Substance abuse treatment for juvenile offenders: A review of quasi-experimental and experimental research

Journal of Criminal Justice 39 (2011) 246–252

Contents lists available at ScienceDirect

Journal of Criminal Justice

Substance abuse treatment for juvenile offenders: A review of quasi-experimental and experimental research Stephen J. Tripodi a,⁎, Kimberly Bender b a b

Florida State University, College of Social Work, United States University of Denver, Graduate School of Social Work, United States

a r t i c l e

i n f o

Available online 12 March 2011

a b s t r a c t Purpose: The purpose of this systematic literature review is to assess the effectiveness of substance abuse treatment on alcohol and marijuana use for juvenile offenders based on existing quasi-experimental and experimental research. Additionally, a secondary aim is to compare the effects of individual-based interventions to family-based interventions. Methods: A systematic search of literature and electronic databases through 2010 generated five experimental or quasi-experimental studies that assessed alcohol outcomes for juvenile offenders and five experimental or quasi-experimental studies that assessed marijuana outcomes for juvenile offenders. Results: Overall, substance abuse treatment appears to have a small to moderate effect on alcohol and marijuana reduction for juvenile offenders. Interventions that showed the most promise were Multisystemic Therapy, Multidimensional Treatment Foster Care, Teaching Family, and Life Skills Training. Individual-based interventions and family-based interventions had similar small to moderate effects on alcohol and marijuana use. Conclusion: This review highlights several promising interventions for this high-risk population; however, further rigorous study is desperately needed to provide a better understanding of what works best in reducing substance use among juvenile offenders. © 2011 Elsevier Ltd. All rights reserved.

Introduction Alcohol and drug use continue to be problems for many adolescents. Monitoring the Future – a longitudinal study of American adolescents’ behaviors and attitudes – reports alcohol and drug use rates for adolescents peaked in 1998 and were on a steady decline until 2008, when rates started increasing again. The most recent survey indicates that alcohol and marijuana are the two most prevalent drugs for adolescents (Johnston, O'Malley, Bachman, & Schulenberg, 2010). Many adolescents who drink alcohol do so at dangerous levels that impair judgment and reduce inhibitions. In 2008, 25% of 12th graders, 16% of 10th graders, and 8% of 8th graders reported binge drinking (defined as having five or more drinks at a given time during the prior two weeks (Johnston et al., 2010). Despite the dangers of binge drinking, it alone does not indicate that an adolescent is a substance abuser, particularly when considering the accessibility of alcohol and the fact that drinking alcohol is a normative behavior in American culture. According to the DSM-IV, an individual has an alcohol abuse disorder if they have one or more of the following criteria for over a

⁎ Corresponding author. E-mail address: [email protected] (S.J. Tripodi). 0047-2352/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jcrimjus.2011.02.007

one year period: 1) Role impairment (such as failed work or home obligations), 2) Hazardous use (such as driving, swimming, or operating machinery while intoxicate), 3) Experience legal problems related to alcohol use, and 4) Experience social or interpersonal problems due to alcohol use (American Psychiatric Association, 2000). Roberts, Roberts, and Chan's (2009) nationally representative study of adolescents (N = 4,175) found that 3% met the criteria for alcohol abuse or dependence. There are several concurrent psychosocial problems associated with adolescent alcohol use disorders. Youth who abuse alcohol have higher rates of comorbid mental health disorders (Rowe, Liddle, Greenbaum, & Henderson, 2004) and neurocognitive deficits (Tapert, Brown, Myers, & Granholm, 1999). Moreover, alcohol abusing youth generally have less motivation to succeed academically (Baer, Garrett, Breadnell, Wells, & Peterson, 2007) and are at risk for subsequent adult alcohol abuse and its related problems (D'Amico, Miles, Stern, & Meredith, 2008). Marijuana is the second most frequently used drug among adolescents, behind alcohol, and the most prevalent illicit drug used by adolescents in the United States (Dennis et al., 2004; Office of Applied Studies, 2000). According to Monitoring the Future, the annual prevalence rates in 2008 for marijuana range were 33% for 12th graders, 24% for 10th graders, and 11% for eights graders (Johnston et al., 2010). In a study comparing American, Canadian, and

