Title: Breaking the Cycle of Drug Use Among Juvenile Offenders.
Series: Final Technical Report
Author: Duane C. McBride, Curtis J. VanderWaal, Yvonne M. Terry, and
Holly VanBuren
Published: National Institute of Justice, November 1999
Subject: Juvenile courts, drug offense sanctions and penalties,
adjudication--juveniles, juvenile substance abuse, and court management
120 pages
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Breaking the Cycle of Drug Use Among Juvenile Offenders

Duane C. McBride, Ph.D.
Curtis J. VanderWaal, Ph.D.
Yvonne M. Terry, M.S.A.
Holly VanBuren, M.S.W.

November 1999
NCJ 179273

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The Authors and This Report

The authors, all from Andrews University, prepared this report for the
National Institute of Justice (NIJ) under contract number OJP-96-C-004.
Dr. Duane C. McBride is Professor and Chair, Behavioral Sciences
Department, and Research Director, Institute for the Prevention of
Addictions. Dr. Curtis J. VanderWaal is Associate Professor, Social Work
Department. Yvonne M. Terry and Holly VanBuren are Research
Associates.

This Web-only report is based on a literature review completed by the
authors in August 1999. An article by them summarizing this report is
scheduled to appear in the May 2000 issue of The Journal of Behavioral
Health Services and Research. In addition, a shorter, practitioner-oriented
print version of this online report is under preparation by NIJ, a
component of the U.S. Department of Justice's Office of Justice Programs,
which also includes the Bureau of Justice Assistance, the Bureau of Justice
Statistics, the Office of Juvenile Justice and Delinquency Prevention, and
the Office for Victims of Crime.

Points of view, research findings, and conclusions expressed in this
document are those of the authors and do not necessarily reflect official
positions or policies of the U.S. Department of Justice.

-------------------------------

Contents

The Authors and This Report

Introduction and Purpose
--Background and context
--Purpose
--Substance use terminology

The Juvenile Drug-Crime Cycle and the Juvenile Substance-Using
Population

Juvenile Justice System Conceptual Underpinnings and Developments
--Conceptual underpinnings
--Conceptual developments

The Juvenile Justice System Process
--System contact: the juvenile justice system and court supervision at
intake
--Social investigation: assessment, case management, management
information systems, and collaboration
o Assessment
-- Culturally sensitive assessment
-- Co-occurring addictive and mental disorders
-- Community assessment centers
-- Assessment instruments
o Case management
-- Youth Evaluation Services (YES)
-- The Amity Project
-- The Iowa Care Management Model
-- The Case Management Enhancements Project (CME)
o Management information systems and confidentiality issues
o Collaborative structures and strategies
-- Collaborative elements
-- Optimum collaboration structure
-- Collaboration and the juvenile justice system
o Dismissal and/or diversion programs
--Fact-finding hearings and adjudication: judicial processing
--Disposition
o The graduated sanctions continuum
o Sentencing options
o Supervision monitoring: biologic testing
o Range of treatment options
-- Treatment correlates
-- Treatment programs
-- Overall treatment program evaluation issues
-- Treatment modalities
-- Meta-analysis of treatment effectiveness
-- Culturally sensitive intervention and treatment programming
o Continuing care services: beyond and within the juvenile justice system

General Recommendations for Future Intervention Research

Summary and Recommendations
--A conceptual model
--Guiding principles
--Systems flow: what a model program might look like
o Single point of entry
o Immediate and comprehensive assessment
o Cross-systems case management
o Continuum of care
o Judicial decision making
o Systems collaboration
o Treatment
o Utilization of traditional services
o Continuing care
o Evaluation
--An integrated model
--Implementation at the local level

Conclusion

Endnotes

Appendix A: Conducted Interviews

Appendix B: Assessment Tools
--Screening tools
--Mid-range comprehensive assessment instruments
o Comprehensive addiction severity index for adolescents
o Adolescent chemical dependency inventory--corrections version
o Other comprehensive assessment instruments

List of Abbreviations

References

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Introduction and Purpose

Background and context

For more than two decades, researchers, clinicians, and juvenile justice
program administrators have been aware of the consistent relationship
between alcohol and other drug (AOD) use and juvenile crime (a list of
abbreviations is at the end of this report). There have been many attempts
to document, understand, and intervene in what is often called the juvenile
drug-crime cycle (while the term AOD is probably the more accurate
descriptive term for substance use, the phrase drug-crime cycle is
commonly used in the literature to encompass the use of alcohol and other
illegal substances in conjunction with criminal acts). While these attempts
have usually promised much, their success is often unknown or not
documented with methodologically rigorous scientific research.

The consequences of the juvenile drug-crime cycle are severe. AOD use
among juvenile delinquents appears to be strongly related to other social
and psychological problems, including lowered school performance, poor
family relationships, and increased interactions with AOD-using peers
(Howell et al., 1995). AOD use also appears to be associated with a
number of delinquent behaviors. Arrestee Drug Abuse Monitoring
Program (ADAM) data strongly suggest that a high proportion of juveniles
(likely the majority) processed by the juvenile court have recently used
illegal substances. Juvenile AOD use appears to be related to recurring,
chronic, and violent delinquency that continues into adulthood (Dembo et
al., 1987, 1997; Sickmund et al., 1997). The juvenile justice system is,
therefore, a viable point of entry for a comprehensive collaborative service
system designed to break the juvenile drug-crime cycle.

Very few juvenile justice jurisdictions provide appropriate substance abuse
treatment services for youth. Thornberry et al. (1991) found that treatment
for adolescent substance offenders was available in less than 40 percent of
the 3,000 public and private juvenile detention, correctional, and shelter
facilities across the United States (see also Dembo et al., 1993).
Jurisdictions that provide treatment generally limit access to support group
services, such as Alcoholics Anonymous (AA) and Narcotics Anonymous
(NA), as well as AOD testing (Schonberg, 1993). While a few settings
conduct individual or group sessions for substance-abusing juveniles,
these facilities do not generally conduct comprehensive treatment needs
assessments or plan and carry out individualized treatment programs along
a continuum of care. New interventions within the system are needed to
address these deficiencies; such programming must be clearly aware of
and logically incorporate the etiology, correlates, and consequences of the
drug-crime cycle.

Purpose

The two primary purposes of this report are to summarize existing
knowledge about programmatic attempts to intervene in the juvenile drug-
crime cycle and, based on that review, to propose intervention models with
the greatest likelihood of successfully addressing the cycle. 

Specifically, the report will:

1. Provide a brief overview of the juvenile drug-crime cycle and a
description of the juvenile substance-using population.

2. Review programmatic attempts to break the drug-crime cycle for
juvenile offenders, including an examination of juvenile justice system
processes and the graduated sanctions continuum.

3. Recommend intervention models or modalities that have received the
strongest empirical support for effectiveness.

4. Based on the review of intervention programs, present a proposed
comprehensive intervention model that will include a focus on the specific
elements of successful interventions as well as programs that combine
various successful intervention elements.

This report is based on an extensive review of existing literature and
research reports as well as interviews with researchers who are active in
developing and evaluating programs designed to break the drug-crime
cycle among juveniles. Many of these researchers were recommended by
either the National Institute of Justice (NIJ) or the National Institute on
Drug Abuse (NIDA) and all have extensive research and/or practice
experience in addressing adolescent substance use and/or delinquency
issues. Please see Appendix A for a listing of conducted interviews.

Substance use terminology

Before proceeding further, the authors feel it is important to discuss the
terminology used in this document. The authors will use substance and
AOD interchangeably in addition to the previously defined use of the
phrase drug-crime cycle. Further, most substance abuse experts make a
distinction between the terms use, abuse, and dependence. For the
purposes of this report, the term substance use includes the occasional and
nonproblematic use of alcohol as well as other illegal substances, such as
marijuana and cocaine. The American Psychiatric Association (1994)
defines substance abuse as a "maladaptive pattern of substance use
manifested by recurrent and significant adverse consequences related to
the repeated use of substances," including "repeated failure to fulfill major
role obligations, repeated use in situations in which it is physically
hazardous, multiple legal problems, and recurrent social and interpersonal
problems" (182). Substance dependence is further defined as "a cluster of
cognitive, behavioral, and physiological symptoms indicating that the
individual continues use of the substance despite significant substance-
related problems. There is a pattern of repeated self-administration that
usually results in tolerance, withdrawal, and compulsive drug-taking
behavior" (American Psychiatric Association, 1994:176). 

Such definitional distinctions are important because use, abuse, and
dependence categories are clinically different and have unique
implications for substance abuse treatment and other interventions. For
example, a juvenile who episodically uses alcohol or marijuana does not
necessarily require traditional AOD treatment programming. However, it
is important to note that any AOD use (even if statistically normative) is
illegal for juveniles and may result in juvenile justice system processing
and some type of program intervention.

Given that alcohol and marijuana can be considered gateway substances
into harder substance use (Golub & Johnson, 1994), attempts to intervene
with AOD treatment services early in a youth's substance use history seem
warranted. Additionally, since alcohol is clearly the substance used most
prevalently by juveniles, it is critical that detection, assessment, and
treatment efforts address alcohol use, abuse, and dependence. However, it
is also important to note that it is difficult to utilize use, abuse, and
dependence diagnostic categories with precision due to adolescents'
relatively short histories of substance use (compared to adults). Further
complicating the issue, few normative data exist to set adolescent age-
appropriate levels of tolerance and withdrawal (Greenbaum et al., 1996).
Despite these barriers, juvenile AOD treatment interventions must be
based on carefully conducted assessments of a juvenile's AOD use and
then tailored to each adolescent's individualized needs.

This being said, most AOD treatment providers downplay the distinctions
between alcohol and other psychoactive substances. Miller (1995)
maintains that "There is an enormous overlap between addiction to alcohol
and addiction to other drugs. Polydrug addiction is the norm, not the
exception, and, except for specific pharmacologic issues and timelines, the
processes of progression, treatment, recovery, and relapse are nearly
identical for addiction to alcohol and other drugs" (84). Within this
framework, most AOD treatment centers treat addictions to alcohol and
other substances in nearly identical ways. While detractors might call for
more careful differentiations between different classes of substances,
current treatment center realities make such distinctions unlikely.

The Juvenile Drug-Crime Cycle and the Juvenile Substance-Using
Population

The existence of the drug-crime cycle among juveniles is broadly
recognized and accepted. Researchers examining the relationship generally
conclude that it is very complex and involves a wide variety of associated
behaviors, socio-demographic and economic characteristics, and other
situational variables (McBride & McCoy, 1993). Development and
implementation of successful intervention programs must include a
knowledge of the unique characteristics of the juvenile AOD-using
population as well as known correlates affecting juvenile AOD use and
treatment outcomes. Adolescents present a very specific treatment
population. Compared to adult alcoholics and addicts, adolescent AOD
abusers have shorter substance use histories (De Leon & Deitch, 1985),
are less involved with opiates and have more involvement with alcohol
and marijuana (Johnston et al., in preparation), and report greater binge
drinking and more polydrug abuse (Friedman et al., 1986; Leccese &
Waldron, 1994).

The extent of juvenile AOD use and its relationship to delinquent behavior
has been documented by both self-report and biologic data (such as urine
and hair testing) in a wide variety of national and local studies. Prevalence
data from the Monitoring the Future study show that among 12th grade
students, 32 percent have consumed five or more drinks in a row in the last
2 weeks (Johnston et al., 1998). Twelve percent of 8th graders report use
of any illicit substance in the past 30 days. For 10th graders, this
percentage rises to almost 22 percent, and for 12th graders, the percentage
climbs to almost 26 percent. Rates of marijuana use in the past 30 days are
10 percent, 19 percent, and 23 percent for 8th, 10th, and 12th graders,
respectively (Johnston et al., 1998). Recently reported data also show that
daily marijuana use among 10th graders increased from less than 1 percent
in 1992 to almost 4 percent in 1997 and 1998. The data further show that
cocaine use in the last 30 days among 10th graders increased from less
than 1 percent in 1992 to 2 percent in 1997 and 1998 (Johnston et al., in
preparation). While no large-scale epidemiological studies have been
conducted to determine diagnosable adolescent substance use disorder
rates, some limited community surveys indicate that lifetime prevalence of
any AOD disorder ranges from 3 to 5 percent in 15-year-olds and 10 to 32
percent in 17- to 19-year-olds (Kashani et al., 1987; Reinherz et al., 1993).
It is reasonable to assume that AOD rates for juvenile delinquents are even
higher. In 1992, Cocozza estimated that nearly 320,000 male juvenile
detainees met diagnostic criteria for at least one substance use disorder.
Analyses of data from the National Youth Survey show a strong
correlation between serious substance use and serious delinquent behavior
(Johnson et al., 1993). Johnson and his colleagues (1993) found that only 3
percent of nondelinquents use cocaine, whereas 23 percent of those with
multiple delinquency index crimes are current cocaine users[1].

Data from the 1998 ADAM Annual Report show the extensive prevalence
of substance use among juvenile male arrestees/detainees in many cities
across the United States. The 1998 ADAM report shows that between
1996 and 1998, cities such as Denver, Cleveland, Los Angeles, and
Washington, D.C., reported that about 60 percent or more of their juvenile
arrestees had an illegal substance in their urine. Even the lowest substance
prevalence cities (St. Louis, San Jose, and Indianapolis) reported that over
40 percent of their juvenile arrestees tested positive for illegal substances
(ADAM, 1999). While marijuana was by far the most common substance
found, in many cities such as Cleveland, Denver, Indianapolis, Los
Angeles, Phoenix, and Portland, 10 to 20 percent of the juvenile arrestees
had used cocaine during 1998 (ADAM, 1999). It should also be noted that
there are significant local variations in use patterns among juvenile
arrestees. West Coast juvenile arrestees are more likely to have
methamphetamine in their urine than in other cities. For example, in San
Diego, the proportion of juvenile arrestees testing positive for
methamphetamine (around 10 percent in 1998) is higher than for cocaine
(ADAM, 1999; see also Penell et al., 1999). The report further notes that
male juvenile arrestees who are in school are less likely to test positive for
substances than juveniles who are not in school (ADAM, 1999),
suggesting that those outside of school systems would be even more likely
to test positive for illicit substances.

