Youth substance use treatment programs aim to reduce alcohol and illicit drug use, and the misuse of licit drugs, in youths who have been clinically diagnosed with a substance use problem. These programs differ from prevention programs, which aim to promote abstinence in youths to prevent their initial or escalating use. Treatment programs can take a multitude of approaches, such as court-based, residential-based, and family-inclusive programs to help youth develop skills and knowledge to reduce substance use (Drake, 2012; Van Ryzin et al., 2016; Winters, Botzet, and Fahnhorst, 2011).
Substance use disorder in youth is a prevalent problem. An estimated 2.8 percent (712,000) of youths ages 12 to 17 experienced an alcohol use disorder in the past year, and 6.3 percent (1.6 million) of youths ages 12 to 17 experienced a substance use disorder in the past year (SAMSHA, 2021). However, the rate of utilization of substance use treatment programs is low. According to a study by Haughwout and colleagues (2016), fewer than 12 percent of youths who have a substance use disorder participate in treatment.
This literature review focuses on substance use disorder among youths under 18 and on the utilization of substance use treatment programs. The review describes the scope of substance use among youth, the theoretical base of substance-use treatment programs, risk factors that can lead to substance use disorders, protective factors that can buffer against substance use disorders, various types of treatment programs and outcome evidence, limitations to treatment programs, and the research currently available.
Overview of Substance Use Disorders
Among youth in the United States, it is estimated that 8 percent will experience an alcohol use disorder, and 2 percent to 3 percent will experience an illicit drug use disorder before turning 18 Merikangas et al., 2010; Swendsen et al., 2012; SAMSHA, 2011). Several surveys collect information on youths' self-reported use of alcohol and their use of illicit and licit drugs. These self-reported data are then used to calculate the prevalence rates of youth substance use (such as 30-day prevalence in alcohol use or past-year use of narcotics). However, few surveys collect information specifically regarding the prevalence of substance use disorders in youth. Substance use disorder is a diagnosable condition of ongoing and habitual use, and is distinct from substance use, which refers to episodes of occasional use. Most of the information provided below on prevalence rates of youth substance use disorders (and specific disorders such as alcohol use disorder) come from one survey, the National Survey on Drug Use and Health (NSDUH), which is the most comprehensive and up-to-date federal survey.
The NSDUH is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) and collects national and state-level data annually from all 50 states and the District of Columbia. In 2020, more than 36,000 people ages 12 and older were surveyed, including 6,337 interviews conducted with youths ages 12 to 17. Findings pertaining to substance use disorders—including alcohol use disorder, illicit drug use disorder, and more-specific disorders resulting from marijuana, cocaine, heroin, prescription pain reliever, or opioid use—are presented in an annual report.
In general, rates of substance use disorder among youth have declined and leveled off since the first decade of the 2000s. Specifically, among 12- to 17-year-olds, past-year alcohol use disorder declined from 5.9 percent (or 1.5 million youths) in 2002 to 1.7 percent (or 414,000 youths) in 2019. Within the same age group, 3.4 percent (or 894,000 youths) had a past-year illicit drug use disorder in 2019, which was higher than estimates in 2017 and 2018, but similar to estimates in 2015 and 2016.[3
In 2020 the NSDUH used the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5) criteria to assess substance use disorder. The DSM-5 is the most current diagnostic tool published by the American Psychiatric Association (APA), and it serves as the principal authority for psychiatric diagnoses. Previous surveys used the DSM–4 criteria, meaning that the 2020 findings cannot be easily compared with previous years. In 2020, respondents were identified as having a substance use disorder if they met two or more of the following criteria in a 12-month period:
- Consuming the substance in larger amounts or over a longer period of time than intended.
- Desiring to cut back on or stop use of the substance but being unsuccessful in these attempts.
- Spending a significant amount of time obtaining, using, or recovering from using the substance.
- Experiencing cravings and urges to use the substance.
- Failing to meet school, home, or work obligations because of substance use.
- Continuing to use the substance despite problems it has caused.
- Giving up important social, occupational, or recreational activities because of substance use.
- Continuing to use substances, even in situations where it is physically dangerous.
- Continuing to use substances, despite having physical or psychological problems that may have been caused or made worse by the substance.
- Needing more of the substance to achieve the desired effect (increased tolerance).
- Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Using these criteria, it was estimated that 6.3 percent (1.6 million) of youths ages 12 to 17 experienced a substance use disorder in the past year (SAMHSA, 2021).
Alcohol Use Disorder
Alcohol is the most commonly used drug among youth (NIAAA, 2022). According to the 2020 NSDUH, 8.2 percent of youths reported using alcohol in the past month, 4.1 percent reported binge alcohol use, and 0.6 percent reported heavy alcohol use in the past month (SAMHSA, 2021). However, while any alcohol use by youths is problematic, not all youths who drink alcohol meet the criteria for an alcohol use disorder.
The NSDUH identified respondents as having alcohol use disorder if they had used alcohol on 6 or more days in the past 12 months and if they also met two or more of the DSM–5 criteria for alcohol use disorder. The criteria for alcohol use disorder are as follows:
- Used alcohol in larger amounts or for a longer time period than intended.
- Had a persistent desire or made unsuccessful attempts to cut down on alcohol use.
- Spent a great deal of time in activities to obtain, use, or recover from alcohol use.
- Felt a craving or strong desire to use alcohol.
- Engaged in recurrent alcohol use resulting in failure to fulfill major role obligations at work, school, or home.
- Continued to use alcohol despite social or interpersonal problems caused by the effects of alcohol.
- Gave up or reduced important social, occupational, or recreational activities because of alcohol use.
- Continued to use alcohol in physically hazardous situations.
- Continued to use alcohol despite physical or psychological problems caused by alcohol use.
- Developed tolerance (i.e., needed to use alcohol more than before to get desired effects or noticing that the same amount of alcohol had less effect than before.
- Experienced a required number of withdrawal symptoms after cutting back or stopping alcohol use.
Based on these requirements, the NSDUH estimated that 2.8 percent (712,000) of youths ages 12 to 17 experienced alcohol use disorder in the past year.
Illicit Drug Use Disorder
Many youths experiment with illicit drugs, in addition to alcohol. In 2020, 13.8 percent of youths who responded to the NSDUH indicated past-year illicit drug use (SAMHSA, 2021). However, not all youths who engage in illicit drug use will meet the criteria for an illicit drug use disorder.
The NSDUH identified respondents as having an illicit drug use disorder if they met the DSM–5 substance use disorder criteria (described above under Overview of Substance Use Disorders) for one or more of the following illicit drugs: marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, or prescription psychotherapeutic drugs (stimulants, tranquilizers or sedatives, and pain relievers). For respondents whose drug use concentrated on a certain substance, specific disorders (such as marijuana use disorder, opioid use disorder, prescription pain reliever use disorder, cocaine use disorder, and heroin use disorder) were included.
In 2020, using past-year use rates among 12- to 17-year-olds, the NSDUH (SAMHSA, 2021) estimated that 4.9 percent (1.4 million youths) met criteria for at least one illicit drug use disorder. Specifically:
- 4.1 percent (1 million youths) met criteria for marijuana use disorder.
- 0.3 percent (80,000 youths) met criteria for opioid use disorder.
- 0.3 percent (80,000 youths) met criteria for prescription pain reliever use disorder.
- 0.1 percent (28,000 youths) met criteria for cocaine use disorder.
- Estimates for heroin use disorder could not be calculated with sufficient precision.
