Two Article Summaries

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Faculty Research and Publications Williams, Robert

Williams, Robert J.

2000

A Comprehensive and Comparative

Review of Adolescent Substance Abuse

Treatment Outcome

https://hdl.handle.net/10133/419

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Running Head: OUTCOME OF ADOLESCENT SUBSTANCE ABUSE TREATMENT

A Comprehensive and Comparative Review of Adolescent Substance Abuse Treatment Outcome

Robert J. Williams, Samuel Y. Chang, and ACARG

Addiction Centre, Foothills Medical Centre, Calgary, Alberta, Canada

in Clinical Psychology: Science & Practise (2000, Vol 7, 138-166)

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Abstract

There are relatively few studies on adolescent substance abuse treatment. The ones that exist tend to be methodologically weak. Methodologically stronger studies have usually found most adolescents receiving treatment to have significant reductions in substance use and problems in other life areas in the year following treatment. Average rate of sustained abstinence after treatment is 38% (range 30-55) at 6 months and 32% at 12 months (range 14-47). Variables most consistently related to successful outcome are treatment completion, low pre-treatment substance use, and peer/parent social support/nonuse of substances. There is evidence that treatment is superior to no treatment, but insufficient evidence to compare the effectiveness of treatment types. The exception to this is that outpatient family therapy appears superior to other forms of outpatient treatment.

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There have been several reviews and commentaries on the adolescent drug treatment literature (e.g., Brown, 1993; Brown, Mott and Myers 1990; Bukstein, 1994; Davidge and Forman, 1988; Dusenbury, Khuri and Millman, 1992; Kaminer, 1994; Spicer, 1991; U.S. Department of Health and Human Services, 1995a; Winters, Latimer and Stinchfield, in press). The most thorough review has been that of Catalano, Hawkins, Wells, Miller and Brewer (1990/1991). In this review Catalano and his colleagues identified 16 treatment outcome studies and an additional 13 studies that examined factors affecting treatment progress or treatment outcome. Four of these studies were multi-site, multi-program evaluations (Friedman, Glickman and Morrissey, 1986; Drug Abuse Reporting Program (DARP) reported in Sells and Simpson, 1979; Treatment Outcome Prospective Study (TOPS) reported in Hubbard, Cavanaugh, Craddock and Rachal, 1985; and the Uniform Data Collection System (UDCS) reported in Rush, 1979). In their review of all of these studies, they concluded that treatment was likely better than no treatment, but there was no evidence that one treatment type was superior to another. Pre-treatment factors associated with outcome were race, seriousness of substance use, criminality, and educational status. During-treatment factors predictive of outcome were time in treatment for residential programs, involvement of family in treatment, experienced staff who used practical problem solving, and programs that provided comprehensive services (school, recreation, vocation, contraceptive). Post- treatment factors were believed to be the most important determinants of outcome. These included involvement in work and school, association with nonusing friends, and involvement in leisure activities. Unfortunately, Catalano et al.’s (1990/1991) review has several limitations. Catalano et al. (1990/1991), as well as several other reviewers of the adolescent literature (e.g. Newcomb and Bentler, 1989), have pointed out that the small number of treatment outcome studies makes conclusions very tentative. For comparison purposes, in the adult literature, there have been over 1000 studies on alcohol treatment (Miller et al., 1995). A second major problem concerns the poor methodological quality of the adolescent treatment studies that do exist. Small sample sizes, lack of post-treatment follow-up, poor follow-up rates, failure to include treatment drop-outs in the results, and lack of control groups are characteristic of many of these studies. Only four out the sixteen outcome studies cited by Catalano et al. (1990/1991) employed control groups. By contrast, Miller et al. (1995), in their review of alcohol treatment in adults, were able to draw on 219 controlled studies. A final problem with Catalano et al.’s (1990/1991) review concerns their selection of studies. In three studies the average age was 19 or older (DeJong and Henrich, 1980; Khuri, Millman, Hartman and Kreek, 1984; Roffman, Stephens, Simpson and Whitaker, 1988). Ten studies did not report substance use either at discharge or post-discharge (determination of factors affecting treatment outcome cannot be made unless treatment outcome is known) (e.g., Barrett, Simpson and Lehman, 1988; DeAngelis, Koon and Goldstein, 1978; Iverson, Jurs, Johnson and Rohen, 1978; Williams and Baron, 1982). Finally, Catalano et al. (1990/1991) did not include eight studies that were available at the time and would have been appropriate to include (i.e., Brown, Vik and Creamer, 1989; Feigelman, Hyman and Amann, 1988; Friedman, 1989; Harrison and Hoffman, 1987; Query, 1985; Szapocznik, Kurtines, Foote, Perez-Vidal and Hervis, 1983; Szapocznik, Kurtines, Foote, Perez-Vidal and Hervis, 1986; Vaglum and Fossheim, 1980). Fortunately, there have been many additional adolescent treatment outcome studies published since 1991. The purpose of the present paper is to provide a more comprehensive and updated review of this literature to re-examine treatment

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effectiveness and factors related to outcome. Only 13 out of the 53 studies in the present review were included in Catalano et al. (1990/1991).

Inclusion Criteria

Studies were found by consulting all prior reviews and by conducting keyword searches of the databases ETOH, PsycINFO, and Medline using the terms adolescent, youth, drug, alcohol, polydrug, substance abuse, therapy and treatment. All studies providing substance abuse treatment to adolescents that reported substance use results at discharge or post-treatment were included. Nonpublished studies were included, when available, because of the possibility that published studies might be biased toward higher quality programs and better results. Non-controlled studies were included because so few controlled studies exist. Studies were excluded from the review only if the average age of the clients was <13 or >19 (i.e., Baer et al., 1992; Bensen, 1985; DeJong and Henrich, 1980; Gorelick, Wilkins and Wong, 1989; Holsten, 1980; Khuri et al., 1984; Langrod, Alksne and Gomez, 1981; Nigam, Schottenfeld and Kosten, 1992; Roffman et al., 1988; Wilkinson and LeBreton, 1986), or if the sample size was 20 or less (i.e., Bry and Krinsley, 1992; Duehn, 1978; Frederiksen, Jenkins and Carr, 1976; Kaminer, 1992; Myers, Donahue and Goldstein, 1994; Smith, 1983; Vik, Grizzle and Brown, 1992).

Organization

Study characteristics and outcome are reported in Tables 1 and 2. Table 1 reports studies that combined results from different programs located in different sites (‘‘multi- site, multi-program studies”) and Table 2 reports single program studies. Each table describes, if available, the number of adolescents entering treatment, characteristics of the treatment population, characteristics of the treatment program(s), methodology used to obtain information on substance use, and results of treatment.

Number of studies and publication date

The first thing apparent from Tables 1 and 2 is the small total number of studies (n = 53). Although this is considerably more than identified by Catalano in 1991, it is still a small number compared to the number of adult studies. It is also a very small number when you consider that in 1991 there were over 3000 adolescent treatment programs in the United States (U.S. Department of Health and Human Services, 1993). One of the reasons for the small number is that research on adolescent substance abuse treatment is much more recent than research on adult substance abuse. Only 3 of the studies in the current review were published in the 1970’s, versus 19 in the 1980’s and 32 in the 1990’s.

Client characteristics

The treatment populations appear to be homogeneous. For studies reporting demographic features: 90% have an average age between 15-17 (ranging 14-19); in 96% of studies males comprise the majority (ranging 0-100%); and in 89% Caucasians comprise the majority (ranging 0-100%). Pattern of substance abuse is also fairly similar between studies. In the large majority of studies adolescents are polydrug users with alcohol and marijuana being the most commonly used substances. Finally, most studies

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identify high levels of associated family, school, legal and psychological problems. It is estimated that approximately half of substance-abusing adolescents have a comorbid DSM mental disorder (‘‘dually-diagnosed”) (Greenbaum, Foster-Johnson and Petrila, 1996). The only sub-populations that have been examined to any extent in these studies are conduct disordered youth (6 studies) and Hispanics (3 studies). It is important to note that the demographic characteristics of adolescents in these studies appear to be representative of the general adolescent treatment population in the United States (Friedman and Beschner, 1990; U.S. Department of Health and Human Services, 1995b) and also representative of the adolescent substance-abusing population (U.S. Department of Health and Human Services, 1997a).

Program Characteristics

In contrast to the homogeneity of the treatment population, there is great diversity in the types of programs. The main dimensions upon which they vary are their location (hospital or substance abuse treatment facility); their intensity (residential, day treatment, outpatient); their duration (few sessions to over a year); and their comprehensiveness. Comprehensiveness is reflected in whether the program is theoretically focused (e.g., 12 step, outward bound) or eclectic; whether it provides a limited or broad range of services (i.e., just substance abuse treatment or substance abuse treatment and recreational, occupational, educational, psychiatric services); and the number of modalities by which treatment is provided (e.g., group therapy or individual, group and family therapy).

Treatment programs can be roughly grouped into four main types, although there is considerable (and increasing) overlap between these programs. The most common type reported in this review, is the ‘‘Minnesota model’’. This is a short (4-6 week) hospital inpatient program typically offering a comprehensive range of treatment (individuaI counselling, group therapy, medication for comorbid conditions, family therapy, schooling, and recreational programming). This type of program sometimes also has an AA/NA 12 step orientation and is often followed by outpatient treatment (Winters et al., in press). Most of the large multi-site, multi-program treatment outcome studies such as the Treatment Outcome Prospective Study (TOPS) and the Chemical Abuse Treatment Outcome Registry (CATOR) have studied this type of program. The second most common type of treatment reported in this review are outpatient programs (e.g., Azrin, Donohue, Besalel, Kogan and Acierno, 1994; Lewis, Piercy, Sprenkle and Trepper, 1990). The focus is usually individual counselling, although sometimes family therapy and group treatment are also used. Alternatively, family therapy is sometimes the primary treatment modality. Outpatient treatment tends to be less intensive than hospital treatment (e.g. 1-2 sessions per week), but longer in duration. Treatment usually has no set length, varying anywhere from 1 session to 6 months, with a modal length of perhaps 3 months. A third, less common type of treatment, is a lengthy (6 month - 2 year) ‘‘therapeutic community’’ type program based in a specialized substance abuse treatment facility (Jainchill, Bhattacharya and Yagelka, 1995; Pompi, 1994). These tend to be highly regimented residential settings with treatment facilitated by paraprofessionals, but run by the residents themselves. Members progress through a hierarchy of responsibilities within this community of former substance abusers. In the older, traditional therapeutic communities, adolescents comprise only a small minority of the treatment population (e.g., Hubbard et al., 1985; Rush, 1979; Sells and Simpson, 1979). However, there are newer forms of this treatment that provide services

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exclusively to adolescents (e.g., Friedman, Schwartz and Utada, 1989; Feigelman et al., 1988). These programs retain the indoctrinational and highly structured nature of traditional therapeutic communities. However, they are often day programs where the recovering adolescent lives in the home of an adolescent further progressed in treatment. Because of their structured nature and length, these types of programs tend to have very high drop-out rates (in the present studies ranging from 34-90% with a median of 75%). A fourth type of program is the ‘‘outward bound’’/lifeskills training type program (e.g., McPeake, Kennedy, Grossman and Beaulieu, 1991; Richardson, 1996). This type of program is occasionally provided as the primary treatment, and sometimes as a supplement to other treatment types. It is typically an intensive 3 or 4 week outing that exposes adolescents to a non-drug lifestyle and presents them with challenges intended to facilitate personal development and resistance to drugs. In addition to these formal treatment programs, many high schools provide on- site group counselling for substance use and abuse. These programs are not included in the present review because they tend to target students in earlier stages of substance abuse and because there are virtually no published outcome studies (Wagner, Brown, Monti, Myers and Waldron, 1999).

The considerable variability in the types of treatment programs in the present review reflects the variability in adolescent treatment programs generally (U.S. Department of Health and Human Services, 1995b). However, it is important to note that the present studies are not proportionally representative of adolescent treatment programs. The most commonly studied program in the present review is the hospital inpatient program, whereas the large majority of adolescents in the United States are treated in outpatient programs, particularly self-help groups (Friedman and Beschner, 1990; U.S. Department of Health and Human Services, 1997a). It is also important to note that because 48 of the studies presented were conducted in the United States (4 in Canada, 1 in Norway), the results do not necessarily reflect international adolescent substance abuse treatment or outcome.

Methodology

The methodology used in these studies tends to be inconsistent. There is no standard time period at which outcomes are typically evaluated. Some studies have evaluated outcome at the end of treatment (e.g., Rush, 1979) while others have evaluated outcome as long at 6 years post-treatment (e.g., Feigelman et al., 1988). The most common time periods in the present studies are at discharge, 6 months post-treatment and 12 months post-treatment. Similarly, the window of time being assessed at outcome varies from ‘‘current use’’ (e.g., Grenier, 1985) to substance use in the previous 6 years (e.g., Feigelman et al., 1988). The most common assessment windows are time since discharge or the past year.

