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Treatment of Adolescents With Substance Use Disorders
Treatment Improvement Protocol (TIP) Series 32

[Figures]

Figure 1-1: Perceived Risk of Harm From and Use of Marijuana Among High School Students, 1991 and 1995

Figure 1-2: Contrasts Between Confrontation of Denial and Motivational Interviewing

Figure 1-2 Contrasts Between Confrontation of Denial and Motivational Interviewing
Confrontation of denial approach	Motivational interviewing approach
Heavy emphasis on acceptance of self as having a problem; acceptance of diagnosis seen as essential for change	De-emphasis on labels; acceptance of "alcoholism" or other labels seen as unnecessary for change to occur
Emphasis on personality pathology, which reduces personal choice, judgment, and control	Emphasis on personal choice and responsibility for deciding future behavior
Therapist presents perceived evidence of problems in an attempt to convince the client to accept the diagnosis	Therapist conducts objective evaluation, but focuses on eliciting the client's own concerns
Resistance is seen as "denial," a trait characteristic requiring confrontation	Resistance is seen as an interpersonal behavior pattern influenced by the therapist's behavior
Resistance is met with argumentation and correction	Resistance is met with reflection
Goals of treatment and strategies for change are prescribed for the client by the therapist; client is seen as "in denial" and incapable of making sound decisions	Treatment goals and change strategies are negotiated between client and therapist, based on data and acceptability; client's involvement in and acceptance of goals are seen as vital
Source: Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991. p. 53. Reprinted with permission.

Figure 2-1: Treatment Stages and the Problem Severity Continuum

Figure 2-2: Adolescent Development: General Features of Early and Later Stages

Figure 2-2 Adolescent Development: General Features of Early and Later Stages
	Early Adolescence	Later Adolescence
Cognitive Thinking	Concrete Thinking: Emphasizes immediate reactions to behavior May not be fully aware of later consequences	More Abstract Thinking: Greater use of inductive/deductive reasoning More introspective and more sensitive to later consequences
Task Areas Family independence	Beginning rejection of parental guidelines Ambivalence about wishes (dependence/independence)	Insistence on independence, privacy May have overt rebellion or sulky withdrawal; limits are often tested
Peers--Social and Sexual	Most often "best" friend is same sex Boy-girl fantasies; little if any sexual experimentation	Dating, intense interest in opposite sex; sexual experimentation normal Risk-taking common Need to please significant peers of either sex heightens
School and Vacation	Structured school setting preferred	Beginning to identify skills, interests Starting part-time job
Self-Perception Identity Social Responsibility Values	Emphasis on "Am I normal?" Tendency to use denial ("It can't happen to me")	Conformity--behavior that meets peer group values Some continue to pursue group/peer acceptance Some are able to reject group pressure if not in self-interest
Professional Approach To retain sanity, staff should Like teenagers Understand development Be flexible Keep a sense of humor	Provide firm, direct support Convey limits--simple concrete choices Do not align with parents, but do be an objective caring adult Encourage transference (hero-worship) Sexual decisions--directly encourage to wait Encourage parental presence in clinic, but interview teen alone	Be an objective sounding board (but let adolescents solve own problems) Negotiate choices Be role model Don't get too much history ("grandiose stories") Confront gently--about consequences, responsibilities Consider "What gives them status in the eyes of peers?" Use peer group sessions Adapt systems to crises, walk-ins, impulsiveness, testing Ensure confidentiality Allow teens to seek care independently

