Winters 2018

Adolescent Substance Abuse
Treatment: A Review of Evidence-Based

Research
Ken C. Winters, Andria M. Botzet, Randy Stinchfield, Rachel Gonzales-

Castaneda, Andrew J. Finch, Timothy F. Piehler, Kadie Ausherbauer,
Kristen Chalmers, and Anna Hemze
Introduction
Use of alcohol and other drugs (hereafter referred to as drugs) by American

teenagers continues to present a significant public health concern. Whereas sub-
stance use among adolescents has leveled-off, and in some instances declined,
in recent years (Miech, Johnston, O’Malley, Bachman, & Schulenberg, 2016)
K. C. Winters (*)
Oregon Research Institute, Falcon Heights, MN, USA
e-mail: [email protected]
A. M. Botzet
Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
R. Stinchfield
Saint Paul, MN, USA
R. Gonzales-Castaneda
Department of Psychology, Azusa Pacific University, Azusa, CA, USA
A. J. Finch
Peabody College, Vanderbilty University, Nashville, TN, USA
T. F. Piehler · K. Ausherbauer
Department of Family Social Science, University of Minnesota, Saint Paul, MN, USA
e-mail: [email protected]; [email protected]
K. Chalmers · A. Hemze
Minneapolis, MN, USA
e-mail: [email protected]; [email protected]
© Springer Science+Business Media LLC 2018 141

C. G. Leukefeld, T. P. Gullotta (eds.), Adolescent Substance Abuse, Issues in Children’s
and Families’ Lives, https://doi.org/10.1007/978-3-319-90611-9_5
142 K. C. Winters et al.
the rates of use are still a public health concern (National Institute on Drug
Abuse, 2014). Adolescence represents a critical period for the onset of drug use;
onset of use during these years increases the likelihood of negative impacts on
a range of developmental factors, including cognitive, physical, and psychoso-
cial. Also, early onset use also increases the likelihood for developing a sub-
stance use disorder (SUD), and for some youth, it contributes to the progression
of a long-term SUD (Volkow, Baler, Compton, & Weiss, 2014). There are con-
cerns that recent trends in the USA to legalize marijuana for recreational or
medical purposes may contribute to a rise in adolescent marijuana use. Marijuana
is the most commonly used illicit drug among adolescents in the USA and is
now used at higher rates than tobacco (Miech et al., 2016). Nearly one-quarter
(23.4%) of high school students report use at least one or more times per month
(Kann et al., 2014).
For youth who meet criteria for a SUD, treatment may be indicated. According
to the National Survey on Drug Use and Health, approximately 1.3 million adoles-
cents had a past year SUD (Center for Behavioral Health Statistics and Quality,
2015). Yet it is estimated that about 90% of youth with a SUD do not receive drug
treatment (Substance Abuse and Mental Health Services Administration, 2013).
There are several reasons for the large gap between SUDs and treatment utilization
by youth: little if any local treatment options, poor health coverage, low motivation
by the youth, and unsupportive parents.
Developmental Issues
The adolescent drug abuse treatment field continues to make significant strides in
the expanding the field of evidence-based approaches. A common theme across
contemporary approaches is their developmental relevance. Adolescents seeking
treatment differ from their adult counterparts in many ways: the length and severity
of substance use is usually less; typical patterns and context of use differ; the type
of substance-related problems most often experienced also differ; and in most
instances there is not a self-referral to treatment (National Institute on Drug Abuse,
2014). Moreover, developmental neuroscience research, which supports the view
that brain develops during adolescence in a way that contributes to risky judgments,
including the tendency to make choices based on heavily on emotion, (Spear, 2002;
Volkow et al., 2014), have led to various speculations that youth may be less moti-
vated to change drug use behaviors than adult clients, that advice alone may be
ineffective for promoting change for a teenager, and that positive peer influences
and interactions during treatment may be particularly important to treatment out-
come (Riggs et al., 2007). Furthermore, because youth typically enter treatment
because of a referral by a concerned parent, mental health clinician, or school staff)
(Battjes, Gordon, O’Grady, & Kinlock, 2004), a negative attitude about drug treat-
ment may be a prevalent among adolescents.
Adolescent Substance Abuse Treatment: A Review of Evidence-Based Research 143
Intensity of Treatment
Based on several client characteristics (e.g., severity of drug involvement; mental

health condition; current and past medical condition; environment support for
recovery; readiness to change), it is advisable to initially place an adolescent into
one of the following five treatment levels (American Society of Addiction Medicine,
2013): (1) brief intervention; (2) outpatient; (3) intensive outpatient; (4) residential/
inpatient; or (5) medically managed inpatient treatment.
Treatment Approaches
Most adolescent drug treatment programs use an eclectic treatment approach, inte-
grating multiple therapeutic strategies within their treatment service framework.
Common themes among them are that they teach skills to resist the triggers associ-
ated with the individual’s drug use pattern, address life functioning issues that likely
contributed to the onset and maintenance of the drug use (e.g., mental health, family
issues), and identify and build upon a youth’s strengths.
Research has established that several types of therapeutic practices and
approaches, regardless of intensity of treatment or therapeutic approach, are vital to
providing effective treatment for adolescents with a drug problem. Recently the
National Institute of Drug Abuse (2014) identified 13 practice principles that are
elements of quality care spanning assessment, treatment and aftercare (see Table 1).
Treatment Outcome Research
Overview
Despite this issue of low treatment utilization, significant advances have been made
since 1990 in the development and scientific evaluation of treatments for adolescent
drug abuse (e.g., Winters, Tanner-Smith, Bresani, & Meyers, 2014). Perhaps the most
significant sign of these advances is that the field is now characterized by rigorous
controlled studies on the effectiveness of treatment approaches and strategies. Many
treatments for adolescents with a SUD that are now considered evidenced based.
We focused our literature search on controlled evaluations of drug abuse treat-
ment approaches for adolescent clients since 1990, owing to the principle that
drug treatment for adolescents prior to that time may not be comparable to more
contemporary and rigorous standards. The criteria for study inclusion were as fol-
lows: (1) adolescents had to be the primary target of the intervention or treatment;
(2) drug use outcomes had to be measured; and (3) the study consisted of essential
components of a controlled evaluation, including favorable sample sizes, com-
Table 1 Principles of adolescent substance use treatment