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Dutch adolescents, Simons-Morton, Picket, Boyce, ter Bogt, and Vollerbergh (2010) found that 33% of teenage boys and 26% of teenage girls reported marijuana use in the past 12 months. Excessive marijuana use has also been associated with psychosocial risk (Volkow, 2005). Adolescents who abuse marijuana often demonstrate short-term memory problems and difficulty maintaining attention in school (Ashton, 2001; Heishman, Arasteh, & Stitzer, 1997; Pope & Yurgelun-Todd, 1996). Additionally, severe marijuana use is associated with dropping out of high school and disruptions transitioning into adulthood, including unemployment and juvenile/ criminal justice involvement (Brook, Adams, Balka, & Johnson, 2002; Brook, Richter, Whiteman, & Cohen, 1999). Due to the significant social and behavioral concerns associated with alcohol and marijuana abuse during adolescence, a variety of treatments have been developed and tested. Syntheses of these outcome studies provide preliminary guidance for practitioners in selecting promising approaches to reducing their adolescent clients’ substance abuse. Meta analyses on alcohol and marijuana treatments Tripodi, Bender, Litschge, and Vaughn (2010) conducted a metaanalysis to assess the effectiveness of substance abuse interventions to reduce adolescent alcohol use; the analysis also compared familybased interventions with individual-based interventions and analyzed the long-term effects of existing interventions. Primary outcome measures in the meta-analysis included: alcohol abstinence, frequency of alcohol use, and quantity of alcohol use measured between one month and one year upon completion of treatment. Tripodi et al. (2010) found that interventions aiming to reduce alcohol use appeared to be successful, and that interventions with the largest effects were Cognitive-Behavioral Therapy integrated with the 12-step approach (Tomlinson, Brown, & Abrantes, 2004), Brief Motivational Interviewing (D'Amico et al., 2008), Active Aftercare (Kaminer, Burleson, & Burke, 2008), Multidimensional Family Therapy (Liddle, Dakof, Parker, Diamond, Barrett, & Tejada, 2001), and Brief Interventions with both the adolescent and a parent (Winters & Leitten, 2007). Contrary to previous research comparing individual counseling to family counseling (Stanton & Shadish, 1997), Tripodi et al. (2010) found larger effects for individual counseling (Hedges g = − 0.75; 95% confidence interval − 1.05 to − 0.40) than family-based interventions (Hedges g = − 0.46; 95% confidence interval − 0.66 to − 0.26). Furthermore intervention effects, for the most part, diminished over time, as pooled effect sizes were lower for studies that contained a follow-up period of over six months than studies with a follow-up period of less than six months. A similar meta-analysis conducted by Bender, Tripodi, Sarteschi, and Vaughn (in press) assessed the effectiveness of substance abuse interventions on adolescent marijuana use, examining effects of interventions on marijuana abstinence, frequency of marijuana use, and quantity of marijuana use. The interventions that yielded the largest effects were a behavioral-oriented treatment targeting youth and adult mentors (Braukmann et al., 1985), other behavioral treatments (Azrin et al., 1994), Integrated Family Cognitive Behavioral Therapy (Latimer, Winters, D'Zurilla, & Nichols, 2003), Multidimensional Family Therapy (Liddle, Dakof, Turner, Henderson, & Greenbaum, 2008) and Cognitive Behavioral Therapy (Waldron, Slesnick, Brody, Turner, & Peterson, 2001). Compared to the effect sizes reported above for reducing adolescent alcohol use using individual approaches (Hedges g = −0.75; 95% confidence interval −1.05 to − 0.40), Bender et al.'s (in press) found smaller effects of individual treatments on adolescent marijuana use (Hedges's g = −.437; 95% confidence interval −.671 to −.203). Family-based interventions (Hedges's g = −.404; 95% confidence interval − .613 to − .195) for reducing marijuana use were comparable to effects for reducing alcohol use using family-based

