[Senate Hearing 108-749]
[From the U.S. Government Publishing Office]
S. Hrg. 108-749
PROVIDING SUBSTANCE ABUSE PREVENTION AND TREATMENT SERVICES TO
ADOLESCENTS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON SUBSTANCE ABUSE AND
MENTAL HEALTH SERVICES
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
ON
EXAMINING SUBSTANCE ABUSE PREVENTION AND TREATMENT SERVICES FOR
ADOLESCENTS, FOCUSING ON THE EFFECTS OF BINGE DRINKING, AND MONTHLY
CIGARETTE, BEER, AND MARIJUANA USAGE, AND THE DEVELOPMENTS OF THE
JUVENILE TREATMENT NETWORK
__________
JUNE 15, 2004
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
U.S. GOVERNMENT PRINTING OFFICE
94-384 PDF WASHINGTON : 2005
_____________________________________________________________________________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
JUDD GREGG, New Hampshire, Chairman
BILL FRIST, Tennessee EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama PATTY MURRAY, Washington
JOHN ENSIGN, Nevada JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia HILLARY RODHAM CLINTON, New York
Sharon R. Soderstrom, Staff Director
J. Michael Myers, Minority Staff Director and Chief Counsel
______
Subcommittee on Substance Abuse and Mental Health Services
MIKE DeWINE, Ohio, Chairman
MICHAEL B. ENZI, Wyoming EDWARD M. KENNEDY, Massachusetts
JEFF SESSIONS, Alabama JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada JACK REED, Rhode Island
Karla Carpenter, Staff Director
David Nexon, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
TUESDAY, JUNE 15, 2004
Page
DeWine, Hon. Mike, a U.S. Senator from the State of Ohio, opening
statement...................................................... 1
Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island,
opening statement.............................................. 2
Kennedy, Hon. Edward M., a U.S. Senator from the State of
Massachusetts, prepared statement.............................. 3
Curie, Charles G., Administrator, Substance abuse and Mental
Health Services Administration, U.S. Department of Health and
Human Services................................................. 5
Prepared statement........................................... 7
Brown, Sandra A., Professor of Psychology and Psychiatry,
University of California-San Diego; Chief of Psychology
Services, Veterans Affairs San Diego Health Care Systems;
Associate Director, Child and Adolescent Services Research
Center, Children's Hospital of San Diego; Roger Weissberg,
Department of Psychology, University of Illinois at Chicago,
Executive Director, Collaborative for Academic, Social and
Emotional Learning; Rhonda Ramsey-Molina, President and CEO,
Coalition for a Drug-Free Greater Cincinnati; Ronald Anton,
Director of Juvenile Justice and Community Programs, Day One;
and Kris Shipley, Pasadena, MD................................. 17
Prepared statements of:
Sandra A. Brown.......................................... 19
Roger P. Weissberg, Ph.D................................. 51
Rhonda Ramsey-Molina..................................... 59
Ronald Anton............................................. 65
Kris Shipley............................................. 112
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Adolescence and The Trajectory of Alcohol Use: Basic to
Clinical Studies........................................... 23
Neurocognitive Functioning of Adolescents: Effects of
Protracted Alcohol Use..................................... 30
Neural Response to Alcohol Stimuli in Adolescents With
Alcohol Use Disorder....................................... 41
Norman G. Hoffmann, Ph.D. Ana M. Abrantes, Ph.D. and Ronald
Anton, LCPC, LADC, MAC..................................... 70
Juvenile Automated Substance Abuse Evaluation (JASAE)........ 77
Practical Adolescent Dual Diagnostic Interview (PADDI)....... 107
The Alliance for Consumer Education (ACE).................... 122
Mary Melton, Ph.D., MBA...................................... 125
(iii)
PROVIDING SUBSTANCE ABUSE PREVENTION AND TREATMENT SERVICES TO
ADOLESCENTS
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TUESDAY, JUNE 15, 2004
U.S. Senate,
Subcommittee on Substance Abuse and Mental Health Services,
of the Committee on Health, Education, Labor and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:17 a.m., in
room SD-430, Dirksen Senate Office Building, Hon. Mike DeWine
(chairman of the subcommittee) presiding.
Present: Senators DeWine and Reed.
Opening Statement of Senator DeWine
Senator DeWine. Our hearing will come to order.
Thank you all for being here today. My colleague, Senator
Reed from Rhode Island, will be here in a moment. Let me thank
him for his continued dedication to issues affecting children
and adolescents. Senator Reed is certainly a great advocate for
youth in need.
Today, we are meeting to talk about substance abuse
prevention and treatment issues concerning adolescents. We all
know that alcohol and drug abuse and dependence represent major
problems for young people in this country. Providing effective
services to adolescents is particularly challenging. Despite
the best efforts across the field, much remains to be learned
about the types and mix of services and strategies that are
most effective in preventing and treating youth with alcohol
and drug problems.
Some data highlight this challenge: the most recent
information we have from the National Household Survey on Drug
Use and Health shows that 11.6 percent of youth aged 12 to 17
currently use illegal drugs; 20.2 percent of those aged 18 to
25 currently use illegal drugs. Marijuana is the drug used by
the majority of these young people.
Of those aged 12 to 20, 28.8 percent are current alcohol
users, with 19.3 percent of this age group having binged within
the last month--that is defined as five or more drinks on a
single occasion--while 6.2 percent can be considered heavy
drinkers.
Research has shown that prevention can be very effective.
Comprehensive, community-based approaches, combining
individually focused strategies with more ``environmental''
approaches, have yielded very positive results in communities
around the country. Yet, as we can see in the data I just
mentioned, we have a lot of work to do.
If our prevention efforts fail, we must provide treatment
services to address substance abuse among our youth. Yet, the
Household Survey reveals a crisis in this area as well. For
example, 2.3 million youth aged 12 to 17, (9.1 percent of that
total age group) needed treatment, yet only 187,000 (8 percent
of the total) received services.
Clearly, we need to do much better. I am glad to say that
there is some good news. Results from the 2003 monitoring and
future surveys show an 11 percent decline in drug use by 8th,
10th and 12th grade students over the past 2 years. This
decline correlates with data showing a shift in youth attitudes
about drug use. The perceived risk of using drugs, especially
marijuana, continues to increase among youth.
As important as our focus on illegal drugs is and must
continue to be, we know that alcohol is the primary substance
of abuse among young people and that it is a contributor to the
three leading causes of death among this population:
unintentional injuries, such as traffic crashes, homicide, and
suicide.
The annual societal cost of underage drinking has been
estimated at over $50 billion per year. That is why I am
working with Senator Dodd and five members of the House on a
bipartisan, bicameral bill specifically addressing underage
drinking prevention. We hope to introduce that bill soon.
Further research now is showing that substance abuse and
dependence among our youth can be characterized as a
developmental disorder. The prevalence of alcohol and drug
dependence actually peaks in the 18 to 25 age group, and of
course, a co-occurrence of major mental health disorders such
as depression and bipolar disorder is also an important factor
as well.
With this important challenge, we must act on what these
data tell us. Research must continue to search for answers and
services based on what we have learned from that research must
receive adequate funding. If we fail our youth in their
developmental years, we may be condemning them to a life of
difficulty and lowered expectations.
That is why I am committed to doing what I can to prevent
that from happening. I believe that from this hearing, we can
learn more specifically what the state-of-the-art is in
adolescent prevention and treatment. I believe we also can
learn the important gaps in our knowledge, the particular
challenges and difficulties faced by government, providers,
communities and families and what we might do to assist or
facilitate in developing a broader, more effective system
focusing on adolescents' needs.
Let me at this point turn to Senator Reed for any opening
comments.
Opening Statement of Senator Reed
Senator Reed. Thank you very much, Mr. Chairman. Let me
again commend you for holding this hearing.
You and your staff have been scheduling some very important
and very significant hearings, and I thank you for the
opportunity to participate. As we all know, the problem of
adolescent substance abuse is a grave one. Nearly 20 million
children age 12 and older are currently using illicit drugs.
This represents almost 10 percent of the adolescent population,
and when we factor in the presence of comorbid conditions such
as depression in these children, these statistics are
staggering.
The issue here is not simply that so many adolescents are
affected but that we are doing so little to help the vast
majority of these children. On average, States are only able to
treat 8 percent of those in need of substance abuse services.
Access to care is a critical issue for these adolescents.
In Rhode Island, as in most communities in this country, a
lack of providers, combined with limited substance abuse
treatment programs and virtually nonexistent residential
treatment facilities has left families with nowhere to turn.
Some families in Rhode Island are forced to travel as far as
Arizona and Maine because they cannot get their children into a
suitable residential treatment facility in our own State.
A particularly alarming finding is the lack of services for
youth transitioning out of juvenile justice facilities and back
into the community. Despite substantial evidence that as many
as 60 percent of juvenile offenders have a substance abuse
problem, and despite evidence that proper treatment reduces
recidivism by as much as 75 percent, this high risk population
is left largely untreated.
In the past, we did not comprehend the prevalence of
substance abuse by our adolescents, and we certainly did not
know how to help these children. Today, however, we have made
great strides at understanding these illnesses. We have
developed effective treatments, and we now can help many of
these children to live much better lives.
Although more research and medical advancement are always
needed, we must act to help youngsters currently coping with
substance abuse problems. I look forward to the panel's
testimony, and I thank the chairman again for holding this
hearing.
Thank you, Mr. Chairman.
Senator DeWine. At this time I would like to submit Senator
Kennedy's statement for the record.
[The prepared statement of Senator Kennedy follows:]
Prepared Statement of Senator Edward M. Kennedy
One of our major priorities in this committee is to do more
to see that all children in communities have access to vital
health services. Preventing and treating substance abuse
addiction is an essential part of protecting their potential to
succeed and lead productive lives.
On some health issues, the Federal, State and local
response has produced significant progress. We can see the
results in lower smoking rates and in other quantifiable ways.
But alcohol and drug use continue to plague our communities,
especially college communities.
Adults who began alcohol, tobacco or drug use before the
age of 21 are far more likely to become addicted. The number of
young people who initiate drug use at a very early age is
alarming. In Massachusetts, according to a recent study, 20
percent of youth had their first cigarette, 28 percent had
their first alcoholic drink, and 12 percent had used marijuana
before turning 13. Nationally, one in five persons from ages 12
to 20 had engaged in binge drinking.
Reaching children and adolescents effectively means more
than just making contact. It means providing prevention
services that are science-based and effective. It means
following up with later sessions, so the lessons won't be lost.
And it means involving schools, families and local agencies in
prevention efforts.
Schools are particularly important, because children are
most accessible there. Yet few schools use proven and effective
prevention curricula. Instead, they typically rely on a
patchwork of programs with no consistent approach.
Interactive programs specifically tailored to a school's
demographics are highly effective. Programs focused on single
drugs are more effective than general anti-drug programs. If we
build on proven approaches, we can have a nation-wide
initiative to make the best prevention practices available to
every school in the country.
On treatment, we're still learning what works, but we know
we have to involve communities more effectively in the effort--
from schools, to law enforcement to health providers. Research
is needed on what interventions work best. The goal is to have
individualized and age-appropriate treatment for every child
and adolescent who needs it. If necessary, treatment for
substance abuse should go hand in hand with treatment for
emotional disorders. Treating one without the other means
almost certain failure. Screening and assessing are important
too, so that youths are less likely to be overlooked.
Recovery has to be the goal for anyone with an identified
addiction. Again, building on best practice models across the
country, we can end the shameful nationwide disparities that
exist today and make our goals a reality for far more students.
We'll hear today from Administrator Charles Curie of the
Substance Abuse and Mental Health Services Administration,
which is coordinating the Federal response through its block
grant and other programs. The continuum of care provided under
those programs can change lives in every State.
We'll also hear today from academic experts, from hands-on
program directors, and from a brave former consumer who can
speak to these and other issues.
I thank all of our witnesses and I look forward to their
testimony.
Senator DeWine. For our first panel this morning, I would
like to introduce Charles Curie, Administrator of the Substance
Abuse and Mental Health Services Administration. He has served
in this role since October 2001. He reports directly to Health
and Human Services Secretary Tommy Thompson and leads the $3.2
billion agency responsible for improving the accountability,
capacity and effectiveness of our Nation's substance abuse
prevention, addictions treatment and mental health services.
Good to see you again.
STATEMENT OF CHARLES CURIE, ADMINISTRATOR, SUBSTANCE ABUSE AND
MENTAL HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Mr. Curie. Good to see you, Mr. Chairman.
Senator DeWine. Thank you very much.
Mr. Curie. Thank you so much, and thank you, Senator Reed,
as well, for this opportunity today. As you said, I am Charles
Curie, the Administrator of what is known as SAMHSA in the
Department of Health and Human Services, and I do request that
my formal written testimony be submitted to the record.
Senator DeWine. That will be made a part of the record.
Mr. Curie. Thank you.
Again, today, we have an opportunity to describe how we are
working together to provide effective substance abuse treatment
to people who want and need it, including young Americans. Drug
abuse, as you have both indicated, is a major public health
problem. Overall, there are an estimated 22 million Americans
aged 12 and older struggling with a drug or alcohol problem.
Among adults 18 and older with a serious substance abuse
problem, again, just over 20 percent have a co-occurring
serious mental illness. Addiction often begins during childhood
and adolescence, and research shows that while substance abuse
was once thought to be an adult onset disease, as you indicated
in your remarks, Mr. Chairman, it actually is a developmental
disease. And there is a clear correlation between the age of
first use of drugs and alcohol and the potential for developing
a serious problem.
For example, one-third, 2.3 million, of alcohol-dependent
adults aged 21 or older in 2002 had first used alcohol before
the age of 14. Over 80 percent, 5.8 million, had first used
alcohol before they were aged 18, and 96 percent, 6.6 million,
had first used alcohol before the age of 21.
The rate of dependence for those who first drank at age 21
or older was only 1 percent. Conversely, 99 percent of adults
21 or older who first drank alcohol at 21 or older do not have
a dependence problem. It is plain to see why improving
treatment services for adolescents and ratcheting up prevention
programs targeted at this age group are top priorities for
SAMHSA.
During my tenure, we have restructured our work around the
vision of a life in the community for everyone, and our
mission, building resilience and facilitating recovery. To
focus and guide our program development and resources, we have
developed a matrix of program priorities and cross-cutting
management principles. Two priorities I want to highlight for
you are prevention and treatment of adolescent substance abuse.
On our matrix, you will see Strategic Prevention Framework.
Through this framework, we are working to more effectively and
efficiently align our prevention resources. Fortunately, we
know more about what works in prevention, education and
treatment than ever before. Over the years, we have shown that
prevention programs can and do produce results. Currently, we
have 60 model programs listed in our National Registry of
Effective Programs. These programs yield an average of a 25
percent reduction in substance use.
To help provide a structured approach to prevention that is
based on the best that science has to offer, Secretary Thompson
launched SAMHSA's Strategic Prevention Framework during the
National Healthier U.S. Prevention Summit in Baltimore on April
29th. This new $45 million competitive grant program will
enable States, territories and the District of Columbia to
bring together multiple funding streams from multiple sources
to create and sustain a community-based, science-based approach
to substance abuse prevention and mental health prevention and
promotion.
In the area of substance abuse treatment, this year, we
launched the President's Access to Recovery program with a $100
million investment. The administration's commitment to expand
clinical treatment and recovery support services to reach those
in need extends beyond the immediate fiscal year.
Our 2005 request doubles Access to Recovery's appropriation
to $200 million and increases the Substance Abuse Prevention
and Treatment Block Grant by $53 million, for a total of $1.8
billion. Critically, Access to Recovery provides States the
opportunity, if they choose, to target resources to providing
treatment for adolescents. We also support treatment for
adolescents through our Targeted Capacity Expansion Grants.
Each of our efforts, whether through the block grant,
Targeted Capacity Expansion or Access to Recovery to expand
treatment for adolescents are based on the undeniable need. Key
to achieving our goals is developing an ability to report on
meaningful outcomes. These outcome measures must be concise,
purposeful and useful. They must get real outcomes for real
people. We are changing the emphasis from how did you spend the
money, and did you spend the money according to the rules, to
how did you put your dollars to work, and how did your
consumers benefit.
Through an internal data strategy work group, we are
conducting an examination of our data collection and analysis
systems, and a central component is the development of national
outcomes. Through collaboration with the States, we have
identified a key set of domains or national outcomes. These
domains are, one, abstinence from drug use and alcohol abuse or
decreased symptoms from mental illness; two, increased or
retained employment and school enrollment; three, decreased
involvement with the criminal justice system; four, increased
ability in family and housing conditions; five, increased
access to services; six, increased retention in services; and
seven, increased social connectedness to family, friends and
coworkers.
These national outcomes ultimately will be aligned across
all of SAMHSA's programs, including Access to Recovery, the
Community Mental Health Services Block Grant and Substance
Abuse Prevention and Treatment Targeted Capacity Expansion
Grants.
We do know, based on our experience that prevention works,
treatment works. And it helps people triumph over addiction and
leads to recovery. Mr. Chairman and Members of the Committee,
thank you for the opportunity to appear today. I will be
pleased to answer any questions you may have.
[The prepared statement of Mr. Curie follows:]
Prepared Statement of Charles G. Curie, M.A., A.C.S.W.
Mr. Chairman and Members of the Subcommittee, good morning. I am
Charles G. Curie, Administrator of the Substance Abuse and Mental
Health Services Administration (SAMHSA), part of the U.S. Department of
Health and Human Services (HHS).
Thank you for providing me the opportunity to describe how SAMHSA
and our Federal, State, and local community-level partners are working
to provide effective substance abuse treatment to people who want and
need it, including young Americans.
Drug abuse and mental illness are major public health problems that
affect us all. In terms of dollars, substance abuse, including alcohol,
illicit drugs, and tobacco use, costs our Nation more than $484 billion
per year. The economic costs of mental illness are also staggering. The
President's New Freedom Commission on Mental Health reports the cost in
the U.S. from both direct (treatment-related) and indirect
(productivity loss) expenses may exceed $150 billion per year with
rapid annual increases, especially in the drug treatment area. Mental
illnesses, including depression, account for four of the top six causes
of disability among 15-44 year olds in the Western world.
Although not as well known as the deaths due to substance abuse,
mental illnesses are a substantial source of mortality. Of the 30,000
Americans who die by suicide each year, 90 percent have a mental
illness. The fact that deaths from suicide outnumber deaths from
homicide (18,000) is often a surprising finding. Suicide rates are high
among several ethnic minority groups, though it remains highest in
older white males. Between 1952 and 1992, the incidence of suicide
among adolescents and young adults nearly tripled; currently it is the
third-leading cause of death in adolescents. We know that substance use
increases the probability of a person with mental illness attempting
suicide and increases the person's likelihood of succeeding.
Addiction's toll on individuals, their families, and the
communities they live in is a cumulative devastation with a ripple
effect. This ripple effect leads to costly social and public health
problems including HIV/AIDS, domestic violence, child abuse, and crime
in general, as well as accidents and teenage pregnancies.
Addiction often begins during childhood and adolescence. Research
has shown that substance use dependence, while once thought to be an
adult-onset disease, is actually a ``developmental disease.'' It is
developmental in terms of having its start during the early stages of
adolescence and even childhood, when children use drugs or consume
alcohol. The introduction of an illicit drug or of alcohol to the
adolescent brain has a dramatic impact because of the changes occurring
in the brain during this developmental stage.
The data from SAMHSA's 2002 National Survey on Drug Use and Health
provides the scope of the problem. In 2002, there were 2.3 million
youths aged 12 to 17 who needed treatment for an alcohol or illicit
drug problem. Of this group, only 186,000 received treatment. Without
help, it is very likely that these young people, at the very beginning
of their lives, will continue on a destructive path of addiction,
disability, criminal involvement, and premature death.
Overall, there are an estimated 22 million Americans struggling
with a drug or alcohol problem. There is a clear correlation between
age of first use of drugs and alcohol and the potential for developing
a serious problem. For example, in 2000, 18 percent of people age 26
and older who had begun using marijuana before age 15 met the criteria
for either dependence or abuse of alcohol or illicit drugs, compared to
2.1 percent of adults who never used marijuana. Among past year users
of marijuana age 26 and older who had first used marijuana before age
15, 40 percent met the criteria for either dependence or abuse of
alcohol or illicit drugs.
The story is very similar for alcohol. One-third, 2.3 million, of
alcohol-dependent adults age 21 or older in 2002, had first used
alcohol before age 14. Over 80 percent, 5.8 million, had first used
before they were age 18. And 96 percent, 6.6 million, had first used
before age 21. The rate of dependence for those who first drank at age
21 or older was only 1 percent. Conversely, 99 percent of adults 21 and
older who first drank alcohol at age 21 or older do not have a
dependence problem.
It is plain to see why improving treatment services for adolescents
and bolstering prevention programs targeted to this age group are top
priorities for SAMHSA.
THE SAMHSA ROLE
SAMHSA is working to improve how we approach substance abuse
treatment and prevention, not only at the Federal level, but also at
the State and community levels. During my tenure, we have restructured
our work around the vision of ``a life in the community for everyone''
and our mission of ``building resilience and facilitating recovery.''
To focus and to guide our program development and resources, we
have developed a Matrix of program priorities and cross cutting
principles that pinpoints SAMHSA's leadership and management
responsibilities. These responsibilities were developed as a result of
discussions with Members of Congress, our advisory councils,
constituency groups, people working in the field, and people working to
attain and sustain recovery.
The Matrix priorities are also aligned with the priorities of
President Bush and HHS Secretary Tommy Thompson, whose support for our
vision of a life in the community for everyone we appreciate. The
Matrix has produced concrete results by focusing SAMHSA staff and the
field on planting a few ``redwoods'' rather than letting ``a thousand
flowers bloom.'' I see my responsibility as Administrator to make solid
program and management improvements that will last beyond my tenure.
I am proud of our success over the past 2\1/2\ years since I came
to SAMHSA. I believe the SAMHSA Matrix is the underpinning of our
success and has helped us to focus on solid investments in the future
of mental health and substance abuse prevention and treatment services.
In particular, I will highlight the ways we support the prevention and
treatment of adolescent substance abuse.
On our matrix you will see the program ``Strategic Prevention
Framework.'' Through this Framework we are working to more effectively
and efficiently align our prevention resources. The Framework is
aligned with the President's and Secretary Thompson's HealthierUS
initiative. HealthierUS is a plan to improve overall public health by
capitalizing on the power of prevention to help prevent, delay, and/or
reduce disability from chronic disease and illnesses, including
substance abuse and mental illnesses.
I am pleased to report that the most recent data confirms that the
President's 2-year goal to reduce illicit drug use among youth by 10
percent in 2 years has been exceeded, with an 11 percent reduction in
the past 2 years. This is a clear indication that our work with our
many Federal and State partners, along with schools, parents, teachers,
law enforcement, religious leaders, and local community anti-drug
coalitions, is paying off. But our work is far from over, and
prevention is key.
Fortunately, we know more about what works in prevention,
education, and treatment than ever before. Over the years, we have
shown prevention programs can and do produce results. Currently, we
have 60 model programs listed in our National Registry of Effective
Programs. These programs yield, on average, a 25 percent reduction in
substance use and affect a broad range of behavioral issues, from
violence and delinquency to emotional problems. Primary access to the
programs in the Registry is through the SAMHSA Model Programs website.
The website describes and provides contact information for each of the
programs in the Registry (www.modelprograms.samhsa.gov).
Unfortunately, as we all know, individuals, communities, or State
and Federal agencies do not always translate, or make it easy to
translate, into action what is known about prevention. To help provide
a structured approach to substance abuse prevention and mental health
promotion that is based on the best that science has to offer,
Secretary Thompson launched the Strategic Prevention Framework during
the national HealthierUS Prevention Summit in Baltimore on April 29.
This new $45 million competitive grant program will enable States,
Territories, and the District of Columbia to bring together multiple
funding streams from multiple sources to create and sustain a
community-based, science-based approach to substance abuse prevention
and mental health promotion.
The Framework is based on the risk and protective factor approach
to prevention. For example, family conflict, low school readiness, and
poor social skills increase the risk for conduct disorders and
depression, which in turn increase the risk for adolescent substance
abuse, delinquency, and violence. Protective factors such as strong
family bonds, social skills, opportunities for school success, and
involvement in community activities can foster resilience and mitigate
the influence of risk factors.
Clearly, these risk and protective factors exist at several
levels--at the individual level, the family level, in schools, the
community level, and in the broader environment. People working in
communities with young people and adults understand the need to create
an approach to prevention that is citizen centered, cuts across
existing programs and system levels, and has common outcome measures.
Just as when we are promoting exercise and a healthy diet or
advancing vaccination, when we speak about abstinence or rejecting
drugs, tobacco, and alcohol and promote mental health, we really are
all working towards the same objective--reducing risk factors and
promoting protective factors. The challenge is to build a national
framework for prevention on that common foundation.
Moving the framework from vision to practice will require the
Federal government, States, and communities to work in partnership.
Under the new grant program, States will provide leadership, technical
support, and monitoring to ensure that participating communities are
successful in implementing a five-step public health process that will
promote youth development, reduce risk-taking behaviors, build assets
and resilience, and prevent problem behaviors across the life span. The
five steps are:
First, communities assess their mental health and substance abuse-
related problems including magnitude, location, and associated risk and
protective factors. Communities also assess assets and resources,
service gaps, and readiness.
Second, communities must engage key stakeholders, build coalitions,
and organize, train, and leverage prevention resources.
Third, communities establish plans that include strategies for
organizing and implementing prevention resources. They must be based on
documented needs, build on identified resources, and set baselines,
objectives, and performance measures.
Fourth, communities implement evidence-based prevention efforts
specifically designed to reduce risk and promote protective factors
identified.
Finally, communities will monitor and report outcomes to assess
program effectiveness and service delivery quality, and to determine if
objectives are being attained or if there is a need for correction.
The success of the Strategic Prevention Framework will be measured
by specific national outcomes that are true measures of whether our
programs are helping young people achieve our vision of a life in the
community, for example, whether they are in stable homes, in school,
and are not involved with the criminal justice system. We are rapidly
moving to implement these national outcomes across all of SAMHSA's
programs.
In the area of substance abuse treatment, we are already using
National outcomes. This year we commenced the President's Access to
Recovery program with a $100 million investment. The Administration's
commitment to expand clinical treatment and recovery support services
to reach those in need extends beyond the immediate fiscal year, with
its fiscal year 2005 request to double Access to Recovery's
appropriation to $200 million and to increase the Substance Abuse
Prevention and Treatment Block Grant by $53 million for a total of $1.8
billion.
As you may know, Access to Recovery is based on the knowledge that
there are many pathways to recovery. It empowers people with the
ability to choose the path best for them--whether it is physical,
mental, medical, emotional, or spiritual. In particular, we know that
for many Americans, treatment services that build on spiritual
resources are critical to recovery. Access to Recovery ensures a full
range of clinical treatment and recovery support services are
available, including the transforming powers of faith. Critically,
Access to Recovery provides States the opportunity to target resources
to providing treatment to adolescents.
Over the years, SAMHSA, through its Center for Substance Abuse
Treatment (CSAT), has made significant strides in addressing the
shortage of adolescent substance abuse treatment. Between 1970 and
1997, there were only 14 published studies of the effectiveness of
adolescent substance abuse treatment. In response, SAMHSA funded the
Cannabis Youth Treatment (CYT) Study in 1997. Its purpose was to
explore whether proven adult models of intervention could be made
developmentally appropriate for adolescents and achieve effective
outcomes in real-world, community-based treatment settings. The CYT
study of over 600 youth randomized to five different treatment
interventions resulted in five effective treatment protocols that are
now available in manuals that are in use across the country. The five
volumes of the CYT Series are based on treatment approaches
specifically designed for use with adolescents. The CYT manuals are
part of SAMHSA's larger Science to Services Initiative that is working
to speed the delivery of effective, evidence-based programs into
communities where clinical intervention and treatments are put into
practice.
In 1999, a few years after the CYT study began, SAMHSA funded the
Adolescent Treatment Models program. The purpose was to identify
potentially exemplary programs that existed in the field and to have
them rigorously evaluated to determine their effectiveness. The same
core assessment and follow-up instruments, as well as data collection
points from CYT, were used, which afforded the opportunity to draw
critical comparisons. The outcomes of this study generated 10 treatment
program manuals that include effective programs for intensive
outpatient, short-term residential and long-term residential programs
that are available on-line and are being adopted within the adolescent
treatment field as we speak.
Having worked to identify effective treatment interventions, SAMHSA
proceeded to develop the Strengthening Communities--Youth (SCY) program
in 2001. With a $39 million investment, twelve sites were funded for 5
years to develop a continuum of adolescent services and a system of
care for youth within their communities.
Although these programs have clearly and undoubtedly strengthened
treatment programs for this age group, an identified weakness is the
lack of continuing care models for youth after they complete the active
phase of treatment. For example, too often when youth complete
residential placements and return to their families and communities,
they are cut-off from treatment services and quickly resume their
substance abuse and other destructive behaviors. In response, SAMHSA
awarded grants under its program to Improve the Quality and
Availability of Residential Treatment and its Continuing Care Component
for Adolescents (ART) during 2002. As a result, numerous residential
programs have developed and implemented models of providing continuing
care to youth.
Along with improving after-care services for adolescents, SAMHSA
launched the Effective Adolescent Treatment (EAT) program in 2003 to
assist the field in adopting a previously proven effective approach of
the CYT initiative. This approach, Motivational Enhancement Therapy/
Cognitive Behavioral Therapy, for adolescents with substance use
disorders is now being implemented in 22 sites around the country. In
2004, an additional 16 sites will be funded, which will result in a
total of 38 programs implementing a practice for which there is
evidence of effectiveness and will directly impact success rates for
adolescents who are in a battle for their very lives.
In tandem with improving and extending the continuum of care in
residential settings, which often include court-adjudicated youth from
the criminal justice system, CSAT also provides for critical treatment
services through the Juvenile Justice Drug Treatment Court. Six
programs are up and running smoothly, and others will be operational
soon through our Youth Offender Re-entry Program, which will support
12-14 new programs in Fiscal Year 2004.
CSAT also supports treatment programs for adolescents through its
Targeted Capacity Expansion program (TCE), Targeted Capacity Expansion/
HIV (TCE/HIV), and HIV Outreach programs. These grantees are encouraged
and supported to adopt only effective treatment practices. They are
included in meetings and trainings to further facilitate the evolution
and improvement of the field of adolescent substance abuse treatment.
Each of these efforts to expand treatment services for adolescents
have been well thought out, and each resulting program has been funded
based on the underlying and undeniable fact that all we can do to help
our Nation's youth is what must be done--nothing less is acceptable.
The treatment services afforded through the opportunities I just
mentioned are improving services for adolescents, and we are improving
and building upon the services for consumers of all ages--children,
adolescents, young adults, adults, and older adults alike.
I am particularly proud to tell you that improving services for all
of these age groups, from this Nation's elderly down through and
including our youngest citizens, is the driving force behind achieving
our agency goals--goals which are independent yet interconnected and
goals which are clearly outlined in our Matrix of agency priorities.
Key to achieving our goals is developing an ability to report on
meaningful outcomes. These outcome measures must be concise,
purposeful, and useful. They must get at real outcomes for real people.
We are changing the emphasis from, ``How did you spend the money?''
and, ``Did you spend the money according to the rules?'' to, ``How did
you put the dollars to work?'' and, ``How did your consumers benefit?''
Through an internal data strategy workgroup we are conducting a
thorough examination of our data collection and analysis systems. The
goal is to take steps now to ensure that decisions related to SAMHSA's
priorities are based on the most comprehensive and accurate information
available.
As I mentioned previously, an essential component of SAMHSA's data
strategy is development of ``National Outcomes'' and related ``National
Outcome Measures.'' Through collaboration with the States we have
identified a set of key domains. These domains are:
(1) abstinence from drug use and alcohol abuse, or decreased
symptoms from mental illness;
(2) increased or retained employment and school enrollment;
(3) decreased involvement with the criminal justice system;
(4) increased stability in family and living conditions;
(5) increased access to services;
(6) increased retention in services for substance abuse treatment
or decreased utilization of psychiatric inpatient beds for mental
health treatment; and
(7) increased social connectedness to family, friends, co-workers,
and classmates.
As I mentioned, these national outcomes are already being
implemented through the President's Access to Recovery program and the
Strategic Prevention Framework. Ultimately the National Outcomes will
be aligned across all of SAMHSA's programs, including the Community
Mental Health Services Block Grant and the Substance Abuse Prevention
and Treatment Block Grant. The National Outcomes are an attempt to
provide greater flexibility and accountability while limiting the
number of reporting requirements on the State. Ultimately we are
confident this approach will ensure the data collected is relevant and
useful and helps to improve services for the people we serve.
Putting the data to work is a responsibility that SAMHSA is happy
to shoulder. We can now clearly and definitively demonstrate that
Federal investments in prevention and treatment are beneficial.
Prevention works. Treatment works--it helps people triumph over
addiction and leads to recovery. The vital treatment and prevention
efforts and programs that I have discussed today are working to improve
services for adolescents, and for people of all ages.
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to appear today. I will be pleased to answer any questions
you may have.
Senator DeWine. Thank you very much.
Senator Reed?
Senator Reed. Thank you very much, Mr. Curie, for your
excellent testimony and for your good work. The SAMHSA program
Access to Recovery, the voucher program, for substance abuse
treatment would children and adolescents be eligible to
participate in this program? If they can, would you please walk
the Committee through this process, particularly a more
challenging case of an adolescent from a family that is not
able to adequately care for him or her; how would this person
get access to a voucher? Who would make these judgments?
Mr. Curie. Absolutely; in fact, we, in terms of Access to
Recovery, a major premise of Access to Recovery is States,
territories and tribal organizations have the opportunity to
shape these voucher programs among meeting their immediate
needs. We encourage adolescents as a specialty population. So
we anticipate, with the over--I think there are about 66
applications right now we have received for Access to Recovery,
and we will be making those awards this summer as they are
going through review right now.
Some of the States, territories or tribal organizations
would indeed target children and adolescents through their
juvenile justice system, child welfare system, and there is a
wide range of latitude that we have given States to be able to
do that so they can address their most immediate needs. Also,
it allows for adolescent treatment, be it residential,
outpatient, various forms of counseling and support.
The way it could work and the way in terms of based on our
standards is, one, an entity that receives Access to Recovery
needs to demonstrate that there will be a professional
assessment conducted by a qualified professional, that they
have opened more portals of entry to assessment and treatment
in their system due to Access to Recovery.
If, for example, they decided to work with their juvenile
justice system, if an individual looked as though they were
having an issue with drugs or alcohol, they would be sent to
the deemed professional for an assessment. Based upon that
assessment, then, a voucher would be issued which would
basically be for the treatment based upon that recommendation
and a list of qualified providers that provide that kind of
service that have been approved by the State or by the tribal
organization would be available for a decision to be made as to
where the individual would seek treatment.
Senator Reed. And who would make that decision, Mr. Curie?
Would the youngster or someone in the social welfare service?
Mr. Curie. We would expect in the situation of children and
adolescents that, you know, if there is a parent or guardian
involved that they would be the primary ones working in making
that decision. If they are under custody of the State or county
in terms of welfare that again, those decisions would be made
by whoever is responsible for that child or adolescent.
But we would encourage, obviously, if there is some sort of
preference in the type of treatment that they would have input
to that. Obviously, in the adult situation, the adults would
have more of a primary choice.
Senator Reed. In my view, the system is conceived such
that, the individual patient can make the judgment in terms of
the type of treatment.
Mr. Curie. Right.
Senator Reed. That is the difference. And here, in many
cases, because of the lack of family support and the situation
of the child, it is not much different than what you do today
except, instead of having one approved vendor or two from the
State, you now have a longer list.
Mr. Curie. I think that is one point. There will be a goal
of Access to Recovery, more providers being available. Second,
another goal would be using outcomes to promote accountability,
and the seven domains I mentioned----
Senator Reed. Yes.
Mr. Curie [continuing].----in my testimony would be driving
Access to Recovery. So after a period of time of being in
treatment, assessing how well is that adolescent doing in terms
of staying drug-free or alcohol-free; how well are they doing
in terms of educational or employment pursuits; do they have a
more stabilized living situation; do they have access to the
services they need? Are they staying out of trouble with the
juvenile justice system and measure those real outcomes which
depict recovery and which depict building resilience in the
young person's life.
And Access to Recovery is really our first program that we
have tied these particular seven domains, and our goal, then,
is to make sure all these domains are part of what we are
measuring through all of our programs, that these seven domains
that reflect recovery, whether we are talking block grant, our
other Targeted Capacity Expansion Grants, that we are measuring
the same things, because if we are funding something that is
not promoting resilience or facilitating recovery, then, I
question why SAMHSA is funding it.
Senator Reed. Right.