Principle Description
1. Identify and address Identifying and addressing adolescent substance use as soon as
substance use as soon as possible is important due to the negative effects early use can have
possible on the brain. Additionally, adults with substance use disorders
often report using drugs as adolescents or young adults.
2. Adolescents do not have Interventions can successfully treat a range of substance use
to be addicted to benefit disorders from problematic use to severe addiction. Youth in
from a substance use particular can benefit from intervention at early stages. Even use
intervention that does not seem problematic can lead to heavier use and other
risky behaviors.
3. Medical visits are an Medical doctors (e.g., pediatricians, emergency room doctors,
opportunity to ask about dentists) can use standardized screenings to determine if an
drug use adolescent is using substances and if an intervention is warranted.
In some instances, it is possible to provide a brief intervention in
the physician’s office and in other cases referral to treatment is
more appropriate.
4. Legal or family pressure Most adolescents with a substance use disorder do not think they
may be an important need treatment and rarely look for treatment. Treatment can be
influence on adolescent’s successful even if the adolescent is legally mandated to treatment
involvement in treatment or goes due to family pressures.
5. Treatment should be Many factors need to be considered when developing a treatment
tailored to the adolescent’s plan for an adolescent including sex, family, and peer relationships,
needs and community environment. Therefore, it is necessary to begin
with a comprehensive assessment.
6. Treatment should not Treatment is most successful when it focuses on the whole person.
focus on just substance use Treatment should address housing, medical, social, and legal
needs.
7. Behavioral therapies can Behavioral therapies have been shown to be an effective treatment.
effectively treat substance These therapies help build motivation to change by providing
use disorders incentives for abstinence, teaching skills to deal with cravings, and
finding positive and rewarding activities.
8. Family and community There are several evidence-based interventions for adolescent
support are important substance use that involve family members and individuals in the
features of treatment community. These interventions try to improve family
communication and provide the adolescent with support.
9. Mental health conditions Adolescents with a substance use disorder often have co-occurring
need to be addressed in mental health conditions. It is important that adolescents are
order to effectively treat screened and treated for these other conditions in order for
substance use substance abuse treatment to be successful.
10. Sensitive issues should It is common for adolescents with substance use disorders to have
be addressed and a history of abuse or other trauma.69 whereas maintaining
confidentiality maintained confidentiality with respect to sensitive issues is important in the
when possible therapeutic setting, appropriate authorities need to be informed if
abuse is suspected.
11. Drug use should be It is important to monitor an adolescent’s drug use while in
monitored during treatment treatment and identify a relapse early on. The relapse could
indicate that treatment should be intensified or needs to be altered
to better meet the adolescent’s needs.
(continued)
Table 1 (continued)
Principle Description
12. Completing treatment The length of treatment will vary based on the severity of the
and having a continuing adolescent’s substance use disorder; however, studies have shown
care plan are important outcomes are best when an individual is in treatment 3 months or
longer. The adolescent can also benefit from continuing care.
13. Adolescents should be Drug using adolescents are at an increased risk for sexually
tested and treated for transmitted and blood borne diseases (e.g., human
sexually transmitted immunodeficiency virus, hepatitis B and C) due to the increase in
diseases and hepatitis high-risk behaviors that result from drug use. Addressing this in
treatment can help decrease high-risk behaviors thereby reducing
the likelihood of infection.
Note. From the National Institute on Drug Abuse. Principles of Adolescent Substance Use Disorder
Treatment: A Research-Based Guide. Bethesda, MD: National institute on Drug Abuse, 2014.
Available from http://www.drugabuse.gov/publications/principles-adolescent-substance-use-dis-
order-treatment-research-based-guide/principles-adolescent-substance-use-disorder-treatment
parison group (i.e., control group, waiting list control, or contrasting treatment
group), use of standardized assessment instruments, treatment interventions that
are well-described, and outcome evaluation ratings by individuals who did not
conduct the therapy.
Treatment outcome studies were identified from a computerized literature search
of standard journal databases (e.g., MEDLINE, PsychINFO, Social Sciences
Abstracts), as well as from drug treatment websites and the sites of well-known
treatment research organizations. Close reviews of the reference sections of relevant
books, identified studies, and the handful of literature summaries and reviews were
also conducted. We benefited from recent reviews of the literature (Deas & Thomas,
2001; Tanner-Smith, Wilson, & Lipsey, 2013; Vaughn & Howard, 2004).
The review is organized around these strategies or approaches: 12-step-based
treatment, therapeutic community (TC), family-based interventions, behavioral
therapy, cognitive behavioral therapy (CBT), motivational-based therapy (motiva-
tional enhancement and motivational interviewing), electronic and web-based ther-
apy, and pharmacotherapy approaches (see Table 2 for an overview description of
each). As noted above, multiple approaches are commonly integrated in clinical
interventions, and thus, some overlap of approaches exists within the review pre-
sented here. Additionally we discuss these approaches aimed at maximizing out-
come: recovery high schools, use of reinforcements, and adaptive strategies.
In addition to providing an overview of the prominent types of treatment
approaches noted in Table 2, we also summarize a major multisite study (Cannabis
Youth Treatment project) and highlight a recent meta-analysis on outpatient treat-
ment (a meta-analysis refers to statistical techniques used to synthesize quantitative
findings across multiple studies included in a review). Regardless of therapeutic
modality, one underlying goal of adolescent treatment for drug abuse involves pro-
moting recovery by preventing or minimizing relapse. The definition of relapse var-
ies, but in most instances it refers to a return to drug use. Some definitions of relapse
include categories for the level of problems resulting from the return to drug use or
Table 2 Descriptions of seven primary treatment approaches

Approach Description
1. 12-step-based The goal of 12-step therapy is to encourage the adolescent to become
involved in a 12-step program. These programs incorporate a self-help
approach centered within the context of reciprocal support. They are
organized around the basic tenets of alcoholics anonymous (AA), and are
a commonly applied strategy in inpatient and outpatient treatment
programs, as well as a standalone approach (i.e., attending AA, narcotics
anonymous, or cocaine anonymous meetings). Approximately 2.3% of
AA members in the USA and Canada are under the age of 21.
2. Therapeutic The therapeutic community is typically rooted in self-help principles and
community experiential knowledge of the recovery community. This treatment option
views the community as the key agent of change and emphasizes mutual
self-help, behavioral consequences, and shared values for a healthy
lifestyle. For adolescents, therapeutic communities use various therapeutic
techniques which may include individual counseling sessions, family
therapy, 12-step techniques, life skills techniques, and recreational
techniques, and are usually long-term residential treatment programs.
3. Family-based Family-based approaches seek to reduce an adolescent’s use of drugs and
correct the problem behaviors that often accompany drug use by
addressing the mediating family risk factors, such as poor family
communication, cohesiveness, and problem-solving. These approaches are
based on the therapeutic premise that the family has the most profound
and long-lasting influence on child and adolescent development. Family
therapy typically includes the adolescent and at least one other parent or
guardian, but can also include siblings, other family members, and
friends. There are five evidence-based family-based treatments that are in
use today: Brief strategic family therapy; family behavior therapy;
functional family therapy; multidimensional family therapy; and
multisystemic therapy.
4. Behavior therapy Behavioral approaches generally focus on teaching and reinforcing new
skills, behaviors, and new ways of thinking and coping so as to compete
with or minimize drug-using behaviors. The ultimate goal is to reinforce
desirable behaviors and eliminate unwanted or maladaptive ones.
5. Cognitive- Cognitive-behavioral therapy (CBT) is centered on the notion that
behavior therapy thoughts cause behaviors, and these thoughts determine the way in which
people perceive, interpret, and assign meaning to the environment. Thus,
maladaptive behaviors can be changed by modifying our thought
processes, even if one’s environment does not change. In the context of
adolescent substance use, CBT encourages adolescents to develop self-
regulation and coping skills by teaching youth to identify stimulus cues
that precede drug use, to use various strategies to avoid situations that
may trigger the desire to use, and to develop skills for communication and
problem-solving.
(continued)
Table 2 (continued)
Approach Description
6. Motivational Motivational enhancement therapy is based on motivational interviewing
enhancement techniques that have come to the forefront of therapeutic approaches for
therapy/brief addiction in the past decade, and even more so recently for adolescents.
intervention The goal of motivational enhancement therapy is to help encourage the
adolescent to engage in treatment and stop using drugs. Motivational
enhancement therapists use a person-centered, nonconfrontational style in
assisting the youth to explore different facets of his or her use patterns.
Adolescents are encouraged to examine the pros and cons of their use and
to create goals to help them achieve a healthier lifestyle. The therapist
provides personalized feedback and respects the youth’s freedom of
choice regarding his or her own behavior. Motivational enhancement
therapy is typically delivered in conjunction with other treatment
approaches, including brief interventions. Brief intervention often consists
of educational or brief intervention services that aim to help the
adolescent recognize the negative consequences of substance use and to
understand and address the adolescent’s problems that are likely related to
their substance use.
7. Electronic and Current use of electronic-assisted therapy includes internet “treatment
web-based therapy programs” that employ various elements, such as psychoeducation, social
support through chat rooms, monitoring of symptoms and progress, and
feedback. Also included here are telephone-based treatment approaches.
8. Pharmacotherapy This treatment approach uses medication to address various aspects of
addiction, including craving reduction, aversive therapy, substitution
therapy, and treatment of underlying psychiatric disorders. Specifically,
medication can be used to treat addiction to opioids, alcohol, or nicotine
in adults, but there are no medications approved by the US Food and Drug
Administration to treat cannabis, cocaine, or methamphetamine abuse.
Research is quite limited on this treatment strategy for adolescents, and
there are no medications that are currently approved to treat adolescents.
The applicability of adult findings to adolescents is unclear given that
youth may react differently to the potential side effects of medications.
However, doctors will sometimes prescribe medications to older
adolescents.
Note. Adapted from “Adolescent Substance Abuse Treatment: A Review of Evidence-Based
Research,” by K. C. Winters, A. M. Botzet, T. Fahnhorst, R. Stinchfield, & R. Koskey, 2009, In
C. G. Leukefeld, T. P. Gullotta & M. Staton-Tindall (Eds.), Adolescent Substance Abuse: Evidence-
Based Approaches to Prevention and Treatment, pp. 73-96. New York, NY: Springer
for the levels of drug use frequency. Among youth receiving treatment for an SUD, it
can be expected that from one-third to one-half are likely to return to some drug use
at least once within 12 months following treatment (Grella, Joshi, & Hser, 2004;
National Institute on Drug Abuse, 2014; Williams, Chang, & Addiction Centre
Adolescent Research Group, 2000; Winters, 1999).
12-Step-Based Treatment
Organized around the basic tenets of Alcoholics Anonymous (AA), it is generally