Co-Occurring Mental Health Disorders and Substance Use Disorders Among Youth
Youth substance use and mental health problems are commonly experienced simultaneously; an estimated 60 percent to 75 percent of youths with substance use disorders also have a co-occurring mental health disorder (Torrens et al., 2012; Burkstein and Horner, 2010; Chan, Dennis, and Funk, 2008; Turner et al., 2004; Hoffman et al., 2004). Common co-occurring mental health problems include conduct disorder, Attention Deficit Hyperactivity Disorder (ADHD), mood disorders, and trauma-related disorders (Burkstein and Horner, 2010).
Youths may turn to alcohol or drugs to help alleviate symptoms associated with mental health disorders, such as hopelessness, anxiety, irritability, or negative thoughts. However, substance use can have the opposite effect, which can lead to exacerbating and/or worsening these symptoms (Ramo et al., 2005). As a result, co-occurring disorders are associated with more-severe substance use disorder symptoms (Chan, Dennis, and Funk, 2008; Wise, Cuffe, and Fischer, 2001).
Research on co-occurring substance use disorder and mental health disorders in youth has largely focused on mood disorders, or mental health disorders that largely affect one’s emotional state such as depression and anxiety. Youths who have experienced a major depressive episode (MDE) are twice as likely to engage in alcohol or illicit drug use, compared with youths who have not experienced one (SAMHSA, 2021). Using DSM–5 criteria, youths were identified as having experienced an MDE if in the past year if 1) they had at least one period of 2 weeks or longer when, for most of the day nearly every day, they felt depressed or lost interest or pleasure in daily activities, and 2) they also had problems with sleeping, eating, energy, concentration, or self-worth or had recurrent thoughts of death or recurrent suicidal ideation. In 2020, 2.7 percent of adolescents surveyed (644,000 people) experienced a substance use disorder and a major depressive episode in the same year (SAMHSA, 2021). The 2020 NSDUH examined rates of substance use disorder in youths who experienced MDE in the past year. Based on these criteria, an estimated 2.7 percent (644,000) of youths ages 12 to 17 experienced both MDE and substance use disorder in the past year (SAMHSA, 2021).
Overall Key Findings
Findings from the NSDUH showed that 2.8 percent of youths ages 12 to 17 met the criteria for alcohol use disorder and 4.9 percent met the criteria for at least one illicit drug use disorder. The most common type of illicit drug use disorder was marijuana use disorder (4.1 percent), with well under 1 percent of youths experiencing opioid, prescription pain reliever, or cocaine use disorder. The NSDUH also found that 2.7 percent of youths experienced both a substance use disorder and a major depressive episode. Yet, substance use treatment use remained low among youths who met the criteria for substance use disorder and therefore demonstrated a need for treatment (SAMHSA, 2021).
Differences in Substance Use Disorder by Gender
While many studies have described the differences between adult men and women in the prevalence of substance use disorders (e.g., Vasilenko, Evans–Polce, and Lanza, 2017), and some research have focused on the differences between adolescent boys and girls in substance use and initiation (e.g., Johnston et al., 2020), there is limited research on the difference in the prevalence of substance use disorders between adolescent boys and girls (Aarons et al., 2001; Gau et al., 2007; McHugh et al., 2018). For example, a study of prevalence of adolescent substance use disorders among youth ages 13 to 18 across five sectors of care (e.g., juvenile justice system, mental health system, child welfare) found that rates of substance use disorder were higher among males (Aarons et al., 2001). Also, a study from Taiwan found that boys were more likely than girls to develop substance use disorders in adolescence (Gau et al., 2007). Studies of older youth (ages 16 to 25) have found that documented opioid use disorder was higher for males than females (Bagley et al., 2021). However, several sources find that there is more gender parity in problematic substance use in adolescence than in adulthood (e.g., Young et al., 2002; McHugh et al., 2018) and that the differences by gender that had existed in the past have been getting smaller.
 Illicit drugs include marijuana (in 40 states), opioids (e.g., heroin), certain stimulants (e.g., methamphetamine, cocaine), hallucinogens (e.g., LSD), and dissociative drugs (e.g., PCP) [NIDA, 2020].
 Licit drugs include alcohol, nicotine (e.g., cigarettes), marijuana (as of 2022, in Alaska, California, Colorado, the District of Columbia, Maine, Massachusetts, Michigan, Nevada, Oregon, and Washington), certain stimulants (e.g., coffee), medicines used for illnesses, over-the-counter drugs used as directed, and prescription medicines used by the person to whom the drugs were prescribed (NIDA, 2020).
 The 2015 NSDUH was the first year during which estimates were provided for any illicit drug use disorder among youths. Previous years collected data on specific illicit drug use disorders only (e.g., marijuana, cocaine, and heroin use disorders).
 The NSDUH defines binge drinking for males as having 5 or more drinks on the same occasion at least 1 day in the past 30 days. Binge drinking for females is defined as having 4 or more drinks on the same occasion at least 1 day in the past 30. Heavy alcohol use is defined as binge drinking on 5 or more days in the past 30 days based on the thresholds described (SAMHSA, 2021).
The various treatment approaches for youths experiencing substance use disorders are grounded in numerous theories. These theories inform treatment programming that works to encourage behavioral change and improve youths’ interpersonal relationships (Liddle et al., 2018, Slesnick and Prestopnik, 2009, Akers et al., 1979). Prevalent theories underlying substance use disorder treatment programs for youth include various learning theories (i.e., cognitive–behavioral), family-based theories, and therapeutic justice. Also, several authors use self-determination theory to examine the influence of motivation in treatment engagement among youths (Bowers et al., 2017; Cleverley, Grenville, and Henderson, 2018).
Learning Theories. Classical, operant, and social learning theories have been applied to understand youths' substance use behavior and to inform treatment programming. Within these theories, substance use is viewed as behavior that is learned in the context of social interactions (e.g., observing parents, siblings, or peers) and that persists depending on whether there are rewards or punishments for the behavior (Akers et al., 1979). These theories inform behavior or cognitive–behavioral models that conceptualize adolescent substance use as learned behaviors initiated and maintained in the context of environmental factors (Waldron and Kaminer, 2004) and that can be changed by modifying thought processes or reinforcing new behaviors (Winters et al., 2018). With this, the majority of individual and group-based cognitive–behavioral treatments have involved multicomponent approaches of cognitive strategies, such as identifying distorted thinking patterns, combined with behavioral strategies, such as problem-solving, coping with cravings, and substance refusal skills training, which teach strategies for avoiding high-risk drug use situations (Waldron and Turner, 2008). These treatments help build youths' motivation to change by providing incentives for abstinence (Winters et al., 2018). Often, cognitive–behavioral therapy for substance use will include components such as self-monitoring, avoidance of stimulus cues, altering reinforcement contingencies, and coping-skills training to manage and resist urges to use. The use of modeling, behavior rehearsal, feedback, and homework assignments are characteristic during treatment sessions (Waldron and Kaminer, 2004).
Self-Determination Theory. This is a theory of human motivation based on three basic psychological needs: 1) autonomy, 2) competence, and 3) relatedness (Deci and Ryan, 2012; Ryan and Deci, 2000). It has been applied in many life domains, including substance use treatment engagement (Bowers et al., 2017; Groshkova, 2010). The theory proposes that there are several types of external motivation and that levels of engagement in treatment are determined by how individuals subjectively perceive these external pressures (Cleverley, Grenville, and Henderson, 2018; Deci and Ryan, 1985; Wild and Enzle, 2002). For example, youths often are extrinsically motivated by their parents to enter treatment. This could result in youths’ resentfully complying out of fear of consequences or, by contrast, understanding and accepting that substance use is an instrumental step toward a better future. These differing patient perceptions lead to different treatment experiences (Cleverley, Grenville, and Henderson, 2018; Ryan and Deci, 2000).