Mr. Curie. Because that is our goal. So Access to Recovery
gives us that opportunity.
Senator Reed. You quite rightly have put a lot of weight on
this notion of the outcome measures, and that raises some
obvious questions. Who is collecting the data? Is there a
uniform system that is understood by everyone and that is
statistically, you know, reliable?
Mr. Curie. Sure.
Senator Reed. We all know that there are some systems that
purport to measure but, do not measure very well. Can you talk
about that in terms of your proposal?
Mr. Curie. Yes; yes. In Access to Recovery, we outline the
broad domains and requirements that we are looking for, and we
would be expecting, again, whatever entity is awarded a grant,
whether it be a State, tribal organization or territory, that
they would have a uniform way of collecting this data and
demonstrate that in their proposal, because we would be looking
for a way of uniformly----
Senator Reed. Right.
Mr. Curie [continuing].----assessing outcomes.
Senator Reed. But their uniform method might be different
than the next grantee; and theirs might be different than the
next grantee.
Mr. Curie. Well, we would expect consistency at least
within the State, as a beginning point, because you are right:
we want to see what kind of baselines they are establishing.
Again, there may be some variance from State to State, but we
would not be looking for each grantee only to self-report on
their own criteria, but there would be some consistent uniform
way of measuring these particular outcomes.
Senator Reed. Some of these are necessarily subjective,
like the increase in stability in family and living conditions,
etc. Are you going to provide any, guidance? There is always
the danger that the further you move away from quantitative
measures--recidivism, further engagement with law enforcement,
you get into subjective areas where it may be fudged.
Mr. Curie. Right, understood. There have been, among these
seven domains, and we have had a range of researchers examine
these domains and feel they are very valid for measuring
recovery, and there are measures within those domains which are
much more quantifiable: length of stay in a housing situation,
time that they are living with their family.
Senator Reed. Right.
Mr. Curie. You know, when did they gain employment? How
long are they staying in school? So there clearly will need to
be more precise measures within those domains.
Senator Reed. Mr. Chairman, you have been very kind, but if
you would indulge me with one more question.
Why will SAMHSA not develop a framework, a national data
framework that could be applied in every State?
Mr. Curie. Well, that is a very good question. Actually, we
have embarked this past year on what we are calling our data
strategy, because up until now, there really has been no clear
national data strategy, and I know that we have been grappling
with moving in the direction of national treatment outcome
measures. And in one sense, the data infrastructure that we
have funded and developed through the years has been State by
State, as that is how the block grants were allocated.
And to make that move from State by State to a national
level, while not impossible at all, is going to take an
endeavor which we partner clearly with the States, and we are
actually looking to do that type of data framework through what
we were calling Performance Partnership Grants with the States
but working with the State drug and alcohol authorities and
mental health authorities to come to common agreement on the
measures as a major first step.
And we are actually much further down that road than we
ever have been, and then, it is a matter of operationalizing
it. So the answer to your question is yes, we are committed to
doing that. But we want to make sure we do it in building on
the infrastructure that we have already been funding with the
States.
It also, as we have examined it, to start all over with
some national treatment outcome measures approach, which is not
connected with what we have already done, could be extremely
costly, and also, it would be experimental. So we are trying to
build on that sure footing. But you are exactly right: the more
consistent we can have national measures, the stronger we will
all be.
Senator Reed. Thank you very much, Mr. Curie.
Thank you, Mr. Chairman.
Senator DeWine. One of the age-old problems, as we have
discussed a little bit this morning, but I would like for you
to get into a little more detail, is to take the research into
practice. Do you want to describe how SAMHSA works with its
Federal partners in the field to move research into practice
and ensure that the results of research get used by SAMHSA, but
also get used out into the field in the most appropriate ways?
Mr. Curie. Absolutely; in fact, you are right: age-old is a
good word for it, because it has been documented by the IOM
study: 17 to 20 years' lag time between research findings being
realized on the front line. What we have done with our partners
in NIH, both NIAAA, NIDA and NIMH, is SAMHSA has embarked with
our partners upon a course of action that we are calling our
science to services project and initiative.
And our goal is to facilitate more rapid implementation of
effective evidence-based, science-based practices to the front
line. And we are doing this in several different ways, in
several different avenues. And again, I see this as a process
that we have really embarked upon much more formally over the
past 2 years. There have been initiatives in the past, but we
have tried to bring it together to view the science to service
cycle, where the first phase is research and development by the
Institutes; the second phase is dissemination and
implementation; and the third phase is monitoring and feedback.
And part of this has been in terms of moving ahead is also
clarifying the roles of the Federal agencies in doing this. And
I think that had not been totally clarified previously.
Obviously, the Institutes are responsible for research, and we
are a services administration, so we are responsible for
services.
So phase one that I described is clearly more of an
Institute responsibility which they fulfill; two, dissemination
and implementation is a partnership between us, and three,
monitoring and feedback rests on us to bring back feedback to
feed into the services research agenda in the Institutes.
Some of the activities that we actually have done: NIMH and
SAMHSA have jointly funded programs to facilitate the State
planning for implementation of evidence-based programs. We are
looking to release what we call six tool kits around practices
that are working that we make available through both State
authorities and to providers.
In partnership with NIDA, NIDA has committed $15 million
for 5 years to evaluate SAMHSA's newly-developed Strategic
Prevention Framework, which I mentioned earlier, and we also
are contributing $15 million to that evaluation process. We
also have, as I mentioned earlier, our National Registry of
Effective Programs, and again, we are expanding that beyond
prevention programs to include treatment programs and are
working with the Institutes in arriving at, first of all, what
is an effective program? Do they meet certain scientific
thresholds of effectiveness, and then, as we list them, how can
we begin to implement them?
Also, we have addiction transfer technologies, technology
transfer centers in CSAT. We have TA centers, technical
assistance centers, in CMHS and what we call our CAPS, our TA
centers in the Prevention all have partnerships with the
Institutes in bringing those practices to the field, regionally
and through States.
So again, we have a framework now for the first time that
we are calling science to service. We are putting our endeavors
that we have been doing under that framework, and we are
actually encouraging new endeavors as well.
Senator DeWine. Good. We know that we face serious work
force issues which limit the expansion of treatment services.
What is SAMHSA doing to show leadership to create and also
sustain a qualified work force for adolescent treatment as well
as adult treatment?
Mr. Curie. No, absolutely. This has been a problem for
quite some time. It has been a challenge to recruit people to
our fields. It has been a challenge to keep people in our
fields, and it has been a challenge to keep qualified
individuals in our fields.
Again, we have several initiatives addressing this. I
mentioned the addiction treatment technology centers as well as
the CAPS and the TA centers. Each one of them have a major
focus on providing training and services to work force to both
grantees and providers at the regional level. Each one of them
also have partnerships with universities. For the ATTCs, for
example, we have a listing on our Website of all of the
universities affiliated with them that provide ongoing
certification training for professionals.
And so, we are strengthening in that area in terms of
providing ongoing certification and training. Also, we have
minority fellowship grants to encourage minorities to receive
education in our field, in our area, to fund that type of
training. And also, we have $6 million for a children's SIG,
State Incentive Grant, to fund seven States, which the purpose
of that is to develop an infrastructure around--which includes
developing workforce and training workforce around services to
children and adolescents, that we are just actually issuing at
this point in time.
The other thing that we must do is have an ongoing
relationship. I know I met with NAADAC, the association of drug
and alcohol certified counselors as well as Therapeutic
Communities of America. These are organizations, these types of
associations are consistently looking at workforce development
issue, and we have got to strengthen our partnership with the
professional associations to make sure the linkages are being
made as well.
Senator DeWine. Well we thank you very much, and certainly,
this subcommittee looks forward to working with you on SAMHSA
reauthorization in the future.
Mr. Curie. Thank you, Mr. Chairman, thank you.
Senator DeWine. We will be talking a lot in the future.
Mr. Curie. I am looking forward to it.
Senator DeWine. Good. Thank you very much.
Let me ask our second panel to come up, and I will begin to
introduce you as you come up. On the second panel, we have
Sandra Brown from the Department of Psychology at the
University of California, San Diego. Dr. Brown is a professor
of psychology and psychiatry and also the chief of psychology
services at the Veterans Affairs San Diego Health Care Systems.
She is associate director of the Child and Adolescent Services
Research Center at Children's Hospital of San Diego. Dr. Brown
is an internationally-recognized researcher whose work has
covered many of the topics of interest at today's hearing.
We also have Dr. Roger Weissberg, from the Department of
Psychology at the University of Illinois at Chicago. He is also
the executive director of the Collaborative for Academic,
Social and Emotional Learning, an international organization
committed to supporting the development and dissemination of
effective school-based programs that enhance the positive
social, emotional, academic, moral, and healthy development of
young people. He is a well-respected prevention researcher who
has spent much of his career focusing on issues of interest to
us in this hearing.
We also have Rhonda Ramsey-Molina, who has served as
president and CEO of the Coalition for a Drug-Free Greater
Cincinnati since 1999. She brings to this position over 10
years of experience in the field of substance abuse prevention
and community coalition building. Prior to this, she directed
the Monroe County Community Prevention Coalition in
Bloomington, Indiana; served on the Governor's Commission for a
Drug Free Indiana and worked as a prevention specialist for the
Cincinnati Alcoholism Council.
We also have Ronald Anton, director of juvenile justice and
community programs at Day One, Maine's largest provider of
substance abuse services to adolescents and families. He has
over 30 years of experience as a mental health and substance
abuse clinician, clinical supervisor, consultant, trainer and
administrator. He currently oversees a broad range of programs,
including the Juvenile Treatment Network, which uses vouchers
to assist youth in obtaining substance abuse services.
Let me also acknowledge Ann Dolan Peletier, who is the Day
One program manager of the Juvenile Treatment Network of Maine.
She has traveled with Mr. Anton to be with us today.
Finally, we have Kris Shipley, a young man who has
struggled with his own addiction and now works to help others
avoid the kind of problems he faced. Let me welcome you to the
committee Kris. Kris, thank you very much for being with us.
Let me welcome all of you to the committee, and Dr. Brown,
we will start with you, and we have received testimony from all
of you. It will be made a part of the record, and we have a 5
minute rule for your testimony, and you can watch the light
come on here, and if you could keep your testimony to 5
minutes, and that will give us the opportunity to ask you all
some questions.
Dr. Brown?
STATEMENTS OF SANDRA BROWN, PROFESSOR OF PSYCHOLOGY AND
PSYCHIATRY, UNIVERSITY OF CALIFORNIA-SAN DIEGO; CHIEF OF
PSYCHOLOGY SERVICES, VETERANS AFFAIRS SAN DIEGO HEALTH CARE
SYSTEMS; ASSOCIATE DIRECTOR, CHILD AND ADOLESCENT SERVICES
RESEARCH CENTER, CHILDREN'S HOSPITAL OF SAN DIEGO; ROGER
WEISSBERG, DEPARTMENT OF PSYCHOLOGY, UNIVERSITY OF ILLINOIS AT
CHICAGO, EXECUTIVE DIRECTOR, COLLABORATIVE FOR ACADEMIC, SOCIAL
AND EMOTIONAL LEARNING; RHONDA RAMSEY-MOLINA, PRESIDENT AND
CEO, COALITION FOR A DRUG-FREE GREATER CINCINNATI; RONALD
ANTON, DIRECTOR OF JUVENILE JUSTICE AND COMMUNITY PROGRAMS, DAY
ONE; AND KRIS SHIPLEY, PASADENA, MD
Ms. Brown. Thank you. Thank you, Mr. Chairman and Senator
Reed.
I am delighted to have the opportunity to speak with you
today on this very important topic, and I think that it will
become clear through my testimony that current research has
exciting new information that can bear on the development of
prevention and intervention services for adolescents, and this
is a very exciting time from a researcher's perspective in this
arena. Research that is supported by the National Institutes of
Health and other agencies is leading to a new and very common
understanding about the critical role of early onset of
addictive disorders in their course, their consequences and
their progression.
We are finding that these disorders begin during
adolescence and sometimes even during early childhood, and
therefore, our interventions may prevent many of the social,
behavioral, health and economic consequences that are caused by
alcohol and drug abuse as well as provide us an opportunity to
treat problems before they become full-blown and to damage the
lives of our youth.
I would really like to highlight three points today from a
research perspective. One is that in just the past few years,
it is becoming increasingly evident that these disorders start
routinely much earlier than previously appreciated. Second,
that hazardous drinking, particularly binge drinking, is on the
rise, and third, that we have a new understanding of the
substantial problems that alcohol and drugs produce in
adolescent brain functioning, and I would like to highlight
those in my testimony this morning.
NIAAA and NIDA-supported researchers are finding that
alcohol and drug addictions commonly start earlier than
previously understood, and the earlier youth start, the greater
the lifetime risk for dependence. New findings regarding the
patterns of abuse and dependence dramatically underscore the
importance of reducing underage drinking and drug use. The age
of most prevalent tobacco dependence onset, for example, is 15.
For alcohol dependence, age 18 is the most common period of
first diagnosis of dependence.
It is now clear that most cases of alcohol dependence begin
before age 25. The epidemiological research message, I think,
is obvious: that youth is a critical window of opportunity for
preventing alcohol, tobacco and other disorders. Alcohol, which
is the most commonly abused substance, has found an increasing
rise in hazardous drinking over the past few years. Binge
drinking, which we have mentioned are episodes of heavy
drinking of five drinks or more for males or four drinks or
more for females is a problem for people of any age, whether or
not the drinker is addicted to alcohol.
But an alarming number of children and adolescents binge
drink, and it is becoming increasingly evident. As Senator
DeWine highlighted earlier, 11 percent of 6th graders and a
third of high school seniors and half of all college students
binge drink just within the past 2 weeks. Drinking too much too
fast in this manner carries substantial risks for youth,
additional risks for youth beyond those carried with this
behavior among adults. They include car crashes, injury, death,
property damage, encounters with the justice system, family,
school and workplace problems.
Each drink increases the fatal crash risk for youth moreso
than adults. At a blood alcohol level of 0.08 percent at every
age and gender group, there is at least an elevenfold increase
in single vehicle fatal crash risk. But among males ages 16 to
20 at that same level of 0.08 percent, there is a 52-fold
increase in single vehicle crash risk compared to sober drivers
in that same age range.
In a series of recent studies, we have begun to understand
how the exposure to alcohol and other drugs of abuse during
adolescence produce substantially more adverse effects than
exposure during adulthood, in part because of very important
changes that are occurring in the brain during adolescence.
Advances in science have now brought us to the point where we
can use new animal models, modern brain imaging technology that
was previously not available and other neurobehavioral
assessment tools to probe the effects of alcohol, tobacco and
other drugs on the developing brain and determine immediate as
well as long-term behavioral consequences.
Emerging findings from our neuroimaging studies demonstrate
that brain structures change substantially during adolescence,
and in particular, brains become more specialized and
efficient. Our developmentally-focused research indicates that
there are distinct neurocognitive disadvantages among
adolescents with alcohol and drug use disorders compared to
teens without substance involvement.
So, for example, alcohol-dependent adolescents who have 3
weeks of abstinence still show a 10 percent decrement in their
memory skills relative to teens who do not have a history of
alcohol abuse. Neuropsychological testing following these youth
throughout adolescence and into young adulthood show decreased
attentional abilities, additional memory problems, visual-
spatial skills, all of which add to the evidence of substantial
brain damage to adolescents as a function of alcohol and drug
involvement.
Our new directions in adolescent research can help inform
us on important aspects of cognition and decision making,
emotional regulation and risk perception by adolescents that
can help us determine how these factors play a role in the use
and consequences of alcohol and drugs, and armed with this
knowledge about how teens make decisions and control their
impulses and desires and what motivates their behaviors, we
will be poised to improve on the current prevention programs
and intervention programs that are in place.
I thank you.
[The prepared statement of Ms. Brown follows:]
Prepared Statement of Sandra A. Brown
INTRODUCTION
Recent research supported by the National Institutes of Health and
other agencies is leading to a common understanding about the critical
role of age of onset of addictive disorders in their course,
consequences and progression. Researchers are finding that these
disorders often begin during adolescence and sometimes even during
childhood; therefore early intervention may prevent many of the social,
behavioral, health, and economic consequences caused by alcohol and
drug abuse as well as provide an opportunity to treat problems before
they become full blown and damage in the lives of our youth.
EARLY ONSET
NIAAA and NIDA-supported researchers are finding that alcohol and
other drug addictions commonly start earlier than previously
understood, and the earlier youth start the greater the lifetime risk
for dependence. New findings regarding early patterns of abuse and
dependence dramatically underscore the importance of reducing underage
drinking and drug use. As shown in Figures 1 and 2, the age of most
prevalent tobacco dependence onset is 15 and for alcohol dependence age
18 is the most common period of first diagnosis of dependence. It is
now clear that most cases of alcohol dependence begin before age 25.
After that age, new cases drop off precipitously. The epidemiological
research message is obvious: youth is a critical window of opportunity
for preventing alcohol, tobacco and other drug disorders. Previous
studies have suggested that this is so, but the new research findings,
corroborated by independent sources, have confirmed these findings.
Ongoing research may reveal a cause-and-effect relationship between
early use and subsequent dependence, or it may reveal that common
biological and environmental factors drive the risk for both use and
dependence, as well as other addictive and psychiatric disorders. In
either case, these new data are a powerful indicator of the need for
more effective preventive interventions for youth.
Given the new epidemiologic findings, the fact that alcohol use is
so widespread among children and adolescents is troubling. Alcohol is
the primary substance of abuse among American children and adolescents.
47 percent of 8th graders, 67 percent of 10th graders, and
78 percent of 12th graders have used alcohol.
11 percent of 6th graders have reported binge drinking
(five or more drinks per occasion for males; four for females) in the
past 2 weeks.
30 percent of high-school seniors have reported binge
drinking at least once a month.
44 percent of college students have reported binge
drinking in the past 2 weeks.
23 percent have reported that they binge drink frequently.
Youth who drink alcohol before age 14 are four times more
likely to become alcohol dependent in their lifetime than those who
wait until age 21 or older.
NEURODEVELOPMENTAL STUDIES
A series of recent studies indicate that exposure to drugs of abuse
during adolescence may produce more adverse effects than exposure
during adulthood in part because of the important changes occurring in
the brain during adolescent development.
Advances in science have now brought us to a point where
researchers can use new animal models, modern brain imaging technology
and other neurobehavioral assessment tools to probe the effects of
alcohol, tobacco and other drugs on the developing brain and determine
immediate as well as its long-term behavioral consequences.
For example, as shown in Figure 3, emerging findings from
neuroimaging studies demonstrate that brain structures change during
adolescence to become more specialized and efficient in their
functioning. Our developmentally focused research indicates important
neurocognitive disadvantages among adolescents with alcohol and drug
use disorders as compared to teens without substance involvement. For
example, even after 3 weeks of abstinence, alcohol dependent youth
display a 10 percent decrement in delayed memory functions (Figure 4).
Neuropsychological testing of these youth followed up to 8 years
demonstrates that continued heavy drinking during adolescence is
associated with diminished memory of verbal and nonverbal material, and
poorer performance on tests requiring attention skills. Alcohol and
drug withdrawal over the teen years appears to uniquely contribute to
deterioration in functioning in visuospatial tasks. Recent brain
imaging studies of alcohol and drug using youth compared to youth
without such experience have also shown reduced hippocarmpal volumes,
white matter microstructure irregularities, and brain response
abnormalities while performing cognitive tasks among those with early
alcohol/drug exposure. Additionally, youth who have extensive
experience with alcohol have increased brain response when viewing
alcohol advertisements compared to other beverage advertisements.
Animal studies are consistent with the findings that alcohol or
drug exposure during adolescence has more adverse consequences than
delayed (adult) exposure. In these investigations, adolescent alcohol
exposure is associated with more frontal lobe damage and poorer spatial
memory. Further research is needed to understand how age of drinking or
drug use onset and duration of abstinence at the time of assessment
affect cognitive and behavioral findings. Longitudinal studies are
needed to clarify neuromaturational changes associated with early
alcohol and drug exposure and patterns of resiliency. Although the
magnitude of effects observed in adolescents' neurocognition is modest,
the implications are major given the prevalence of alcohol involvement,
and the important educational, occupational, and social transitions
that occur during adolescence.
These new directions in adolescent research will help to inform us
on important aspects of cognition, decision-making, motivation,
emotional regulation, and risk perception during adolescence, and will
help us determine how these factors play a role in the use and
consequences of alcohol and drugs. Armed with new knowledge about how
adolescents make decisions, control their impulses and desires, and
what motivates their behavior, researchers and agencies will be poised
to design better preventions and interventions to reduce alcohol,
tobacco and other drug experimentation, abuse and dependence, as well
as other risky behaviors. Adolescents have in common unique
neurobiological and neurocognitive developmental factors that affect
risk and resiliency vis-a-vis substance use. Few studies have addressed
these developmentally specific neurobiological and neurocognitive
mechanisms and consequences of heavy drinking/use in this group despite
the importance of these for long-term development.
VULNERABILITY
While early initiation of substance involvement is a powerful
predictor of subsequent dependence, not everyone who uses at a young
age later develops abuse or dependence. Even among youth with two
alcoholic parents, only about one-half become alcohol dependent. The
outcome is determined largely by the interplay of environmental and
genetic/biological factors.
Environmental factors have the biggest influence on whether a child
first uses alcohol, tobacco or other substances. However, genetic
factors have an influence on whether a child continues to use.
Understanding how these factors result in initiation and continuation
of use or make resolution of drinking/drug use more difficult is
essential to disrupting the developmental process of addictive
behavior. Thus, a focus on genetic/biological aspect of use may clarify
how variations in genes result in differences in how our bodies absorb,
distribute, and eliminate substances and variability in tolerance.
BINGE DRINKING
Binge drinking, episodes of heavy drinking (five or more drinks for
males; four or more drinks for females), is a problem for people in any
age group, whether or not the drinker is addicted to alcohol. An
alarming number of children and adolescents binge drink and that it is
increasing. Drinking too much, too fast in this manner carries
additional risks especially for youth. They include car crashes,
injury, death, property damage, encounters with the justice system, and
family, school, and workplace problems. Each drink increases the fatal
crash risk more for youth than adults. At a blood alcohol level of 0.08
percent in every age and gender group there is at least a 11-fold
increase in single vehicle fatal crash risk. Among males 16-20 at a
blood alcohol level of 0.08 percent there is a 52-fold increase in
single vehicle crash risk compared to sober drivers the same age.
Epidemiology studies have shown beyond doubt that genes play a role
in risk of alcohol, tobacco and other drug dependence. Research toward
discovering which genes are involved, what biochemical pathways they
influence in brain cells, and how these pathways translate into
specific behaviors is the next step to this line of investigation. Such
findings provide information about genetic/molecular events in the
brain that influence use, and provide potential targets for
pharmacological intervention. For example, new findings about a
naturally occurring marijuana-like substance in the brain also provide
potential new molecular targets for pharmacological intervention.
PREVENTION OF ABUSE AND DEPENDENCE
Prevention of alcohol and substance use problems among youth need
to be understood as a continuum of services and consequently research
needs to span this continuum. This continuum ranges from universal
prevention (those appropriate for all children and adolescents who
might use alcohol, tobacco or other drugs) to selective preventative
measures for subgroups with risk factors for abuse or dependence, to
indicated preventative measures for those individually at high risk for
the disorder. Preventive interventions for alcohol, tobacco, and other
drug use disorders and related problems can be improved through early
detection and diagnosis, and through testing of new behavioral
strategies at the individual, family, and community levels. Of
particular interest are longitudinal data on children entering the age
of risk, adolescents and young adults in high-risk environments
(college and the military), youth who resolve use/problems without
formal treatment, and women of childbearing age. New interventions to
prevent early-onset of use can be gleaned through studies that identify
developmental and environmental features as well as biological factors
that stimulate or suppress addictive behavior.
It is important to evaluate prevention programs on an ongoing basis
as well as disseminate research findings to communities, educators,
parents, and health care providers who are the first line of defense
against alcohol, drugs and other risky behaviors. Both NIAAA and NIDA
offer free educational materials designed to help students learn about
the impact of alcohol and drugs on the brain and body. Parents,
educators, and community leaders can use these materials to help guide
their thinking, planning, selection, and delivery of drug abuse
prevention programs at the community level. NIAAA and NIDA also have
websites that offer science-based information specifically designed for
teens. The Leadership to Keep Children Alcohol-Free has recruited 33
Governors' spouses to spearhead a national prevention campaign which
influences both public policy and local practices. The Task Force on
College Drinking has brought together university presidents and
researchers, and is making headway in efforts to reduce the seemingly
intractable problem of drinking by college students.
Clearly, alcohol and substance use disorders are the result of a
complex combination of genetic and environmental interactions that
influence how people respond to the substance and their initial
propensity for using alcohol and drugs. Longitudinal studies of these
genetic and environmental factors are crucial for understanding (1)
early initiation of drinking and drug use, (2) transition to harmful
use, abuse, and dependence, and (3) remission and abatement of alcohol
and drug related problems in untreated populations. This is
particularly critical for youth as some resolve problematic use without
treatment and research in this area can teach us how to facilitate
changes in alcohol and drug involvement in ways that are most
developmentally appropriate and acceptable to youth. Developmentally
specific research in these areas has potential to help identify
mechanisms of vulnerability and protection which can be used in
prevention.
IMPROVING EFFECTIVENESS OF TREATMENT
Findings from the National Household Survey on Drug Abuse indicate
that about 10 percent of 12- to 17-year-olds (about 2.3 million) are
heavy users of alcohol or drugs, yet only 187,000 (8 percent) received
services. Although estimates of the cost-effectiveness of early
intervention are speculative, research suggests that early treatment
has the potential to be cost-effective, especially in comparison with
incarceration or treatment for a long-term abuse problem. For instance,
cost benefit research on drug and alcohol treatment generally (Office
of National Drug Control Policy, 2001) suggest that the range of
savings is between $2.50 and $9.60 for every dollar spent on treatment.
Unfortunately, only one person in seven who would qualify for treatment
was admitted to treatment in 1999 (National Institute on Drug Abuse
Community Epidemiology Work Group, 1999). The proportion of youth who
are admitted to treatment is even smaller.
Much progress has been made in developing behavioral/psychosocial
interventions for alcohol and other substance use disorders, but much
remains to be investigated. Controlled research trials provide evidence
that several psychosocial treatment approaches may be effective in
reducing alcohol and other drug use while also improving associated
behavioral, familial, and psychosocial outcomes. These outcomes are
enhanced when a combination of modalities are offered in a
comprehensive, integrated treatment plan that addresses alcohol and
drug abuse and a broad range of biopsychosocial problems, skills
deficits, and comorbid psychiatric problems. For example, having
families involved in the treatment program increases the likelihood of
success in youth. Brief Strategic Family Therapy (BSFT) and Cognitive
Behavioral Interventions are examples of promising youth specific
treatment already in the field. The evaluation and dissemination of
more evidence-based interventions in a variety of community venues,
including schools, healthcare settings, and prisons, should be a high
priority. Developing, evaluating, and improving efficacy and cost-
effectiveness of treatments is a central goal in alcohol, tobacco and
drug research. Adolescent focused treatment research lags behind adult
treatment research. Studies are needed to develop and test new
behavioral therapies; conduct clinical trials in existing treatment
settings, examine cost-effectiveness of behavioral and pharmaceutical
therapies; clarify mechanisms of action that make effective treatments
successful; and conduct trials of dissemination strategies, to test how
effective they are at introducing behavioral and pharmacological
treatments into real-world clinical practice.
Alcohol, tobacco and other drugs affect genders and subpopulations
differently, and some groups suffer more adverse effects of alcohol,
tobacco and drugs than other groups. For treatment of these youth
problems to be optimally effective, research to study the role of
gender, ethnicity, socioeconomic status, and other variables in
determining the effects of various substance abuse interventions is
sorely needed. For example, we need to support studies on specific
facilitators and barriers to alcohol and drug treatment in minority and
rural populations.
Clearly multifaceted longitudinal research is sorely needed to
fully understand the development and resolution of alcohol and drug use
disorders in the context of child and adolescent development. Through
such focused process research (e.g., changes in brain structure and
recovery of functioning, decision making process, social and family
dynamics) can improved prevention and intervention policies emerge.
ATTACHED REFERENCES
Brown, S.A. & Tapert, S.F. (In Press). Adolescence and the
trajectory of alcohol use: Basic to clinical studies. In Dahl, R.E. and
Spear, L.P. (Eds.), Adolescent Brain Development: Vulnerabilities and
Opportunities, Volume 1021 of the Annals of the New York Academy of
Sciences.
Brown, S.A., Tapert, S.F., Granholm, E., & Delis, D.C. (2000).
Neurocognitive functioning of adolescents: Effects of protracted
alcohol use. Alcoholism: Clinical and Experimental Research, 24 (2):
164-171.
Tapert, S.F., Cheung, E.H., Brown, G.G., Frank, L.R., Paulus, M.P.,
Schweinsburg, A.D., Meloy, M.J., & Brown, S.A. (2003). Neural response
to alcohol stimuli in alcohol use disordered adolescents. Archives of
General Psychology, 60: 727-735.
Adolescence and the Trajectory of Alcohol Use: Basic to Clinical
Studies
SANDRA A. BROWN AND SUSAN F. TAPERT
ABSTRACT
Emerging findings from developmentally focused research indicates
subtle but important neurocognitive disadvantages among adolescents
with alcohol use disorders (AUD) as compared to teens without AUD. Even
after 3 weeks of abstinence AUD youth display a 10 percent decrement in
delayed memory functions. Neuropsychological testing of youth followed
at 4 and 8 years demonstrates that heavy drinking during adolescence is
associated with diminished retrieval of verbal and nonverbal material,
and poorer performance on tests requiring attention skills. Alcohol
withdrawal over the teen years appears to uniquely contribute to
deterioration in functioning in visuospatial tasks. Brain imaging
studies suggest reduced hippocampal volumes, white matter
microstructure irregularities, brain response abnormalities while
performing challenging cognitive tasks, and enhanced brain response
when viewing alcohol cues (i.e., alcohol advertisements) among
adolescents with AUD. Family characteristics such as history of
alcoholism and socioeconomic status as well as personal features,
including adolescent psychopathology, gender, and age of onset, must be
carefully considered when investigating the influence of teenage
drinking on neurocognition. Further research is needed to understand
how age of drinking onset and duration of abstinence at the time of
assessment affect cognitive findings. Longitudinal studies are needed
to clarify neuromaturational changes associated with early alcohol
exposure and patterns of resiliency. Although the magnitude of alcohol-
related effects observed in adolescents' neurocognition is relatively
modest, the implications are major given the prevalence of alcohol
involvement, and the important educational, occupational, and social
transitions that occur during adolescence. KEYWORDS: adolescence;
alcohol; neurocogntition; fMRI; development.
The present chapter highlights the relation of alcohol involvement
among youth and neurocognitive functioning over the course of
adolescent development. Following a brief review of adolescent alcohol
use patterns and related problems, the chapter focuses on
neurocognitive and neuroimaging studies from our research program.
Emerging evidence demonstrates the cognitive and behavioral impact of
early alcohol involvement and potential deleterious effects on brain
functioning.
BACKGROUND
Adolescence is the most common time for initiation of alcohol use.
By the time high school students graduate, over 80 percent will have
begun drinking alcohol. Heavy drinking (five or more drinks per
occasion) is also prevalent, with 18 percent of 10th graders and 30
percent of 12th graders reporting that they got drunk in the past
month.\1\ Approximately 6 percent of high school students consume
quantities of alcohol and drink in problematic patterns such that they
meet diagnostic criteria for alcohol abuse or dependence.\2\ Alcohol is
a contributor to the top causes of death for youth: accidents,
suicides, and homicides.\3\ For example, the leading cause of death for
youth age 16 to 20 is unintentional injury, primarily related to motor
vehicle accidents, of which one in three involve alcohol.\4\
The earlier alcohol use is initiated, the greater the risk for a
variety of adverse consequences. Youth that begin drinking alcohol
before age 14, have a 41 percent chance of developing alcohol
dependence during their lifetime compared to individuals who wait to
the legal drinking age of 21 when lifetime risk is reduced to 10
percent.\5\ Early use of alcohol elevates risk for a multitude of
mental health and social problems.\6\ Rates of conduct disorder,
antisocial personality disorder, nicotine dependence, and illicit drug
abuse and dependence are significantly higher among youth that drink
early.\7\ Cross-culturally, studies also indicate that heavy adolescent
alcohol use is associated with psychological distress, anxiety, and
depression.\7\ Youth with early problems such as school difficulties,
personal difficulties (e.g., hyperactivity, impulsivity, and
inattentiveness), or family problems are more likely of begin drinking
early. Although alcohol use is prevalent among adolescents, those most
disadvantaged, such as the homeless, abused, or neglected, evidence
high rates of alcohol use disorders (AUD), as well as behavioral and
psychological symptoms.\6\
Youths with certain mental health disorders evident in early
adolescence are more likely to initiate alcohol use and accelerate
their use throughout adolescence. Disruptive disorders, including
conduct problems and aggressive or oppositional behaviors, have been
most consistently associated with the early onset of alcohol use and
abuse.\7\ \8\ In girls, early anxiety disorders may also accelerate
alcohol involvement,\7\ and girls appear more vulnerable to the adverse
consequences under conditions of low parental monitoring.
HOW ALCOHOL AFFECTS ADOLESCENT BRAIN DEVELOPMENT
Despite the prevalence of alcohol use and related disorders in
adolescence, we are just beginning to understand how protracted alcohol
consumption during this period affects brain development and cognition.
Central nervous system abnormalities including neurocognitive deficits,
atrophy of several brain structures, abnormal electrophysiology,
altered blood flow, abnormal brain function, and disruptive sleep have
clearly been observed in adults with chronic heavy drinking histories
(e.g., Refs. 9-11). Although it is less clear how adolescent brains are
affected, mounting evidence from animal and human studies suggest a
potentially greater impact of alcohol prior to full brain maturation.
Understanding the neuromaturational implications of adolescent alcohol
use is critical, since maladaptive patterns of alcohol use during
adolescent development appears to limit educational, occupational, and
social opportunities.
ADOLESCENT BRAIN DEVELOPMENT
To understand alcohol effects on adolescent brain development, it
is helpful to briefly review the maturational processes unfolding
during these years. As summarized in FIGURE 1, substantial
neuromaturation continues throughout adolescence. Structural magnetic
resonance imaging (MR1) studies have described disproportion-ate growth
in the hippocampal region, and decreases in gray matter volume and
density during adolescence, particularly in frontal and parietal brain
regions, which underlies maturation of cognitive processing.\12\ \13\
\14\ Neuronal myelination continues throughout adolescence and young
adulthood \15\ \16\ and is thought to be related to in-creases in
cognitive efficiency. Stages of increased cerebral blood flow support
periods of rapid brain growth.\17\ Synaptic pruning occurs through
midadolescence, varies in relation to environmental stimulation, and
results in greater efficiency, as evidenced by decreased energy
requirements and diminished glucose metabolism.\18\ \19\ Changes in
functional regional activity become increasingly evident and are
indicative of regional specialization and maturation.\20\
ANIMAL STUDIES
While human research on alcohol's impact on the brain has
mushroomed over the past decade with the advent of more sensitive
neuroimaging technology, animal studies have previously demonstrated
that alcohol affects adolescent brain development processes in several
ways.\21\ In general, animal studies consistently show that adolescents
appear to be more sensitive than adults to the learning and memory
impairments produced by alcohol exposure, but less sensitive to the
sedation and temperature regulation effects of this drug. For example,
in a recent study investigators gave adolescent and adult rats multiple
exposures of large quantities of alcohol, mimicking the binge drinking
pattern characteristic of one-third of U.S. teens. Once rats reached
adulthood, those who had been given alcohol during adolescence showed
more impairments on a spatial learning memory task than those who had
been given alcohol only as adults.\22\ Furthermore, studies of
adolescent and adult rats reveal that chronic alcohol use during
adolescence alters sensitivity to alcohol-induced motor
dyscoordination.\21\ Another study examined the behavioral and
neuroanatomical effects of a 4-day alcohol binge on adolescent and
adult rats. While significant brain damage was found in both groups
during the autopsy, several frontal brain regions were damaged only in
the adolescent exposed rats, suggesting that different brain regions
vary in vulnerability to alcohol effects across development.\23\
NEUROPSYCHOLOGICAL STUDIES
Through a series of studies we have longitudinally examined youths
with and without alcohol abuse and dependence and monitored their
alcohol and drug involvement into adulthood to investigate
neurocognitive functioning over time. Neuropsychological studies of
adults with AUD have consistently revealed visuospatial, executive
functioning, psychomotor, and memory impairments secondary to heavy
alcohol exposure.\6\ \24\ However, until recently it was unclear
whether the neurocognition of teenagers might be affected by protracted
alcohol consumption. The limited number of studies that have examined
neurocognition in adolescents with AUD have generally demonstrated
modest functional decrements. For example, an early neuropsychological
study by other investigators recruited teens with AUD from treatment
centers, and demonstrated subtle deficits in verbal skills among youths
with AUD compared to nonabusing controls, as well as problem-solving
errors among girls with AUD relative to control girls.\25\ Tarter and
colleagues \26\ examined cognition among 106 female youths with AUD,
most of whom met criteria for other substance use disorders as well.