In a study of nonincarcerated delinquents in Miami, Florida, Inciardi and
his colleagues (1993) found that about three-fourths of both males and
females self-report cocaine use at least weekly. Comparing self-reported
use with hair analysis results, Dembo and associates (1996) found that
adolescents accurately report their use of soft substances such as marijuana
but underreport use of hard substances such as heroin, suggesting that the
self-report rates of the Miami youth could be even higher.

Overall, these epidemiological reports document frequent AOD use among
juveniles, recent increases in AOD use frequency, and the correlation
between frequent AOD use and extensive and sustained delinquent
behavior. These data suggest a strong need to intervene in the juvenile
substance use and delinquency cycle.

Juvenile Justice System Conceptual Underpinnings and Developments

An examination of the current juvenile justice system requires a brief
review of its conceptual underpinnings and current conceptual
developments as well as a review of the system's usual operational
practices. These reviews have implications for how programmatic
interventions may occur in the juvenile drug-crime cycle.

Conceptual underpinnings

The juvenile court system arose from attempts to develop a justice system
for juveniles that differed from the adult system. From its very beginnings
in Cook County (Chicago), Illinois, the juvenile justice system defined
itself as a caring parent as opposed to punishing judge. While the
developing juvenile system involved classic elements of the adult system
in that it operated in the framework of laws regulating behavior and
utilized aspects such as prison-like punishment, the primary focus was on
rehabilitation. At times, this conceptual underpinning resulted in a lack of
careful attention to constitutional due process rights. Beginning in the
1960s, the juvenile court increasingly found itself under constitutional
review regarding the application of due process criminal court elements. 

A classic illustration of problems with due process occurred in the case of
15-year-old Gerald Gault. In 1964, Gault and a friend were taken into
custody by police based on a verbal complaint. Gault's parents were never
informed of his being taken into custody. Neither Gault nor his parents
were ever given notice of the charges or his basic constitutional right to
remain silent. In addition, Gault was not even present at the formal
juvenile court hearings in which a judge adjudicated him delinquent and
sent him to a state industrial/training school until he was 21. In 1967, the
Supreme Court ruled that juveniles have the right to basic constitutional
due process, including knowing the charge against them, being informed
of their constitutional rights, and actually being present at their own
hearings (Re Gault, 387 U.S. 1, 18 L. Ed. 2d 527, 87 S Ct. 1428, 1967).
The 1970s saw a continuing application of Federal constitutional rights to
juveniles and major movements to close State industrial/training schools
(Bartollas, 1997).

During the 1980s, American society experienced a very large increase in
the rate of juvenile crime, with a particular increase in the rate of violent
juvenile crime. This trend resulted in increasing willingness on the part of
Federal and State governments to try juveniles accused of serious (violent)
crime as adults (Bartollas, 1997; Strom et al., 1998; Sickmund, 1994).
However, while there appears to be an increased willingness to define
juveniles as adults, there continues to be strong support for incorporating a
rehabilitative philosophy with community protection and justice models
based on the initial caring parent approach of the early juvenile justice
system.

Conceptual developments

While the concept of using the justice system to address human behavior
problems is not new, it has received new impetus in recent years. A recent
issue of the Notre Dame Law Review (Hora et al., 1999) is entirely
devoted to the concept of therapeutic jurisprudence and how its application
can and is revolutionizing America's response to the drug-crime cycle.
Therapeutic justice advocates suggest that psychological, sociological,
cultural, and other factors should be fully considered in law applications,
and that the goal of the courts should be not only protecting the
community and punishing the offender but also addressing the underlying
reasons for criminal/problem behavior. Within this framework, key players
in the justice system (including judges, prosecutors, and defense attorneys)
transition from adversarial roles to problem solvers as part of a
collaborative team while at the same time continue to perform traditional
roles of community protection, applicators of law, and protectors of due
process (Spangenberg & Beeman, 1998). Therapeutic jurisprudence
appears to be very consistent with the philosophical underpinnings of the
juvenile justice system. As Hora and her colleagues (1999) note, the
juvenile court applies therapeutic jurisprudence in its broadest sense by
including the family and a wide variety of other relevant factors in
decision making.

Within the juvenile justice system, a perspective called Balanced and
Restorative Justice (BARJ) has emerged in the last few years that provides
a useful framework for examining and developing programmatic
interventions to address the juvenile drug-crime cycle (Office of Juvenile
Justice and Delinquency Prevention, or OJJDP, 1998). The BARJ
perspective attempts to integrate the traditional rehabilitative philosophy
of the juvenile court with increasing concerns about victim rights and
community safety. Specifically, the model focuses on: 

1. Offender accountability, which enables the offender to make amends to
victims and the community.

2. Competency development, which helps a juvenile change his or her
behavior and have the skills necessary to function in today's society and
economy.

3. Community safety, which involves protecting the community by
monitoring juvenile behaviors and implementing graduated sanctions. 

This model suggests that any response to youth crime must strike a
balance between the needs of victims, offenders, and the community.
Further, it suggests that victims, offenders, and the community should be
as involved in the justice process as possible (Bazemore & Nissen, in
press). Rather than asking the question "What should be done to punish
the offender?" restorative justice asks the following questions (Zehr,
1990):

--What is the nature of the harm resulting from the crime?

--What needs to be done to "make it right" or repair the harm? 

--Who is responsible for the repair? 

This process takes place through collaborative involvement of key players
in the juvenile justice system and community and, if desired, the victim.

BARJ has become a guiding principle in juvenile justice system change
for at least 12 States (OJJDP, 1998). Illinois provides an excellent example
of a strongly proactive attempt to use the model in system reorganization.
A recent publication of the Cook County, Illinois, State's Attorney's office
describes how BARJ has changed the current system, including required
interagency collaborative agreements and practices that are monitored by
the State's Department of Human Services (Devine, 1998). The BARJ
model is relatively new and has not been subjected to extensive
evaluation. However, it is an important part of a developing framework in
the justice system. While the BARJ model is used as part of the
background material of this report, it has not been formally integrated into
the evaluation presented on interventions. The focus of this report is on
reviewing the effectiveness of interventions at various points of the
juvenile justice system and suggesting guiding principles and a possible
model for applying those principles. Where this is consistent with the
BARJ model or seems implied by that model, it is noted. The BARJ model
provides a general framework rather than a detailed critical analysis of
intervention systems and collaborative models.

An additional and related trend in juvenile justice is the recent emergence
of the strengths-based approach. Juvenile justice systems in general, and
AOD treatment centers in particular, have historically been based on
models which emphasize an individual's deficits and problems: "...it
appears that many treatment programs are based on the assumption that
offenders can be 'fixed' in isolation from the rest of the world. This is due
to an all-too-familiar and well-rooted history of treatment grounded in a
medical model that suggests that therapeutic intervention acts as a kind of
emotional surgery" (Bazemore & Nissen, in press:9-10). Bazemore and
Terry (1997) suggest that the juvenile justice system has been designed to
see youth either as victims or villains while ignoring the natural capacities
of both the youth and their communities. These programs fail to address
the role of relationships and the institutional and community contexts
which nurture criminal behaviors. 

Rather than focus on what is wrong with individuals, the strengths-based
perspective suggests that youth have internal resources and community-
based supports which can be tapped to encourage appropriate functioning
within the community. As such, strengths-based approaches focus on what
youth are good at, who their naturally occurring, positive community
supports are, what they want which is positive and interesting to them, and
what they can be in spite of their past histories (Bazemore & Nissen, in
press; Nissen, submitted for publication). The approach seeks to
incorporate concepts such as respecting and looking for client strengths,
engaging client motivation for change by tapping into those strengths,
seeing the environment as full of resources, and being a collaborator with
the client in therapeutic work (Saleebey, 1992). These concepts can be
integrated into the entire juvenile justice continuum and have recently
been introduced in some drug courts, case management systems, and
multidimensional family approaches to intervention. Each of these areas,
including program outcome results, will be reviewed later in this report.

The Juvenile Justice System Process

With the foregoing conceptual trends and frameworks in mind, a brief
overview of the juvenile justice system process will provide a context for
understanding where and how substance abuse services may be
appropriately offered (substance abuse treatment services can be and are
offered at any stage of the process).[2] The juvenile justice system is
composed of six main phases:

--Intake. A preadjudication intake officer at a local juvenile court decides
to release a juvenile into parental custody, place him or her on informal
probation, or detain the youth in a detention facility. Many juveniles are
also counseled by the intake officer and diverted into other community
agencies.

--Social investigation. A probation officer examines the juvenile's family,
education, history of delinquency, etc., for the juvenile court. Some
investigations are supplemented by reports from child advocates or court-
appointed social workers.

--Fact-finding hearing. A juvenile appears before a judge who reviews the
complaint and the social investigation. Special juvenile drug courts have
been established in some locations to facilitate the evaluation and
adjudication of AOD-related offenses.

--Adjudication. Based on the fact-finding hearing, the court determines if
the juvenile is delinquent. The judge's decision is strongly influenced by
the intake officer's recommendations.

--Disposition. If the juvenile is determined to be delinquent, a hearing is
held where the judge decides case disposition. Options include releasing
the delinquent with a warning, community supervision, or commitment to
a specialized treatment or detention facility, such as a State training
school, boot camp, or community residential facility. Recent trends favor
placing youth in detention facilities (Schonberg, 1993).

--Continuing care. After the juvenile has completed the court's
recommendations, he or she is often released to the supervision of a
variety of continuing care providers. Provider services include counseling,
school dropout prevention, structured social activities, etc.

Each of these phases will be examined relative to their role in breaking the
juvenile drug-crime cycle. As juvenile justice system phases and their
relationship to AOD treatment interventions are described, it is important
to recognize three overarching concepts and strategies that affect each
phase: case management, systems collaboration, and graduated sanctions.
These concepts/strategies are raised and discussed in this report within the
juvenile justice system phase where each would be primarily applied. Case
management and systems collaboration are discussed during the social
investigation phase, and graduated sanctions are discussed in the
disposition phase.

System contact: the juvenile justice system and court supervision at intake

Intake is the first point of official system contact between youth and the
juvenile justice system. The etiology of youth access into the system is
varied and may include parental referral based on incorrigible youth
behavior, teacher referral, arrest as a result of an accusation within an
ongoing criminal investigation, or arrest as a result of an observed legal
infraction of the law. As noted above, juvenile justice system involvement
at this stage involves preadjudication intake officers of the local juvenile
court. Decisions to dismiss, divert to various collaborative community
agencies, or move to disposition/detention are usually made by the intake
officer.

OJJDP's National Juvenile Justice Action Plan (Coordinating Council on
Juvenile Justice and Delinquency Prevention, 1996) outlines several
characteristics which any system must include in order to adequately
address the comprehensive needs of juvenile offenders. The three
characteristics relating to the intake process follow:

1. The system must include a single point of entry which screens and
assesses the needs of AOD-involved youth at the time of intake. Currently,
most systems of treatment are decentralized with multiple points of entry;
this decentralization often results in provision of inappropriate services,
unnecessary duplication of services, and major gaps in problem
identification, assessment, referral, and overall access to services by youth
in need of AOD treatment (Coordinating Council on Juvenile Justice and
Delinquency Prevention, 1996).

2. The Action Plan calls for immediate and comprehensive assessment.
Supporting this contention, OJJDP's study of risk assessment in 14 States
found that, on average, 31 percent of incarcerated youth could be safely
placed in less secure settings, resulting in more appropriate rehabilitation
in a less restrictive environment. Considerable financial savings would be
an added bonus.

3. Assessment should be culturally sensitive and designed to identify
environmental, familial, personal, and systemic factors which contribute to
delinquency and substance use (Bilchik, 1995).

Social investigation: assessment, case management, management
information systems, and collaboration

Assessment

AOD treatment services can be provided at several points along the
juvenile justice continuum. At the point of entry into the juvenile justice
system (intake), the preadjudication intake officer provides a critical
gatekeeping function in identifying and intervening with substance abuse
problems. Such problems are usually enmeshed within a wide variety of
other issues; thus, comprehensive assessment is necessary in order to
successfully address substance abuse. Hoge (1999) notes that juvenile
justice systems may make poor decisions about juvenile placement
because they fail to gather adequate assessment information. Considerable
discretion is afforded to personnel who collect such information, and there
is often heavy dependence on informal and unsystematic assessment and
decision procedures that may result in invalid inferences about clients. 

Because the recommendations of the preadjudication intake officer often
heavily affect judicial decisions, it is imperative that intake personnel be
thoroughly trained in the use of comprehensive assessment tools. More
careful screening mechanisms not only will help identify services most
needed by juveniles but also will prevent system duplication leading to
inefficient and poorly coordinated service delivery. By properly assessing
and coordinating point-of-entry services, the juvenile justice system can
more effectively work toward preventing increasing levels of future
delinquency. However, in order to make appropriate assessment and
treatment decisions, assessment personnel must consider and incorporate
issues of culture and ethnicity into comprehensive juvenile evaluations, as
well as be prepared for the complexities of clients with multiple diagnoses.

Culturally sensitive assessment. Statistics indicate that a disproportionate
number of juvenile detainees are minorities. Minority group membership
is often characterized by social injustice, differential treatment by society,
and a sense of personal impotence and powerlessness. Comprehensive
program development should address these and other issues of ethnicity
and how they relate to assessment, intervention, and treatment in juvenile
populations. Because of the danger of overgeneralization and its
accompanying stereotypes and prejudices, broad guidelines will be
introduced both here and in later sections of this report dealing with
intervention and treatment that focus on increased awareness of cultural
differences and how they might affect a juvenile's progress through the
justice system.