Figure 2-3: Client Assessment Criteria

Figure 2-3 Client Assessment Criteria
Type of Treatment	Use Pattern	Medical Concerns	Intrapersonal	Interpersonal	Environmental
Primary prevention	No history of use No current use	Not applicable	Developmentally appropriate Effective coping skills Moderate-to-high emotional/cognitive functioning	Demonstrates developmentally appropriate, prosocial interpersonal behavior Maintains responsible relationships with significant others	May have no significant impact
Anticipatory guidance and support	Positive history of use No current use	Not applicable	Less effective coping skills, but competent emotional and cognitive functioning	Demonstrates developmentally appropriate prosocial interpersonal behavior Maintains responsible relationships with significant others History of substance use and/or other risk-related behaviors that increase the potential for developing a psychoactive substance use disorder (PSUD) Able to function in a nonstructured setting	One or more environmental/con-textual factors that increase personal vulnerability (family history of substance use disorders)
Brief office intervention	Problem resulting from use Low-to-moderate current use	No anticipated withdrawal	High-risk peer group Still able to function in nonstructured setting	Maintains responsible relationships with significant others	One or more environmental risk factors
Outpatient treatment	Problem(s) resulting from use or low-to-moderate current use	Low-to-moderate use without anticipated withdrawal	Less effective coping skills Less competent emotional/cognitive functioning Still able to function in a nonstructured setting	Identified deficiencies in relationships with significant others and history of substance use and/or other risk-related behaviors that increase the potential for developing a PSUD Able to function in a nonstructured setting	Environmental/ contextual factors affect the individual but do not warrant removal from current living situation Needs to be supported by minimal treatment
Intensive outpatient treatment	Problem(s) resulting from use Moderate-to-heavy recent use	Subacute toxicity Social support for detoxification Compliance regimen	Ineffective but functional coping skills Less competent emotional/cognitive functioning Requires marginally structured setting	Identified deficiencies in relationships with significant others and history of substance use and/or other risk-related behaviors that increase the poten-tial for developing a PSUD Requires marginally structured setting	Environmental/ contextual factors impact the individual but do not warrant removal from current living situation Needs to be supported by moderate treatment
Day treatment partial hospitalization	Problem(s) resulting from use Moderate-to-heavy recent use	Premorbid/sub-acute toxicity Compliant with detoxification regimen	Ineffective but functional coping skills Less competent emotional/cognitive functioning Requires moderately structured setting	Identified deficiencies in relationships with significant others and history of substance use or other behaviors that place individuals at risk for developing PSUD Requires moderately structured setting	Environmental/ contextual factors impact the individual but do not warrant removal from current living situation Needs to be supported by intensive treatment
Medically monitored intensive inpatient	Problem(s) resulting from use Moderate-to-heavy recent use	Premorbid subacute toxicity requiring 24-hour medical monitoring Other medical concerns that cannot be handled with outpatient treatment	Dysfunctional coping skills Emotional/cognitive/ psychiatric impairment requiring 24-hour structured setting	Dysfunctional relationships and behaviors that do not pose an immediate threat to self and/or others but that require 24-hour structured care	Environmental/ contextual factors dictate individual must be removed from adverse influences of the current living situation
Medically managed intensive inpatient	Problem(s) resulting from use Moderate-to- heavy recent use	Morbid, acute toxicity (overdose) that may require life support All medically complicating conditions, including those requiring life sup-port/intensive care	Dysfunctional coping skills Emotional/cognitive/ psychiatric impairment requiring 24-hour structured care and continuous psychiatric monitoring	Dysfunctional relationships and behaviors that may pose an immediate threat to self and/or others and that require 24-hour structured care and psychiatric management	Environmental/ contextual factors dictate individual must be removed from adverse influences of the current living situation
Intensive residential treatment	Problems resulting from use No recent moderate-to-heavy use	No detoxification required Medical conditions that cannot be handled with outpatient medical management and/or which do not require life support/intensive treatment services	Dysfunctional coping skills Emotional/cognitive/ psychiatric impairment Requires long-term residential treatment, including psychiatric and activities of daily living (ADL) services	Dysfunctional relationships and behaviors that do not pose an immediate threat to self and/or others but which require 24-hour structured care, including ADL services and possibly psychiatric services Behavior manageable within a structured setting	Environmental/ contextual factors dictate individual must be removed from adverse influences of the current living situation
Residential psychosocial care	Problems resulting from use No recent moderate-to-heavy use	Detoxification services not required No special medical services required on site	Dysfunctional coping skills Emotional/cognitive/ psychiatric impairment Requires supervision in structured setting, ADL, and other psychosocial rehabilitation	Dysfunctional relationships and behaviors that do not pose an immediate threat to self and/or others but which require behavior management within a structured setting which provides supervision, ADL, and other psychosocial rehabilitation	Environmental/ contextual factors dictate individual must be removed from adverse influences of current living situation
Halfway house	Problems resulting from use No recent moderate-to-heavy use	Detoxification services not required No special medical services required on site	Adequate coping skills Has moderate-to-high level of emotional/ cognitive functioning but requires some supervision	Ability to establish prosocial relationships that support recovery Able to self-regulate behavior with minimal structure/supervision	Environmental/ contextual factors dictate individual must be removed from current living situation, or other adverse circumstances
Group home/ group living	Problems resulting from use No recent moderate-to-heavy use	Detoxification services not required No special medical services required on site	Adequate coping skills Has moderate-to-high level of emotional/ cognitive functioning Able to live independently	Ability to establish prosocial relationships that support recovery Self-regulates behavior consistent with standards of responsible group living without supervision	Environmental/ contextual factors dictate individual must be removed from current living situation, or other adverse circumstances