Compared to 74 control girls, those with AUD performed poorly in
several domains, including language, attention, perceptual efficiency,
general intelligence, and academic achievement.
In a series of studies, our group has assessed AUD youths recruited
from alcohol-and drug-treatment facilities and nonabusing control teens
from the same communities who were matched for gender, age,
socioeconomic status, and family history of alcohol and substance use
disorders. In one study of 15-16 year olds with at least 100 episodes
of heavy alcohol use (M=753), youths with an AUD and 3 weeks of
abstinence used fewer learning strategies to acquire new information
and showed a 10 percent deficit in the ability to retrieve verbal and
nonverbal information compared to control teens.\24\ While both abusing
and nonabusing youths were able to learn verbal and nonverbal (visual-
spatial) information, as shown in TABLE 1, delayed recall was reduced
approximately 10 percent across tasks (e.g., Wechsler Memory Scale-
Visual Reproduction, California Verbal Learning Test) for those with a
history of AUD.
We followed samples of abusing and nonabusing youths
longitudinally, and read-ministered a neurocognitive testing battery at
4 and 8 years subsequent to initial testing.\27\ \28\ Among those who
continued substance involvement after treatment, alcohol withdrawal
symptoms experienced at any point during the follow-up period predicted
poorer with visuospatial functioning at 4 years after treatment
discharge, and those with recent use and a past history of withdrawal
evidenced the poorest neurocognitive outcomes.\27\ Further, at 8 years
post initial assessment (average age=24 years) greater cumulative
lifetime alcohol experiences predicted poorer attention functioning as
well as poorer working memory scores at the 8-year follow-up.\28\ A
history of alcohol withdrawal symptoms predicted reductions in visual-
spatial functioning as measured by the Wechsler Memory Scale-Visual
Reproduction as well as Rey-Osterrieth figure, These predictions
remained significant even after excluding youths who had drank heavily
( 4 drinks/occasion for females, 5 drinks for males) and used other
substances in the 28 days prior to testing. Together, these studies
indicate that heavy alcohol involvement during adolescence is
associated with cognitive deficits that worsen as drinking continues
into late adolescence and young adulthood. Specifically, adolescents
who by age 15-16 years of age have over 100 heavy drinking episodes and
meet criteria for an AUD, use fewer strategies to learn new information
and demonstrate significantly reduced memory skills. For those who
continue alcohol involvement during the next 4 years and experience any
withdrawal symptoms, deterioration in attention and visual-spatial
functioning continues. By young adulthood these skills continue to
deteriorate relative to the youth's own baseline and those not abusing.
These findings suggest that use and withdrawal differentially affect
neurocognitive functioning across this stage of development.
As part of our longitudinal program of research we have examined
the complex relationship between neurocognitive skills and onset and
persistence of AUDs. Neurocognitive functioning appears to moderate
outcome through its relation with coping skills and alcohol
reinforcement expectancies. Adolescent coping skills significantly
predict less alcohol and other drug use after treatment for those with
lower levels of cognitive functioning, while coping skills do not
predict outcomes for youths with higher levels of cognitive
functioning.\23\ In contrast, for youths with above average language
skills, having more favorable alcohol expectancies predicted more
alcohol and drug use and dependence symptoms after treatment, while
expectancies played a smaller role for young people with lower levels
of language ability.\24\ These longitudinal investigations highlight
changing neurocognitive functioning in relation to clinical course as
well as the adverse cumulative effect of prolonged alcohol use during
the course of adolescent development. Finally, neurocognition plays an
active role in promoting or retarding alcohol involvement, depending on
personal and environmental characteristics.
BRAIN-IMAGING STUDIES
The recent advent of noninvasive neuroimaging techniques has
provided unique opportunities to examine the influence of alcohol
involvement on brain structure and function in adolescents. De Bellis
and colleagues used MRI to quantify volumes of several brain structures
among youths ages 13 to 21 years.\29\ Those with adolescent-onset AUD
had reduced hippocampal volumes, but similar cortical gray and white
matter, amygdala, and corpus callosum sizes compared to controls. We
have used diffusion tensor imaging to investigate corpus callosum
microstructure integrity among teenagers with AUD and nonabusing
controls.\30\ All participants were free from psychiatric disorders,
and had limited experience with other drugs. Preliminary results
indicated that AUD youths exhibit subtle white matter abnormalities,
particularly in the splenium of the corpus callosum. Thus, although
adolescents with AUD show normal corpus callosum volumes, subtle
abnormalities in white matter micro-structure may represent the
beginnings of a more profound disruption than is observed in chronic
heavy drinking adults.
Functional brain changes have also been demonstrated among youths
with AUD. Young women, ages 18-25, who started drinking heavily during
adolescence and had a lifetime history of an AUD showed significantly
diminished frontal and parietal functional MRI (fMRI) response as well
as less accurate performance during a spatial working memory task
relative to demographically similar young women with comparable family
histories of alcoholism.\31\ We used the same paradigm to examine brain
activation among adolescents, ages 14-17, with little alcohol
experience and age and gender-matched teens with AUD but without
histories of other psychiatric disorders or heavy drug use. In contrast
to our findings with young adult women, AUD boys and girls showed
increased parietal response during spatial working memory compared to
control teens, despite similar task performance.\30\ These findings, if
replicated, suggest that in the early stages of AUD, youth may be
capable of compensating for subtle alcohol-induced neuronal
disturbances by recruiting additional resources and more intense and
widespread neuronal activation. However, the neurocognitive and fMRI
findings among young adult women suggest that, as heavy drinking
continues, neural injury may increase,\32\ the brain may be less able
to counteract alcohol-related disruption, and behaviors may begin to
show signs of impairment.
Functional neuroimaging has also been used to evaluate response to
alcohol cues among adults with AUD and adolescents.\33\ In our study of
14-17 year olds, teens were shown pictures of alcoholic beverage
advertisements and visually similar non-alcoholic beverage ads during
fMRI. The images presented were individualized based on personal
drinking experiences and preference in order to ensure familiarity with
cues. Compared to youth with limited alcohol experience, teens with AUD
demonstrated increased brain response to alcohol pictures in left
anterior, limbic, and visual regions commonly associated with emotion,
visual processing, and reward circuitry. Although family history of AUD
was a significant predictor of responsivity, personal alcohol use was a
stronger predictor of brain response to visual alcohol cues.
Moreover, AUD teens reporting greater monthly alcohol consumption
and more intense desires to drink showed the greatest extent of' neural
response to the alcohol advertisements. Given the strong neural
response to alcohol beverage advertisements among teens with AUD, it is
possible that these media images may influence continued drinking among
teens with alcohol problems, and may interfere with effective coping
strategies in youths attempting to stop using.
DEVELOPMENTAL CONSIDERATIONS
Several factors are critical in the consideration of alcohol's
influence on the neurocognitive and neuroanatomical functioning of
youth. First, while adverse behavioral and social trajectories are
evident with the onset AUDs during adolescence, it remains unclear
whether the adolescent brain is ultimately more vulnerable to this
toxin or will be more resilient and capable of recovery than adults
(e.g., Refs. 6 and 24). Evidence with animals suggests greater
vulnerability to adverse learning consequences and our human studies
suggest cumulative neurocognitive impairment over the course of middle
to late adolescence. However, neuroimaging findings are consistent with
early compensation, and only prospective longitudinal studies can
resolve this apparent discrepancy.
Gender differences have been evident in studies of AUDed adults,
with females more susceptible to alcohol-related brain injury than
males.\34\ Hormonal fluctuations, differences in alcohol metabolism,
and gender-specific drinking patterns, may partially account for the
mounting evidence that adolescent girls suffer greater alcohol-related
neurocognitive deficits than adolescent boys. Girls with AUDs show more
perseveration errors than nonabusing girls, while boys with AUDs show
fewer perseverative errors than control boys, suggesting that this
component of frontal lobe functioning may be more adversely affected by
heavy alcohol use in girls.\25\ In our longitudinal research of 70
adolescents followed over 8 years, young women demonstrated more
adverse cognitive effects related to alcohol and other drug use,
especially in working memory and visuospatial functioning, whereas
young men showed a greater relationship between verbal learning and
substance involvement. Further, while alcohol withdrawal and hangovers
were associated with poorer performance in both males and females, this
effect was stronger in females.\28\ Additionally, our recent fMRI
spatial working memory investigations have shown greater magnitude of
response change in girls than boys. Gender differences in fMRI response
may reflect gender-specific disruptions in brain development related in
part to hormonal changes or dysregulation in puberty,\35\ which may
ultimately influence subsequent neural development and functioning.
Studies of alcohol-related neurocognitive and neural sequelae, need
to consider other sources of abnormalities that may predate the onset
of heavy drinking among youth. Two such factors are familial alcoholism
and personal comorbid psychopathology, both of which are risk factors
for developing an AUD and have been associated with unique
neurocognitive features. Youths with multigenerational and dense family
histories of alcoholism have shown modest neuropsychological
differences compared to youths without such family histories
independent of personal substance intake and maternal drinking during
pregnancy.\36\ Adolescent males who do not personally abuse alcohol or
other drugs, but have family histories of alcohol dependence commonly
perform worse on tests of language functioning and academic
achievement, organization of new information, executive cognitive
functioning, perseveration, working memory, nonverbal memory,
visuospatial skills, and attention (e.g., Ref. 37). In our studies,
family history of alcohol dependence and adolescent alcohol/substance
use operate as separate risk factors for poorer neuropsychological
performance in youth.\36\
Disruptive disorders (e.g., conduct disorder, attention deficit
hyperactivity disorder) and certain internalizing disorders are also
associated with specific neurocognitive disadvantages that elevate risk
for adolescent AUDs. Conduct disorder and related behavior disorders,
characterized by disinhibition (e.g., ADHD) have been associated with
poorer performance on academic achievement and IQ tests, and are more
likely to show deficits on measures of executive functioning, including
sequencing, cognitive flexibility, selective attention, and initiating
planned strategies, including nonverbal tests.\38\ Internalizing
disorders, some of which parallel adolescent AUD results, have also
been associated with alterations in cognitive performance and brain
functioning in adolescents, Youths with familial alcoholism often show
a low amplitude P3 component of the event-related potential, which has
a slow rate of change during adolescence. However, in girls, this
neurophysiological developmental pattern is also associated with
childhood internalizing and externalizing psychopathology as well as
psychiatric diagnoses in young adulthood.\39\
YOUTH RECOVERY OF NEUROCOGNITIVE ABILITIES
It remains uncertain to what extent the observed abnormalities in
cognition of heavy drinking youth repair with sustained abstinence,
and, if such abnormalities are repaired, how much sobriety is required
until performance and brain integrity measures resume predrinking
levels. Adults with histories of chronic heavy drinking have been shown
to improve even after extended (i.e., multiple years) abstinence on
neuropsychological testing, magnetic resonance spectroscopy, and brain
volume in-dices (e.g., Refs. 43 and 44). In our studies, measurable
memory deficits (10 percent) are evident after 3 weeks of abstinence,
and neurocognitive functioning after 4 years of abstention appears
comparable to baseline (e.g., Refs. 24 and 27). It remains to be seen
if recoverability of brain integrity and cognitive function might be
more complete in youth, whose brains are more plastic, or if recovery
is less likely because neurotoxic insult may have adversely affected
the course of neuromaturation.
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Neurocognitive Functioning of Adolescents: Effects of Protracted
Alcohol Use
sandra a. brown, susan f. tapert, eric granholm, and dean c. delis
Background: The present study examined associations between alcohol
involvement in early to middle adolescence and neuropsychological (NP)
functioning.
Methods: Alcohol-dependent adolescence (n=33) with over 100
lifetime alcohol episodes and without dependence on other substances
were recruited from alcohol/drug abuse treatment facilities. Comparison
(n=24) adolescents had no histories of alcohol or drug problems and
were matched to alcohol-dependent participants on age (15 to 16 years),
gender, socioeconomic status, education, and family history of alcohol
dependence. NP tests and psychosocial measures were administered to
alcohol-dependent participants following 3 weeks of detoxification.
Results: Alcohol-dependent and comparison adolescents demonstrated
significant differences on several NP scores. Protracted alcohol use
was associated with poorer performance on verbal and nonverbal
retention in the context of intact learning and recognition
discriminability. Recent alcohol withdrawal among adolescents was
associated with poor visuospatial functioning, whereas lifetime alcohol
withdrawal was associated with poorer retrieval of verbal and nonverbal
information.
Conclusions: Deficits in retrieval of verbal and nonverbal
information and in visuospatial functioning were evident in youths with
histories of heavy drinking during early and middle adolescence.
Key Words: Adolescence, Alcohol Dependence, Withdrawal,
Neuropsychology, Memory.
DOMAINS OF NEUROPSYCHOLOGICAL (NP) functioning most commonly
studied in conjunction with alcohol dependence do not isomorphically
map with neuroanatomical effects, but reflect prevalent behavioral
indices of neurocognitive integrity. Language functioning has emerged
as a risk factor in children of alcoholics (Najam et al., 1997),
although it is not generally affected by personal heavy drinking.
Visuospatial, executive, psychomotor, and memory functioning yield the
most robust performance decrements associated with substance use
disorders in adults (Grant, 1987).
Impaired NP performance may be associated with changes in superior
frontal and parietal cortices, mesial temporal lobe structures, and
subcortical regions (e.g., di-encephalon and caudate nucleus). Although
some NP studies have suggested that the right hemisphere is selectively
vulnerable to ethanol effects, most studies report no lateralization
(Kwon et al., 1997; Nicolas et al., 1993). Executive functioning seems
to have the slowest neurocognitive recovery from central nervous system
(CNS) exposure to ethanol due to increased likelihood of neural death
in the frontal lobe relative to other brain regions (Fein et al.,
1994). However, only 30-60 percent of adults with alcohol dependence
evidence significant deficits on NP tests (Grant et al., 1984). In
addition, drinking variables rarely account for significant variance in
NP functioning when demographic factors are appropriately controlled.
This has lead some researchers to explore specific mechanisms linking
alcohol use to NP decrements.
Sullivan and colleagues (1996) found that adult patients with
histories of alcohol-withdrawal related seizures evidenced greater
white matter volume loss in temporal regions, relative to both normal
controls and alcohol-dependent adults without seizure histories.
Repeated withdrawal experiences may increase the risk of alcohol-
related seizures, which may in turn compound cerebral abnormalities.
Animal models of alcohol dependence (e.g., Eckardt et al., 1992) have
reported that cerebral glucose utilization is increased in gray and
white matter regions among alcohol-dependent rats during withdrawal,
suggesting that certain brain regions have abnormal physiologic
responding during withdrawal.
This abnormal physiology could lead to longer term or permanent
cellular alterations, influencing subsequent neurocognitive
performance. Alcohol withdrawal has also been shown to induce depressed
mood symptoms in adults (Brown and Schuckit, 1988).
Recent studies have begun to evaluate neurocognitive functioning
patterns in alcohol-dependent adolescents (Giancola et al., 1998; Moss
et al., 1994; Tapert and Brown, 1999; Tarter et al., 1995). Problems
that have been detected pose a threat to healthy development, as
significant neuromaturation continues during adolescence. For example,
synaptic connections disappear as a function of redundancy and
environmental stimulation up until about age 16 (Huttenlocher, 1990).
Continued myelination in frontal and parietal association areas (Kolb
and Pantic, 1989) suggests that speed of information transfer in these
regions is less efficient before age 15. Cerebral metabolic rates
increase greatly during childhood and taper toward adult levels by
approximately age 20 (Harris, 1995).
CNS exposure to neurotoxins such as ethanol during adolescent
development has undetermined consequences. Thus, adolescence is a
period of potential differential impact of ethanol exposure compared
with adulthood, when such neuroanatomical changes have stabilized. At
present, the. NP impact of alcohol dependence during early and middle
adolescence, and the pattern of NP impairment in contrast with alcohol-
dependent adults, is relatively unknown. Several processes may
influence the adolescent risk of neurocognitive damage. First,
adolescent brains may have more resilience: maturation is not fully
complete, allowing more opportunity for compensatory development.
Second, neurological development and/or cognitive maturation may be
disrupted, altered, or impeded by exposure to neurotoxins during this
time in development. Neurotoxins may also accelerate other risks, such
as head trauma and academic drop-out.
This study examined associations between protracted alcohol
involvement during early to middle adolescence and the neurocognitive
functioning in middle adolescence. Youths with repeated alcohol
exposure were predicted to evidence difficulties in aspects of verbal
and nonverbal memory and visuospatial functioning, based on results
from the adult literature. In addition, repeated alcohol withdrawal
experiences were predicted to be associated with deficient performance
on measures of these neurocognitive domains.
METHODS
Participants
Participants were recruited from treatment programs and surrounding
communities as part of an ongoing longitudinal study (e.g., Brown et
al., 1994). The alcohol-dependent participants were recruited from
adolescent inpatient alcohol and drug abuse treatment programs in
metropolitan San Diego, and met DSM-111-R criteria (American
Psychiatric Association, 1987) for a lifetime diagnosis of alcohol
dependence. Alcohol-dependent participants with more than 100 lifetime
alcohol use episodes and one or more heavy drinking episodes in the
past 3 months were selected to test hypotheses for the present study.
The alcohol-dependent participants drank alcohol heavily during early
and middle adolescence, when maturational changes (e.g. myelination of
frontal and parietal association areas; Kolb and Pantie, 1989) would
normally take place.
Table 1. Demographic Characteristics of Alcohol-Dependent and
Comparison Adolescents
------------------------------------------------------------------------
Alcohol-
dependent Comparison
mean (SD) mean (SD)
(n^33) (n=24)
------------------------------------------------------------------------
Male (%).................................... 58 58
Age (range, 15-16 yr)....................... 16.2 (0.56) 15.9 (0.59)
Caucasian (%)............................... 71 74
Grades completed............................ 9.5 (0.66) 9.2 (0.82)
Hollingshead socioeconomic status........... 31.2 (11.6) 32.5 (14.3)
Family history of alcohol dependence (%).... 57 71
Frequency mothers drank during pregnancy
(%):
No drinking............................. 52 50
Less than once per month................ 30 32
1-3 times per month..................... 6 14
More than 4 times per month............. 12 5
Average drinks mother consumed per occasion. 0.88 (1.17) 0.86 (1.04)
Maximum drinks mother consumed.............. 1.00 (1.46) 1.45 (2.36)
------------------------------------------------------------------------
Note: all conparisons nonsignificant (ex^0.05).
Range 11-77; higher score reflects lower socioeconomic background.
Age-appropriate comparisons across NP tests were facilitated by
scores from a comparison group of community adolescents without
histories of alcohol or other drug use disorders. These comparison
adolescents were recruited through advertisements in the same
communities from which the clinical sample was drawn and via parents
who were in adult alcohol treatment programs. Comparison adolescents
had no history of alcohol or other drug problems and were recruited to
match the age, gender, socioeconomic status, education, and family
history of substance-dependence characteristics of the alcohol
dependent teens.
Clinical and comparison adolescents were excluded if they: (1) did
not have a resource person (parent) who independently consented to
participate for corroboration of biographical and substance involvement
information; (2) lived over 50 miles from the research facility; (3)
had an Axis 1 psychiatric disorder (predating the onset of regular
substance use); (4) had a history of significant head trauma with loss
of consciousness > 2 min or neurological condition that could
compromise NP performance (e.g., seizure disorder); (5) did not speak
English; or (6) had a history of drug dependence or heavy recent drug
use. Analyses were performed on 33 alcohol-dependent and 24 comparison
adolescents. The nonabusing sample was comparable to the alcohol-
dependent sample on gender, age (15-16 years), ethnicity, years of
education, Hollingshead socioeconomic index (mostly lower middle
class), family history of alcohol and other drug dependence, and
maternal drinking during pregnancy (see Table 1). Informed consent,
approved by the University of California, San Diego institutional
review board and clinical agencies, was independently obtained from all
youths and parents.
Measures
Structured Clinical Interview. This 90-min interview (Brown et al.,
1987) assessed demographic information, social and academic
functioning, physical and emotional health, behavioral intentions and
attitudes regarding substance use, and maternal alcohol use during
pregnancy. Mood was assessed with the Profile of Mood States (POMS;
McNair et al., 1981). Family history of alcohol and other drug
dependence was assessed with DSM-111-R criteria and Schuckit's problem
list (Schuckit et al., 1988) for all biological first- and second-
degree relatives. For purposes of the present study, a minimum of one
alcohol-dependent biological parent was required for classification as
positive for family history.
Customary Drinking and Drug Use Record (CDDR). The lifetime version
of the CDDR (Brown et al., 1998) was administered to obtain information
on lifetime and recent (past 3 months) involvement with alcohol (beer,
wine, liquor) and eight types of drugs (i.e., marijuana, amphetamines,
barbiturates, hallucinogens, cocaine, inhalents, opiates, and
prescription medications or other substances not previously specified),
life problems related to alcohol and drug use, DSM-III-R and DSM-IV
substance abuse and dependence criteria, and alcohol and other drug-
withdrawal symptoms. The CDDR incorporates the Cahalan drinking
classification procedure (Cahalan, 1970), Drug Indulgence Index (Lee,
1974), and Alcohol Dependence Scale (Skinner and Horn, 1984). Good
internal consistency, test-retest reliability, Inter-rater reliability,
and convergent and discriminant validity have been demonstrated with
adolescents (Brown et al., 1996; Stewart & Brown, 1995).
Table 2. Description of Neuropsychological Test Battery
------------------------------------------------------------------------
Measure Ability tested
------------------------------------------------------------------------
WISC-R Subtests
Vocabulary......................... Language development; general
intelligence.
Information........................ Store at general knowledge.
Similarties........................ Abstract reasoning.
Arithmatic......................... Mental tracking and
computation.
Digit Span......................... Auditory attention.
Block Design....................... Visual-motor organization;
visual-spatial reasoning.
Coding............................. Psychomotor processing and
speed.
California Verbal Learning Test-
Children's Version (CVLT-C)
List A trial 1..................... Words recalled on first
learning trial.
List A total....................... Words recalled on five learning
trials.
Long-delay free recall (LDF)....... Target words recalled after 20-
minute delay.
Samantic clustering................ Ratio of observed to expected
semantic grouping on recall
trials.
Retention (LDF/List A Trial 5)..... Proportion of words recalled on
fifth learning trial also
recalled on LDF.
Recognition discriminability....... Proportion correct on
recognition testing of target
words embedded among
distractor words.
WMS Visual Reproduction
Immediate recall (IR).............. Visual stimuli reproduced after
initial presentation.
Delayed recall (DR)................ Visual stimuli reproduced after
10-minute delay.
Retention (DR/IR).................. Proportion of visual stimuli
reproduced on IR also recalled
on DR.
Trail Making Test
Part A time........................ Psychomotor processing speed.
Part B time........................ Cognitive flexibility and
speeded processing.
B-A time.......................... Part B time minus Part a time
(subtracting out simple motor
speed).
Embedded Figures Test.................. Visual memory: visuoperception:
contour analysis.
Boston Naming Test..................... Word finding: confrontation
naming.
Letter Fluency......................... Letter-specific verbal fluency.
Category Test.......................... Nonverbal concept formation and
deductive reasoning.
------------------------------------------------------------------------
Neuropsychological Test Battery. This 2-hr battery was designed to
measure verbal and nonverbal learning and memory, visuospatial
functioning, language skills, attention, and problem solving skills,
based on literature indicating impairment among adults with alcohol and
drug dependence (see Table 2), The battery consisted of the following
tests: Wechsler Intelligence Scale for Children-Revised (WISC-R;
Wechsler, 1974) subtests of Vocabulary, Information, Similarities,
Arithmetic, Digit Span, Block Design, and Coding; Wechsler Memory Scale
Visual Reproduction subtest (WMS-VR; Wechsler, 1945); Trail Making Test
(Reitan and Wolf-son, 1985); Embedded figures Test (Witkin et al.,
1971); an adapted 30-item Boston Naming Test (Kaplan et al., 1983);
Controlled Oral Word Association Test (Benton et al., 1983); Booklet
Category Test (DeFillippis and McCampbell, 1979); and California Verbal
Learning Test-Children's version (CVLT-C; Delis et al., 1994).
Administration of the CVLT-C involved oral presentation of a list
of 15 words (List A) over five trials. After each trial, participants
were asked to recall as many words from the list as possible. The
clustering of words into semantic categories was trucked. An
interference word list (List B) was presented and asked to be recalled.
Next, participants were asked to recall List A in a free recall format,
then in a cued recall format in which semantic category names were
provided. After a 20-min delay, participants recalled List A in free
and cued formats again, then were asked to discriminate List A words
from distractor words on a yes-no recognition trial.
Procedure
Youths were administered the battery of NP tests, structured
clinical interview, and CDDR by Bachelors- and Masters-level
psychometrists trained to criterion. Alcohol-dependent adolescents were
interviewed and tested during the 3rd week of their inpatient treatment
programs, and thus were detoxified from alcohol and other drugs at the
time of testing. Comparison adolescents were administered assessments
at the research facility. A resource person (typically a parent) was
separately interviewed for corroboration of historical, family history,
and substance use information. Separate psychometrists interviewed
adolescents and parents to enhance self-disclosure and to ensure
confidentiality. In cases of discrepant information, additional data
were obtained from other family members (see Brown et al., 1996).
RESULTS
Lifetime and current alcohol and drug use characteristics differed
greatly between alcohol-dependent and comparison teens (see Table 3).
Alcohol-dependent adolescents reported an average of 753 alcohol use
episodes spanning approximately 5 years, as well as larger quantities
of alcohol per drinking episode and more alcohol withdrawal symptoms in
their lifetimes than nonabusing comparison participants. Although
alcohol-dependent youths with lifetime or current dependence on other
drugs were excluded, the alcohol-dependent group reported exposure to
other drugs, primarily cannabis and stimulants.
WISC-R Vocabulary (p<0.01), information (p<0.01), Similarities
(p<0.05), and Coding (p<0.01) subtest scores were significantly worse
in the alcohol-dependent sample (see Table 4). The group difference in
Coding scores remained statistically significant (p<0.05) after
covariation for Vocabulary as a proxy for IQ (Kaufman, 1975).
Table 3. Alcohol and Other Drug Involvement Characteristics of Alcohol
Dependent and Comparison Adolescents
------------------------------------------------------------------------
Alcohol- Comparison
dependent mean mean (SD)
(SD) (n=33) (n=24)
------------------------------------------------------------------------
Lifetime
Age of first alcohol use*......... 10.93 (3.46) 12.89 (2.49)
Age of first weekly alcohol use*.. 13.45 (2.05) 13.83 (1.17)
Total times drank***.............. 753.21 (658.38) 82.38 (185.63)
Alcohol dependency symptoms***.... 6.67 (3.66) 0.29 (0.55)
Alcohol withdrawal symptoms***.... 2.06 (2.19) 0.36 (0.72)
Have used any alcohol (%)......... 100 80
Have used any drugs (%)***........ 100 8
Have used marijuana (%)***........ 94 4
Have used amphetamines (%)***..... 78 0
Have used cocaine (%)*............ 33 4
Have used hallucinogens (%)***.... 18 4
Have used Inhalants (%)**......... 6 4
Past 3 months
Drinking days per month***........ 18.76 (17.15) 1.79 (2.15)
Drinks per day***................. 5.13 (6.33) 0.19 (0.16)
Maximum drinks on an occasion***.. 16.33 (9.62) 2.63 (3.44)
Drinks per month***............... 154.00 (189.93) 3.38 (4.61)
Alcohol withdrawal symptoms*...... 1.48 (1.79) 0.25 (0.68)
------------------------------------------------------------------------
* Includes only recent (past 3 month) drinkers.
* p<0.05;** p<0.01;*** p<0.001.
Table 4. WISC-R Scores for Alcohol-Dependent and Comparison Adolescents
------------------------------------------------------------------------
Alcohol-
dependent Comparison
Test mean (SD) mean (SD)
(n=33) (n=24)
------------------------------------------------------------------------
Verbal
Vocabulary**............................ 9.30 (2.01) 10.88 (2.31)
Information**........................... 8.79 (2.00) 10.75 (3.31)
SImilarities*........................... 10.15 (2.85 11.92 (2.76)
Arithmetic.............................. 10.45 (3.32) 10.38 (2.30)
Digit Span.............................. 9.27 (2.80) 10.25 (2.88)
Performance
Block Design............................ 10.91 (2.94) 11.33 (2.32)
Coding**................................ 8.94 (3.26) 11.54 (3.62)
------------------------------------------------------------------------
* p<0.05;** p<0.01.
New learning of verbal material was not associated with exposure to
ethanol, as evidenced by comparable group performances on CVLT-C
learning trials (see Table 5). However, alcohol-dependent youths
employed fewer semantic learning strategies than comparison youths
(p<0.05), and retention rates were significantly worse among the
alcohol-dependent adolescents (p<0.05). However, when asked to
discriminate between words previously presented and distractor words,
both groups fared equally well, and alcohol-dependent youths were often
able to correctly recognize words they had failed to recall.
Table 5. Neuropsychological Test Scores for Alcohol-Dependent and
Comparison Adolescents
------------------------------------------------------------------------
Alcohol-
Measure dependent mean Comparison mean
(SD) (n=33) (SD) (n=24)
------------------------------------------------------------------------
CVLT-C
List A trial 1.................. 7.15 (1.79) 6.68 (1.70)
List A total.................... 54.12 (8.21) 55.12 (8.15)
Long-delay free recall.......... 11.30 (2.80) 12.60 (2.27)
Semantic clustering*............ 1.84 (0.60) 2.18 (0.63)
% Retention*.................... 85.84 (17.90) 96.16 (16.15)
% Recognition discriminability.. 95.36 (3.47) 95.58 (4.48)
Visual Reproduction:
Immediate recall................ 10.03 (2.39) 11.13 (1.73)
Delayed recall**................ 8.82 (2.70) 10.75 (1.85)
% Retention**................... 87.85 (16.40) 97.79 (9.42)
Embedded Figures Test time.......... 442.00 (256.98) 415.38 (207.18)
Trail Making Test, Part B time...... 61.70 (25.78) 56.68 (18.75)
Trail Making Test B-A time.......... 33.45 (19.77) 29.46 (13.14)
Boston Naming Test (correct without 24.36 (2.97) 25.92 (3.94)
cue, Max=30).......................
Latter Fluency...................... 35.39 (9.09) 34.83 (9.14)
Category Test errors................ 19.82 (10.71) 16.79 (10.44)
------------------------------------------------------------------------
* p<0.05;** p<0.01.
Visual reproduction retention rates were significantly lower in the
alcohol-dependent sample (p<0.01). Although alcohol-dependent and
nonabusing youths were similar on immediate delay reproductions,
alcohol-dependent adolescents reproduced less nonverbal information
after the 10-min delay period, and their delayed recall performances
were proportionately worse than what they had recalled immediately
after exposure to the stimuli.
Verbal and nonverbal retention rates were not significantly related
to gender, family history of alcohol/drug dependence, or maternal
drinking during pregnancy.
To examine the hypothesis that alcohol withdrawal is associated
with neurocognitive functioning during early to middle adolescence,
correlations between alcohol withdrawal symptoms and NP scores were
evaluated (see Table 6). A modest but statistically significant pattern
of correlations was evident in that 20 of 22 lifetime withdrawal-NP
correlations and 19 of 22 recent withdrawal-NP correlations were in the
predicted direction (p<0.01; Ghahramani, 1996, p. 241). In particular,
more lifetime alcohol-withdrawal experiences were associated with
poorer performance on delay trials of the CVLT-C (r=^0.28,p<0.05) and
WMS-VR (r=^0.32,p< 0.05), WMS-VR retention rates (r=^0.33,p<0.05), and
scores on WISC-R Information (r=^0.27,p< 0.05). Recent withdrawal
symptom counts were associated with poorer WISC-R Block Design scaled
scores (r=^0.26,p<0.05) and Embedded Figures Test completion times
(r=0.26,p<0.07). Moderate correlations were found with between both
lifetime and current withdrawal symptom counts and a task involving
multiple brain systems (Trail Making Test, p's<0.07).
NP performances were associated with other drinking variables,
although to a lesser extent than lifetime alcohol withdrawal, and with
POMS depression scale scores (see Table 7). Frequency of drinking was
correlated with WISC-R Information and Block Design scores, and DSM-IV
alcohol dependence criteria were correlated with WMS-VR delay and
retention rates (p's<0.05). Depressed mood was related to CVLT-C and
WMS-VR delay trials, WMS-VR retention (p's 0.05 to 0.01), and also with
lifetime (p<0.01) and current (p<0.05) alcohol withdrawal. Because
alcohol withdrawal commonly involves depressed mood, and depressed mood
may affect neurocognition, two mediational models were tested: (1) to
see if depressed mood mediates the relationship between withdrawal and
poor retention, and (2) to see if withdrawal mediates the relationship
between depressed mood and poor retention. Hierarchical regressions
suggested the former: that depressed mood mediates the relationship
between withdrawal and poor WMS-VR retention rates in a mixed gender
sample F(2,51)=5.58, p<0.01; R\2\D=15%, p<0.05).
Table 6. Correlations Between Withdrawal Symptoms and Neuropsychological
Test Scores for Alcohol-Dependent and Comparison Adolescents (N=57)
------------------------------------------------------------------------
Alcohol Withdrawal
Measure -------------------------
Lifetime Recent
------------------------------------------------------------------------
WISC-R
Vocabulary................................ ^0.12 0.18
Information............................... ^0.27* ^0.24
Similarities.............................. ^0.04 ^0.23
Arithmetic................................ ^0.14 ^0.21
Digit Span................................ 0.21 0.13
Block Design.............................. ^0.18 ^0.26*
Coding.................................... ^0.20 ^0.17
CVLT-C
List A trial 1............................ 0.05 0.05
List A total.............................. ^0.10 0.07
Long-delay free recall.................... ^0.28* ^0.17
Semantic clustering....................... ^0.19 ^0.18
Retention rate............................ ^0.22 ^0.04
Recognition discriminability.............. 0.06 0.01
WMS Visual Reproduction
Immediate recall.......................... ^0.14 ^0.15
Delayed recall............................ ^0.32* ^0.17
Retention rate............................ ^0.33* ^0.07
Embedded Figures Test time a.................. 0.08 0.26**
Trail Making Test, Part B time................ 0.25** 0.13
Trails B-A time............................... 0.22 0.25**
Boston Naming Test............................ ^0.10 ^0.07
Letter Fluency................................ 0.06 0.13
Category Test errors*......................... 0.07 0.04
Correlations In predicted direction (p<0.01) 20/22 19/22
------------------------------------------------------------------------
a Positive correlations predicted; all other
correlations predicted to be negative.
* p< 0.05; ** p<0.07.
To see if the pattern of scores might be affected by the inclusion
of both boys and girls, analyses were tested on boys only (n=19
alcohol-dependent and n=15 comparison). The same pattern of results
emerged for group differences on NP tests and for NP correlations with
withdrawal symptoms as were found with the full sample. Of note, boys'
lifetime alcohol-withdrawal symptoms correlated highly with CVLT-C
retention (r=^0.49,p< 0.005) and WMS-VR retention (r=^0.55,p<0.001)
rates. In contrast to the mixed gender analyses, boys' lifetime
alcohol-withdrawal symptoms predicted retention rates independent from
the influence of depressed mood in hierarchical regressions
(coefficient p's<0.05). Withdrawal mediated the relationship between
depressed mood and CVLT-C retention (B=^0.37,p<0.05), whereas de-
pressed mood did not mediate the relationship between alcohol
withdrawal and retention rates.
DISCUSSION
This study identified subtle to modest NP deficiencies associated
with repeated heavy alcohol use and withdrawal during early to middle
adolescence. In particular, alcohol-dependent adolescents with a
minimum of 3-weeks of abstinence differed from sociodemographically and
family history-matched nonabusers on several NP measures. As
hypothesized, aspects of memory functioning and visuospatial cognition
were poor, compared with the demographically and family history-matched
controls. Verbal skill deficiencies were also found in the alcohol-
dependent group.
The pattern of memory functioning results was internally consistent
and suggested deficits among heavy drinking adolescents. New learning
did not appear to be affected by alcohol involvement when measured
after 3-weeks of abstinence, but alcohol-dependent youths, especially
those with histories of alcohol withdrawal symptoms, failed to
reproduce some words or figure components that they had recalled on
trials administered immediately after exposure to the stimuli (see Fig.