Since both formal and informal assessments are initiated at the juvenile's
first point of contact with the system, cultural competencies need to be
developed with all front-line staff, including law enforcement, justice
system professionals, assessors, case managers, and any others who
become involved early in the process. While cultural competence is
desirable at all points in the continuum of care, it is crucial that the people
making decisions about how the juvenile will be initially processed have
an understanding of the roles of ethnicity and culture.

Validation of screening and assessment instruments has typically been
based on European-American values (Canino & Spurlock, 1994; Ho,
1992; Paniagua, 1994). Culturally sensitive practitioners should select
instruments shown to have the least bias with the minority population
encountered. According to Flaherty and colleagues (1988), in order to be
valid, assessment instruments must have content, semantic, technical,
criterion, and conceptual equivalence across cultures (for lists of
recommended instruments, please see Canino & Spurlock, 1994;
Paniagua, 1994). An assessment model developed by R.H. Dana (as
summarized by Paniagua, 1994) suggests that the following elements are
needed in culturally sensitive assessment: assessing degree of
acculturation, providing culturally specific service delivery styles, using
the client's preferred language when possible, selecting appropriate
assessment measures and methods, and displaying cultural sensitivity
when informing clients about findings resulting from assessment. 

Paniagua (1994) summarizes various assessment methods according to
their degree of bias, recommending that the least biased method be used
whenever possible. Methods which reflect the least cultural bias include
physiological assessment, direct observation of behaviors, self-monitoring
or behavioral self-reporting scales and instruments, and clinical interviews.
Methods more prone to bias include trait measures, self-report of psycho-
pathology, and projective tests. Some general guidelines for culturally
sensitive assessments include asking culturally appropriate questions,
focusing on ethnic identification rather than race, addressing socio-
economic status as it interacts with ethnicity, and self-awareness of
prejudices, biases, and stereotypes which may lead to faulty conclusions
about the client (Canino & Spurlock, 1994; Paniagua, 1994).

Co-occurring addictive and mental disorders. Assessment of AOD abuse is
further complicated by the co-occurrence of mental disorders (also referred
to as dual diagnoses). Both mental health and substance abuse treatment
providers have long known that AOD abuse and mental disorders often
coexist in the same individuals. A recent study based on data from the
National Household Survey on Drug Abuse (Substance Abuse and Mental
Health Services Administration, 1999) determined that adolescents who
self-reported emotional problems were nearly four times more likely to be
dependent on alcohol or illicit substances than other adolescents. They
were also four times more likely to have used marijuana and were seven
times more likely to have reported use of other illicit substances in the
previous month.

Treatment for a client with co-occurring addictive and mental disorders is
typically hard to obtain. Clinicians often find it difficult to diagnose both
disorders due to mixed and overlapping symptoms. However, both
psychiatric and chemical dependency treatment centers routinely refuse to
admit individuals who are judged to have coexisting disorders. If a client
is admitted to one type of center who later is found to have significant
symptoms of the other disorder, he or she can be told they are no longer an
appropriate treatment subject. Such problems occur for several reasons:

--Treatment providers feel inadequately trained and equipped to deal with
the unique problems associated with co-occurring disorders.

--The unique contributions of each disorder to the existing functional
impairment are often difficult to determine, thus complicating both
assessment and treatment interventions.

--Differing philosophies of what has caused the disorder lead clinicians
from both professions to downplay the importance of the other disorder.

--Acting-out behaviors associated with both disorders can be difficult for
many facilities to handle.

Large-scale epidemiological studies of co-occurring disorders have not yet
been undertaken for adolescents. However, a major review of smaller scale
general population and clinical studies has been conducted in both
inpatient psychiatric and addictions settings (Greenbaum et al., 1996).
While many of the studies reviewed contained numerous methodological
problems, results show that approximately half of all adolescents receiving
mental health services also have co-occurring substance abuse problems.
Conduct disorder and depression are the two most frequently reported co-
occurring mental disorders, with most clinicians considering depression to
be a major element of dual diagnoses. In a review of 16 clinic- and
community-based studies, Winters (1998) found that diagnosable
substance use disorders are two to five times more prevalent among youth
with a conduct disorder diagnosis than among control group youth. In
addition, Winters, Latimer, et al. (in press) reported that a general
delinquency factor is responsible for nearly 50 percent of the variance in
AOD use severity in an AOD-clinic referred sample for both boys and
girls across all ethnic groups. Other less commonly reported co-occurring
psychiatric disorders include bipolar disorder, anxiety disorder, and
attention deficit/hyperactivity disorder (ADHD) (Thompson et al., 1996). 

When ADHD and conduct disorders co-exist in the same youth,
researchers estimate that co-occurring substance use disorder rates range
from approximately 30 to 60 percent (Wilens et al., 1994).
Pharmacotherapy treatments for these co-occurring disorders have not
been well researched for adolescents (see Solhkhah & Wilens, 1998, for a
review of studies on the effects of medication for treating children or
adolescents with AOD disorders). One further difficulty in assessing and
treating juveniles with co-occurring disorders is the lack of a coordinated
and centralized approach to assessment. Community assessment centers
provide one solution to this problem.

Community assessment centers. While the OJJDP Action Plan calls for the
establishment of community assessment centers, few jurisdictions
currently provide a single point of system entry or comprehensive
screening and assessment for juveniles during the intake process. Notable
exceptions are Target Cities programs, Treatment Alternatives for Safe
Communities (TASC), and the Juvenile Assessment Center (JAC).

1. Target Cities. Target Cities programs (supported through the Center for
Substance Abuse Treatment, or CSAT) provide comprehensive screening
and assessment. Target Cities sites are required to improve coordination
among relevant human service agencies, establish or enhance a Central
Intake Unit (CIU) and referral services, include quality monitoring, and
focus on treatment services for at least one specified subpopulation, which
may include adolescents (Department of Health and Human Services, or
DHHS, 1995; Scott et al., forthcoming; Cleveland C.A.R.E.S., 1999; Kraft
& Dickinson, 1997). Juvenile offenders are served at two Target Cities
sites (Albuquerque, New Mexico, and Cleveland, Ohio).

2. TASC. TASC programs follow a case management model, including
single-point-of-entry assessment and diagnosis; specialized service
planning and treatment matching; intervention, service referrals, and
placement; and monitoring and reporting (Baille & Breslin, 1996).

3. JAC. The JAC began in Tampa, Florida, but has spread to nine other
Florida locations. While services in each location vary, the basic elements
and functions of the model include centralized location of relevant
agencies which can conveniently provide needed services to at-risk youth;
screening, diagnosis, and, if appropriate, linkage of arrested and high-risk
youth with area service providers; case management of juveniles assigned
to diversion programs within the juvenile justice system; and tracking,
which is usually limited to the purpose of determining referral disposition
(Dembo & Rivers, 1996). Ideally, the JAC is designed to move juveniles
through the system in the following way:

--Law enforcement officers bring the arrested youth to the JAC where he
or she is processed by Department of Juvenile Justice detention intake and
JAC assessor personnel.

--JAC assessors conduct breathalyzer and urine tests for substance use;
substance abuse and mental health histories are also collected. In addition,
the juvenile undergoes preliminary screening using the NIDA Problem
Oriented Screening Instrument for Teenagers (POSIT) to identify potential
problems in 10 different psychosocial functioning areas (the POSIT is
described in greater detail below). Based on the results of this preliminary
screening process, indepth assessments are conducted in problem areas
such as AOD abuse, mental illness, physical and sexual victimization, and
delinquency.

--On the basis of assessment findings, current charges, and arrest history,
intake staff determine whether the youth should be placed in secure
detention, home detention, or released into the care of a parent, guardian,
or responsible relative.

--When a minor is not appropriate for detention, he or she is assigned to
the misdemeanor case management staff at the JAC. This unit reviews the
arrest histories and current charges of the youth to determine his or her
eligibility for arbitration or various diversion programs within the local
juvenile justice system.

--JAC misdemeanor case managers follow the case until the juvenile
successfully completes the program to which he or she is assigned. If the
program is not successfully completed, the case manager has the option to
file a delinquency petition, and the case is turned over to the Department
of Juvenile Justice case manager.

One obvious component of a successful community assessment center is
the use of valid and reliable screening instruments. The following section
describes a number of assessment instruments for adolescents that the
research literature suggests are considered valid and commonly used.

Assessment instruments. The number of adolescent AOD assessment tools
has grown rapidly in recent years (Farrow et al., 1993; Winters &
Stinchfield, 1995), with over 30 tools currently available for both
screening and assessment. This increasing growth has made selection of an
appropriate screening instrument more difficult than ever before: "The rate
of development of this new generation of measures has out-paced efforts
to critically evaluate them, leaving the field somewhat at a loss as to their
absolute and relative merits" (Stinchfield & Winters, 1997:63).
Recognizing that alcohol is the mood-altering substance most commonly
used by juveniles, most of these instruments assess alcohol as well as other
substance use, abuse, and dependence.

Substance abuse assessment tools are commonly divided into screening
and comprehensive assessment instruments. Several full-range assessment
systems have also been designed to combine screening, diagnostic
evaluation, and comprehensive assessment in one package. The primary
purpose of screening is to determine if the need for a more comprehensive
assessment exists. Thus, it is inappropriate to use screening instruments to
formulate a diagnosis or decide treatment needs. If the screening
instrument indicates an AOD problem, a more comprehensive assessment
is indicated. At minimum, the comprehensive assessment should include:
(1) an in-depth examination of the severity and nature of the AOD abuse
identified by the screening process, (2) a more thorough assessment of
additional problems flagged during the screening and additional inquiry
into problems that may not have been included in the screening, and (3) a
strong effort to use multiple methods and sources with special emphasis on
including the youth's family in the assessment, using standardized
assessment instruments, and obtaining prior assessments and other
relevant records (Winters & Stinchfield, 1995). 

Appendix B includes an overview of a number of stand-alone substance
abuse screening tools and mid-range instruments. It is recommended that
both screening tools and mid-range substance abuse instruments be
supplemented with more comprehensive assessments of the juvenile's
broader psychosocial needs.[3]

Assessment systems integrate screening, diagnosis, and comprehensive
assessment into one package. Advantages include rapid referral of
adolescents to more indepth assessment, standardization of the assessment
and referral process, assurance that an adolescent's comprehensive needs
have been adequately addressed, and evaluation of client needs with
adequate referral to appropriate adjunctive services. Disadvantages include
higher costs for commercial assessment instruments and the need for staff
expertise and training to administer and interpret the instruments (Winters
& Stinchfield, 1995), as well as comparatively longer time periods for
administration than non-comprehensive assessment instruments. Two full-
range assessment systems commonly used with juvenile delinquent
populations are discussed below:

1. Adolescent Assessment/Referral System (AARS). NIDA initiated the
AARS in order to identify reliable and valid assessment instruments that
could be used to assess the broad psychosocial problem areas of AOD-
involved youth and guide treatment decision development (Rahdert,
1991). The AARS includes three components plus a treatment plan, which
are described below.

--The POSIT. The POSIT is available in both Spanish and English and is a
139-item, yes/no, self-administered instrument which explores difficulties
in 10 high-risk areas of functioning: AOD use/abuse, physical health
status, mental health status, family relationships, peer relations,
educational status, vocational status, social skills, leisure and recreation,
and aggressive behavior and delinquency. The POSIT is designed to
quickly identify problems in any functional area requiring further
assessment and/or treatment. A reliability study indicates that the POSIT
consistently identifies potentially troubled youth who are in need of
indepth assessment and intervention or treatment services (Dembo et al.,
1996).

NIDA is currently pilot-testing an HIV/STD-risk mini-questionnaire
designed to be administered alone or as a supplement to the POSIT
(Rahdert, 1999). This questionnaire will provide valuable information on
juveniles' high-risk sexual practices. Early evaluation supports internal
consistency and test-retest reliability, as well as content and criterion
(predictive and concurrent) validity.

--The Client Personal History Questionnaire (CPHQ). The CPHQ is
included with the POSIT and identifies client demographics, history of
juvenile justice and mental health contacts, school performance, health
care utilization, and current life stressors. Academic information and
school discipline information are gathered when available. Collateral
information is also collected from parents or guardians using the Problem
Oriented Screening Instrument for Parents (POSIP). This information is
useful in helping assessment professionals corroborate juvenile claims.

--The Comprehensive Assessment Battery (CAB). The CAB includes a
variety of psychometrically validated assessment tools which probe more
deeply into each of the 10 problem areas identified by the POSIT.
Examples of recommended CAB assessment instruments are the Personal
Experience Inventory (PEI) and the Adolescent Diagnostic Interview
(ADI) for AOD abuse (Winters, 1991; 1992; Winters & Henly, 1989), and
the Family Assessment Measure (FAM) for family relations (Skinner et
al., 1983).

--Treatment planning. The AARS recommends that staff develop a
treatment plan after completing the assessment phase. The AARS manual
guides programs in developing their own local directory of adolescent
services, which assists the case manager or referral agent in locating
appropriate resources and placing troubled youth in services which match
their treatment needs.

2. Minnesota Chemical Dependency Adolescent Assessment Package
(MCDAAP). Like the AARS, the MCDAAP attempts to provide both
screening and more intensive assessment. However, the MCDAAP differs
from the AARS in several ways: "The MCDAAP tools are primarily
geared to measure drug abuse characteristics and related problems and
only screens [sic] for coexisting mental and behavioral disorders; the
MCDAAP screening tool contains fewer items than the POSIT; and the
MCDAAP does not include resources related to additional assessment and
treatment referral" (Winters & Stinchfield, 1995:153). The MCDAAP has
three components, described below.

