[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




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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

                              ----------                              


                         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
    American Psychiatric Association (1994). Diagnostic and Statistical 
Manual of Mental Disorders (4th ed.). Washington, DC: Author.
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Statistical Manual of Mental Disorders, Fourth Edition, Text 
Revision.Washington, DC: Author.
    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 
treatment outcomes for adolescents with comorbid mental and substance 
use disorders. Journal of Nervous and Mental Disease, 189, 384-392.
    Grilo, C.M., Becker, D.F., Walker, M.L., Levy, K.N., Edell, W.S., & 
McGlashan, T. H. (1995). Psychiatric comorbidity in adolescent 
inpatients with substance use disorder. Journal of the American Academy 
of Child and Adolescent Psychiatry, 34, 1085-1091.
    Hoffmann, N.G., Estroff, T.W., & Wallace, S.D. (2001). Co-occurring 
disorders among adolescent treatment populations. The Dual Network,2 
(1), 10-13.
    Hoffmann, N.G., DeHart, S.S., & Campbell, T.C. (2002). Dependence: 
Whether a disorder or a disease; it is not a ``concept.'' Journal of 
Chemical Dependency Treatment,8 (1), 45-56.
    Hoffmann, N.G. & Hoffmann, T.D. (2003). Construct validity for 
alcohol dependence as indicated by the SUDDS-IV. Journal of Substance 
Use and Misuse,38 (2), 293-305.
    Lehman, A.F., Myers, C.P., Corty, E., & Thompson, J.W. (1994). 
Prevalence and patterns of ``dual diagnosis'' among psychiatric 
inpatients. Comprehensive Psychiatry,35, 106-112.
    Myers, M.G., Stewart, D.G., & Brown, S.A. (1998). Progression from 
conduct disorder to antisocial personality disorder following treatment 
for adolescent substance abuse. American Journal of Psychiatry, 155, 
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 
Schedule for Children Version 2.3 (DISC-2.3): description, 
acceptability, prevalence rates, and performance in the MECA Study. 
Methods for the Epidemiology of Child and Adolescent Mental Disorders 
Study. Journal of the American Academy of Child and Adolescent 
Psychiatry, 35(7), 867-877.
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American Academy of Child and Adolescent Psychiatry,31, 1036-1040.




    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.]

                                    

      
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