1). This retrieval deficiency was mediated by depression scores for the
full sample, but for boys, withdrawal had an independent contribution
to poorer retention and withdrawal that mediated the mood-retrieval
relationship. As participants were screened for primary mood disorders,
the relationship between depression and withdrawal suggests that
alcohol-dependent adolescents may have experienced alcohol-induced mood
changes that affected neurocognition. This mood change seems to have
affected boys and girls differently.
In examining the process of learning, alcohol-dependent youths were
found to underutilize semantic clustering strategies, which may have
hampered efficient recall performance. When asked to discriminate
between words previously presented and distractor words, both alcohol-
dependent and nonabusing groups performed equally well. This resembled
a pattern of NP performance observed in patients with mild frontal-
subcortical dysfunction (review Butters et al., 1995). However, the
reduced level of recall on delay in alcohol-dependent adolescents
relative to controls contrasts with studies of alcohol-dependent
adults. In a study of access, availability, and efficiency of verbal
information processing, alcohol-dependent adults demonstrated
comparable recall relative to controls (Nixon and Bowlby, 1996). One
possible explanation for this developmental difference is that deficits
in recall may be compensated over time, whereas efficiency of recall
may become increasingly impaired with continued years of drinking.
The association between visuospatial functioning and substance
withdrawal found in the present study was also reported by Tapert and
Brown (1999) using other statistical procedures. Youths who experienced
alcohol-withdrawal symptoms performed more poorly on tests of visual
motor integration and visuoperception. These functions appeared more
related to withdrawal histories than to other indices of substance
involvement. A complex substitution task involving speeded scanning and
processing was performed significantly slower in the alcohol-dependent
sample, as reported in studies of alcohol-dependent adults (e.g.,
Brandt et al., 1983).
Table 7. Intercorrelations Between Retention Rates, Mood, and Substance Involvement in Alcohol-Dependent and
Comparison Adolescents (N^57)
----------------------------------------------------------------------------------------------------------------
Variable 1 2 3 4 5 6 7
----------------------------------------------------------------------------------------------------------------
1. CVLT-C retention rate
2. Visual Reproduction retention rate............ 0.34*
3. POMS Depression scale......................... ^0.26 0.41**
4. Drinking episodes per month................... 0.02 ^0.08 0.38**
5. DSM-IV Alcohol Dependence criteria............ ^0.17 ^0.30* 0.49** 0.67**
6. Alcohol withdrawal symptoms, lifetime......... ^0.22 ^0.34* 0.58** 0.54** 0.57**
7. Alcohol withdrawal symptoms, recent........... ^0.04 ^0.07 0.33* 0.69** 0.51** 0.73**
----------------------------------------------------------------------------------------------------------------
* p<0.05;** p<0.01
Vocabulary and Information scores were lower in the alcohol-
dependent sample. Environmental, economic, or family factors can
adversely affect language functioning (e.g., Rourke et al., 1983).
Language skills may have been inferior among alcohol-dependent
adolescents because substance use prevented adequate attendance,
attention, and/or participation in or processing of educational
experiences. Alternatively, verbal IQ deficits that commonly mark
academic problems and conduct disorder (review Moffitt, 1993) may have
been associated with CNS differences that predated the use of alcohol.
The association between tests of language functioning and alcohol
involvement differentiated these adolescent findings from those of
adult alcoholics.
The present study has several limitations. First, the carefully
selected but small sample size prohibited exploration of gender and
family history differences. Second, the use of other drugs may have
independently affected cognitive performance (e.g., Beatty et al.,
1997), but could not be explored in this relatively small sample.
Third, there was no recognition trial on the nonverbal memory test, so
we cannot distinguish between pictorial retention and retrieval
processes. Fourth, although a relationship between alcohol dependence
and NP difficulties was indicated by this and other cross-sectional
studies, the directionality can be determined only by longitudinal
studies. Although protracted alcohol or drug involvement may cause NP
impairment, cognitive deficits may also be a risk factor or marker for
the development of substance use disorders. For example, aggressive
youths (Giancola et al., 1998) and those with family histories of
alcohol dependence (Harden and Pihl, 1995; Najam et al., 1997) have
demonstrated executive and language dysfunction and self-regulation
deficiencies (Henry et al., 1996) before the onset of substance use.
Although not exclusively an alcohol-dependent sample, one longitudinal
study has suggested that continued substance involvement in adolescence
leads to greater neurocognitive difficulties (Tapert and Brown, 1999).
In summary, these results, taken with other studies (Giancola et
al., 1998; Moss et al., 1994; Tapert and Brown, 1999; Tarter et al.,
1995), suggest that NP deficits are detectable among middle-aged
adolescents with histories of extensive alcohol use. Limitations in the
retrieval of recently acquired information put alcohol-dependent
adolescents at risk for falling farther behind in school, thus
compounding their risk for social problems (Newcomb and Bentler, 1988).
Treatment programs may improve outcomes by measuring teens' memory
capacities and using efficacious methods of presenting new information
that consider impaired retention. Future studies could determine if
multi-modal learning, repetition, and active learning procedures (e.g.,
role playing) help to successfully teach coping skills and appraisal of
post-treatment relapse risks (Myers et al., 1993; Roehrich and Goldman,
1993; Tapert et al., 1999).
Deficits on visuospatial and retention measures suggest that
underlying brain mechanisms may be affected by ethanol exposure, even
after 3 weeks of abstinence. These results share a consistent pattern
with adult studies in that verbal and visual memory deficits suggest
potential mesial temporal lobe, caudate nucleus, and/or diencephalic
damage, regions implicated in studies of adult alcohol-dependent
patients (e.g., Jernigan et al., 1991). Overall, lifetime alcohol
withdrawal symptoms were associated with poorer retrieval functioning
(mesial temporal lobe and diencephalic regions and frontal-subcortical
circuits), whereas recent withdrawal was associated with lower levels
of visuospatial functioning (frontal-parietal regions). Structural and
functional neuroimaging studies may help examine these hypotheses.
ACKNOWLEDGMENT
Appreciation is expressed to San Luis Roy Hospital, Mesa Vista
Hospital, Harborview Medical Center, and Scripps Memorial Hospital for
their participation in the project.
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Senator DeWine. Dr. Weissberg?
Mr. Weissberg. Good morning, Chairman DeWine and Senator
Reed. I would like to thank you and Senator Kennedy for
inviting me here today to comment as a psychologist, researcher
and practitioner on effective substance abuse prevention for
young people. I am Roger Weissberg, a professor of psychology
and education at the University of Illinois at Chicago. I also
serve as president of the Collaborative for Academic, Social
and Emotional Learning, or CASEL. CASEL is a national
organization of researchers and educators with the mission of
establishing and disseminating evidence-based social and
emotional learning as an essential part of preschool through
high school education.
Recently, I co-chaired the American Psychological
Association Task Force on Prevention and subsequently coedited
a special issue of the American Psychologist on prevention that
works for children and youth. Building from our findings, my
testimony briefly highlights some research-based principles of
effective prevention programming and offers a few key
recommendations for prevention practice and policy.
As detailed in my written testimony, too many adolescents
still engage in substance use, and significant percentages
experience mental health problems, engage in other risky
behaviors and lack social and emotional competencies such as
stress management, problem solving and relationship skills.
Given these high rates of substance use and related problem
behaviors, our society urgently needs effective prevention and
youth development approaches that are broadly disseminated and
implemented with high quality.
A convincing research base now shows that well-designed and
well-implemented school-based prevention programs can reduce
substance use, enhance mental health and improve academic
performance. The best school-based efforts are multiyear,
skill-based and coordinated. They are school-wide and involve
families and communities as partners. They help schools
coordinate and unify categorically-funded prevention programs
that are often fragmented. They offer developmentally and
culturally appropriate instruction and clear learning
objectives at each grade level.
In addition to preventing the negative, they promote the
positive, such as teaching children to apply social and
emotional skills and ethical values in daily life through
service learning. They build connection to school through
caring people and engaging classroom and school practices. They
address the effective and social dimensions of academic
learning. They provide high-quality staff development and
administrative support, and they incorporate continuing
evaluation and improvement. Finally, in this era of No Child
Left Behind pressures for academic accountability, there is a
new generation of research indicating school-based prevention
can also enhance academic performance.
Unfortunately, despite scientific advances, there is still
a wide gap between prevention research and practice. Most
schools still do not use prevention programs of proven
effectiveness. Even when schools select research-based
programs, the majority of them do not implement those programs
with fidelity and thus fail to obtain their expected benefits.
Furthermore, there is widespread fragmentation and lack of
coordination among prevention programs. No matter how many
prevention programs schools have, those programs will not
achieve their intended effects when they are introduced in a
categorical manner targeting one negative outcome at a time.
There are a variety of steps that could improve prevention
practice and benefit more children. At the State level in
Illinois, our governor recently signed the Children's Mental
Health of 2003, which makes mental health promotion integral to
education. It requires the Illinois State Board of Education to
incorporate social and educational development standards as
part of the Illinois Learning Standards, and it requires every
school district to develop a policy for incorporating social
and emotional development into the district's plan.
The Illinois legislation can serve as a national model for
innovative education that fosters social and emotional learning
to enhance students' academic performance, health, character
and citizenship. For school-based prevention to succeed, it is
crucial that schools have prevention coordinators who are
explicitly responsible for the selection, effective
implementation, coordination, evaluation and continuous
improvement of evidence-based programming.
We are finding that providing training and technical
assistance to National Safe and Drug Free School coordinators
improves practice and benefits children. This investment is
starting to pay off and should be continued.
Finally, I applaud SAMHSA's leadership to translate
rigorous science into effective practice. Recently, SAMHSA
announced that it will provide $45 million to support States in
implementing the new Strategic Prevention Framework to prevent
substance abuse and promote mental health. The SAMHSA framework
will facilitate collaboration among different prevention
programs across schools, families and communities.
This promising prevention initiative requires new and
substantial funds if we are to reduce significantly the number
of young people who develop substance abuse and mental health
problems.
In closing, I also thank the Committee and Senator DeWine
even asked today about the importance of encouraging stronger
interagency linkages between Federal agencies such as the U.S.
Department of Education, Health and Justice. Such collaboration
is critical both to improve coordinated prevention through
practice through research and to understand factors that
influence high quality dissemination and utilization of
prevention programs and policies.
Once again, thank you, Mr. Chairman, for the opportunity to
present this testimony and for holding this timely hearing. I
would be glad to answer any questions the Subcommittee may have
for me.
[The prepared statement of Mr. Weissberg follows:]
Prepared Statement of Roger P. Weissberg, Ph.D.
Good morning, Chairman DeWine, Senator Kennedy, and Members of the
Subcommittee. Thank you for inviting me here today to comment from my
30-year perspective as a psychologist, prevention researcher, and
practitioner addressing the challenges facing school and other
community-based prevention programs as they work to prevent youth
substance abuse.
I am Roger Weissberg, Professor of Psychology and Education at the
University of Illinois at Chicago, where I direct a Prevention Research
Training Program in Urban Children's Mental Health and AIDS Prevention
funded by the National Institute of Mental Health. I also serve as
President of the Collaborative for Academic, Social, and Emotional
Learning (CASEL), an organization dedicated to the development of
children's social-emotional competencies and the capacity of schools,
parents, and communities to support that development. CASEL's mission
is to establish integrated, evidence-based social and emotional
learning (SEL) as an essential part of preschool through high school
education (for information on advances research and practice in this
area see www.CASEL.org).
Recently, I co-edited a Special Issue of the American Psychologist
on ``Prevention that Works for Children and Youth'' (Weissberg &
Kumpfer, 2003). The articles in the Special Issue are an outgrowth of
an American Psychological Association Presidential Task Force on
``Prevention: Promoting Strength, Resilience, and Health in Young
People'' that I co-chaired. The task force members concluded that
prevention research has matured substantially in recent decades,
synthesizing new knowledge and offering important findings to guide
prevention practice and policy. Part of my testimony will highlight
some common features of effective prevention programming identified by
scholars representing diverse perspectives. I am pleased to emphasize
that there is great overlap between our views and the principles
emphasized in the new Strategic Prevention Framework to advance
community-based programs for substance abuse prevention and mental
health promotion announced by the Substance Abuse and Mental Health
Services Administration (SAMHSA).
In Part I of this testimony, I briefly introduce findings about
trends in adolescent substance use and other risky behaviors and
comment on the implications of these findings for coordinated
prevention and youth-development programming. In Part II, I review
results from recent large-scale studies and reviews on effective
school-based prevention programs. Part III presents some of the
challenges and difficulties that schools face in administering school-
based prevention programs. In Part IV, I share with you some of the
work CASEL is doing to reduce the gap between research and practice. In
the last part, I comment on SAMHSA's ``Strategic Prevention Framework''
as a powerful tool towards collaboration and coordination among
multiple prevention programs.
I. Trends in Adolescent Substance Use and Other Risky Health Behaviors
The news regarding recent national trends in adolescent substance
use is mixed. Perhaps the simplest set of headlines is ``During the
past 12 years, tobacco and alcohol use has declined; marijuana,
cocaine, and illegal steroid use has increased; and, overall, too many
students engage in all forms of substance use.'' To support this
summary, I highlight some findings recently reported by the Centers for
Disease Control and Prevention (CDC) from the 2003 Youth Risk Behavior
Surveillance System (www.cdc.gov/yrbss). The National Youth Risk
Behavior Survey is conducted every 2 years during the spring semester
and provides data gathered from students in grades 9-12 in public and
private schools throughout the United States. The chart below
summarizes changes in percentages of self-reported substance use
between 1991 and 2003.
------------------------------------------------------------------------
Behavior 1991 2003
------------------------------------------------------------------------
Lifetime cigarette use.................. 70.1 58.4
Current cigarette use (last 30 days).... 27.5 21.9
------------------------------------------------------------------------
Lifetime alcohol use.................... 81.6 74.9
Current alcohol use (last 30 days)...... 50.8 44.9
Episodic heavy drinking (last 30 days).. 31.3 28.3
------------------------------------------------------------------------
Lifetime marijuana use.................. 31.3 40.2
Lifetime cocaine use.................... 5.9 8.7
Lifetime illegal steroid use............ 2.7 6.1
------------------------------------------------------------------------
Defying some commonly held stereotypes, substance use crosses
geographic and economic boundaries. For example, studies comparing
substance use between adolescents from affluent suburban versus low-
income urban families show that high rates of teens from affluent
families use substances (Luthar & Becker, 2002; Levine & Coupey, 2003).
Such findings speak to the importance of universal (i.e., targeting all
children) rather than selective approaches to prevention. Targeting
only selective groups of children and youth in our prevention efforts
may result in ignoring substantial numbers of children and youth who
are in urgent need of prevention programs. Some may argue that broadly
targeted prevention programming may not be appropriate for at-risk
groups. However, research findings suggest that as long as we provide
programs with fidelity, that is, implement them in a way that is
faithful to the original program design, most programs are equally
beneficial for all students (Griffin, Botvin, Nichols, & Doyle, 2002).
Furthermore, Caulkins and his colleagues (2002) recently examined
whether the benefits of a model school-based prevention program exceed
its costs. According to their best estimates, they concluded that
society would currently realize quantifiable benefits of $840 from a
student's participation compared with a program cost of $150 per
participating student, a saving of almost $6 for every $1 invested.
It may sound as though I am making an argument that early and
effective substance abuse prevention for young people should be our
highest priority. But, actually, I will argue that a broader
perspective is needed. Preventing substance abuse is a worthy endeavor,
but it is a limited goal. It is indisputable that young people who are
not drug abusers may still lack the resources to become healthy adults,
caring family members, responsible neighbors, productive workers, and
contributing citizens (Pittman, Irby, Tolman, Yohalem, & Ferber, 2001).
In addition to having drug-free sons and daughters, parents across the
United States want children who:
1. are intellectually reflective and committed to lifelong
learning;
2. interact with others in socially skilled and respectful ways;
3. practice positive, safe, and healthy behaviors;
4. contribute ethically and responsibly to their peer group,
family, school, and community; and
5. possess basic competencies, work habits, and values as a
foundation for meaningful employment and engaged citizenship.
Although the prevalence of substance use calls for action, there is
also reason for concern about high rates of related adolescent risk
behaviors in domains such as violence, sexual behavior, depression, and
suicide. Consider the following percentages of student involvement in
problem behaviors from the 2003 CDC Youth Risk Behavior Surveillance
System:
------------------------------------------------------------------------
Behavior 2003
------------------------------------------------------------------------
Threatened or injured with a weapon on school property 9.2
(last 12 months).......................................
Engaged in a physical fight on school property (last 12 12.8
months)................................................
------------------------------------------------------------------------
Currently sexually active partners (lifetime)........... 34.3
Had 4 or more sex partners (lifetime)................... 14.4
------------------------------------------------------------------------
Felt so hopeless almost every day 2 weeks or more in a 28.6
row that they stopped doing some usual activities (last
12 months).............................................
Made a suicide plan (last 12 months).................... 16.5
Attempted suicide (last 12 months)...................... 8.5
------------------------------------------------------------------------
When we look at the broader picture of adolescent functioning, it
is clear that, beyond substance use, significant percentages of young
people experience mental health problems, engage in other risky
behaviors, and lack social-emotional competencies. The 1999 Surgeon
General's report on mental health indicated that 20 percent of children
and adolescents experience the symptoms of a mental disorder during the
course of a year, and that 75-80 percent of these children do not
receive appropriate services (U.S. Department of Health and Human
Services, 1999). Dryfoos (1997) estimated that 30 percent of 14 to 17
year-olds engage in multiple high-risk behaviors, and that another 35
percent, considered to be at medium risk, are involved with one or two
problem behaviors. Approximately 35 percent have little or no
involvement with problem behaviors, but even these young people require
strong and consistent support to avoid becoming involved.
Such a constellation of multiple high-risk behaviors points to the
importance of moving beyond the problem-focused approach and especially
beyond targeting only one problem behavior at a time. Ripple and Zigler
(2003) argued that such approaches fail to take into consideration the
complicated etiology of individual target problems and the significant
overlap of multiple problems. The design of prevention programs should
be guided by the theoretical knowledge on risk and protective factors
commonly underlying multiple problem behaviors. Furthermore, programs
should not merely aim at reducing risk conditions; they also should
explicitly promote personal and environmental assets that will decrease
problem behaviors and, more important, serve as foundations for healthy
development (Greenberg et al., 2003; Kumpfer & Alvarado, 2003;
Wandersman & Florin, 2003).
In assessing the functioning of young people and families, I draw
three major conclusions that have relevance for prevention policy and
practice. First, a significant proportion of children will fail to grow
into contributing, successful adults unless there are major changes in
the ways they are taught and nurtured. Second, families and schools
must work together more systematically and effectively to enhance the
social-emotional competence, character, health, and academic learning
of all children. Finally, new kinds of community resources and
arrangements are needed to support the positive development of young
people into responsible, healthy, productive workers and citizens.
II. Principles of Effectiveness Based on Meta-Analyses and Large-Scale
Reviews of Prevention Programs
The No Child Left Behind Act has prompted heightened awareness of
educational accountability as well as the need for evidence-based
programs to improve student performance. Federal and State government
agencies are mandating that only programs proven to be effective should
receive public funds. Due to significant advances in prevention
science, there have been increasing efforts to identify effective
prevention programs and the characteristics that underlie such programs
(Nation et al., 2003).
A number of institutions, both public and private, including the
Centers for Disease Control and Prevention, the Center for Substance
Abuse Prevention, the Office of Juvenile Justice and Delinquency
Prevention, the U.S. Department of Education, and CASEL have put forth
lists of model programs. However, there have been growing concerns
about the gap between scientific knowledge about prevention programs
and actual practice (Wandersman & Florin, 2003). Therefore, with the
intention to inform practitioners about the availability and
characteristics of effective programs, several researchers have
conducted reviews and meta-analyses of prevention programs. These
studies have yielded noteworthy principles of successful prevention
programming (Catalano et al., 2002; Durlak, 1998; Eccles & Appleton,
2002; Greenberg, Domitrovich & Bumbarger, 2001; Kumpfer & Alvardo,
2003; Nation et al., 2003; Tobler, 2000; Wilson, Gottfredson, & Najaka,
2001).
In their meta-analysis of 207 universal prevention programs
published between 1978 and 1998, Tobler et al. (2000) found that
programs that only emphasized information and lacked an interactive
approach were minimally effective. Among three types of programs
categorized under interactive approaches--interpersonal skills training
programs, comprehensive life skills training programs, and school-wide
restructuring programs--system-wide restructuring showed the strongest
impact. As researchers have consistently pointed out, thoughtful
school-based prevention and youth development interventions should
enhance students' personal and social assets and at the same time
improve the quality of the environments in which students are educated
(Catalano et al., 2002; Eccles & Appleton, 2002; Greenberg et al.,
2003). Given that peer social influences are the most salient
determinant of substance use, no one will doubt the crucial role that
refusal skills (the ability to ``say no'' and mean it) play in
preventing teens from using tobacco, alcohol, and other substances.
However, skills training alone is not sufficient. Considering that many
youth involved in substance use lack a sense of connectedness to school
and family, instruction of skills and knowledge should take place in
tandem with changes in school-wide culture that help children feel more
engaged, safe, and supported.
Weissberg, Kumpfer, and Seligman (2003) highlighted six
characteristics of effective prevention programming across school,
family, and community levels for young people:
1. Uses a research-based risk and protective factor framework that
involves families, peers, schools, and communities as partners in
coordinated programming that targets multiple outcomes;
2. Is long-term, age-specific, and culturally appropriate;
3. Fosters development of individuals who are healthy and fully
engaged by teaching them to apply social-emotional skills and ethical
values in daily life;
4. Aims to establish policies, institutional practices, and
environmental supports that nurture optimal development;
5. Selects, trains, and supports interpersonally skilled staff to
implement programming effectively; and
6. Incorporates and adapts evidence-based programming to meet local
community needs through strategic planning, ongoing evaluation, and
continuous improvement.
Despite advances in scientific knowledge about ways to make
prevention programs effective, there still is a wide gap between
research and practice--what we know and what we do. In the case of
school-based prevention programs, many schools still do not use
programs of proven effectiveness (Gottfredson & Gottfredson, 2001).
Even when schools select research-based programs, the majority of them
report that they do not implement those programs with fidelity.
Bolstering the quality of schools so that they work effectively with
families to foster both the social-emotional development and academic
performance of all students must be the top priority of any
comprehensive prevention strategy for young people (Osher, Dwyer, &
Jackson, 2002).
III. Barriers to Successful Implementation of School-Based Prevention
Programs
Several observations can help to explain the disparity between
research and practice. Taken together, they represent a set of barriers
to the successful implementation of beneficial school-based prevention
programs.
First, there is widespread fragmentation and lack of coordination
among prevention programs. In most cases, schools are flooded with
programs covering such topics as character education, substance abuse
prevention, and HIV/AIDS awareness, with no effort to coordinate what
are in fact closely interrelated realms. No matter how many prevention
programs schools have, those programs are not likely to achieve their
intended effects as long as they are introduced in a piece-meal and
uncoordinated manner.
A second challenge is the lack of administrator-teacher support and
professional development opportunities. Bombarding principals and
teachers who are already overburdened by academic duties with a
succession of new programs with minimum support and guidance is likely
to raise educators' resistance and ultimately result in ineffective
program results. As seen in the work of Osher et al. (2002) and Adelman
and Taylor (2000), for a prevention program to achieve maximum impact,
the entire school community should embrace the program's mission and
goals, thereby changing whole school culture. However, without the
ownership of the school community, active leadership of administrators,
and high-quality implementation by teachers and student-support staff,
the program is not likely to be successful.
A third challenge is the lack of an accountability system. I have
already noted that the majority of the programs are not implemented
with fidelity. The problem is exacerbated by the absence of
accountability systems through which both the implementation and the
impact of a prevention program is assessed and shared publicly in an
ongoing fashion. Therefore, to achieve faithful and successful
implementation of prevention programs, we should adopt accountability
systems for children's social-emotional development and health with the
same vigor as we do for their academic performance.
IV. The Social and Emotional Learning Framework: Bridging the Gap
Between Science and Practice
In 1994 a group of educators, school-based prevention researchers,
and child advocates came together to address the ineffective nature of
so many prevention and health promotion efforts. The result was the
formation of the Collaborative for Academic, Social, and Emotional
Learning (CASEL) Since its inception, CASEL has been working toward the
goal of establishing social and emotional learning (SEL) as an
essential element of education from preschool through high school. SEL
is the process of acquiring the skills to recognize and manage
emotions, demonstrate caring and concern for others, make responsible
decisions, establish positive relationships, and handle challenging
situations effectively. SEL is fundamental to children's social and
emotional development, health and mental well-being, ethical
development, citizenship, motivation to achieve, and academic learning.
Developmentally and cultury appropriate SEL-focused classroom
instruction in the context of a safe, caring, well-managed, and
participatory school environment enables young people to learn,
practice, and apply SEL skills. It also enhances students' connection
to school through caring, engaging classroom and school practices.
Learning social and emotional skills is similar to learning other
academic skills in that the effect of initial learning is enhanced over
time to address the increasingly complex situations children face. SEL
outcomes are best accomplished through effective classroom instruction;
student engagement in positive activities in and out of the classroom;
and broad student, parent, and community involvement in program
planning, implementation, and evaluation. Ideally, planned, systematic
SEL instruction should begin in preschool and continue through high
school. We at CASEL believe that the rationale for SEL can serve as a
powerful framework to facilitate coordination and integration of
multiple fragmented prevention efforts (Greenberg et al., 2003) and
thus address more effectively some of the most pressing problems facing
prevention and health promotion programs today.
There is growing evidence that school-based SEL programming can
successfully enhance students' academic performance as well as reduce
substance use and address other problem behaviors (Greenberg et al.,
2003; Zins, Weissberg, Wang, & Walberg, 2004). In spite of the fact
that most schools' mission statements embrace the notion of the whole
child, most schools do not make systematic efforts to institutionalize
promotion of social and emotional competencies and creation of
environments supporting their development.
CASEL believes that schools should explicitly address children's
social and emotional development as an educational priority. We are
conducting a variety of activities to help educators and prevention
professionals create and sustain more effective approaches to
prevention programming. These activities include:
Disseminating scientific knowledge about the conceptual
framework for SEL and evidence-based SEL programs through CASEL's
publications, web site, and monthly electronic newsletters;
Providing support and technical assistance for the pre-
service and in-service training of teachers and administrators to
ensure fidelity and sustainability of school-based SEL prevention
programs;
Promoting school-family-community partnerships; and
Developing and facilitating local, State, and national
networks of educational leaders who are concerned about effective
prevention and positive youth development programming
At the State level in Illinois, our Governor recently signed the
Children's Mental Health Act of 2003 (Public Act 93-0495). Section 15
(Mental Health and School) requires the following:
1. The Illinois State Board of Education shall develop and
implement a plan to incorporate social and emotional development
standards as part of the Illinois Learning Standards for the purpose of
enhancing and measuring children's school readiness and ability to
achieve academic success.
2. Every Illinois school district shall develop a policy for
incorporating social and emotional development into the district's
educational program. The policy shall address teaching and assessing
social and emotional skills and protocols for responding to children
with social, emotional, or mental health problems, or a combination of
such problems, that impact learning ability.
CASEL is currently working with the Illinois State Board of
Education and the Illinois Children's Mental Health Partnership to
implement this legislation. The Illinois effort can serve as a national
model for fostering educational systems that focus on student
competencies that serve as foundations for successful academic
performance, health, character, and citizenship.
At the national level, CASEL trains school building-level and
school district-wide coordinators who support the implementation,
evaluation, and continuous improvement of evidence-based school safety
and substance use prevention programs. Specifically, we, as a team with
three other groups (the American Institutes for Research, the Education
Development Center, and the National Association of School
Psychologists) provide training and technical assistance to the
National and Middle School Prevention Coordinators under the Office of
Safe and Drug-Free Schools in the U.S. Department of Education. The
coordinators play a critically important role in their schools and
districts by ensuring successful implementation of evidence-based
programs. Their roles include: (1) integrating and coordinating
multiple programs, (2) conducting needs assessments and establishing
baseline data related to prevention and youth-development programming,
(3) conducting implementation and outcome assessments, and (4)
overseeing and facilitating prevention-related school staff
development.
We applaud the Office of Safe and Drug-Free Schools for its
effective leadership in conceptualizing and advancing efforts to train
and support Safe and Drug-Free School Coordinators. Given the crucial
role that they play in successful implementation of programs and the
host of tasks for which the coordinators are responsible, more funding
should be provided for training the coordinators and selecting and
hiring more individuals to join in this important endeavor. For school-
based prevention to succeed, it is crucial that districts and schools
have staff members who are explicitly responsible for assuring the
selection, effective implementation, coordination, evaluation, and
continuous improvement of evidence-based programming.
Another important avenue for informing and supporting educators to
implement research-based SEL programming is through the Regional
Education Laboratories. CASEL is effectively collaborating with the
Mid-Altlantic Regional Educational Laboratory for Student Success at
Temple University to disseminate information and provide supports to
thousands of educators who implement school-family prevention
programming (CASEL, 2003; Zins et al., 2004).
V. Toward Further Collaboration and Coordination: The SAMHSA Strategic
Prevention Framework
In recent years, SAMHSA has provided groundbreaking and high-
quality national leadership in translating rigorous science into
effective practice. For example, through its Model Programs initiative,
Training and Technical Assistance Centers, and informative
publications, SAMHSA has focused on making sure that the highest
quality, evidence-based programs are provided effectively and broadly
to American children and families. Given the common risk and protective
factors for substance abuse and mental health problems, it is good to
see increased coordination between CSAP and CMHS so that their science-
based interventions focus simultaneously on the fundamental and common
factors that influence both types of outcomes. The best payoff from
these efforts will come from programming that begins in early and
middle childhood and works with schools, families, and communities to
create integrated systems of prevention and treatment in which
prevention is seen as the front line of defense to reduce the number of
new cases as well as an important offensive strategy to enhance the
competence of all young people.
SAMHSA has recently announced that it will provide $45 million to
support States in implementing the new ``Strategic Prevention Framework
(SPF)'' to prevent substance abuse and promote mental health. The
Framework is based on the belief that effective prevention programs
must (1) involve individuals, families, and entire communities, (2)
acknowledge the importance of health promotion as well as problem
prevention, (3) emphasize common risk and protective factors among
multiple problems, and (4) have accountability systems through which
program implementation and impact are monitored in an ongoing fashion.
The SPF recognizes the lack of collaboration and coordination among
multiple prevention efforts and the absence in too many cases of a
comprehensive theoretical framework. I applaud SAMHSA for creating this
comprehensive framework. It has tremendous potential to, in SAMHSA's
own words, ``bring together multiple funding streams from multiple
sources to create the true cross-program and cross-system approach that
health promotion and disease prevention demand.''
The newly proposed SAMHSA Framework will facilitate collaboration
among different prevention programs in multiple settings that include
schools, families, and communities, a crucial component for effective
prevention strategies. SAMHSA's strategic planning represents an
exciting set of directions, but their prevention initiatives require
new and substantial funds if we are to reduce significantly the number
of young people who develop substance abuse and mental health problems.
I urge you to provide more funding for SAMHSA's prevention efforts. In
addition, I hope that you will encourage stronger interagency linkages
between Federal agencies--such as the U. S. Department of Education,
SAMHSHA, and the National Institutes of Health--both to improve
practice and to understand factors that influence high quality
dissemination and utilization of effective prevention programs and
policies.
Once again, thank you, Mr. Chairman and Senator Kennedy for the
opportunity to present this testimony and for holding this timely
hearing. I would be glad to answer any questions the subcommittee may
have.
Senator DeWine. Good. Doctor, thank you very much.
Ms. Ramsey-Molina?
Ms. Ramsey-Molina. Good morning, Chairman DeWine, Senator
Reed.
As president of the Coalition for a Drug Free Greater
Cincinnati, it is truly my pleasure to be here today. Thank you
for the opportunity to speak.
The Coalition was founded in 1996 by Congressman Rob
Portman as a long-term effort to mobilize all sectors of the
community to address the issue of adolescent substance abuse.
He understood that to be successful, we must convene the
community at large to deal with each child as an individual
while changing the community norms, attitudes and standards of
conduct.
I want to, before I start my testimony, I want to share a
story about why I do what I do. Many years ago, several years
ago, I was providing direct service to the Coalition through
the Alcoholism Council of Cincinnati, and I worked with
children of single, crack-addicted mothers within the city. I
had a group of young girls, and one of the girls said to me,
when I grow up, I am not going to do drugs. And I said that is
great. She said let me tell you what I am going to do: when I
grow up, I am going to have a baby, and then, I am going to get
married, and my boyfriend is going to sell drugs so we can be
rich.
And I took a step back, and I said my goodness, we have an
issue here. And I said, well, it is against the law to sell
drugs. What happens to men who sell drugs and women who sell
drugs? And she said, well, they go to jail for 30 or 90 days.
When they get out, we have a party.
And so, I took another step back and said, well, if that is
what your boyfriend is going to do to be rich, what do you want
to do? Well, she had recently lost her grandfather, who was her
only consistent male influence, positive male influence in her
life to heart disease. She wanted to grow up and be a
cardiologist. She wanted to work on people with sick hearts.
I did not last in direct service much longer after that. I
moved into community coalition building, because I realized
that one single program intervening with that small child for
50 minutes over the course of 10 weeks was not going to get us
where we needed to be. We needed to convene the community at
large. The individual programs are extremely important, but we
had to intervene with the systems and the messages she was
receiving throughout the community the other 23 hours of the
day.
We must address the community at large. Coalitions do this.
We must look at community norms, attitudes and behavior.
Coalitions are uniquely positioned to engage all sectors and to
create community change that supports all youth, including this
young little girl.
Coalitions develop a broad base of support and
collaboration. They promote shared resources so that together,
we can achieve more. Linda Verst, a volunteer in Northern
Kentucky, in the rural parts of Northern Kentucky, they were
having challenges meeting the adolescent treatment needs; had
limited resources, many youth were going untreated. She
convened roundtables as a member of the Coalition for a Drug
Free Greater Cincinnati to look at what are our resources,
local, State and national, and how do we work together?
After the course of 18 months' studying and looking at the
issues, the result is increased access and utilization of
adolescent treatment spots in Northern Kentucky. Collaboration
works through coalitions. Coalitions implement data-driven
processes that ensure that our limited resources have maximum
impact, making sure that we understand the data, and we
understand the issue, so that we can focus what it is that we
are doing.
Coalitions apply the science of prevention and treatment
through all sectors of the community. Coalitions work within
communities, with community members, take the science and
implement through the fabric, through the culture of the
individual community. Coalitions engage multiple individuals
across the community to decrease drug use by increasing
protective factors and decreasing risk factors for individual
youth. Coalitions do work.
Our comprehensive efforts through the Coalition for a Drug
Free Greater Cincinnati has allowed us the opportunity to
surround the issue and to provide a single message, a single,
unified community that says to kids, it is not okay, it is not
healthy; we can make better choices. The result? Fewer kids in
Greater Cincinnati are using. Southwest Ohio boasts lower use
rates among adolescents than the State and the national
averages.
Why and how does it work? Tammy Sullivan, a single parent
from Greater Cincinnati, chaired our parent school-youth task
force and implemented the Strong Voices, Smart Choices
campaign, which put parenting for prevention tips into the
hands of over 750,000 parents in Greater Cincinnati. This
contributed to a 54 percent reduction in use among adolescents
whose parents talked to them about the issue and set and
enforced clear and consistent rules.
Rob Matucci, working in global hair care for Procter and
Gamble, oversees the implementation of the local anti-drug
media campaign for the Cincinnati market. As a volunteer, he
facilitates over $1 million worth of donated air time. The
result? A 19 percent decrease in adolescent use among youth who
see or hear anti-drug commercials. Mike Hall, the principal at
a local suburban high school, implements the Coaches, Kids and
Chemicals clinic. The result, a 42 percent decrease in use
among adolescents who are active in schools that have athletic
programs that implement substance abuse prevention.
Pastor Wilkins, from the Faith Community Alliance,
implements the Reviving the Human Spirit project. The result? A
50 percent decrease in use among kids who are actively involved
in prevention programs through their church. I could provide
many examples of individuals from throughout Greater Cincinnati
who have dedicated their time and talent to the table of
coalition building and shared that with our resources.
Since our inception in 1996, we have grown to include 31
neighborhoods and coalitions in communities throughout Greater
Cincinnati. We see greater decreases in use, adolescent drug
use, in these communities than similar communities that do not
have coalitions.
I am a firm believer in the power of communities to come
together as a coalition and decrease adolescent substance
abuse. I do it; I work it; and I have seen it. It works.
Thank you for the opportunity to speak today.