--The Personal Experience Screening Questionnaire (PESQ). The PESQ
(Winters, 1991; 1992) is a 40-item, self-report screening instrument
primarily designed to estimate the potential need for AOD treatment
services among adolescents. The instrument evaluates problem severity
(18 items), psychosocial problems (8 items), substance use history (4
items), defensiveness or faking good (5 items), and infrequency or faking
bad (3 items). The index measures behaviors, attitudes, and consequences
related to AOD use by adolescents. The PESQ's advantages include its
format, brevity, and relatively easy reading level (fourth grade).
Evaluation indicates internal consistency, reliability, accurate prediction of
comprehensive AOD assessment need, and follow-through of referral.[4]

--Adolescent Diagnostic Interview. The ADI assesses symptoms found in
substance use disorders as described in the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV). The interview format includes a substance
abuse history and signs of abuse or dependence in all major AOD
categories. The ADI also screens other mental health disorders and several
domains of functioning (e.g., school performance, peer and family
relationships, legal problems, and leisure activities) (Winters &
Stinchfield, 1995). Evaluation supports interrater and test-retest reliability,
as well as criterion validity.[5]

--Personal Experience Inventory. The PEI is a multiscale instrument which
identifies problems and makes referral and treatment recommendations
based on a differential diagnosis of a client's problems. It is divided into
two sections: chemical involvement problem severity and psychosocial
risk factors. The PEI measures AOD misuse problem severity and use
frequency as well as psychosocial and environmental correlates of
adolescent AOD abuse (e.g., negative self-image, social isolation, physical
and sexual abuse, and estrangement from family). Several additional
clinical problems are also measured, including eating disorders, suicide
potential, other mental health symptoms, and parental history of substance
abuse. "PEI scores have been found to be highly correlated with other
measures of drug abuse problem severity and psychosocial risk factors,
independent recommendations regarding need for drug abuse treatment,
and independent clinical diagnoses" (Winters & Stinchfield, 1995:9). The
PEI is recommended by a NIDA publication for use in comprehensive
evaluation of adolescent substance use/abuse (Rahdert, 1991).

Case management

Whatever assessment instrument is chosen, it is crucial to use the
assessment for the development of a comprehensive intervention/treatment
plan. Such a plan must be housed within an organizational structure
including roles that facilitate meeting the identified needs of the juvenile.
Case management provides one way for juvenile justice systems to
coordinate meeting the comprehensive needs of adolescents. The function
of the case manager (CM) is "to secure and coordinate continued social,
mental health, medical, and other services for a client" (Healey, 1999:1).
The approach has emerged as an intake, during-treatment, and
posttreatment strategy which can connect clients (adults and juveniles) to
needed resources throughout the service continuum resulting in more rapid
access to services (Bokos et al., 1992), higher levels of goal attainment
(Godley et al., 1994; Rapp, 1997), longer lengths of stay in treatment
(Rapp et al., 1997), improved AOD treatment outcomes (Rapp, 1997),
improved employment functioning (Siegal et al., 1996), and improved
connection to needed resources over time (Dennis et al., 1992; Godley et
al., 1994; Schlenger et al., 1992) when compared to standard treatment
services. Due to its individualized nature, case management appears
particularly effective in meeting the needs of special populations, such as
homeless persons (Conrad et al., 1993; Perl & Jacobs, 1992), injection
drug users (Falck et al., 1994), persons with AIDS (Lidz et al., 1992;
McCoy et al., 1992), youth with dual diagnoses (Evans & Dollard, 1992),
and juvenile delinquents (Enos & Southern, 1996). Research suggests that
case management may be useful as an adjunct to substance abuse
treatment for two reasons: (1) retention in treatment is generally associated
with better outcomes, and one of case management's primary goals is to
keep the adolescent engaged in the treatment process (Kolden et al., 1997;
Siegal et al., 1995), and (2) treatment is more likely to succeed when a
youth's non-substance abuse problems (e.g., school performance, family
problems, etc.) are also being addressed (Westermeyer, 1989).

According to a recent NIJ examination of case management within the
criminal justice system (Healey, 1999), optimum case management
models currently combine two broad approaches: strengths-based and
assertive. Strengths-based case management focuses on a client's self-
identified strengths and talents when developing a service plan, assuming
a client's ability to use these strengths in order to move toward "socially
acceptable choices" (Enos & Southern, 1996:44-45). Within the criminal
justice setting, CMs combine support and positive regard for a client's
strengths with clear disapproval of the behaviors leading to justice system
involvement. Assertive case management requires active involvement of
the CM in seeking out and delivering services to clients as opposed to
passive service provision (Inciardi, 1996; Healey, 1999). Many current
versions of case management methodologies have followed a passive
approach to service provision, providing clients with referral information
but not actively engaging in obtaining such services for the client.
According to much of the research, by combining strengths-based and
assertive case management, aggressive service provision based on a
client's own strengths and talents can best support client success.

Case managers support and reinforce treatment continuum goals by
providing five major functions: 

1. Engagement. CMs orient, support, and meet immediate adolescent
needs, as well as serve as linkages to resources and services. 

2. Assessment. CMs assess the appropriateness and eligibility of both
internal and external resources. Some CMs provide the majority of
assessment services, including the collection of information from family,
school, and court systems (Babor et al., 1991). 

3. Planning, goal-setting, and implementation. CMs are not treatment
providers but instead focus on the longer term recovery needs of juveniles
while assisting in the maintenance of the treatment plan as devised by the
treatment service provider(s). CMs follow youth as they move through and
at times beyond the treatment continuum, acting as system guides to
ensure that youth obtain needed resources and stay motivated to maintain
treatment progress. 

4. Linking, monitoring, and advocacy. CMs can enhance adolescents'
commitment to seek needed resources, help implement plans derived from
such contacts, troubleshoot obstacles which may prevent client success,
and model, rehearse, and summarize the implementation of those plans
(Ballew & Mink, 1996). CMs can also help navigate the often confusing
social service system and advocate for needed resources where necessary. 

5. Disengagement. CMs help youth summarize and review progress
toward goals, with a focus on treatment gains and planning for youth to
continue to access services on their own.

At posttreatment, the CM might help the adolescent reintegrate with his or
her family or an out-of-home placement, coordinate care between staff and
services at other agencies, and/or help with reintegration into the school
system. In addition, CMs may intervene in crisis situations or assist youth
in finding work and/or appropriate substance-free friends and leisure
activities. Intensive case management services are most critical during the
vulnerable 2-month period following discharge from primary treatment
with the purpose of providing continuity of care while simultaneously
working to move the adolescent toward independence (Spear & Skala,
1995).

While a CM can help a juvenile navigate through an interconnected array
of treatment services, it is also clear that such services must occur within
the context of the juvenile justice system. System representatives, such as
drug courts or probation offices, will maintain primary responsibility for a
juvenile's movement through the juvenile justice system via the use of
graduated sanctions. The graduated sanctions process allows the judge or
probation officer to maintain an appropriate balance between community
protection and juvenile rehabilitation (graduated sanctions will be
discussed in greater detail below). However, judges generally have neither
the time nor training to ensure that juveniles receive a continuum of
services. It should be noted that if a community has Intensive Probation
Supervision (IPS) services, IPS probation officers are likely able to fulfill
the case management role if trained in clinical and evaluation
methodology. However, the reality of traditional probation case loads (as
well as potential limitations from collective bargaining agreements) may
prevent probation officers from serving in case management functions to
provide the vital role of linking adolescents to needed and appropriate
interconnected community resources including AOD treatment services.

Case management in the criminal justice system requires unique
methodologies of service provision. Healey (1999:2) notes that criminal
justice case management often involves a conscious blurring of roles
between CMs, mental health providers, substance abuse counselors,
domestic violence program counselors, and other social service providers.
Significant cross-training is often necessary to allow such blurring to take
place without confusion of appropriate role responsibility. Therefore, role
expectations should be clearly negotiated between service providers before
service provision begins. In addition, it is critical that philosophical
differences between criminal justice personnel and AOD treatment and
mental health service providers be shared and discussed in order to ensure
smooth communication and successful treatment for the client (Healey,
1999; McBride & VanderWaal, 1997).

While case management has been used in the delivery of residential
(Godley et al., 1994) and inpatient (Siegal et al., 1995) substance abuse
treatment services, little is known about its effectiveness in juvenile justice
settings. Conceptually, case management could be an important part of the
juvenile justice system, providing a coordinated control point for
implementing judicial decisions and reporting back to the court. Three
promising case management programs designed to assist high-risk, AOD
abusing adolescents are described below, as well as one program with
potential applicability to juvenile justice settings.

Youth Evaluation Services (YES) (Del Boca et al., 1995). YES is an
integrated assessment and case management system. Its primary goal is to
coordinate services for youth with substance abuse problems; in addition,
the system collects data on treatment utilization, service costs, and
outcomes. Adolescents are screened and comprehensively assessed using
the AARS (described earlier). This information is supplemented by data
gathered from parents, CMs, and schools. YES personnel formulate a
treatment plan based on the results of the assessment process utilizing a
Treatment Matching Criteria system. Finally, adolescents are referred to
various substance abuse treatment services. Following acceptance of the
treatment plan by the youth and his or her parents, CMs begin performing
a variety of client-specific functions, including monitoring the adolescent's
progress, linking him or her to appropriate services, coordinating
continuing care services, and advocating for his or her needs. Formal
monitoring of treatment and progress toward recovery continues at regular
intervals for up to 18 months (treatment outcomes were not available).

The Amity Project (Healey, 1999; Stiles & Mullen, 1993; Adult Probation
Department, 1994, 1995). This model was a collaborative effort between
Amity, Inc., and the Pima County (Arizona) Department of Probation.
Minorities and younger offenders at high risk of probation revocation due
to continued substance abuse were served in a day-and-evening program
resembling a therapeutic community. A graduated sanctions approach
incorporating case management and a variety of other services (including
educational/vocational training, health services coordination, and
continuing care) was provided at a community-based site. Two years after
initiation of the program, reductions in AOD use relapse were observed, as
well as increases in employment. Positive urine screens (part of program
monitoring) fell by over 50 percent in the first year of program operation.
Funding issues caused the closure of this program.

The Iowa Case Management Model (Hall, 1997). This model assists
juveniles in maintaining an AOD-free lifestyle following discharge from
an inpatient treatment facility. The CM targets both individual and
environmental outcomes for change in the youth's social system. The Iowa
Case Management philosophy emerges from the principles of strengths-
and solution-based therapeutic models. Client-driven goals are described
in behavioral terms using solution-oriented language emphasizing the
presence of positive behaviors rather than the elimination of negative ones.
The program is divided into three primary phases conducted over a 1-year
period: active case management with regular CM/adolescent meetings,
transitional case management with less frequent meetings, and self-
directed case management. Case management functions include: 

1. Assessment and monitoring. Using assessments to discover the
adolescent's strengths, resources, ambitions, goals, and past successes, as
opposed to problems and past failures.

2. Negotiating and contracting. Together with the youth, jointly
developing a solution plan including involvement and responsibilities of
each party.

3. Solution-based problem solving, and planning and referral. Using an
individual solution plan to develop referrals to necessary services.

4. Evaluation of process and outcomes. Monitoring and providing
feedback on activity or goal achievement. 

As of this writing, the Iowa Case Management Model was still undergoing
evaluation relative to its effectiveness for juveniles.

The Case Management Enhancements Project (CME) (Siegal et al., 1996).
This NIDA demonstration project is designed to examine the impact of
community-based aftercare and strengths-based case management on
retention and outcomes related to adult AOD treatment. It is described in
this report because of the program's strengths-based approach (Rapp,
1997) and its potential applicability to juvenile justice settings. Case
management within the CME is designed to supplement an existing
medically based, disease concept-oriented treatment program. Clients are
first evaluated using a strengths assessment covering nine life domains;
within each domain, CMs ask participants to describe specific incidents
where they successfully demonstrated skills and abilities. CMs then help
participants set their own goals and strategies, including target and review
dates. Researchers (Rapp et al., 1998) randomly assigned AOD-using
Veterans Hospital participants to a CME experimental case management
group (n=313) or a control group (n=319; approximately 75 percent of
participants were retained at 6-month follow-up). Multivariate analyses
revealed that case-managed clients stayed longer in aftercare programs
than noncase-managed participants, leading to improved substance use
treatment outcomes. Cluster analysis data suggested that providing
strengths-based case management was associated with retention in
aftercare treatment for over one-third of the group (Siegal et al., 1997).
While researchers caution that case management by itself should not be
expected to have a direct impact on substance-using behavior, it may
indirectly improve treatment outcomes by retaining clients in treatment.

How case management is organized in the juvenile justice system is an
important question. Challenges to offender case management include: how
to provide continuous service to juveniles who are returning to the
community, how to best apply graduated sanctions in ways that optimize
service participation while avoiding unnecessary incarceration, and how to
measure program effectiveness (Healey, 1999). Most of the examples
given previously are based in a treatment program-centered case
management system. That is, the CM is structurally located in a treatment
program or some other type of human service agency. In many ways,
probation officers have provided case management services within the
justice system. They carry out and manage court orders regarding
conditions of probation, including ensuring the obtainment of needed
mental health and other social services. It has recently been argued
(Healey, 1999) that case management can be effectively located and
applied within the criminal justice system. The literature suggests that the
courts have utilized other administrative structures, such as drug courts,
and other programs, such as TASC, to provide case management apart
from probation (Inciardi et al., 1996). Healey (1999) has suggested that a
criminal justice CM may (at least in some cases) be a part of a team of
CMs who coordinate service delivery and achievement of criminal justice
goals. The structural location of a CM in a particular community will
depend on a variety of local conditions, including available community
resources, probation case loads, or the existence of a successful drug court
or a TASC program that would have the expertise and resources to provide
case management.

Management information systems and confidentiality issues

Effective use of assessment data within a case management framework
requires a complex information system that can ensure the availability of
relevant information to those involved in service provision. Many of the
current attempts to intervene in the juvenile drug-crime cycle have
included a management information system (MIS) as part of the necessary
infrastructure to support principles of client confidentiality and juvenile
justice system responsibility. 

