Practice Guidance:  Treatment Services for Youth and Their Families

I.  Rationale:  
BSAS is committed to building a comprehensive, effective system of care for youth and their families, in which programs and services are tailored to the ages, resources and environments of those at risk. This commitment is a critical component of the Massachusetts Substance Abuse Strategic Plan.  Indeed, this investment is timely.   Despite a period of decline in alcohol and illicit drug use among youth in Massachusetts 2007, indicators of substance use problems remain robust.  Alcohol dependence and abuse hovers between 4% and 5% of youth.  In FY 2010, opiate dependence, abuse or poisoning by youth accounted for nearly 3% of non-fatal opiate related hospitalizations in Massachusetts. 

Recent national surveys  report illicit drug use increasing.  Use of marijuana has increased in all youth age groups, with one in sixteen 12th graders reporting daily use.  At the same time the perception of risk in using marijuana is dropping, and more than 4 in 5 12th graders report it is easy to get.  Monitoring the Future reports oxycontin use by 5% of 12th grade students; and an increase in needle use by youth from less than 7% in 2004 to 10% in 2010. The same sources report that in Massachusetts 10% of youth have reported binge drinking; 10% report illicit drug use; 10% report tobacco use. Like adults, youth use an array of substances, but they are more likely to use inhalants, ecstasy, as well as prescription drugs non-medically.  

	While youth alcohol and drug use patterns may share similarities with those of adults, their developmental status and life circumstances are vastly different.  At a time when many adolescents are differentiating themselves from accustomed roles and relationships in families, damaged family relationships may be felt less keenly. A teen’s embrace of a youth or peer group culture may clash with family or community cultural expectations, sanctions or prohibitions.  Uneven cognitive development means adolescents have limited capacity for the abstraction and executive functioning that allows for perception of risk or consequences, and that supports a capacity to tolerate delayed responses or gratification.  Many youth are unable to envision longer term consequences of educational losses and involvement with criminal activity.  Within the span of years from 13 to 17, huge changes occur not only developmentally, but in experiences.  For example, older male youth are more likely to be involved in the juvenile justice system than are younger males (and than are females).   

Prevalence of co-occurring disorders among youth, often linked with trauma, amplify the need for comprehensive care.  At least one-fifth of youth admitted to treatment are diagnosed with a co-occurring mental health disorder.   These youth are more likely to be female, and females are more likely than males to have been sexually abused.  Overall, substance use increases risk of suicide.  Risk behaviors increase with alcohol and drug use, exacerbating dangers of sexually transmitted diseases, interpersonal violence, and other traumas – risk that are even greater for homeless youth, who are vulnerable in all areas of physical, mental and emotional health, and who account for up to 5% of the homeless population.

Lesbian, gay, bisexual and transgender youth use alcohol and drugs in many of the same ways as their heterosexual peers, but studies suggest they do so at greater rates.  Their vulnerability to adverse consequences is heightened by shame, stigma and homophobia, which increase isolation and fear of violence.  Common developmental exploration of identity is complicated and daunting for youth who may perceive that their identity is scorned by those whose care and respect they seek.

The scope of developmental variations, mental health needs, and the diversity of the youth population require treatment approaches that are both finely tuned and flexible.  Balancing these two key characteristics can be challenging to most organizations where clearly defined structures and schedules make for smoother operations.  Further, while involvement of family and friends in supporting treatment is important for all, it is a critical component for youth.  Among the most important elements of treatment is provision for supporting, or building, relationships which promote recovery.  Strong positive relationships with parents are key protective factors for youth.  Some parents may be disaffected and discouraged in their attempts to help their children, while others may require intervention for their own substance use.  Regardless of parent capacity, or availability, failure to engage adults who are important to the youth will significantly weaken the youth’s resources for recovery.