accepted in the field that this treatment approach is the most commonly applied
strategy to youth with an SUD. It is estimated that about two-thirds of treatment
programs utilize these basic principles as part of their approach, and some programs
are primarily organized around the AA principles (Sussman, 2010). The first 5 steps
of the 12 steps are typically addressed with adolescents during the primary treatment
experience. These five steps are the following: (1) admitting that you are powerless
over the addictive substance and that it has made life unmanageable, (2) believing
that a power greater than yourself could restore you to health, (3) making a decision
to turn your will over to a higher power as you interpret it to be, (4) taking moral
inventory of yourself, and (5) admitting to yourself and to others the nature of your
wrongs. One typically embarks upon the remaining seven steps during aftercare.
Applicability of the 12-step method for youth has been questioned due to limita-
tions in developmentally appropriate content. Adolescence is a time of identifying a
personal identity and independence from authority figures, developmental mile-
stones that can be inconsistent with the main tenants of AA of acceptance and sur-
render. In addition, 12-step-based aftercare programs (e.g., AA, NA) are mainly
composed of adults. It is estimated that only 2% of participants in self-help groups
are under the age of 21 (Alcoholics Anonymous 2001 Membership Survey, 2001),
which creates barriers for adolescents as they may struggle to relate to older group
members (Kelly, Brown, Abrantes, Kahler, & Myers, 2008; Kelly & Urbanoski,
2012). Thus, efforts to adapt 12-step treatment for adolescents are important. Current
adaptations of this approach include the Minnesota Model treatment approach for
adolescents (Anderson, McGovern, & DuPont, 1999) and Jaffe’s (1990) develop-
mentally appropriate modifications of the first five steps of a 12-step program.
An approach that incorporates the 12-step method, the Minnesota Model, has
been researched. The Minnesota Model includes a range of therapeutic elements
(e.g., group and family therapy) in conjunction with the 12-step method (Winters,
Stinchfield, Opland, Weller, & Latimer, 2000). Winters and colleagues followed a
group of 179 adolescents who participated in either an outpatient or inpatient
Minnesota Model treatment and a group of 66 adolescents who were on a treatment
waiting-list (primarily due to insurance coverage limitations or no insurance).
Results indicated that among the treated youth, those who finished the treatment
program reported superior outcomes in contrast to those who left the program prior
to completion and to a waiting-list group (Winters et al., 2000). At the 12-month
follow-up, categorical data revealed that 53% of the treatment completers reported
abstinence or minor relapse (used once or twice) compared to 15% for the treatment
incompleters and to 27% for the waiting-list group. Continuous variable data
revealed similar results. The comparison of setting (inpatient versus outpatient) did
not yield any outcome differences. A longer-term follow-up study (approximately
5 years post-treatment) of the same youth (Winters, Stinchfield, Latimer, & Lee,
2007) showed a similar pattern of outcome, although the major predictor of favor-
able outcomes was involvement in aftercare. Whereas the studies above showed that
favorable outcome is associated with treatment engagement, the study designs did
not permit opportunity to evaluate the specific contribution of 12-step elements.
AA/NA attendance has been researched among teenagers who have received
12-step treatment. The prominent work by Kelly and colleagues suggests that
despite spotty AA/NA attendance over time, adolescents with greater addiction
severity and those who believed that they needed to maintain abstinence had higher
attendance rates, and greater early participation was associated with more favorable
long-term outcome (Kelly et al., 2008). As many have written (e.g., Kelly, Magill,
& Stout, 2009), AA/NA’s value to teenagers may be that it provides a free, semis-
tructured therapeutic service with the flexibility allowing the youth to modulate
level of involvement.
Therapeutic Community
Like the 12-step Minnesota Model, TC is typically classified as a community-based

therapy based in self-help principles and experiential knowledge of the recovery
community (Morral, McCaffrey, & Ridgeway, 2004). This treatment approach
views the community as the key agent of change, and it emphasizes mutual self-
help, behavioral consequences, and shared values for a healthy lifestyle (Jainchill,
1997). Adolescent TCs tend to be long-term residential treatment programs, and
typically include a wide variety of therapeutic techniques, including (but not limited
to) individual counseling sessions, family therapy, 12-step method, life-skills, and
recreational techniques.
Morral et al. (2004) examined the TC approach using a rigorous evaluation design
that compared nearly 450 adolescents in a 9- to 12-month residential TC program
(Phoenix Academy) and a comparison group of treatment as usual (probation dispo-
sitions). The findings indicated that participation in Phoenix Academy was associ-
ated with significantly reduced drug use and improved psychological functioning
outcomes compared to the comparison group at 12-month posttreatment.
Family-Based Therapy
The family therapy approach seeks to reduce an adolescent’s use of drugs and cor-
rect the problem behaviors that often accompany drug use by addressing the mediat-
ing family risk factors such as poor family communication, cohesiveness, and
problem solving. This approach is based on the therapeutic premise that the family
carries the most profound and long-lasting influence on child and adolescent devel-
opment (Szapocznik & Coatsworth, 1999). Family therapy typically includes the
adolescent and at least one other parent or guardian. Ideally, siblings and other adult
household members are included. Other approaches and theoretical positions are
commonly integrated into family-based treatment, such as CBT (Latimer, Winters,

D’Zurilla, & Nichols, 2003) and family empowerment theory (e.g., Dembo et al.,
2000). In addition, social, neighborhood, community, and cultural factors are also
considered within the treatment plan (Ozechowski & Liddle, 2002).
Austin and colleagues (Austin, Macgowan, & Wagner, 2005) identified and
reviewed five family-based treatment approaches, all of which involved random
assignment and other rigorous design features: (1) Brief strategic family therapy
(BSFT; Santisteban et al., 2003); (2) Family behavior therapy (Azrin, Donohue,
Besalel, Kogan, & Acierno, 1994); (3) Functional family therapy (FFT; Waldron,
Slesnick, Brody, Turner, & Peterson, 2001); (4) Multidimensional family therapy
(MDFT; also referenced in the Cannabis Youth Treatment, CYT, section of this
chapter) (Liddle, Rowe, Dakof, Henderson, & Greenbaum, 2009); and (5)
Multisystemic treatment (MST; Henggeler, Clingempeel, Brondino, & Pickrel,
2002; Henggeler, Pickrel, & Brondino, 1999). Of these five, MDFT demonstrated
both clinically and statistically significant favorable drug use outcomes at the con-
clusion of treatment and at the 1-year posttreatment assessment. Whereas the other
four approaches (BSFT, MST, FFT, and FBT) showed greater improvement com-
pared to the control group at the completion of treatment, posttreatment follow-up
assessments did not reveal group differences for MST and FFT, and there are no
posttreatment outcomes reported for the BSFT and FBT studies (Austin et al., 2005).
Smith and colleagues (Smith, Hall, Williams, An, & Gotman, 2006) compared an
outpatient family intervention (Strengths oriented family therapy, SOFT; Smith &
Hall, 2008), with a group therapy approach (The Seven Challenges®; Schwebel,
2004) The SOFT intervention incorporated a pretreatment motivational family ses-
sion, multifamily skills training, and case management. The comparison group
(Seven Challenges) utilized interactive journaling, skills training, and motivational
interviewing. Results at 6-month posttreatment revealed that the two interventions
were comparable in terms of achieving abstinence (39% for SOFT and 31% for
Seven Challenges), being symptom free (61% and 60%, respectively), and extent of
reduction of drug use frequency and affiliated problems (Smith et al., 2006).
Some family therapy models being used to treat adolescent drug use were spe-
cifically designed to address the problem of drug use, such as Multidimensional
Family Therapy (MDFT) and Brief Strategic Family Therapy (BSFT). Other family
treatment models have been applied to adolescent drug use, but were initially
designed to treat delinquency more generally. Functional Family Therapy (FFT)
and Multisystemic Therapy (MST) are two such family treatment models that have
been applied to adolescent drug use problems. Currently, these four family treat-
ment models are the most prevalent in terms of clinical use and empirical research.
Multidimensional Family Therapy (MDFT) was designed to treat adolescent
drug use as well as delinquency (Liddle, 2013). It employs a developmental model
and considers risk and resilience factors in terms of their roles in developmental
cascades. The treatment has elements that focus on the adolescent and the adolescent-
parent relationship, while considering social and contextual factors (Liddle, 2013).
MDFT has been tested in several randomized control trials. One review article com-
pared results of randomized controlled trials (RCTs) testing MDFT to those testing
Cognitive Behavior Therapy (CBT) and Motivational Enhancement Therapy