Family Systems Theory. General systems theory, which focuses on how the parts of a system interact with one another, helped inform development of family systems theory, which was developed in the late 1960s and early 1970s. Key concepts in family systems theory are feedback, homeostasis, and boundaries (Lander, Howsare, and Byrne, 2013). Homeostasis refers to the idea that it is the tendency of a system to seek stability and equilibrium (Brown and Christensen, 1986), and in family systems theory this means that each family member tends to function in such a way that keeps the whole system in balance, even if it is not healthy for specific individuals (Lander, Howsare, and Byrne, 2013). Feedback refers to the circular way in which parts of the family system communicate with one another. Finally, boundaries regulate interpersonal contact, either in a healthy way (e.g., boundaries define healthy adult and child roles in the family) or an unhealthy way (e.g., maintaining secrets) [Lander, Howsare, and Byrne, 2013].
Multiple models of family therapy have been developed using the family systems theory and focusing on improving family functioning and social relationships (Waldron and Turner, 2008; Liddle et al., 2009; Liddle et al., 2018), including the multisystemic family systems therapy model. Some treatment programs incorporate concepts from the crisis intervention theory, which contends that families are more amenable to counseling and open to change during a crisis (e.g., youth running away, youth using alcohol or drugs) [Slesnick and Prestopnik, 2009]. Therefore, these programs start by bringing the family together to address the immediate issues the youth is experiencing. In general, approaches that involve family are based on the therapeutic premise that the family has the most significant and long-lasting influence on adolescent development (Winters et al., 2018).
Although family is an important part of a young person's social environment and often is essential to resolving a young person's substance use problems, interventions at the family system level alone may not be sufficient depending on the individual's situation (Liddle, 1999). Therefore, many family and individual treatment approaches address the multiple systems that maintain youths' substance use, including individual, familial, and extrafamilial systems (Liddle, 1999). Many substance-use-treatment programs for youth integrate multiple therapeutic strategies within their treatment service framework, incorporating elements from family-based treatment, group and individual cognitive–behavioral therapy, motivational approaches, among others to enhance outcomes (Gray and Squeglia, 2018). Common components among them are teaching skills to resist the triggers associated with a youth's substance use, addressing life functioning issues that may have contributed to both the onset and maintenance of the substance use (including mental health and family issues), and identifying and building on a young person's strengths (Winters et al., 2018).
Therapeutic Jurisprudence. In addition, courts-based treatment programs for youth are often grounded in the theoretical perspective of therapeutic jurisprudence, which integrates knowledge of mental health and behavioral change with the implementation of law (Wilson, Olaghere, and Kimbrell, 2019). Under therapeutic jurisprudence, it is argued that legal rules and procedures can be used to improve the mental and physical well-being of youths (that is, justice-involved juveniles often with drug-involved offenses) within the court system. The emphasis under this model is on the selection of a therapeutic option that promotes health but does not conflict with the normative values of the justice system, such as due process (Rottman and Casey, 1999). Principles of therapeutic justice include close monitoring of a youth's behavior, multidisciplinary involvement, and collaboration with community-based and governmental organizations (Wilson, Olaghere, and Kimbrell, 2019). Drug courts are a primary example of court-based programs that use the principles of therapeutic jurisprudence (BJA, 2003).
Risk factors consist of personal traits, characteristics of the environment, and conditions in the family, school, and community that are linked to a youth's likelihood of engaging in delinquency and other problem behaviors such as substance use (Murray and Farrington, 2010). These risk factors can exist at the individual, peer, school, family, and community levels. Research on risk factors that can affect youths' likelihood of success in substance use treatment programs is largely limited; therefore, the research discussed below focuses on risk factors that are linked to a youth's likelihood of developing a substance use disorder. However, this research is limited, as many studies focus on risk factors of substance use initiation rather than on specific disorders (Bacio et al., 2015). Additional information on substance use initiation can be found in the Substance Use Prevention Programs Literature Review.
Individual. These risk factors include any characteristic directly related to or within a youth that affect the likelihood of their engaging in a specific behavior, such as substance use. These risk factors can stem from genetics, early moral development, personality traits, temperament, and negative life events (Development Services Group, 2015; Wong, Slotboom, and Bijleveld, 2010; Dick et al., 2013; Hodgins, Kratzer, and McNeil, 2001). For example, research has found that genetics play a role in the development of a substance use disorder in youth, and some biobehavioral traits attributed to predisposition for substance use disorders are influenced by genetics (Dick et al., 2013). However, studies emphasize that parenting and environmental factors affect risk factors related to genetics (Hines et al., 2015; Sloboda, Glantz, and Tarter, 2012; Prom–Wormley et al., 2017); this is seen especially in studies involving twins (Dick et al., 2013).
Other researchers have examined the effect of personality profiles on youth substance use disorders. One study found that youths with substance use disorders had greater levels of neuroticism, lower agreeableness, and lower conscientiousness than siblings of similar ages without substance use disorders (Anderson et al., 2007; Kotov et al., 2010).
As previously mentioned, various mental health disorders, such as Attention Deficit Hyperactivity Disorder (ADHD), conduct disorders, and mood disorders, are associated with substance use disorders (Lee et al., 2011; Mason et al., 2019; Torrens et al., 2012; Wilens et al., 2011). A 3-year longitudinal study of adolescents in Taiwan found that conduct disorder and ADHD were two of the most significant predictive factors for adolescent substance use disorder (Gau et al., 2007). In addition, a meta-analysis of 37 longitudinal studies with more than 750,000 participants examining the relationship between childhood psychiatric disorders and subsequent substance abuse found that childhood ADHD, oppositional defiant disorder, conduct disorder, and depression increased the risk of developing substance-related disorders (Groenman, Janssen, and Oosterlaan, 2017). However, researchers in several different studies have emphasized that the relationship between mental health disorders and substance use disorders can be multidirectional, which means causation cannot necessarily be established (Wilens et al., 2004; Winters et al., 2014). In other words, it is difficult to determine whether the mental health disorder preceded the substance use disorder, or the other way around.
Peer. Research on peer influences and substance use disorder is limited. However, available research indicates many findings of the impact of peer influences on youth substance use and initiation. Peer risk factors for substance use include having friends who engage in delinquent behavior, having friends who use substances, and gang membership. Research demonstrates that an association with peers who engage in deviant behavior and use substances is one of the strongest risk factors for youth substance use and initiation (Coffman, Melde, and Esbensen, 2015; Ferguson and Meehan, 2011; Handren, Donaldson, and Crano, 2016; Whitesell et al., 2013). For example, a study of youths in Ohio found that association with delinquent peers was the strongest correlate to substance use, even when other relevant factors (such as family and neighborhood) were controlled for (Ferguson and Meehan, 2011). Peer influences also appear to affect frequency of substance use among youth. A study of 16- to 21-year-olds found that the perceived extent of peer substance involvement was statistically significantly correlated with frequency and intensity of cannabis use, and frequency of drinking alcohol (Boys et al., 1999).
As with studies on individual risk factors, research has shown that the causal pathway between peers and substance use is multidirectional (Winters et al., 2014). Youths choose their peers based on shared interests and behaviors, but interests and behaviors are shaped by peers. Evidence shows that youths who use substances seek friendships with other youths who use substances (Light et al., 2013, Osgood et al., 2013; Young and Rees, 2013). However, there is limited research on the development of youth substance use disorders and peer relationships, compared with the available research on the impact of peer relationships on substance use in general.