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methods. Therefore, individual and family-based methods appear to have similar moderate sized effects in reducing adolescent marijuana use. Results also indicated treatment effects diminished over time. Substance use and juvenile justice involvement Research finds highly elevated rates of alcohol and drug problems among the approximately one million U.S. youth involved in the juvenile justice system annually (Chassin et al., 2009; Dembo, Pacheco, Schmeidler, Fisther, & Cooper, 1997; Rossow, Pape, & Wichstorm, 1999; Chassin, Knight, Vargas-Chanes, Losoya, & Naranjo, 2009). The number of adolescent offenders entering the juvenile justice system with alcohol or drug problems, or entering the system on drug charges, has been increasing consistently over the past 20 years. While adolescents in the juvenile justice system meet criteria for a variety of psychiatric problems meeting DSM-IV criteria, alcohol and drug disorders are by far the most common (Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). More severe substance use is associated with increased severity of criminal behavior, with higher degrees of substance use differentiating incarcerated and violent adolescents from less serious juvenile delinquents (Sealock, Gottfredson, & Gallagher, 1997; Tripodi, Springer, & Corcoran, 2007). In fact, incarcerated adolescents are approximately three times more likely to have substance abuse problems in the past year than non-incarcerated adolescents (Molider, Nissen, & Watkins, 2002; Office of Applied Studies, 2004), and approximately 50% of incarcerated adolescents report using alcohol and/or drugs when committing the act for which they were arrested (DeMatteo & Marczyk, 2005). Considering consistent evidence of the relationship between adolescent substance abuse and criminality, it appears alcohol and marijuana treatment should be a vital component of treatment for youthful offenders. Scarce resources and high substance abuse treatment needs require careful selection of existing interventions most likely to be successful in reducing alcohol and marijuana use. Subsequently, the aim of this paper is to review the scientific literature regarding substance abuse treatments to reduce adolescent alcohol use and marijuana use, and to synthesize the state of knowledge regarding effective interventions. Additionally, a secondary aim of this review is to compare the effects of individual-based interventions to family-based interventions in order to highlight treatment formats with the most empirical support. Finally, this review aims to determine which interventions are associated with positive long-term outcomes. Methods The researchers aimed to identify all studies that involved a control or comparison group with a focal treatment targeting alcohol and/or marijuana outcomes for adolescent clients with juvenile justice system involvement between the ages of 12–19 for a 50-year time span (1960–2010). Databases that were searched include the following: MEDLINE; PsychINFO; ERIC; Wilson Social Science Abstracts; Criminal Justice Abstracts; Social Work Abstracts; Social Science Citation Index; Dissertation Abstracts International; National Criminal Justice Research Service; Social, Psychological, Criminological, Education Trials Register; and the Psi Tri database of randomized controlled trials in mental health. Moreover, the researchers searched alcohol and drug treatment websites such as the National Institute of Drug Abuse, the Alcohol and Drug Abuse Institute at the University of Washington, and the Center on Alcoholism, Substance Abuse and Addictions at the University of New Mexico. The researchers also searched reference sections of selected articles. Keyword searchers included the following were entered singularly and in Boolean formula with and or or: adolescent, alcohol, alcohol abuse, alcohol dependence, ethanol, cannabis, cannabis abuse, marijuana, marijuana

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Table 1 Characteristics of studies with alcohol outcomes Author(s)

Research Design

Intervention

Baseline Comparison of Groups after Randomization

Collaterals

Attrition

Site

Duration and # of Sessions

Outcome

Follow-up

Friedman et al. Godley et al. Godley et al. Henggeler et al.

Experimental

TMSL

Yes

6 months

Yes

ACC

Yes

QuasiExperimental

MST

Yes (no randomization)

Days of alcohol use Time abstinent from alcohol Frequency of alcohol use

3 months

Experimental

Experimental

MTFC

Yes

Collaterals interviewed

Considered in outcome

24 weeks, 1 session per week 12 weeks, frequency not reported 90 days, 1 session per week 40 hours direct contact with therapist in 4–5 months N/A

Alcohol use

ACC

Considered in outcome Considered in outcome Considered in outcome Considered in outcome

Clinic

Experimental

Collaterals interviewed Collaterals interviewed Collaterals interviewed Collaterals interviewed

Smith et al.