(MET), and found evidence in favor of MDFT on cannabis use outcomes for
younger adolescents and those with more severe dependence (Walther, Gantner,
Heinz, & Majic, 2016). The four RCTs evaluating MDFT reported on in the review
were comprised of two studies comparing MDFT to a treatment-as-usual control
and two studies comparing MDFT to a CBT control condition (Walther et al., 2016).
Those adolescents in MDFT had greater reductions in cannabis use at the end of the
treatment compared to treatment-as-usual, with comparable end-of-treatment can-
nabis outcomes when compared to CBT. However, in one study with a CBT control,
there were reductions in dependence for youth in the MDFT treatment condition at
a 12-month follow-up, with even greater gains among the higher severity of canna-
bis use sub-group. Multiple meta-analyses have evaluated the effect size of MDFT
treatment from RCTs comparing MDFT to other treatment models (Liddle, 2016).
The reductions of drug use outcomes of MDFT from RCTs, even when compared to
other high-quality evidence-based treatments such as CBT, tend to be durable and
often are preferable to other treatments at 1 year follow-ups (Liddle, 2016).
In a multisite, randomized control trial of outpatient drug treatment for adoles-
cents between the ages of 13–18 in Western Europe, MDFT was compared to indi-
vidual counseling for the treatment of cannabis use disorder (Rigter et al., 2013).
Across five countries (Belgium, France, Germany, The Netherlands, and Switzerland)
450 youth were randomized to either individual psychotherapy (IP) (which referred
to the current practice of the clinician or agency, including CBT and other models)
or Multidimensional Family Therapy (MDFT). Clinicians administering the MDFT
treatment condition reported higher rates of treatment retention to successful com-
pletion (90% of cases) than did the clinicians administering the IP treatment condi-
tion (48% of cases). For low-severity users (below the median of number of days
used in past 90 days), MDFT and IP models were comparatively similar in reducing
use at 3, 6, 9, and 12 months post-baseline (Rigter et al., 2013). However, for high-
severity users, MDFT reduced the number of days of use notably more than did IP,
with the high severity MDFT group nearly matching the 12 month outcome of the
low-severity IP group. The effect size of this difference between IP and MDFT
reduction in use for the high severity group across sites was medium to large
(d = 0.60; Rigter et al., 2013).
Multisystemic Therapy (MST) was designed to treat antisocial behavior in youth
who are at imminent risk of out-of-home placement and has been applied to drug-
abuse populations (Sheidow & Houston, 2013). MST identifies antisocial behavior
as resulting from multiple determinants; thus, treatment efforts are made to simul-
taneously generate change in family, school, community, and peer contexts (Sheidow
& Houston, 2013). The modality of MST is intensive and generally involves approx-
imately 60 h with the MST therapist over the course of three to five months. MST
includes 24/7 on-call access to MST therapists (Sheidow & Houston, 2013). MST
has been tested with many RCTs in terms of delinquency, with considerably fewer
studies on MST measuring drug use outcomes. MST generally has greater impact
on delinquency than on drug use (Henggeler & Schaeffer, 2016). However, in a
meta-analysis of MST RCTs that considered included drug use among delinquency
outcomes (n = 5), there was evidence of significant improvements in drug use com-
pared to control groups with a mean of small to moderate effect size (d = 0.291)
(van der Stouwe, Asscher, Stams, Deković, & van der Laan, 2014).
An adaptation of MST, coined as Multisystemic Therapy—Substance Abuse
(MST-SA), was designed to treat adolescents with a substance use disorder
(Swenson, Henggeler, Taylor, & Addison, 2005). Henggeler et al. (2006) conducted
a randomized controlled trial in which MST-SA in a drug court was compared to
three other conditions: family court with usual community services, drug court with
usual community services, and drug court with MST. In general, findings supported
the view that drug court was more effective than family court services in decreasing
rates of adolescent substance use and criminal behavior. MST and MST-SA were
equivalent on the drug use outcomes (Henggeler et al., 2006).
Brief Strategic Family Therapy (BSFT) was designed to treat conduct problems,
delinquency, and drug use (Szapocznik, Muir, & Schwartz, 2013). BSFT incorpo-
rates traditional family therapy models of Structural Family Therapy and Strategic
Family Therapy (Szapocznik et al., 2013). BSFT has been tested in fewer RCTs than
MDFT and MST; however, there has been two RCTs with adolescents), including
one efficacy trial and one effectiveness trial (Szapocznik et al., 2013). The efficacy
trial measured marijuana use outcomes compared to group counseling control con-
dition, and it was found that BSFT had preferable outcomes to group counseling.
Notably, the group counseling consition demonstrated some potential iatrogenic
effects with increased marijuana use among control participants. The effectiveness
trial measured drug use through self-reported days of use per month in the past year,
and compared BSFT) to a treatment-as-usual control condition (Szapocznik et al.,
2013). Using a sample referred from juenvile justice or residential treatment settings
with relatively limited drug use, the BSFT intervention group demonstrated fewer
days of use per month when compared to the control condition.
Functional Family Therapy (FFT) was designed to treat adolescents with con-
duct disorder, delinquency, and disruptive behavior and their families, and has also
been applied to youth with addictive behaviors (Waldron, Brody, Robbins, &
Alexander, 2013). FFT considers alcohol and drug abuse as problems that develop
in the context of maladaptive family relationships; thus, the mechanism of change
is improving family interactions (Waldron et al., 2013). FFT targets the whole fam-
ily and is designed for all family members who are living together. In three RCTs
comparing FFT, CBT, and FFT plus CBT, the outcomes supported FFT as an equiv-
alent or superior choice to CBT (Waldron et al., 2013). FFT had much higher rates
of engagement than the comparison of a parenting intervention in one study (93%
and 67%, respectively); however, both conditions resulted in equivalent significant
reductions in drug use (Waldron et al., 2013). A RCT comparing FFT, FFT + CBT,
and CBT found that the FFT conditions generated greater reductions in marijuana
use in the first 4 months of treatment when compared to the CBT-only condition.
However, by a follow-up assessment at 19 months, all conditions demonstrated
comparable reductions in drug use, indicating that while both FFT and CBT are
effective, FFT may produce an earlier reduction in drug use when compared to CBT
(Waldron et al., 2013). In a second RCT, comparison groups were FFT, FFT + CBT,
individual CBT, and group CBT to address adolescent alcohol-related problems. All
four conditions were successful in reducing alcohol use from pretreatment to post-
treatment, and additionally the FFT, individual CBT, and group CBT were effective
in reducing marijuana use despite not being targeted in treatment (Waldron et al.,
2013). In a third RCT comparing FFT + CBT to CBT, the researchers found that
while the two conditions were comparably effective for reducing drug use in White,
non-Hispanic youth, the FFT + CBT condition was more effective for Hispanic
youth in reducing drug use (Waldron et al., 2013).
Whereas several of the family-based treatments show preferable outcomes for
the targeted youth compared to traditional individual focused treatments (e.g.,
Latimer et al., 2003) a perhaps unique benefit of family based treatment is the
implications for other members of the family. In MST and FFT, some RCTs have
also measured the rates of drug use in siblings of the targeted adolescent. In both
MST and FFT trials, the research teams found decreases in the drug use of siblings
in the family, not just in the targeted youth (Henggeler & Schaeffer, 2016; Waldron
et al., 2013). This has interesting implications for cost-effectiveness analysis from
treatment and prevention perspectives if siblings are also reaping the benefits of
family treatment modalities.
Behavioral Therapy
Therapeutic techniques based on behavioral psychology theories are another approach

