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Drug, Alcohol Therapy/Education
Science has made great progress in recent years with regard to the prevention and treatment of substance abuse. We still have much to learn about adapting interventions and treatments to effectively address specific risks by gender, ethnic identification and geographic settings. However, from universal prevention aimed at children to offender treatment for substance use disorders in institutions and communities, much has been learned in the past two decades about what works and what doesn't (BJA, 2003; Dusenbury and Falco, 1997; Ferrer-Wreder, et al., 2003; NIDA, 2003).
PREVENTION
Much of the research on preventing drug use among children and adolescents has focused on reducing risks and promoting factors that lead to use and abuse (Hawkins, Catalano, and Arthur, 2002). These interventions are designed and tested to help optimize the development of children. Scientists have found effective ways to work with families, schools, and communities in order to help young people develop skills and approaches to stopping problems related to substance use before they occur (NIDA, 2003).
Mothers and Early Caregivers
There can be no question that the best way to start out life is by having a substance free environment from conception (Olds and Henderson, 1994). Further, being cared for in a family with many protective factors and few risk factors is another key element in fostering a propensity toward being drug free (Olds, et al., 1998). Olds and colleagues' program, Nurse-Family Partnership, is aimed at just that, promoting a solid beginning in life. This program serves to promote emotional-, physical-, and behavioral health in at-risk, first time mothers and their children who live in communities of disorganization and marginalization. The program seeks to give new mothers the tools, knowledge and, most importantly, support needed to initiate and maintain healthy lifestyles that are free of substance use, full of positive parenting and armed with the understanding of developmentally appropriate child behaviors. To date, Olds program has shown both short- and long-term positive effects on both the children and the families that it serves (Olds, Kitzman, Cole, and Robinson, 1997).
School Age
Problem behaviors such as alcohol or drug use often begin during the school-age years. Many believe that implementing prevention programs in the school setting increases the chance of averting the problems associated with alcohol, tobacco, and other drug use and abuse. According to the National Institute on Drug Abuse, prevention programs should address all forms of drug abuse, alone or in combination. This means programs should include preventing the underage use of legal drugs such as tobacco or alcohol as well as the use of illegal drugs such as marijuana or heroin. Further, programs should address the inappropriate use of legally obtained substances such as inhalants, prescription medications or over-the-counter drugs (NIDA, 2003).
Drug prevention efforts the past two decades have largely relied on classroom curricula usually designed for primary and middle school children (Dusenbury and Falco, 1997). The nation's schools spend $125 million on drug abuse prevention curricula each year however many of these programs may not be effective in preventing substance abuse (Dusenbury and Falco, 1997). The reason for this is drug and alcohol abuse prevention curricula have traditionally been based on pure information dissemination. Previous evaluations show that this didactic approach may be effective at transmitting information regarding drug and alcohol abuse however, used alone, it is not effective at changing the underlying attitudes and behaviors (Sherman, 2000; Gottfredson, 1997; Botvin, Botvin and Ruchlin, 1998; Miller, 2001; Mendel, 2000; Sherman, et al., 1998; Rosenbaum and Hanson, 1998; Wyrick, et al., 2001).
However, a review of the literature in the drug abuse prevention field suggests certain types of school-based curricula can effectively reduce substance abuse in adolescence (Botvin and Botvin, 1992; Dusenbury and Falco, 1997; Perry et al.,1996; Tobler and Stratton, 1997). Efficacious prevention curricula consist of several key elements. Curricula delivered in an interactive format with smaller groups of young people have been shown to produce strong and lasting positive results (Tobler and Stratton, 1997). Effective curricula gives students the tools to recognize internal pressures like stress or anxiety and external pressures like peer attitudes and advertising that may influence them to use alcohol, tobacco and other drugs. Following this, another useful component is helping students develop and practice personal, social and refusal skills in order to resist these influences effectively (Dusenbury and Falco, 1997). Effective school-based programs include Life Skills Training.
Family
Drug prevention efforts focusing on the family have shown considerable progress over recent years (Ashery, Robertson, & Kumpfer, 1998; Dishion & Kavanagh, 2000; Dusenbury, 2000; Kumpfer & Alvarado, 1998; Sanders, 2000). Family training at the time of transition from childhood to adolescence may be particularly important for parents. Such programs prepare parents for the changes their child will experience and offer parents tools that can help them to steer their children away from early- and heightened drug involvement (Bry, et al., 1998; Ferrer-Wreder, 2003; Kumpfer & Alvarado, 1998).