According to the Office of Justice Programs' (OJP) Drug Courts Program
Office, MIS development should include the following key characteristics
(Mahoney et al., 1998:2): rapid recording and transmittal of a variety of
data on individuals involved in court processing; effective integration with
all involved service providers and the justice system; ability to provide
detailed information on an individual from the point of intake onward;
design specifications to provide information aiding decision making at all
stages of the justice system process; ability to expand and modify as
needed; user-friendliness for a variety of levels of technology
sophistication; proficiency in monitoring and evaluation use; and location-
specificity regarding cost, size, and scope needs.

Examples of MIS approaches include both adaptations of existing software
and development of new programs. For example, drug court MIS
programs such as both the Jacksonville Drug Court MIS and Buffalo Drug
Court MIS use the Microsoft Access software (Mahoney et al., 1998),
while the Brooklyn Treatment Court MIS, the Washington, D.C. Pretrial
Real-time Information System Manager, and the Washington/Baltimore
High Intensity Drug Trafficking Area Treatment Tracking System have all
developed specialized systems (Mahoney et al., 1998). Recent efforts by
OJP to determine the success of these programs have resulted in the
recognition of three required MIS functions (Mahoney et al., 1998:16-17):

1. To facilitate initial decision making, such as program admission,
treatment level, and testing (current charge, criminal and AOD abuse
history, detoxification needs, insurance eligibility, basic socio-
demographic data including employment, housing and family situation,
and assessment results).

2. To support ongoing participant supervision (AOD test results, treatment
service level, treatment participation and compliance, medical and family
issues, major life events, new arrest data, and relapse information).

3. To support provision of treatment services (court-ordered decisions
affecting treatment provision).

Target Cities projects have also developed advanced MIS programs,
including the Person Tracking System (PTS) within the Philadelphia
Target Cities project (System Design Associates, 1996). The PTS involves
a central registry (for screening and identification) and the following eight
modules: (1) intake (for demographics and other pertinent data), (2)
assessment (including the Addiction Severity Index), (3) evaluation
(assisting CMs in combining information gained through previous
modules for the purpose of determining an appropriate level of client care
and other needed services), (4) service plan (facilitating placement of the
client by summating available treatment modalities and provider
capacities), (5) slot/capacity registry (real-time monitoring of patient care
service slots in the collaborative area), (6) service tracking, (7) case
management, and (8) discharge (including data on coordination of needed
continuing care services). An additional component is also available that
includes various justice department data, such as the tracking of court
petitions, assignment of parole officers, etc.

Sharing of information and MIS development must precede coordinated
planning, budgeting, service delivery, and meaningful program evaluation.
Recognizing that information systems are crucial to successful program
design, it must also be stated that one of the most difficult barriers to the
development and execution of coordinated and intensive services for
AOD-involved juveniles is the necessity to comply with the special
confidentiality requirements involved in juvenile proceedings. As
electronic storage and retrieval of participant information becomes more
widespread, threats to confidentiality increase. Confidentiality becomes
particularly important when a participant is connected to several systems.
For example, it is common for drug court participants to have contact with
judges, prosecutors, defense attorneys, probation officers or CMs, child
protection workers, and various treatment providers and coordinators. In
such circumstances, the juvenile could rightly fear that his or her personal
disclosures in, for example, an AOD treatment facility would lead to
further sanctions in the criminal justice setting.

Confidentiality laws relating to AOD treatment were originally created to
encourage substance abusers to obtain help with their AOD problems. The
most significant Federal confidentiality law is Section 290dd-2 of Title 42
of the United States Code. Under this law, covered information acquired
by affected programs is kept confidential subject to exceptions described
in the statute and accompanying regulations.[6] Lawmakers reasoned that
such laws would make it more likely that substance abusers would enter
treatment if they were assured that information about their AOD use
would not readily be available to the public, including employers and the
media. Assurances of confidentiality also make it more likely that the
substance abuser will communicate freely in a therapeutic setting.

Consent by participants who are under 18 years of age raises a special
concern. Some States require the consent of a parent or guardian for a
minor to enter a treatment facility. However, even in those States, Federal
confidentiality laws protect minors who have sought treatment. Under this
provision, treatment or drug court practitioners may not approach a child's
parents or guardians to ask them to approve a child's request for admission
unless the child authorizes disclosure of that request or lacks the ability to
make the choice. Once a parent/guardian has agreed to treatment and the
child has been admitted, further disclosures again require the consent of
both the child and the parent/guardian (National Drug Court Institute, or
NDCI, 1999b).

Because information sharing is necessary to facilitate multiple system
involvement, it is important that the participant give his or her consent to
communications between systems. Improper disclosures of information
covered by confidentiality laws can result in criminal prosecutions and
civil lawsuits. The simplest way to ensure that such communications do
not violate Federal and State confidentiality laws is to obtain valid consent
from the participant (examples of consent forms can be found in NDCI,
1999b). Information sharing between various systems can best be
facilitated using a memorandum of understanding (MOU). MOUs serve to
facilitate trust and communication between systems by ensuring that all
parties are aware of how other organizations will access, share, and use
participant information. MOUs can also be used to explain to participants
how information will be distributed between systems. MOUs should 

specify the following:

--Discussions in team meetings are confidential.

--All parties are bound by redisclosure provisions, meaning that any
information an agency receives from another agency remains confidential
and cannot be passed on to other entities without participant consent.

--The prosecutor's office will not use the information to prosecute a
participant (with exceptions made for child abuse or neglect and crimes
committed at the treatment center or against treatment personnel).

--Parameters are described for sharing and refusing to share information.

--Rules are set governing storage of and access to written and automated
records. 

In addition to the use of MOUs, some States are revising their juvenile
justice reform provisions to address confidentiality issues. Effective
January 1, 2000, lawmakers in Illinois have moved to clearly limit the
disclosure of juvenile case and clinical records to judges, parties involved
and their attorneys, probation officers and court-appointed special
advocates, custodial bodies, placement providers, law enforcement officers
and prosecutors, prisoner review boards, authorized military personnel,
and members of the Illinois General Assembly (Devine, 1998).[7] These
revisions were made to replace previous legislation allowing broader
disclosure at the discretion of the Department of Children and Family
Services Director.

Record storage is a particularly important issue in this era of computerized
records. Federal laws require that written records be stored in a secure
room or locked container. However, these laws do not address
computerized records. The NDCI (1999b) recommends that all
computerized records covered by Section 290dd-2 be password-protected,
with the password guarded in the same manner as a key to a file cabinet.
Computers which are networked to one another in the same system or
between two or more systems should be protected by both passwords and
encryption systems. Fears of data tampering within a system or between
systems can be addressed in greater detail by utilizing a computer
consultant with knowledge of security systems (Gelman et al., 1999).

One of the most important uses of an effective MIS is the coordination of
services among the different agencies or community groups that are used
to meet the assessed service needs of juveniles. If services are to be
effectively integrated, it is crucial that intake, assessment, and progress
information be shared and not be needlessly duplicated. Such information
can play a major role in increased service delivery efficiency and outcome.
A recent article by Taxman (1998) provides an excellent illustration of
how an MIS can be use for seamless case management in the justice
system.

Collaborative structures and strategies

A restorative justice model, as advocated in a BARJ approach, calls for a
community response to the juvenile drug-crime cycle. However, as long
ago as the early 1960s, service providers were frustrated by a lack of
coordinated response to multiple-needs clients, such as substance-abusing
juvenile delinquents (Agranoff, 1991). The lack of communication was
(and still is) complicated by the lack of an effective MIS as well as by
increasingly fragmented services, high numbers of multiple-needs
families, poor cross-systems communication, increased specialization, and
inadequate funding. Such factors have forced human services
professionals at all levels to rethink and reform service delivery structures
and systems. Interest in systems collaboration has been further
strengthened by the devolution and decentralization of resource control at
Federal, State, and local levels. In addition, managed care models have
emerged at both State and county levels, forcing service providers to
compete, subcontract, and collaborate with other agencies in efforts to cut
costs, avoid duplication of services, and survive in the competitive
environment.

In 1994, CSAT called for solutions to such coordination problems to be
built on a systems perspective, stating that "The problem of AOD abuse
absolutely defies a solution by an individual agency or program" (Crowe
& Reeves, 1994:153). As a result of widespread recognition of such
conditions, communities are increasingly forming interorganizational
collaboratives (also known as multipurpose collaboration, comprehensive
service provision, or systems integration). Collaborative partners share
expertise, resources, and responsibility while working together to meet
identified needs. Dembo (1996:87) has specifically addressed the
importance of systems integration with juveniles, calling for "...linkages
and coordination among various community agencies dealing with 'high-
risk' youth--including law enforcement, the courts, schools, human service
agencies, and treatment programs. Such an effort would reduce duplication
of services and barriers to treatment, and respond to youth in a
comprehensive manner." 

Community-based collaborative efforts will ensure that services are
accessible to the target population, be relevant to the community's unique
needs and structures, build on community-specific strengths, and increase
ownership and accountability with all parties (North Central Regional
Educational Laboratory, 1996). In addition, collaboratives can impact
public policy through a larger and stronger advocacy base, increase
funding options by accessing funds that require collaborative partnerships,
and reduce wasteful duplication of services (Bailey & Koney, 1996).

Many of the successful interventions designed to address substance use
within the juvenile justice system are built on a foundation of collaborative
structures, including juvenile drug courts, Target Cities projects, and
TASC programs. A key concept of drug courts (including juvenile drug
courts) is that "forging partnerships among Drug Courts, public agencies,
and community-based organizations generates local support and enhances
Drug Court effectiveness" (Tauber & Huddleston, 1999:6). Target Cities
provide an example of collaboration in provision of AOD treatment
systems, calling for "model infrastructures to coordinate and enhance local
treatment networks" (DHHS, 1995:1). Target Cities projects typically
involve collaborative efforts with AOD abuse, health, mental health,
education, law enforcement, judicial, correctional and human services
agencies (Scott et al., forthcoming). Observed success of Target Cities
collaborative efforts may be due, in part, to the pressure from outside
funding sources to both develop and formalize interagency agreements
(Kraft & Dickinson, 1997). TASC programs emphasize the need to
develop an integrated care system for juveniles. Such a system requires
successful collaboration, including identification of expectations, realities
of service provision limitations and resources, utilization of established
community collaboration methods, and a dedication to making sure all
stakeholders are involved in collaborative plan development (Mull, 1998).

When developing a collaborative specifically for the purpose of linking
treatment and juvenile justice systems, CSAT (McPhail & Wiest, 1995:27-
29) has focused on five major issues that  need to be successfully
addressed by collaborative members: community decisions; juvenile
justice decisions; AOD abuse treatment decisions; physical, mental health,
and social services decisions; and management system decisions. Specific
issues included in each type of decision are summarized below:

1. Community decisions. These include identifying stakeholders to be
involved in the process, agreeing on community accountability,
anticipating locational differences, defining family roles and expectations,
and planning for community diversity.

2. Juvenile justice decisions. Included here are developing and
implementing education and training programs for court personnel
regarding treatment resources and effectiveness, helping other
collaborative members understand the flow of the justice system,
establishing AOD abuse treatment responses for the judiciary, defining the
juvenile justice system target population, defining treatment
noncompliance and completion, identifying outcomes measures for
decision making, and developing supervision ability for the treatment
process.

3. AOD abuse treatment decisions. These decisions involve defining and
identifying the needed services continuum, treatment modalities, treatment
expectations, and supervision roles of providers. Also needed are decisions
to define and locate services, establish eligibility and acceptance criteria,
develop the assessment process to be used, and specify procedures for
dealing appropriately with culture, gender, and ethnicity.

4. Physical, mental health, and social services decisions. These include
defining physical, mental health, and social services needed for youth and
their families, and deciding on linkages between these systems and the
AOD treatment system as it is integrated with the juvenile justice system.

5. Management decisions. Two types of decisions are included in this
group: ethical and legal decisions as well as management decisions.
Ethical and legal decisions include deciding what information is
appropriate to exchange, agencies/individuals appropriate to receive such
information, MIS and between-agency confidentiality issues, and
compliance procedures for local, State, and Federal reporting
requirements. Other management decisions relate to funding and cost
considerations, communication assistance between collaborative members,
assurance of program management capabilities, cooperation and
collaboration, preparation of training and public education, system
oversight and evaluation, feedback analysis and outcomes reporting, and
definition of ongoing data requirements (including demographics).

Before beginning a discussion of the various components that have been
identified as important considerations within collaborative development, it
is important to clearly state that all successful community collaborative
efforts will have one thing in common: they will be specific to the
communities they are in. The literature on collaborative development
repeatedly maintains that no single system can function effectively for all
locations (OJJDP, 1998; Join Together, 1999) and that collaborative
guides should not be used as blueprints for organizing new groups (Mull,
1998). With this in mind, the following components are presented as a
springboard from which collaborative organizers can move toward
formalizing an approach best suited for their own distinct communities
and issues.

Collaborative elements. In developing and/or seeking out collaboratives,
local juvenile justice systems should be aware of interrelated elements that
guide and affect interorganizational collaboratives. Each element is
equally important and should be considered in collaboration development
(Bailey & Koney, 1996; Gutierrez et al., 1996; Chrislip, 1995; Rosenblum
et al., 1995; Weinstock, 1995; Markze & Both, 1994).

1. Ownership. Leadership within a collaborative body is a delicate issue.
By definition, a collaborative group should be made up of members who
are equally able to participate in discussion and dialogue. However, the
current discussion of treatment reform within the juvenile justice system
calls for recognition of (1) the primary role the justice system will play in
monitoring adolescents along the graduated sanctions continuum and (2)
the primary role substance abuse treatment services will play in providing
appropriate and effective treatment services. Ownership of successful
collaborative efforts to provide AOD treatment services with the juvenile
justice setting will vary by community depending on available community
resources and programs.