to treating adolescent substance abuse. Behavioral strategies, which target actions and
behaviors presumed to be influenced by one’s environment, include modeling,
rehearsal, self-recording, stimulus control, urge control, and written assignments. In
current practice, behaviorism is most often coupled with techniques that modify cog-
nitions, referred to as CBT (which we review in the next section). We identified one
behavioral study that met our review inclusion criteria. Azrin and colleagues randomly
assigned drug-abusing youth to either a supportive counseling group (n = 11) or a
behavioral treatment group (n = 15) for ~6 months of treatment (Azrin et al., 1994).
The results indicated that drug use significantly decreased over the course of the treat-
ment for the behavioral treatment group, with 73% reporting abstinence during the
last month of treatment, compared to only 9% of the comparison group. Other drug
use outcome measures were also significantly improved for the behavioral group.
A variant if behavioral treatment is the adolescent community reinforcement
approach (A-CRA; Godley et al., 2014, 2017). This intervention targets areas of the
adolescent’s life and surrounding community that reinforce reducing or eliminating
substance use and helps the adolescent to replace these negative influences with
healthier prosocial behaviors. A-CRA can address problem-solving, c ommunication
skills, relapse prevention, and encourage participation in positive social and com-
munity activities.
Cognitive Behavioral Therapy
CBT is based in the belief that thoughts cause behaviors, and these thoughts deter-
mine the way in which people perceive, interpret, and assign meaning to the environ-
ment (Beck & Weishaar, 2005). Thus, by changing our thought processes, maladaptive
behaviors can be changed even if our environment does not change. When used within
the context of adolescent substance use, CBT encourages adolescents to develop self-
regulation and coping skills. Techniques commonly used include the identification of
stimulus cues preceding drug use, the use of strategies to avoid situations that may
trigger the urge to use, and skill development for refusal techniques, communication,
and problem solving (Waldron et al., 2001). CBT is a frequently used therapeutic
approach, but it is commonly integrated into other approaches (Beck & Weishaar,
2005), especially family systems therapy and motivational enhancement/brief inter-
ventions (BIs). For this reason, some CBT methods are also mentioned in other sec-
tions of this chapter as an integral part of another therapeutic approach.
Barrett and colleagues (Barrett, Slesnick, Brody, Turner, & Peterson, 2001) con-
ducted a randomized clinical trial that compared CBT, family therapy, combined
individual and family therapy, and a group intervention for 114 substance-abusing
adolescents. Drug use outcomes were the percentage of days that marijuana was
used and the percentage of youths achieving minimal use. Each intervention demon-
strated some efficacy. From pretreatment to 4 months, significantly fewer days of use
were found for the family therapy alone and the combined interventions. Significantly
more youths achieved minimal use levels in the CBT, family, and combined condi-
tions. From pretreatment to 7 months, reductions in percentage of days of use were
significant for the combined and group interventions, and changes in minimal use
levels were significant for the family, combined, and group interventions.
Kaminer, Burleson, and Goldberger (2002) examined a sample of 51 adolescents
who were randomly assigned to a CBT intervention in comparison to 37 adolescents
who received psychoeducational treatment. A greater reduction in substance use
was found for older adolescents and for males in the CBT group at a 3-month fol-
low-up, as compared to the psychoeducational group, but at 9-month follow-up the
two groups did not differ on drug use outcome.
Motivational Enhancement Therapy (MET)/Brief Intervention
MET techniques have recently come to the forefront of therapeutic approaches for
addiction, and even more so recently for adolescents. MET (also referred to as moti-
vational interviewing) utilizes a person-centered, nonconfrontational approach to
assist the youth to explore the different facets of their use patterns. Clients are
encouraged to examine the pros and cons of their use and to create goals to help
them achieve a healthier lifestyle. The therapist provides personalized feedback and
respects the youth’s freedom of choice regarding his/her own behavior. Although
the relationship between the therapist and client is more of a partnership than an
expert/recipient role, the therapist is directive in assisting the individual to examine
and resolve ambivalence and to encourage the client’s responsibility for selecting
and working on healthy changes in behavior (Rollnick & Miller, 1995).
MET is frequently incorporated into a brief intervention format, in which a thera-
pist meets with the client for only a brief period, anywhere from a single 10-min
session to multiple 1-h sessions (Winters, 2016). BIs are becoming an attractive
therapeutic approach due to cost-containment policies of managed care, and many
BIs are included in a more comprehensive model, Screening, Brief Intervention and
Referral to Treatment (SBIRT; Vendetti et al., 2017). They may be particularly
attractive to youth because of the brief number of therapeutic contacts, and the
approach is developmentally fitting given that many drug-abusing youth are not
“career” drug abusers and young people are likely to be more receptive to self-
guided behavior change strategies, a cornerstone of MET (Miller & Sanchez, 1994;
Winters, Leitten, Wagner, & O’Leary Tevyaw, 2007).
There is growing support for the efficacy of MET/BI. We located eight published
meta-analyses or literature reviews of this model for adolescents (Carney & Myers,
2012; Erickson, Gerstle, & Feldstein, 2005; Grenard, Ames, Pentz, & Sussman,
2006; Jensen et al., 2011; Macgowan & Engle, 2010; Tait & Hulse, 2003; Tanner-
Smith & Lipsey, 2015; Wachtel & Staniford, 2010). These meta-analyses concur
that, despite some exceptions (see Haller et al., 2014; McCambridge & Strang,
2004; Walker et al., 2011; Walker, Roffman, Stephens, Berghuis, & Kim, 2006), the
efficacy of MET/BI is generally encouraging. These findings have occurred in mul-
tiple settings, including schools (e.g., Winters, Lee, Botzet, Fahnhorst, & Nicholson,
2014), juvenile offender (e.g., Dembo et al., 2014; Stein et al., 2006), primary care
(e.g., Levy & Knight, 2008), and emergency departments (e.g., Monti et al., 1999;
Walton et al., 2010). Of note is that this approach significantly outperformed control
or comparison conditions, which include education (e.g., Ögel & Coskun, 2011)
and assessment-only conditions (e.g., Conrod, Castellanos-Ryan, & Mackie, 2011;
Goti et al., 2010; Winters, Lee, et al., 2014; Winters, Tanner-Smith, et al., 2014).
Electronic-Based Therapy
The use of technology for behavioral interventions and therapies has become an
emerging approach for supporting the delivery of treatment and aftercare for youth
populations challenged with substance use disorders. With increasing advances in
technology, the types of technology-based applications have grown in diversity over
the years, ranging from computers/Internet, tablets, iPads, mobile apps, and text
messaging. Access to, and usage of such devices among youth populations is com-
mon. According to the International Telecommunications Union (2012), ownership
of mobile phones is particularly pervasive within youth culture, with roughly 90%
of this segment of the population having access to mobile devices and texting being
“the preferred form of communication” (Campbell & Park, 2014; ITU, 2012;
Madden, Lenhart, Duggan, Cortesi, & Gasser, 2013). Such high access increases the
possibility of reaching youth who are unlikely to return to the traditional system for
aftercare services, for example (Moore, Dickson-Deane, & Galyen, 2011).
Computer-based interventions and text-messaging resources have become
embraced and accepted as a promising and effective technology-based health tools
within behavioral health systems for preventing, treating, and supporting therapeutic
regimens (i.e., medication compliance) for a wide array of health issues, including
but not limited to diabetes, mental health (schizophrenia, depression, anxiety),
smoking cessation, sexual and reproductive health, asthma, alcohol drinking and
substance use (e.g., Bickel, Christensen, & Marsch, 2011; Kaltenthaler, Parry,
Beverley, & Ferriter, 2008; Rooke, Thorsteinsson, Karpin, Copeland, & Allsop,
2010). Online consultation is also available in which individuals can chat online with
therapists who have verified credentials (e.g., the International Society for Mental
Health Online, www.ismpo.org). Feasibility studies have demonstrated high accep-
tance and satisfaction for using cell phones as a means of communicating about
health and service delivery (e.g., Gonzales, Ang, Murphy, Glik, & Anglin, 2014).
Based on a systematic review of the literature, there have been growing outcome-
based studies conducted on the efficacy and effectiveness of technology-based
approaches. Collective results show high promise: lowering rates of impairment,
improving functioning, decreasing risk behaviors, and increasing adherence or
compliance with therapeutic/recovery regimens. Unfortunately, to date, few studies
are available that examine the cost efficiency of technology-based approaches.
There are several benefits to integrating technology based approaches for sup-
porting the delivery of treatment and aftercare for youth populations challenged
with substance use disorders. One major advantage is maintaining therapeutic fidel-
ity, i.e., ensuring the delivery of evidence based content effectively, reliably, and
flexibly. Workforce costs are also minimized with such methods (Newman, Szkodny,
Llera, & Przeworski, 2011), as the majority of costs are directed to development
rather than delivery; however there is monitoring and follow-up that needs to be
built in. Also, technology-based approaches increase the degree of therapeutic flex-
ibility a program or provider has to address treatment and aftercare participation
barriers linked to youth concerns about physically attending programs to receive
services. Studies support that youth in particular are a group that tends to prefer
such interactions more favorably than face-to-face meetings with providers
(Pilowsky & Wu, 2013). Technology is also a way to address access and service
obstacles specific to youth with unstable housing as they are not required to have a
physical residence address to receive services as is required of most treatment pro-
grams. Technology devices also enhance the system’s ability to readily monitor and
assess for youth progress and outcomes via the collection of real time data (in the
moment during lived recovery experiences), as well as, increase the likelihood of
honest reporting linked to privacy and confidentiality provided by such devices
(Turner et al., 1998; Weisband & Kiesler, 1996). Lastly, such technologies allow for
potential tailoring and personalization of services (Ondersma, Chase, Svikis, &
Schuster, 2005), which is important for youth with substance use issues who tend to
have divergent experiences, risk and protective factors, and pathways to recovery.
Pharmacotherapy
Various medications with different approaches have been used to address addiction.
These approaches include craving reduction, aversion aversive therapy, substitution
therapy, and treatment of underlying psychiatric disorders. Medications approved by
the US Food and Drug Administration can be used to treat addiction to opioids,
alcohol, or nicotine in adults, but there are no approved medications to treat canna-
bis, cocaine, or methamphetamine addiction, and no medications are currently
approved to treat adolescents. Anecdotal reports indicate that doctors will sometimes
prescribe addiction-treatment medications to older adolescents, but the applicability
of adult findings to adolescents is unclear given that youth may react differently to
the potential side effects of medications (Deas & Thomas, 2001). The approved
medications that target alcohol dependence are disulfiram (Fuller et al., 1986), a type
of aversive therapy that causes severe nausea, vomiting, and flushing (via the block-
age of an enzyme involved in the metabolism of alcohol), and two that seek to reduce
cravings—Naltrexone (ReVia) (Morris, Hopwood, Whelan, Gardiner, & Drummond,
2001) and Acamprosate (Campral) (Mann, Lehert, & Morgan, 2004).
Cannabis Youth Treatment Study
One of the largest and most comprehensive research studies to examine the effec-
tiveness of adolescent drug treatment. The Cannabis Youth Treatment Study (CYT),
initiated by the Center for Substance Abuse Treatment, was designed to compare the
clinical efficacy and cost-effectiveness of multiple short-term (less than 3 months)
interventions for adolescents who have a cannabis use problem (Dennis et al., 2004).
Researchers from four sites [University of Connecticut Health Center (UCHC),
Operation PAR, Inc. (PAR), Chestnut Health Systems (CHS), and Children’s
Hospital of Philadelphia (CHOP)], along with other community stakeholders,
formed a 35-member steering committee and selected five short-term, manual-
driven interventions to investigate. Feasibility limitations guided the study to be
divided into two trials. Trial 1, implemented at UCHC and PAR, compared three
interventions (1) MET and five sessions of CBT; (2) MET and 12 sessions of CBT;
and (3) Family Support Network (FSN). Trial 2, conducted at CHS and CHOP, also
compared three interventions: (1) MET and five sessions of CBT; (2) Adolescent
community reinforcement approach (A-CRA); and (3) MDFT. Participants were
randomly assigned to the various interventions per site and qualified for this study if
they were 12–18 years old, reported one or more cannabis abuse or dependence
symptom(s) (DSM-IV; American Psychiatric Association, 1994), and qualified for
outpatient treatment (American Society of Addiction Medicine, 2013). Additional
information about participant qualifications and other methodological specifications
of this study are reported elsewhere (Dennis et al., 2004; Diamond et al., 2002).
Favorable treatment effects, as defined by increased days of abstinence during