Home Aftercare Services Home/School community center Foster Home

Frequency of alcohol use

9 months 10 months

18 months

TMSL = Triple modality social learning, ACC = Assertive continuing care, MST = Multisystemic therapy, MTFC = Multidimensional Treatment Foster Care.

abuse, substance use disorders, psychosocial interventions, psychosocial treatment, youth, behavioral interventions, behavioral treatments, psychotherapy, offender, delinquent, juvenile justice, randomized controlled trials, and controlled clinical trials. Studies were included in this review if they met the following criteria: 1) tested an intervention to reduce alcohol or marijuana use (excluding prevention studies, observational studies, and literature reviews/conceptual articles, 2) targeted adolescents between the ages of 12–19, 3) either took place in a juvenile justice setting or at least 50% of the sample were involved in the juvenile justice system, 4) examined quantitative alcohol or marijuana use treatment outcomes, 5) provided necessary information to calculate effect sizes, 6) used a contrast condition for comparison (control group, wait-list control, or contrasting treatment group as part of design). Results Alcohol outcomes As shown in Table 1, there were five experimental (n = 4; 80%) or quasi-experimental studies (n = 1; 20%) with alcohol reduction outcomes with juvenile offenders that met the eligibility criteria. All studies provided a baseline comparison of groups, and attrition was

considered in examining outcomes in all five studies. Interventions took place in clinic, home, foster home, aftercare services, and school community center settings. Outcomes included alcohol use (yes/no), days of alcohol use, time abstinent from alcohol, and frequency of alcohol use. Follow-up periods ranged from 3 months to 18 months. Table 2 shows the intervention, comparison group, sample size, Hedges's g effect size, 95% Confidence Interval, and p-value for the five studies that assessed an intervention's effectiveness in reducing alcohol use for juvenile offenders. While all of the studies yielded a decrease in offenders’ alcohol use, only two of the studies found statistically significant result (Friedman, Terras, & Glassman, 2002; Henggeler, Pickrel, & Brondino, 1999). Friedman et al. (2002) compared 24 sessions of Triple Modality Social Learning – a classroom-based intervention composed of substance abuse prevention, violence prevention, and values clarification lessons – to basic residential treatment. The study found significantly greater reductions in alcohol use among the intervention group participants compared to youth receiving residential treatment only six months after the intervention ended (Hedges's g = −0.514; 95% Confidence Interval = −0.796 to −0.233; p b 0.001). Henggeler et al. (1999) compared multisystemic therapy (MST) – an in-home intervention – to a treatment as usual control group and found significantly greater reductions in alcohol use among youth receiving MST compared to control group members after a 130 day

Table 2 Results of studies targeting alcohol use Study Name Study name Friedman et al. Godley et al. Godley et al.

Henggeler et al.

Smith et al.

Comparison (Time Point)

Sample size Treatment

Comp

Statistics for Each Study Hedges's g

Lower limit

Upper limit

p-Value

TMSL* vs. BRT (6 mo)# ACC* vs. TAU (3 mo) ACC* vs. TAU (3 mo) ACC *vs. TAU (9 mo) MST** vs. TAU (130 days) MST** vs. TAU (10 mo) MTFC** vs GC (12 mo) MTFC** vs GC (18 mo)

63

91

− 0.514

− 0.796

− 0.233

b 0.001

98

51

− 0.477

− 1.811

0.858

0.484

98

78

− 0.129

− 1.509

1.250

0.854

54

78

− 0.100

− 1.479

1.280

0.888

58

56

− 0.390

− 0.758

− 0.022

0.038

54

54

− 0.337

− 0.714

0.041

0.08

37

39

− 0.360

− 0.810

0.10

0.23

32

38

− 0.32

− 0.80

0.15

0.25

Abbreviations: ACC, assertive continuing care; BRT, basic residential treatment; GC, group care; MST, multisystemic therapy; MTFC, multidimensional treatment foster care; TAU, treatment as usual; TMSL, triple modality social learning. *Denotes intervention focus on the individual. **Denotes intervention focus on the family. #Considered “individual” because family was not included in intervention.

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Table 3 Characteristics of studies with marijuana outcomes Author(s)

Research Design

Intervention

Baseline Comparison of Groups after Randomization

Collaterals

Attrition

Site

Duration and # of Sessions

Outcome

Follow-up

Braukmann et al. Godley et al. Godley et al.