School. School risk factors can also affect the risk of developing a future substance use disorder. Poor performance in school, such as low grades and low academic motivation, is linked to initiation of substance use and substance use disorders in youth (Bugbee et al., 2019; Patte, Qian, and Leatherdale, 2017; Weinberg, 2001). Other school factors, such as truancy and suspension, also are associated with substance use disorders (Henry, Knight, and Thornberry, 2012; Flaherty, Sutphen, and Ely; 2012). A longitudinal study of 1,241 girls found that many school behaviors in youth were associated with later substance use disorders, such as low seventh and eighth grade standardized math scores, suspension from school, truancy, and not having a high school diploma (Fothergill et al., 2008). However, this is yet another area where the direction of association is unclear. Whether academic failure leads to substance use disorders or substance use disorders lead to academic failure cannot be determined clearly (Cooley–Strickland et al., 2009; Weinberg, 2001).
Family. Family-level risk factors, such as parental behaviors and family structure, can also affect a youth’s likelihood of developing a substance use disorder. Research has shown that neglect and abuse can make a strong impact on substance use and disorder on a youth. A study of more than 34,000 people found that physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect in youth were all associated with various substance use disorders later in life (Danielson, 2016; Afifi et al., 2012). While research has found that substance use disorders in parents also make a strong impact on youth substance use, there is little research on how parents' substance disorders influence disorders in their children (Biederman et al., 2000; Lucenko et al., 2015, Whitten et al., 2019). Some research indicates that family risk factors may differ by gender. For example, a study of 1,421 youths ages 10 to 16 found that family conflict was significantly associated with substance use disorder for girls but not for boys (Skeer et al., 2011).
Community. Community-level risk factors are another area where there is much research on youth substance use and initiation, but not a lot of research focused on the impact on youth substance use disorders. One study, using data from 38,115 youths ages 11 to 17, found that higher self-reported neighborhood disorganization (defined by the study as perceived levels of safety and crime) was associated with higher levels of substance use dependence as defined by the DSM–4, even after controlling for individual- and family-level risk factors. Youths who reported both medium and high levels of neighborhood disorganization had higher odds of both substance use and dependence, compared with youths who reported low levels of neighborhood disorganization (Winstanley et al., 2008).
Protective factors are factors in a youth's life that can prevent or mitigate the likelihood of substance use disorder. These factors are aspects of a youth's life that act as a buffer to reduce negative effects of adversity (Vanderbilt–Adriance and Shaw, 2008). Compared with risk factors, there is less research on protective factors regarding substance use. There is even less research focused on protective factors and substance use disorders or protective factors that increase the likelihood of success in substance use treatment programs (Cleveland et al., 2008).
Similar to risk factors, protective factors can occur on the individual, peer, school, family, and community level. As previously stated, protective factors mitigate the effect of adversity and other risk factors. For example, prosocial peers serve as a protective factor against many forms of deviant behavior, and against substance use and initiation (Osgood et al., 2013). The presence of close peers can also mitigate the effect that metal health disorders, such as depression, have on the likelihood of developing a substance use disorder (Mason et al., 2019).
Additionally, early-sustained abstinence following residential substance use treatment has been shown to be predictive of long-term abstinence, suggesting that even a short period of continuing-care posttreatment can significantly improve long-term abstinence rates (Godley et al., 2007).
Though research on community-level factors often focuses on substance use and initiation, it has been found also to make an impact on a youth’s likelihood of developing a substance use disorder. One study found that higher levels of social capital, defined as community engagement and involvement in various volunteering programs, decreased the likelihood of a youth’s using substances or developing a substance dependence as defined by the DSM–4 (Winstanley et al., 2008). Researchers have also found that family factors, such as living in a household with two parents (Gau et al., 2007), and school factors, such as good academic performance (Gau et al., 2007), can protect against developing a substance use disorder.
For youths with certain mental health disorders, there also is some research on the effect of treatments that use medications on later substance use. For example, some research on treatment for ADHD found that the use of medication as part of treatment reduced later substance use problems in adolescence (Hammerness et al., 2017; Wilens et al., 2003), though other researchers have found that this treatment did not influence substance use outcomes (Wise, Cuffe, and Fischer, 2001; Humphreys, Engs, and Lee, 2013).
Research indicates that treatment initiation, engagement, and completion among youths with substance use disorders is low—significantly lower than among adults (Alinsky et al., 2020; Brorson et al., 2013; Cummings et al., 2011; Merikangas et al., 2010). Because engagement and retention in treatment is one of the strongest predictors of improved outcomes among adolescents (Acevedo et al., 2020), examining utilization is important.
The NSDUH asks respondents who have used alcohol or illicit drugs in their lifetime whether they ever have received substance use treatment, and for those who have received treatment whether this treatment was received in the 12 months before completing the survey. Treatment includes care received at any location, such as a hospital (inpatient), a rehabilitation facility (inpatient or outpatient), a mental health center, an emergency room, a private doctor's office, prison or jail, or a self-help group (e.g., Alcoholics or Narcotics Anonymous). In acknowledgment of the COVID–19 pandemic, the NSDUH also asked respondents whether they had received professional counseling, medication, or treatment through virtual or telehealth services. The 2020 NSDUH additionally collected information on treatment received at specialty facilities, which was defined as treatment received at a hospital (inpatient only), a drug or alcohol rehabilitation facility (inpatient or outpatient), or a mental health center. Specialty facilities did not include any services received virtually (SAMHSA, 2021).
In 2020, 6.4 percent (1.6 million) of youths ages 12 to 17 demonstrated a need for substance use treatment (regardless of whether they met criteria for substance use disorder). This is defined by the NSDUH as if respondents indicated they felt they needed treatment. Among these youths, 3.5 percent previously received substance use treatment in a specialty facility. Among youths ages 12 to 17 who met the criteria for a substance use disorder, 7.6 percent received any kind of substance use treatment within the past year. The 2020 NSDUH found that 98.4 percent of youths ages 12 to 17 who did not receive treatment at a specialty facility cited that they did not feel they needed treatment (SAMHSA, 2021).
Among the 644,000 youths ages 12 to 17 in 2020 with a co-occurring substance use disorder and a major depressive episode in the past year, 69 percent (438,000 youths) received either substance use treatment at a specialty facility or mental health services in the past year, 66.8 percent (424,000 youths) received only mental health services, and 0.9 percent (6,000 youths) received both substance use treatment at a specialty facility and mental health services (SAMHSA, 2021).
Factors That Influence Participation in Treatment
Several factors influence participation in treatment programs. A small body of literature evaluates these factors, which include motivation, preexisting mental health disorders, diagnoses, family support, and demographic variables such as gender, race, ethnicity, and age (Haughwout et al., 2016; Settipani et al., 2018; Groshkova, 2010; McHugh et al., 2018). Studies examine various aspects of participation, including program initiation, program engagement, and program completion (Bowers, 2021; Haughwout et al., 2016; Becan et al., 2015).
Severity of the problem. Haughwout and colleagues (2016) used NSDUH findings from 2002 through 2013 to examine treatment-seeking behaviors among youth. They found that treatment utilization was higher among those youths who met criteria for a substance use disorder, compared with those youths who used substances but did not meet criteria for substance use disorder. Treatment engagement was greater for youths with illicit drug use disorders, such as marijuana dependence, compared with alcohol use disorder. Overall, findings indicated that, among youths with a substance use disorder, the severity of the problems caused by substance use (e.g., involvement in the criminal justice system) and the perceived need for treatment were associated with higher treatment utilization. Additionally, youths with illicit drug use disorders using more than one substance had an increased treatment utilization rate (Haughwout et al., 2016).