Figure 7-1: Status of Drug Courts in the United States

Figure 7-1 Status of Drug Courts in the United States
	Adolescent Programs	Adult Programs
Estimated total number of individuals who have enrolled	850^a	45,000^b
Average retention rates	96 percent^c	70 percent^c
^aBased on 13 active programs ^bBased on 99 active programs ^cBased on number of graduates and active participants in comparison with total participants enrolled

Figure 7-2: Number of Drug Court Programs Underway/Planned

Figure 8-1: Decision Tree

Figure 8-2: Sample Consent Form

Figure 8-2 Sample Consent Form
Consent for the Release of Confidential Information
I, ___________________________, authorize XYZ Clinic to receive (name of client or participant)
from/disclose to ________________________________________ (name of person and organization)
for the purpose of _______________________________________ (need for disclosure)
the following information__________________________________ (nature of the disclosure)
I understand that my records are protected under the Federal and State Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires automatically on ____________________ unless otherwise specified below. (date, condition, or event)
Other expiration specifications:
_________________________ Date executed
_________________________ Signature of client
________________________ Signature of parent or guardian, where required

Figure 8-3: Consent Form: Criminal Justice System Referral

Figure 8-3 Consent Form: Criminal Justice System Referral
Consent for the Release of Confidential Information
I, _____________________________, hereby consent to communication (name of defendant)
between __________________________________________________ and (treatment program)
______________________________________________________________ (court, probation, parole, and/or other referring agency)
the following information______________________________________ (nature of the information, as limited as possible)
The purpose of and need for the disclosure is to inform the criminal justice agency(ies) listed above of my attendance and progress in treatment. The extent of information to be disclosed is my diagnosis, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program prognosis, and
I understand that this consent will remain in effect and cannot be revoked by me until: _____ There has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment or _____ (other time when consent can be revoked and/or expires)
I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records and that recipients of this information may redisclose it only in connection with their official duties.
____________________________ (Date)
____________________________ (Signature of defendant/patient)
____________________________ (Signature of parent, guardian, or authorized representative if required)

Figure 8-4: Qualified Service Organization Agreement

Figure 8-4 Qualified Service Organization Agreement
XYZ Service Center ("the Center") and the _______________________________ (name of the program)
("the Program") hereby enter into a qualified service organization agreement, whereby the Center agrees to provide (nature of services to be provided)
Furthermore, the Center: (1) acknowledges that in receiving, storing, processing, or otherwise dealing with any information from the Program about the clients in the Program, it is fully bound by the provisions of the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Client Records, 42 C.F.R. Part 2; and (2) undertakes to resist in judicial proceedings any effort to obtain access to information pertaining to clients otherwise than as expressly provided for in the Federal Confidentiality Regulations, 42 C.F.R. Part 2.
Executed this ____________ day of _____________________, 199_____ __________________________ President XYZ Service Center [address] __________________________ Program Director [name of program] [address]

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	Center for Mental Health Services
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	Center for Substance Abuse Treatment

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Español: (877) 767-8432

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Treatment of Adolescents With Substance Use Disorders Treatment Improvement Protocol (TIP) Series 32

[Figures]

Treatment of Adolescents With Substance Use Disorders
Treatment Improvement Protocol (TIP) Series 32