There are differences in how success is measured between studies. A common measure in the adolescent literature is abstinence rates (reported in 31 of the present studies). However, abstinence is arguably a less appropriate measure of success than reduction in substance use (reported in 31 of the present studies). Focusing on the fact that only a minority of people are abstinent following treatment and that the proportion of people with sustained abstinence declines with time disguises the fact that most people tend to have reduced substance use as a consequence of treatment as well as experiencing improvements in other areas of functioning (Agosti, 1995; Valliant, 1995).

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Secondly, while lifelong abstinence may be an appropriate long-term goal for an older person with many years of drug dependence, this is probably a less realistic or clinically essential goal for a 15 or 16 year old, at least with respect to substances such as alcohol. Finally, since substance abuse is typically associated with problems in various life areas (employment/school, social, legal, family, psychological, medical) it is reasonable to measure the impact of substance abuse treatment on these other areas, which was only done in 29 of the present studies. The usual motivation for treatment is not the substance use itself, but the impact that substance abuse is having on the person’s life. Although there is evidence that abstinence rates are highly correlated with drug reduction rates and improvements in other life areas, the relationship is far from perfect (Brown, Myers, Mott and Vik, 1994). The methodology in these studies also tends to be weak. The current standard used in evaluating treatment effectiveness is to report success rates for all individuals that the program intended to treat. It is useful to know the effectiveness of treatment for people who completed treatment versus people who dropped out prematurely. However, it is not appropriate to simply report success rates for people who completed treatment, as treatment completion is strongly associated with treatment success (Baekeland and Lundwall, 1975; Stark, 1992). Also, a high success rate with treatment completers is not particularly useful if only a small percentage of people actually complete treatment. Unfortunately, some of these studies, including the multi-program, multi-site CATOR study (Harrison and Hoffman, 1987; Hoffmann and Kaplan, 1991), have only reported results for treatment completers. A poor follow-up rate is another common problem. Adolescents who are difficult to contact or who refuse to participate in follow-up outcome studies are known to have significantly poorer outcomes than individuals who are easy to contact and cooperative (Stinchfield, Niforopulos and Feder, 1994). Forty-eight percent of the studies in this review have follow-up rates less than 75% of those entering treatment. Seventeen percent have rates below 50%. Ascertainment of substance use is a problematic issue. Many studies have relied exclusively on adolescent self-report for determination of substance use post-treatment. Adolescent self-report tends to be reasonably reliable and valid (Adair, Craddock, Miller and Turner, 1996; Smith, McCarthy and Goldman, 1995). However, this is influenced by the demand characteristics and memory requirements of the situation. Under reporting is characteristic of recent arrestees (Fendrich and Xu, 1994; Harrison, 1995; Magura and Kang, 1996); for less socially acceptable drugs (e.g., cocaine) (Lundy et al., 1997; Wish, Hoffman and Nemes, 1997); when parents are present (Aquilino, 1997); and when answers are given verbally (Aquilino, 1997; Turner, Lessler and Gfroerer, 1992). Similarly, individuals tend to be less honest about substance use after treatment than before treatment (Wish et al., 1997), with repeated assessments being associated with progressively less honest reporting (Fendrich, Mackesy-Amiti, Wislar and Goldstein, 1997). Retrospective reports are influenced by current substance use status, with higher reports of retrospective use being associated with higher current use and vice versa (Czarnecki, Russell, Cooper and Salter, 1990; Collins, Graham, Hansen and Johnson, 1985).

It is preferable to provide some corroboration of adolescent self-report. Some studies have done this by means of parental report. The problem with this is that parental awareness of adolescent substance use tends to be quite poor (Friedman, Glickman and Morrissey, 1990; Williams, McDermitt and Bertrand, submitted for publication). Establishing that substance use is occurring by means of a positive report

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by either the adolescent or parent may improve validity, but procedures that require a positive report by both the adolescent and parent likely decrease validity. Studies in the present review that have relied exclusively on parental report (Ralph and McMenamy, 1996; Knapp, Templar, Cannon and Dobson, 1991; Grenier, 1985) have questionable validity. Other studies have corroborated adolescent self-report through urinalysis drug testing (Azrin et al, 1994; Feigelman et al., 1988; Jenson, Wells, Plotnick, Hawkins and Catalano, 1993; Joanning, Quinn, Thomas and Mullen, 1992; Lewis et al, 1990; Liddle et al., 1993 (as cited in Stanton and Shadish, 1997)). Here again, although a positive drug testing result almost always indicates use, a negative result does not reliably indicate lack of use as many substances (e.g. cocaine, alcohol) are quickly metabolized and will not show up in urine unless testing is done within 1-2 days of use. A final problem concerns how long to wait after discharge to evaluate treatment effectiveness. Evaluations done at the end of treatment, or shortly thereafter, tend to overestimate the enduring effects of treatment (Miller and Sanchez-Craig, 1996). However, very long follow-up periods may also distort the effects of treatment depending on age of follow-up. Longitudinal studies consistently show a steady increase in prevalence of drug and alcohol use peaking in the late teens to early 20’s and diminishing significantly thereafter (Fillmore, 1988; Kandel and Logan, 1984; Kandel and Raveis, 1989; Labouvie, 1996; Pape and Hammer, 1996). Diminished use in the mid to late 20’s is thought to occur because adult roles (jobs, marriage, parenting) become incompatible with continued substance use (Kandel and Raveis, 1989; Labouvie, 1996). These trends are even more pronounced for heavy substance use and are consistent across various historical periods (Kandel and Logan, 1984; Pape and Hammer, 1996). Therefore, it should not be surprising that studies in the present review that have done follow-up in the late teens or early 20’s show very low rates of substance reduction or even increases (e.g., Sells and Simpson, 1979; U.S. Department of Health and Human Services (SROS); 1998; Marzen, 1990). By comparison, studies providing follow-up in the mid 20’s tend to show fairly high rates of abstinence and substance reduction (e.g., Richardson, 1996; Vaglum and Fossheim, 1980). This issue of natural recovery illustrates the need for control groups. Without a control group it is impossible to attribute improvements to the treatment rather than natural recovery or a placebo effect. Reid Hester, who, along with William Miller, have been pre-eminent researchers in adult alcohol abuse treatment, has commented that ‘‘......one of the most important lessons we learned from this (treatment outcome research) was the value of controlled clinical trials. Historically, a number of treatments have been introduced with glowing results from case studies and uncontrolled clinical trials only to have subsequent controlled studies find that the new treatment did not contribute in any significant way to outcome’’ (Hester, 1994, p.36). Only 14 studies in the present review had comparison groups with either random or matched assignment to condition (Amini, Zilberg, Burke and Salasnek, 1982; Azrin et al., 1994; Braukmann et al., 1985; Friedman, 1989; Grenier, 1985; Hennggeler et al., 1991; Joanning et al., 1992; Kaminer, Burleson, Blitz, Sussman and Rounsaville, 1998; Lewis et al., 1990; Liddle et al., 1993 (as cited in Stanton and Shadish, 1997); Scopetta, King, Szapocznik and Tillman, 1979 (as cited in Waldron, 1997); Szapocznik et al., 1983; Szapocznik et al., 1986; Vaglum and Fossheim, 1980).

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Results

Studies with serious methodological problems were excluded from the results

section. Specifically, studies were excluded if drop-outs were not included in the results, if follow-up rates were less than 75%, if only parental report was used to establish substance use, or if the average age of the treatment group was > 21 at time of follow-up. The following results are based on the 21 remaining studies (#’s 1, 3, 5, 7, 11, 12, 15, 16, 17, 18, 19, 24, 28, 34, 36, 39, 42, 43, 47, 49, 52).

Sustained Abstinence Eight studies reported abstinence rates at discharge or post-discharge (7, 16, 17, 18, 19, 39, 42, 47), with four of them assessing abstinence at more than one time period (16, 17, 42, 47). Figure 1 is a graphic presentation of these results. The one multi-site, multi-program study is identified, as are studies with repeated measures. The only time periods with more than two data points are 6 months and 12 months. Average sustained abstinence at 6 months is 38% (range 30-55) and 32% at 12 months (range 14-47)1.

Although there appears to be some tendency for abstinence rates to decrease with time since discharge, the amount of decrease is fairly small. Richter, Brown and Mott’s (1991) repeated measures study actually obtained a slight increase due to sampling differences between the two time periods. The one study reporting abstinence at discharge (Lewis et al., 1990) found only 39-40% of adolescents receiving outpatient family therapy or family education were abstinent by the end of treatment. This low rate of abstinence at discharge is also found in the outpatient studies not included in the review because of having methodological weaknesses potentially inflating success (studies 9, 13, 35, 48 have an average abstinence rate of 44% at discharge). Brown et al. (1989) and Brown et al. (1990) have reported that 2/3rds of adolescent relapse occurs in the first three months post-treatment (see also Brown, 1993). While this might be true for the short inpatient programs Brown and her colleagues have studied, it does not appear to be the case for outpatient programs, where only a minority of adolescents actually achieve abstinence by the end of treatment.

Reduced Substance Use

Thirteen studies reported the percentage of adolescents with decreased substance use following treatment (3, 12, 15, 16, 18, 36, 39, 42, 47, 49, 52) or the average group decrease in substance use (1, 24). In 12 out of 13 studies there was a reduction in substance use following treatment. Braukmann et al. (1985) did not find group homes or teaching family group homes to reduce substance use in conduct disordered males. Most studies did not quantify the extent to which substance use had been reduced. Friedman, Glickman and Morrissey (1986), in their examination of 30 outpatient programs (sample of 5603), reported that average drug usage at discharge decreased to approximately 50% of pre-treatment levels. Friedman (1989) reported a 50% reduction in average drug usage at 9 months post-treatment for adolescents in family therapy groups as well as adolescents whose parents attended parent support groups. In Lewis et al. (1991), 38% of adolescents receiving outpatient family education reported reduced substance use at discharge and 55% receiving family therapy reported reduced

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substance use. At 6 months post-discharge 57% of adolescents reported reduced substance use in the inpatient programs studied by Brown et al. (1990) and by Richter et al. (1991). At 12 months post-discharge 51-55% of adolescents reported reduced marijuana use in the multi-site, multi-program DATOS-A study (Hser, Grella, Hsieh and Anglin, 1999) and 62% reported reduced substance use in Richter et al. (1991). Functioning in Other Life Areas

Eight studies evaluated the effect of treatment on other aspects of the adolescent’s life (1, 3, 7, 12, 15, 24, 42, 52). Most of these studies simply reported whether there were group improvements as a result of treatment and did not indicate the degree of improvement. Four out of the 5 studies that examined iIlegal behaviour found decreases following treatment, with Braukmann et al. (1985) being the exception. Sixteen to 30% fewer adolescents committed an illegal act in the previous year compared to the year before treatment in the multi-site, multi-program DATOS-A study (Hser et al., 1999). Forty-one to 48% fewer adolescents committed an illegal act in the previous year compared to the year before treatment in the multi-site, multi-program NTIES study (U.S. Department of Health and Human Services, 1997b). The four studies that examined change in mental health all found improvements following treatment. The three studies examining change in family problems all found improvement following treatment. Two of the 3 studies examining school functioning reported improvements. Friedman, Glickman and Morrissey (1986) did not find improved school functioning in their study of 30 different outpatient programs but did find improvements in employment following treatment. Type of Treatment It would be interesting to compare treatment outcome between treatment types. The above results are general findings across outpatient programs, outward-bound programs, short-term inpatient, and long-term residential programs. Unfortunately, there is an insufficient number of each type of program to make comparisons. Even if there were, the lack of randomized controlled studies would prevent any definitive conclusions. The randomized controlled studies that have been done have focused primarily on types of outpatient treatment (see below). No controlled studies have investigated the relative merits of the major treatment types, treatment setting, treatment length, or intensity. Controlled Comparisons The evidence presented thus far indicates that the majority of adolescents who enter into substance abuse treatment have significantly reduced substance usage and significant improvements in life functioning in the year subsequent to treatment. However, in the absence of no-treatment control groups, the extent to which this improvement is due to treatment, as opposed to natural recovery, regression to the mean, or a placebo effect, is uncertain. There are only two studies that provide evidence on this issue. Braukmann et al. (1985) compared the effectiveness of group home treatment on male conduct disordered youth to a no-treatment group of matched friends. Although teaching-family group homes produced superior drug reductions during treatment, at 3 month follow-up there was no significant difference between the