Family influence. Some studies examine family factors such as parental discipline styles, expectations, support, and socioeconomic status (e.g., Berridge et al., 2017; Dakof, Tejeda, and Liddle, 2001; Haughwout et al., 2016; Santisteban et al., 2015; Settipani et al., 2018). For example, a study of 224 youths ages 12 to 17 who were referred to drug treatment found that youths who had parents with higher expectations for their children’s educational attainment were more likely to participate in at least four drug abuse treatment sessions than youths who did not have parents with these high expectations (Dakof, Tejeda, and Liddle, 2001). Also, analysis of NSDUH data from 2002 through 2013 found that talking with parents about the need for treatment increased treatment utilization (Haughwout et al., 2016). A qualitative study of 31 youths and young adults ages 17 to 25 found that those who entered treatment indicated that pressure from parents to enter treatment, and parental support such as making appointments, providing financial support, and ensuring medication adherence were significant motivations for entering treatment (Cleverley, Grenville, and Henderson, 2018). A study of 110 Hispanic substance-misusing adolescents assessed parenting practices in five dimensions: 1) positive parenting, 2) discipline effectiveness, 3) discipline avoidance, 4) rules on having a set time to be home, and 5) extent of involvement. They found that youths who had parents with better discipline strategies and who felt effective and competent in their parenting were more likely to seek residential or outpatient treatment services (Santisteban et al., 2015). This study also found that youths with parents who had spent more years in the United States were more likely to use outpatient services (as compared with no services), and youths with parents who had lower parenting stress were more likely to use residential treatment services (compared with no services).
Finally, some studies have found that family financial and educational situations can influence treatment seeking behaviors. In a study of 189 youths seeking treatment for substance use concerns, 70 percent reported that they expected their finances to have an impact on their treatment (Settipani et al., 2018). Additionally, a longitudinal study of 358 adolescents in outpatient programs found that parental education was significantly associated with attendance at 12-step programs, meaning that adolescents whose parents had higher levels of education were more likely to attend the treatment program than those with parents with lower levels of education (Lui et al., 2017). However, the same study found no socioeconomic differences in treatment initiation or treatment retention. This may be due to everyone in the sample's having health insurance and to the near-full employment status of the adolescents' parents.
Other mental health diagnoses. Externalizing disorders have been identified as risk factors for not participating in or not successfully completing substance use treatment (Santisteban et al., 2015; Wise, Cuffe, and Fischer, 2001), while internalizing disorders have been identified as predictors of participating in treatment (Bowers, 2021). A study of 91 adolescents in a residential substance abuse treatment program examined factors associated with successful treatment, as defined by the treatment team at the time of discharge in terms of attendance, positive interactions in groups, level of denial, quality of projects, interactions with peers and staff, and meeting individualized treatment plan goals (Wise, Cuffe, and Fischer, 2001). They found that participants with Attention Deficit Hyperactivity Disorder (ADHD) or Conduct Disorder were less likely to participate successfully in treatment than those without ADHD or Conduct Disorder. Another study of more than 300 youths and young people ages 14 to 24 who were receiving outpatient services for concurrent disorders found that the strongest predictor of attending five or more sessions was having an internalizing problem (Bowers, 2021). In other words, individuals with higher levels of internalizing problems (such as depression) were more engaged in treatment than those with lower levels of internalizing problems.
Motivation. Motivation is considered a key factor in successfully engaging in substance use treatment (DiClemente, 1999; Groshkova, 2010). The role of motivation is particularly relevant to youth, since many enter treatment because it has been mandated or recommended, as opposed to self-referring (Bowers et al., 2017; Cleverley, Grenville, and Henderson, 2018; Knight et al., 2016). Several studies have examined the influence of motivation on participation in substance use treatment. A study of 547 youths from multiple substance use treatment programs found that participants with higher pretreatment motivation were more likely to have stronger relationships with program counselors, which predicted more successful outcomes after leaving the programs (Joe et al., 2014). Motivation also predicted stronger relationships with peers in the treatment program. A small qualitative study of 31 youths ages 17 to 25 in mental health treatment found that internal factors, such as wanting to better their academic, social, or financial situation, and external factors, such as familial pressure, were identified as motivating these young people to seek treatment (Bowers et al., 2017). Several interventions have been designed to increase youths' motivation to engage in treatment (Becan et al., 2015; Knight et al., 2016).
Gender. There is limited information on gender differences in treatment engagement for substance use disorders. Some research has found that adolescent girls are more likely than adolescent boys to receive treatment for alcohol use disorder, while boys are more likely than girls to receive treatment for marijuana use disorder, or for any type of illicit substance treatment overall (Haughwout et al., 2016; McHugh et al., 2018). Other studies have found no difference in treatment initiation or retention by gender (e.g., Lui et al., 2017). Several studies have found that girls have a higher comorbidity between substance use disorder and mental health disorders and greater histories of trauma than boys (e.g., Fernández-Artamendi, Martínez-Loredo, and López-Núñez, 2021; Yildiz, Ciftci, and Yalcin, 2020), which can affect engagement and success in treatment interventions. Once youths are in a treatment program, some studies have found that girls are more likely than boys to engage, succeed, and complete the program. For example, a study of 91 adolescents in a residential substance abuse treatment program (Wise, Cuffe, and Fischer, 2001, mentioned above) found that girls were more likely than boys to successfully participate in treatment.
Race and ethnicity. Several studies have examined racial and ethnic disparities among substance use treatment utilization. In their analyses of more than 140,000 adolescents from the NSDUH, Cummings and colleagues (2011) found that among youths with substance use disorders Black and Hispanic adolescents were less likely than white adolescents to receive treatment. A literature review of behavioral health services for youths of racial and ethnic minority groups found that, compared with non-Latino white adolescents with a substance use disorder, Black adolescents with a substance use disorder reported receiving less specialty and informal care, while Latinos with a substance use disorder reported receiving fewer informal services (Alegria et al., 2011). Several studies of youth in the juvenile justice system have found similar racial and ethnic disparities (e.g., Farenthold, 2010; Mansion and Chassin, 2016). A systematic literature review of studies examining juvenile justice system processing found that most studies examining referral to mental health or substance misuse treatment from within the juvenile justice system found at least some race effects disadvantaging youths of color (Spinney et al., 2016). For example, a study of about 600 juveniles on probation in New York found that, relative to white juveniles, Black and Hispanic juveniles who were screened and referred for mental health or substance use services were significantly less likely to access them (Wasserman et al., 2009). The study also found that Black juveniles were significantly less likely than others to participate in the initial screening. However, racial and ethnic disparities in referral to and utilization of substance use treatment are not always found (e.g., Mulvey, Schubert, and Chung, 2007; Yan and Dannerbeck, 2011).
Treatment programs primarily focus on helping youths with existing substance use issues who have been clinically diagnosed with a substance use disorder by the Diagnostic and Statistical Manual for Mental Disorders criteria. However, some treatment programs serve youths without a formal diagnosis who exhibit or report risky substance use behavior or have come into contact with the justice system.
For youths currently experiencing substance use disorders, particularly youths involved in the juvenile justice system, more intensive services may be needed, compared with the programming youths may receive in prevention interventions. Treatment services typically are more comprehensive than prevention programs, owing to their retroactive (rather than proactive) focus. Specifically, treatment programs include components related to prosocial development as a means to address existing antisocial behaviors, negative peer relations, and poor family functioning (Development Services Group, 2015).
It is important to recognize that programs that have been shown to reduce adult substance use may not translate as well for youth. Substance-using youths seldom are dependent on substances in the traditional sense that adults experience addiction. Youths and adults may misuse drugs for different reasons, and there are differences in the psychology of juvenile and adult substance use disorders (Bureau of Justice Assistance, 2003). Adolescence is an important development phase that involves changes in cognitive, emotional, behavioral, and social skills necessary for a productive life that are influenced by important relationships, such as those with family, friends/peers, school, and the community (Development Services Group, 2015; Gray and Squeglia, 2018).
