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Journal Issue: Juvenile Justice Volume 18 Number 2 Fall 2008

Juvenile Justice and Substance Use
Authors: Laurie Chassin

Does Treatment in Juvenile Justice Settings Use "Best Practices?"

Researchers who have examined substance use treatment have found that no single treatment produces the best outcome. Instead, several treatments, including Multisystemic Therapy, cognitive-behavioral therapy, contingency management, family therapy, motivational enhancement, and residential therapeutic communities, have shown some (although mixed) success. Because no one method of treatment is clearly superior, recommendations for "best practices" have focused on the treatment dimensions associated with more favorable outcomes. These "best practices" have been derived from a combination of empirical evidence and professional consensus.

In 2006 the National Institute on Drug Abuse (NIDA) issued thirteen principles of drug abuse treatment for criminal justice populations, including both adults and adolescents.69 These principles begin with the premise that drug addiction is a brain disease because drug use changes neural mechanisms associated with reward and self-regulation, and these changes in turn increase the likelihood of relapse. The NIDA principles also state that recovery from addiction requires effective treatment followed by management of the problem over time (often including multiple treatments). Treatment must last long enough to produce stable behavioral changes, and individuals with severe drug problems and co-occurring disorders may require longer treatment (three months or more) as well as requiring more comprehensive services. The NIDA principles propose that assessment of the problem (including mental health evaluation) should be the first step in treatment planning and that treatment must then be tailored to the needs of the individual (including differences in age, gender, ethnicity, culture, problem severity, recovery stage, and level of supervision that is required by the justice system). Drug use during treatment should be carefully monitored. Drug treatment in the justice system should target factors that are associated with criminal behavior (including beliefs and attitudes that promote criminal offending), and criminal justice supervision should incorporate treatment planning. The NIDA principles recognize the importance of continuity of care during community re-entry and the use of a balanced mix of rewards and sanctions to encourage treatment participation and prosocial behavior. Medications are thought to be an important part of treatment for many offenders, and those with co-occurring mental health problems require an integrated treatment approach. Finally, because of the link between substance use and broader risk behaviors, treatment planning should include strategies to prevent and treat medical conditions such as HIV/AIDS, hepatitis B and C, and tuberculosis.

These NIDA principles apply to criminal justice populations, but are not specific to adolescents. For example, little is known about the use of medications to treat adolescent substance use disorders, and medications are less commonly used in adolescent than in adult treatment.

The American Academy of Child and Adolescent Psychiatry (AACAP) has also issued a set of minimum standards of care for the treatment of adolescent substance use disorders, which include: an appropriate level of confidentiality, screening older children and adolescents for substance use, formal evaluation (including biological measures) for those with positive screens, specific treatment for disorders of those who meet diagnostic criteria, treatment in the least restrictive setting that is safe and effective, family involvement in treatment, and assessment and treatment of co-occurring disorders.70 Although not required as minimal standards, the AACAP also suggests that treatment programs develop procedures to minimize dropout and maximize compliance, encourage and develop peer support for not using substances, use twelve-step programs as an adjunct to professional treatment, provide services in associated areas like education, vocational training, and medical and legal issues, and, finally, arrange for aftercare. These guidelines overlap substantially, but not completely, with the NIDA principles. For example, they do not mention the role of medications. The standards are meant to apply to adolescents, but are not specific to adolescents in the justice system, for whom such issues as maintaining confidentiality are more complex.

Recently a set of quality elements that constitute "best practices" in adolescent substance abuse treatment has been developed for services specifically within the juvenile justice system.71 The recommendations, which emerged from a review of empirical research and the consensus of an expert panel, converge substantially with the NIDA and AACAP principles. These quality elements include: assessment and treatment matching; a comprehensive, integrated treatment approach; family involvement in treatment; developmentally appropriate programming; engagement and retention of adolescents in treatment; qualified staff; gender and cultural competence; continuing care; and measurement of treatment outcomes. A subset of quality elements based on empirical evidence (rather than professional consensus) has also been identified. It includes treatment orientation (for example, cognitive-behavioral or standardized evidence-based intervention, or therapeutic community), use of a standardized risk assessment tool, continuing care, engagement techniques (for example, motivational interviewing), ninety-day duration, and family involvement.72

Do the services now delivered within the juvenile justice system incorporate these best practices? A study by Craig Henderson and several colleagues considered both secure confinement settings and community-based non-residential programs and found that, on average, the programs scored 5.5 out of a possible 10 in the use of effective practices.73 Although the program response rates were low and were limited to self-reports of program directors, they do provide one estimate of the extent to which the juvenile correctional system is implementing effective practices. Moreover, the level of implementation found by the study is quite similar to that found in a survey of 144 "highly regarded" adolescent treatment programs, which were not specific to the juvenile justice system, and which scored an average of 23.8 out of a possible 45 in the use of these elements.74 Thus, adolescent treatment programs, whether inside or outside the justice system, do not routinely incorporate a majority of "best practices." Many justice system programs reported using several of the quality indicators. In the study by Henderson and colleagues cited above, more than two-thirds of programs reported having systems integration, qualified staff, standardized assessment, family involvement in treatment, treatment to address co-occurring disorders, and use of engagement techniques to motivate treatment retention. Only 10.7 percent of programs used developmentally appropriate treatment, 25.4 percent made use of continuing care, 41.8 percent used comprehensive services, and 59 percent used assessment of treatment outcomes. Program features that have been associated with greater use of "best practices" include community programs (compared to institutions), network connectedness (having connections both with other criminal justice and with non-justice system facilities), and the level of program resources and training environment.75

These findings pinpoint several ways in which treatment within the juvenile justice system is failing to incorporate "best practices." Particularly striking are the low levels of continuing care services and comprehensive services. Henderson and colleagues interpret these findings to mean that agencies use effective practices that they can implement within their own setting, but that they have difficulty using best practices that require working jointly with other agencies. The finding of very low levels of developmentally appropriate services is somewhat surprising, and warrants replication. However, consistent with a relative neglect of developmental appropriateness of services, it has been reported that (as of 2002) no state in the United States had provisions for adolescent-specific provider certification, and the National Association of Alcoholism and Drug Abuse Counselors had no adolescent-specific requirements as of 2004.76 Finally, no study to date has assessed the use of "best practices" concerning gender or cultural competence, probably because little is yet known about how to tailor treatment of adolescent substance use disorders with respect to cultural competence or gender or about the results of such tailoring.77