In point of fact, ownership of the program will likely emerge as a result of
the level of involvement in program development. While all key
stakeholders will share in the ownership of the collaborative, there will
likely be a lead agency that provides the majority of the energy and drive
to form the group. TASC and Target Cities programs maintain that
optimum organization would place a neutral group (i.e., one that is not
involved in direct service provision) in the position of managing partner in
order to ensure unbiased service organization referrals, case management,
and collaborative organization. For example, TASC fills this role, while a
single State agency, or SSA, is advocated in Target Cities programs.
Program ownership success in individual communities will be affected by
the managing partner's level of community trust and respect, past patterns
of community authority, experience, expertise, and understanding of
funding opportunities.

A policy committee should be established at each collaborative site,
chaired by a representative from the managing partner (such as the SSA)
and made up of a member of the funding agency in addition to juvenile
justice and treatment provider staff. The presence of the funding agency is
critical to the agency's understanding of program needs and effectiveness.
Such a model has proven successful in both Target Cities and TASC
programs (DHHS, 1995; Rivers, 1997; Mull, 1999) and would be
adaptable to the formation of community collaboratives focusing on
service provision within both the juvenile justice and substance abuse
treatment systems. Within drug court collaboratives, political leadership of
community collaboratives follows various formats. Some jurisdictions
utilize a cochair (from both the court and treatment provider services),
while others prefer a rotating chair (where the private sector holds the
position for one year and the public sector the next). Regardless of the
entity that acts as the managing partner, it is crucial that this lead agency
actively include all stakeholders from the beginning of design and
implementation of the proposed program.

2. Funding. External funding for program development requiring
collaborative applications may provide valuable incentives for the
development of successful juvenile justice collaboratives (evaluations of
the Target Cities programs indicate that external funding requirements
helped hold the collaborative together during initial formation struggles)
(Kraft & Dickinson, 1997). Such funding has been sought in the form of
block grants for drug court programs (such as the Juvenile Accountability
Incentive State Block Grant funded through OJJDP), primary and relapse
prevention funding through Title V Incentive Grants for Local
Delinquency Prevention Programs (or the Community Prevention Grants
Program, also funded through OJJDP), as well as private foundations such
as The Annie E. Casey Foundation. Federal demonstration grants are also
available (such grants supported the development of TASC and Target
Cities programs). Some communities have developed pooled funds from
various sources such as child welfare, juvenile justice funds budgeted for
residential treatment, Medicaid capitation, and mental health funds
(Milwaukee County Mental Health Division Child and Adolescent
Services Branch, 1998). Depending on the nature and structure of the
collaborative, application for funds can be made through the managing
entity (TASC, the SSA, or the collaborative as a whole) but only after all
key stakeholders within the collaborative have been involved with
proposal development. Such funds are necessary for program start-up, but
collaboratives should seek to utilize evaluation data and networking efforts
to attain legislative budget line-item support to continue programs with
demonstrated success.

The following is a brief overview of general funding options as
summarized by Crowe and Reeves (1994:159-160; see also Romig &
Rasmussen, 1991):

Federal funding. Grants (such as the State block grants noted above),
entitlement programs (Medicaid, Medicare, supplemental security income,
Social Security disability insurance), and other programs (including the
Drug Free Schools and Communities Program).

State and local funding. State general fund revenues, State Medicaid funds
for substance abuse services, substance taxes, seized assets from AOD
crimes, property tax revenues, sales taxes, and court fines/assessments
imposed on intoxicated drivers. 

Private sector funding. Insurance coverage, client fees, private
foundations, donations, and United Way fund appropriations.

3. Membership formation. Collaborative formation should include partners
who contribute resources, perspectives, expertise, and diversity to the
overall effort. Membership should represent as complete and as wide a
spectrum as possible of knowledge and experience relative to the
community's needs and systems (Mull, 1998). In addition, membership
should strive to include two types of individuals: "1) those who understand
and have an interest in the broad and specific problems of community
welfare, juvenile justice, AOD abuse, and health and social services and 2)
community leaders who can ensure that productive change occurs"
(McPhail & Wiest, 1995:28). Such membership might include judges,
probation and social services representatives, the State/district attorney as
well as private attorneys, the public defender, and representatives of the
following systems: law enforcement, child welfare, State and local
corrections, child advocates, families and family advocates, managed
behavioral healthcare, community treatment, the health department,
State/local managed care initiatives, and the welfare agency (Mull,
1998:7). Additional members to consider are public and private sector
employers, consumers, elected officials, religious and other community
leaders, nonprofit organizations, administrators, and adolescents. Efforts
should be made to involve all key stakeholders in the planning and
implementation of collaborative agendas. Individual members must have
some level of authority and credibility within their own agencies as well as
within the collaborative. They must also acknowledge and be committed
to the interdependence of collaborative partnerships and develop effective
conflict negotiation skills.

4. Visioning based on issue identification. Collaborative visioning should
include identifying needs, developing a joint vision and goals to meet such
needs, and creating or strengthening strategies that bring together
resources to address identified needs.

5. Role clarifications, cross-training, and communication. For membership
within collaborative structures to be productive, it is essential that all
parties clearly understand the roles each play within the group, as well as
the basic processes involved in each role. Mull (1998) suggests that during
the collaboration establishment process, each party should inform all other
parties of the flow of their system, including usual service gateways,
admission criteria, service levels (with accompanying time and outcomes
expectations), and system goals. Points at which services from other
collaborative partners might be warranted would also be discussed. It is
important that collaborative members remain open to being educated by
other groups. For example, those in the treatment community need to
educate judges on the nature of addictions, the approach of seeing a legal
infraction as part of a larger behavioral problem, and the perception of a
defendant as a client with his or her own strengths and resources. Judges
have the need to educate the treatment community on the legitimacy of
community safety. Such communication efforts that familiarize
collaborative partners with each other's systems and theoretical
foundations help the various groups to anticipate the effects of their
actions on other members and can improve overall collaborative efforts
(Crowe & Reeves, 1994). The NDCI has recognized this cross-training
need and has established a training series to educate the various members
of drug court teams, including judges, prosecutors, drug court
coordinators, treatment providers, and defenders. For example, juvenile
drug court judges receive training in substance abuse issues, AOD testing,
sanctions, incentives, community resources, ethics and confidentiality, the
drug court environment, MIS development and use, adolescent
development, eligibility and screening, sanctions, and incentives (NDCI,
1999a).

It is worth noting that collaborative efforts will likely require significant
changes in service provider roles. The traditional adversarial court
environment will not support the collaborative and therapeutic team nature
of successful partnerships (Hora et al., 1999). For example, judges in drug
courts "must assume, according to [Judge] Tauber, 'the role of confessor,
task master, cheerleader, and mentor'" (Setterberg, 1994), as well as of
team leader as opposed to the traditional position of referee (Drug
Strategies, 1999). Prosecutors will need to act as change agents,
ascertaining if a juvenile is appropriate for the program (as opposed to sole
focus on the likelihood of winning a case), while the defense attorney will
need to place energy into keeping a client in treatment versus attempting
to minimize the legal ramifications on the juvenile (Hora et al., 1999;
Drug Strategies, 1999). Judge, prosecution, and defense must work
together as part of the treatment team.

6. Decision-making processes. Effective collaboration is best achieved
through consensus building. In recommending methods for combining
treatment and diversion programming within the juvenile justice system,
CSAT encourages consensus-building decision making. This flows from
the approach's emphasis on dialogue that brings the various collaborative
members together to reach common ground: "Consensus builds ownership
and does not require absolute agreement on every point" (McPhail &
Wiest, 1995:27).

7. Structures and strategies. Agreed-upon structural connections, including
those with the greater community and society, allow goal setting, strategy
development, and desired outcome achievement. These linkages provide
two-way streams of information, funds, and services without which the
collaborative cannot be effective. The goals of strategy development are to
share work and experience among partners to improve or increase the
impact of services and programs. Regular assessment of intervention
effectiveness should occur that considers how various interventions fit into
the collaborative's larger vision.

8. Ongoing support for collaborative efforts. Management and
administrative support within the various partner agencies must be
obtained. Examples of such support include pledging existing funds or
working together to obtain funds to provide ongoing training to keep staff
engaged in the collaborative process and aware of resources outside of
their own agencies or organizations.

9. Resource development. Collaboratives must effectively utilize existing
resources and outline strategies to replenish them as needed. By having a
managing partner as the representative of the original funding application,
sustainability will be enhanced as this body will then be able to take a lead
role in seeking project continuation after the initial funding period is
completed. Such activity might include the assessment of, application for,
and establishment of interagency funding pools, Federal grants or
matching funds, Federal or State demonstration funds, block-grant
applications, private foundation funding, and local contributions as well as
efforts to establish legislative line-item support.

Optimum collaboration structure. A variety of approaches exist for the
start-up of collaborative groups. However, a recent survey of coalitions
formed to prevent substance abuse and gun violence points to the
possibility that coalitions demonstrating success in fighting substance
abuse in their communities share some similar characteristics. Among
those coalitions reporting that the substance use problems in their
communities were improving, the following community resources were
reported: a responsive local government, community institution
involvement, and improved treatment service access (Join Together,
1999:20). Further, successful collaboratives reported the following
characteristics specifically related to coalition formation/structure: the
existence of a strategic plan (including specific coalition goals, an outline
of programs related to achieving those goals, evaluation methods, regular
public progress updates, and a description of goal and program review and
change); growth in membership; a large number of volunteers; increases in
the range of and intensity of effort given to problems; and current or
former Center for Substance Abuse Prevention funding (Join Together,
1999:4,22). In addition, it may be helpful for communities considering
collaborative development to refer to documents that outline broad goals
and tasks to accomplish in the process, such as Developing a Managed
Care Response for Juvenile Justice: A Guide (Mull, 1998), and
Development and Implementation of Drug Court Systems (Tauber &
Huddleston, 1999). Once collaborative system connections are in place,
adolescents require assistance to help them access services throughout
those systems. CMs can effectively serve this function.

Collaboration and the juvenile justice system. The juvenile justice system
can integrate with a collaborative model in a variety of ways, including
diversion, adjudication, or a juvenile probation program. As will be noted
in the following sections on supervision and treatment programs,
mandated treatment appears to be related to treatment retention and
positive outcome. The leadership and monitoring of the juvenile justice
system could play a crucial role in the successful functioning of a
collaborative model by helping to ensure that assessment
recommendations are carried out and that the juvenile actually receives the
recommended and/or mandated services. It is important that in its
leadership/monitoring role, the juvenile justice system recommend and
utilize the professional services available through community
collaborative agencies. Such agencies are integral partners in providing
collaborative resources and expertise to the system.

Dismissal and/or diversion programs

At the conclusion of intake and assessment, intake officers and/or CMs
generally have the option of dismissal of the case with no further action,
utilization of diversion programs, or referral to further juvenile justice
system processing. Diversion programs include sending juveniles home in
parental custody, placing them on informal probation, or diverting them to
another facility or community program. Although judges and police
officers often utilize diversion programs, the most common utilization of
such programs is through intake officers after completion of assessment. 

Diversion programs generally fall under the category of early intervention
in that a juvenile's behavior is not yet serious enough to merit formal entry
into the juvenile justice system. This period offers a crucial time in which
to provide interventions with the potential to successfully move high-risk
adolescents away from more serious substance-abusing or delinquency
behaviors. Dembo et al. (1993) argue that resources are best placed in
assessing and providing needed services to adolescents and their families
at the earliest, and preferably the first, point of contact with the juvenile
justice system. These services are more likely to be cost-efficient and
effective than those targeted toward juveniles who have already had
repeated exposure to the juvenile court system. Several reviewers
(Hawkins et al., 1992; Kumpfer, 1989; Henggeler, 1997a) have gone
further to maintain that prevention and early intervention services should
be specifically targeted toward high-risk youth. This makes good social
and economic sense since "the determinants of drug abuse are generally
the same as the determinants of delinquency, school dropout, and
unprotected sexual activity" (Henggeler, 1997a:261).

In a major review of early intervention literature, Klitzner and his
colleagues (1991; see also Dembo et al., 1993) found a lack of consensus
in defining what constitutes early intervention and determining how it
differs from prevention or treatment. Those concerns aside, Klitzner and
his colleagues concluded that early intervention programs are ideally
targeted toward individuals or groups whose AOD use puts them at high
risk for problem behaviors and related consequences, whose AOD use has
created clinically significant dysfunction or outcomes, and who
demonstrate certain problem behaviors that lead to AOD use (e.g.,
spending time with AOD-using peers) (see also Brewer et al., 1995, for a
comprehensive review of early intervention programs). Klitzner and his
colleagues found relatively few preadjudication or postadjudication early
intervention programs in the juvenile justice system, perhaps because the
system does not become concerned over the behavior of adolescents until
they have appeared in court several times (Dembo, 1997). The majority of
the programs which did exist at the time of the review had not been
formally evaluated.[8]

Fact-finding hearings and adjudication: judicial processing

One of the possible outcomes of the petition (charge) made against the
juvenile is formal referral to the juvenile court and formal adjudication. A
decision to refer a juvenile for formal hearings is usually based on a
combination of the seriousness of the charge, previous offenses, social
investigation results, and some type of assessment. Judges will generally
use the assessment and arrest report as well as other facts to determine
disposition and, if necessary, sentencing. In most jurisdictions, fact-
finding and adjudication take place in a conventional juvenile court
system. However, in recent years, a specialized court called the juvenile
drug court has evolved. While juvenile drug courts utilize the general
juvenile justice processes described elsewhere in this report (including the
possible use of case management, systems collaboration, and graduated
sanctions), it is important to briefly examine the unique aspects of this new
and developing trend in juvenile justice.

In an attempt to play a more active role in breaking the linkage between
substance use and crime, the judicial system developed the drug court.
Drug courts allow judges to take a more active role than that provided by
previous options, such as mandated lengthy sentences.[9] Judges draw on
a variety of professionals in assessing needs and recommending services
and are then actively involved in the decision-making process of what
services are to be received, monitoring compliance, and applying sanctions
when a lack of compliance is evident.[10] Thirty-eight states currently
operate some type of juvenile drug court (including the District of
Columbia and Guam) for a total of 69 programs under way and an
additional 48 in the planning stages as of June 1999 (American University,
1999a). A recent American University report indicates that 20 percent of
drug courts in the United States serve juveniles either as a separate
program or as part of an overall community drug court program (1999b).

