Edelen M.O., Slaughter M.E., McCaffrey D.F. et al.
Drug and Alcohol Dependence: 2010, 107, p. 62–68.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Edelen at Maria_Edelen@rand.org. You could also try this alternative source.
The title speaks of long-term effects but in fact there were none from sending young US substance users to a youth therapeutic community specialising in substance use problems compared to non-specialist group homes; early gains had all eroded, an instance of the general difficulty of sustaining youth treatment outcomes.
Summary Few studies have reported on the long-term impacts of substance use treatment for adolescents, and those which have provide at best limited evidence that impacts persist. In particular, no such study has yet assessed long-term outcomes for drug-involved juvenile offenders receiving treatment outside custody, the majority of adolescent treatment admissions.
This US evaluation offers the first assessment of long-term effects nearly nine years after offenders had been referred by the juvenile justice system either to a drug-specialist residential therapeutic community for adolescents (the Phoenix Academy), or to other residential group living programmes of similar size and structure, but which did not offer specialised Though they did offer some less intensive services such as drug education classes and the availability of drug and alcohol self-help groups. substance use treatment.
Relative to the group homes, the community had previously been shown to result 12 months after referral in significantly better substance use and psychological functioning. This report sets out to establish whether these improvements persisted and even 'snowballed', or were eroded by time and other influences.
In 1999 and 2000, 449 young people aged 13–17 joined the study after being contacted at a juvenile court; all were legal wards of the court. Of these, 175 were initially admitted the specialist community where they stayed for on average just over five months, about the same time as other young people stayed after being sent instead to one of the six comparison group homes.
The featured report drew its data from the 412 youngsters who completed any of the long-term follow-up interviews about three, seven and eight and a half years after the baseline interviews; of these, nearly 90% had completed the final interview. Typically they were 15–16-year-old Hispanic/Latino boys who by the final follow-up would have averaged about 24 years of age. At study intake nearly 8 in 10 had met criteria for substance abuse and 55% for dependence. For about half their main substance was cannabis. Despite extensive substance use, 59% did not feel they needed treatment.
There were some appreciable differences between those sent and not sent to the Phoenix Academy, notably in motivation for treatment, extent of recent cannabis use, and substance use problems. An attempt was made to adjust outcomes for differences on these and other (totalling 88) dimensions as assessed before starting treatment. Then estimates were made of how well the young people would have done had they all been sent to Phoenix, or all to the other centres.
Variables tested included substance use, crime, imprisonment and institutionalisation, physical and psychological health, education and employment. After adjusting for the risk that with so many outcomes, one might test significantly different purely by chance, neither over the period from three months after baseline to eight and half years after, nor at the final follow-up itself, were there any statistically significant differences between youngsters sent and not sent to Phoenix. Generally too the differences were insubstantial. The apparent benefits of being sent to the community seen one year after baseline had evaporated due to trends between that time and seven and half years later.
Most notably, the relative suppression in crime seen a year after starting treatment disappeared because the Phoenix cohort increased or sustained their criminal activity while those sent to other centres began to commit fewer crimes. At the 12-month point psychological health too had improved more among the Phoenix cohort, but in the next two years the other children caught up leaving no significant differences. Similarly, abstinence from drug or alcohol use became less common as the years progressed but the decline was steeper after leaving the Phoenix Academy, leaving former residents at roughly the same level as the other children. Early gains in non-smoking eroded even more quickly.
The question posed by the study of whether initial 12-month benefits from specialist substance use treatment would persist, snowball or erode, was decisively answered; all eroded. Relative to youngsters referred from juvenile court to other group home settings, those referred to a residential therapeutic community had not progressed better when evaluated up to eight and half years after referral.
Though the findings are disappointing, society may still have benefited from the cost savings associated with the temporary extra decreases in adolescent crime and substance use after specialist treatment; these may even have saved lives by reducing drinking and drug use at a time when adolescents may be at highest risk of harming themselves and others. Other analyses of the same dataset revealed that on many counts, how well the youngsters were doing a year after referral did not predict how they would do later, suggesting that early outcomes had been overwhelmed by the many and substantial changes in the lives of adolescents as they become young adults.
Extending initial gains may require structured aftercare and/or multiple treatment episodes. Without this it may be unrealistic to expect one dose of treatment to have long-term effects, especially on high-risk adolescents such as those in this study, who confront multiple risk factors on return to their original environments, including family, peers, and neighbourhood.
Results from this study are vulnerable to differences between the children sent and not sent to Phoenix which the study may not have been able to fully adjust for, and may not generalise to other young people, especially those not required to enter treatment by the juvenile justice system.
commentary The featured study's findings are a reminder that especially for young people, good results seen on leaving treatment (such as those in England) often do not persist. This is also the case for young cannabis users in particular – the main caseload in the featured study – where the effects of treatment overall are modest and then become even more so with time.
Less so than adults, children cannot build on treatment by altering the environments they are returned to; resources, occupations, homes, relationships, parents, neighbourhoods, siblings, schools and other important influences are beyond their reach or beyond their control, and largely beyond that of the treatment service. Another difference from most adults is that teenagers typically enter treatment under pressure from or directed by families, courts, schools or welfare services (1 2). These unwilling, sometimes angry and uncooperative youngsters often (like those in the featured study) see no need for treatment for their substance use.
Youngsters who have got in to such serious trouble early in their lives often face daunting difficulties and live with families unable to effect positive changes for them. With escape routes constricted, the periodic drug use or under-age drinking which typically brings them into trouble with the law may to them seem a valued way of coping; the downsides may be hard to identify, the upsides more salient. For some their assessments that substance use is not for them a core or pressing problem may have some validity; even the youngsters sent for specialist substance use treatment in the featured study told researchers they had drunk or used drugs on just six of the last 90 days at the start of the study.
If we make the assumption that many of these youngsters were right in downplaying the centrality of their substance use, it becomes easier to understand why a treatment focused on this non-central issue failed to have more persisting impacts than regimens which were not. It and the comparison regimens may nevertheless both have had positive lasting impacts – a speculation suggested by a study which exploited the limitations of the US health insurance system to conduct a rare quasi-random test of whether (in this case, 12-step based) substance use treatment is more effective for adolescents than merely being placed on a waiting list. Twelve months after completing treatment, 44% of the treatment groups had barely touched alcohol or drugs in the past year and on average each had cut their substance use by a quarter. Those on the waiting list continued to use drugs on average at the same rate as a year before and just 27% maintained near abstinence.
If the return environment is the key to post-treatment relapse for young substance users, one way to alter it is to engage the family and especially the parent(s) in the treatment, presumably not an option for many of the children in the featured study. Multidimensional Family Therapy tries to do this and also to intervene in other influential areas of the child's life without requiring them to admit they need substance use treatment. This approach in particular has distinguished itself by the sustainability (and even the growth; for example, 1 2) of the gains made during treatment. A plausible explanation is that the therapy initiates a mutually reinforcing set of interactions between the child, their family and the wider environment. However, not all implementations have succeeded.
Thanks for their comments on this entry in draft to author Maria Orlando Edelen of the US RAND Corporation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 22 March 2013. First uploaded 19 March 2013
STUDY 2011 Treatment of adolescents with a cannabis use disorder: Main findings of a randomized controlled trial comparing multidimensional family therapy and cognitive behavioral therapy in The Netherlands