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treatment group and no-treatment group. Grenier (1985) compared a wait control group to a random sample of former patients in a hospital inpatient program. At 9 months post-treatment, 66% of the treatment group were not currently using drugs versus only 20% of the control group. Unfortunately, only parental report was used in the no- treatment group (versus adolescent and parental report in the treatment group) and the follow-up rate for the no-treatment group was only 36%. However, these methodological problems would normally tend to inflate improvement rates. There have been 13 studies comparing the effectiveness of one treatment type against another. A few of these studies employed conditions that could be construed as no-treatment controls. For example, Amini et al. (1982) compared the effectiveness of 132 day residential drug abuse treatment versus outpatient probation. One year after entering treatment significant decreases in substance use and antisocial behaviour were found in both groups, but there was no significant difference between the groups. Hennggeler et al. (1991) compared four months of multisystemic family therapy to monthly meetings with a probation officer for conduct disordered youth in South Carolina. At discharge adolescents receiving family therapy had significantly lower marijuana and alcohol use in the previous 3 months as compared to adolescents who just met with their probation officer. Vaglum and Fossheim (1980) compared three different 5-6 month inpatient drug treatment programs for youths in Norway to a control group of individuals treated on other psychiatric wards. At 3 years post-treatment, they found 24% abstinent in group 1, 56% in group 2, 45% in group 3, and 27% in the control group (reduced drug use in 41%, 82%, 81% and 56% respectively). At 4.5-5.5 years post- treatment they found 41% abstinent in group 1, 63% in group 2 and 38% in the control group (reduced drug use in 65%, 85%, and 61% respectively). Other studies made comparisons between treatments that were both presumed to have beneficial effects on drug abuse. Braukmann et al. (1985) compared teaching- family group homes to non-teaching family group homes for male conduct disordered youth. Teaching-family homes specifically taught adaptive skills in the areas of relationship development and self-discipline. Teaching-family group homes produced superior drug reductions during treatment, but there was no difference at 3 month follow-up. Azrin et al. (1994) compared 15 sessions of supportive counselling to 15 sessions of behavioural treatment (intended to restructure family and peer relations and improve urge control) in a small group of 26 adolescents. At the end of treatment only 9% of the adolescents receiving counselling were abstinent versus 73% in the behavioural group. Superior improvements in school/work attendance, family relations, and mood were also found in the behavioural group. Kaminer et al. (1998) compared a small group receiving 2-3 weeks of inpatient group therapy followed by 12 weeks of outpatient cognitive-behavioural group therapy to a small group receiving 2-3 weeks of inpatient group therapy followed by 12 weeks of outpatient interactional group therapy. Three months after treatment, he found significantly greater substance use reduction in the group receiving the cognitive-behavioural training. Several studies compared family therapy to other substance abuse treatments. Hennggeler et al. (1991) found that at 4 years post-treatment family therapy produced significantly lower drug-related arrests compared to individual counselling for a group of conduct disordered youth in Missouri. Friedman (1989) found no difference in substance use at 9 months post-treatment between a group of adolescents receiving 6 months of outpatient family therapy versus a group whose parents enrolled in a 6 month parent support group. Joanning et al. (1992) compared 7-15 sessions of family therapy to 12 sessions of adolescent group therapy and to 6 sessions of family drug education.

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Substance use at discharge was found to be significantly lower in the family therapy condition compared to the other two conditions. Liddle et al. (1993) (as cited in Stanton and Shadish, 1997) compared 16 sessions of family therapy to 16 sessions of family psychoeducation to 16 sessions of adolescent peer group treatment. At 6 and 12 months post-treatment family therapy was more effective at reducing substance abuse and improving school grades than either peer group treatment or multifamily psychoeducation group. Lewis et al. (1990) compared 12 session family therapy to 12 sessions of family education. At discharge greater substance use reduction was found in the family therapy group, but there were no differences in abstinence rates. Scopetta et al. (1979) (as cited in Waldron, 1997) compared family therapy to family therapy plus systems intervention in a small sample of 33 Hispanic youths. No difference in abstinence rates were observed at discharge. Szapocznik et al. (1983) and Szapocznik et al. (1986) compared family therapy to ‘‘one-person family therapy” where the therapist attempted to change the family system through working with one family member. Both techniques produced reductions in substance use at discharge and 6-12 month follow-up with no significant differences in effectiveness between the conditions. Table 3 is a summary of all controlled comparisons and their results. To summarize, there have been an insufficient number of studies comparing treatment to no treatment. On the other hand, a treatment effect above and beyond natural recovery, placebo response, or regression to the mean is implied by the fact that 9 out of 15 treatment comparisons found an advantage for one type of treatment over another (9 out of 12 if eliminating the three studies comparing variants of family therapy).

There are no well-designed studies providing comparisons between the main treatment types (outpatient, short-term inpatient, long-term residential, outward bound). However, there are several studies comparing variants of outpatient treatment. There is preliminary evidence that behavioural or cognitive-behavioural treatment may be superior to supportive counselling (Azrin et al., 1994) or interactional group therapy (Kaminer et al., 1998). There is good evidence that family therapy may be superior to other outpatient treatments. Family therapy was more effective than other forms of non- family outpatient treatment (individual counselling, adolescent group therapy, family drug education, meetings with probation officer) in five out of six studies. The only comparison finding no difference was with parent support groups. There is no evidence to date that one type of family therapy is superior to other types of family therapy. The superiority of family therapy in substance abuse treatment has also been identified in a couple of recent reviews of the general family therapy literature (Stanton and Shadish, 1997; Waldron, 1997). Variables associated with successful treatment The variables associated with treatment success are reported in Table 4. The table identifies the variable, studies finding it to be related to decreased substance use post-treatment, and studies finding it not to be related to decreased substance use. Variables are divided into pre-treatment, treatment, and post-treatment variables. Studies were excluded from the table if they did not use adolescent report, had follow-up rates <75%, or if they did not include drop-outs.

The pre-treatment variable with the most consistent relationship to positive outcome is lower pre-treatment substance use, found in 6 out of 7 studies. Peer and parental social support, particularly in their nonuse of substances, was related to positive outcome in the three studies examining this. Better school attendance and functioning at

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pre-treatment was related to success in 3 out of 4 studies. Other variables with some evidence of a relationship to success are less conduct disorder, being employed, greater motivation for treatment, having fewer prior substance abuse treatments, and less psychopathology. Studies examining demographic variables have not found these variables to be consistently related to outcome. Treatment completion is the treatment variable with the most consistent relationship to positive outcome. However, it is unclear whether this reflects the impact of treatment or is just another indicator of motivation. Larger programs with larger budgets, therapist experience, and program comprehensiveness (i.e., provision of schooling, vocational counselling, recreational activities, birth control, etc.) were predictive of better outcome in a comprehensive analysis of 30 treatment programs (sample of 5603) by Friedman and Glickman (1986). (Number of different services received has also been shown to be robustly associated with outcome for adults (McLellan et al., 1994)).

Post-treatment variables related to a positive outcome are attendance in aftercare (motivational or treatment effect?), having nonusing parents and peers, and having better relapse coping skills. Prior analyses have found post-treatment variables to be the most powerful predictors of post-treatment outcome in adolescents (Shoemaker and Sherry, 1991). However, to some extent this is to be expected, as many post-treatment variables are reflections of successful treatment (e.g., better coping skills, association with nonusing peers, decreased interpersonal conflict, etc.).

Summary

A comprehensive review of the literature on the effectiveness of adolescent substance abuse treatment identified 8 multi-program, multi-site studies and 45 single program studies. Client characteristics have been similar between studies and representative of the adolescent treatment population in the United States as a whole. Treatment programs are diverse, however. The three main types of treatment are hospital inpatient, outpatient therapy, and therapeutic community programs. Published reports on hospital inpatient programs are over-represented in the literature relative to their actual use in treatment. The methodology used in treatment outcome research studies is inconsistent with regards to the time period at which outcome is evaluated, the number of prior months of substance use being assessed, and how success is measured. Reduction in substance use is a more appropriate measure of success than abstinence, but is only reported in 50% of studies. The methodology in treatment outcome studies also tends to be weak. The most common problems are poor follow-up rates, lack of control groups, failure to include drop-outs in the results, reliance on parental rather than adolescent report, and follow-up periods that are either too short (at discharge) or too long (>3 years). Methodologically stronger studies have usually found most adolescents receiving treatment to have significant reductions in substance use and problems in other life areas in the year following treatment. Sustained abstinence averages 38% (range 30-55) at 6 months post-treatment and 32% at 12 months (range 14-47). Pre- treatment variables most consistently related to successful outcome are lower substance use, peer/parental social support, and better school functioning. Treatment variables most consistently related to successful outcome are treatment completion, programs that provide comprehensive services, programs with experienced therapists, and larger programs with larger budgets. Post-treatment variables most consistently related to outcome are attendance in aftercare and peer/parental social support. There is evidence

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that treatment is superior to no treatment, but insufficient evidence to compare the effectiveness of treatment types. The exception to this is that outpatient family therapy appears superior to other forms of outpatient treatment. There is no evidence concerning the relative merits of treatment setting, treatment length, treatment intensity, treating homogenous versus heterogeneous populations, or whether certain types of adolescents are best treated by certain types of programs.

Implications and Recommendations

The most obvious implication of the present review is that more and better- designed studies need to be conducted. There is a particular need for randomized controlled studies to compare treatment against no treatment and to investigate the advantages of treatment types, length, setting, intensity, population homogeneity, and patient-treatment matching. It is recommended that these studies have the following methodological characteristics: 1. The treatment population the program intended to treat should be described in terms

of how they were selected, average age, gender, race/ethnicity, psychopathology, exclusionary criteria, baseline substance use, and baseline measure(s) of problems in other life areas.

2. Substance use should be established by adolescent self-report along with some type of corroboration (i.e., biochemical analysis, third party report). Validity will be enhanced if procedures are used that provide privacy, confidentiality and/or anonymity (e.g., self-administered questionnaires, interviews conducted by individuals not connected with treatment). Validity will also be enhanced if procedures are used that minimize recall artifact. An example of this is the Time-Line Follow-Back procedure (Sobell and Sobell, 1996) which provides the person with a calendar with important dates as anchors and asks him/her only to recall which days/weeks which substances were used, rather than to estimate overall averages or frequencies. The time window being assessed should include a past month measure (in addition to possibly a 6 or 12 month measure), to minimize recall artifact and to allow for biochemical corroboration. Baseline measure(s) of problems in other life areas should be obtained in a similar fashion.

3. The nature of the treatment should be described in terms of its length, intensity, setting, therapist characteristics, and components (i.e., groups, individual therapy, schooling, recreational programming, medication, parent support, aftercare).

4. Outcome evaluation should take place at time periods commonly used by other studies to allow for comparison and accumulation of data. Evaluation at 6 and 12 months post-treatment is currently recommended. Documentation of the dropout rate, dropout characteristics, and follow-up rate is needed. Efforts need to be made to ensure follow-up rates above 75%, perhaps through financial incentives (e.g., Richter et al., 1991; Shoemaker and Sherry, 1991; Hser et al., 1999). When sample sizes are large it may be preferable to exhaustively follow a small random sample (e.g. 50%) than to obtain low follow-up rates for the entire sample.

5. Post-treatment substance use and problems in life areas should be established in the same manner used at baseline. Results should report reduction in substance use, reduction of problems in other life areas, and abstinence. These results should be reported separately for the entire sample and for treatment completers.

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It is much more difficult to make programmatic recommendations on the basis of the limited evidence available. However, the evidence suggests a few things. 1. Because treatment appears preferable to no treatment, programs should strive to be readily accessible and able to provide treatment for large numbers of people. 2. Programs should develop procedures to minimize treatment dropout and to maximize treatment completion. 3. Programs should attempt to provide or arrange for post-treatment aftercare. 4. Programs should attempt to provide comprehensive services in areas other than just substance abuse (i.e., schooling, psychological, vocational, recreational, medical, family, legal). 5. Family therapy should be a component of treatment. 6. Programs should encourage and develop parent and peer support, especially in regards to nonuse of substances.

There is insufficient evidence to make recommendations about other aspects of

treatment. However, there are two others areas of related research that may provide some guidance. One is adult substance abuse treatment and the other is treatment for adolescent emotional/behavioural problems. Both of these areas have clearly established that treatment is superior to no treatment (Agosti, 1995; Hoag and Burlingame, 1997; Kazdin, 1990; Mann and Borduin, 1991; Miller et al., 1995; Target and Fonagy, 1996; U.S. Department of Health and Human Services, 1995a; Weisz, Weiss, Han, Granger and Morton, 1995).

With regards to treatment setting (outpatient, residential, inpatient), adult substance abuse research has found a slight advantage for inpatient over outpatient treatment in some circumstances (Annis, 1996; Finney, Hahn and Moos, 1996; Longabaugh, 1996). The impact of treatment setting on adolescent emotional/behavioural problems is less well researched, but evidence to date has not found any differential impact on outcome (Bates, English and Kouidou-Giles, 1997; Curry, 1991).

Duration of treatment also has a weak effect on outcome. A review of brief interventions for alcohol problems has found them often to be as effective as more extensive treatment (Bien, Miller and Tonigan, 1993). It also appears that short hospital stays and time-limited therapy do not adversely affect mental health outcome for most people (Johnston and Zolese, 1999; Pfeiffer, O’Malley and Shott, 1996; Steenbarger, 1994).

Type of treatment is important. When treatment advantages have been found for alcohol abuse they have favoured a community reinforcement approach (because of its comprehensiveness and behavioural orientation?), behavioural contracting, social skills training and motivational enhancement (Miller et al., 1995). Behavioural treatment is superior to nonbehavioural treatment for adolescent emotional/behavioural problems (Target and Fonagy, 1996; Weisz et al., 1995). Family therapy appears particularly effective for conduct disordered youth (Mann and Borduin, 1991; Target and Fonagy, 1996).