the 12 months following treatment and percentage of adolescents in recovery at the
end of the study were found to be stable across sites and conditions (Dennis et al.,
2004). Highly similar clinical outcomes were also observed across sites and condi-
tions. Additional findings were that increased dosage was not necessarily associated
with improved outcomes and a cost-effectiveness analysis indicated that FSN in
Trial 1 and MDFT in Trial 2 were the least cost-effective.
Meta-Analysis of Outpatient Treatment
Given that outpatient treatment is the predominant setting in which adolescents

receive drug treatment, it is pertinent to highlight the recent analyses performed by
Tanner-Smith and colleagues (Tanner-Smith et al., 2013). They conducted a meta-
analysis on the effects of outpatient treatment on substance use outcomes for ado-
lescents with substance use disorders. Whereas a systematic literature review
identifies and summarizes the empirical evidence from the studies that fits prespeci-
fied eligibility criteria, a meta-analysis is the use of statistical methods to summa-
rize the results of these studies.
The authors located 45 eligible experimental or quasi-experimental studies
reporting 73 treatment–comparison group pairs, with many of the comparison
groups also receiving some treatment. The most prevalent treatment types were
family therapy, MET/motivational interviewing, psychoeducational therapy (PET),
adolescent community reinforcement approach (ACRA), and CBT. In order to
assess the comparative effectiveness, the authors examined the effect sizes for pre–
post changes in substance use of each treatment type compared to whatever diverse
treatment or control conditions was used in the respective studies.
Results from the pre–post analysis indicated an almost universal reduction in
substance use between treatment entry and termination regardless of treatment type.
A closer look at the results indicated that family therapy, behavioral therapy, CBT
and MET were among the treatment types showing the largest substance use reduc-
tions. The most convincing and consistent comparative effectiveness finding was for
family therapy, which showed relatively large positive effects relative to other treat-
ments in both analyses. Not surprisingly, placebo and no treatment controls were
among those showing the smallest reductions.
The authors reported an additional exploratory analysis of pooled data from
Chestnut Health System’s GAIN database pertaining to outpatient treatment
(Dennis, White, Titus, & Unsicker, 2008). They conducted a meta-analysis analo-
gous to that reported above. Analyses were based on data from 102 outpatient
treatment programs serving over 9000 adolescents across the United States. Those
results provided convergent results - there was almost universal reduction in sub-
stance use between treatment entry and termination regardless of treatment type.
Thus, one major take-away from the Tanner-Smith et al. (2013) work is that most
types of treatment appear to be beneficial in helping adolescents reduce their sub-
stance use. As the authors note, “given the indications that at least some treatments
are effective in reducing substance use, it is encouraging to see widespread reduc-
tions among the adolescents in the research studies” (p. 154–155).
A final topic addressed in this study was the issue of outcome and adolescent
characteristics. The authors coded all the baseline information reported in the stud-
ies about those characteristics and included them in the analysis to identify sub-
groups more or less responsive to treatment. The analysis of pre–post reductions in
substance use showed that, save for one variable, there were no differences related
to gender, race/ethnicity, age, baseline substance use severity, comorbidity, or delin-
quency level. Also, the authors examined the interactions of these variables with the
different distinct treatment types and found only a handful of chance levels of sta-
tistical significance. The one participant variable related to outcome was type of
substance. The pre–post comparison showed that reductions in substance use were
smaller for alcohol and other substances (e.g., heroin and cocaine) than for mari-
juana. But in the main, these analyses, albeit far short of definitive, suggest that
treatments are relatively effective across a wide range of youth that differ in terms
of demographics and problem severity.
Approaches Aimed at Maximizing Outcome
Recovery Schools
School is a critically important social environment for adolescents with SUDs.

