used to derive a target level of A-CRA exposure, which was found to be significantly related to being in recovery at follow-up. The current findings are useful, as little research to date has identified significant mediators of the relationship between retention and treatment outcomes or identified target thresholds of treatment exposure.

Contingency management (CM) is efficacious in improving outcomes of substance-abusing patients, but CM studies are relatively rare in adolescents. CM approaches can reinforce both abstinence and adherence to treatment-related goal areas. This paper describes 1,739 different activities in 10 goal areas (e.g., education, family/friends, and social/recreational) chosen by 86 adolescents who were participating in a multiple week CM study that reinforced both abstinence and adherence with goal-related activities. The mean activities selected was 20, and the mean completed was 13. Overall, 1,114 or 64% of chosen activities were completed. The clinical feasibility of activity incentive programs for adolescents is discussed.

This study examined the rates and correlates of self-reported receipt for mental health services among 1,190 adolescents, aged 12–19, who were admitted to community-based substance abuse outpatient clinics and had a co-occurring mental health problem. Utilization of mental health service was ascertained 3 months post-intake. About one third (35%) of adolescents with a co-occurring mental health problem identified at intake received mental health service in the 3 months after treatment entry. After holding other correlates constant, history of mental health treatment, suicidal behavior, family history of mental disorder and insurance coverage at intake were associated with mental health service utilization at the 3-month follow up. Predictors of service utilization varied by gender and racial/ethnic status. Implications for integrated substance use and mental health services are discussed.

This longitudinal study examined the relationships among the working alliance, treatment satisfaction, and posttreatment use among adolescents in treatment for substance abuse. Adolescents (N = 600) from the Cannabis Youth Treatment study (M. L. Dennis et al., 2002) completed measures of working alliance and treatment satisfaction as well as substance use and substance-related problems at intake and 3, 6, 9, 12, and 30 months' postintake. When controlling for initial substance use and substance-related problems, working alliance, but not treatment satisfaction, predicted use at 3 and 6 months' postintake. Neither working alliance nor treatment satisfaction were predictive of longitudinal patterns of posttreatment use. Implications for the assessment of working alliance and treatment satisfaction are discussed.

Resources for the treatment of adolescent substance use disorders have increased over the past century in tandem with the increased visibility and cultural alarm regarding adolescent substance-related problems. The United States now has a multi-branched and growing system of adolescent treatment services that spans public and private sectors and offers services in both specialty and non-specialty service settings. Most adolescents are entering treatment due to alcohol and/or cannabis-related problems (and, to a lesser degree, other illicit drugs), but present with a wide array of co-occurring problems and obstacles to recovery. Multiple levels of specialized care are available but most adolescents being treated via outpatient counseling. The number and methodological rigor of adolescent treatment outcome studies have increased dramatically in recent years. The findings of these studies suggest the need for earlier systems of problem identification and intervention, a model of sustained recovery support for adolescents presenting with high problem severity and complexity, and sustained interventions with the adolescent's post-treatment family and social environment. In the opening decade of the twenty-first century, the treatment of adolescent substance use disorders is itself maturing into a professionalized and science-guided service arena.

Aims To identify adolescent relapse trajectory groups following discharge from out-patient substance abuse treatment. Design, setting and participants Adolescents aged 12–18, who were assigned randomly to one of five out-patient interventions (n = 563) in four United States communities and followed-up 3, 6, 9, 12 and 30 months post-intake. Outcome measures Self-report measures of days using any alcohol or other drugs (AOD), days of alcohol use, days of cannabis use, days of heavy use, days of crack/cocaine use, days of heroin/opiate use, days AOD use interfered with responsibilities and days in a controlled environment. Findings Adolescents can be grouped empirically into five relapse trajectories over 30 months following out-patient treatment: (a) low AOD use with limited days in a controlled environment; (b) low AOD use with high days in a controlled environment; (c) moderate/decreasing AOD use; (d) increasing AOD use; and (e) consistently high AOD use. Conclusions There was considerable heterogeneity in the relapse trajectories, varying by the initial response to treatment, the stability (versus increase/decrease) of the response and an interaction with time in a controlled environment. Cannabis and alcohol were the two main substances involved, although the two groups with the poorest trajectories had increasing levels of cocaine, opiate and other substance use at the 30-month follow-up. This study demonstrates the chronicity of substance use even among a subgroup of adolescents and the importance of studying more complex longitudinal patterns of recovery.