In general, therapist experience, training and professional discipline have a very weak relationship to mental health treatment outcome (Roth and Fonagy, 1996; Smith et al., 1980; Weiss et al., 1995), although experience may enhance client retention and improve outcome for more severely disturbed patients (Roth and Fonagy, 1996). Much more important than training or experience is the quality of the therapeutic relationship between therapist and client (Horvath and Symonds, 1991; Morris and Nicholson, 1993;

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Roth and Fonagy, 1996). This is believed to be fostered through therapist qualities of flexible/intelligent thinking, good interpersonal skills, and genuine empathy (Lazarus, 1993; Miller, 1993; Miller et al., 1995; Mohr, 1995; Najavits and Weiss, 1994).

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26

Author Note

Robert J. Williams, Addiction Centre, Foothills Medical Centre; Samuel Y. Chang,

Addiction Centre, Foothills Medical Centre; Addiction Centre Adolescent Research Group (ACARG): Brian Cram and Mark Lagimodiere, Addiction Centre, Foothills Medical Centre.

The authors would like to thank Nady el-Guebaly and David Hodgins for useful critiques of earlier drafts of this paper.

Correspondence concerning this article should be addressed to Dr. Robert J. Williams, Addiction Centre, Foothills Medical Centre, 6th Floor North Tower, 1403-29th Street NW; Calgary, Alberta, CANADA, T2N 2T9. Electronic mail may be sent to [email protected].

27

Footnotes 1 Abstinence rates are similar when all 53 studies are included: average of 39%

abstinence at discharge, 37% at 6 months, and 35% at 12 months.

59

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1 y

r pr

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•

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w ith

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p as

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r pr

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le ga

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•

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w ith

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1 yr

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% w

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ny h

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w ith

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9 8%

1 yr

p re

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• 20

% h

ea vy

d rin

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in p

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m pa

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to 3

3% 1

y r

pr e-

tx

• 28

% w

ith a

ny h

ar d

dr ug

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in p

as t y

r co

m pa

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to 5

4% 1

y r

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• 48

% c

om m

itt ed

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ga l a

ct in

p as

t y r c

om pa

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8% 1

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tx

H

ub ba

rd ,

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gh ,

C ra

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R

ac ha

l (1

98 5)

T

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S

4a

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an do

m

se le

ct

fr om

33

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57 %

< 18

& 4

3% 1

8- 19

; 66

% m

al e;

8 6%

w hi

te ;

m os

t p ol

yd ru

g us

er s;

1 4%

pr

io r

dr ug

tx ; 2

8% le

ga l

pr es

su re

fo r

tx

11 p

ub lic

ly fu

nd ed

ou

tp at

ie nt

p ro

gr am

s;

U S

A

• 24

0 S

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R o

f A a

t 1 y

r po

st -t

x

1 ye

ar fo

llo w

-u p

• de

cr ea

se s

in m

os t d

ru g

us e

in p

re vi

ou s

ye ar

, a lth

ou gh

le ss

th an

o bt

ai ne

d fo

r re

si de

nt ia

l t x;

in cr

ea se

s in

u se

fo r

in di

vi du

al s

in tx

< 3

m o

• in

cr ea

se in

c rim

in al

a ct

iv ity

; i nc

re as

e in

fu ll-

tim e

w or

k ex

ce pt

1 8-

19 y

r ol

ds in

tx

<3 m

o; d

ec re

as e

in s

ui ci

da l t

ho ug

ht s

• 33

% tx

d ro

p- ou

t r at

e

4b

40 2

(r an

do m

se

le ct

fr

om

33 89

)

50 %

< 18

& 5

0% 1

8- 19

; 70

% m

al e;

7 8%

w hi

te ;

m os

t p ol

yd ru

g us

er s;

2 6%

pr

io r

dr ug

tx ; 3

9% le

ga l

pr es

su re

fo r

tx

14 p

ub lic

ly fu

nd ed

re

si de

nt ia

l p ro

gr am

s,

m os

tly th

er ap

eu tic

co

m m

un iti

es ;

77 d

ay s

m ed

ia n

tim e

in tx

; U

S A

• 64

% in

cl ud

ed in

1 y

r po

st -t

x fo

llo w

-u p

(N R

S )

1 ye

ar fo

llo w

-u p

• de

cr ea

se in

u se

fo r

al l s

ub st

an ce

s in

p re

vi ou

s ye

ar

• de

cr ea

se in

c rim

in al

a ct

iv ity

; in

cr ea

se in

fu ll-

tim e

w or

k ex

ce pt

1 8-

19 y

r ol

ds in

tx

<3 m

o; d

ec re

as e

in s

ui ci

da l t

ho ug

ht s

• va

ria bl

es r

el at

ed to

s uc

ce ss

: tim

e in

tx

• 90

% tx

d ro

p- ou

t r at

e

R us

h (1

97 9)

U

D C

S

5a

24 17

<1

8; 5

5% m

al e;

8 7%

w

hi te

; 4 7%

m ul

ti- dr

ug

us er

s; 1

5% p

rio r

tr ea

tm en

t; 14

% w

ith

co nv

ic tio

ns

ou tp

at ie

nt s

fr om

a ll

pu bl

ic P

en ns

yl va

ni a

dr ug

tr ea

tm en

t f ac

ili tie

s;

12 3

da ys

m ed

ia n

tr ea

tm en

t t im

e; U

S A

• �p

ro du

ct iv

ity �

(e ith

er in

s ch

oo l,

in tr

ai ni

ng p

ro gr

am o

r em

pl oy

ed )

at d

is ch

ar ge

as

se ss

ed

• 75

% in

cl ud

ed in

a na

ly si

s

D is

ch ar

ge

• va

ria bl

es r

el at

ed to

s uc

ce ss

: st

ro ng

es t p

re di

ct or

w as

b ei

ng in

s ch

oo l a

t ad

m is

si on

, w ea

ke r,

b ut

a ls

o si

gn ifi

ca nt

p re

di ct

or s

w er

e be

in g

em pl

oy ed

a t

ad m

is si

on , b

ei ng

o ld

er w

he n

fir st

b eg

an u

si ng

d ru

gs a

nd h

av in

g fe

w er

fe lo

ny

co nv

ic tio

ns a

t a dm

is si

on

13

60

18 &

1 9

ag e;

7 0%

m al

e;

81 %

w hi

te ; 5

1% m

ul ti-

dr ug

u se

rs ; 2

7% p

re vi

ou s

tr ea

tm en

t; 30

% w

ith

co nv

ic tio

ns

ou tp

at ie

nt s

am pl

e; 1

00

da ys

m ed

ia n

tr ea

tm en

t •

�p ro

du ct

iv ity

� at

d is

ch ar

ge

as se

ss ed

•

87 %

in cl

ud ed

in a

na ly

si s

D is

ch ar

ge

• va

ria bl

es r

el at

ed to

s uc

ce ss

: st

ro ng

es t p

re di

ct or

w as

b ei

ng e

m pl

oy ed

a t

ad m

is si

on ; w

ea ke

r, b

ut a

ls o

si gn

ifi ca

nt w

er e

sc ho

ol s

ta tu

s at

a dm

is si

on , b

ei ng

w

hi te

, a nd

le ng

th o

f t im

e in

tr ea

tm en

t

61

5 b

50 3

<1 8;

7 0%

m al

e; 8

8%

w hi

te ; 7

6% m

ul ti-

dr ug

; 36

% p

rio r

tr ea

tm en

t; 39

%

w ith

c on

vi ct

io ns

th er

ap eu

tic c

om m

un ity

sa

m pl

e; 3

6 da

ys

m ed

ia n

tr ea

tm en

t

• �p

ro du

ct iv

ity �

at d

is ch

ar ge

as

se ss

ed

• 97

% in

cl ud

ed in

a na

ly si

s

D is

ch ar

ge

• va

ria bl

es r

el at

ed to

s uc

ce ss

: at

te nd

in g

sc ho

ol a

t a dm

is si

on , l

en gt

h of

ti m

e in

tr

ea tm

en t,

an d

nu m

be r

of y

ea rs

in s

ch oo

l

45

8 18

& 1

9 ag

e; 7

9% m

al e;

80

% w

hi te

; 5 9%

m ul

ti- dr

ug ; 4

5% p

re vi

ou s

tr ea

tm en

t; 50

% w

ith

co nv

ic tio

ns

th er

ap eu

tic c

om m

un ity

sa

m pl

e; 3

4 da

ys

m ed

ia n

tr ea

tm en

t

• �

pr od

uc tiv

ity �

at d

is ch

ar ge

as

se ss

ed

• 97

% in

cl ud

ed in

a na

ly si

s

D is

ch ar

ge

• va

ria bl

es r

el at

ed to

s uc

ce ss

: tim

e in

tx b

es t p

re di

ct or

; f ol

lo w

ed b

y em

pl oy

m en

t at

a dm

is si

on , a

tte nd

in g

sc ho

ol a

t a dm

is si

on , m

or e

fe lo

ny a

rr es

ts p

rio r

to tx

S el

ls &

S

im ps

on

(1 97

9) D

A R

P

6a

27

45

72 %

< 17

; 6 3%

m al

e; 8

5%

w hi

te ;

31 %

o pi

at e

us er

s;

10 %

p rio

r tx

1. d

oz en

s of

p ub

lic

ou tp

at ie

nt p

ro gr

am s;

10

8 da

ys m

ed ia

n tim

e in

tx

2. c

on tr

ol g

ro up

o f 3

8 w

ho c

ho se

n ot

to

en te

r tx

U S

A

• S

R o

f A d

ur in

g tx

a nd

4 -6

y r

po st

tx

• st

ra tif

ie d

sa m

pl e

of 1

58

in cl

ud ed

in fo

llo w

-u p

(7 6%

o f

in te

nd ed

s am

pl e)

D ur

in g

tr ea

tm en

t •

si gn

ifi ca

nt r

ed uc

tio ns

in s

ub st

an ce

u se

( pa

rt ic

ul ar

ly o

pi od

s) a

nd c

rim in

al ity

w ith

so

m ew

ha t s

m al

le r

im pr

ov em

en ts

in p

ro du

ct iv

e ac

tiv iti

es (

ho m

em ak

in g,

s ch

oo l),

em

pl oy

m en

t, et

c. ; m

os t i

m pr

ov em

en t o

cc ur

re d

in fi

rs t 2

m on

th s

• va

ria bl

es r

el at

ed to

s uc

ce ss

: tim

e in

tx s

tr on

gl y

pr ed

ic tiv

e; n

on cr

im in

al ity

4-

6 ye

ar fo

llo w

-u p

• 85

% a

bs tin

en t f

ro m

o pi

at es

; 1 4%

fr om

a lc

oh ol

; 3 4%

fr om

m ar

iju an

a; 7

1% fr

om

ot he

r no

no pi

od s

in p

re vi

ou s

2 m

o; d

ec re

as e

in o

pi od

u se

, n on

op io

d us

e, m

in or

de

cr ea

se s

in m

ar iju

an a

an d

al co

ho l u

se c

om pa

re d

to 2

m o

pr e-

tx ; �

co nt

ro l

gr ou

p� to

o di

ss im

ila r

to m

ak e

co m

pa ris

on s

(h ig

he r

pr e-

tx o

pi od

u se

a nd

de

lin qu

en t a

ct iv

ity )

• in

cr ea

se in

e m

pl oy

m en

t a nd

p ro

du ct

iv e

ac tiv

iti es

, d ec

re as

e in

a rr

es ts

in 2

pr

ev io

us m

o co

m pa

re d

to 2

m o

pr io

r to

tx

• va

ria bl

es r

el at

ed to

s uc

ce ss

: tim

e in

tx ; l

es s

pr e-

tx s

ub st

an ce

u se

•

48 %

tx d

ro p-

ou t r

at e

6

b 12

22

46 %

< 17

; 6 3%

m al

e; 7

1%

w hi

te ; 7

3% o

pi at

e us

er s;

16

% p

rio r

tx

1. d

oz en

s of

p ub

lic

re si

de nt

ia l p

ro gr

am s

in cl

ud in

g th

er ap

eu tic

co

m m

un iti

es ,

m et

ha do

ne

m ai

nt en

an ce

, a nd

de

to xi

fic at

io n;

9 0

da ys

m ed

ia n

tim e

2.

c on

tr ol

g ro

up o

f 3 8

w ho

d id

n ot

a tte

nd tx

U S

A

• S

R o

f A d

ur in

g tx

a nd

4 -6

y r

po st

tx

• st

ra tif

ie d

sa m

pl e

of 2

38

in cl

ud ed

in fo

llo w

-u p

(7 6%

o f

in te

nd ed

s am

pl e)

D ur

in g

tr ea

tm en

t •

si gn

ifi ca

nt r

ed uc

tio ns

in s

ub st

an ce

u se

( pa

rt ic

ul ar

ly o

pi od

s) a

nd c

rim in

al ity

w ith

so

m ew

ha t s

m al

le r

im pr

ov em

en ts

in p

ro du

ct iv

e ac

tiv iti

es , e

m pl

oy m

en t,

et c.