[The prepared statement of Ms. Ramsey-Molina follows:]
Prepared Statement of Rhonda Ramsey-Molina
Good Morning Chairman DeWine and other distinguished Members of the
Sub-committee. My name is Rhonda Ramsey Molina and I serve as the
President of the Coalition for a Drug Free Greater Cincinnati.
The Coalition for a Drug Free Greater Cincinnati was founded in
1996 by Congressman Rob Portman as an effort to mobilize all sectors of
the community to address adolescent substance abuse and the effects on
neighborhoods throughout Greater Cincinnati. Our mission--promoting
drug free environments for youth and mobilizing and supporting local
anti-drug coalitions is served through implementation of multiple
strategies through multiple sectors aimed at changing community norms,
attitudes and standards of conduct. Hailed as a national model for
coalitions with its innovative approach to adolescent substance abuse,
the Coalition has grown dramatically since its inception to include 31
local coalitions in neighborhoods throughout Greater Cincinnati.
I begin my testimony by sharing a brief story of why I am committed
to coalitions as an integral part of adolescent substance abuse
prevention and treatment.
Several years ago, prior to joining the coalition field, I provided
direct services to children of chemically dependent parents within the
city of Cincinnati. One day with a group of five 4th grade little girls
who were all daughters of single, crack addicted mothers, I realized
the importance of coalitions. One of the girls in the group stated,
``When I grow up I am not going to use drugs.'' She said, ``When I grow
up I am going to have a baby, then get married and my boyfriend is
going to sell drugs so I can be-rich.''Astonished by her thought
pattern, I took a deep breath and step back and shared with her that it
is against the law to sell drugs. I asked her what happens to people
who sell drugs. She stated, ``They go to jail for 30 or 90 days then
they get out and you have a party.'' Again, astonished by her thought
process, I said that that may be what your boyfriend does to make
money, but what do you want to do. Come to find out, she wanted to be a
heart surgeon. Recently, her grandfather, the only constant, positive
male influence in her life, had died of a heart attack and she wanted
to help people like her grandfather who had sick hearts.
The reality is that any program, provided only once a week for 50
minutes over a 10-week period, while valuable, is not able to address
the larger community issues that adolescents face the other 23 hours a
day they are not participating in the program. Direct service programs
focus on individuals, not the community at large. The messages
adolescents receive in their community are not necessarily the same
messages they receive in the program.
Coalitions address the community at large. In an effort to
support every child and enhance the effectiveness of individual
programs, coalitions build a community consensus of non-use so that
youth receive a consistent message regardless of what system they
interact with in the community.
Coalitions develop a broad base of support and
collaboration. They convene the energy and resources of multiple
sectors to enhance the effectiveness of individual approaches.
Congressman Rob Portman initiated the Coalition in
Cincinnati because he realized that he could not simply legislate away
the drug problem from Washington. He needed to partner with the
community at large so that together we could attack the issue from all
sides. We could collaboratively legislate, educate, recreate, arrest,
intervene, treat, etc.
We mobilize more talents, resources and approaches to
influence an issue than any single organization could achieve alone.
Coalitions implement data driven planning processes to
define the issue within their community and then program accordingly.
In 1996 the Coalition For a Drug Free Greater Cincinnati
implemented the Student Drug Use Survey in an effort to provide the
region the most current and reliable source of validated information on
youth substance abuse. In 2004, this survey gathered drug use data from
nearly 70,000 7th through 12th grade students in Greater Cincinnati.
Data from this survey and other surveys were used to
identify key risk and protective factors present in Greater Cincinnati
and to develop a comprehensive community plan to address the issues
using strategies that enhance protective factors and reduce risk
factors.
The community plan is implemented through partnerships and
collaboratives with the many partners who make up the coalition.
Example--Linda Verst, a prevention specialist, partnered
with the Coalition to sponsor community roundtables to assess community
needs regarding adolescent substance abuse treatment. In a large, rural
geographic area of Northern Kentucky, treatment services were scarce
and needs were going unmet. The roundtables promoted the spirit of
collaboration among providers who in turn shared resources and planned
cooperatively. This resulted in increased access to adolescent
substance abuse treatment throughout Northern Kentucky.
Given their collaborative approach, coalitions are
uniquely positioned to plan and implement a diverse set of strategies
to change community norms, attitudes and standards of conduct.
Example--Tamie Sullivan, a parent in the community,
chaired our Parent Task Force and facilitated the implementation of the
``Strong Voices, Smart Choices'' parent education campaign. This
campaign partnered with businesses, doctors, pharmacies, the local
media, and the Ohio National Guard to put parenting tips into the hands
of over 750,000 parents in Greater Cincinnati. The campaign changed
community attitudes and norms. Middle school parents often pull away
from the issue at this critical time, this campaign under Tamie's
leadership, changed the standard so that the expectation is that
parents become increasingly involved during the middle school years.
The result, a 57 percent decrease in drug and alcohol use among youth
who report that parents talk to them and set clear rules regarding
substance abuse.
The coalition focuses on increasing protective factors and
decreasing risk factors. And we are moving the needle.
Examples of measurable impact (see attached table)
Rob Matteucci, a Vice President at Procter & Gamble
volunteers to oversee the implementation of the anti-drug media
campaign in our market. The result, a 12 percent decrease in drug use
among youth who have seen or heard anti-drug advertisements.
Mike Hall, Principal at a local high school, partners with
businesses, a local hospital and professional athletes in Greater
Cincinnati to implement the ``Coaches, Kids and Chemicals'' program.
Over 1,200 coaches, principals and athletic directors have been trained
to incorporate substance abuse prevention into their athletic programs.
The result, a 34 percent decrease in drug and alcohol use among youth
involved in school sports.
Pastor Wilkins, Chair of the Faith Community Alliance,
partners with local service providers and other faith leaders to
implement the ``Reviving the Human Spirit'', a faith-based initiative
aimed at increasing the effectiveness of faith based programs in our
region. The result, a 55 percent reduction in drug and alcohol use
among youth involved in these programs.
Marty Herf , with the Ohio Bureau of Workers Compensation
worked with the Drug Free Workplace Task Force to convene local
businesses, EAP (Employee Assistance Program) providers and State
representatives to implement the ``Say Yes To A Drug Free Workplace''
program. This program initiated the creation of a statewide incentive
for businesses who implement a qualified drug free workplace program.
The result, southwest Ohio has the highest percentage of drug free
workplaces in the State.
By working through multiple systems within the community to address
adolescent substance use and abuse the Coalition for a Drug Free
Greater Cincinnati has positively impacted the issue. All of the
strategies that have been implemented to enhance protective factors,
that the Coalition has organized the community around, have become
increasingly more effective for the last 6 years. And, for the first
time in over a decade, drug use is declining in Greater Cincinnati. In
fact, for the first time since the 80's, data indicate that less than
20 percent of the combined 7th through 12th population are 30-day users
of alcohol, tobacco and marijuana.
I am a firm believer in the power of communities to reduce the use
and abuse of illicit drugs and alcohol among adolescents. Communities
that attack their drug problems in a comprehensive way, involve as many
individuals, groups and institutions as possible have the greatest
likelihood of success. With such strong coalitions working to convene
the community to work collaboratively, Southwest Ohio boasts adolescent
use rates that are significantly lower than State and national
averages, which are also declining. Additionally, we see much greater
reductions, by as much as 41 percent, in adolescent drug and alcohol
use in communities where strong coalitions exist than in control
communities where there are no coalitions.
Senator DeWine. Great. Thank you very much.
Mr. Anton?
Mr. Anton. Chairman DeWine and Senator Reed, good morning.
My name is Ronald Anton, and I am the director of Juvenile
Justice and Community Programs for Day One in Cape Elizabeth,
Maine.
First of all, I would like to recognize you, Mr. Chairman,
for your leadership in assisting people across the country who
have addiction problems. Thank you for the opportunity to offer
testimony today on behalf of Day One, the Maine Association of
Substance Abuse Programs and the State Association of Addiction
Services, the national organization of State alcohol and drug
abuse treatment and prevention provider associations, whose
mission is to ensure the availability and accessibility of
quality drug and alcohol treatment, prevention, education and
related services.
Day One has been making a difference in the lives of youth
for over 30 years. Our spectrum of care provides prevention,
intervention, treatment and after-care services for youth and
their families throughout Maine. Today, we are Maine's premier
agency dealing with adolescent substance abuse. We use a
variety of evidence-based prevention and treatment programs,
and we are respected as a resource and authority in the field.
Maine is a frontier State with a population of
approximately 1.2 million people, and geographically, it is the
size of all of the rest of New England combined. Maine's
publicly-supported substance abuse service system is complex
and community-based, providing education, prevention, early
intervention and treatment services.
Now, I could talk about many of those programs, but I
really want to focus on one in particular today. Our most
innovative approach to treatment has been through the creation
of a systems approach to identifying adolescents with the
potential for substance abuse and accessing and providing
services for them. Our collaborations began in 1996. And then,
thanks to the impetus provided by a SAMHSA CSAT Treatment
Capacity Expansion Grant that Maine received in 1998, Day One
worked to formally develop the Juvenile Treatment Network.
The Juvenile Treatment Network is a coordinated, State-wide
initiative whose goal is to identify, screen and refer
adolescents with substance abuse issues to State-approved
treatment providers of their choice. The Juvenile Treatment
Network works to increase access to substance abuse treatment
services by providing a system to coordinate a last resort
funding for these services while identifying and addressing
barriers to adolescent substance abuse treatment services.
The Juvenile Treatment Network is a collaboration of the
Office of Substance Abuse, substance abuse treatment providers,
Maine juvenile drug treatment courts, the Maine judiciary, the
Department of Corrections, schools, police, the Native American
tribes, and other community agencies. Day One is contracted by
the Office of Substance Abuse to staff and manage the network.
It is with thanks to Annie Peletier, the program manager of
the network, who is here with me today, and to her staff, that
this program has reached its high level of success and
acceptance in Maine. Prior to the Juvenile Treatment Network,
although many treatment providers existed, few provided any
significant substance abuse treatment services to adolescents.
Now, identification, screening, assessment and treatment
services to adolescents and their families are available
through more than 50 provider agencies at more than 80
locations across the State of Maine.
The Juvenile Automated Substance Abuse Evaluation Screening
and Referral Process, which was implemented in January 1998 as
part of the Juvenile Treatment Network: results to date include
close to 10,000 adolescents have been identified in the State
of Maine as being at risk for developing a substance abuse
problem, and more than 10,000 screenings have been conducted.
Of these, about 57 percent of the screenings recommended a
further substance abuse evaluation to determine to what extent
services were needed. Through this process, Maine reaches 18
percent of kids in need of treatment, exceeding the national
average of 8 percent by more than double. Between 1996 and
2003, adolescent admissions to Maine's substance abuse
treatment services increased by 137.5 percent, compared to only
21.7 percent for adults.
Now, the benefits of this voucher program model that we
have has demonstrated the following: it provides a structure
that has helped to increase access to substance abuse treatment
services and recovery support services for adolescents. It
provides client choice and informed selection of treatment
providers through the State of Maine; provides an effective
infrastructure through which to distribute last resort funds
for substance abuse treatment services. It maintains the
professional integrity of licensing and certification
standards. It provides for performance accountability of
treatment providers, and it offers funding for a limited range
of recovery support services that can readily be expanded when
appropriate.
Additionally, the network funds will cover transportation
costs for adolescents to get them to and from treatment
appointments as well as providing child care support. Day One
continues to strive for quality and comprehensiveness in all of
its prevention and treatment services. Equally as important, we
work diligently to address barriers to treatment and systems
issues that negatively affect the ability of Maine's youth and
families to access these needed treatment and recovery support
services.
We believe that our model, the only Statewide model in the
Nation to build a system for adolescents that identifies youth
in need of services, expands access to and improves treatment
Statewide and engages all collaborative partners positively has
produced positive results in a relatively short period of time.
Surveys from our members support this direction and approach.
We hope that the subcommittee will continue to study this model
and encourage and support the expansion of adolescent
prevention and treatment services nationwide.
Thank you for listening to this testimony today. I would be
happy to answer any questions.
[The prepared statement of Mr. Anton follows:]
Prepared Statement of Ronald Anton
Introduction
Chairman DeWine and Members of the Subcommittee, thank you for the
opportunity to present testimony on behalf of Day One, the Maine
Association of Substance Abuse Programs, and the State Associations of
Addiction Services, a national organization of State alcohol and drug
abuse treatment and prevention provider associations whose mission is
to ensure the availability and accessibility of quality drug and
alcohol treatment, prevention, education, and related services. Day One
has been making a difference in the lives of youth for over 30 years.
Our spectrum of Care provides prevention, intervention, treatment and
aftercare services for youth and their families throughout Maine.
Today, we are Maine's premier agency dealing with adolescent substance
abuse and we are respected as a resource and authority in the field.
Our innovative programs and collaborative ethos provided adolescents,
parents, schools and communities the training, treatment, and support
needed to bring hope, healing and recovery to Maine youth and their
families. Our mission is to dramatically reduce substance abuse among
Maine youth to help them live productive, healthy, and rewarding lives.
Overview
We would like to present you with information about adolescent
treatment in Maine and to share with you highlights of Day One's
Juvenile Treatment Network, our ``voucher system'' for adolescent
services. But first, here is some information about our State.
Maine is a frontier State with a population of approximately 1.2
million and geographically the size of all of the rest of New England
combined. Maine has the largest county east of the Mississippi River
(equal to the size of Connecticut and Rhode Island combined), and this
county is in the most northern and rural part of the State. Maine's
Office of Substance Abuse (the State's Single State Authority) has
stated that it maintains a viable treatment continuum of services in
the State that includes: shelters, extended shelters, detoxification,
extended care, residential rehabilitation, halfway houses, non-
residential rehabilitation, outpatient care, as well as facilities for
treating adolescents. This range of services is designed to help
clients receive the level of care they need.
Maine's publicly supported substance abuse service system is
complex and community based, providing education, prevention, early
intervention, and treatment services. Currently, OSA has 45 contracts
for services with 33 substance abuse treatment agencies. Our Juvenile
Treatment Network has reached beyond these contracted treatment
agencies in an attempt to reduce barriers, and provide access and
choice to adolescent substance abuse treatment services.
In State Fiscal Year (SFY) 2003, 14,747 clients and 19,784
admissions were reported through OSA's Treatment Data System. This was
a 12.4 percent increase in clients served since the previous fiscal
year. Of those clients admitted for services in State Fiscal Year 2003,
66.3 percent were males and 33.7 percent were females, continuing a
similar pattern from past years. Eighty-five percent were adults and 15
percent were youth, continuing a growing pattern in serving youth.
Day One's Adolescent Treatment is Research-Based
As an agency dedicated to providing services to adolescents and
families affected by adolescent substance abuse, we constantly have
been aware of the uniqueness of adolescents, and the special needs that
they present. Adolescents are not just young adults. They present with
varying and different issues than do adults, and need to have an
ability to look at their specific risk and protective factors as they
address their substance use and other life issues in treatment.
Consequently, the challenges in providing services are to find and
utilize effective prevention and treatment strategies. Day One supports
the ongoing professional development of our staff in the various
programs that we operate.
Treatment through Day One is available across the full continuum,
from outpatient services and intensive outpatient, to long-term
residential and transitional housing for youth in need. In the last 6
years, as more and more research has become available, we have (through
both our Day One programming and through training sponsored or provided
by our Juvenile Treatment Network) introduced and reinforced the use of
evidence-based and other ``best-practices'' in prevention and treatment
services to youth. We have worked collaboratively with the Office of
Substance Abuse in all of these endeavors. In the prevention area, Day
One currently provides a number of science-based and model prevention
programs, including ``Guiding Good Choices'' and ``Reconnecting
Youth.''
In addition, in the assessment and treatment area, for the past
number of years we have worked with Dr. Norman Hoffmann, on the faculty
of Brown University, and an international expert on screening and
assessment instruments, in the use of the ``Practical Adolescent Dual
Diagnosis Interview'' (PADDI) as part of a co-occurring assessment in
most of our Day One treatment services. Our studies of the results of
the use of the PADDI have been published in a number of professional
journals, including Addiction Professional and Offender Substance Abuse
Report. Other publications are pending and our use of the PADDI
continues. Also, our outpatient treatment services here at Day One are
recent participants as a ``Center of Excellence'' in a private
foundation grant award that will bring strong collaborations and
additional skills development in the area of services to youth
presenting with co-occurring substance abuse and mental health issues.
This grant initiative will allow Day One the opportunity to work
closely with Dr. Ken Minkoff, a psychiatrist and specialist in the
development of service systems for people with both substance abuse and
mental health issues. Day One will also participate as a founding
member in the Maine Institute for Quality Behavioral Health Care.
Day One's juvenile corrections programs utilize the evidence-based
treatment modalities found to be most effective with adolescents in the
juvenile justice system. Consequently our substance abuse treatment
programs in the two State juvenile correctional facilities and in our
Statewide Juvenile Drug Treatment Courts system make use of these
approaches. Research conducted with our Juvenile Drug Treatment Courts
demonstrate that adolescents in that program are less likely to return
to the justice system with new offenses, and more likely to address
their substance use and abuse issues in a positive manner than
adolescents in the juvenile justice system that do not participate in
this program.
Development of the Juvenile Treatment Network or ``Voucher Program''
Our most innovative approach to treatment has been through the
creation of a systems approach to accessing and providing services for
youth. The initial collaborations that ultimately resulted in the
formation of the Juvenile Treatment Network began in 1996 with the
receipt of a small State grant. Then, thanks to the impetus provided by
a CSAT Treatment Capacity Expansion Grant that Maine received in 1998,
Day One worked to formally develop what is called the Juvenile
Treatment Network. The Juvenile Treatment Network is a coordinated
Statewide initiative whose goal is to identify, screen and refer
adolescents with substance abuse issues to State approved treatment
providers of their choice and to increase access to substance abuse
treatment services by providing a system to coordinate a last resort
funding for these services. The Network is a collaboration of the
Office of Substance Abuse (OSA), substance abuse treatment providers,
Maine Juvenile Drug Treatment Courts and Judiciary, the Department of
Corrections, schools, police and other community agencies. Day One is
contracted by the Office of Substance Abuse to staff and manage the
Network.
Prior to the Juvenile Treatment Network substance abuse treatment
services to adolescents in Maine were provided by only a handful of
agencies across the State. Resources were scarce, and so our approach
to treatment capacity expansion was to develop a system of services for
adolescents that could be accessed across the State. Screening,
assessment and treatment services are now available through more than
50 provider agencies at more than 80 locations across Maine.
The Juvenile Treatment Network utilizes the ``Juvenile Automated
Substance Abuse Evaluation'' (JASAE), a standardized tool to screen
adolescents and to provide information to determine if and to what
extent further substance abuse assessment and treatment services are
needed. These screening services are available throughout Maine and are
conducted by a cadre of individuals who are trained by the Network to
administer this screening instrument. If it is determined that further
services are needed the adolescent is referred to one or more of over
50 participating treatment providers Statewide. In addition, the
Network coordinates and distributes last resort payment funds for
adolescents referred to Network member substance abuse treatment
providers and who meet funding eligibility criteria.
The JASAE screening and referral process was implemented in January
1998 as part of the Juvenile Treatment Network. Results to date
include:
Close to 10,000 JASAE surveys have been administered which
translates to just under 10,000 adolescents being identified in the
State of Maine as being at risk for developing a substance abuse
problem.
Of those, about 57 percent of the screenings recommended a
further substance abuse evaluation to determine to what extent services
are needed. Through this process, Maine reaches 18 percent of kids in
need of treatment, exceeding the national average of 8 percent by more
than double.
Adolescents identified as needing treatment were given the
choice to select one of the 50 participating treatment providers for
services in over 80 locations throughout the State. Maine is the only
State to have a Statewide coordinated system of care for adolescent
substance abuse screening, assessment and treatment services.
Through a combination of Federal Targeted Capacity
Expansion Grant funds (SAMHSA/CSAT funds) and State funds, over
$750,000 was distributed through the Juvenile Treatment Network to pay
for screening and treatment services.
Provided five treatment capacity expansion loans to
treatment providers in 1999 as incentives to begin additional treatment
services in underserved areas of the State.
Provided five treatment capacity expansion start-up grants
in 2002 for new and/or innovative substance abuse treatment programs
totaling over $70,000.
Additional data from the JASAE administrations is included
at the end of this testimony.
The Juvenile Treatment Network has demonstrated success in
implementing an effective centralized identification, screening,
referral and last resort funding system to increase access to substance
abuse treatment services for adolescents. This model is an effective
``Voucher program'' and shares common goals and objectives for
implementation. In a January 2004 report, prepared by the Office of
Substance Abuse, and presented to the Maine Legislature Joint Standing
Committee on Health and Human Services regarding ``An Act to Obtain
Substance Abuse Services for Minors,'' it was stated that ``Capacity to
treat adolescent substance abuse has expanded dramatically over the
past few years, particularly at the outpatient level because of the
creation of the Juvenile Treatment Network.''
The benefits that this ``voucher program'' model has demonstrated
include:
Providing a structure that has helped to increase access
to substance abuse treatment services and recovery services for
adolescents;
Providing client choice and informed selection of
treatment providers throughout the State of Maine;
Providing an effective infrastructure through which to
distribute last resort funds for substance abuse treatment services;
Maintaining professional integrity of licensing and
certification standards;
Providing for performance accountability of treatment
providers;
Offering funding for a limited range of recovery support
services that can readily be expanded when appropriate; and
Providing assessment and treatment services at an average
cost of $1,597 per adolescent admitted to treatment.
The Programs
There are two programs the Network manages: the Juvenile
Corrections Substance Abuse Treatment Network (JCSATN) and the more
recently created (2002) Substance Abuse Treatment Network for
Adolescents (SATNA).
The Juvenile Corrections Substance Abuse Treatment Network was
created in response to the increasing number of juvenile offenders who
have substance abuse issues and who need and cannot obtain substance
abuse treatment. In January of 1998, substance abuse treatment
providers throughout the State formally applied for membership in the
Network and a standardized screening tool, the Juvenile Automated
Substance Abuse Evaluation (JASAE), was chosen for the purpose of
screening and referring juvenile offenders in the State of Maine.
Because of the success of the Juvenile Corrections Substance Abuse
Treatment Network, and to implement recommendations from the Third Year
Evaluation Report (conducted by the University of Southern Maine,
Department of Social and Behavioral Research) of the Juvenile Treatment
Network and Juvenile Drug Treatment Courts, the Substance Abuse
Treatment Network for Adolescents was created to address the needs of
adolescents with substance abuse issues before they became involved
with the juvenile justice system. This program began on July 1, 2002,
and identifies adolescents who may have a substance abuse problem
through participating schools and other community-based organizations
Statewide. The Substance Abuse Treatment Network for Adolescents also
uses the Juvenile Automated Substance Abuse Evaluation for screening
and assessment purposes.
In addition to screening and referral services, the Network also
has a last-resort payment source for adolescents in both programs who
meet certain eligibility guidelines and are accessing further
evaluation/substance abuse treatment as a result of their JASAE
recommendations.
The Treatment Providers
Network member treatment providers are selected based on the
following criteria:
Agency must be licensed by the State Office of Substance
Abuse.
Agency must be Medicaid Eligible.
Agency must provide outpatient and/or intensive outpatient
substance abuse services in one or more services locations.
Agency must adhere to Network policies.
Participating treatment providers commit to the following:
Participation in Network-sponsored training and attendance
at a minimum of three Network meetings per year.
Incorporation of best practices into treatment programs
for adolescents, with best practices defined by the Network in
collaboration with the State Office of Substance Abuse and demonstrated
by research;
Use of Network-developed protocols and forms for
communication between the Juvenile Treatment Network, Network Member
Treatment Providers, Department of Corrections, schools and other
community organizations;
Collaboration with other Network members and participants
to identify gaps in treatment services and work cooperatively to fill
those gaps;
Participation in a Network screening and referral system
designed to match client needs with provider strengths;
Development of program admission and discharge criteria
consistent with best practices for adolescents; and
Participation in Network development of policy, procedures
and training designed to implement Network goals and encourage provider
compliance; and
Timely completion of required State Office of Substance
Abuse Admission and Discharge forms with the appropriate Network Code.
Members of the Juvenile Treatment Network receive the following
benefits:
Last resort outpatient treatment reimbursement eligibility
for providers;
Free registration for Network-sponsored trainings;
Participation in the Network screening and referral
system;
Input into the development of Network policy and a system
of comprehensive continuum of care for adolescents;
Participation in a data collection system that will assist
in identifying barriers to substance abuse treatment services
throughout the State; and
Improved communication between referral sources and
treatment providers through attendance at quarterly Network meetings.
Last Resort Funding Distribution
Network funds are available to pay for substance abuse treatment
for adolescents that have no other means of payment. Adolescents must
meet identified criteria to be considered eligible for last resort
payment funds.
The goal of the Network is to reduce barriers to treatment services
and partial funding is available if a hardship or barrier that would
prevent the adolescent from accessing treatment services has been
identified by the treatment provider.
Eligible adolescents must not have private insurance that will
cover substance abuse treatment services. If an adolescent's coverage
does not include substance abuse treatment services, or the juvenile
has exceeded the allowable benefits, Network funds may be an option. If
an adolescent and his/her parents do have insurance but paying their
co-pay would be a financial hardship, the Network funds may be an
option. This is also true if the family has a deductible that must be
met before the insurance will cover services.
Any adolescent who is eligible for Medicaid is not eligible for
Network funds until Medicaid resources are exhausted or if a particular
service is not covered by Medicaid (e.g. assessment and other
transitional services from institutional care to community-based
services).
If a client can pay a certain amount per session, Network funds may
be able to fund part of the session providing that the total amount
does not exceed the maximum allowance listed on the Substance Abuse
Treatment Network for Adolescents billing form.
By accepting Network funds for treatment services the provider
agrees not to bill the adolescent/family for any fees over and above
the maximum reimbursement paid by the Substance Abuse Treatment Network
for Adolescents.
The Network funds will cover transportation costs for adolescents
to get to and from treatment appointments. This option is available
regardless of payment source. If, in the provider's judgment,
transportation is a barrier to treatment, the Network funds will cover
bus or cab fare, or pay mileage to the adolescent or friend/family
member that drives the adolescent to and from treatment.
As with transportation costs, the Network funds will cover
childcare regardless of the funding source for treatment.
Additional Services
In addition to the centralized identification, screening, referral
and payment system in place, the Network also functions to facilitate
collaboration between the Department of Corrections, Office of
Substance Abuse, Maine Department of Behavioral and Developmental
Services, Maine Juvenile Drug Treatment Courts, substance abuse
treatment providers, schools, police and other community agencies. To
facilitate this collaboration the Network annually hosts 28 meetings
throughout the State. Representation from all of the above mentioned
agencies are typically present. These meetings are a place where
individuals and agencies can and do discuss barriers to treatment
services and how to address these issues. The meetings also serve to
provide a forum to disseminate information as it relates to the Network
or the field. In addition, the Network will provide training in
response to provider and other partners' needs.
The Network has a comprehensive database in which data is recorded
from the JASAE assessment tool, information related to the referral for
the JASAE and further evaluation as well as data relating to the last
resort payment source. To date the Network has information pertaining
to close to 10,000 JASAEs. This information is used in a number of ways
by various agencies. This information has been used to identify trends
and barriers, gauge service capacity needs and support grant proposals.
In addition, the Network has developed Policy and Procedure Manuals
for all of the Network operations and has shared these manuals with
other States and agencies looking to implement a similar structure to
address substance abuse treatment.
Closing
Day One continues to strive for quality and comprehensiveness in
all of its prevention and treatment services. Equally as important, we
work diligently to address barriers to treatment and systems issues
that negatively affect the ability of Maine's youth and families to
access these needed treatment and recovery support services. We believe
that our model, one of the first Statewide models in the Nation to
build a system for adolescents that identifies youth in need of
services, expands access to and improves treatment Statewide, and
engages all collaborative partners, has produced positive results in a
relatively short period of time. Surveys from our members support this
direction and approach. We hope that the subcommittee will continue to
study this model and encourage and support the expansion of adolescent
prevention and treatment services nationwide. Thank you for listening
to this testimony today. I would be happy to answer any questions.
Additional JASAE Screening Data
Percentage of those referred for further evaluation: 57 percent
(Percentages below based on total number of JASAE's screened)
Male/Female ratio: 65 percent Males, 35 percent Females
Percentages regarding living status:
Living at home with both parents: 41 percent
Living at home with mom: 26 percent
Living at home with dad: 8 percent
Living with relatives: 3 percent
Living with sister/brother: <1 percent
Living with non-family: 3 percent
Living in foster home: <1 percent
Other: 6 percent
Unknown (pre-data collection for this variable): 12 percent
Percentages regarding educational status:
In school full time: 66 percent
In school part time: 5 percent
Suspended: 2 percent
Quit school: 9 percent
Kicked out of school: 4 percent
Finished school: 2 percent
Unknown (pre-data collection for this variable): 12 percent
Most frequently used drug:
Alcohol: 48.5 percent
Marijuana: 34.8 percent
None: 10.7 percent
Sedatives/Hypnotics: 1.2 percent
Barbiturates, Amphetamine, Cocaine, Crack,
Hallucinogens, Heroin, Inhalants, Tranquilizers, Other: Each <1
percent
Prepared Statement of Norman G. Hoffmann, Ph.D. Ana M. Abrantes, Ph.D.
and Ronald Anton, LCPC, LADC, MAC
ABSTRACT
The PADDI (Practical Adolescent Diagnostic Interview) is a
structured diagnostic interview, designed to gather basic information
about substance use disorders, other mental health conditions, and
related experiences. It is used for the evaluation of all adolescents
committed to juvenile detention centers in Maine. Anonymous data from
230 adolescents interviewed as part of routine clinical assessments in
the detention centers were analyzed to assess the prevalence and
severity of problem areas of importance to correctional officials.
Results demonstrated that the majority of individuals manifested
multiple problems. Relative prevalence rates and implications of the
findings for clinical services and case management are discussed. The
case is made for pragmatic routine intake assessments for adolescents
entering the juvenile justice system.
INTRODUCTION
Observed prevalence rates for co-occurring mental health and
substance use disorders vary from setting to setting, but consistently
show levels suggesting a necessity for routine assessment. Estimates
tend to range from about 50 percent in adolescent psychiatric
populations (Grilo, Becker, Walker, Levy, Edell, & McGlashan, 1995) to
as high as 80 percent among adolescents receiving services for
substance dependence (Stowell & Estroff, 1992). Such differentials may
be consistent with observations in adult populations that many co-
existing mental health conditions may be substance-induced (Lehman,
Myers, Corty, Thompson, 1994).
Concomitant psychopathology among substance abusing adolescents has
been associated with significant negative consequences including more
severe substance involvement, greater suicidal ideation, academic
problems, and family difficulties. While it has been well established
that concomitant psychopathology is associated with poorer treatment
outcomes among adult substance abusing populations, recent evidence
points to similar findings among adolescent substance abusers as well.
Findings from the Drug Abuse Treatment Outcome Study for Adolescents
(DATOS-A) showed greater substance involvement and illegal acts among
adolescents with a concomitant mental health disorder compared to those
without a co-occurring disorder (Grella, Hser, Joshi, Rounds-Bryant,
2001). In addition, conduct disorder among substance abusing
adolescents has been associated with greater alcohol and drug
involvement and poorer psychosocial functioning in young adulthood
(Myers, Stewart, & Brown, 1998). Therefore, given the prevalence and
clinical correlates of co-occurring disorders among adolescents,
accurate identification and assessment of these disorders is crucial
for the development of effective treatment interventions and reducing
criminal recidivism.
While some structured interviews such as the Diagnostic Interview
Schedule for Children (DISC) have been developed for evaluating co-
occurring conditions, they were initially developed for research and
have limitations for routine clinical applications (Shaffer, Fisher,
Dulcan, et al., 1996). For example, administrations of the DISC are
time consuming, averaging over one hour to complete. Extensive
assessment instruments such as the GAINS (Dennis, et al., 1999) are
also too time consuming to be used as an initial screening or
assessment instrument for juvenile justice settings. Given the limited
resources available in juvenile justice environments, these measures,
while well suited for research or treatment applications, are not the
optimal choice for use in these settings.
A practical instrument to accurately assess adolescents with co-
occurring conditions should be adolescent-specific, developmentally
appropriate, and obtain a continuous measure of symptomatology to
provide indications of severity. The instrument should also demonstrate
strong psychometric properties across a wide range of mental health
problems, including substance use disorders. In addition, the
instrument should be able to be capable of providing a foundation for
diagnostic documentation in accordance with current diagnostic criteria
(APA, 1994, 2000). To date, we are not aware of an assessment
instrument that has demonstrated all of these characteristics.
The Practical Adolescent Dual Diagnostic Interview (PADDI) was
developed as a pragmatic clinical assessment tool to standardize
diagnostic assessments of adolescents (Estroff & Hoffmann, 2001). The
structured questions are designed to collect information about specific
symptoms and behaviors in an objective and value neutral tone. It does
not attempt to cover all possible diagnoses, nor does it attempt to
probe every aspect of some of the covered conditions. Rather, it is
designed to address the more common symptoms and indications of
problems in the context of an interview limited to approximately 30 to
45 minutes. The PADDI has demonstrated its utility in clinical
populations (Hoffmann, Estroff, & Wallace, 2001) and in initial
assessment of adolescents in juvenile justice settings (Hoffmann,
Abrantes, & Anton, 2003). The present study considers the presenting
problems for both males and females committed to juvenile detention
centers. These adolescents are expected to be under the supervision for
some time so that proper care and case management are likely to be an
ongoing concern for juvenile justice officials.
METHODS
The PADDI is a structured diagnostic interview that covers
indications of prevalent mental health conditions and substance use
disorders. It is designed explicitly for use with adolescents and is
not an adaptation of an adult tool. The PADDI is structured for routine
clinical administration facilitated by a detailed manual (Hoffmann &
Estroff, 2001). Therefore, juvenile justice personnel, trained
technicians, or behavioral health professionals can administer the
interview.
Interpretation of findings or making diagnostic determinations
requires a professional or team of professionals with the appropriate
training and expertise covering both mental health and substance use
disorders. Professionals who may not have expertise in both mental
health and substance use disorders can gather pertinent information to
aid in determining diagnoses within their areas of competence and
making focused and appropriate referrals to other professionals for
those areas in which they might not practice. Juvenile justice staff
can use the interview to gather sufficient information to inform
referrals to professionals for further evaluation or services.
The interview includes questions related to depressive and manic
episodes, mixed states, psychosis, PTSD, panic attacks, generalized
anxiety and phobias, obsessive-compulsive disorder, conduct and
oppositional defiant disorders, and possible paranoid and dependent
personality disorders in addition to substance use disorders. Questions
about dangerousness to self and others as well as victimization
(physical, sexual, and emotional abuse) are also included. As
mentioned, the design and branching allow the interview to be
administered in a relatively short amount of time-30 to 45 minutes
depending upon the extent of problems reported.
Procedures
The study obtained anonymous data consisting of the item responses
to PADDI interviews conducted in routine assessments from the two
detention centers in Maine. The organization providing the behavioral
health coverage for the detention centers uses the PADDI as part of the
standard clinical assessment. The staff removed names and unique
identifiers from copies of the protocol for all consecutively admitted
committed adolescents to be processed for statistical analyses of
problem prevalences. These data and analyses facilitate administrative
oversight of the services and comparisons of prevalences between the
two facilities. They also provide the information for this report.
Sample
Data from a total of 230 adolescents (199 males and 31 females)
were analyzed. Ages ranged from 13 to 18, and the average age of the
sample was 16.3 (S.D.=1.10). Approximately 64 percent of the
adolescents were between the ages of 16 and 17. The vast majority of
the adolescents were Caucasian (88 percent), and Native Americans (5
percent) constituted the only minority ethnic group with more than 10
cases. The remainder of the sample was from other ethnic groups or of
mixed ethnicity.
Educational achievement appears low for a number of these
adolescents. Although more than 75 percent were over the age of 15, 38
percent had passed no higher than the 8th grade in school.
Approximately 30 percent were at least 1 year behind the expected grade
level for their age group. Although only 13 percent reported
substantial reading difficulties, more than 50 percent had been in
special classes for academic or behavioral problems.
A large number of the sample had been prescribed medication for
either a medical or mental health condition. Almost two in five (37
percent) reported being on medications at the time of the interview and
an additional 23 percent reported receiving medications previously.
Non-violent offences were cited as the most frequent issue related
to the admission (55 percent), followed by substance related issues (42
percent). Violent offenses were acknowledged by 27 percent. There were
no significant differences between males and females for the prevalence
of either violent or non-violent offenses. A statistically significant
differential for substance related offenses was noted with males
reporting more (44 percent vs. 23 percent) than females (p<.05).