Various types of youth substance use treatment programs, including those featured in the Model Programs Guide, are discussed below.
Motivational interviewing (MI) is a counseling method that can be implemented as a standalone program or can be incorporated as an element of a larger program. MI uses collaborative, client-centered, goal-oriented communication to address hesitancy toward behavioral change by encouraging and evoking personal desires for transformation (Stein et al., 2006b, Naar–King, 2011). MI aims to increase an individual's perspective on the importance of change. When provided to youths with substance use issues, the long-term goal is to help them reduce or stop using drugs and alcohol. A youth's subtle desires for change are uncovered through a series of selective interviews guiding the youth to concentrate on their behaviors and explore overarching goals in regard to personal motivations, values, and opinions and reasons to change (Stein et al., 2006b; D’Amico et al., 2013).
Stein and colleagues (2006b) examined the effects of a standalone MI program for substance abuse issues of juveniles in a state facility. The program focused on youth engagement with substance use therapy and targeted youths who reported regular or binge marijuana or alcohol use or who were sentenced to a post-adjudication facility. For this program, motivational interviewing was designed to be modified as appropriate to be meaningful for each youth and their desire to change. This MI program was delivered by research counselors and consisted of four components: 1) establishing rapport, 2) assessing the youth’s motivation for change, 3) motivational enhancement, and 4) establishing goals for change. The study authors compared youths receiving MI with a control group of youths who did not receive MI. They found that the control group experienced statistically significantly more negative engagement with substance use therapy than the MI treatment group, meaning that youths who received MI were more likely than youth in the control group to take treatment seriously (Stein et al., 2006b). However, there was no statistically significant impact on positive treatment engagement, meaning juveniles who received MI were no more likely to actively participate in treatment sessions, compared with youths in the control group. Another study by Stein and colleagues (2006a), which examined the same sample of youths 3 months later, found the effectiveness of MI treatment appeared to be mediated by depressive symptoms. The authors found that, compared with the control group, the MI treatment group had statistically significantly lower self-reported measures of risky driving behavior (such as driving under the influence of alcohol and marijuana), but only for youths with low depressive symptoms. When examining youths with high depressive symptoms, researchers found the control group had statistically significantly lower self-reported measures of risky driving behavior, compared with the MI treatment group. The entire treatment group was statistically significantly less likely to report driving solo under the influence of alcohol, compared with the control group, but there were no statistically significant differences between the groups in driving alone under the influence of marijuana or being a passenger in a car operated by a driver under the influence of alcohol or marijuana (Stein et al., 2006b).
Juvenile Drug Courts/Court-Based Programs
Juvenile drug courts (JDCs)are specialized juvenile court dockets for youths with substance use problems and substance use disorders in need of specialized treatment services, allowing for intensive judicial supervision that is not ordinarily available in traditional juvenile courts (Latimer, Morton–Bourgon, and Chrétien, 2006; Mitchell et al., 2012; Shaffer, 2006; Drake, 2012). JDCs work conjointly with treatment providers, social services, school and vocational programs, law enforcement, probation, and other agencies (Latimer, Morton–Bourgon, and Chrétien, 2006; Mitchell et al., 2012; Shaffer, 2006; Drake, 2012). Core elements of JDCs include drug testing and treatment services, regular judicial contact, and meetings with a case manager and/or a probation officer. Additionally, most JDCs make referrals for educational programs, job training, and mental health services.
Evaluations of programs have found mixed results with regard to the effectiveness of JDCs in both substance use and recidivism outcomes. For example, Juvenile Drug Courts in Utah operate with basic drug court components, including screening and assessment, individualized treatment plans, judicial supervision, community-based treatment, regular court hearings, accountability and compliance monitoring, comprehensive services, and a nonadversarial team approach (Hickert et al., 2011). An evaluation of the four largest JDCs in Utah by Hickert and colleagues (2011) found no statistically significant difference between youths who participated in the JDCs and youths in the probation comparison group for alcohol and other drug recidivism after 30 months. However, they did find that youths in the JDCs had statistically significantly fewer subsequent criminal offenses (i.e., recidivism of any offense), compared with youths in the comparison group. Other evaluations have shown more positive results. The Baltimore County (Md.) Juvenile Drug Court targets 13- to 17-year-olds who admit to drug or alcohol abuse. The program has four phases, each of which focuses on different aspects of treatment and services. The first two phases are highly structured and include frequent treatment sessions, supervision meetings, and drug testing. The last two phases are designed as aftercare phases, which involve decreasing supervision and treatment sessions and focus on relapse prevention. An evaluation by Mackin and colleagues (2010) showed youths in the program had statistically significantly lower average numbers of re-arrests for drug charges and total re-arrests (for any charge), compared with youths in the comparison group, at the 2-year follow-up.
Numerous meta-analyses examining the effectiveness of juvenile drug courts have also found mixed effects. When examining measures of general recidivism, Drake (2012) and Shaffer (2006) found small, statistically significant decreases in the recidivism of JDC participants, compared with nonparticipants. Conversely, Latimer and colleagues (2006) did not find a statistically significant impact of JDCs on recidivism measures. With regard to other outcomes, Mitchell and colleagues (2012) reviewed four studies that examined the effect of JDCs on drug use and found no statistically significant effect. Tanner–Smith and colleagues (2016) reviewed eight studies and also found an overall non–statistically significant effect on drug use, suggesting that JDCs have not been found to have a consistent effect on drug use.
An example of a court-based program is the Juvenile Breaking the Cycle (JBTC) Program in Lane County, Oregon. The program was a post-arrest effort designed to help substance-using youth, using a comprehensive approach. The primary goals of the program were to increase access to treatment, reduce substance use, and reduce delinquency among high-risk, antisocial youths through intensive case-management services. Youths ages 9 to 18 with alcohol or other drug problems and assessed as high risk for involvement in serious and chronic offenses were eligible for JBTC. Components of the model included substance abuse treatment, mental health services, judicial oversight (incorporating drug court for some participants), and case management that consisted of supervision by a probation counselor and service coordination by a service coordinator (along with urinalysis). Lattimore and colleagues (2004) found that participation in the JBTC program had no statistically significant effect on whether youths reported using alcohol or illicit drugs (other than marijuana), at the follow-up period. However, participation in the JBTC program was associated with a statistically significant reduction in marijuana use. Regarding recidivism outcomes, JBTC youths were statistically significantly less likely to be re-arrested, and participation in the JBTC program was associated with a statistically significant decrease in the number of re-arrests after 12 months (Lattimore et al., 2004).
As previously discussed, research has shown that family dynamics often contribute to the development of youths' substance use disorders (Van Ryzin et al., 2016). The importance of family involvement and familial relationships in the recovery of substance-using youths is regularly reiterated throughout evaluation research of treatment programs (Christie, Cheetham, and Lubman, 2020). Other studies have shown family-based treatments to have higher retention rates, which may be related to positive treatment outcomes (Rowe and Liddle, 2003; Liddle et al., 2018). Further, intensive family-based treatments have been shown to reduce family and community environmental risk factors (such as familial conflict or association with negative peer groups) that contribute to adolescent substance use problems and disorders (Liddle et al., 2009; Liddle et al., 2018; Horigian, Anderson, and Szapocznik, 2016).
In general, family-based interventions can include a wide range of programs that are designed to decrease youths’ problem and antisocial behaviors, including substance use, by making positive changes in their familial and social environments (Dopp et al., 2017). Specifically, these interventions focus on establishing better communication and reducing conflict between parents and youths, improving parenting skills, and helping youths better engage with their families and in their school environment (Baldwin et al., 2012). Various therapies inform the specific treatment techniques used, including behavioral and cognitive–behavioral therapies. Dopp and colleagues (2017) conducted a meta-analysis of 24 effect sizes from 10 studies and found that family-based treatment had statistically significant positive effects on substance use for treatment group youths, compared with control group youths.