Experimental

TF

Yes Yes

Experimental

ACC

Yes

Aftercare Services

289 days group home care 12 weeks, frequency not reported 90 days, 1 session per week

Henggeler et al.

QuasiExperimental

MST

Yes (no randomization)

Collaterals interviewed

Considered in self-report

Smith et al.

Experimental

MTFC

Yes

Collaterals interviewed

Considered in outcome

Home/School community center Foster Home

40 hours direct contact with therapist in 4–5 months N/A

Days of cannabis use Days of cannabis use Time abstinent from cannabis Frequency of cannabis use

12 months

ACC

Considered in outcome Considered in outcome Considered in outcome

Group homes

Experimental

Collaterals interviewed Collaterals interviewed Collaterals interviewed

Frequency of marijuana use

18 months

Home

3 months 9 months

10 months

ACC, assertive continuing care; MST, multisystemic therapy; MTFC, multidimensional treatment foster care; TF, teaching families.

follow-up (Hedges's g = −0.390; 95% Confidence Interval = − 0.758 to − 0.022; p = .038). Despite having longer outcome periods overall, family-based interventions had a slightly larger average effect size (g = −.351) than individual-based interventions (g = −.305). Finally, none of the studies that had a follow-up period of at least nine months provided a statistically significant Hedges's g effect size. Marijuana outcomes As shown in Table 3, there is only one study that met the eligibility criteria unique to marijuana outcomes that did not also provide alcohol outcomes (Braukmann et al., 1985). Braukmann et al. (1985) conducted an experimental study to assess the influence of Teaching Families – a community-based group-home treatment for adolescent offenders – on reducing adolescent marijuana use compared to a control group with a 12 month follow up. Similar to the alcohol outcomes, all of the interventions helped engender a reduction in marijuana use – however, just three of the interventions had a statistically significant effect on marijuana reduction (Braukmann et al., 1985; Henggeler et al., 1999; Smith, Chamberlain, & Eddy, 2010). As shown in Table 4, Braukmann et al. (1985) found significantly greater reduction in marijuana use frequency among adolescent offenders who participated in Teaching Families compared to adolescent offenders who did not (Hedges's g = −1.991; 95% Confidence Interval = − 2.344 to − 1.638; p b .001).

Henggeler et al. (1999) found multisystemic therapy to successfully decrease marijuana use compared to a treatment as usual control group at the 130 day follow-up (Hedges's g = − 0.390; 95% Confidence Interval = − 0.758 to − 0.022; p = .038), and Smith et al. (2010) found multidimensional treatment foster homes to be effective compared to group care at the 18 month follow-up (Hedges's g = −0.64; 95% Confidence Interval = −1.13 to -.016; p = .02). The average Hedges's g effect for family-based interventions to reduce marijuana use (g = .727) is higher than the average Hedges's g effect size for individual-based interventions (g = .345). When removing the outlier for family-based intervention effect sizes (Braukmann et al., 1985), family-based interventions still produce a higher average effect size than individual-based interventions (g = .412 compared to g = .345). Four of the outcomes included in this analysis were assessed within nine months of the intervention ending and four of the outcomes had follow-up periods over nine months. The average Hedges's g effect size for the four studies with follow-up periods of nine months or less was g = .356 while the average Hedges's g effect size for the four studies with follow-up periods of over nine months was g = .812 (g = .419 with removal of outlier). Discussion This review suggests rigorously tested interventions to reduce substance use among juvenile offenders have small to moderate

Table 4 Results of studies targeting marijuana use Study Name Study name Braukmann et al. Godley et al. Godley et al.

Henggeler et al.

Smith et al.