The general philosophy of drug courts--including an emphasis on an active
judicial role in service decisions and management--was developed within
an adult framework. However, this philosophy is consistent with the
traditional role and function of juvenile courts and juvenile court judges.
As noted previously, juvenile courts have traditionally focused on service
interventions designed to change problem behavior rather than on
punishing criminal behavior. Given this role, a recent publication of the
OJJDP (Roberts et al., 1997) indicated that six approaches appeared to be
more common to juvenile drug courts than regular juvenile court
procedures:

1. Much earlier and more comprehensive intake assessment procedures.
Procedures usually involve initial screening and later comprehensive
assessment designed to identify a wide variety of environmental, family
and psychosocial functioning problems. Typically, screening and
assessment provide the basis for referral and service decisions.

2. Greater focus on juvenile and family functioning throughout the
juvenile court process. There is a recognition that the emergence of
juvenile delinquency and AOD use usually occurs within the context of
significant family functioning problems.

3. Closer integration of information obtained during the assessment
process as it relates to the juvenile and the family. This includes collecting
information on individual characteristics and well as on family behavior,
interaction, and functioning. Assessment is designed to result in the
integration of individual and family intervention services.

4. Greater coordination between the court, treatment community, school
system, and other community agencies in responding to the needs of the
juvenile and the court. This strongly implies recognition of the need for
active case management to try to ensure barrier-free integration and
coordination of needed services.

5. More active and continuous judicial supervision of the juvenile's case
and treatment process. To a significant degree, this results in the judge
playing the role of CM in assessing service needs, making referral
decisions, and monitoring progress.

6. Increased use of immediate sanctions for noncompliance and of
progress incentives for both the juvenile and family. From the judicial
perspective, these options provide the rationale for the effectiveness of
judicial involvement. Judges often argue that it is within their power to
provide immediate sanctions to help ensure compliance with required
services. Such power significantly increases the probability of improved
service effectiveness through increased retention of participants in
programs.

Overall evaluations of juvenile drug courts have not occurred, perhaps due
to their relatively short history. The research that does exist has tended to
focus primarily on formative and process evaluation rather than impact
evaluation. However, a recent report on the last decade of drug courts
notes a high level of program retention (over 70 percent) and participant
satisfaction with the drug court experience (American University, 1998;
see also Turner et al., 1999). There are also very positive reports about
lower rates of AOD use and criminal justice recidivism. 

A number of presentations made at the 1999 National Association of Drug
Court Professionals Annual Training Conference suggested that drug
courts meet the needs of key system participants, including giving judges a
strong sense of active involvement in addressing a very complex problem.
For district attorneys, drug courts may provide an effective means of
addressing the underlying causes of criminal behavior while at the same
time providing for community safety. Public defenders and defense
attorneys appear to support drug courts because the approach keeps their
clients out of jail/detention and, if they are successful in the program,
generally they do not have a felony conviction or were not adjudicated
delinquent. Treatment program providers often see the drug court carrot
(no criminal/delinquent record) and stick (incarceration/adjudication on
the original criminal charge) approach as an important part of ensuring
client participation in treatment. 

While drug court personnel are often very enthusiastic about the program,
researchers and the Government Accounting Office (GAO) have been
critical of some aspects of drug court evaluation research methodology,
leading to significant questions regarding drug court effectiveness
conclusions. Inciardi and his colleagues (1996), as well as the GAO
(1997), expressed considerable concern regarding a lack of appropriate
comparison groups in drug court evaluation research, the widely varying
populations involved in drug courts, and lack of consistent standards for
assessment and referral. The GAO concluded that the 20 evaluation
studies reviewed "...did not permit the GAO to reach definitive
conclusions concerning the overall impact of drug courts. " (13).

Despite these concerns, positive initial perceptions of drug court
effectiveness have strongly encouraged their application to the juvenile
justice system as evidenced by the recent increases in juvenile drug courts
noted earlier. While it is likely too early to adequately evaluate
effectiveness, a literature is emerging suggesting that like adult drug
courts, juvenile drug courts are being successfully implemented, are
receiving positive responses from all system and client participants, and
seem to result in lower rates of AOD use and recidivism (Shaw &
Robinson, 1999). It is expected that over the next few years, there will be
further increases in the number of juvenile drug courts and hopefully
prospective scientific evaluations measuring the behavioral change impact
of juvenile drug courts.

Disposition

Both the conventional juvenile justice system and the juvenile drug court
system utilize the adjudication process to determine case disposition and,
if necessary, sentencing. Case disposition generally takes place within the
framework of a graduated sanctions continuum.

The graduated sanctions continuum

The material presented in this report focuses primarily on the need for
comprehensive assessment, appropriate referral, effective interventions,
and effective services along a continuum of care within a case
management framework in a community with systems collaboration.
Within this therapeutic framework and consistent with the BARJ
philosophy, there exists a responsibility to hold juveniles accountable for
their actions and to protect the community. Even with the very best
assessment, services, interventions, and case management, there will be
youth who do not respond to therapeutic interventions and who continue to
engage in substance use and delinquent behavior. Within the concept and
application of graduated sanctions, accountability and community
protection needs are integrated with assessment, referral, service
provision, and case management. Assessment techniques are used to
incorporate offense history and other behaviors to determine community
risk from the juvenile and probability of recidivism. This information then
informs final judicial decisions on the types of services to be received and
the delivery location (State training school, a detention center, or in the
community).

Within the framework of case management, the graduated sanctions
continuum is used as part of a carrot-and-stick approach to treatment
progress. The concept of graduated sanctions applies to (1) the initial type
of treatment intervention (outpatient, residential, or types of collaborative
services), (2) the sentencing context of service delivery (from community
diversion to incarceration in a State training school), (3) overall
intervention/treatment program outcome goals, and (4) progress within the
program. 

The lowest levels of juvenile justice sanctions and therapeutic/service
interventions generally occur for first-time offenders with minimal AOD
use from two-parent families. Higher initial sanction levels and
increasingly intensive therapeutic/service interventions are likely to be
applied to repeat offenders with extensive AOD use histories involving
cocaine and/or opiates. If a participant successfully completes a mandated
treatment program (recognizing the need for continuing care), his or her
charge may not be filed in the juvenile court or, if adjudicated, the charge
may be dismissed (forming the carrot part of sanctions). If the participant
fails in treatment and/or is referred again to the juvenile court for a new
charge, the stick aspect of sanctions may result in formal processing of the
original referral/charge and the carrying out of the previously imposed
sentence.

Based on an individual's progress, sanctions and therapeutic/service
interventions can become more or less intense.[11] If AOD use and/or
delinquency recidivism occur at any particular point in the treatment
process, the application of graduated sanctions generally involves placing
the individual in a higher security, more intensive therapeutic
environment. Avoiding the application of graduated negative sanctions
(and thus decreased freedoms) is seen as an incentive for treatment
progress. If the program participant is making good progress in treatment,
the application of positive graduated sanctions generally means increased
freedom or other rewards designed to provide personal and public
recognition of a juvenile's achievements. This may involve more freedom
of movement, fewer treatment or supervision contacts, rewards within a
token economy, or public recognition, such as applause in open court. It is
important to recognize that all entry points into the justice and treatment
intervention systems should be integrated into a comprehensive sanctions
program.

Many AOD treatment providers are suspicious of treatment coerced by the
justice system. Conventional wisdom in the treatment community has
generally maintained that providing treatment services to participants
against their wishes will generate resistance from the participant and
ultimately lead to treatment failure. However, many researchers have
determined that court-ordered treatment is as effective as or more effective
than voluntary treatment (Anglin & Hser, 1990; Hubbard et al., 1989;
Collins & Allison, 1983). Compared to individuals in voluntary treatment,
individuals legally mandated for treatment have been found to stay in
treatment longer and are more successful in posttreatment measures
(Allison & Hubbard, 1985; De Leon, 1985; Siddall & Conway, 1988).

Few specific evaluations of the effectiveness of graduated sanctions as a
separate and distinct program have been conducted. One of the few
exceptions is a basic study comparing an adult program using graduated
sanctions to a regular court process in a pretrial intervention program
(Harrell, 1998). The graduated sanctions program involved substance use
testing and, based on urinalysis results, could result in a range of
graduated sanctions from additional program activities to time in jail. The
regular court process also included substance use testing but used the
results only for sentencing without a graduated sanctions framework. The
study reported that those in the graduated sanctions program had a lower
rearrest rate for both short- and long-term (1 year) follow-up. 

In addition, Lipsey and Wilson (1998) recently performed a meta-analysis
on the effectiveness of juvenile intervention programs. Overall, they
concluded that the most successful intervention programs incorporated
graduated sanctions as part of a comprehensive intervention strategy. Such
inclusion was associated with both lower AOD use and delinquency
recidivism rates. Generally, Lipsey and Wilson found these programs
reported recidivism rates between 30 and 50 percent lower than those of
comparison groups. However, Lipsey and Wilson (1998), as well as
Krisberg and Howell (1997), noted some qualifications to such findings.
Youth who experienced significant damage to their self-concept through
incarceration did not appear to reduce recidivism. Thus, less severe
sanctions may reduce recidivism more than incarceration. It may be that
when the level of sanctions stipulating incarceration is applied, problem
behavior patterns are strongly established; sufficiently intensive
therapeutic/service intervention strategies have perhaps not yet been
developed. All of these researchers further argue that well-structured
community programs may be able to offer sufficient community security
without the apparently negative consequences of incarceration.

Results of research on the comparative cost benefits of comprehensive
graduated sanctions programs have been positive. Greenwood and Turner
(1993) imply that such programs are as effective at serious crime reduction
as California's three-strikes law at only 20 percent of the cost. Analysis by
Rivers and Trotti (1995) found that in South Carolina, reducing the
movement from probation to incarceration by just 5 percentage points
could save the State $37 million per year.

In an era of increasing demands for juveniles to be tried as adults and
imprisoned if convicted, the above findings on the effectiveness of
graduated sanctions, particularly in a community setting, provide an
important counterbalance to the current emphasis on incarceration.
According to some research, a comprehensive program including
graduated sanctions could be more effective than incarceration and much
less costly. Since many researchers argue for an intervention program that
incorporates graduated sanctions, it is important to briefly review the
range of sentencing options that are used as part of a comprehensive
graduated sanctions program or as stand-alone interventions. Specifically,
brief examinations of both supervision and treatment options will be
provided.

Sentencing options

The graduated sanctions continuum utilizes two broad intervention tracks
operating simultaneously to affect juvenile offenders: supervision options
and treatment options. While supervision and treatment will be discussed
separately in this report, both operate concurrently along their own
continua and should be viewed as complementary and essential aspects of
any judicial processing and sentencing methodology. All supervision and
treatment programs take place within the framework of graduated
sanctions and thus should be considered as part of the whole as well as
programs in and of themselves.

Supervision options range from light to intensive and include monitoring
through various means. This review will follow a light-to-intensive
continuum including juvenile TASCs, intensive probation, boot camps,
and State training schools.

1. Juvenile TASCs. TASC programs seek to provide a linkage between the
justice system and the treatment system. TASC attempts to provide
screening, assessment, referral, case monitoring, and reporting to the
justice system. A number of juvenile TASC sites exist in the United
States, and a recent TASC evaluation by Anglin and his colleagues (1996)
included a juvenile site in Orlando, Florida. This quasi-experimental
evaluation focused on changes in AOD use, crime, and HIV risk
behaviors. The study compared a TASC group with a comparison group in
which participants were placed on probation and received services
associated with that status.

The analysis found that juvenile TASC participants were significantly
more likely to obtain needed services than those in the comparison group.
In addition, TASC participants were found to have significantly reduced
their sexual risk behaviors in comparison to the control group. The
reduced sexual risks included increased use of condoms and a significant
reduction in sex while high on various substances. However, the analysis
did not find significant differences in AOD use change measures. In
addition, no differences were found for any type of criminal behavior
recidivism.

The evaluation by Anglin and his colleagues concluded that TASC,
including juvenile TASC, has an overall positive benefit. However, they
note that problems with comprehensive case management, community
intervention resources, and the lack of a coordinated continuum of care
likely result in limited impact. It was further suggested that community
TASC programs be integrated with local drug courts. It is important to
note that very few TASC programs were evaluated in this study and only
one juvenile program was assessed. In addition, that assessment did not
involve a tightly controlled experimental design.

2. Intensive probation supervision. Probation is the most widely used form
of case disposition in the juvenile court. Nonintensive probation involves a
set of conditions the juvenile must adhere to, often including behavioral
and association requirements as well as receiving needed services.
Assuring compliance with these conditions is the task of a probation
officer. Historical concerns regarding probation supervision include
overburdened probation officers with exceedingly large case loads, high
rates of recidivism, lack of appropriate assessment, lack of available
needed services, overcrowding of services, and limited resources to pay
for services. Indeed, data do not suggest that regular juvenile probation
services are effective at preventing recidivism or addressing the
underlying causes or correlates of delinquent behavior (Armstrong, 1991;
Palmer, 1991).

Both adult and juvenile probation programs are now trying to combat high
recidivism by utilizing intensive social control approaches and close
monitoring. Monitoring techniques may include electronic monitoring,
urine monitoring, and monitoring through personal visits and telephone
calls. Commentators have often noted that the mere fact of being watched
so closely will likely result in increased detection of minor or technical
violations. Such increases should be considered when evaluating
heightened monitoring programs.