; m os

t im

pr ov

em en

t o cc

ur re

d in

fi rs

t 2 m

on th

s •

m et

ha do

ne m

ai nt

en an

ce h

ad g

re at

er im

pr ov

em en

ts th

an o

th er

tx

• va

ria bl

es r

el at

ed to

s uc

ce ss

: tim

e in

tx s

tr on

gl y

pr ed

ic tiv

e; w

hi te

4-

6 ye

ar fo

llo w

-u p

• 91

% a

bs tin

en t f

ro m

o pi

at es

; 1 0%

fr om

a lc

oh ol

; 3 3%

fr om

m ar

iju an

a; 7

6% fr

om

ot he

r no

no pi

od s;

6 %

h ad

p ro

bl em

s re

la te

d to

a lc

oh ol

in p

re vi

ou s

2 m

o ;

de cr

ea se

d op

io d

us e,

n on

op io

d us

e, n

o ch

an ge

in a

lc oh

ol u

se , s

lig ht

in cr

ea se

in

m ar

iju an

a us

e in

p re

vi ou

s 2

m on

th s

co m

pa re

d to

2 m

on th

s pr

io r

to tx

; n o

tx

gr ou

p ha

d im

pr ov

em en

ts a

s w

el l,

bu t t

x gr

ou p

im pr

ov em

en ts

s om

ew ha

t g re

at er

fo

r op

io ds

a nd

a lc

oh ol

•

in cr

ea se

in e

m pl

oy m

en t a

nd p

ro du

ct iv

e ac

tiv iti

es , d

ec re

as e

in a

rr es

ts ; n

o tx

gr

ou p

ha d

le ss

fa vo

ur ab

le o

ut co

m e

on a

ll va

ria bl

es

• va

ria bl

es r

el at

ed to

s uc

ce ss

: tim

e in

tx ; f

ew er

p ro

bl em

s at

a dm

is si

on

• 67

% d

ro p-

ou t r

at e

62

U .S

. D ep

t o f

H ea

lth a

nd

H um

an

S er

vi ce

s (1

99 7b

)

N T

IE S

7

23

6 13

-1 7=

ag e;

7 9%

m al

e;

33 %

w hi

te ; m

os t p

ol yd

ru g

us er

s w

ith M

,A m

os t

co m

m on

; 3 3%

w ith

p rio

r tx

F ed

er al

ly fu

nd ed

pr

og ra

m s;

5 9%

ou

tp at

ie nt

; 3 7%

lo ng

- te

rm r

es id

en tia

l; 3%

sh

or t-

te rm

r es

id en

tia l;

m ed

ia n

le ng

th o

f 2 m

o;

U S

A

• S

R o

f A +

u rin

al ys

is fo

r 50

%

at 1

y r

po st

-t x

• 82

% o

f e nt

ire s

am pl

e (4

41 1)

in

cl ud

ed in

fo llo

w -u

p (N

R S

)

1 ye

ar fo

llo w

-u p

• 30

% a

bs tin

en t i

n pr

ev io

us y

r ; 1

0% d

ec re

as e

in n

um be

r of

o ut

pa tie

nt s

us in

g an

y ill

ic it

dr ug

a nd

2 2%

d ec

re as

e in

n um

be r

of r

es id

en tia

l p at

ie nt

s us

in g

an y

ill ic

it dr

ug in

p re

vi ou

s yr

c om

pa re

d to

y r

pr io

r to

tx

• S

ig ni

fic an

t r ed

uc tio

n in

c rim

in al

a ct

iv ity

in p

re vi

ou s

yr c

om pa

re d

to y

r pr

io r

to tx

(4

8% fe

w er

a do

le sc

en ts

r ep

or te

d be

at in

g so

m eo

ne u

p; 4

1% fe

w er

s el

lin g

dr ug

s;

48 %

fe w

er s

ho pl

ift in

g; 4

8% fe

w er

c om

m itt

in g

m aj

or p

ro pe

rt y

cr im

es )

• 70

% d

ro p-

ou t r

at e

U

.S . D

ep t o

f H

ea lth

a nd

H

um an

S

er vi

ce s

(1 99

8)

S R

O S

8

15

6 13

-1 8=

ag e;

5 0%

w ith

le

ga l p

re ss

ur e

fo r

tx

N at

io nw

id e

re pr

es en

ta tiv

e sa

m pl

e of

9 9

di ff

er en

t d ru

g tr

ea tm

en t p

ro gr

am s;

8 0

ou tp

at ie

nt ; 4

7 in

pa tie

nt ;

28 r

es id

en tia

l; 1

ou tp

at ie

nt m

et ha

do ne

U

S A

• S

R o

f A c

or ro

bo ra

te d

by

ur in

al ys

is a

t 5 y

r po

st -t

x •

59 %

fr om

to ta

l s am

pl e

of

30 47

in cl

ud ed

in fo

llo w

-u p

(N R

S )

5 ye

ar fo

llo w

-u p

• si

gn ifi

ca nt

in cr

ea se

in %

o f i

nd iv

id ua

ls u

si ng

a lc

oh ol

a nd

c ra

ck in

p re

vi ou

s 5

ye ar

s co

m pa

re d

to 5

y ea

rs b

ef or

e tr

ea tm

en t (

80 .2

% to

9 2.

0% fo

r al

co ho

l; 5.

1%

to 1

5. 4%

fo r

cr ac

k) ; n

o si

gn ifi

ca nt

c ha

ng es

in u

se o

f o th

er s

ub st

an ce

s •

si gn

ifi ca

nt in

cr ea

se in

% o

f i nd

iv id

ua ls

w ith

a lc

oh ol

-r el

at ed

d riv

in g

of fe

ns es

a nd

dr

ug tr

af fic

ki ng

in p

re vi

ou s

5 ye

ar s

co m

pa re

d to

5 y

ea rs

b ef

or e

tx ; n

o si

gn ifi

ca nt

ch

an ge

s in

r at

es o

f p ro

st itu

tio n,

th ef

t, br

ea k

& e

nt ry

, o r

pa ro

le v

io la

tio n

N =

n um

be r

en te

rin g

tr ea

tm en

t C

LI E

N T

C H

A R

A C

T E

R IS

T IC

S :

A =a

lc oh

ol ; M

=m ar

iju an

a; C

=c oc

ai ne

; A m

=a m

ph et

am in

es ; H

=h al

lu ci

no ge

ns

M E

T H

O D

O LO

G Y

: S

R =s

el f r

ep or

t; A

=a do

le sc

en t;

P =p

ar en

t; N

R S

=n on

ra nd

om s

am pl

e

63

T ab

le 2

S

in gl

e P

ro gr

am O

ut co

m e

S tu

di es

o f A

do le

sc en

t S ub

st an

ce A

bu se

T re

at m

en t

S tu

dy

N

C

lie nt

C

ha ra

ct er

is tic

s

P

ro gr

am

C ha

ra ct

er is

tic s

M

et ho

do lo

gy

R

es ul

ts

A A

D A

C

(1 99

5)

9

39

5 12

-1 7

ag e;

6 3%

m al

e;

m aj

or ity

p ol

yd ru

g us

er s

w ith

A ,M

,H m

os t

co m

m on

; 7 6%

h x

ar re

st s;

27

% h

x su

ic id

e at

te m

pt s;

35

% p

hy si

ca lly

& 2

4%

se xu

al ly

a bu

se d

26 A

A D

A C

fa ci

lit ie

s in

A

lb er

ta , C

A N

A D

A ;

83 %

ou

tp at

ie nt

( 13

% G

; 1 7%

F

; 3 s

es si

on s

av e)

; 8%

da

y tx

& 5

% n

on -h

os pi

ta l

re si

de nt

ia l t

x (S

, R , 8

4%

G ; 6

5% F

; 2 9

da ys

a ve

);

sk ill

s or

ie nt

at io

n;

C A

N A

D A

• S

R o

f A &

P b

y ph

on e

at

di sc

ha rg

e &

3 m

o po

st -t

x •

53 %

A &

1 4%

P in

cl ud

ed a

t di

sc ha

rg e

an d

49 %

A &

1 4%

P

in cl

ud ed

in fo

llo w

-u p

(N R

S )

D is

ch ar

ge

• 27

% a

bs tin

en t a

nd a

dd iti

on al

3 3%

w ith

d ec

re as

ed s

ub st

an ce

u se

in p

re vi

ou s

m on

th

• 56

% d

ec re

as ed

li fe

p ro

bl em

s co

m pa

re d

to p

re -t

x •

64 %

tx d

ro p-

ou t r

at e

3 m

on th

fo llo

w -u

p

• 29

% a

bs tin

en t a

nd a

dd iti

on al

4 0%

d ec

re as

ed s

ub st

an ce

u se

in p

re vi

ou s

m on

th ;

19 %

a bs

tin en

t i n

pr ev

io us

3 m

on th

s •

56 %

w ith

d ec

re as

ed li

fe p

ro bl

em s

co m

pa re

d to

p re

-t x

•

va ria

bl es

r el

at ed

to s

uc ce

ss :

en ro

lle d

in s

ch oo

l a t d

is ch

ar ge

, m ot

iv at

io n,

n o

fa m

ily s

ub st

an ce

u se

, i nc

re as

ed p

ar tic

ip at

io n

in r

ec re

at io

na l a

ct iv

iti es

, i m

pr ov

ed

pr ob

le m

s ol

vi ng

A A

R C

( 19

94 )

10

56

16 .9

=a ve

a ge

( 13

-2 2)

; 76

% m

al e;

8 7%

w hi

te ;

po ly

dr ug

u se

w ith

M &

A

m os

t c om

m on

; 2 4%

tx

m an

da te

d; 6

8% h

x ar

re st

; 37

% h

x su

ic id

e at

te m

pt s

da y

tx (

F ,G

, R , 1

2 st

ep ,

pe er

p re

ss ur

e) w

hi le

li vi

ng

in h

om e

of a

do le

sc en

t fu

rt he

r al

on g

in tx

; 9 -1

2 m

o m

od al

ti m

e in

tx ;

C A

N A

D A

• S

R o

f A &

P a

t 2 -2

4 m

o po

st -

tx (

av e=

8- 12

m o)

•

68 %

A in

cl ud

ed a

t f ol

lo w

-u p

(d id

n ot

in cl

ud e

dr op

-o ut

s re

ce iv

in g

<2 m

o tx

)

8- 12

m on

th fo

llo w

-u p

• 65

% o

f t x

co m

pl et

er s

ab st

in en

t s in

ce e

nd o

f t x

an d

87 %

v er

y re

du ce

d su

bs ta

nc e

us e;

3 3%

o f 2

-1 2

m o

dr op

-o ut

s ab

st in

en t s

in ce

d ro

p- ou

t a nd

7 8%

w ith

v er

y re

du ce

d su

bs ta

nc e

us e;

c om

bi ne

d sa

m pl

es : 5

4% a

bs tin

en t a

nd 8

4% v

er y

re du

ce d

su bs

ta nc

e us

e si

nc e

di sc

ha rg

e (if

a ss

um e

<2 m

o dr

op -o

ut s

ha ve

s am

e ou

tc om

e as

2 -1

2 m

o dr

op -o

ut s

th en

h av

e 47

.5 %

a bs

tin en

ce a

nd 8

2%

de cr

ea se

d su

bs ta

nc e

us e)

•

91 %

w ith

r ed

uc ed

c rim

in al

in vo

lv em

en t;

94 %

w ith

im pr

ov ed

fa m

ily li

fe

• 55

% tx

d ro

p- ou

t r at

e

A lfo

rd ,

K oe

hl er

&

Le on

ar d

(1 99

1)

11

15 7

16 =a

ve a

ge ; 6

2% m

al e;

di

sp ro

po rt

io na

te h

ig he

r so

ci oe

co no

m ic

; m aj

or ity

po

ly dr

ug u

se rs

w ith

A

,M ,H

m os

t c om

m on

; >4

4% h

x ar

re st

s; 6

1% h

x sc

ho ol

s us

pe ns

io n

45 d

ay h

os pi

ta l i

np at

ie nt

fo

llo w

ed b

y 45

d ay

ha

lfw ay

h ou

se ; N

A /A

A 1

2 st

ep p

ro gr

am ; G

, F ;

U S

A

• S

R o

f A &

fa m

ily m

em be

r (5

0% in

p er

so n)

a t 6

m o,

1 y

r,

2 yr

p os

t- tx

•

96 %

o f A

in cl

ud ed

in 6

m o

fo llo

w -u

p, 9

3% a

t 1 y

r; 8

9% a

t 2

yr

6 m

on th

fo llo

w -u

p •

71 %

m al

e (m

) tx

c om

pl et

er s

(c )

es se

nt ia

lly a

bs tin

en t (

no u

se o

r on

ly 1

-3

re la

ps es

); 3

7% m

n on

co m

pl et

er s

(n c)

; 7 9%

fc ; 3

0% fn

c in

p re

vi ou

s 6

m o

1 ye

ar fo

llo w

-u p

• 48

% m

c; 4

4% m

nc ; 7

0% fc

; 2 8%

fn c

es se

nt ia

l a bs

tin en

t i n

pr ev

io us

y r

2 ye

ar fo

llo w

-u p

• 40

% m

c; 3

7% m

nc ; 6

1% fc

; 2 7%

fn c

es se

nt ia

lly a

bs tin

en t i

n pr

ev io

us 2

y r

• 72

% o

f e ss

en tia

lly a

bs tin

en t A

�s h

ad g

oo d

so ci

al fu

nc tio

ni ng

v s

37 %

fo r

hi gh

fr

eq ue

nc y

us er

s •

va ria

bl es

r el

at ed

to s

uc ce

ss :

tx c

om pl

et io

n; a

tte nd

an ce

a t A

A /N

A

A

m in

i, Z

ilb er

g,

B ur

ke &

S

al as

ne k

(1 98

2)