II. Guidance:  
A.  Organization: 
Policy
•	Policies state that engagement and treatment are responsive to youth capacities and interests
•	Policies state agency’s commitment to reach out in order to serve youth ‘where they are’ and to reduce functional barriers to treatment 
•	Policies state agency’s commitment to include youth and families in design and assessment of programs.
Operations
•	Outreach efforts are directed toward youth venues including schools, community centers, neighborhoods, streets and homeless shelters.
•	Agencies establish active collaborations, through QSOA’s, with schools, community centers, faith based organizations, health clinics, juvenile justice and probation settings, and other venues serving youth.  
•	Collaborations specify means of providing substance abuse treatment services in venues congenial to youth, as well as specifying methods of referral and providing cross-training.
•	Agencies build collaborative relationships with local DMH, DYS and DCF offices
•	Agencies investigate innovative approaches aimed at engaging youth, including flexible structures and schedules for services.
•	Agencies ensure youth are not required to negotiate complex voicemail or other systems which may delay contact with an individual.
•	Agencies explore methods of using existing payment mechanisms in creative ways, i.e. for off-site groups; phone ‘therapy’
•	Websites, posters and brochures emphasize agency’s commitment to youth by displaying images of diverse youth; websites avoid complex navigation.
•	Agencies actively engage families, and other supportive relationships, providing clinical interventions, and promoting opportunities for supported family social activities (directly or through collaborations).
•	Agencies establish mechanisms for providing family therapies either directly or through QSOA referrals.
•	Agencies monitor trends in youth alcohol and drug use and periodically evaluate services in light of changes.
Supervision, Training & Staff Development
•	Agency clinical and case management staff are informed about community youth and family resources.
•	All staff, including reception, clerical and clinical staff recognizes and responds to the need for information to be presented in ways which reduce number of required contacts, forms, telephone calls or other communications.
•	Agency ensures that staff who come into contact with youth are those who evidently like and respect youth.
•	Staff are trained to use tools and therapeutic approaches that are proven effective with youth and families.
•	Staff are knowledgeable about 
o	adolescent development, particularly cognitive and neurological development;
o	gender differences in development and in effective treatment approaches;
o	sexuality, sexual orientation and gender identity as specific areas of youth exploration and development;
o	strengths-based services;
o	legal issues related to services to youth;
o	cultural variations, including youth culture, cultural and family perceptions of roles and abilities of youth, and cultural influences on substance use and recovery;
o	resources and requirements of DCF, DYS and DMH.
•	Staff are knowledgeable about the different physical effects of alcohol and drugs on youth, for example, that less severe withdrawal symptoms may lead to underestimating severity of dependence.  
•	Staff are knowledgeable about developmentally different processes of recovery, and relapse, for youth, e.g. in perceptions of risk or capacity to anticipate consequences.
•	Staff are knowledgeable about and skilled in engaging youth and families.
•	Staff are knowledgeable about phases and processes of coming out for LGBT youth.
B.  Service Delivery and Treatment:  
Assessment
•	Agencies use assessments tools established as reliable with youth.  
•	Assessments include review of 
o	developmental status, 
o	educational experiences,
o	trauma history,
o	mental health status,
o	family relationships,
o	youth’s own goals.
•	Assessments identify adults who can provide committed support to the youth’s recovery.
Planning
•	Treatment plans identify and involve individuals’ significant relationships, schools, primary care providers, and others who may promote or undermine recovery.  
•	Treatment plans ensure integration of treatment with domains of youth’s life, e.g. family, school, sports, employment.
•	Treatment plans include services and resources which match the youth’s developmental status and capacities.
Service Provision
•	Staff use a variety of means to engage youth, including electronic communications.
•	Staff are able to discuss risks and benefits of electronic communications (e.g. texting) and social networking related to sobriety and support of recovery
•	Agencies incorporate physical activities, art and expressive opportunities (such as music and poetry) as treatment components, ensuring strong, engaged adult monitoring.
•	Relapse prevention efforts focus on short-term planning, with emphasis on risks related to social settings and interactions with peers, and what youth might do to reduce or respond to risks.
•	Education and support groups are available for parents and family members (directly or by active collaboration).

III. Measures:  

Programs can assess their effectiveness by formulating questions specific to their goals in applying standards.  Some examples of questions related to serving youth include:
•	Data on engagement and retention
•	Data on significant involvements for youth, such as school and employment
•	Growth of active collaborations and QSOA’s with other entities serving youth
•	Data on engagement and involvement of families
•	Training topics such as: adolescent development; media and social networking; trends in adolescent substance use

IV. Resources:  

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services: 
TIP 21 Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System 
TIP 31 Screening and Assessing Adolescents for Substance Use Disorders. 
TIP 32 Treatment of Adolescents with Substance Use Disorders 
TIP 39 Substance Abuse Treatment and Family Therapy, 
MET and CBT for adolescent cannabis users: 5 sessions, CYT series, volume 1. Sampl, S., & Kadden, R. (2001). 
A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual and Transgender Individuals,
BSAS Resources

Youth Treatment resources:  Youth treatment
Current Survey of Knowledge of Adolescent and Young Adult Heroin Use Prevention 

V.  Forms  
Global Appraisal of Individual Needs:  An evidence based assessment used in conjunction with a number of research studies and evidence based adolescent treatment approaches.
Gay and Lesbian Youth Support project: provides a wide array of resources including model agency assessment tools.  

BSAS welcomes comments and suggestions.  Contact:  BSAS.Feedback@state.ma.us