Numerous specific therapeutic models concentrate on including the family in treatment services for youth. Multidimensional Family Therapy (MDFT) is a well-established approach for youth substance use treatment (Liddle et al., 2001; Waldron and Turner, 2008; Rigter et al., 2013; van der Pol et al., 2018) that promotes communication among family members, targeting social competence and parental involvement/relationships. The MDFT approach is individualized, family based, and comprehensive, requiring collaboration across many social systems (Liddle et al., 2009). Using a multidimensional approach, the MDFT intervention emphasizes improving four major domains for youth, which are seen as contributing factors to the rise and decline of behavioral problems in a youth's life: 1) the youth, 2) parents, 3) family, and 4) the community (that is, peers, school, and so forth) [Liddle et al., 2018; Rigter et al., 2013; van der Pol, 2018]. Overall, the goal of the program is to improve individual and family functioning to reduce substance misuse and related problem behaviors (such as committing crimes). There have been numerous evaluations of MDFT. Rigter and colleagues (2013) evaluated the efficacy of MDFT on substance use and dependence among Western European youths ages 13 to 18 from five outpatient treatment sites. Eligible youths were diagnosed with a cannabis-use disorder by the DSM–4 guidelines and had at least one parent willing to participate. However, at the 12-month follow-up, there were no statistically significant differences in the prevalence of diagnosis of cannabis use disorder between youths in the MDFT intervention group and youths in the treatment-as-usual comparison group. Conversely, Liddle and colleagues (2018) evaluated the efficacy of MDFT in a sample of youths in the United States diagnosed with a substance use disorder and at least one comorbid psychiatric disorder. At the 18-month follow-up, youths in the MDFT intervention group reported a statistically significant decrease in substance use problems, compared with youths in the treatment-as-usual group.
Another example of an intervention that incorporates family into programming services is the Multisystemic Therapy | Family Integrated Transitions (MST–FIT) program, which provides integrated and family services to youths in a residential facility who have committed offenses and have co-occurring mental health and chemical dependency disorders (Trupin et al., 2011). Services are provided during a youth's transition from incarceration back into the community. The overall goal of MST–FIT is to provide necessary treatment to youths to reduce recidivism. The program also seeks to connect youths and families to appropriate community supports, increase youths' abstinence from alcohol and drugs, improve youths' mental health, and increase youths' prosocial behavior. Trupin and colleagues (2011) found that the MST–FIT program statistically significantly reduced felony recidivism at 36 months postrelease; however, the program did not have a statistically significant effect on measures of overall recidivism (i.e., felony and misdemeanors combined), misdemeanor recidivism, or violent felony recidivism. In addition, the program evaluation did not examine the impact on youths' substance use.
Multisystemic Therapy | Substance Abuse (MST for substance use) is a version of multisystemic therapy (MST) for youths with substance abuse and dependency issues who are diagnosed using the DSM–4. Although the emphasis is on youths, MST operates by incorporating the youths' family and friends and addressing all potential spheres of behavioral influence. It aims to enhance a family's capacity to keep track of adolescent behavior and instill clear rewards and punishments for positive and negative/irresponsible behavior. Henggeler and colleagues (2002) found that youths who received MST for substance abuse showed statistically significantly higher rates of abstinence from marijuana, compared with control group youths who did not receive MST, at the 4-year follow-up. However, there were no statistically significant differences between groups on cocaine use. Another study by Henggeler and colleagues (2006) found no statistically significant difference in alcohol use between youths who participated in a drug court program and received MST for substance abuse and youths in the control group who received no services, at the 12-month follow-up. However, youths who received MST in a drug court program showed statistically significant reductions in heavy alcohol use, marijuana use, and multiple-/poly-drug use, compared with control group youths.
Some interventions specifically aim to treat youths' substance abuse after a family crisis. Ecologically Based Family Therapy (EBFT) is a home-based, family preservation model for families in crisis because a youth has run away from home. The model targets 12- to 17-year-olds who are staying in a runaway shelter and dealing with substance use issues. Treatment begins by preparing the youth and the family members, in individual sessions, to come together and talk about the issues that led to the runaway episode. After the individual sessions, the family and youth are brought together to address the issues associated with the dysfunctional interactions between family members and the continuation of problem behaviors. An evaluation by Slesnick and Prestopnik (2009) found that treatment group youths who participated in EBFT reported a statistically significant reduction in the percentage of days they used alcohol or drugs, compared with control group youths who received services as usual, at the 15-month follow-up.
Youths may receive treatment while they are placed in a residential facility. The period of residential placement offers an opportunity to intervene in the cycle of youths' drug or alcohol use. Different types of residential-based substance use treatment programs are available, including therapeutic communities or group counseling (Mitchell, Wilson, and MacKenzie, 2012). Residential treatment is an important option for youths at high risk of overdose or suicide, those who present a public safety risk, or are without family members who can be involved in treatment (Liddle et al., 2018).
Incarceration-Based Therapeutic Communities (TC) for Juveniles employ a comprehensive, residential drug-treatment program model for substance-using youths who have committed offenses. The programs are designed to foster changes in attitudes, perceptions, and behaviors related to youth substance use. The TC for juveniles uses a developmentally appropriate comprehensive approach to a) address substance use and mental health issues and b) promote healthy development. Mitchell, Wilson, and MacKenzie (2012) synthesized four studies looking at the effectiveness of incarceration-based TCs for youths in reducing recidivism and found no statistically significant difference between treatment group and comparison group youths on recidivism postrelease. Drake (2012) analyzed the effect sizes from three studies on the efficacy of incarceration-based TCs for juveniles on recidivism and also found no statistically significant difference between treatment group and comparison group youths on recidivism postrelease. However, the results from both meta-analyses should be interpreted with caution, given the limited number of studies included. Further, neither meta-analysis examined the effectiveness of incarceration-based TCs in reducing substance use.
Brief interventions designed to address substance use in youth vary in terms of length and structure and can be delivered in an electronic format, in-person by a service provider (such as a counselor, physician, or nurse), or even self-administered by youth. In general, these are concise, convenient, and cost-effective interventions designed to motivate and provide resources to participants to help them change their alcohol or drug consumption behavior, and to seek more intensive treatment if needed (Tanner–Smith and Lipsey, 2015). However, one limitation to this type of program is that it usually is not targeted specifically toward substance use disorder, and therefore substance use disorder is not typically an outcome of interest. This is an area where more research is required (Smedslund et al., 2017).
Computerized Brief Interventions for Youth Alcohol Use are designed to appeal to younger generations who have grown up in the digital media age (Smedslund et al., 2017). Specifically, these interventions target individuals ages 15 to 25, who are high or risky consumers of alcohol but motivated to change. Risky consumption of alcohol is defined as consuming 1) at least 5 beverages during any one drinking session or more than 14 alcoholic beverages a week for males and 2) 4 beverages during any one drinking session or more than 7 alcoholic beverages a week for females. Computerized brief interventions usually consist of three components: 1) assessment, 2) feedback, and 3) decisionmaking. The assessment component classifies users as low-risk, medium-risk, high-risk, or very high-risk alcohol drinkers and provides the individuals with a recommendation on whether they would benefit from a more formalized treatment program than the computerized brief intervention. The feedback component provides the users with information on their scores after each assessment and responds to their reactions to their assessment. Finally, the decisionmaking component asks users to specify their motivation for behavioral change. Smedslund and colleagues (2017) aggregated the results of 15 studies (those that included both assessment and feedback components, but no decisionmaking component) and found that computerized brief interventions statistically significantly reduced short-term alcohol consumption for youths who participated, compared with youths who received no interventions.