Comparison (Time Point)

Sample size Treatment

Comp

Hedges's g

Lower limit

Upper limit

p- Value

TF** vs. TAU (12 mo) ACC* vs. TAU (3 mo) ACC* vs. TAU (3 mo) ACC *vs. TAU (9 mo) MST** vs. TAU (130 days) MST** vs. TAU (10 mo) MTFC** vs GC (12 mo) MTFC** vs GC (18 mo)

82

103

− 1.991

− 2.344

− 1.638

b.001

98

51

− 0.427

− 1.674

0.819

0.502

98

78

− 0.289

− 0.725

0.148

0.195

54

78

− 0.319

− 0.755

0.118

0.152

58

56

− 0.390

− 0.758

− 0.022

0.038

54

54

− 0.337

− 0.714

0.041

0.080

37

39

− 0.28

− 0.73

0.17

0.15

32

38

− 0.64

− 1.13

− 0.16

0.02

Statistics for Each Study

ACC, assertive continuing care; GC, group care; MST, multisystemic therapy; MTFC, multidimensional treatment foster care; TAU, treatment as usual; TF, teaching families. *Denotes intervention focus on the individual. **Denotes intervention focus on the family.

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effects. Compared to previous meta-analyses (Bender et al., 2011; Tripodi et al., 2010) that examine the effectiveness of substance abuse treatment among adolescents in the general population, effect sizes are smaller for juvenile offender samples. For example, in comparing Hedges g effect sizes for reducing alcohol use in non-offending adolescents was -.75 for individual-based treatments and -.46 for family-based treatments, while effect sizes among offending adolescents was -.31 for individual-based treatments and -.35 for familybased treatments. This suggests, not only that substance use behavior change may be more difficult among juvenile offenders, but the effects of individualbased treatments appear particularly less effective among juvenile offenders, while family-based approaches are more comparable between non-offending and offending youth populations. Similar results were found for reducing marijuana use, where effect sizes among juvenile offender samples were smaller than among nonoffending samples of adolescents. These reductions in effect size may be due to the challenges inherent in working with adjudicated youth, including difficulty engaging youth in treatment, a high incidence of involuntary clients encouraged to participate in treatment by other authority figures, and a preponderance of individual, familial, and social risk factors among youth involved in the juvenile justice system. Despite smaller effects compared to non-offending adolescent substance users, several intervention approaches demonstrated success for reducing substance use among youth offenders. To aid in clinical application of these findings, a brief description of those programs found to be most effective is provided below followed by analysis of the commonalities across effective programs.

Multisystemic Therapy (MST) Multisystemic Therapy was highlighted as a potentially effective treatment to reduce adolescent substance use both among youth at risk of out of home placement. MST is a home-based approach that aims to intervene across youth relevant systems, including the home, school, peer groups, and the community. The socio-ecological model of development (Bronfenbrenner, 1979) guides MST's multi-system approach. The premise of the approach is that substance use is a function of the effects of multiple systems and youths’ interactions with each system (Henggeler, Smith, Melton, 1992). The approach is intensive, with clinicians available to work with the youth (age 11–18) and his/her family 24 hours per day and 7 days per week. Clinicians individualize treatment by focusing on those systems particularly influential in the youth's problem behavior, and empower the youth and his/her family to identify areas for change. The work is goal oriented and pragmatic, focusing on ameliorating risk factors as well as harnessing strengths and resources within each system. For example, a key goal is to aid parents in developing skills to supervise and monitor their adolescent, and to expand their own support networks (Timmons-Mitchell et al., 2006). Evidence-based family therapy models, including strategic family therapy, structural family therapy, and behavioral parent training inform work with youth and their parents (Henggeler, Pickrel, & Brondino, 1999). Simultaneously, MST clinicians would likely work with the youth to identify and engage pro-social peer groups and decrease their association with delinquent peers. Parallel to this process, is individual work with the youth to reduce favorable attitudes toward drug use. Such goals are achieved by collaborating with many invested individuals, including teachers, coaches, parents, family members, community members, and church leaders. By providing services in-home, MST teams are able to reduce barriers to services (Schaeffer & Borduin, 2005). Although such intensive in-home treatment is costly, previous cost-benefit analysis indicates preference for MST over punitive sentences to locked facilities (Aos, Miller, & Drake, 2006).