Analyses
Item responses from the PADDI forms were entered and verified into
Excel spread sheets and converted into SPSS (Statistical Packages for
the Social Science) system files for analyses. Algorithms for scoring
the scales related to conditions for which the PADDI captures
sufficient information to suggest a specific diagnosis. Thus the scales
for symptoms of psychosis and generalized anxiety and phobias were not
analyzed for placement into diagnostic groups because these scales
serve more as screens than documenting diagnostic indications.
The algorithms placed individuals into one of five priorities
defined categories: no symptoms, sub-diagnostic, meeting minimal
criteria, exceeding minimal criteria, and far exceeding minimal
criteria. The sub-diagnostic category includes individuals who reported
at least one positive response, but not enough to meet the minimal
indications for a diagnosis. Those in the ``exceeds criteria'' group
report positive indications on at least one additional criterion beyond
the minimum, and those in the last group typically endorsed 70 percent
to 85 percent of the possible criteria items. For substance use
disorders, only substance dependence was considered since it has been
shown to be the more severe (Hoffmann, DeHart, & Campbell, 2002;
Hoffmann, & Hoffmann, 2003) and chronic condition (Schuckit, Smith,
Danko, Bucholz, Reich, & Bierut, 2001).
RESULTS
General prevalence rates for various problem areas and disorders
are presented for male and female adolescents in Table 1. Although
these adolescents have committed offenses resulting in commitment to a
juvenile detention center, many have been victims of various forms of
abuse. Abuse categories as determined by the PADDI are very
conservative and require substantial indications of maltreatment.
Physical abuse is defined as being hit so hard or so as to result in
marks or fear of the perpetrator or to have resulted in the need for
medical attention in an emergency room. Sexual abuse is identified as
unwanted physical contact or coercion to engage in sexual acts.
Emotional abuse is defined as being persistently ridiculed or
humiliated over a period of time. Given these definitions, almost 75
percent of the females and 45 percent of the males have been subjected
to some form of abuse.
Emotional and physical abuses are the most common for both genders.
The majority of females (52 percent) report emotional abuse followed by
sexual abuse (45 percent). For males, physical and emotional abuses are
reported by about 30 percent of the adolescents. The overall
prevalences for emotional and sexual abuse are greater for females at
statistically significant levels.
For both genders, sexual abuse is highly related to other forms of
abuse. From 36 percent to 40 percent of all sexual abuse victims report
all three forms of abuse regardless of gender. Fifty percent of females
and 67 percent of males who were sexually abused also report other
forms of physical abuse.
Table 1: Problem Prevalences by Gender
------------------------------------------------------------------------
Females
Problem Area N=31 Males N=199
------------------------------------------------------------------------
Physically abused............................. 36% 30%
Sexually abused **............................ 45% 11%
Emotionally abused *.......................... 52% 28%
Any prior suicide attempts.................... 39% 24%
Multiple prior suicide attempts............... 26% 18%
Considered killing someone.................... 13% 18%
Auditory plus other hallucinations **......... 23% 4%
Major depressive episodes **.................. 64% 24%
Manic episodes................................ 40% 19%
Panic attacks................................. 13% 8%
PTSD.......................................... 36% 15%
Conduct Disorder.............................. 74% 83%
Oppositional Defiant Disorder................. 61% 51%
Substance Dependence.......................... 69% 60%
------------------------------------------------------------------------
* p<.01; ** p<.001.
All prevalences exclude apparent substance induced indications.
Suicidal ideation and possible suicide risks appear to be of
concern with a substantial minority of cases. Overall, 26 percent of
females and 18 percent of males report a history of more than one
suicidal attempt or gesture. A substantial number have considered
specific ways in which they might kill themselves, which may serve to
increase concerns in this area.
Compared to a history or thoughts of self-harm, serious
consideration of harming others appears to be considerably lower. Fewer
than 20 percent of males and 15 percent of females acknowledged
thoughts of serious harm to others. Positive responses to the question
of harming others were positively related to confinement for a current
violent offense, to acknowledging initiation of fights and to having
used a weapon in a fight.
Conduct disorder and substance dependence are the most prevalent of
the behavioral health conditions. However, it is probable that some
behaviors associated with the substance dependence may account for a
portion of the conduct disorder indications. For example, some theft or
initiation of fights may be related to getting money for drugs or
related to alcohol or other drug use.
Before considering some of the severity indications, for these
conditions, a discussion of the other mental health areas is
appropriate. The indications for psychoses, affective and anxiety
disorders are of significance in that many of these conditions require
medications for their proper treatment and management. While some of
these disorders could be substance induced, many are likely to exist as
independent conditions and will contribute to relapse to substance
misuse if left unaddressed.
Indications of psychosis are problematic to assess from responses
to structured questions because many of the indications of these
disorders include observational information. However, acknowledgment of
hallucinations does provide in indication that this area warrants
further consideration. This is particularly true for auditory
hallucinations in the absence of substance use or when they occur at
times other than when the individual is drifting off to sleep or
awakening. Of the females, 23 percent reported both auditory and other
hallucinations in the absence when obvious associations with substances
or sleep are excluded. In contrast, only 4 percent of males report such
events.
Another area of major concern involves affective disorders because
these too may indicate a need for medications for proper management of
such conditions. When only a constellation of symptoms consistent with
major depressive episodes is considered and exclusions for obvious
substance induced instances are excluded, a majority (64 percent) of
females and almost a fourth of males report such a constellation of
symptoms. Manic episodes are also relatively common as can be seen in
Table 1. Of particular concern are those cases where both manic and
major depressive episodes are both reported by the same individual.
This would suggest the possibility of an emerging bipolar disorder in
which the individual alternated between depressive and manic episodes.
Of the entire cohort, 13 percent report both depressive and manic
episodes with symptoms levels that exceed the DSM-IV requirements for
both types of episodes. This suggests that as many as one in ten of the
adolescents committed to the detention centers may require mood
stabilizing medications if the bipolar condition is confirmed by a
psychiatrist.
Anxiety disorders may take many forms. The PADDI conducts a brief
screening for generalized anxiety, phobias, and obsessive-compulsive
indications, but covers panic attacks and posttraumatic stress disorder
(PTSD) in greater depth. Females are more likely to reach levels of
symptoms for concern for the various anxiety indicators; however, PTSD
shows the greatest and most significant differential. This is not
surprising in light of the level of abuse reported by females. That is,
given the levels of physical, emotional, and sexual abuse, among
females, it is expected that a significant number of them would report
experiencing indications of PTSD.
If only the more prevalent conditions are considered (major
depressive episodes, mania, PTSD, conduct disorder, and substance
dependence), 92 percent of the consecutive admissions report positive
indications suggesting a possible diagnosis. Even when the thresholds
for each disorder is increased so as to exceed the criteria of the DSM-
IV so as to decrease the likelihood that the findings might include
false-positive indications, 77 percent still emerge as positive for one
or more conditions. Using the more stringent requirements, almost 25
percent of the consecutive admissions are positive for only one
condition, but most (52 percent) are positive for multiple conditions.
Not surprisingly, the combination of substance dependence and conduct
disorder is one of the most prevalent (10 percent of the cohort), but
these estimates do not include possible psychoses or anxiety disorders.
For those who meet diagnostic criteria, the extent of symptoms and
the pattern formed by the number of diagnostic indications provide both
an indication of severity and validity for several of the diagnostic
formulations. The distributions for the number of positive diagnostic
indicators are in Table 2. The diagnostic and severity of seven
conditions presented in the table suggest that for most conditions, the
PADDI items make a relatively clear distinction for those who meet
diagnostic criteria. Major depression, manic episodes, and substance
dependence produce profiles where the majority of cases fall into
either the category for no symptoms or the one indicating extensive
symptomatology. These conditions appear more categorical while
conditions such as conduct disorder appear more dimensional with more
of a normal distribution of problems.
Table 2: Symptom Profiles for Selected Conditions N=230
----------------------------------------------------------------------------------------------------------------
Sub- Minimal Exceeds Far Exceeds
Condition (Lifetime) No Symptoms diagnostic Criteria Criteria Criteria
----------------------------------------------------------------------------------------------------------------
Major Depressive Episode *..................... 62% 8% 9% 10% 11%
Manic Episode *................................ 73% 5% 5% 8% 9%
Panic Attacks **............................... 81% 10% 3% 5% 1%
Posttraumatic Stress Disorder.................. 64% 18% 1% 10% 7%
Conduct Disorder............................... 3% 15% 35% 27% 20%
Oppositional Defiant Disorder.................. 12% 35% 14% 7% 32%
Substance Dependence ......................... 19% 20% 5% 8% 48%
----------------------------------------------------------------------------------------------------------------
* Substance induced conditions are counted as sub-diagnostic.
** Only symptoms for attacks in the previous 12 months are considered.
Diagnosis considered only if use is reported in the past 12 months; abuse cases are counted in the sub-
diagnostic category.
Several points need to be made concerning the categorizations in
the tables. First, those individuals denying any substance use in the
previous 12 months were placed into the ``no symptom'' category for
substance dependence and those meeting abuse criteria only were placed
into the ``sub-diagnostic'' category. Second, oppositional defiant
disorder is subsumed by conduct disorder in the DSM-IV criteria. That
is, if the individual meets both criteria, only the conduct disorder
diagnosis is given. This is ignored in the present analyses to
illustrate the profile of symptoms for both sets of items. Finally,
conditions such as depression and mania that might be substance induced
are placed in the ``sub-diagnostic'' category if the individual reports
the symptoms to be associated only with use.
As can be seen in Table 2, a number of conditions present
relatively clear syndromes while others do not. That is, for clear
syndromes those who meet at least the minimum number of diagnostic
criteria fall into the moderate to high range of symptoms while those
who do not meet criteria usually have no symptoms. This results in a
bimodal where the majority of individuals fall either into the no
symptom category or into the moderate or above range of symptoms, and
the fewest cases are seen in the sub-diagnostic or minimal criteria
categories. When a clear syndrome is not found, or sees more of a
normal distribution where most cases are in the sub-diagnostic to
minimal criteria categories.
In the case of substance dependence, the majority of cases (67
percent) fall either in the no symptom or highest symptom groups. When
the abuse only cases are considered as sub-diagnostic, 20 percent are
seen in this category and only 5 percent of the cases fall into the
dependence with minimal criteria met. In contrast 48 percent of the
entire sample fall into the high symptom category meaning that they are
positive for at least five of the seven dependence criteria. Similarly,
major depressive and manic episodes appear to be categorically
distributed. Most cases meeting at least minimal diagnostic criteria
tend to be in the higher ranges of symptoms while the majority of cases
are in the no symptom category.
On the other hand, conduct disorder symptoms appear to be
distributed much differently. In this example, conduct symptoms are
approaching a normal distribution with most cases falling into the
minimal diagnostic category and few cases in the no symptom and highest
symptom categories.
These general distributions are similar for both males and females
although the exact percentages vary between the genders. Since the
number of females is relatively small, no specific comparisons are made
at this time.
DISCUSSION
The results of this study suggest a number of issues that merit
specific discussion. First, the distribution of scores across the five
diagnostic categories (no symptoms, sub-diagnostic, meeting minimal
criteria, exceeding minimal criteria, and far exceeding minimal
criteria) is such that, for most problem areas, a clear distinction
exists between those individuals meeting DSM-IV diagnostic criteria
from those that do not. This finding supports the utility of the PADDI
as a screening instrument with the ability to discriminate between
adolescents likely to meet diagnostic criteria for a given disorder and
those who are not.
Second, the prevalence and extent of problems noted in these
consecutive admissions to juvenile centers suggest that routine
screening and assessment should be conducted for both mental health and
substance use disorders. Many of these conditions require professional
services and in some cases medications for proper care and case
management.
This analyses as to most have some limitations. First, these data
from the PADDI cannot definitively rule out the possibility of
substance induced mental health problems and the instrument is not
intended to make comprehensive diagnostic determinations on all
conditions. Thus, while a positive indication on the PADDI may be a
clear signal of a need for further evaluation, it is by itself not a
diagnosis. Additionally, concurrent validity cannot be assumed, as no
data exists to corroborate how often the PADDI's impressions are
confirmed with a firm clinical diagnosis. Second, the participants in
this study may not be representative of all potential users of the
instrument. The study is based on consecutive admissions from
facilities in a State where the number of minority individuals is
small. This precludes generalizing to inner city populations where
minority subcultures might influence reporting.
Despite the limitations, these analyses do provide basic
statistical information on the PADDI and support for its use.
Information on the severity of diagnostic conditions and forms of
victimization also support the argument for routine assessment of
youths entering juvenile facilities. Further research with other
populations and concurrent validity measures will provide more
definitive perspectives on this critical area.
REFERENCES
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Manual of Mental Disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text
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Dennis, M. L., Titus, J.C., White, M., Unsicker, J., & Hodgkins, D.
(2002). Global Appraisal of Individual Needs (GAIN) Administration
guide for the GAIN and related measures. Bloomington, IL Retrieved from
http//www.chestnut.org/li/gain/gadm1299.pdf.
Estroff, T. W. & Hoffmann, N.G. (2001). PADDI: Practical Adolescent
Dual Diagnosis Interview. Smithfield, RI: Evince Clinical Assessments.
Grella, C.E., Hser, Y., Joshi, V., & Rounds-Bryant, J. (2001). Drug
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Grilo, C.M., Becker, D.F., Walker, M.L., Levy, K.N., Edell, W.S., &
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Hoffmann, N.G., Estroff, T.W., & Wallace, S.D. (2001). Co-occurring
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Use and Misuse,38 (2), 293-305.
Lehman, A.F., Myers, C.P., Corty, E., & Thompson, J.W. (1994).
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Myers, M.G., Stewart, D.G., & Brown, S.A. (1998). Progression from
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479-485.
Schuckit, M.A., Smith, T.L., Danko, G.P., Bucholz, K.K., Reich, T.,
& Bierut, L. (2001). 5-year clinical course associated with DSM-IV
alcohol abuse or dependence in a large group of men and women. American
Journal of Psychiatry, 158(7):1084-1090.
Shaffer, D., Fisher, P., Dulcan, M.K., Davies, M., Piacentini, J.,
Schwab-Stone, M. E., Lahey, B.B., Bourdon, K., Jensen, P.S., Bird,
H.R., Canino, G., & Regier, D.A. (1996). The NIMH Diagnostic Interview
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Appendix A
Authorization for Release of Information (JASAE)
Region I
Region II
Region III
Region IV
Appendix B
JASAE Administrators
Region I
Region II
Region III
Region IV
Appendix C
Participating Schools
Region I
Region II
Region III
Region IV
Appendix D
Network Member Treatment Providers
Region
Region II
Region III
Region IV
Appendix E
Profile of Network Member Outpatient Substance Abuse Services
Region I
Region II
Region III
Region IV
Appendix F
Instructions for Administering the JASAE
Appendix G
JASAE Screening
Introduction
The Substance Abuse Treatment Network for Adolescents is modeled on
the successful Juvenile Corrections Substance Abuse Treatment Network.
In 2002, the Office of Substance Abuse contracted with Day One to
manage the expansion of the Juvenile Corrections Substance Abuse
Treatment Network to adolescents not currently in the Department of
Corrections System.
The Juvenile Corrections Substance Abuse Treatment Network is a
coordinated Statewide system providing a centralized screening and
referral process to identify juvenile offenders with substance abuse
issues. The Office of Substance Abuse and the Department of Corrections
collaborated on this project and the Office of Substance Abuse
contracted with Day One to staff and manage the Network.
In January 1996, treatment providers throughout the State formally
applied for membership in the Network and a standardized screening
tool, the Juvenile Automated Substance Abuse Evaluation (JASAE), was
chosen for the purpose of screening and referring juvenile offenders in
the State of Maine.
Since the JASAE screening and referral process was implemented in
January 1998, 5,461 juvenile offenders have been screened. Of those
2,968 (54 percent) were referred on for a further substance abuse
evaluation. The Network, as a collaborative program of the Office of
Substance Abuse and the Department of Corrections, is committed to its
goals of expanding the capacity of the State to provide substance abuse
treatment to juveniles, and to enhance the continuum of care as
juveniles move in the justice and treatment systems.
The Juvenile Treatment Network employs two Regional Support
Coordinators to work within the four Department of Corrections regions
and provide support for JCCOs and Network providers within their
respective regions. The Substance Abuse Treatment Network for
Adolescents will continue to work within these four regions to maintain
a continuity of services. The Regional Support Coordinators schedule
and facilitate quarterly meetings within each region to allow for
discussion between JCCOs, community based organizations and Network
providers on a variety of issues including problems/issues identified
by the JASAE, best practice approaches to treatment, communication and
information sharing, and other community issues.
Mission Statement
To foster collaboration throughout the State of Maine between
community based organizations and providers of adolescent substance
abuse treatment services, so that adolescents can access appropriate
levels of assessment and treatment that match client needs with
provider strengths.
Maine Department of Behavioral and Developmental Services, Office
of Substance Abuse, Marquardt Building, 3rd Floor--AMHI Complex, 159
State House Station, Augusta, ME 04333-0159, Phone (207) 287-2595, FAX
(207) 287-4334 or 287-8910, http://www.state.me.us/bds/osa.
Network Administrator: Day One, Juvenile Treatment Network, 525
Main St., South Portland, ME 04106, PHONE (207) 842-3637, FAX (207)
842-3639, http://www.JuvenileTreatmentNetwork.org.
SCREENING AND ASSESSMENT
Screening
The purpose in using the Juvenile Automated Substance Abuse
Evaluation (JASAE) standardized screening tool is to identify
adolescents that may have a problem abusing substances, or the
potential for developing a problem. Adolescents identified by the JASAE
screening (see Appendix G) as having a problem, or the potential for
one, will be referred to a Network Member Treatment Provider for a full
substance abuse evaluation to determine whether or not further services
are needed.
The Juvenile Substance Abuse Treatment Network for Adolescents has
in place a centralized screening and referral system. Network
affiliated schools have access to a Network trained JASAE administrator
(hence forth referred to as JASAE administrator) who will administer
the JASAE to juveniles referred by a Network authorized school contact
(hence forth referred to as school contact). Once the juvenile has
taken the JASAE screening the Network Coordinator will contact the
juvenile and parent or guardian, if authorized by the juvenile, of the
JASAE screening referral recommendations. If the juvenile scores high
enough he/she will be referred to a Network Member Treatment Provider
for a further substance abuse evaluation. In addition, the Network will
communicate with the school contact to give recommendations for further
substance abuse evaluation and school based services follow up based on
the JASAE screening results.
Criteria for Referring Adolescents for JASAE Screeninq
When referring a juvenile for the JASAE screening please use the
following criteria:
1. AGE:
Refer adolescent if between the ages of 12 and 20 and currently
enrolled or attempting to enroll in school (does not apply to post
secondary education). Ages 11 and under refer directly to provider for
evaluation.
2. NOTICEABLE SUDDEN CHANGES IN ADOLESCENTS:
Refer the adolescent for a JASAE screening if any sudden changes
have occurred in:
? School performance
? School attendance
? Change in peers
? Interest in extra curricular activities
? General disposition or personality
3. VIOLATION OF CHEMICAL HEALTH POLICY HAS OCCURRED
Refer the adolescent for a JASAE screening if the juvenile has
violated the school chemical health policy.
SUBSTANCE ABUSE TREATMENT NETWORK FOR ADOLESCENTS
IDENTIFICATION, SCREENING AND REFERRAL FLOW CHART
1)
Adolescent is identified by nurse, primary teacher,
guidance counselor or other school personnel and referred to school
contact.
School contact administers JASAE screening or refers
juvenile to JASAE administrator for JASAE screening.
2)
JASAE administrator gives the JASAE in school setting or
outside agency location.
JASAE administrator has adolescent sign consent for
release form and contact form.
JASAE administrator sends bubble sheet, consent for
release of confidential information and JASAE referral form to the
Network office.
3)
Network office scores JASAE.
Network office records data and creates file.
If adolescent scores high enough on the JASAE, adolescent
will be referred for further substance abuse evaluation to a Network
Member Treatment Provider.
A full copy of the screening is sent to the Network Member
Treatment Provider.
Network Coordinator communicates JASAE referral
recommendations by mail and/or phone follow up with parent/legal
guardian.
4)
Network will communicate with the school contact to give
recommendations for further substance abuse evaluation based on the
JASAE screening results.
KEY PARTICIPANTS AND ROLES
Network Affiliated Schools
Identification of adolescent by school personnel who may
refer adolescents to take the JASAE.
School Contact
Timely and appropriate referral to a Network trained JASAE
administrator.
Collaborates with Network Member Treatment Provider to
coordinate appropriate services.
May be trained by Network staff to administer the JASAE.
Network Member Treatment Providers
May be trained as JASAE administrator by Network staff.
Receive referrals for further substance abuse evaluation
and outpatient substance abuse treatment services.
Collaborate with the school contact to coordinate
appropriate services.
The Juvenile Treatment Network
Scoring of JASAE screening.
Data collection and record keeping.
If the adolescent scores high enough, referral to a
Network member treatment provider for a further substance abuse
evaluation.
If authorized, shares JASAE screening results with Network
Member Treatment Provider.
Communicates with school contact to give recommendations
for further substance abuse evaluation.
Shares recommendations for further substance abuse
evaluation with parent or legal/guardian.
JASAE ADMINISTRATION
JASAE Administrators must have completed a training session with
ADE Inc., the developer and owner of the JASAE screening tool, or a
Network staff person. The JASAE Administrator will have documentation
of JASAE training completion on file. Please see Appendix F for step-
by-step instructions on how to administer the JASAE.
JASAE Administrators administering the JASAE on behalf of agencies
participating in the Network will receive $15 per individual JASAE
screening or $20 per group JASAE screening. The Network will pay for up
to two JASAE no-shows on one adolescent for an individual JASAE
screening if the agency schedules the adolescent for a third time and
he/she does not show, the Network will not cover the no-show fee.
JASAE Administrators will receive timely JASAE screening referrals
from school contacts. The JASAE administrator will conduct the
screening per Network policy and forward the JASAE screening answer
sheet, Authorization for Release of Information and JASAE referral form
to the Network office for scoring within 5-7 days of completion. The
Network will score and distribute results (or inform the school contact
and/or JASAE administrators of problems with the completed JASAE)
within 1-2 days after receipt of the completed JASAE. If the juvenile
scores high enough he/she will be referred to a Network Member
Treatment Provider for a further substance abuse evaluation. In
addition, the Juvenile Treatment Network will communicate with the
school contact to give recommendations for further substance abuse
evaluation based on the JASAE screening results.
Recommendations based on the JASAE screening will be shared with
the parent/legal guardian. Once a client has signed the Authorization
for Release of Information there should not be any changes made to the
form without the client's permission.
INTERAGENCY REFERRALS AND CASE MANAGEMENT
Network members provide not only a variety of services but have
differing service capacities. Some of these treatment providers serve
overlapping geographic areas. To maximize resources and provide for
proper client/service matching, Network members are encouraged to refer
clients they are either unable to serve (e.g., limited space) or who
require specialized service provided by another Network member.
Adolescents will be referred to treatment programs that meet their
individual profiles. To assist Network members, a list of member
services for each region is provided (see Appendix A). This list will
be updated on an annual basis.
The treatment provider performing the evaluation or providing
treatment services is responsible for recommending new or additional
services and any transitional programming. Recommendations will be made
to the client.
The client and the treatment provider resolve payment for treatment
services. Medicaid and private insurance will be utilized whenever
possible. Client self-pay will be used according to the provider's
individual scale. When none of these payment sources are available, the
provider may access OSA Contract Funds, managed by the Network, in
accordance with policy and procedures established by the Office of
Substance Abuse. Please see the section titled, ``Billing Policies and
Procedures'' for more information on these funds.
RIGHTS OF CLIENTS
The client has the final choice of services and provider. Network
treatment providers will inform clients that, although Network members
are recommended service providers, other choices do exist. When
requested by the client, Network members will inform the client of
other treatment providers.
Participation by the juvenile in the Substance Abuse Treatment
Network for Adolescents is voluntary. Information about the juvenile
may only be shared with the juvenile's consent in the form of a signed,
initialed and witnessed authorization for release of information
meeting CFR 42 criteria. Under no circumstances should the juvenile be
coerced to participate in the Juvenile Treatment Network at any level,
against their wishes.
NETWORK MEMBERSHIP GUIDELINES
Members of the Juvenile Treatment Network commit to the following:
Participation in Network-sponsored training and attendance
at a minimum of three Network meetings per year (Network members
failing to attend at least three meetings will not receive free
registration for Network-sponsored trainings and will not receive
Network referrals);
Incorporation of best practices as defined by the Network
and demonstrated by research, into treatment programs for adolescents;
Use of Network-developed protocol and forms for
communication between the Juvenile Treatment Network, Network Member
Treatment Providers, Department of Corrections and community
organizations;
Collaboration with other Network members and participants
to identify gaps in treatment services and work cooperatively to fill
those gaps;
Participation in a Network screening and referral system
designed to match clients and providers;
Development of program admission and discharge criteria
consistent with best practices for adolescents; and
Participation in Network development of policy, procedures
and training designed to implement Network goals and encourage provider
compliance; and
Timely completion of required TDS Admission and Discharge
forms with the appropriate Network Code.
Members of the Juvenile Treatment Network receive the following
benefits:
Last resort outpatient treatment reimbursement eligibility
for providers;
Free registration for Network-sponsored trainings;
Participation in the Network screening and referral
system;
Input into the development of Network policy and a system
of comprehensive continuum of care for adolescents;
Contribute to data collection that will assist in
identifying barriers to substance abuse treatment services throughout
the State; and
Improved communication between referral sources and
treatment providers through attendance at quarterly Network meetings.
Network membership criteria:
Agency must be licensed by the Office of Substance Abuse.
Agency must be Medicaid eligible.
Agency must provide outpatient and/or intensive outpatient
substance abuse services in one or more service locations.
Agency must adhere to Network policies.
NETWORK MEMBER CRITERIA EXCEPTION
The Juvenile Treatment Network will accept membership from
individual practitioners who are not OSA agency licensed and who work
in a rural area where there is no other Network Member Treatment
Provider Agency within a 30-mile radius.
If a treatment provider who meets Network criteria for membership
joins the Juvenile Treatment Network within the 30-mile radius, the
individual practitioner will no longer receive referrals from the
Juvenile Treatment Network.
The Juvenile Treatment Network will continue to fund juveniles
currently on that individual practitioner's caseload who meet Juvenile
Treatment Network criteria for funding. The Juvenile Treatment Network
will not extend this exception to any Substance Abuse Treatment Agency
that is eligible for OSA agency licensure and Medicaid seed.
BILLING POLICIES AND PROCEDURES
In 2002 the Juvenile Treatment Network received continued and
expanded funding from the Office of Substance Abuse in anticipation of
the conclusion of the Targeted Capacity Expansion grant from the Center
for Substance Abuse Treatment. Network funds are available to pay for
substance abuse treatment for adolescents that have no other means of
payment. The Network funds are to be used as a last resort for payment,
therefore, Network providers will be asked to provide information about
the juvenile's household income and/or insurance to ensure that only
eliqible juveniles are receiving Network funds. It is the Network
Member Treatment Provider's responsibility to exhaust all other funding
sources with the client before submitting bills for Network funds.
Following are the criteria that adolescents must meet in order to
be considered eligible for Network funds. If there is any question as
to whether or not an adolescent is eligible for Network funds, please
call the Network Coordinator at 842-3637. Under no circumstances should
a family member or insurance agency be referred to the Network
regarding payment. The Network funds are for providers to access for
eligible adolescents.
Client does not have private insurance that will pay for outpatient
substance abuse treatment services. Eligible adolescents must not have
private insurance that will cover substance abuse treatment services.
If an adolescent's coverage does not include substance abuse treatment
services, or the juvenile has exceeded the allowable benefits, Network
funds may be an option. If an adolescent's insurance will cover certain
``in-network'' providers, and there are no Network providers in the
geographic area, Network funds may be an option. However, if there is a
Network agency within the geographic area that is considered ``in-
network'' by the insurance company, the adolescents may be referred to
that provider. If an adolescent and his/her parents do have insurance
but paying their co-pay would be a financial hardship, the Network
funds may be an option. This is also true if the family has a
deductible that must be met before the insurance will cover services.
Approved documentation of insurance denial must be submitted with
the billing form for Network funds.
Client is not eligible for Medicaid. Any adolescent who is eligible
for Medicaid is not eligible for Network funds. There is space on the
billing form for providers to report the number of people in an
adolescent's household and that household's income. If the income falls
between 100-150 percent of the Federal poverty level, the adolescent
may be eligible for Medicaid and that option will need to be explored
by the client before Network funds can pay for services. Although this
is not the only indication of whether or not an adolescent is eligible
for Medicaid, it is currently the only feasible way for the Network to
determine if an adolescent is eligible to receive Network funds to
cover treatment. If the family has applied for Medicaid and been
denied, approved documentation of denial must be submitted with the
billing form for Network funds.
Client cannot pay the full cost of treatment based on the
provider's sliding fee scale. If a client can pay a certain amount per
session, Network funds may be able to fund part of the session
providing that the total amount does not exceed the maximum allowance
listed on the Substance Abuse Treatment Network for Adolescents billing
form. For example, if a Juvenile Treatment Network provider's hourly
rate for family counseling is $85 per hour, and the family can afford
to pay $20 per hour, the Network funds may be able to cover $55 per
hour, as the maximum allowable reimbursement for Network funding is $75
per hour for family counseling.
Client has taken the JASAE screening. An adolescent is not
considered part of the Substance Abuse Treatment Network for
Adolescents until he/she has taken the JASAE screening by referral
through their high school.
Please keep in mind:
Any incomplete billing forms will be returned to the
provider, e.g., the household size and income has not been filled out;
and
By accepting Network funds for treatment services the
provider agrees not to bill the adolescent/family for any fees over and
above the maximum reimbursement paid by the Substance Abuse Treatment
Network for Adolescents.
Transportation
The Network will cover transportation costs for adolescents to get
to and from treatment appointments. THIS OPTION IS AVAILABLE REGARDLESS
OF THE ADOLESCENT'S FUNDING SOURCE FOR TREATMENT. If, in the provider's
judgment, transportation is a barrier to treatment, the Network funds
will cover bus or cab fare, or pay mileage ($.30/mile) to the
adolescent or friend/family member that drives the adolescent to and
from treatment. While the Network funds will cover mileage to and from
treatment appointments, it will not cover mileage for a friend or
family member to drive back home, or somewhere else, while waiting for
the adolescent.
The Juvenile Treatment Network provider is responsible for
reimbursing the adolescent or friend/family member at the appointment
and submitting a Substance Abuse Treatment Network for Adolescents
billing form to the Juvenile Treatment Network for the amount. If this
is a hardship for the Network Member Treatment Provider and creates a
barrier to outpatient substance abuse treatment services for
adolescents, please apply for a Transportation Loan (see table of
contents).
In order to be eligible for transportation reimbursement from the
Network funds, the adolescent must have had a JASAE. The Juvenile
Treatment Network provider is required to complete a TDS admission and
discharge form.
Child Care
As with transportation costs, the Network funds will cover
childcare (up to $10 per treatment session) for adolescents REGARDLESS
OF THE FUNDING SOURCE FOR TREATMENT.
In order to be eligible for childcare reimbursement from the
Network funds, the adolescent must have had a JASAE and the treatment
provider is required to complete a TDS admission and discharge form.
The Juvenile Treatment Network provider is responsible for reimbursing
the adolescent at the appointment and submitting a Substance Abuse
Treatment Network for Adolescents billing form to the Juvenile
Treatment Network for the amount.
Please Include the following when submitting for billing:
(Required) Completed Juvenile Treatment Network Billing
Form.
(Required) Copy of Completed TDS admission Form for client
with appropriate Network code-23021-99.
Any relevant supportive documentation for last resort
payment source.
JUVENILE TREATMENT NETWORK
TRANSPORTATION LOAN
BILLING POLICIES AND PROCEDURES
The Juvenile Treatment Network transportation loan is available for
providers to access when current Juvenile Treatment Network
transportation reimbursement procedures are a barrier to treatment
services. Upon submission of a check request form from the Network
provider to the Juvenile Treatment Network office, Day One will issue a
check to the provider to be used for transportation expenses as they
occur for clients eligible for transportation funds. Day One will
create a debit account in an amount not to exceed $200 in the
provider's name. THE PROVIDER WILL CONTINUE TO BILL FOR CLIENTS, using
the Transportation Billing Form but instead of receiving payment, the
billable amount will be subtracted from the debit account until a zero
balance is reached. At that time the provider may request another
Transportation loan.
Transportation loan funds may be used to cover transportation costs
for juveniles to get to and from treatment appointments. THIS OPTION IS
AVAILABLE REGARDLESS OF THE JUVENILE'S FUNDING SOURCE FOR TREATMENT.
If, in the provider's judgment, transportation is a barrier to
treatment, the transportation funds can cover bus or cab fare, or pay
mileage ($.30/mile) to the juvenile or friend/family member that drives
the juvenile to and from treatment. While the Transportation Loan Funds
can cover mileage to and from treatment appointments, it will not cover
mileage for a friend or family member to drive back home, or somewhere
else, while waiting for the juvenile.
KEEP IN MIND THAT IN ORDER FOR CLIENTS TO BE ELIGIBLE FOR SET-ASIDE
FUNDS, THE FOLLOWING CRITERIA MUST BE MET:
The client must have had a JASAE.
A TDS admission form must be completed for the adolescent.
To obtain a Transportation Loan, providers must submit a Juvenile
Treatment Network Transportation Fund Check Request Form to the
Juvenile Treatment Network office at:
JUVENILE TREATMENT NETWORK
525 MAIN ST.
SOUTH PORTLAND, ME 04106
Appendix A
Authorization for Release of Information (JASAE)
Region I
Region II
Region III
Region IV
Appendix B
JASAE Administrators
Region I
Region II
Region III
Region IV
Appendix C
Juvenile Community Corrections Officers
Region I
Region II
Region III
Region IV
Appendix D
Network Treatment Providers
Region I
Region II
Region III
Region IV
Appendix E
Profile of Network Member Outpatient Substance Abuse Services
Region I
Region II
Region III
Region IV
Appendix F
Instructions for Administering the JASAE
Appendix G
JASAE Screening
Juvenile Corrections Substance Abuse Treatment Network
INTRODUCTION
The Juvenile Corrections Substance Abuse Treatment Network is a
coordinated Statewide system providing a centralized screening and
referral process to identify juvenile offenders with substance abuse
issues. The Office of Substance Abuse and the Department of Corrections
collaborated on this project and the Office of Substance Abuse
contracted with Day One to staff and manage the Network.
In January 1998, treatment providers throughout the State formally
applied for membership in the Network and a standardized screening
tool, the Juvenile Automated Substance Abuse Evaluation (JASAE), was
chosen for the purpose of screening and referring juvenile offenders in
the State of Maine.
The referral for the JASAE is made by the Juvenile Community
Corrections Officer (JCCO) and is administered by a Network agency or
the JCCO in some cases. The screening is scored at the Network office,
where it is determined, based on the JASAE results, whether or not the
juvenile should be referred to one of the 60 Network providers for a
substance abuse evaluation. Many times, the JCCO refers for the JASAE
even if he/she has no further action with a juvenile. Therefore, we
believe we are able to identify substance abuse problems early on in a
juvenile's contact with the justice system.
Since the JASAE screening and referral process was implemented in
January 1998, 5,427 juvenile offenders have been screened. Of those
5,427, 2,950 (54 percent) were referred on for a further substance
abuse evaluation. The Network, as a collaborative program of the Office
of Substance Abuse and the Department of Corrections, is committed to
its goals to expand the capacity of the State to provide substance
abuse treatment to juveniles, and to enhance the continuum of care as
juveniles move in the justice and treatment systems.
The Network employs two Regional Support Coordinators to work
within the four Department of Corrections regions and provide support
for JCCOs and Network providers within their respective regions. The
Regional Support Coordinators schedule and facilitate quarterly
meetings within each region to allow for discussion between JCCOs and
Network providers on a variety of issues including problems/issues
identified by the JASAE, best practice approaches to treatment,
communication and information sharing, and other community issues.
MISSION STATEMENT
Structured collaboration between substance abuse treatment
providers and Juvenile Community Corrections Officers in every region
of the Department of Corrections to provide access to treatment that
matches client needs with provider strengths for all juvenile
offenders.
(Maine Department of Behavioral and Developmental Services, Marquardt
Building, 3rd Floor--AMHI Complex, 159 State House Station, Augusta, ME
04333-0159, Phone (207) 287-2595; FAX (207) 287-4334 or 287-8910,
http://www.state.me.us/bds/osa.) (Maine Department of Corrections,
Juvenile Services Division, 111 State House Station, Augusta, ME 04333-
0111, Phone (207) 287-2470, FAX (207) 287-5150.) (Network Contractor/
Administrator: Day One, Juvenile Treatment Network, 525 Main Street,
South Portland, ME 04106, PHONE (207) 842-3637, FAX (207) 842-3639,
http://www.JuvenileTreatmentNetwork.org.)