12

87

16 .1

=a ve

a ge

; 6 9%

m al

e;

52 %

w hi

te ; 1

00 %

c on

du ct

di

so rd

er ed

y ou

th r

ef er

re d

th ro

ug h

pr ob

at io

n;

ex cl

ud ed

S �s

w ith

ps

yc ho

si s,

m en

ta l

re ta

rd at

io n

& s

er io

us

vi ol

en ce

p ot

en tia

l

1. n

on -h

os pi

ta l r

es id

en tia

l tx

( F

,G ,R

,S , 1

32 d

ay s

av e)

2.

o ut

pa tie

nt p

ro ba

tio n;

U

S A

• ra

nd om

a ss

ig nm

en t t

o tx

gr

ou p

• S

R o

f A 1

y r

af te

r en

te rin

g pr

og ra

m

• 84

% in

cl ud

ed in

fo llo

w -u

p

~6 m

on th

fo llo

w -u

p •

si gn

ifi ca

nt d

ec re

as e

in d

ru g

an d

al co

ho l u

se in

b ot

h gr

ou ps

in p

re vi

ou s

6 m

o •

no s

ta tis

tic al

d iff

er en

ce b

et w

ee n

ou tc

om es

fo r

in pa

tie nt

v s

ou tp

at ie

nt

• si

gn ifi

ca nt

d ec

re as

e in

s ch

oo l d

is tu

rb an

ce a

nd a

nt is

oc ia

l b eh

av io

ur ; s

ig ni

fic an

t de

cr ea

se in

s ev

er al

M M

P I c

lin ic

al s

ca le

s in

p re

vi ou

s 6

m o

64

A zr

in ,

D on

oh ue

, B

es al

el , e

t a l.

(1 99

4)

13

26

16 =a

ve a

ge ; 7

7% m

al e;

79

% w

hi te

; p ol

yd ru

g us

er s

w ith

M ,C

,H m

os t

co m

m on

1. s

up po

rt iv

e co

un se

lli ng

( 6

m o;

1 5

se ss

io ns

)

2. b

eh av

io ur

al tx

( re

st ru

ct ur

e fa

m ily

&

p

ee r

re la

tio ns

, u rg

e

c

on tr

ol )

(6 m

o; 1

5

s

es si

on s)

; U

S A

• ra

nd om

a ss

ig nm

en t t

o tx

gr

ou p

• ur

in al

ys is

s up

pl em

en te

d by

fa

m ily

r ep

or t a

nd S

R a

t di

sc ha

rg e

D is

ch ar

ge

• 9%

o f A

in c

ou ns

el lin

g tx

a bs

tin en

t i n

pr ev

io us

m o

vs 7

3% in

b eh

av io

ur al

tx

• su

pe rio

r sc

ho ol

/w or

k at

te nd

an ce

, f am

ily r

el at

io ns

, m oo

d, c

on du

ct in

b eh

av io

ur al

gr

ou p

B ia

nc o

&

W al

la ce

(1

99 1)

14

11 6

15 .6

=a ve

a ge

; 1 00

%

fe m

al e;

p ol

yd ru

g us

er s

w ith

A ,M

,A m

m os

t co

m m

on ; 1

6% o

ut o

f sc

ho ol

; 5 3%

h x

ab us

e;

17 %

h x

ar re

st s;

5 4%

pr

ev io

us tx

re si

de nt

ia l t

x (1

5 m

o av

e)

(F ,G

) w

ith g

ra du

al

tr an

si tio

ni ng

b ac

k to

co

m m

un ity

; U

S A

• st

af f�s

in de

p ra

tin gs

a bo

ut

po st

-t x

fu nc

tio ni

ng 4

6 m

o (a

ve )

po st

-t x

(b as

ed o

n fo

llo w

- up

c as

e re

co rd

s, p

os t-

di sc

ha rg

e co

nt ac

ts &

in

te rv

ie w

s w

ith 5

9% )

• 54

% in

cl ud

ed in

a na

ly si

s (N

R S

)

D is

ch ar

ge

• 48

% a

bs tin

en t a

t t im

e of

d is

ch ar

ge ; 8

9% w

ith li

ttl e

or n

o dr

ug in

vo lv

em en

t 46

m on

th fo

llo w

-u p

• 38

% h

ig hl

y su

cc es

sf ul

o n

gl ob

al m

ea su

re o

f s uc

ce ss

th at

in cl

ud ed

c rim

in al

ac

tiv ity

, d ru

g us

e, e

m pl

oy m

en t/h

om em

ak in

g/ sc

ho ol

, f am

ily fu

nc tio

ni ng

s in

ce

di sc

ha rg

e; 3

2% m

od er

at el

y su

cc es

sf ul

; 3 0%

n ot

s uc

ce ss

fu l

• va

ria bl

es r

el at

ed to

s uc

ce ss

: in

vo lv

em en

t i n

sc ho

ol /e

m pl

oy m

en t/h

om em

ak in

g at

di

sc ha

rg e;

d ru

g us

e at

d is

ch ar

ge ; f

am ily

in vo

lv em

en t i

n tx

; t ra

di tio

na l f

am ili

es ; t

x co

m pl

et io

n; c

om pl

et io

n of

e du

ca tio

na l o

r sk

ill d

ev el

op m

en t d

ur in

g tx

B ra

uk m

an n,

B

ed lin

to n,

B

el de

n, e

t a l

(1 98

5)

15

24 1

15 .6

=a ve

a ge

; 1 00

%

m al

e; 7

3% w

hi te

; 1 00

%

ju ve

ni le

o ff

en de

rs r

ef er

re d

th ro

ug h

co ur

t e xc

lu di

ng

S �s

w ith

h x

of e

xt re

m e

vi ol

en ce

1. T

ea ch

in g-

F am

ily g

ro up

h om

es (

18 9

da ys

a ve

)

2. n

on -T

ea ch

in g-

F am

ily

g ro

up h

om e

(2 89

d ay

s

a

ve )

ho m

es

3. n

o tx

g ro

up o

f 6 1

m

at ch

ed fr

ie nd

s;

U S

A

• m

at ch

ed a

ss ig

nm en

t t o

tx

gr ou

p •

S R

o f A

d ur

in g

tx a

nd b

y ph

on e

at 3

m o

po st

-t x

(o n

av e)

•

25 %

in cl

ud ed

in fo

llo w

-u p

(i. e.

10 0%

o f m

at ch

ed p

ai rs

)

D ur

in g

tr ea

tm en

t •

yo ut

hs in

te ac

hi ng

-f am

ily g

ro up

h om

es h

ad s

ig ni

fic an

tly d

ec re

as ed

s ub

st an

ce

us e

co m

pa re

d to

a ll

ot he

r co

nd iti

on s

• va

ria bl

es r

el at

ed to

s uc

ce ss

: lo

w er

p re

-t x

su bs

ta nc

e ab

us e;

lo w

er p

re -t

x an

tis oc

ia l b

eh av

io ur

3

m on

th fo

llo w

-u p

• ne

ith er

tx h

ad a

s ig

ni fic

an t p

os t-

tx e

ff ec

t o n

su bs

ta nc

e us

e or

p ro

so ci

al

be ha

vi ou

rs c

om pa

re d

to c

on tr

ol g

ro up

•

no s

ta tis

tic al

d iff

er en

ce b

et w

ee n

ou tc

om es

fo r

T ea

ch in

g F

am ily

H om

es a

nd

no n-

T ea

ch in

g F

am ily

H om

es

• va

ria bl

es r

el at

ed to

s uc

ce ss

: lo

w er

p re

-t x

su bs

ta nc

e ab

us e;

lo w

er p

re -t

x an

tis oc

ia l b

eh av

io ur

B ro

w n,

G

le gh

or n,

S

ch uc

ki t,

et

al (

19 96

) &

M

ye rs

, B

ro w

n &

M ot

t (1

99 5)

16

16 6

15 .9

=a ve

a ge

; 6 0%

m al

e;

80 %

w hi

te ; m

os t p

ol yd

ru g

us er

s; e

xc lu

de d

cl ie

nt s

w ith

D S

M a

xi s

I di

ag no

se s

th at

p re

da te

d su

bs ta

nc e

us e

tw o

4- 6

w k

in pa

tie nt

pr

og ra

m s

(F ,G

,R ,S

);

U S

A

• in

de p

S R

o f A

& P

a t 6

m o,

1

yr , 2

y r

po st

-t x

• 80

% in

cl ud

ed a

t 1 a

nd 2

y r

po st

-t x

1 ye

ar fo

llo w

-u p

• 14

% a

bs tin

en t i

n pr

ev io

us y

r ; s

ig ni

fic an

t d ec

re as

e in

d ru

g an

d al

co ho

l u se

in

pr ev

io us

3 m

o co

m pa

re d

to 3

m o

pr e-

tx (

al co

ho l=

11 d

ay s/

m o

-> 5

d ay

s/ m

o;

dr ug

s= 35

ti m

es /m

o ->

9 tim

es /m

o)

2 ye

ar fo

llo w

-u p

• 14

% a

bs tin

en t i

n pr

ev io

us 2

y r ;

s ig

ni fic

an t d

ec re

as e

in d

ru g

an d

al co

ho l u

se in

pr

ev io

us 3

m o

co m

pa re

d to

3 m

o pr

e- tx

( al

co ho

l = 1

1 da

ys /m

o ->

7 d

ay s/

m o;

dr

ug s

= 35

ti m

es /m

o ->

7 tim

es /m

o)

• va

ria bl

es r

el at

ed to

s uc

ce ss

: fe

w er

c on

du ct

d is

or de

r ch

ar ac

te ris

tic s

pr ed

ic te

d be

tte r

tx o

ut co

m e

fo r

al co

ho l,

bu t n

ot o

th er

d ru

gs ; b

et te

r po

st -t

x re

la ps

e co

pi ng

sk

ill s;

p os

t- tx

in te

rp er

so na

l c on

fli ct

; p os

t- tx

e xp

os ur

e to

s ub

st an

ce -a

bu si

ng

m od

el s

(p re

di ct

iv e

fo r

al co

ho l u

se b

ut n

ot d

ru g

us e)

B ro

w n,

V ik

&

C re

am er

(1

98 9)

17

75

15 .6

=a ve

a ge

; 5 4%

m al

es ;

82 %

w hi

te ; m

os t p

ol yd

ru g

us er

s w

ith A

,M ,C

m os

t co

m m

on ; 6

1% h

x ar

re st

s;

54 %

s ch

oo l p

ro bl

em s;

87

% fa

m ily

c on

fli ct

; ex

cl ud

ed S

�s w

ith

ps yc

hi at

ric d

is or

de r

pr ec

ed in

g tx

in pa

tie nt

p ro

gr am

; U

S A

•

in de

p. S

R o

f A &

P a

t 3 &

6

m o

po st

-t x

• 81

% in

cl ud

ed a

t 6 m

o

3 m

on th

fo llo

w -u

p •

36 %

a bs

tin en

t i n

pr ev

io us

3 m

o

• 64

% r

el ap

se d

in 1

st 3

m o

po st

-t x

6 m

on th

fo llo

w -u

p

• 30

% a

bs tin

en t i

n pr

ev io

us 6

m o

• re

la ps

es o

cc ur

m os

t c om

m on

ly in

p re

se nc

e of

s oc

ia l p

re ss

ur e

to d

rin k

65

B ro

w n,

M ot

t &

M ye

rs

(1 99

0)

18

in

de p.

r ep

lic at

io n

of

B ro

w n

et a

l ( 19

89 )

3

in pa

tie nt

p ro

gr am

s;

U S

A

• in

de p.

S R

o f A

& P

a t 6

& 1

2 m

o po

st -t

x •

97 %

in cl

ud ed

a t 6

m o

& 9

5%

at 1

2 m

o

6 m

on th

fo llo

w -u

p •

33 %

a bs

tin en

t a nd

a no

th er

2 4%

im pr

ov ed

in p

re vi

ou s

6 m

o

C ad

y,

W in

te rs

, Jo

rd an

e t a

l. (1

99 6)

19

23 4

67 %

1 5-

17 ; 6

1% m

al e;

83

% w

hi te

; 1 4%

c ou

rt -

or de

re d

re si

de nt

ia l o

r ou

tp at

ie nt

tx

pr og

ra m

( av

e= 23

d ay

s) ;

U S

A

• S

R o

f A a

t 6 m

o �f

ol lo

w -u

p�

• 85

% in

cl ud

ed in

fo llo

w -u

p 6

m on

th fo

llo w

-u p

• 43

% a

bs tin

en t i

n pr

ev io

us 6

m o

• va

ria bl

es r

el at

ed to

s uc

ce ss

: pr

e- tx

s ub

st an

ce a

bu se

; t im

e in

tx ; t

x co

m pl

et io

n;

m ot

iv at

io n

fo r

tx ; f

em al

e •

25 %

tx d

ro p-

ou t r

at e

C or

nw al

l &

B lo

od (

19 98

) 20

23 9

16 .5

=a ve

a ge

; 65

% m

al e;

po

ly dr

ug u

se rs

; 6 3%

sc

ho ol

fa ilu

re ; 6

7% le

ga l

di ff

ic ul

tie s;

6 3%

a bu

se d

1.