Multidimensional Treatment Foster Care (MTFC) Like MST, MTFC targets adolescent offenders, offering an alternative approach to incarceration or hospitalization. However, unlike the in-home approach of MST, MTFC removes youth from their family of origin and places them temporarily (6 to 9 months) in a therapeutic foster home with specially trained foster parents. The MTFC team, consisting of the MTFC program supervisor, a family therapist, individual therapist, consulting psychiatrist, and a behavioral skills trainer, work together with the trained foster care parents to provide services to youth and their family of origin. Foster parents are trained and supported to implement behavior management techniques, including providing structure, clear expectations, limits, reinforcement and sanctions, steering youth toward positive behaviors. Point systems are established to reward positive behaviors and reduce negative or maladaptive behaviors, and privileges are earned or removed accordingly. Foster parents participate in weekly training meetings as well as daily phone conversations to monitor youth progress with the MTFC team (Chamberlain & Mihalic, 1998). Monitoring and supervision of youth behavior is emphasized, not only in the home, but also in school, in the community, and in other social activities. Working individually with youth, MTFC clinicians teach youth interpersonal skills, helping them to identify problematic situations and triggers, and to choose solutions to problems that attenuate risk. A key aspect of working with youth in the foster care home is separating them from delinquent peer groups that might be present in the home community or in other residential facilities for offenders. The MTFC team also works closely with the family of origin to reinforce new behaviors. Through family therapy, the family of origin learns effective parenting techniques and prepare, with their adolescent, for reunification after treatment ends. Traditionally, MTFC aimed to reduce delinquency and has not focused specifically on substance use. Randomized clinical trials find MTFC to be associated with reduced institutionalization and incarceration (Chamberlain, Leve, & DeGarmo, 2007). Teaching Family (TF) The TF model places adjudicated youth in group homes with 4 or 5 other troubled youth. Each group home is directed by a live-in married couple called teaching parents and provides a family-like environment. Teaching parents are specially trained and certified to run the group homes, and they work to improve conditions across systems in youths’ lives. TF parents are trained and supervised on skill building, youth motivation, rapport building, and youth advocacy. Youth receive direct treatment from their teaching parents, and teaching parents also serve as case managers for the youth living in their home, collaborating with school, court, and child welfare professionals involved in each youth's life. Teaching parents work directly with youth on specific skill building, including activities of daily living such as personal hygiene, managing finances, and interpersonal skills for negotiating school and family settings. Teaching parents also work directly with youths’ families of origin, as youth often spend weekdays in the group home and spend weekends with their family of origin (Fixsen, Blase, Timbers, & Wolf, 2001). Life Skills Training (LST) A key component of the Triple Modality Social Learning program demonstrating significant effects in this review was LST. Developed from a clinical and developmental psychological perspective by Dr. Gilbert J. Botvin, LST is typically provided through repeated group sessions provided in school settings. The program is an empirically supported substance use prevention program that aims to reduce

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social and psychological factors associated with use. LST goes beyond teaching youth about the dangers of substance use by promoting alternative behaviors and enhancing positive development. A key focus of LST is to build youth skills. LST aims to improve skills in several areas, including problem solving (brainstorming and strategic decision making) and cognitive skills that support youth in resisting peer pressure and media influences. LST does provide instruction to youth regarding the negative consequences of substance use to inform their personal decision-making. LST also focuses on improving self-esteem and self-control by encouraging youth to set goals and achieve them. Relaxation and other coping techniques are taught in order to help youth relieve anxieties and stresses. Youth learn social and interpersonal skills to aid in building pro-social relationships, helping them to communicate clearly, build relationships, and overcome social shyness. Assertiveness skills are also a focus of LST in order to help youth to appropriately express feelings and resolve conflicts. LST sessions include didactic skill building as well as opportunities for youth to rehearse new skills and receive feedback to reinforce successful skill development.

Across effective interventions An interesting pattern is evident across treatments highlighted as effective in reducing substance use among adolescent offenders. For most interventions, the role of family appears important in changing substance-using behaviors. However, the role of family is stretched and adapted to take various forms in the above treatments. While MST works in-home focusing primarily on changing the family system with the youth present, MTFC offers an alternative surrogate set of parents to temporarily offer intensive services while the family of origin receives intervention with the youth out of the home. Here youth appear to benefit from both a trained set of therapeutic parents who work with them individually as well as changes to their home environment so they may return to a similarly structured setting after foster care. Teaching Family stretches the definition of family further still by introducing youth in a therapeutic foster group home where they receive treatment from therapeutic foster parents in the context of other troubled youth who, from a family perspective, serve as temporary siblings in the household. It is interesting to note that these various forms of family appear to be effective in helping youth change their substance using. Yet, equally important is the involvement of the family of origin in each treatment. Whether the youth stays embedded in the home or is temporarily removed, changes to their primary home environment appear essential in maintaining long-term substance use outcomes. When these options are not available, and more traditional residential care is necessary, this review suggests changes in behavior can still be made if youth offenders receive evidence-based structured substance abuse interventions such as Botvin's Life Skills Training.