SCREENING AND ASSESSMENT
Screening
The purpose in using the Juvenile Automated Substance Abuse
Evaluation (JASAE) standardized screening tool is to identify juvenile
offenders that may have a problem abusing substances, or the potential
for developing a problem. Juvenile offenders identified by the JASAE
screening (see Appendix G) as having a problem, or the potential for
one, will be referred to a Network provider for a full substance abuse
evaluation to determine whether or not further services are needed.
The Juvenile Corrections Substance Abuse Treatment Network has in
place a centralized screening and referral system. All Juvenile
Community Corrections Officers (JCCOs) have access to a provider who
will administer the JASAE (Appendix B) to juveniles referred by the
Department of Corrections. The JCCO may refer a juvenile for the JASAE
at any point during the juvenile's contact with the justice system,
including informal adjustment, probation, and aftercare. Juvenile
Community Corrections Officers may administer the JASAE themselves if
they choose. In many cases this will be more efficient and result in
quicker referral for services than relying on a middle person for JASAE
administration. Juvenile Community Corrections Officers are asked to
use the following criteria when referring a juvenile for the JASAE
screening.
CRITERIA FOR REFERRING ADOLESCENTS FOR JASAE SCREENING
1. Age--Refer adolescent if between the ages of 12 and 18. If
juvenile is under 12, refer directly to a Network provider for an
assessment.
2. Peer Group--Refer adolescent if it is known that he/she has
peers who are involved in substance use.
3. History--Refer adolescent if it is known that he/she or a family
member has a history of substance use and/or abuse.
4. Change--Refer adolescent if any sudden changes in the following
have occurred: school performance/attendance, change in peers, interest
in extracurricular activities and general disposition/personality.
5. Arrest--Refer adolescent if his/her arrest involved substances
directly or indirectly.
6. Unsure--Refer adolescent if there is any doubt at all.
7. Previous JASAE Screening--Refer adolescent if he/she took the
JASAE screening more than 6 months ago. In some cases it may be
appropriate to refer the juvenile for another JASAE if it has been less
than 6 months since the last one (see #4 above, ``Change'').
JASAE Administrators must have completed a training session with
ADE Inc., the developer and owner of the JASAE screening tool, or a
Network staff person. The JASAE Administrator will have documentation
of JASAE training completion on file. Please see Appendix F for step-
by-step instructions on how to administer the JASAE.
JASAE Administrators will receive $15 per individual JASAE plus
mileage if necessary, or $20 per group JASAE administration (not to
exceed 5 juveniles). The Network will pay for up to two JASAE no-shows
on one juvenile for each individual JASAE administration--if the agency
schedules the juvenile for a third time and he/she does not show, the
Network will not cover the no-show fee.
All completed JASAEs are forwarded to the BDS contractor, Day One,
for scoring within 5-7 days of completion. The Network/Day One will
score and distribute the results, or inform JCCOs and/or JASAE
administrators of problems with the completed JASAE, within 1-2 days
after receipt of the completed JASAE. The full results and a summary
are sent to the Juvenile Community Corrections Officer. With the
client's written consent a summary is sent to the parents or guardian
with recommendations for follow-up evaluation when indicated by the
screening results. All referrals for follow-up services will be made to
regional Network members (see Appendix D) when indicated by the client
on the Authorization for Release of Information (see Appendix A). Once
a client has signed the Authorization for Release of Information there
should not be any changes made to the form without the client's
permission.
If a juvenile is referred for a full evaluation, the parent/
guardian will receive a phone call from the Network Coordinator to
ensure that there are no questions or concerns about the screening and/
or results. Any parent/guardian not able to be contacted by phone will
receive a letter from the Network Coordinator with a reference sheet
including frequently asked questions about the JASAE and the answers to
those questions.
RESTRICTIONS ON REDISCLOSURE
Notice prohibiting redisclosure must accompany any disclosure made
with patient's consent (42 CFR 2.32). Each disclosure made with the
patient's written consent must be accompanied by the following
statement:
Prohibition on Redisclosure of Information Concerning Client in Alcohol
or Drug Abuse Treatment
This notice pertains to any disclosure of information concerning a
client in alcohol/drug abuse treatment, made to you with consent of
such client. This information has been made to you from records
protected by Federal confidentiality rules (42 CFR Part 2). The Federal
rules prohibit you from making any further disclosure of this
information unless further disclosure is expressly permitted by the
written consent of the person to whom it pertains or as otherwise
permitted by 42 CFR Part 2. A general authorization for the release of
medical or other information is NOT sufficient for this purpose. The
Federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient.
INTERAGENCY REFERRALS AND CASE MANAGEMENT
Network members provide not only a variety of services but have
differing service capacities. Some of these treatment providers serve
overlapping geographic areas. To maximize resources and provide for
proper client/service matching, Network members are encouraged to refer
clients they are either unable to serve (e.g., limited space) or who
require specialized service provided by another Network member.
Juveniles will be referred to treatment programs that meet their
individual profiles. To assist Network members, a list of member
services for each region is provided (see Appendix E). This list will
be updated on an annual basis.
The treatment provider performing the evaluation or providing
treatment services is responsible for recommending new or additional
services and any transitional programming. Recommendations will be made
to the Juvenile Community Corrections Officer and the client.
The client and the treatment provider resolve payment for treatment
services. Medicaid and private insurance will be utilized whenever
possible. Client self-pay will be used according to the provider's
individual scale. When none of these payment sources are available, the
provider may access Targeted Capacity Expansion grant funds, managed by
the Network, in accordance with policy and procedures established by
the Office of Substance Abuse. Please see the section titled, ``Billing
Policies and Procedures'' for more information on these funds.
RIGHTS OF CLIENTS
Notwithstanding conditions for probation imposed by the Juvenile
Community Corrections Officer, the client has the final choice of
services and provider. Network treatment providers and Juvenile
Community Corrections Officers will inform clients that, although
Network members are recommended service providers, other choices do
exist. When requested by the client, Network members will inform the
client of other treatment providers.
NETWORK MEMBERSHIP GUIDELINES
Members of the Juvenile Treatment Network commit to the following:
Participation in Network-sponsored training and attendance
at a minimum of three Network meetings per year (Network members
failing to attend at least three meetings will not receive free
registration for Network-sponsored trainings and will not receive
Network referrals);
Incorporation of best practices as defined by the Network
and demonstrated by research, into treatment programs for adolescents;
Use of Network-developed protocol and forms for
communication between the Juvenile Treatment Network, Network Member
Treatment Providers, Department of Corrections and community
organizations;
Collaboration with other Network members and participants
to identify gaps in treatment services and work cooperatively to fill
those gaps;
Participation in a Network screening and referral system
designed to match clients and providers;
Development of program admission and discharge criteria
consistent with best practices for adolescents; and
Participation in Network development of policy, procedures
and training designed to implement Network goals and encourage provider
compliance; and
Timely completion of required TDS Admission and Discharge
forms with the appropriate Network Code.
Members of the Juvenile Treatment Network receive the following
benefits:
Last resort outpatient treatment reimbursement eligibility
for providers;
Free registration for Network-sponsored trainings;
Participation in the Network screening and referral
system;
Input into the development of Network policy and a system
of comprehensive continuum of care for adolescents;
Contribute to data collection that will assist in
identifying barriers to substance abuse treatment services throughout
the State; and
Improved communication between referral sources and
treatment providers through attendance at quarterly Network meetings.
Network membership criteria
Agency must be licensed by the Office of Substance Abuse.
Agency must be Medicaid eligible.
Agency must provide outpatient and/or intensive outpatient
substance abuse services in one or more service locations.
Agency must adhere to Network policies.
NETWORK MEMBER CRITERIA EXCEPTION
The Juvenile Treatment Network will accept membership from
individual practitioners who are not OSA agency licensed and who work
in a rural area where there is no other Network Member Treatment
Provider Agency within a 30-mile radius.
If a treatment provider who meets Network criteria for membership
joins the Juvenile Treatment Network within the 30-mile radius, the
individual practitioner will no longer receive referrals from the
Juvenile Treatment Network.
The Juvenile Treatment Network will continue to fund juveniles
currently on that individual practitioner's caseload who meet Juvenile
Treatment Network criteria for funding. The Juvenile Treatment Network
will not extend this exception to any Substance Abuse Treatment Agency
that is eligible for OSA agency licensure and Medicaid seed.
BILLING POLICIES AND PROCEDURES
In 2002 the Juvenile Treatment Network received continued and
expanded funding from the Office of Substance Abuse in anticipation of
the conclusion of the Targeted Capacity Expansion grant from the Center
for Substance Abuse Treatment. Network funds are available to pay for
substance abuse treatment for adolescents that have no other means of
payment. The Network funds are to be used as a last resort for payment,
therefore, Network providers will be asked to provide information about
the juvenile's household income and/or insurance to ensure that only
eligible juveniles are receiving Network funds. It is the Network
Member Treatment Provider's responsibility to exhaust all other funding
sources with the client before submitting bills for Network funds.
Following are the criteria that adolescents must meet in order to
be considered eligible for Network funds. If there is any question as
to whether or not an adolescent is eligible for Network funds, please
call the Network Coordinator at 842-3637. Under no circumstances should
a family member or insurance agency be referred to the Network
regarding payment. The Network funds are for providers to access for
eligible adolescents.
Client does not have private insurance that will pay for outpatient
substance abuse treatment services. Eligible adolescents must not have
private insurance that will cover substance abuse treatment services.
If an adolescent's coverage does not include substance abuse treatment
services, or the juvenile has exceeded the allowable benefits, Network
funds may be an option. If an adolescent's insurance will cover certain
``in-network'' providers, and there are no Network providers in the
geographic area, Network funds may be an option. However, if there is a
Network agency within the geographic area that is considered ``in-
network'' by the insurance company, the adolescents may be referred to
that provider.
If an adolescent and his/her parents do have insurance but paying
their co-pay would be a financial hardship, the Network funds may be an
option. This is also true if the family has a deductible that must be
met before the insurance will cover services.
Approved documentation of insurance denial must be submitted with
the billing form for Network funds.
Client is not eligible for Medicaid. Any adolescent who is eligible
for Medicaid is not eligible for Network funds. There is space on the
billing form for providers to report the number of people in an
adolescent's household and that household's income. If the income falls
between 100-150 percent of the Federal poverty level, the adolescent
may be eligible for Medicaid and that option will need to be explored
by the client before Network funds can pay for services. Although this
is not the only indication of whether or not an adolescent is eligible
for Medicaid, it is currently the only feasible way for the Network to
determine if an adolescent is eligible to receive Network funds to
cover treatment. If the family has applied for Medicaid and been
denied, approved documentation of denial must be submitted with the
billing form for Network funds.
Client cannot pay the full cost of treatment based on the
provider's sliding fee scale. If a client can pay a certain amount per
session, Network funds may be able to fund part of the session
providing that the total amount does not exceed the maximum allowance
listed on the Substance Abuse Treatment Network for Adolescents billing
form. For example, if a Juvenile Treatment Network provider's hourly
rate for family counseling is $85 per hour, and the family can afford
to pay $20 per hour, the Network funds may be able to cover $55 per
hour, as the maximum allowable reimbursement for Network funding is $75
per hour for family counseling.
Client has taken the JASAE screening. An adolescent is not
considered part of the Substance Abuse Treatment Network for
Adolescents until he/she has taken the JASAE screening by referral
through their high school or JCCO.
Please keep in mind:
Any incomplete billing forms will be returned to the
provider, e.g., the household size and income has not been filled out;
and
By accepting Network funds for treatment services the
provider agrees not to bill the adolescent/family for any fees over and
above the maximum reimbursement paid by the Substance Abuse Treatment
Network for Adolescents.
Transportation
The Network funds will cover transportation costs for adolescents
to get to and from treatment appointments. THIS OPTION IS AVAILABLE
REGARDLESS OF THE ADOLESCENT'S FUNDING SOURCE FOR TREATMENT. If, in the
provider's judgment, transportation is a barrier to treatment, the
Network funds will cover bus or cab fare, or pay mileage ($.30/mile) to
the adolescent or friend/family member that drives the adolescent to
and from treatment. While the Network funds will cover mileage to and
from treatment appointments, it will not cover mileage for a friend or
family member to drive back home, or somewhere else, while waiting for
the adolescent.
The Juvenile Treatment Network provider is responsible for
reimbursing the adolescent or friend/family member at the appointment
and submitting a Substance Abuse Treatment Network for Adolescents
billing form to the Juvenile Treatment Network for the amount. If this
is a hardship for the Network Member Treatment Provider and creates a
barrier to outpatient substance abuse treatment services for
adolescents, please apply for a Transportation Loan (see table of
contents).
In order to be eligible for transportation reimbursement from the
Network funds, the adolescent must have had a JASAE. The Juvenile
Treatment Network provider is required to complete a TDS admission and
discharge form.
Child Care
As with transportation costs, the Network funds will cover
childcare (up to $10 per treatment session) for adolescents REGARDLESS
OF THE FUNDING SOURCE FOR TREATMENT.
In order to be eligible for childcare reimbursement from the
Network funds, the adolescent must have had a JASAE and the treatment
provider is required to complete a TDS admission and discharge form.
The Juvenile Treatment Network provider is responsible for
reimbursing the adolescent at the appointment and submitting a
Substance Abuse Treatment Network for Adolescents billing form to the
Juvenile Treatment Network for the amount.
Please Include the following when submitting for billing:
(Required) Completed Juvenile Treatment Network Billing
Form.
(Required) Copy of Completed TDS admission Form for client
with appropriate Network code-23021-99.
Any relevant supportive documentation for last resort
payment source.
JUVENILE TREATMENT NETWORK
TRANSPORTATION LOAN
BILLING POLICIES AND PROCEDURES
The Juvenile Treatment Network transportation loan is available for
providers to access when current Juvenile Treatment Network
transportation reimbursement procedures are a barrier to treatment
services. Upon submission of a check request form from the Network
provider to the Juvenile Treatment Network office, Day One will issue a
check to the provider to be used for transportation expenses as they
occur for clients eligible for transportation funds. Day One will
create a debit account in an amount not to exceed $200 in the
provider's name. THE PROVIDER WILL CONTINUE TO BILL FOR CLIENTS, using
the Transportation Billing Form but instead of receiving payment, the
billable amount will be subtracted from the debit account until a zero
balance is reached. At that time the provider may request another
Transportation loan.
Transportation loan funds may be used to cover transportation costs
for juveniles to get to and from treatment appointments. THIS OPTION IS
AVAILABLE REGARDLESS OF THE JUVENILE'S FUNDING SOURCE FOR TREATMENT.
If, in the provider's judgment, transportation is a barrier to
treatment, the transportation funds can cover bus or cab fare, or pay
mileage ($.30/mile) to the juvenile or friend/family member that drives
the juvenile to and from treatment. While the Transportation Loan Funds
can cover mileage to and from treatment appointments, it will not cover
mileage for a friend or family member to drive back home, or somewhere
else, while waiting for the juvenile.
KEEP IN MIND THAT IN ORDER FOR CLIENTS TO BE ELIGIBLE FOR SET-ASIDE
FUNDS, THE FOLLOWING CRITERIA MUST BE MET:
The client must have had a JASAE
A TDS admission form must be completed for the adolescent
To obtain a Transportation Loan, providers must submit a Juvenile
Treatment Network Transportation Fund Check Request Form to the
Juvenile Treatment Network office at: Juvenile Treatment Network, 525
Main St., South Portland, ME 04106.
Criminals, Troubled Youth, or a Bit of Both
MULTIPLE DISORDERS SEEN IN JUVENILE POPULATION PRESENT TREATMENT
CHALLENGES
Crime, especially violent crime, is a frequently voiced concern and
often a hot political topic during elections. According to Federal
statistics, juveniles accounted for 17 percent of all arrests in 2000,
and for 16 percent of all violent criminal arrests.\1\ Crimes committed
by adolescents are particularly troubling since rearrest rates have
been found to range from 37 percent to over 50 percent within 2 years
\2\ and up to 67 percent within 4 to 5 years.\3\
Unfortunately, most of the recidivism reports not only ignore
substance use disorders in adolescent populations, they also ignore
other co-occurring conditions. Even among the treatment studies, there
is a tendency to focus on a single problem or diagnosis. But as Weisz
and Hawley \4\ point out, ``. . .adolescent problems do not come in
such neat, one-diagnosis units, but in bundles. . .'' According to
their literature review, it is not unusual for adolescents in clinical
populations to average three or more diagnoses.
Adolescents in the juvenile justice system resemble clinical
populations in the elevated prevalence of co-occurring conditions. One
general literature review found that about 60 percent of adolescents
with a substance use disorder had a co-occurring mental health
diagnosis as well.\5\ Teplin and colleagues found that, even when
conduct disorder is ignored, 60 percent of males and 65 percent of
females in juvenile justice populations had one or more diagnoses.\6\
The prevalence of co-occurring conditions appears to apply to
minorities as well as whites. For example, a study of American Indian
detainees found that more than 20 percent met diagnostic criteria for
two or more disorders.\7\
In Maine, Day One is the program responsible for assessing all
juveniles committed to the State's two detention centers or entering
its various adolescent drug treatment courts. In order to standardize
the assessment procedure across all sites, the Practical Adolescent
Dual Diagnostic Interview (PADDI), a structured diagnostic interview,
is administered to each juvenile. The PADDI covers a number of mental
health domains in addition to substance use disorders. It also inquires
about suicidal ideation, thoughts of harming others, and victimization
(physical, sexual and emotional).
An analysis of the first 218 consecutive admissions (187 males and
31 females) ranging in age from 13 to 18 revealed that almost 90
percent of the cases were between ages 15 and 17. The majority were
Caucasian (89 percent), and American Indians (5 percent) constituted
the only other group with more than 10 cases. Most came from single-
parent homes, with fewer than 20 percent living with both parents.
Educational attainment appeared low for these adolescents. Although
almost 75 percent were over the age of 15, 65 percent had not passed
beyond the 8th grade in school. Half of the adolescents had been in
special classes for behavioral or academic problems, and 15 percent
reported reading difficulties that caused serious problems. This is
consistent with other reports indicating that while more than 70
percent of delinquent juveniles have some reading or spelling problems,
slightly over 10 percent of the problems were considered serious.\8\
When asked about the reason for incarceration or being in
adolescent court, most (61 percent) responded that it was due to a
nonviolent offense, but 24 percent acknowledged violent offenses. A
substantial proportion (43 percent) reported substance abuse as being a
factor in their current detention.
Almost three out of four adolescents (73 percent) reported that
they had been in trouble for the same problem before. Of those
reporting nonviolent offenses, 73 percent reported prior problems,
compared to 77 percent for the violent offenders and 85 percent for
those indicating a substance use problem. This is consistent with the
rates of recidivism in other juvenile samples.\2\\3\
Although they had committed either a criminal or statutory offense,
these adolescents were often themselves victims of abuse. More than 75
percent of the females and about half of the males reported physical,
sexual and/or emotional abuse. For females, emotional abuse (61
percent) was the most prevalent, followed by sexual abuse (42 percent)
and physical abuse (39 percent). For males, physical and emotional
abuse were most common (33 percent and 29 percent, respectively), and
sexual abuse was least prevalent (11 percent).
Multiple disorders
In addition to the prevalence of victimization, the pattern of
diagnostic disorders in this population is staggering. More than 90
percent appear to meet at least minimal criteria for a mental health or
substance use disorder, and 80 percent meet such criteria convincingly.
Of the five most prevalent conditions (substance use disorder, conduct
disorder, oppositional defiant disorder, major depressive episode, and
manic episode), 75 percent appear to meet diagnostic criteria for more
than one of these conditions.
Of the adolescents in this juvenile sample, 80 percent met criteria
for conduct disorder and 71 percent met criteria for substance
dependence. An additional 14 percent meet criteria for substance abuse
only, so that a total of 85 percent appear to meet criteria for a
substance use disorder. Because substance dependence is the more severe
and chronic condition,\9\ we chose to focus on this condition rather
than including abuse, or misuse.
There are two notable differences in the severity indications
between substance dependence and conduct disorder. The first is that if
both abuse and dependence are considered, substance use disorders would
be the most prevalent conditions. Secondly, when the extent of
diagnostic indicators is examined, 65 percent of the entire sample
reported events and behaviors that exceeded the minimal criteria for
substance dependence. In contrast, 35 percent of the sample met only
minimal criteria for conduct disorder and 45 percent substantially
exceeded the minimal criteria for this condition. Furthermore, it is
probable that some of the apparent conduct disorder behaviors were a
consequence of substance dependence rather than an independent co-
occurring condition.
For major depression and mania, the PADDI attempts to identify
those episodes that are related to substance use. This identified 7
percent of the sample as having apparent substance-induced episodes.
When these cases are excluded, almost 30 percent of the youths provide
indications of a major depressive episode and about one in four reports
symptoms consistent with a manic episode.
Approximately 13 percent meet at least minimal DSM-IV criteria for
both depression and mania, and about half of those clearly exceed
minimal criteria for both conditions. These findings highlight the
possibility of emerging bipolar conditions among a substantial minority
of delinquent adolescents.
Indications of anxiety disorders are also common. Given the
victimization histories, it is not surprising that more than 20 percent
of the youths indicate symptoms compatible with post-traumatic stress
disorder (PTSD). Almost one-fourth of the cases endorsed more than half
of the symptoms for generalized anxiety or phobias. Approximately 10
percent reported panic attacks and associated physiological experiences
compatible with a panic disorder.
Because of the varied presentation for anxiety disorders and the
need to carefully rule out other possible causes, these prevalences
should be considered tentative. However, the level of reported symptoms
does suggest that a substantial portion of these youths may suffer from
a range of anxiety disorders.
Treatment Recommendations
The results of this study point toward strong indications that a
majority of adolescents entering juvenile justice systems merit mental
health and/or substance abuse treatment services.
More than half of the adolescents in this cohort report positive
indications for at least five of the seven dependence criteria, and 36
percent exceed diagnostic criteria for a mental health condition other
than conduct disorder or oppositional defiant disorder. Even if we were
to assume that half of the mental health conditions were substance-
induced beyond those already identified as such, we would still be left
with a substantial proportion of adolescents with serious mental health
conditions that are likely to require attention.
In addition to conduct disorder, substance dependence and
conditions such as bipolar disorder are likely to be related to
recidivism. Therefore, failure to identify and treat these mental
health and substance use problems is likely to further con-tribute to
the recidivism issue. However, caution should be exercised when
considering treatment options or other solutions, as the politically
popular boot camps for juvenile offenders have often yielded
disappointing outcomes and, in one case, higher-than-expected
recidivism.\10\
The findings from this systematic assessment of consecutive
admissions to the Maine juvenile justice system provide support for
several recommendations. First, and most obvious, routine assessments
and not simply perfunctory screening should be undertaken with all new
cases entering the juvenile justice system. This would include
admissions to detention centers and cases considered for diversion
courts. The present study has shown that such initial assessments can
be conducted in less than an hour using a structured interview process.
The second recommendation involves the allocation of resources for
treatment in order to address the identified conditions. Treatment
services should be available not only in the juvenile institutions but
also in the community upon release to adequately address both chronic
and acute conditions. To the extent that such services reduce
recidivism, they are likely to pay for themselves in overall cost
savings. The costs for incarcerating a juvenile for a year have been
estimated to range from $34,000 to $64,000.\11\ Thus, if treatment can
reduce recidivism for a portion of cases, it may more than pay for
itself.
Finally, due to the prevalent academic problems in juvenile
populations, remedial educational services and vocational counseling
are necessary investments to facilitate the path toward productive
citizenship instead of career recidivism in the adult correctional
system.
Norman G. Hoffmann is president of Evince Clinical Assessments and
clinical associate professor of community health at Brown University.
Ana M. Abrantes is a post-doctoral fellow at Brown University's Center
for Alcohol and Addiction Studies. Ronald Anton is director of juvenile
justice and community programs at Day One for Youth and Families, in
Maine.
Hoffmann may be contacted at Evince Clinical Assessments, P.O. Box
17305, Smithfield, RI 02917; phone (401) 231-2993; fax (401) 231-2055;
e-mail [email protected]. For more information, visit
www.evinceassessment. com.
References
\1\ Snyder, H.N. (2002). Juvenile Arrests 2000. Juvenile Justice
Bulletin, NCJ 191729, Washington, DC: OJJDP, U.S. Department of
Justice.
\2\ Blechman, E.A., Maurice, A., Buecker, B., & Helberg, C. (2000).
Can mentoring or skill training reduce recidivism? Observational study
with propensity analysis. Prev Sci, 1(3), 139-155.
\3\ Steiner, H., Cauffman, E., & Duxbury, E. (1999). Personality
traits in juvenile delinquents: relation to criminal behavior and
recidivism. Journal of the American Academy of Child and Adolescent
Psychiatry, 38(3), 256-262.
\4\ Weisz, J.R. & Hawley, K.M. (2002). Developmental factors in the
treatment of adolescents. Journal of Consulting and Clinical
Psychology, 70(1), 21-43.
\5\ Armstrong, T.D., Costello, E.J. (2002). Community studies on
adolescent substance use, abuse, or dependence and psychiatric
comorbidity. Journal of Consulting and Clinical Psychology, 70, 1224-
1239.
\6\ Teplin, L.A., Abram, K.M., McClelland, G.M., Dulcan, M.K., &
Mericle, A.A. (2002). Psychiatric disorders in youth in juvenile
detention. Archives of General Psychiatry, 59(12) , 1133-1143.
\7\ Duclos, C.W., Beals, J., Novins, D.K., Martin, C., Jewett,
C.S., & Manson, S.M. (1998). Prevalence of common psychiatric disorders
among American Indian adolescent detainees. Journal of the American
Academy of Child and Adolescent Psychiatry, 37(8), 866-873.
\8\ Svensson, I., Lundberg, I., & Jacobson, C. (2001). The
prevalence of reading and spelling difficulties among inmates of
institutions for compulsory care of juvenile delinquents. Dyslexia,
7(2) , 62-76.
\9\ Hoffmann, N.G. (2003). Distinguishing ``Dependence'' from
``Abuse.'' Addiction Professional, 1(2) , 19-21.
\10\ Greenwood, P.W. (1996). Responding to juvenile crime: Lessons
learned. Future Child, 6(3), 75-85.
\11\ Kumpfer, K.L., Alexander, J.F., McDonald, L., & Olds, D.L.
(1998). Family-focused substance abuse prevention: What has been
learned from other fields. In Drug Abuse Prevention Through Family
Intervention (NIDA Research Monograph 177, pp. 78-102). Washington, DC:
NIDA.
Senator DeWine. Thank you very much.
Mr. Shipley?
Mr. Shipley. Thank you. Chairman DeWine, Senator Reed,
distinguished Members of the Substance Abuse and Mental Health
Services Subcommittee, thank you for holding this hearing.
There is no greater issue impacting families in America
today than teenage drug use and abuse. I am here today before
you as a client of the Second Genesis Residential Treatment
Program. My name is Kris Shipley. I am 28 years old and began
my use of alcohol and drugs at the age of 11. I appear before
you proud today that I have been clean for 4 years; am
gainfully employed as an administrative assistant, but every
day is a challenge.
I have a 7-year-old son, and I pray every night that I can
give him the necessary tools and mentoring to stay drug free
and not follow in the footsteps of myself or those of his
grandfather. My recovery is part of my child's prevention.
I began my substance abuse drinking beer and moved to hard
liquor when I was 12. My substance abuse escalated when I got
my driver's license and could spend time roaming the streets. I
graduated to harder drugs, including marijuana, cocaine,
ecstasy and PCP. I unfortunately fell between the cracks and
weaved in and out of the juvenile criminal justice system,
bouncing between my parents' home and living on my own.
My parents were divorced, middle-class and skilled
employees. My father loved to party, which included drug use.
Often, when I stayed at his house, he would return from a night
of partying and wake me up to join him and his friends in the
living room to continue the party. His house became a haven for
my friends and me to use and abuse drugs. My only goal was to
party with him, with my friends, and to get high with whatever
was available.
My mother enabled my use and was helpless to intervene with
my behaviors. When I started getting into trouble, she took me
to family therapy and one-on-one counseling sessions, but
nothing worked. At age 16, I quit school. I got to the point
where no one could intervene, because I was completely engulfed
in this lifestyle. Nothing was more important than getting
high, hurting people and selling drugs. I got comfortable with
my negative behaviors. It became a way of life.
As an adult, I weaved through the court system many times
until I got caught and sentenced to a 20-year sentence in
prison. The treatment program that I am in is a residential
program that predominantly serves individuals who are in the
criminal justice system. I came to Second Genesis from prison.
After serving 3 years of my sentence, I was sent to Second
Genesis in the fourth year of my sentence. Sixteen years of my
sentence will be suspended when I successfully complete
treatment.
I have been very motivated to change after realizing what
my losses have been and could be. I have since found out that
Second Genesis also runs an adolescent program, but I was not
lucky enough as a youth to have been mandated to that level of
treatment and care during those years.
I am committed to helping at risk adolescents because I
know what they are going through. As part of Second Genesis'
education and community prevention outreach program, residents
are asked to speak to kids in local schools. Because of our
history from living in the lifestyle and progressing through
treatment, we can easily identify those kids that are
potentially at risk. These are the same kids that an untrained
eye will not identify until it is too late. We try hard to
reach these kids and deter the larger group.
The more I give these high school testimonies, the more I
realize it cannot just be a one-time effort, but efforts must
be available to students constantly and continuously. Youth
feel invincible and think that what has happened to me could
never happen to them. I tell them differently. To this day, the
damage to my body and mind is irreversible, and the most
evident damage is my short-term memory loss due to my excessive
use of ecstasy.
But I am still lucky that I am living to tell my story. I
did not die from my substance abuse habit. I could have
overdosed, committed suicide, been in an accident while
driving, or even worse, killed an innocent bystander.
I know most people wonder what could my school, family or I
have done differently to intervene and stop my downward cycle.
That is a difficult question. My best advice to you is to
please keep funding substance abuse treatment and educational
programs. Drug education for America's youth should start at a
young age. Intervention should come early in an adolescent's
life, whether through prevention or mandated treatment.
It is also important that education, prevention and
treatment services are provided both to adolescents and their
parents. I know everything in policy is based on statistics, so
you should be aware that the University of Maryland conducted a
study on the Second Genesis program and found that 79 percent
of clients that completed residential treatment while
continuing care remained drug free. Fewer than 10 percent were
arrested after 6 months.
We all must share the success of treatment and let
communities and individuals know that treatment works. Other
prevention programs can help youth from starting or sustaining
a lifestyle of drug use, programs including outreach and
education in the schools, community-based programs, peer
counseling, tutoring and mentoring programs.
We must focus on an adolescent's strengths to facilitate
healing. We come into treatment at all levels of ability to be
open to treatment. Adolescents need more than one-on-one and
family counseling. For treatment to work, you need to improve
major life domains for clients while they are in treatment.
Treatment supports and helps clients achieve permanent
sobriety.
The goal is to support adolescents to develop necessary
skills and confidence to be drug free. Kids need structure and
support to develop their personal growth necessary to stay drug
free and for lasting recovery. The therapeutic community
treatment model is created to provide treatment services that
adapt to the individual's needs. These services include
assessment and treatment planning, therapeutic drug testing,
health education and intervention, family education and
counseling, parenting skills and family support groups,
individual and group counseling for adolescents, vocational
counseling, recreational programs, anger management, social
skills building, educational programs and services, relapse
prevention, transitional services and continuing care and
followup.
The components of an adolescent program must address the
developmental issues of an adolescent and be holistic in
approach. I thank you for your interest and commitment. Your
job is not an easy one; your leadership is desperately needed.
Never give up on trying to keep America's youth free from
substance abuse through prevention and treatment. I am a living
testament that your leadership has helped me to remain in
recovery, and hopefully, we can empower youth like my son and
generations to come not to start a life of drug abuse.
[The prepared statement of Mr. Shipley follows:]
Prepared Statement of Kris Shipley
Introduction
Chairman DeWine and distinguished Members of the Substance Abuse
and Mental Health Services Subcommittee, Senate Committee on Health,
Education, Labor and Pensions, thank you for holding the hearing
``Providing Substance Abuse Prevention and Treatment Services to
Adolescents.'' I am here today before you as a client of the Second
Genesis Residential Treatment Program. My name is Kris Shipley. I am a
28-year old parent and began using alcohol and drugs at age 11.
Second Genesis is a nonprofit drug and alcohol rehabilitation
program with residential and outpatient centers in Maryland, Virginia,
and Washington, DC. Second Genesis is a member of Therapeutic
Communities of America, a nonprofit membership association that
represents over 500 therapeutic community programs throughout the
United States. TCA members are predominately funded through public
funds.
Second Genesis, is a therapeutic community, designed to help
individuals empower themselves and to lead healthy, responsible drug
free lives. Treatment is holistic in nature and incorporates not only
treatment for individuals' addictions but also understands the
importance of habilitation. It includes vocational services,
educational services, social skill building, relapse prevention, family
services, transitional living services and continuing care to help
transition an individual back into their community.
I have been drug free for 4 years and I am now gainfully employed
as an administrative assistant but every day is challenging. I will
forever live with the possibility that I will use again. My 7-year-old
son lives with me. I appreciate the committee's commitment to helping
future generations of Americans not to abuse drugs and alcohol. I pray
every night that I can give my son the necessary tools and mentoring to
stay drug free and not follow in my footsteps. With my sobriety, I hope
that my son has a better chance than I was given, and I hope to see a
day when all adolescents have access to substance abuse prevention and
treatment services. One of the most difficult problems facing American
families today is teen drug use. The most important action you can take
is to help parents know where to turn when their kids are at risk of
using by making prevention and treatment services readily available.
Journey to Recovery
I am going through a residential treatment program that
predominately serves individuals who are in the criminal justice
system. I came to Second Genesis from prison. I had served 3 years of
my jail term and was sent to this community residential substance abuse
treatment for the 4th year of my 20-year sentence. As a condition of
successfully completing treatment, the remaining 16 years, will be
suspended. For the first time, I was motivated for treatment when I
entered the program.
I began using drugs when I was 11 years old. My parents are
divorced, middle class skilled employees. I started my substance abuse
drinking beer and progressed to harder drugs including marijuana,
cocaine, ecstasy, and PCP. Due to my drug use I have significant short-
term memory loss that has been directly related to my extensive use of
ecstasy.
But I am still here to tell my story. A significant number of
adolescent drug abusers loose their lives to overdose, suicide or motor
vehicle fatalities, to name a few.
Second Genesis also runs an adolescent program, but I was not lucky
enough in my youth to have been mandated to that level of care. My drug
abuse has cost me, my family and society immeasurable amounts of
heartache and money. I unfortunately fell between the cracks and weaved
in and out of the criminal justice system bouncing between my parent's
homes, and quitting school at the age of 16. I had one parent who liked
to party and another parent that enabled my use and seemed unable to
intervene with my behaviors.
I started drinking hard liquor when I was 12, but my substance
abuse escalated when I got my driver's license and I could spend time
``roaming''. My goal was to party with my friends. I used to take my
friends to my dad's house, which allowed us an environment to abuse
drugs. My dad also liked to party, that included drug use. Often times
when I stayed over at my dad's place, he would get home from partying
with his friends and wake me to join them in the living room to
continue the party.
My mother took me to family and individual counseling when I
started getting in trouble with the law but no one directly intervened
with my drug use. In the 10th grade, my mother sent me to a private
school because I was having fights in public school. I dropped out of
that school after one quarter. I got to a point where no one could
intervene because I was completely engulfed in this lifestyle. Nothing
was more important than getting high, hurting someone, and selling
drugs. Nothing was more important than my drugs and my life style. As
an adolescent you violate your values in stages and you get more and
more comfortable with negative behaviors. My mother would buy me cars
and tell me that I had to pay for them, but I would wreck them when I
was high and she would replace the car without any consequence. I went
through 11 cars from 16--21 years of age.
I went through the juvenile court system 5 times for such offenses
as assault and served time on 3 of those occasions but I was never
mandated to treatment. At 17 I was arrested running in the streets in
my boxer shorts with a meat cleaver in my hand, high out of my mind on
PCP, ready to assault anyone. I thank the police officers that subdued
me for sparing my life and not shooting me. I lived independently in my
own apartment and had lots of money from drug sales. I had several
arrests after that until at 24, I was sent to prison and then sent to
long-term residential care for the 4th year of my jail sentence.
Giving Back
As part of a Second Genesis prevention outreach program, I and
other residents go to local high schools and speak with students in
their classrooms about drug use and abuse. We help them identify
options for help and try to deter other kids from even beginning to use
drugs.