10 w

k da

y tr

ea tm

en t;

G ,S

,F ,R

2.

12

w k

in pa

tie nt

pr

og ra

m ; G

,S ,F

,R

C A

N A

D A

• no

nr an

do m

a ss

ig nm

en t t

o gr

ou p

(in pa

tie nt

m or

e se

ve re

dr

ug a

bu se

) •

S R

o f A

a t d

is ch

ar ge

a nd

6

m o

fo llo

w -u

p •

56 %

in cl

ud ed

in d

is ch

ar ge

an

al ys

is ; 4

4% in

cl ud

ed a

t 6

m o

(t x

dr op

-o ut

s no

t i nc

lu de

d)

di sc

ha rg

e •

si gn

ifi ca

nt r

ed uc

tio n

in d

ru g

ab us

e co

m pa

re d

to p

re -t

x •

si gn

ifi ca

nt im

pr ov

em en

t i n

se lf-

es te

em , f

am ily

fu nc

tio ni

ng , p

sy ch

ol og

ic al

pr

ob le

m s,

b eh

av io

ur al

p ro

bl em

s co

m pa

re d

to p

re -t

x •

37 %

d ro

p- ou

t r at

e fo

r da

y tx

; 4 1%

fo r

in pa

tie nt

6

m on

th fo

llo w

-u p

• si

gn ifi

ca nt

r ed

uc tio

n in

d ru

g ab

us e

•

si gn

ifi ca

nt im

pr ov

em en

t i n

se lf-

es te

em , p

ee r

re la

tio ns

, f am

ily fu

nc tio

ni ng

, ps

yc ho

lo gi

ca l p

ro bl

em s,

b eh

av io

ur al

p ro

bl em

s co

m pa

re d

to p

re -t

x •

no s

ig ni

fic an

t d iff

er en

ce s

in tx

o ut

co m

e be

tw ee

n in

pa tie

nt a

nd d

ay tx

D eL

eo n

(1 98

4)

21

84

64 %

m al

e; 2

3% w

hi te

; m

os t p

ol yd

ru g

us er

s,

op ia

te s

pr im

ar y

dr ug

fo r

1/ 4;

4 5%

c ou

rt r

ef er

re d

re si

de nt

ia l t

he ra

pe ut

ic

co m

m un

ity (

P ho

en ix

H

ou se

); U

S A

• 2

yr p

os t-

tx

• 78

% fo

llo w

-u p

at b

ot h

1 &

2

yr s

(N R

S )

1 &

2 y

ea r

fo llo

w -u

p •

co m

po si

te s

uc ce

ss in

de x

th at

in cl

ud ed

s ub

st an

ce u

se a

nd c

rim in

al ity

s ho

w ed

de

cr ea

se s

in ce

d is

ch ar

ge

• va

ria bl

es r

el at

ed to

s uc

ce ss

:: tx

c om

pl et

er ; n

on le

ga lly

r ef

er re

d; p

rim ar

ily o

pi od

us

er

• 83

% tx

d ro

p- ou

t r at

e

F ei

ge lm

an ,

H ym

an &

A

m an

n (1

98 8)

22

73

68 %

m al

e; 1

00 %

w hi

te ;

hi gh

er s

oc io

ec on

om ic

; m

os t p

ol yd

ru g

us er

s w

ith

M ,A

,H m

os t c

om m

on ;

71 %

h x

ar re

st s

no n-

ho sp

ita l d

ay tx

o f 1

9- 39

m on

th s;

G ,F

,S ,R

; U

S A

• S

R o

f A (

19 %

p ho

ne )

+ ur

in e

sc re

en +

c he

ck o

f M V

of

fe ns

es a

t 6 .1

y r

(3 -8

y r

ra ng

e) p

os t-

tx

• 48

% in

cl ud

ed in

fo llo

w -u

p (N

R S

)

3- 8

ye ar

fo llo

w -u

p •

3% to

ta lly

a bs

tin en

t, ad

di tio

na l 2

6% h

ad n

o us

e of

il le

ga l d

ru gs

a nd

o nl

y m

od er

at e

us e

of a

lc oh

ol in

p re

vi ou

s 6

ye ar

s •

va ria

bl es

r el

at ed

to s

uc ce

ss :

tx c

om pl

et io

n; a

ge o

f 1 st

s ub

st an

ce u

se ; #

p rio

r tx

s •

86 %

tx d

ro p-

ou t r

at e

F ils

te ad

(1

99 2)

23

11

27

16 .3

=a ve

a ge

; 7 0%

m al

e;

91 %

w hi

te ;

m os

t po

ly dr

ug u

se rs

w ith

A

,M ,C

m os

t c om

m on

27 d

iff er

en t n

on -h

os pi

ta l

re si

de nt

ia l p

ro gr

am s

op er

at ed

b y

P A

R K

S ID

E

M ed

ic al

S er

vi ce

s C

or p;

3 3

da ys

a ve

ra ge

; U

S A

• S

R o

f A b

y ph

on e

at 1

1 m

o po

st -t

x •

49 %

in cl

ud ed

in fo

llo w

-u p

(N R

S )

11 m

on th

fo llo

w -u

p •

37 %

a bs

tin en

t & a

dd iti

on al

1 0%

w ith

o ne

r el

ap se

s in

ce d

is ch

ar ge

; 7 8%

r ep

or t

lo w

er s

ub st

an ce

u se

s in

ce d

is ch

ar ge

•

67 %

r ep

or t i

m pr

ov em

en t i

n ge

ne ra

l o ve

ra ll

fu nc

tio ni

ng c

om pa

re d

to p

re -t

x •

va ria

bl es

r el

at ed

to s

uc ce

ss :

fe m

al e;

tx c

om pl

et io

n; a

fte rc

ar e

in vo

lv em

en t

• 34

% d

ro p-

ou t r

at e

fr om

p rim

ar y

tx ; 7

1% d

ro p-

ou t r

at e

fr om

fu ll

pr og

ra m

(c

on tin

ui ng

c ar

e an

d se

lf- he

lp a

ct iv

iti es

)

F rie

dm an

(1

98 9)

24

16 9

17 .9

=a ve

a ge

; 6 0%

m al

e;

90 %

w hi

te ; m

os t p

ol yd

ru g

us er

s w

ith M

,A ,A

m m

os t

co m

m on

; 3 5%

h x

ar re

st s

1. f

am ily

th er

ap y

in 6

di

ff er

en t o

ut pa

tie nt

pr

og ra

m s

of 6

m o

du ra

tio n

2.

p ar

en t s

up po

rt g

ro up

s in

6 o

ut pa

tie nt

pr

og ra

m s

of 6

m o

du ra

tio n;

U S

A

• ra

nd om

a ss

ig nm

en t t

o tx

gr

ou p

• S

R o

f A &

P a

t 9 m

o po

st -t

x •

80 %

in cl

ud ed

in fo

llo w

-u p

9 m

on th

fo llo

w -u

p •

re du

ct io

n in

s ub

st an

ce u

se a

nd a

bu se

b y

50 %

in b

ot h

gr ou

ps �

at ti

m e

of fo

llo w

- up

� •

si gn

ifi ca

nt d

ec re

as e

in p

sy ch

ol og

ic al

p ro

bl em

s, fa

m ily

p ro

bl em

s �a

t t im

e of

fo

llo w

-u p�

•

no d

iff er

en ce

b et

w ee

n gr

ou ps

in d

eg re

e of

im pr

ov em

en t

66

F rie

dm an

&

G lic

km an

(1

98 7)

25

20 5

16 .2

=a ve

a ge

; 1 00

%

m al

e; 7

5% w

hi te

; p ol

yd ru

g us

er s

w ith

A ,M

,A m

m os

t co

m m

on ; 1

00 %

c ou

rt -

or de

re d

da y

pr og

ra m

e m

ph as

iz in

g co

un se

lli ng

a nd

su

pp or

tiv e

sk ill

le ar

ni ng

; U

S A

• S

R o

f A a

t 2 2

m o

af te

r ad

m is

si on

•

63 %

in cl

ud ed

in fo

llo w

-u p

(N R

S )

fo llo

w -u

p 22

m on

th s

af te

r ad

m is

si on

•

va ria

bl es

r el

at ed

to s

uc ce

ss :

A w

ith m

or e

ps yc

hi at

ric s

ym pt

om s

ha d

so m

ew ha

t be

tte r

su bs

ta nc

e us

e ou

tc om

es ; h

ig he

r pr

e- tx

s ub

st an

ce u

se

F rie

dm an

, G

ra ni

ck ,

K re

is he

r &

T

er ra

s (1

99 3)

; F

rie dm

an ,

G ra

ni ck

&

K re

is he

r (1

99 4)

; F

rie dm

an ,

T er

ra s

& A

li (1

99 8)

26

45 3

16 .1

=a ve

a ge

; 5 2%

m al

e;

83 %

w hi

te ; s

ig ni

fic an

tly

hi gh

er le

ve l o

f s ub

st an

ce

ab us

e an

d ot

he r

pr ob

le m

s th

an o

ut pa

tie nt

s am

pl e

15

.7 =a

ve a

ge ; 7

0% m

al e;

52

% w

hi te

2 sh

or t h

os pi

ta l i

np at

ie nt

pr

og ra

m s

4 lo

ng o

ut pa

tie nt

pr

og ra

m s;

U S

A

• S

R o

f A a

t 6 -1

3 m

on th

s af

te r

en te

rin g

tx (

av e=

10 .8

m o)

6-

13 m

on th

fo llo

w -u

p af

te r

be gi

nn in

g tr

ea tm

en t

• ou

tp at

ie nt

tx s

ig ni

fic an

tly g

re at

er e

ff ec

t i n

re du

ci ng

s ub

st an

ce a

bu se

fo r

pa tie

nt s

w ith

m or

e se

ve re

s oc

ia l p

ro bl

em s,

fa m

ily p

ro bl

em s

an d

em pl

oy m

en t p

ro bl

em s;

tr

en d

to w

ar d

si gn

ifi ca

nc e

fo r

ps yc

hi at

ric p

ro bl

em s

• in

pa tie

nt v

ar ia

bl es

r el

at ed

to s

uc ce

ss :

yo un

ge r,

m ot

iv at

io n

fo r

tx , n

ot b

ei ng

C

at ho

lic , f

ew er

p re

tx s

oc ia

l p ro

bl em

s, n

ot b

ei ng

e xp

el le

d, a

tte nd

in g

sc ho

ol ;

va ria

bl es

w ith

n o

re la

tio ns

hi p

to s

uc ce

ss :

g en

de r,

r ac

e, in

ta ct

fa m

ily ,

so ci

oe co

no m

ic s

ta tu

s, p

re tx

m ed

ic al

, s ch

oo l,

fa m

ily , p

sy ch

ol og

ic al

, l eg

al , a

nd

dr ug

p ro

bl em

s •

ou tp

at ie

nt v

ar ia

bl es

r el

at ed

to s

uc ce

ss :

fe m

al e,

h ig

he r

so ci

oe co

no m

ic c

la ss

, m

ot iv

at io

n fo

r tx

, l es

s ill

eg al

b eh

av io

ur , l

es s

dr ug

u se

, n ot

b ei

ng e

xp el

le d;

va

ria bl

es w

ith n

o re

la tio

ns hi

p to

s uc

ce ss

: ag

e, r

ac e,

r el

ig io

n, in

ta ct

fa m

ily , p

re tx

m

ed ic

al , s

ch oo

l, so

ci al

, f am

ily , a

nd p

sy ch

ol og

ic al

p ro

bl em

s

F rie

dm an

, S

ch w

ar tz

&

U ta

da (

19 89

) 27

33 0

16 .6

=a ve

a ge

; 7 0%

m al

e;

99 %

w hi

te ; m

os t p

ol yd

ru g

us er

s w

ith A

,M ,A

m m

os t

co m

m on

; 2 9%

s us

pe nd

ed

or d

ro pp

ed -o

ut fr

om

sc ho

ol

14 m

o (a

ve )

no n-

ho sp

ita l

da y

pr og

ra m

; G ,F

,R ; 5

ph

as e

pr og

ra m

s ta

rt in

g w

ith li

vi ng

in h

os t h

om e

an d

gr ad

ua lly

m ov

in g

to w

ar d

co m

m un

ity

in te

gr at

io n;

U S

A

• in

de p.