Evaluations of promising family training programs that work to prevent youth drug use have shown both short- and long-term promise particularly in terms of lowering alcohol initiation- and use-rates. Positive programmatic-related changes in alcohol and family variables have been found to persist between two- to three-and-half years post intervention (Kumfer, Molgard and Spoth, , Loveland-Cherry, et al., 1999; Park, et al., 2000).
While research is continuing about the usefulness of particular intervention actions, (Dusenbury, 2000; Etz, Robertson, & Ashery, 1998), exemplar interventions of this type regularly include some key components. These effective features include giving parents accurate information about alcohol and drugs and encouraging parents to clarify their own views about youth substance use. Other useful tools are to support the family in defining and enforcing a family policy on youth substance use, as well as involving young people and parents in social resistance training (Bry, Catalano, Kumpfer, Lochman, and Szapocznik, 1998; Dusenbury, 2000; Kumpfer and Alvarado, 1998). For a few examples of well-tested, effective programs see Preparing for the Drug Free Years and the Child and Parent Relations Project.
Higher Risk Youth and Families
In the case of higher risk youth with behavioral problems in general and those related to substance issues in particular, family therapies may be more effective (Ferrer-Wreder, et al., 2003; Hogue, Liddle, Becker and Johnson-Leckrone, 2002; Szapocznik and Williams, 2000). These interventions work with single families on a one-to-one basis. This approach helps to target specific strengths within the family and provide a setting for youth and parents to practice new, positive ways of interacting directly with each other (Etz, Robertson, & Ashery, 1998; Kumpfer & Alvarado, 1998). Exemplar family initiatives that have shown efficacy in reducing overall reoffending rates, violence-drug related crimes, and other institutional assignments include Functional Family Therapy, and Multisystemic Therapy.
For youth whose problem behaviors and risk is largely associated with their parents' drug abuse, interventions seem to be most successful when explicit drug treatment for parents is combined with the previously mentioned effective family intervention components. These family-focused interventions expressly treat parental addiction and relapse, codependence issues, as well as youth knowledge, attitudes, and expectations regarding alcohol and other drugs (Dusenbury, 2000; Ferrer-Wreder, et al., 2003; Kumpfer, Alexander, McDonald, and Olds, 1998).
While only a few rigorously tested therapies for substance-addicted parents exist (Bry, et al., 1998; Ferrer-Wreder, et al., 2003), one program stands out. In the Focus on Families efficacy trial, results indicated declines in parental drug use and improvements in related family variables with endurance up to one year after the intervention.
The same level of success in reducing youth substance use among the offspring of these parents has been more difficult to achieve. There is evidence that points to a possible trickle down intervention effect for children whose parents have successfully undergone addiction treatment (O' Farrell and Feehan, 1999). Longer-term follow up of participating children will offer a more precise test of the potential benefits of these family therapies (Bry, et al., 1998; Dusenbury, 2000). Future work may also profit from a greater incorporation of youth-focused components that are tailored to the social and developmental changes taking place in childhood and adolescence (Ferrer-Wreder, et al., 2003).
Community Awareness: Policy and Norms
Limiting a young person's access to alcohol and tobacco through community initiatives and policy change and enforcement has taken on renewed efforts (Ferrer-Wreder, et al., 2003). Using policy as an instrument for prevention is largely based on the premise that this approach has the potential to yield population level changes in youth problem behavior and adult conduct (Ferrer-Wreder, et al., 2003). Analyses of public policy related to alcohol- and tobacco- purchase and consumption offer evidence that policy change and enforcement can be an effective deterrent (Holder, et al., 1998; Holder and Wagenaar, 1994). Well-tested, efficacious community focused interventions include Project Northland, Midwestern Prevention Project, and Communities Motivated for Change on Alcohol (CMCA). CMCA has proven that effectively limiting the access to alcohol to people under the legal drinking age not only directly reduces teen drinking but also communicates a clear message to the community that underage drinking is inappropriate and unacceptable. CMCA employs a range of social organizing techniques to address legal, institutional, social, and health issues to reduce youth alcohol use by eliminating illegal alcohol sales to youths by retailers and obstructing the provision of alcohol to youths by adults.