This paper provides a description of the rationale, study design, treatments and assessment procedures used in the Cannabis Youth Treatment (CYT) experiment.CYT was designed to (a) test the relative effectiveness, cost and benefit-cost of five promising treatment interventions under field conditions and (b) provide evidence based manual-guided models of these interventions to the treatment field.The study involved two community-based treatment programs and two major medical centers.Participants were 600 adolescents recruited from the regular intake who were between the ages of 12 and 18, had used marijuana in the past 90 days, and met one or more criteria of dependence or abuse.Participants were randomly assigned to one of five interventions: Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT), Family Support Network (FSN), Adolescent Community Reinforcement Approach (ACRA), or Multidimensional Family Therapy (MDFT).Self-report data were collected at intake, 3, 6, 9 and 12 months post discharge using the Global Appraisal of Individual Needs (GAIN), as well as several supplemental self-reports, collateral reports, urine testing, and service logs.This paper reports on the study's implementation including the psychometric properties of the measures (alphas over 0.8), validity of self-report (kappa over 0.6), high rates of treatment completion (81% completed two or more months), and high rates of follow-up (over 94% per wave).The feasibility of implementing the CYT manual-guided treatment and quality assurance model in community-based adolescent treatment programs is discussed.

In many treatment systems, adolescents referred to residential treatment have the most serious alcohol or other substance use disorders and are at high risk of relapse. Upon discharge, these adolescents are typically referred to continuing care services, however, linkage to these services is often problematic. In this study, 114 adolescents (76% male) who stayed at least 7 days in residential treatment were randomly assigned to receive either usual continuing care (UCC) or UCC plus an assertive continuing care protocol (ACC) involving case management and the adolescent community reinforcement approach. ACC participants were significantly more likely to initiate and receive more continuing care services, to be abstinent from marijuana at 3 months postdischarge, and to reduce their 3-month postdischarge days of alcohol use. Preliminary findings demonstrate an ACC approach designed for adolescents can increase linkage and retention in continuing care and improve short-term substance use outcomes.

Objective To test whether pay for performance (P4P) is an effective method to improve adolescent substance use disorder treatment implementation and efficacy. Design Cluster randomized trial. Setting Community-based treatment organizations. Participants Twenty-nine community-based treatment organizations, 105 therapists, and 986 adolescent patients (953 with complete data). Intervention Community-based treatment organizations were assigned to 1 of the following conditions: the implementation-as-usual (IAU) control condition or the P4P experimental condition. In addition to delivering the same evidence-based treatment (ie, using the Adolescent Community Reinforcement Approach [A-CRA]), each organization received standardized levels of funding, training, and coaching from the treatment developers. Therapists in the P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (ie, A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions (ie, target A-CRA) that has been found to be associated with significantly improved patient outcomes. Main Outcome Measures Outcomes included A-CRA competence (ie, a therapist-level implementation measure), target A-CRA (ie, a patient-level implementation measure), and remission status (ie, a patient-level treatment effectiveness measure). Results Relative to therapists in the IAU control condition, therapists in the P4P condition were significantly more likely to demonstrate A-CRA competence (24.0% vs 8.9%; event rate ratio, 2.24; 95% CI, 1.12-4.48; P = .02). Relative to patients in the IAU control condition, patients in the P4P condition were significantly more likely to receive target A-CRA (17.3% vs 2.5%; odds ratio, 5.19; 95% CI, 1.53-17.62; P = .01). However, no significant differences were found between conditions with regard to patients' end-of-treatment remission status. Conclusion Pay for performance can be an effective method of improving treatment implementation. Trial Registration clinicaltrials.gov Identifier: NCT01016704

A case management model for adolescent substance abusers whose problems are severe enough to warrant residential treatment is presented, based on the experience of a demonstration project. The five integral functions of case management (assessment, planning, linking, advocacy, and support) are described within the framework of each phase of an adolescent's treatment program (screening, residential treatment, and continuing care). Detailed descriptions of case management activities and the philosophy underlying case management are addressed. The integrated client tracking and program evaluation monitoring system developed for the case management project is described, and evaluation data are presented. Among the advantages case managers are able to offer to the entire treatment process include encouragement of family involvement in the youth's recovery; providing support; tracking substance abuse relapse episodes following treatment; connecting the youth with school, work, and community resources; and helping youth to fulfill legal obligations.