S R

o f A

& P

a t 1

4. 6

m o

(o n

av er

ag e)

p os

t- tx

•

67 %

in cl

ud ed

in fo

llo w

-u p

(N R

S )

14 .6

m on

th fo

llo w

-u p

• 65

% a

bs tin

en t f

ro m

a lc

oh ol

, 7 4%

fr om

m ar

iju an

a, 9

1% fr

om a

m ph

et am

in es

, 90

% fr

om h

al lu

ci no

ge ns

, 8 6%

fr om

c oc

ai ne

, 9 5%

s ed

at iv

es , 9

2% in

ha la

nt s

si nc

e di

sc ha

rg e ;

8 5%

r ep

or t l

ow er

s ub

st an

ce u

se s

in ce

d is

ch ar

ge

• si

gn ifi

ca nt

im pr

ov em

en t i

n su

ic id

al id

ea tio

n, fi

gh ts

, a rr

es ts

c om

pa rin

g st

at us

a t

ad m

is si

on to

s ta

tu s

at fo

llo w

-u p

• va

ria bl

es r

el at

ed to

s uc

ce ss

: de

lin qu

en cy

, c hu

rc h

at te

nd an

ce , p

re -t

x dr

ug

ab us

e, d

ru g

ab us

e in

p ee

rs , s

ch oo

l a tte

nd an

ce , s

ib lin

g re

la tio

ns hi

ps , p

ar en

ta l

dr ug

u se

, •

34 %

tx d

ro p-

ou t r

at e

F

rie dm

an ,

T er

ra s

&

K re

is he

r (1

99 5)

; F

rie dm

an &

T

er ra

s (1

99 6)

28

21 9

17 .9

=a ve

a ge

; 6 4%

m al

e;

90 %

w hi

te ; p

ol yd

ru g

us er

s w

ith A

,M ,A

m m

os t

co m

m on

; 4 0%

h ad

b ee

n in

ja il

6 di

ff er

en t o

ut pa

tie nt

pr

og ra

m s;

F ,G

; a ve

o f 8

.5

se ss

io ns

; U

S A

• se

lf- re

po rt

o f A

& P

a t 1

5 m

on th

s af

te r

st ar

t o f t

re at

m en

t •

80 %

in cl

ud ed

in fo

llo w

-u p

15 m

on th

fo llo

w -u

p af

te r

be gi

nn in

g tr

ea tm

en t

• va

ria bl

es r

el at

ed to

s uc

ce ss

: m

al es

w ith

ou t p

ar an

oi a;

in di

vi du

al s

w ith

b or

de rli

ne

ps yc

ho tic

s ym

pt om

s; p

os iti

ve fa

m ily

fu nc

tio ni

ng ; p

os iti

ve r

el at

io ns

hi p

w ith

pa

re nt

s •

19 %

tx d

ro p-

ou t r

at e

F rie

dm an

, U

ta da

&

G lic

km an

(1

98 6)

(G

au s

&

H en

de rs

on ,

19 85

) 29

20 5

16 =a

ve a

ge ; 1

00 %

m al

e;

75 %

w hi

te ; m

os t p

ol yd

ru g

us e

w ith

M ,A

,A m

m os

t co

m m

on ; 1

00 %

c ou

rt -

re fe

rr ed

c on

du ct

di

so rd

er ed

y ou

th ; 8

2%

di ss

at is

fie d

w ith

s ch

oo l

of f-

ca m

pu s

lif e

sk ill

ac

tiv iti

es (

ou tw

ar d

bo un

d;

ad ve

nt ur

e le

ar ni

ng ;

co m

m un

ity s

ki lls

) fo

r ad

ol es

ce nt

s at

te nd

in g

a pr

iv at

e vo

ca tio

na l h

ig h

sc ho

ol ;

U S

A

• S

R o

f A in

p er

so n

at 2

2 m

o af

te r

ad m

is si

on to

p ro

gr am

•

63 %

in cl

ud ed

in fo

llo w

-u p

(N R

S )

F ol

lo w

-u p

22 m

on th

s af

te r

ad m

is si

on

• si

gn ifi

ca nt

d ec

re as

e in

fr eq

ue nc

y of

P C

P a

nd h

al lu

ci no

ge n

us e

pe r

m on

th

co m

pa re

d to

p re

-t x,

b ut

s ig

ni fic

an t i

nc re

as e

in fr

eq ue

nc y

of a

lc oh

ol , c

oc ai

ne a

nd

he ro

in u

se p

er m

on th

c om

pa re

d to

p re

-t x

• si

gn ifi

ca nt

d ec

re as

e in

le ga

l o ff

en se

s; s

ch oo

l p ro

bl em

s; s

lig ht

d ec

re as

e in

fa m

ily

pr ob

le m

s; m

ix ed

e ff

ec ts

o n

ps yc

ho lo

gi ca

l p ro

bl em

s co

m pa

re d

to p

re -t

x

67

G re

ni er

(1

98 5)

30

? 15

=a ve

a ge

; 6 0%

m al

e;

m os

tly w

hi te

a nd

m id

dl e-

cl as

s; m

os t p

ol yd

ru g

us er

s w

ith A

,M ,A

m m

os t

co m

m on

; 6 0%

w ith

d ru

g- ad

di ct

ed fa

m ily

m em

be r

1. h

os pi

ta l i

np at

ie nt

� A

A -

fa m

ily �

m od

el , F

, G , S

, R

; 1 w

k ev

al ua

tio n;

4

w ks

tx ; 6

w ks

ou

tp at

ie nt

; 2 y

rs

af te

rc ar

e 2.

w ai

t c on

tr ol

g ro

up o

f 74

w ho

c on

ta ct

ed

pr og

ra m

b ut

d id

n ot

re

ce iv

e tx

; U

S A

• ra

nd om

s am

pl e

of 1

17 fo

rm er

pa

tie nt

s co

nt ac

te d

fo r

tx g

ro up

•

S R

o f A

& P

b y

ph on

e an

d m

ai l f

or tx

g p

an d

S R

o f P

fo r

co nt

ro l g

p; 9

m o

si nc

e co

nt ac

t ( 1-

18 m

o ra

ng e)

•

36 %

c on

tr ol

s in

cl ud

ed in

fo

llo w

-u p

(N R

S )

9 m

on th

fo llo

w -u

p •

66 %

tx g

ro up

n ot

� cu

rr en

tly u

si ng

� (in

cl ud

in g

gr ad

ua te

s an

d no

ng ra

du at

es ),

w

hi ch

is s

ig ni

fic an

tly h

ig he

r th

an th

e 20

% in

c on

tr ol

g ro

up

• 41

% o

f c on

tr ol

g ro

up h

ad im

pr ov

ed b

eh av

io ur

; n ot

r ep

or te

d fo

r tx

g ro

up

• 45

% tx

d ro

p- ou

t r at

e

G rif

fe n-

S he

lle y,

S

an dl

er &

P

ar k-

C am

er on

(1

99 1)

31

10 0

17 =a

ve a

ge ; 7

7% m

al e;

m

os tly

w hi

te a

nd m

id dl

e- cl

as s;

m os

t p ol

yd ru

g us

er s

w ith

A m

os t

co m

m on

sh or

t- te

rm h

os pi

ta l

in pa

tie nt

p ro

gr am

sp

ec ia

liz in

g in

d ua

lly -

di ag

no se

d pa

tie nt

s; U

S A

• S

R o

f A &

P b

y m

ai l a

t 1 .5

y rs

po

st -t

x •

13 %

in cl

ud ed

in fo

llo w

-u p,

48

% fo

r dr

ug r

es ul

ts (

N R

S )

1. 5

ye ar

fo llo

w -u

p •

35 %

a bs

tin en

t a t t

im e

of fo

llo w

-u p

• im

pr ov

em en

ts in

p sy

ch ol

og ic

al fu

nc tio

ni ng

, f am

ily r

el at

io ns

, s ch

oo l p

er fo

rm an

ce ,

ph ys

ic al

h ea

lth

H en

ng ge

le r,

B

or du

in ,

M el

to n

et a

l (1

99 1)

(S

ou th

C

ar ol

in a)

32

a

47

15 .1

=a ve

a ge

; 7 2%

m al

e;

26 %

w hi

te ; l

ow er

so

ci oe

co no

m ic

; 1 00

%

co nd

uc t d

is or

de re

d yo

ut h

1. m

ul tis

ys te

m ic

fa m

ily

t

he ra

py (

av e=

36 h

r

o

ve r

4 m

o)

2. m

on th

ly m

ee tin

g

w

ith p

ro ba

tio n;

U

S A

• ra

nd om

a ss

ig nm

en t t

o tx

gr

ou p

• S

R o

f A a

t di

sc ha

rg e

D is

ch ar

ge

• ad

ol es

ce nt

s re

ce iv

in g

fa m

ily th

er ap

y ha

d si

gn ifi

ca nt

ly lo

w er

s of

t d ru

g us

e in

pr

ev io

us 3

m o

co m

pa re

d to

3 m

o pr

e- tx

c om

pa re

d to

a do

le sc

en ts

r ec

ei vi

ng

re gu

la r

pr ob

at io

n se

rv ic

es

H en

ng ge

le r,

B

or du

in ,

M el

to n

et a

l (1

99 1)

(M

is so

ur i)

32 b

76

14 .4

=a ve

a ge

; 6 7%

m al

e;

70 %

w hi

te ; l

ow er

so

ci oe

co no

m ic

; 1 00

%

co nd

uc t d

is or

de re

d yo

ut h

re fe

rr ed

th ro

ug h

co ur

t

1. m

ul tis

ys te

m ic

fa m

ily

th er

ap y

(a ve

=2 4

hr s)

2.

i nd

iv id

ua l c

ou ns

el lin

g (a

ve =2

8 hr

s) ;

U S

A

• ra

nd om

a ss

ig nm

en t t

o tx

gr

ou p

• S

R o

f A a

t 4 y

rs p

os t-

tx

• 10

0% in

cl ud

ed in

fo llo

w -u

p

4 ye

ar fo

llo w

-u p

• ad

ol es

ce nt

s w

ho r

ec ei

ve d

m ul

tis ys

te m

ic fa

m ily

th er

ap y

ha d

si gn

ifi ca

nt ly

lo w

er

dr ug

-r el

at ed

a rr

es t r

at es

( 3%

) in

p re

vi ou

s 4

yr s

th an

th os

e w

ho r

ec ei

ve d

in di

vi du

al c

ou ns

el lin

g (1

5% )

• tx

r ef

us er

s ha

d a

17 %

s ub

st an

ce -r

el at

ed a

rr es

t r at

e •

30 %

tx d

ro p-

ou t r

at e

Iv

er so

n &

R

ob er

ts

(1 98

0)

33

13 8

96 %

b et

w ee

n 12

-1 8;

53

% m

al e;

9 9%

w hi

te ; M

pr

im ar

y dr

ug ; 1

8% c

ou rt

re

fe rr

ed

6 w

ee k,

6 s

es si

on

co m

m un

ity b

as ed

ed

uc at

io n

pr og

ra m

; U

S A

• S

R o

f A a

t d is

ch ar

ge a

nd 6

m

o po

st -t

x •

80 %

in cl

ud ed

in fo

llo w

-u p

D is

ch ar

ge

• %

u si

ng m

ar iju

an a

>1 x/

w k

de cr

ea se

d fr

om 7

0% p

re -t

x to

5 5%

; 9%

to 2

% fo

r ha

llu ci

no ge

ns ; 6

% to

2 %

fo r

de pr

es sa

nt s

• si

gn ifi

ca nt

in cr

ea se

in s

el f-

es te

em a

nd fa

m ily

c om

m un

ic at

io n

6 m

on th

fo llo

w -u

p •

30 %

u si

ng m

ar iju

an a

>1 x/

w k;

1 1%

a bs

tin en

t f ro

m m

ar iju

an a

in p

re vi

ou s

6 m

o ;

0% u

si ng

h al

lu ci

no ge

ns >

1x /w

k; 0

% u

si ng

d ep

re ss

an ts

> 1x

/w k

• si

gn ifi

ca nt

d ec

re as

e in

d el

in qu

en cy

a nd

s ch

oo l p

ro bl

em s

fr om

p re

-t x;

s ig

ni fic

an t

in cr

ea se

in fa

m ily

c om

m un

ic at

io n

an d

se lf-

es te

em fr

om p

re -t

x

Je ns

en ,

W el

ls ,

P lo

tn ic

k et

a l.

(1 99

3)

34

14 1

15 .4

=a ve

a ge

; 7 9%

m al

e;

51 %

w hi

te ; 1

00 %

c on

du ct

di

so rd

er ed

y ou

th

re si

de nt

ia l j

uv en

ile fa

ci lit

y (G

, b eh

av io

ur al

s ki

lls

tr ai

ni ng

); 3

m o

av er

ag e

st ay

; U

S A

• S

R o

f A a

t 1 2

m o

po st

-t x

co rr

ob or

at ed

b y

ur in

al ys

is o

n po

rt io

n of

s am

pl e

• 92

% in

cl ud

ed in

fo llo

w -u

p

12 m

on th

fo llo

w -u

p •

va ria

bl es

r el

at ed

to s

uc ce

ss :

go od

p os

t- tx

s oc

ia l s

ki lls

, p ro

bl em

-s ol

vi ng

s ki

lls ,

se lf-

co nt

ro l,

an d

dr ug

a vo

id an

ce s

ki lls

s ig

ni fic

an tly

r el

at ed

to d

ec re

as ed

M u

se ;

lo w

er v

ar ie

ty &

s ev

er ity

o f p

re -t

x su

bs ta

nc e

us e

fo r

fe m

al es

; i nt

en tio

n no

t t o

us e

fo r

m al

es