Limitations The number of substance abuse interventions rigorously tested with juvenile offenders limited this review. Without repeated trials of each of these interventions, it is not possible to compare treatment effects and suggest which intervention is most effective. The restricted number of studies available also required a comparison of randomized control trials and quasi-experimental studies, and it is possible these design differences may have influenced effect sizes reported. Furthermore, studies available for review that demonstrated significant effects all treated male offenders only. Gender-specific services for female offenders has been acknowledged as a priority in juvenile justice settings, yet little rigorous evidence is available as to the effectiveness of substance abuse treatment for female offenders.

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Other efforts in reducing substance use among juvenile offenders In setting high criteria for inclusion in this review (i.e. randomized controlled trials or quasi-experimental designs with a specified active treatment), we excluded other studies that may be informative to readers interested in treatment of adolescent offender substance abuse. For example, Chassin, Knight, Vargas-Chanes, Losoya, and Naranjo (2009) studied a sample of serious male offenders almost all of which had been adjudicated with a felony offense. Chassin and colleagues surveyed youth in their communities every 6 months up until 12 months post treatment, querying them about their participation in various forms of substance abuse treatment and extent of self-reported substance use. The authors found 34% of the sample participated in some form of substance abuse treatment (e.g. outpatient sessions with a mental health provider such as a psychologist, social worker, or therapist; community support groups such as NA or AA; stay in a drug or alcohol unit of a hospital; or participation in court-ordered substance abuse treatment). Overall, participation in treatment was associated with significantly reduced alcohol use. The effects of participating in some form of substance abuse treatment reduced alcohol use in the short and long term, and persisted even when taking into account the amount of time youth spent unsupervised (i.e. opportunities for substance use). Thus, youth who were predicted to be highly at risk of substance use behavior showed significantly reduced alcohol use if they engaged in some form of treatment (Chassin et al., 2009). Also worth noting is a study by Dennis et al. (2004) that examined marijuana treatment for juveniles. Although not meeting inclusion criteria for this review, Dennis et al.'s study was large in magnitude and assessed the influence of motivational enhancement therapy plus cognitive behavioral therapy and multidimensional family therapy with adolescent marijuana users, most of who were involved in the juvenile justice system. Dennis et al. found that all of the interventions demonstrated a significant difference between pretest and posttest in their two main outcomes, which were days of abstinence and the percent of adolescents in recovery. Other work in drug courts also suggests effective interventions in reducing juvenile offenders’ substance use. Drug courts process nonviolent substance abusing youth offenders through an alternative court process that focuses on requiring treatment rather than punishing youth. With an ultimate aim of reducing recidivism, drug courts require youth offenders to engage in substance abuse treatment and monitor participation and progress in mandated treatment overtime through frequent status hearings. Teams composed of a judge and representatives from social services, schools, law enforcement, family members, probation and legal prosecution hold youth accountable while also offering resources (Office of National Drug Control Policy, 2010). Research suggests drug courts are associated with significantly reducing crime and substance use, particularly among high-risk offenders with serious delinquency histories (Lowenkamp, Holsinger, & Latessa, 2005). These studies, although not included in this review, make important contributions to the knowledgebase, as they suggest intervening to change juvenile offenders’ substance use behaviors is worthwhile and can be successful in achieving desired outcomes. Conclusion Juvenile offenders show elevated rates of substance abuse, and this abuse often increases recidivism and deeper involvement in the juvenile justice system. This review highlights several promising interventions for this high-risk population; however, further rigorous study is desperately needed to provide a better understanding of what works best in reducing substance use among juvenile offenders. Investment in adapting existing interventions for juvenile justiceinvolved youth and development of specialized treatments followed

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