Targeted Brief Alcohol Interventions (BAI) for Alcohol Use for Adolescents and Young Adults seek to reduce alcohol use or alcohol-related problems for youths and young adults using a short-term intervention (one to five sessions). BAIs can be delivered in a variety of settings such as primary care/student health centers, schools/universities, and emergency rooms; for youths, they can also be self-administered by participants. They typically include at least one of the following components: a discussion of alcohol consumption, feedback on risk or levels of alcohol use, comparisons with local or national norms, information on potential harms, or coping strategies and goal-setting plans for dealing with drinking situations. Tanner–Smith and Lipsey (2015) reviewed 24 studies that included adolescent samples (ages 11 to 17) and found that youths who participated in BAIs reported statistically significant reductions in levels of alcohol consumption and levels of alcohol-related problems, compared with control group youths.
Prevention programs are typically designed to deter adolescents from initial substance use. However, some early prevention programs are designed specifically with the goal of making a long-term impact on substance use disorders. These programs have a theoretical framework surrounding the goal of reducing early risk factors that can lead to later problem behaviors such as substance use disorders (Kellman et al., 2008).
Good Behavior Game is one such program. It is a classroom management strategy designed to reduce aggressive and disruptive classroom behavior. By preventing these early risk factors, it seeks to reduce future problem behaviors such as criminal activity and substance use. Good Behavior Game is a group-contingent reinforcement game, in which students work in teams and are rewarded as a team for following classroom rules. This creates an incentive for students to manage their own behavior through group reinforcement and mutual self-interest. Kellman and colleagues (2008) conducted a randomized controlled trial to examine the impact of Good Behavior Game on lifetime alcohol abuse or dependence disorders. The participants were ages 5 to 10 during the program and were surveyed 14 years after the program ended. The study authors found that treatment group participants had lower rates for lifetime alcohol abuse or dependence disorders, compared with the control group, at the 14-year follow-up. This difference was statistically significant.
Although there is research on how well treatment programs can (or cannot) reduce youth substance use and/or improve substance use disorders, it has some limitations. Most substance use treatment programs evaluated within the juvenile justice system typically examine recidivism-based outcomes and often neglect to examine substance use outcomes fully (Trupin et al., 2011; Anspach and Ferguson, 2005; Hickert et al., 2011). In addition, because these programs are so closely linked with the juvenile justice system, they usually rely on one measure of substance use, such as one or more positive drug screen results (Anspach and Ferguson, 2005; Hickert et al., 2011). While instances of positive drug screens may be one way to measure substance use, this measure fails to incorporate self-reported drug or alcohol use, or substance use identified through other screening methods administered by service professionals.
Further, with research of youth substance use disorders and treatment programs, there often are barriers to conducting research with young people. It can be particularly challenging to follow up with youths who struggle to access services because of their inaccessibility, and there are ethical considerations related to consent in youth participants (Christie, Cheetham, and Lubman, 2020).
Other limitations exist when attempting to examine the specific components that make a program effective, particularly with regard to different types of illicit or licit substance use. If different family, courts-based, or residential-based programs incorporate similar elements, it is difficult to discern which specific program components successfully affect substance use (Trupin et al., 2011; Henggeler et al., 2006). For example, motivational interviewing can be implemented as a standalone program (Stein et al., 2006a; Stein et al., 2006b) or it may be included as a specific component in a juvenile drug court or as part of a specific program, such as Multidimensional Family Therapy. MDFT and juvenile drug court programs both incorporate some kind of family-based treatment (Waldron and Turner, 2008; Liddle et al., 2018; Liddle et al., 2009; Hickert et al., 2011; Anspach and Ferguson, 2005). Additionally, there is limited research into which types of programs are the most effective for different types of substances (McGovern and Carroll, 2013).
Further, there is little research on pharmacotherapy for youth licit and illicit substance use (Squeglia et al., 2019; Winters et al., 2018). Although research on adults with substance use disorders has shown positive results with treatments such as Methadone Maintenance Therapy and Buprenorphine Maintenance Therapy, especially when addressing opioid use disorders/dependence (Mattick et al., 2009; Mattick et al., 2014), this research has not be conducted much with youth, in part because a) federal regulations restrict methadone access for adolescents, b) training and U.S. Food and Drug Administration approval are required for prescribing buprenorphine, and c) there is stigma regarding medications for opioid use disorder (Chatterjee et al., 2019). However, there is some evidence that reception of medication-assisted treatments influences treatment duration among youths. Researchers examining a sample of more than 4,500 youths ages 13 to 22 found that youths who received opioid use disorder medication (e.g., buprenorphine, naltrexone) within 3 months of diagnosis with an opioid use disorder stayed in treatment longer than those who did not receive the medication (150 days of treatment, compared with 67 days of treatment) [Hadland et al., 2018]. Research indicates that the effect of pharmacotherapy for youth is unclear.
Additionally, most youths who participate in substance use treatment programs are not able to sustain long-term substance use reduction or cessation; some interventions do not see results related to continued substance use lasting more than 1 year posttreatment, including some of the programs discussed in the previous section (Tanner–Smith and Lipsey, 2015; Gray and Squeglia, 2018; Dennis et al., 2004). This has encouraged the development of aftercare or continuing care programs (Godley et al., 2007; Godley et al., 2014), usually after residential treatment or drug court participation. As stated previously, research shows that early-sustained abstinence is predictive of long-term abstinence (Godley et al., 2007). However, many substance use treatment programs for youth still lack this component, with youths returning to the community without the continued support needed to promote continued abstinence (Godley et al., 2007). Further research is needed regarding the effectiveness of aftercare or continuing care for youth following both outpatient and residential treatment, and on the best approaches for implementation (Kaminer, Burleson, and Burke, 2008; Godley et al., 2014; Gonzales et al., 2014).
Though rates of substance use disorder among youth have declined and leveled off since the first decade of the 2000s, it remains a prevalent issue, and research demonstrates a clear need for treatment programs directed toward adolescents (Chatterjee et al., 2019; SAMSHA, 2021).
There are a wide range of substance use treatment programs for adolescents, depending on their needs and situation. Family-inclusive therapies, for example, are common substance-use-disorder treatment programs, because family dynamics often make a strong impact on the development of substance use disorders (Van Ryzin et al., 2016). Residential-based treatment programs are also important in the field, as they are beneficial for youths with a substance use disorder who may not have family able to become involved with their treatment (Liddle et al., 2018).
Though 2.8 percent of youths ages 12 to 17 experienced alcohol use disorder in the past year, and 4.9 percent of 12- to 17-year-olds met criteria for at least one illicit drug use disorder, there is still limited research regarding specific risk factors, protective factors, and treatment options for youths diagnosed with a substance use disorder, according to DSM–4 criteria (Bacio et al., 2015; Cleveland et al., 2008; SAMSHA, 2021). Further research could overcome current limitations, such as examining substance use–related outcomes outside of the juvenile justice system, conducting studies on pharmacotherapy for youths' licit and illicit substance use, and exploring risk and protective factors specifically surrounding substance use disorders in youths.
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Suggested Reference: Development Services Group, Inc. January 2023. "Substance Use Treatment Programs." Literature review. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. https://ojjdp.ojp.gov/model-programs-guide/literature-reviews/Substance-Use-Treatment-Programs
Prepared by Development Services Group, Inc., under Contract Number: 47QRAA20D002V.
Last Update: January 2023