Months after visiting a local high school we returned to speak once
again, we were amazed at the number of kids from the previous session
that asked to participate in the second session. The more I give these
testimonies, the more I realize it cannot just be a one time effort but
our efforts must be available to students on a continuous basis. Drug
use is a disease of denial and stigma and we must give adolescents an
avenue to make informed decisions so they do not use or abuse drugs.
Kids feel invincible and believe that what has happened to me could
never happen to them. I tell them differently. Peer counseling and
mentoring must be important services of any prevention program.
When we speak to kids in school, we can easily spot those kids that
are already at risk. Because of our histories we can identify them
through body language and other identifying markers that a ``blind
eye'' cannot. These are the same students who are at risk of falling
between the cracks and being identified too late. Within our schools
and the community, there should be avenues available to every at risk
child, and options to reach out to that child's positive behaviors to
steer them away from drugs. Adolescent drug use is inevitably a
downward cycle. There is no such thing as a safe drug. A parent
allowing a child to drink instead of using illegal drugs is signing
that child a blank check to abuse.
I know you are wondering what my school, my family or I could have
done to stop my future cycle of drug abuse when I was 11 years old.
This is a difficult question. I watched some kids in my school
experiment with drugs and never become addicted, yet many of us who
used drugs seemed to cross over that invisible line to enormous
consequences. It is difficult for adolescents to comprehend that they
may have to face the ultimate consequence ``death''.
Observations and Recommendations
My best advice to you is do not give up on prevention and treatment
services for adolescents. Please keep funding treatment and prevention
programs. If you save just one life from drug use, you have taken
responsible actions for both the adolescent and society.
It is important that prevention and treatment services are provided
to both the adolescent and their parents. I am scared that my son will
not listen to me. He may already be damaged from the first 7 years of
his life. He and I together need services so I can continue my recovery
and he can make healthy choices, and not follow the role model that he
knew in his formative years. Kids from homes where there is drug use
are at a high risk of using. Public funds need to be spent on both
adult and adolescent treatment and prevention services. My treatment is
part of my child's prevention.
Drug education to America's youth must be continuous and constant
and it should start with children at a very young age. High school is
too late. It is important to ask questions and listen to what they are
saying. Once an adolescent crosses that line to the drug life style
they become hardened and only severe intervention might get their
attention. Intervention should come early in an adolescent's life,
whether through prevention or mandated treatment.
Treatment works and society knows that it works but the stigma
against substance abuse is more powerful than common sense. A
University of Maryland study found that 79 percent of clients who
completed Second Genesis programs with continuing care remained drug
free. In addition, fewer than 10 percent were arrested after 6 months.
As Americans we must stop being cynical about treatment's success and
let our communities and individuals know that treatment works.
Prevention services are also important and might include talks like
the ones I conduct in local high schools. It is important to reach out
and educate youth about their options with the hope that the
information helps them make healthy decisions. Outreach and education
in the schools and community based programs, peer counseling, tutor and
mentoring programs can all help to prevent a youth from starting or
sustaining a lifestyle of drug use.
Adolescents must be placed in the most appropriate care for the
severity of their illness and their treatment should be client based.
When treating the adolescent, you need more than simply one-to-one and
family counseling. You need to provide the appropriate level of
treatment for each client. You must improve major life domains for
clients while they are in treatment, help the client develop healthy
lifestyles, and help the client achieve permanent sobriety.
We must focus on an adolescent's strengths to facilitate healing.
Whether it is through a structured after-school program specifically
designed to for outreach to high-risk children or a residential
adolescent treatment program, the goal is to support adolescents to
develop necessary skills and confidence to be drug free. Kids need
structure and support to develop the personal growth necessary for
recovery.
The model of therapeutic community treatment adapts to the special
needs of adolescents. Treatment services offered include: assessment
and treatment planning, therapeutic drug testing, health education and
intervention, family education and counseling, parenting skills and
family support groups, individual and group counseling for the
adolescent, vocational counseling, recreational programs, anger
management, social skills building, educational programs, relapse
prevention, transitional services, continuing care and follow-up. The
components of an adolescent program must address the developmental
issues of an adolescent and be holistic in approach.
I thank you for your interest and commitment. Your job is not easy
as you use your leadership to empower Americans to make choices, which
enable them to be alcohol and drug free and to lead responsible healthy
productive lives. With your help, as an individual, I can remain in
recovery and empower my son not to start a life of drug use. You can
help by never giving up on trying to sustain an America that is free
from substance abuse by recognizing the importance of treatment and
prevention services. If you would like specifics on adolescent programs
across the United States, Therapeutic Communities of America and/or
Second Genesis, would be glad to supply you with that information.
Senator DeWine. Mr. Shipley, what was the--first of all,
let me thank you very much for your testimony and for being
here today. We appreciate it very, very much. What, if there
was one turning point for you, what was the turning point?
Mr. Shipley. For me?
Senator DeWine. For you. Yes, was it when you went to
prison or jail? Or what was the turning point for you?
Mr. Shipley. For me it was prison.
Senator DeWine. OK.
Mr. Shipley. That is what it took for me.
Senator DeWine. And then, that was pretty much it, and
then, what happened then? Did you get the treatment in prison,
or was the condition that if you got treatment, they would
suspend the rest of it? Is that----
Mr. Shipley [continuing]. For me, prison was--I lost
everything in prison. There were no phone calls; there were no
family visits; there were no--there was nothing. That is when I
actually sat by myself without any drugs, without any alcohol,
without any anything; had to deal with all of the emotions and
thoughts and everything that came along with life and realized
that there was not any treatment available other than just a
12-step program.
At that point, I was not open for that. It actually took
for me to sit and be without everything to realize that this
was not the way I wanted to live my life.
Senator DeWine. Ms. Ramsey-Molina, you have put together a
very good program in Cincinnati. It has gotten a lot of
attention. I have followed it, and we are very proud of what
you all have been able to do. For other communities that would
like to replicate that, what advice would you give to them?
Ms. Ramsey-Molina. Convene the stakeholders. In the process
of convening the stakeholders, really ensuring that you have
broad representation of the community; some of those folks even
that we consider to be strangers to prevention or strangers to
the field, make sure that they are at the table. A skilled
convener, influential leader is very important. And then, my
other piece of advice would be make sure that the work of the
coalition is data-driven.
So many times, we do things in communities, schools,
neighborhoods because it looks good, feels good, those sorts of
things, but does not really meet the needs of the community.
When a community member, regardless of who they are, comes to a
table, knows what they are doing is data-based and can be
measured, the success can be measured over time, they are far
more motivated to stay involved.
So convene the stakeholders carefully and comprehensively
for the community and make sure that your efforts are data-
driven.
Senator DeWine. OK; good.
Senator Reed?
Senator Reed. Thank you very much, Mr. Chairman, and I
thank Mr. Shipley for a very compelling and candid response to
Senator DeWine's question; that was my question also.
Mr. Anton, congratulations to you and to Maine, because you
have a higher record of success compared to the rest of the
Nation, and you have also created a statewide program. Let me
ask some questions, some of which are the ones I addressed to
Mr. Curie. First on, the issue of vouchers, to what extent do
vouchers result in decreased funding for other substance abuse
programs?
Mr. Anton. In the current system, after the CSAT Treatment
Capacity Expansion Grant ended, the State found that the
program was so successful that they fully supported its
continuation and expanded it beyond its initial scope.
Initially, we did business with a juvenile correction substance
abuse treatment network that identified adolescents in the
juvenile justice system that needed services. We have since
been able to expand that to schools and communities across the
State, so that we are trying to access places where kids are
and where this resource can be made available.
We have not fully developed that piece yet because it is
only 2 years old, but we are really looking to move in that
direction. So the State is supportive, and they fund us through
a variety of the mechanisms they have available.
Senator Reed. Let me return to the question I posed to Mr.
Curie: who is actually making the choices of provider, the
vendor, the client or the social worker?
Mr. Anton. Generally, it's a collaboration between the
client, the adolescent, their family member and the people
helping them with the screening process. Obviously, the
adolescent and the family do not necessarily know everything
there is to know about all of the treatment providers, so we
provide them information about who is available in their
geographical area, what their specialties are.
We allow them to make the choice, however. The treatment
providers do not make that choice. They provide information;
they provide resources, but the choice is really up to the
adolescent and their family. Our family program helps to
facilitate that. We make family contact through our network
with over 80 percent of the families of the adolescents who
take the screening instrument.
Senator Reed. And a final question, Mr. Anton. You pointed
out in your testimony that all of these providers are certified
by the State of Maine.
Mr. Anton. Yes, they are.
Senator Reed. And they meet high standards and----
Mr. Anton. They meet all of the licensing requirements that
the State has in place.
Senator Reed [continuing]. Very good. Thank you. Ms.
Ramsey-Molina, thank you, and congratulations on your success
in Cincinnati. It speaks well of your, our efforts, and Mr.
Portman's efforts in getting this program off the ground.
This is sort of a mundane question, but how are you funded?
I mean, that is usually the major issue for any coalition of
community activists.
Ms. Ramsey-Molina. We are funded--we are actually gifted
within Greater Cincinnati; about 50 percent of our budget is
local dollars; local foundations, corporate donations and
individual donations. The other 50 percent comes from local,
State and Federal dollars.
Senator Reed. And the governance of the coalition, do you
have a board of citizens that represents all of the
stakeholders?
Ms. Ramsey-Molina. Yes, we do. We have a Board of
Directors, it is actually a 40-member board of directors that
oversees the activities of the coalition. It was actively
headed by Congressman Ron Portman since its inception in 1996.
In July of last year, he stepped down as active chair; still
comes to all the meetings; cannot quite take himself away. But
we have a new chairman who is senior market researcher with
Procter and Gamble. The membership of the board includes the
faith community, the business community, the schools, parents,
youth, media, a broad representation.
Senator Reed. And this is a question I think Senator DeWine
posed, so I will pose it slightly differently. What other
cities or communities in Ohio or elsewhere have replicated your
approach?
Ms. Ramsey-Molina. Well, one of our goals within--we have a
10-county service region. It is 10 counties in Ohio, Indiana
and Kentucky. And we work with individual neighborhoods and
communities to replicate what we do on the regional level
within their local neighborhood, and we have been able to build
31 neighborhood community-based anti-drug coalitions. They have
replicated the process, the same kind of planning and convening
process, and we see greater reduction in those neighborhoods
than we do in similar comparison neighborhoods where coalitions
do not exist.
Senator Reed. Are these neighborhoods in Cincinnati,
statewide or regional?
Ms. Ramsey-Molina. We work with these 31 within our region,
within our 10 counties.
Senator Reed. Thank you.
Dr. Weissberg, Senator Kennedy asked me to pose two
questions of you. In your testimony, you point out that many
schools do not use programs of proven effectiveness. Which
programs are you referring to, and why are they still being
used if they are not effective?
Mr. Weissberg. Well, there would be a variety of home grown
programs that do not have effectiveness. I think over time,
DARE has become less-used now in schools because of some of the
work there, but more importantly, there are well-intentioned
efforts going on that do not make use of well-evaluated
programs that have demonstrated impact.
Senator Reed. You suggest by your answer and also by your
statement of the need for accountability systems that will
evaluate these programs. We also broached that subject with Mr.
Curie in terms of his performance parameters. Can you speak for
a moment about the accountability systems and what has to be
done in this area?
Mr. Weissberg. There are two types of accountability
systems right now that we are bringing together researchers and
educators and policy makers to develop. One has to do with
practice assessment: are you implementing high-quality
programming? And are you structured in ways to support the
programming through staff development of teachers, through
effective outreach and things like that? The other
accountability system would be on student outcomes, and there,
there can be a variety of things ranging from health behaviors
to connection of kids to schools. There may be behavior ratings
that teachers or parents also can be providing with the system.
Senator Reed. Thank you, Dr. Weissberg.
Dr. Brown, again, thank you for your testimony. With regard
to research, one of its uses is to help form a strategy. So,
based on your research and your colleagues' research, what
should be the strategy to deal with this problem? Is the
Federal Government employing the right strategy? I realize this
is a pretty broad question, but your comments would be
appreciated.
Ms. Brown. You saved the biggest question for me. Actually,
I have been really impressed with Committee Members and the
speakers who have been here who have represented a diversity of
approaches, which is what really needs to happen for prevention
and for intervention.
I think everyone here has advocated that alcohol and drug
problems for youth are a developmental problem, and so, because
of that, we need to have a diversity of approaches. What might
work in one community might not work in another community, but
there needs to be a diversity of options.
Consistent with the Institute of Medicine's perspective on
early prevention, universal, targeted and indicated prevention
efforts, it is really critical that youth have a choice in the
types of prevention or intervention opportunities that they
engage in and that there be sufficient diversity across
settings; that we will not have situations where individuals,
where it is clear that there is a problem, but we will have
missed them in one system; we could pick them up in another.
And so, I guess I am saying to you yes, it is really
critical that small organizations, families, businesses,
communities are involved. It is critical that there is
involvement at the State level, and of course, the Federal
involvement is essential. This would not be possible without
that.
Senator Reed. May I pose one more question Mr. Chairman?
Senator DeWine. Oh, yes.
Senator Reed. This question is open to the entire panel.
What I have taken from our disscusion this morning is that we
are discovering--that substance abuse is in many ways a
developmental problem. Its onset is very early; that usually,
young people sort of stumble into the system of help and care
when they have an obvious problem.
Which begs the question, of whether or not there should be
some screening of children for these predispositions, if it is
urgent to treat youngsters very young. Is that something that
is being considered at all?
Mr. Anton, you are the----
Mr. Anton [continuing]. We have an ability through our
process to look at children as young as 12.
Senator DeWine. But they present themselves to the system.
Mr. Anton. Well, they do in some fashion. Now, to the
system could be through the schools; through guidance; through
day care; through, I mean, you know, through wherever they
happen to be within family situations or in public situations
where they present with problems or issues. So yes, that has to
happen first.
Unless we see something publicly that leads us to believe
there is something going on--there is no--at least in our
State, there is no universal screening right now that looks at
every child at a very young age to see if they are predisposed.
I am not sure if we have all the tools to do that.
Senator Reed. I think that is a fair response.
Ms. Brown. I would like to also make a----
Senator DeWine. Dr. Brown?
Ms. Brown [continuing].----comment about that.
I think that there are some natural venues in which
screening can unfold; for example, in primary care medicine.
Pediatricians are taught to look for these kinds of problems in
late adolescence, but they are not necessarily focusing on this
sort of thing in the age range where the youth of greatest risk
would obviously present themselves.
If kids are starting to use at 11, we need to be sure that
pediatricians are asking these questions long before that, so
it becomes routine. So there are some natural settings.
Senator Reed. That is a good point, Dr. Brown.
Dr. Brown. Yes.
Senator Reed. Dr. Weissberg?
Mr. Weissberg. I think the key argument that all of us
would make is that if you want to have adolescent prevention of
substance abuse, you have to begin much earlier. And there is
screening that I think can go on that you can identify very
early on who is at risk for substance abuse, but you would not
necessarily target it to a narrow substance abuse screening
instrument, that maybe children who are overly aggressive, who
are overly active in school, who have poor peer relations, who
are poorly motivated to achieve.
So there are a number of markers that I think you can use
to identify children who may be at risk and in a general way,
also, the strategy of promoting positive behavior and
connection in kids early on from the start is something that
should be happening to prevent substance abuse later on.
Senator Reed. Thank you.
Ms. Ramsey-Molina, if you have a comment.
Ms. Ramsey-Molina. To echo some of the kind of naturally-
occurring opportunities that happen in communities, with the
Coalition, one of our emphases and efforts is to increase
awareness of folks in multiple systems so that if there is a
young person who presents some of the problem behaviors, there
is an obvious avenue for intervention, whether it is through
the faith-based community, through schools, you know, through
parents. We say all the time through our Coalition to monitor
closely, catch it early and make a big deal out of it if it
happens. Pay attention to the behavior.
So many times, we have school personnel, we have faith
leaders who--they do not do this every day, so it is not
natural for them to pay attention and to refer it to a source
who could do the official assessment or official intervention.
So part of what we do is empowering all members of the
community to understand this is an issue we must all take part
in.
Senator Reed. Thank you.
Anyone else?
Mr. Anton. I think to build on what Dr. Weissberg said, I
think our experience has taught us, especially early on with
our work with the corrections system, the juvenile corrections
system, that there are key risk and protective factors that can
identify criminogenic behavior as well as substance abuse and
mental health-related issues. Dr. Weissberg mentioned many of
those, but I think we can always be looking at that, and we can
be helping, through our systems, to be more collaborative
around how that happens, because I think there are still--there
is a lot of fragmentation, and I agree that, you know, primary
care physicians, family physicians are a place where that can
happen; however, very honestly, they do not always have the
training they need to do this kind of work.
Having been on the faculty at a medical school for a number
of years, I know how little they have as a focus on substance
abuse and mental health issues in their training.
Senator Reed. All right, thank you very much.
Thank you, Mr. Chairman.
Senator DeWine. Good questions.
I have a couple of questions from Senator Sessions that I
would like to ask the panel, and anyone who would like can
respond.
Senator Sessions asks is there comprehensive information
about how well drug treatment works; in other words, are the
current treatment plans working, and if not, what can be done?
Who would like to respond?
Dr. Brown, I will start with you.
Ms. Brown. Well, there are a number of agencies that are
developing collaborative networks to evaluate the effectiveness
of interventions for youth. And typically, what happens is that
these are done in a--as I would consider it a somewhat
disjointed fashion; that is, these are interventions for youth
that are in one type of system or another rather than
comprehensively across systems, distinctively for intervention
versus for prevention.
With that background, there are a number of interventions
for youth, some of which have been already articulated today,
that have remarkable outcomes, outcomes that we would consider
better outcomes than if we were treating major health
disorders, diabetes or multiple sclerosis.
So I think these things need to be thought of in this
broader context, that we have ways, and we have strategies to
reduce alcohol and drug problems. Part of the key is
dissemination; that is, empirically-validated interventions
need to be optimally implemented in communities, and there is
often a disjuncture there between what we know works and what
actually is carried out in communities.
Senator DeWine. Anyone else?
Yes, Mr. Anton?
Mr. Anton. I think prior to the last 4 or 5 years, there
has frankly been very little research on adolescent substance
abuse and mental health issues that has proven to have much
validity.
Senator DeWine. Really?
Mr. Anton. In my opinion.
Senator DeWine. Really?
Mr. Anton. In my opinion.
I think that we have seen an explosion almost of that
research in the last 5 years, newer research that has really
helped to identify model programs, evidence-based and science-
based research programs. SAMHSA and Mr. Curie's department
publishes a prevention model program manual that also includes
prevention and intervention types of programming. Treatment
programming is more and more being able to identify specific
models of treatment that work effectively for different
populations.
But that is all very recent, in the last 4 or 5 years. I
mean, I think we are not--you know, especially on the
adolescent side, I mean, I really believe that from a--you
know, going back to the science to service piece that Mr. Curie
spoke about, that is also very recent, you know, looking at
connecting what happens in science to the everyday real world
of what clinicians and programs have to work with on a day-to-
day basis in the communities they live and work in.
And I think there has been tremendous progress in the last
recent years to help that happen, and so, I fully support the
continuation of that and hope the committee would, too.
Ms. Brown. Senator DeWine, I would like to just highlight--
--
Senator DeWine. Sure, Doctor.
Ms. Brown [continuing].----NIAAA, National Institute of
Alcohol Abuse and Alcoholism approximately 6 or 7 years ago
instituted a program to facilitate the development of
interventions for adolescents with alcohol and drug problems.
NIDA has a program that is a clinical trials network that
focuses on adolescents as well. And so, there is research that
is going on. It lags substantially behind the decades of
research that we have on effective interventions for adults.
And so, it is really critical that we have sufficient
funding for implementation in communities of interventions that
we know are effective and for research in this area to promote
the most optimally, to design and develop and refine
interventions that are most optimal for youth.
Senator DeWine. Well, let me thank you all very much. It
has been a very good panel, very good session, and I think we
have learned a lot, and we appreciate all of you coming in.
Thank you very much.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement Of The Alliance For Consumer Education
The Alliance for Consumer Education (ACE) is a Washington, D.C.-
based 501(c)(3) nonprofit foundation dedicated to advancing community
health and well-being. It is comprised of a volunteer Board of Trustees
who represent a unique blend of safety advocates, consumer groups,
nonprofit organizations, public health officials and household product
manufacturers.
Inhalant Abuse Education is the flagship initiative of ACE. In
partnership with the American School Counselor Association, the
Inhalant Abuse Prevention Program recently completed a six-State pilot
education program. Elementary and middle school counselors provided
Inhalant Abuse education seminars to parents, community leaders and
other adult influencers. This year, a total of 25 States across the
Nation will receive Inhalant Abuse Prevention kits to help empower
parents to discuss the dangers of Inhalants with their children. The
goal of the foundation's program is to increase awareness of Inhalant
Abuse from 47 percent to 80 percent by 2007.
With recent data (June, 2004) from the Partnership for a Drug-Free
America, we know that abuse of Inhalants has increased as much as 44
percent over a 2-year period, driven by fewer children seeing any risk
in this dangerous behavior. New analysis reports that over the past 2
years Inhalant Abuse has increased by 18 percent (from 22 to 26
percent) among 8th graders and by 44 percent (from 18 to 26 percent)
among 6th graders.
Honorary Chairman of the Alliance for Consumer Education, US
Senator Mike DeWine (R-OH), states, ``There's a strong lesson learned
from this recent data and that's the need to remain vigilant in
addressing the threat of Inhalant Abuse among our children. Better
tracking to document incidence and better outreach to educate parents
about risks and symptoms are imperative, since the real impetus for
prevention begins at home.''
What is Inhalant Abuse?
Inhalant Abuse is the deliberate inhalation by ``sniffing'' or
``huffing'' of fumes, vapors or gases from common products for the
purpose of ``getting high.'' To achieve this ``high,'' more than 1,400
household products are misused--products that are found under the
sinks, in the cabinets, in the garage, and throughout the house. These
household products are chosen because they are inexpensive, easily
accessible and legal to purchase.
Inhalant Abuse is a less-recognized form of substance abuse than
use of marijuana, club drugs, cocaine and others, but it is no less
dangerous. Inhalant users can die the very first time, or any time,
they inhale a substance. The number of children that are involved in
this dangerous activity is surprisingly large. Nearly 26 percent of all
eighth graders in the U.S. have experimented with some form of
Inhalant--that's more than 2.6 million children. In addition, the age
of initiation to Inhalants is younger than that for any other
substance, with reported cases of Inhalant users as young as 6 years
old.
Reporting, however, involves some significant challenges, and as a
result, the true magnitude of the problem can only be estimated at this
time. Parents are often completely unaware of Inhalant Abuse, or they
refuse to believe or admit that their child might be involved in this
activity--``Not my child!'' Emergency rooms and doctor's offices have
no standard review criteria, or intake protocol, that helps determine
if the problems of a young patient arise from Inhalant Abuse. This lack
of knowledge, open recognition, and documentation of the disastrous
results of Inhalant Abuse enables the problem to continue unchecked
among our youth today.
Status
Who Uses Inhalants?
The 2002 Youth Risk Behavior Surveillance System Survey showed that
race or ethnicity is not an indicative factor of Inhalant Abuse.
``White'' is listed as the predominate group abusing Inhalants (16.3
percent), but is closely followed by ``Hispanic'' at 15.2 percent.
``Others'' are listed at 14.5 percent, and ``African Americans'' at 5.8
percent.
As for gender differences, boys tend to have slightly higher use
rates than girls (in grades 4 through 6 and 10 through 12). Between
grades 7 through 9, however, girls and boys tend to use Inhalants at
relatively the same rate. After 18 years of age, males are more than
twice as likely as females to use Inhalants.
The survey also showed that between 2000 and 2001, the number of
people age 12 and older having used Inhalants at least once in their
lifetime rose by roughly 1.5 million, to nearly 23 million users. This
means that there are more Inhalant users than users of Ecstasy and
OxyContin combined, but sadly, nine out of ten parents are unaware or
are in denial that their children may have used Inhalants.
What Products Can Be Abused?
There are more than 1,400 products which are potentially dangerous
when inhaled--things like typewriter correction fluid, air conditioning
coolant, gasoline, felt tip markers, spray paint, air freshener,
butane, cooking spray, paint, and glue--all common products that can be
found in the home, garage, office, school, or as close as a
neighborhood convenience store. A complete list can be found and
downloaded from the ACE website that specifically addresses this
problem--www.inhalant.org.
Listed below are some of the most common products that are used as
Inhalants:
------------------------------------------------------------------------
Gases Solvents and Gases Aerosols
------------------------------------------------------------------------
Nitrous oxide................... Nail polish Spray paint
remover.
Butane.......................... Paint thinner..... Hairspray
Propane......................... Paint remover..... Air freshener
Helium.......................... Correction fluid.. Deodorant
Ether........................... Toxic magic Fabric protectors
markers.
Chloroform...................... Pure toluene...... Computer cleaning
spray
Halothane....................... Cigar lighter
fluid.
Gasoline..........
Carburetor cleaner
Octane booster....
Fuel gas..........
Air conditioning
coolant (Freon).
Lighters..........
Fire extinguishers
------------------------------------------------------------------------
------------------------------------------------------------------------
Cleaning Agents Food Products Adhesives
------------------------------------------------------------------------
Dry cleaning fluid.............. Vegetable cooking Model airplane
spray. glue
Spot removers................... Whipped cream..... Rubber cement
Degreaser....................... Whippets.......... PVC cement
------------------------------------------------------------------------
* Please note that this is not an all-inclusive list.
How Are Inhalants Used?
Inhalants are breathed in through the mouth or nose using various
methods:
``Sniffing'' or ``Snorting''--Inhalants can be ``sniffed''
from a container or sprayed directly into the nose or mouth.
``Huffing''--A chemically soaked rag is held to the face
or stuffed in the mouth and the substance is inhaled.
``Bagging''--Substances are sprayed or deposited into a
plastic or paper bag and the vapors are inhaled. Using a plastic bag
may result in suffocation if the individual passes out and his or her
nose and mouth are covered.
Inhalants are placed on sleeves, collars, or other items
of clothing and are sniffed over a period of time. This is a
particularly popular method of disguising inhalation of gasoline fumes.
Fumes are discharged into soda cans and inhaled from the
can.
Users inhale from balloons filled with nitrous oxide and
helium.
To maximize the effect of the Inhalant, the substance is inhaled
deeply and then several more short breaths are taken.
Why are Inhalants Dangerous?
When an individual, child or adult, inhales the chemicals in common
products as described above, the concentration of the fumes are much
greater than the maximum amount that is permitted by safety standards
in industrial settings. Inhaled chemicals are rapidly absorbed through
the lungs into the bloodstream and quickly distributed to the brain and
other organs. Within minutes, the user experiences intoxication, with
symptoms similar to those produced by drinking alcohol. With Inhalants,
however, intoxication lasts only a few minutes, so some users seek to
prolong the high by continuing to inhale repeatedly.
Short-term effects include: headache, muscle weakness, abdominal
pain, severe mood swings and violent behavior, belligerence, slurred
speech, numbness and tingling of the hands and feet, nausea, hearing
loss, visual disturbances, limb spasms, fatigue, lack of coordination,
apathy, impaired judgment, dizziness, lethargy, depressed reflexes,
stupor, and loss of consciousness.
The Inhalant user will initially feel slightly stimulated and after
successive inhalations will feel less inhibited and less in control.
Hallucinations may occur and the user can lose consciousness. Worse
still, he or she may even die. Please see Sudden Sniffing Death
Syndrome.
Long term Inhalant users generally suffer from: weight loss, muscle
weakness, disorientation, inattentiveness, lack of coordination,
irritability and depression.
Regular abuse of these substances can result in serious harm to
vital organs. Different Inhalants produce different harmful effects.
Serious but potentially reversible effects include liver and kidney
damage. Harmful irreversible effects include: hearing loss; limb
spasms; bone marrow and central nervous system (including brain)
damage.
Sudden Sniffing Death Syndrome
Children can die the first time, or any time, they try an Inhalant.
This is known as Sudden Sniffing Death Syndrome, and while it can occur
with many types of Inhalants, it is particularly associated with the
abuse of toluene, butane, propane, and the chemicals in aerosols.
Sudden Sniffing Death is due to cardiac arrest:
The Inhalant can force the user's heart to beat rapidly
and erratically until he/she goes into cardiac arrest.
Death due to Inhalant Abuse is attributed to the following:
Sudden Sniffing Death Syndrome: cardiac arrest.
Suffocation: blocking air from entering the lungs when
inhaling from a plastic bag over the head (huffing).
Choking: inhalation of one's own vomit after Inhalant use.
Fatal injury: accidents involving motor vehicle fatalities
suffered after Inhalant use, falls while under the influence, fires due
to the inflammatory nature of Inhalants, drowning accidents.
Signs and Symptoms
While several warning signs may point to occasional problems most
teens or pre-teens experience at some point, don't be fooled. Parents
and caregivers should know what specific signs may signal real trouble
for a child.
Common Inhalant Abuse warning signs include:
Drunk, dazed, or dizzy appearance.
Glassy, glazed, or watery eyes.
Behavioral mood changes.
Slurred or disoriented speech.
Lack of physical coordination.
Red or runny eyes and nose.
Spots and/or sores around the mouth.
Unusual breath odor or chemical odor on clothing.
Nausea and/or loss of appetite.
Chronic inhalant abusers may exhibit symptoms such as
hallucinations, anxiety, excitability, irritability, restlessness or
anger.
In addition, there are material signs of Inhalant Abuse that
parents should be aware of. The material signs are important to note
because some of the physical symptoms may not last a long time.
Material signs of Inhalant Abuse include:
Traces of paint or other products where they wouldn't
normally be, such as on face, lips, nose or fingers.
Fingernails painted with magic markers or correction
fluid.
Pens or markers held close by the nose.
Constant smelling of clothing sleeves.
Hair scrunchies smelled repeatedly.
Uncharacteristic problems in school.
Numerous butane lighters, empty or partially filled, in
room, backpack or locker.
Chemical odors on the breath or clothing.
Spots or sores around the nose or mouth.
Gasoline, paint-soaked rags, or used spray paint cans in a
child's room or other peculiar location. Hidden rags, clothes or empty
containers of potentially abused products in closets, under the bed, or
in the garage.
Missing household products.
Preventative Steps
Studies show that strong parental involvement in a child's life
makes a child less likely to use Inhalants. Partnership for a Drug-Free
America studies have found ``if you talk to your kids about the risks
of drugs, it is 36 percent less likely they will abuse an Inhalant.''
However, parents are not talking to children about the deadly issue of
Inhalant Abuse because many know very little about it and most do not
realize that their children can die the very first time they try an
Inhalant.
According to a research study by the Alliance for Consumer
Education, Inhalant Abuse falls behind alcohol, tobacco and marijuana
use by nearly 50 percent in terms of parental knowledge and concern.
Take a few minutes to educate yourself about Inhalant Abuse. Learn
the behavior patterns and warning signs to watch for so you can talk to
your children about this issue because parents can make a tremendous
impact on the choices their children make.
1. Educate yourself about this issue
Learn what products can be harmful if intentionally abused
as Inhalants.
Understand the long-term and short-term effects of
Inhalant use.
Learn what slang words are used to describe Inhalants.
Learn the methods of inhalation and their more common
names.
Visit the various websites.
Ask your pediatrician or family doctor about Inhalant
Abuse.
Talk with other parents about this issue.
2. Preventative measures you can take
Discuss Inhalant Abuse with your child.
Be aware of what your child is doing at all times,
especially after school and on weekends.
Know your child's plans and activities.
Meet your child's friends and playmates.
Reinforce age-appropriate peer resistance skills.
Talk with your child's teachers, guidance counselors and
coaches.
Keep products stored safely away from young children.
Talk to your child about the proper use of household
products.
Be clear and firm about risky behavior, set limits and
consequences.
Tell your child you love them and that their safety is
your number one priority.
In conclusion, the Alliance for Consumer Education (ACE) would like
to emphasize the need for increased education methods to stem the tide
of Inhalant Abuse across the Nation. The statistics prove there is a
``Silent Epidemic'' of increased Inhalant Abuse among our youth today.
We simply cannot turn away and permit new cohorts of children to enter
school and be faced with the temptations to experiment with this
dangerous activity. We believe that it is the responsibility of parents
and caretakers everywhere to become educated about Inhalants and to
talk with their children at age-appropriate times.
The Alliance for Consumer Education (ACE) stands ready to help with
the education process and we look forward to working together with the
subcommittee on this important issue. For more information, visit the
Alliance for Consumer Education at www.ConsumerEd.org or
www.Inhalant.org.
Prepared Statement of Mary Melton, PH.D. MBA
Mr. Chairman, thank you for the opportunity to submit written
testimony to your committee regarding adolescent prevention and
treatment issues. I also want to commend you for your leadership and
compassion regarding the issue of Addictive Disorders.
In Ohio, the challenge for Addiction Professionals is always to do
more with less. With adult clients, these forced economies make the
work difficult, but not always impossible. For adolescents, the lack of
resources is devastating. Ten years of my 31-year career in addictions
and mental health were spent as the administrator of an adolescent
treatment center that offered both residential and outpatient services.
Over those years many of the adolescents who received services visited
us to give us their thanks and to share their stories of success; these
nearly always included jobs, and schools and, most meaningful to me,
family reconciliations. They communicated clearly, that without the
intervention and treatment services that they received from us, their
lives would have taken a different path. They offered their gratitude
for our ability and willingness to somehow understand that they both
needed and could benefit from those services. Our faith in them gave
them belief in themselves.
Still in Ohio, addiction professionals have to rely on a patchwork
of Federal, State and local programs to meet the growing demand for
prevention, intervention and treatment services for adolescents with
alcohol, drug and other addictive disorders. It is unclear how many
adolescents are served through public and private efforts and which of
the available initiatives are best at meeting the needs of adolescents
and their families. It is difficult to determine whether Ohio families
know where intervention and treatment resources are located. In
addition, we do not know how many requests for services are denied due
to the lack of resources.What is known is that there are not enough
services or appropriately trained staff available to meet the needs and
that each untreated adolescent grows into an adult with serious issues.
There is a critical need for the Nation to devise and implement a
coordinated effort to meet these challenges. There is a need for more
adolescent prevention and treatment workforce training as well as a
specific coordinated effort to deal effectively with this challenge in
Ohio and other States across the Nation. One of the ways this could be
accomplished is through regional adolescent prevention and treatment
workforce development centers that would focus on such initiatives as
(1) the development of an Internet-based system to collect data on
adolescent alcohol and drug abuse treatment and prevention needs,
challenge areas, available local resources, and gaps in care; (2) the
development of additional education and training resources for the
addiction professional workforce targeting adolescents; (3) the
undertaking of a national assessment of randomly selected school-based
programs in the United States that offer alcohol and other drug
prevention initiatives geared toward adolescents; (4) a survey of
randomly selected school districts to review common practices following
the identification of use by a student. This assessment of services
within school systems would determine the backgrounds, experience,
training, certification, and continuing education needs of
professionals who are working with a school-based population.
Federal support for a national initiative is warranted when one
examines the national trends, statistics, and other factors that
indicate a growing need to support the addiction professionals through
better training, research, and data collection on adolescent related
issues. If we do not address the issues and needs of adolescent
prevention and treatment endeavors, we are ignoring the next generation
of those suffering from alcohol and other drug addiction issues and the
problems surrounding them.
The Problem on a National Level
The Centers for Disease Control and Prevention (CDC)
reported that more than two million youth in the U.S. have diagnosable
dependence on illegal drugs and alcohol. The CDC also found that
alcohol is associated with the three main causes of death for teens:
accidents including motor vehicles, suicide, and homicide.
The White House Office of National Drug Control Policy
reported that more than 20 percent of adolescents have been drunk
before the 8th grade.
According to the latest Substance Abuse for Mental Health
Services Administration (SAMHSA) Drug Abuse Warning Network report,
from 1999 to 2000, total drug-related emergency department visits
increased 20 percent for patients age 12 to 17 (from 52,783 to 63,448).
Adolescent alcohol and drug addictions do not manifest themselves
the same way as these issues in adults. The physical, mental and
emotional damage is lifelong and has a profound impact on their future.
Addiction Professionals need to receive training designed to address
those issues that are specific to adolescent intervention and treatment
efforts.
I submit this written testimony to you today filled with gratitude
and hope. Through the intervention and support of adults who cared, I
was able to go from being a high school drop out, living on the
streets, to being a professional person with four degrees and the
opportunity to help other young people avoid a similar fate. I
understand that it is never too late, that adolescents can change, that
we have to help them and that the smallest of gestures in their lives
can truly make the difference.
[Whereupon, at 11:42 a.m., the subcommittee adjourned.]