MORE INTENSIVE INITIATIVES
While prevention efforts have made great strides in helping stem the risks that lead to substance abuse, there is still high prevalence of substance use and addiction among American youth. According to the Center for Substance Abuse Treatment, addicted people can be helped through comprehensive programs that specifically target the factors associated with substance abuse (U.S. Department of Health and Human Services, 2004). Whether treatment occurs in detention, prison, jail or community settings, evidence shows that effective treatment programming can empower addicted young people to overcome their substance abuse, lead crime-free lives, and become productive citizens.
The key to success to many of these treatment initiatives has been promoting buy-in from all stakeholders, staffing with well-trained providers, encouraging excellent communication between the interested parties (Castellano and Beck, 1991). Further, for treating juvenile offenders, providing adequate aftercare and involving participants' families in the transition is also critical.
Wraparound
Wraparound initiatives have produced promising results in providing support, guidance, and services to at-risk youth and juvenile offenders with substance-use related issues. Wraparound offers a highly structured, integrated services environment that, when well run and staffed by committed individuals, have the potential to offer positive benefits for all.
Baltimore's Choice Program and San Francisco's Detention Diversion Advocacy Program are two examples of programs that have produced promising results by providing at-risk youth and juvenile offenders with intensive supervision and individualized treatment plans. This complex, multifaceted intervention strategy is designed to keep delinquent youth at home and out of institutions whenever possible. Rather than forcing these young people to enroll in pre-determined, inflexible treatment programs these initiatives involve "wrapping" a comprehensive array of individualized services and support networks "around" young people, (Bruns, et al., 2004). A care coordinator assembles and leads child and family teams consisting of family members, paid service providers, and community members (such as teachers and mentors), who know the youth under treatment and are familiar with his or her changing needs. These teams work together to ensure that the individual child's needs are being met across all domains-in the home, the educational sphere, and the broader community at large.
Treatment Centers: Therapeutic Communities and Residential Treatment Centers.
Recent studies have demonstrated that properly implemented treatment programs for juvenile offenders can have a significant impact on both the substance abuse and recidivism rates of incarcerated youth. A recent analysis of Maryland's CREST program indicates that the program significantly increases participants' likelihood of remaining drug free (Mello, 1997). Two analyses of Arizona's Amity TC program (which features an intensive aftercare component) have also found a marked decrease in both substance abuse and rearrest rates for up to 24 months after leaving prison (Mullen et al., 1991; Wexler, 1999). Subjects in the Wexler study had a rearrest rate of 26.9 percent versus a rate of 40.9 percent for nontreatment offenders. Results such as these suggest that TC programs, while challenging to implement in many correctional settings, are nevertheless worth further investigation and refinement. To locate a center see: SAMHSA facility locator
Juvenile Drug Courts
Juvenile drug courts (JDC) are intensive treatment programs established within and supervised by juvenile courts to provide specialized services for eligible drug-involved youth and their families. Drug courts were developed in response to rising levels of drug-related crime and implemented in order to address the complex issues underlying substance abuse. The goals of JDC are to use the law as a therapeutic agent in order stem the tide of young drug offenders flowing into the system, habilitate those already in the system, and reduce recidivism among released offenders.
JDC is a problem-solving partnership where courts work closely with a wide range of stakeholders. The team is comprised of representatives from treatment, juvenile justice, social services, school and vocational training programs, law enforcement, probation, the prosecution, and the defense. Together, the team determines how best to address the substance abuse and related problems of the youth and his or her family (BJA, 2003).
Maine is one of the few States to successfully implement a statewide system of juvenile drug courts. Maine currently operates six juvenile drug courts serving seven counties. The program runs about 50 weeks and in four phases, each with distinct treatment goals and specified completion times. Participants are required to attend drug treatment, weekly court appearances, and attend meetings with a drug treatment court manager. To advance to the next phase, participants must have a specified number of weeks of clean alcohol and drug tests and no unexcused absences from treatment or court appearances. In addition to treatment for substance abuse, the program offers a variety of other services, such as educational programming, job training, mental health services, and recreational planning (Anspach, Ferguson, and Phillips, 2003). In a review of over 35 drug courts, results show short-term positive effects while the youth remain in the program however long-term results while encouraging are still yet to be seen (Belenko, 2001).
References
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