Developing new, sober peer groups is an important yet challenging aspect of recov-
ery for youth completing SUD treatment. Given the documented environmental
substance-exposure risk in high schools, and the vulnerability to early relapse fol-
lowing SUD treatment, school environments play a vital role in maintaining or
undermining treatment gains.
On the one hand, school sits at the heart of the threat of relapse and other
unhealthy and maladaptive behaviors. For youth in recovery from SUDs, traditional
high school is a context likely to involve interactions with peer groups who are
actively using alcohol and other drugs. The National Survey of American Attitudes
on Substance Abuse annual survey of students ages 12–17 found that about two-
thirds of high school students say drugs are used, kept, or sold on the grounds of
their schools (Johnson, Shapiro, & Zill, 2009). Association with drug-using peers,
alcohol or drug availability, and academic challenges are significant relapse-risk
factors for youth after drug treatment (Clark & Winters, 2002; Svensson, 2000). For
the student who attempts to resist peer pressure, difficulty coping with negative feel-
ings and interpersonal conflict may endanger a teen’s newly established sobriety.
Conversely, schools can be opportunities for promoting recovery and protecting
students. Treatment for substance use disorders in any age group does not produce
certain remission. The course of substance use disorders is characterized by cycles
of recovery and relapse (Dennis & Scott, 2007), which may endanger academic
achievement and social functioning. Abstaining represents a challenge for students,
who are especially vulnerable to relapse during the 6- to 12-month post-treatment
period (Winters, Stinchfield, et al., 2007).
Any approach addressing recovery from substance use disorders among youth
therefore must involve school settings. School bonding, school interest, and aca-
demic achievement are negatively associated with substance use, particularly among
low-achieving students (Bryant, Schulenberg, O'Malley, Bachman, & Johnston,
2003). Succeeding academically can help students stay sober and ultimately gradu-
ate, given that “connectedness with school” is a protective factor for adolescents
(Resnick et al., 1997). Continuing care and peer networks are integral to sustaining
long-term sobriety (Brown, 2004; Karakos, 2014; McKay et al., 2009; Stout, Kelly,
Magill, & Pagano, 2012). For high school students, knowing how to relate and
respond to peers given newfound sobriety is a difficult challenge (Finch & Wegman,
2012) and increasing social interaction with non-substance-using peers is associ-
ated with greater odds of remission and recovery. Youth who abstain from substance
use posttreatment report a higher number of non-using social supports (including
peers) than youth who return to heavy drug use (Anderson, Ramo, Schulte,
Cummins, & Brown, 2007; Richter, Brown, & Mott, 1991).
Recovery high schools are an alternative high school option that provides recov-
ery support and a protective environment for students with SUDs and related behav-
ioral, emotional, or mental health needs. Having been diagnosed with a substance
use disorder is not a requirement of most recovery high schools, but SUDs and prior
treatment are the norm for recovery high school students (Moberg & Finch, 2008;
Moberg, Finch, & Lindsley, 2014).
The first recovery high school opened in Maryland in 1979 as a public alternative
school called “Phoenix”. The Association of Recovery Schools (ARS) was formed
in 2002 to advocate for “the promotion, strengthening, and expansion of secondary
and postsecondary programs designed for students and families committed to achiev-
ing success in both education and recovery” (Association of Recovery Schools,
2016). There are currently 40 recovery high schools in 16 states, with at least five
additional schools under development. Over 85 recovery high schools have operated
since 1979 (Association of Recovery Schools; https://recoveryschools.org/).
Recovery support programs such as recovery high schools enhance “recovery
capital,” which encompasses all resources related to the recovery process, including
financial, human, social, and community factors (Granfield & Cloud, 1999;
Hennessy & Finch, 2015; Kelly & Hoeppner, 2015). Recovery high schools provide
services supporting both the academic and therapeutic needs of students. The
schools attempt to support recovery and academic achievement by creating
connectedness and building social and recovery capital in a context with clear path-
ways to success.
Recovery high schools are typically small, with an average enrollment of about
30 students. The programs are schools of choice for which the willingness of a stu-
dent to attend is an enrollment criterion. Students ultimately may either graduate
from the recovery high school or transition to a more traditional school. While there
is no one recovery high school model, certain elements are common (Finch, Moberg,
& Krupp, 2014; Hennessy & Finch, 2015; Moberg & Finch, 2008):
1. Building a base of peer/family connection, social structures, accountability, psy-
choeducational information, and recovery resources;
2. Repairing/replacing disconnected or unhealthy peer, family, and authority rela-
tionships and minimizing contact with high-risk peers during school hours;
3. Providing students the opportunity to meet other students with similar histories
and goals and to practice skills, including how to have sober fun;
4. Identifying and responding to behaviors indicating potential substance use or the
symptoms of a co-occurring disorder by taking advantage of smaller school envi-
ronments and specialized staff;
5. Requiring participation in support and mutual aid groups outside school to pro-
mote contact with additional positive peers and mentors; and
6. Providing an individualized, accredited curriculum taught by licensed teachers
to give students a chance to stay on-course for earning a high school diploma.
Recovery high school-specific research has expanded in recent years (Botzet,
McIlvaine, Winters, Fahnhorst, & Dittel, 2014; Finch et al., 2014; Finch,
Tanner-Smith, Hennessy, & Moberg, 2017; Karakos, 2014; Moberg et al., 2014;
Moberg & Finch, 2008). Finch et al. (2017) provides the strongest evidence yet of a
positive effect of RHSs for adolescents who have received treatment for SUDs. This
article emerges from the first NIH-funded comparative outcomes study of recovery
high schools (RHS). The study used a longitudinal quasi-experimental design to
examine the effects of RHS attendance on adolescents’ outcomes, specifically
examining whether students who have received treatment for SUDs and who subse-
quently attend RHSs, experience significantly better behavioral outcomes (less
alcohol and other drug use) and educational outcomes (higher GPA, better atten-
dance) compared to recovering students who attend school in other settings. The
study was unique in the inclusion of propensity score modeling of a wide range of
important correlates of outcomes selected based on prior meta-analytic research on
adolescent treatment outcomes.
Results at 6 months compared adolescents attending RHSs following treatment
for SUDs to non-RHS students who had received similar SUD treatment:
• RHS students were twice (59% versus 30%) as likely to report complete absti-
nence from alcohol, marijuana, and other drugs at the 6-month follow-up.
• RHS students reported significantly fewer days of marijuana use (9 days com-
pared to 26 days in the past 3 months), and
• RHS students reported significantly less absenteeism from school.
While studies suggest recovery high schools offer a promising approach to
improve both academic and behavioral outcomes, more research is needed (US
Office of the Surgeon General, 2016), especially with regard to diverse populations
and long-term (i.e., post-high school) trajectories.
Overall, reports indicate that recovery high schools are feasible to implement and
sustain, and participating students and staff believe they have positive educational
and behavioral outcomes (Moberg & Finch, 2008). Assuming overall effectiveness
continues to be demonstrated, additional analyses to characterize the most effective
program elements will be needed to guide policy and service development.
Employing Reinforcements to Promote Recovery
Incentive-based approaches, which include contingency management, encourages

healthy changes in behavior by providing adolescents with immediate rewards con-
tingent on positive changes in behavior, such as negative urine tests or meeting treat-
ment goals. This approach is based on the operant conditioning principle that the use
of consequences can modify behavior. Rewards are often in the form of award prizes
(e.g., dollar prizes) (Sindelar, Elbel, & Petry, 2007). Community reinforcement plus
vouchers approach (CRA) is an example. Key features of this strategy are vouchers
to reward treatment compliance and abstinence, frequent and random urine screens
to detect drug use, and several tools to support successful recovery (e.g., functional
analyses to identify triggers for drug use; self-management plans to address identi-
fied triggers; and the development of drug avoidance skills). Incentive-based strate-
gies merit greater research attention and utilization in the treatment field; they can
be readily integrated into the variety of treatment approaches that are becoming the
mainstay in adolescent treatment, including behavior therapy, cognitive behavior
therapy, family therapy, and motivational enhancement.
Adapting Treatment
A promising model to optimize treatment effectiveness is personalizing the content

and or delivery to address those who do not respond readily to the first-line treat-
ment offered. This model, referred to as a “SMART” (Sequential Multiple
Assignment Randomized Trials) approach (Murphy, Lynch, Oslin, McKay, &
TenHave, 2007) applies an algorithm of enhanced treatment for poor responders.
Given that many youth do not initially respond to treatment, the field may benefit
from use of this strategy. The adaptive approach has the potential to increase rates
of participation; the burden on the patient is lower at the outset, and the tailoring that
occurs for nonresponders may be perceived favorably by these clients. Adaptive
care may also increase cost-effectiveness and cost benefit, because lower intensity
treatments are also often less costly.
A challenge of adaptive treatment models is how to define poor treatment
response and when to apply the next step of treatment. Should the client be switched
from initial treatment and switched to a different strategy? If so, what type of
second-line treatment? Perhaps the client should receive a more intensive version of
the first-line treatment, or have a supplemental treatment to augment what the client
is already receiving (McKay, 2009).
Adaptive or stepped care treatment algorithms have been developed and evalu-
ated for adults. McKay (2009) summarized 15 adult drug treatment studies; most of
these studies concluded that the adaptive approach was associated with either better
drug use outcomes or equivalent outcomes compared to treatments with other
advantages (e.g., lower cost and lower patient burden). The senior author knows of
several SMART studies in progress for youth but no published results yet.
Summary
Overall, great advances have been made since 1990 in the development and evalua-
tion of treatments for adolescent drug abuse. This body of research reflects a greater
focus on varying interventions using different theory-based psychotherapies, as
well as a recognition of the unique developmental milestones specific to adoles-
cents. The field is revealing its maturity in several ways: the use of assessment tools
developed and validated on adolescent populations is the norm; many treatment
approaches target multiple drugs, reflecting the fact that most clinical populations of
teenagers abuse multiple substances; treatment manuals and specific protocols that
permit treatment replication are available; and an increased rigor in evaluating the
effectiveness of these approaches. We can now say with relative certainty that sev-
eral modalities and approaches meet standards of evidence-based treatments, and
that, in general, they are comparable in terms of outcomes.
It is our assessment of the treatment outcome studies that family systems-based
treatments and MET/BI approaches have received the most empirical support com-
pared to other modalities. Two approaches that have been applied to drug-abusing
youth over time and still retain a core position among treatment options—the
12-step approach and TCs—have received very little investigation with clinical tri-
als. Also, few pharmacological treatments of adolescents with an SUD have been
published; their role as an effective adjunct to psychosocial-based approaches mer-
its more research.
Moreover, very little is still known as to what extent community programs pro-
vide essential clinical elements or characteristics of effective treatment (e.g., use of
standardized adolescent assessment measures and developmentally adjusted strate-
gies for treatment engagement). Also, the use by community programs of treatment
reinforcements, adaptive treatment strategies, and electronic resources to supple-
ment treatment and promote recovery is an open question.
Despite a maturing treatment outcome research field, important knowledge gaps
exist. Because most treatment research in this field examines stand-alone
approaches, it is not clear to what extent this body of work generalizes to the wider
treatment community field where electric approaches are commonly utilized.
Addressing this issue, along with cost-efficient and sustainable ways to translate
research findings into day-to-day practice with fidelity, is needed. One effort along
these lines is the use of the Screening, Brief Intervention and Referral to Treatment
(SBIRT) approach as means to expand the identification of and treatment for youth
with a substance use problem (Vendetti et al., 2017; Winters, 2016). Other research
needs include the following: which pharmacological treatments for substance use
disorders are effective for adolescents; what factors mediate and moderate engage-
ment in the behavior change process; what variables may be related to treatment
effectiveness for specific substances (e.g., marijuana; opioids); how to maximize
the role of parents in treatment engagement and support of recovery; the role of
technology to promote treatment effectiveness; and understanding how to make
quality treatment across the entire continuum of care accessible to adolescents with
varying degrees of substance use.
In summary, the adolescent substance abuse treatment field has benefitted by
targeted research resulting in evidence-based treatments and practices that are asso-
ciated with reductions in substance use and the associated short-term individual and
societal costs that result from this disorder. Quality treatment approaches are now
available for a wide range of youth suspected of a substance use problem.
Acknowledgement This work was supported in part by grants DA015347 (Winters) and
DA029785 (Finch) from the National Institute on Drug Abuse.
We gratefully acknowledge the contribution of Tamara Fahnhorst and Rachel Koskey to the
prior version of this chapter.
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Adolescent Substance Abuse

Treatment: A Review of Evidence-Based

Ken C. Winters, Andria M. Botzet, Randy Stinchfield, Rachel Gonzales-­

Use of alcohol and other drugs (hereafter referred to as drugs) by American

© Springer Science+Business Media LLC 2018 141

Based on several client characteristics (e.g., severity of drug involvement; mental

Treatment Outcome Research

Table 1 Principles of adolescent substance use treatment

Table 2 Descriptions of seven primary treatment approaches

Organized around the basic tenets of Alcoholics Anonymous (AA), it is generally

Like the 12-step Minnesota Model, TC is typically classified as a community-based

commonly integrated into family-based treatment, such as CBT (Latimer, Winters,

Cognitive Behavior Therapy (CBT) and Motivational Enhancement Therapy

Therapeutic techniques based on behavioral psychology theories are another approach

Cognitive Behavioral Therapy

Motivational Enhancement Therapy (MET)/Brief Intervention

Cannabis Youth Treatment Study

Favorable treatment effects, as defined by increased days of abstinence during

Meta-Analysis of Outpatient Treatment

Given that outpatient treatment is the predominant setting in which adolescents

Approaches Aimed at Maximizing Outcome

School is a critically important social environment for adolescents with SUDs.

Employing Reinforcements to Promote Recovery

Incentive-based approaches, which include contingency management, encourages

A promising model to optimize treatment effectiveness is personalizing the content

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Ken C. Winters, Andria M. Botzet, Randy Stinchfield, Rachel Gonzales-

Cognitive Behavioral Therapy

Motivational Enhancement Therapy (MET)/Brief Intervention

Cannabis Youth Treatment Study

Meta-Analysis of Outpatient Treatment

Approaches Aimed at Maximizing Outcome

Employing Reinforcements to Promote Recovery