Juvenile probation has made some important additions to the probation
system focusing on assessment, use of community agencies, and use of
volunteers. In addition to intensive monitoring, assessment is
recommended to determine the therapeutic and human service needs of the
juvenile and to find available community services. The process may
involve coordinating and utilizing a wide variety of professional services
available in the community including citizen groups and volunteers.
Within this framework, juvenile community probation/corrections operates
not just as a monitoring office protecting the public and ensuring
compliance, but also as comprehensive assessor, resource broker, and
advocate to and for existing services.

Such operations require comprehensive plans that allow juvenile
community correction officers to have the skills and resources necessary to
conduct assessments; to undertake a resource inventory of the community,
including its mental health and substance treatment resources; and to
match the juvenile to needed services. Meeting identified needs must
include addressing the causes of the drug-crime cycle (for example, see
Catalano et al., 1990/91), and requires officers to be able to link the
existing justice system to other agencies and systems in the community.
Throughout this process, juvenile community correction officers must
continue to use monitoring and possible sanctions to increase retention
and, thereby, treatment effect.[12]

An example of this type of program was reported in the literature by
Pennell and Curtis (1990). Near the end of 1982, the San Diego County
Probation Department and the county district attorney's office initiated an
interagency program to serve less serious first-time offenders. The
probation department entered into formal agreement with a variety of
community agencies including substance abuse treatment programs. The
program consisted of a diversion contract requiring specific behaviors and
participation in needed services. Monitoring included frequent reports
from the agencies and the use of graduated sanctions in response to
program violations.

Pennell and Curtis reported a high degree of satisfaction with the program
on the part of the juvenile justice system, parents, and program
participants. While there was an initial increase in rearrest rates after the
implementation of the program (this may again illustrate the problem of
heightened monitoring), the rearrest rate went down over time. Although
this was a small program in one local area, it illustrates the possibility of
interagency cooperation and the possibility of juvenile community
corrections playing an active role in case management.

Many similar programs would have to exist and be implemented before
adequate evaluation could occur. However, this program provides some
important suggestions for facilitating interagency cooperation. These
recommendations include: a clear elucidation of each participant agency's
obligations and role, monitoring to ensure agreements are upheld, periodic
training to ensure new staff understand the arrangements and are more
likely to enthusiastically participate, monitoring the quality of services
provided, agreement to and monitoring of expected outcomes, and
recognition that it takes time to develop a functioning system that can have
an impact.

3. Boot camps. Also referred to as shock incarceration programs, boot
camps were first established in the early 1980s as a viable response to
prison overcrowding. Boot camps are structured on a military model
incorporating discipline, physical training, and hard labor in their program
structure. Additional services (rehabilitation, AOD treatment, etc.) may or
may not be provided for detainees depending on the philosophy and
resources of each individual program. Reducing recidivism is seen as the
primary goal of most programming.

Studies have been inconclusive regarding the effectiveness of the boot
camp model with juvenile populations. Data collected on juvenile boot
camps are often anecdotal or quasi-experimental (Henggeler &
Schoenwald, 1994). A 1997 OJJDP report provided a summary of the
program elements of boot camps for juvenile offenders. Outside of the
military aspects, common elements in most or all of the juvenile camps in
the study included case management (through probation officers or outside
contractors), employment assistance and vocational training, substance
testing, family counseling, and transitional programming. Though self-
reports of program effectiveness were generally positive, few of the
programs had specific supporting data from formal evaluations or
investigations. Several additional studies of juvenile boot camp programs
found that at best, comparisons between control groups and boot camp
graduates showed no difference in recidivism rates. At worst, boot camp
graduates had higher rates of reentry into the justice system (MacKenzie,
1991; MacKenzie et al., 1992; Peters et al., 1997, Peterson, 1994, as cited
in Henggeler & Schoenwald, 1994). The reason for this apparent lack of
success may lie in the historical lack of consistent continuing care
provisions, lack of follow-through at the local level regarding guidelines
for model programs developed by the OJJDP, and poor program
development and planning in regards to community resources and support
(Peterson, 1994, as cited in Henggeler & Schoenwald, 1994). It is also
argued by Henggeler and Schoenwald (1994) that boot camps are
ineffective at addressing or ameliorating the causes of delinquency
because (1) youth are removed from their community and any support
systems which could be used within the home community and (2) youth
are provided with few skills which will be of practical use upon returning
to their home environment. Economic analyses of boot camps also
indicates that the cost of these programs is greater than the economic
benefits which might be derived from felony reductions (Peters et al.,
1997; Washington State Institute for Public Policy, 1998).

Boot camp programs do provide a point in the juvenile justice continuum
of care at which substance abuse problems could be addressed. However,
the lack of conclusive data about their effectiveness and inconsistencies in
treatment provisions across programs indicates that conclusions about this
model's usefulness in meeting the needs of substance-abusing delinquents
are premature.

4. State training schools. The most extreme form of juvenile justice
sentencing supervision usually involves some form of State training
facility that has many of the characteristics of a jail or prison. Facilities
may or may not provide AOD treatment interventions. While the stated
goal of the facility is often rehabilitative, the use of a training school
generally reflects the seriousness of the offense committed by the juvenile
and an end point of repeated criminal offenses. Such offenses are generally
associated with violence and an extensive history of cocaine/crack and/or
heroin use. State training schools are generally considered to be a last
resort to protect the community from a juvenile who has not responded to
any previous levels of treatment or supervision interventions. Despite
recent emphasis on utilizing some type of community corrections for
juveniles versus large State training institutions, a study led by Parent
(1994) found a 26 percent increase in the number of juveniles confined to
training schools between 1979 and 1991.

While critics often recognize that community protection requires
incarceration of dangerous juveniles, evaluation studies have generally
been very skeptical of the positive impact of juvenile institutions. Findings
frequently note the exploitation of weaker juveniles by stronger ones, the
development of maladaptive survival strategies that make success in the
outside world even less likely than the original maladaptive strategies that
brought the juvenile in contact with the justice system in the first place,
and further entrenchment in criminal and AOD-using subcultures
(Krisberg et al., 1989; Bartollas, 1997). Researchers have argued that
incarceration does not reduce recidivism and is less effective than
nonincarceration community-based interventions (Lipsey & Wilson, 1998;
Krisberg & Howell, 1997). These researchers further argue that
community-based interventions can be constructed to protect the
community and effectively address juvenile AOD use and other problems.
In addition, nonincarceration supervision interventions are more cost
effective than incarceration. The use of a training school is the most
expensive intervention in the graduated sanctions continuum, estimated at
an average cost of $27,000 per year per juvenile in the late 1980s
(Bartollas, 1997).

Supervision monitoring: biologic testing

As mentioned previously, monitoring often involves biologic testing. Such
testing can involve urine, hair, and blood analyses. However, urine
analysis is the most widely used and accepted method for several reasons.
It is minimally invasive, carries no religious or cultural taboos on
collection, and cannot be shaved off. Urine monitoring can and often is
used in treatment settings to support the overall monitoring process;
however, it is most commonly used in a supervision context. While urine
monitoring will not be reviewed again in the following section on
treatment, readers should keep in mind its potential for use in that area as
well.

The collection and analysis of urine for the presence of illegal substances
is commonly done for three purposes. First, as has been discussed, urine
monitoring is one of the basic methods of examining the extent of
substance use within the juvenile justice population (Drug Use
Forecasting, 1997). Second, such monitoring is often used as a part of
assessment. The use of urinalysis in assessment helps overcome denial and
is believed to make adolescents more likely to openly discuss their
substance use problems (Lashey, 1994). Third, urine monitoring is used as
a part of monitoring treatment progress and outcome in the context of
graduated sanctions. Urines are monitored to examine the overall
effectiveness of treatment and progress within a treatment level (Hubbard
et al., 1989; Lashey, 1994). If a client's urine is found to contain illegal
substances, that information may be used to increase the intensity of
therapeutic intervention and juvenile justice system supervision.

The use of urine monitoring in juvenile justice system supervision
generally rests on the assumption that substance use is a maladaptive
behavior that can be changed with monitoring and increased consequences
for continuing the behavior. There are those in the juvenile justice system
who argue that urine monitoring alone (with appropriate consequent
sanctions involving incarceration and/or placement in a substance
treatment therapeutic community) may be a cost- effective means of
reducing AOD use and consequent criminal behavior.[13] As part of a
comprehensive graduated sanctions program, urine monitoring is often
seen as an essential component providing the best data on AOD use
(Lipsey & Wilson, 1998). It would appear that urine monitoring is most
applicable as a part of overall comprehensive assessment, graduated
sanctions, and treatment outcome evaluation.

Range of treatment options

Treatment options within the graduated sanctions continuum involve three
primary components: treatment correlates, treatment programs, and
treatment modalities. Like other components within the graduated
sanctions continuum, all treatment option components operate
simultaneously and should be continually evaluated. This section will
examine the three treatment option components and then provide a meta-
analysis summary of treatment approaches.

Treatment correlates. In designing any type of AOD treatment intervention
program, it is crucial that service providers be aware of the correlates of
substance use initiation and how these and other factors affect treatment
outcomes and relapse rates. While it is not within the scope of this report
to thoroughly examine all applicable correlates, research consistently
indicates AOD use and treatment outcome correlates should be considered
in comprehensive assessment and intervention strategies. In their 1990/91
comprehensive review of adolescent AOD treatment literature, Catalano
and associates identified a range of pretreatment, during-treatment, and
posttreatment factors associated with relapse or failure to complete
treatment. These factors should be considered in designing and
implementing effective AOD treatment programs (as summarized by
Dembo et al., 1993:117).

1. Initiation of AOD use or pretreatment factors. Little can be done to
change initiation or pretreatment factors. However, the potential effect on
substance use choices can be reduced through early identification and
appropriate intervention strategies.

--Biological factors. The literature suggests that a number of biological
factors may be related to AOD use. Such factors are thought to be
evidenced by a family history of AOD abuse (Merikangas et al., 1992) that
may reflect genetic contributions and/or variance in brain receptor sites for
a variety of chemicals (Wyman, 1997).

--Personality. Personality characteristics such as low self-esteem
(Henggeler, 1997a), sensation seeking, and aggressive behavior have been
shown to be related to AOD use initiation (Brook et al., 1990). In addition,
Henggeler (1997a) has found that lower intellectual achievement is related
to substance use.

--Ethnicity. In the general population, African-Americans are less likely to
initiate AOD use than white non-Hispanics or Hispanics (Johnston et al.,
1996). However, in arrested populations, African-Americans are more
likely to have used illegal substances (Drug Use Forecasting, 1997).

--Gender. While males are more likely to initiate illegal substance use, use
more frequently, and engage in more violent and other forms of criminal
behavior (Martin et al., 1995), females are more likely to initiate because
of sexual abuse and/or family violence and support their substance use
through prostitution (Nelson-Zlupko, 1995).

--Family. A wide variety of family characteristics have been found to be
related to AOD use initiation, including substance use role modeling
(Brook et al., 1990), conflict and violence (Needle et al., 1990), and lack
of relational attachments (Brook et al., 1993).

--Peers. The role of peers in AOD use initiation and continuation has been
well documented. Peers usually introduce individuals to all types of AOD
use and provide continued access as well as the social context and
justification for use (Elliott et al., 1985; Towberman, 1993; see also
Henggeler, 1997a).

--School. A wide variety of problem behaviors including AOD use and
delinquency have been found to be related to school performance. Poor
school attendance and low grades are consistently related to higher rates of
substance use and delinquency (Hawkins et al., 1992; see also Henggeler,
1997a).

--Co-morbidity. Researchers have often concluded that it is not so much
one or perhaps even a few factors that result in the initiation and
continuation of AOD use, but rather a combination of biological and
personality as well as environmental factors. Research consistently shows
that adolescent substance users and delinquents are characterized by
extensive co-morbidity (Inciardi et al., 1997).

2. Treatment retention and completion.

--Ethnicity. While ethnicity has not been found to be related to completing
treatment, African-Americans are more likely to use substances during
treatment than are white non-Hispanics or Hispanics (Moore, 1992;
Catalano et al., 1990/91).

--AOD use type and age of onset. The younger the age of onset, the more
serious the primary substance of abuse and the abuse of multiple
substances. AOD use type and age of onset are also related to not
completing treatment as well as poorer treatment outcomes (Catalano et
al., 1990/91; Hawkins et al., 1992).

--Educational level. School attendance, performance, and high school
graduation are all positively related to completion of treatment and
positive posttreatment outcome (Catalano et al., 1990/91; Hawkins et al.,
1992).

--Voluntary versus mandated treatment entry. Treatment mandated by the
courts is positively related to treatment retention (Leukefeld & Tims,
1988; Inciardi & McBride, 1991).

--Staff characteristics. Quality staff who establish positive role
relationships with clients can improve treatment outcome (Catalano et al.,
1990/91).

--Involvement of family/parents in treatment. Treatment involvement by
family members is positively related to program completion (Dembo et al.,
1993).

3. Posttreatment factors influencing relapse.

--Criminality. The amount of lifetime criminal involvement is related
negatively to posttreatment outcome (Catalano et al., 1990/91).

--Ethnicity. African-Americans are more likely to have slightly higher
relapse rates than are white non-Hispanics or Hispanics (Moore, 1992;
Catalano et al., 1990/91).

--Length of time in treatment. Treatment duration is related positively to
long-term positive treatment effect (Hubbard et al., 1989).

--Comprehensive services. Programs that provide comprehensive
assessment and needed services along a continuum of care, including
continuing care within a case management framework, have significantly
lower recidivism rates (Rapp et al., 1998).

--Thoughts and feelings about substances and substance cravings.
Substance-focused thoughts and cravings are related to relapse (Catalano
et al., 1990/91).

--Involvement in productive activities. Activities such as school or work
are related positively to posttreatment outcome (Catalano et al., 1990/91).

--Few and less satisfactory active leisure activities. Low levels of activity
and satisfaction are related to relapse (Catalano et al., 1990/91).

--Physical abuse and sexual victimization. Dembo and associates (1990)
found that at initial entrance into the juvenile justice system, 60 percent of
youth reported being physically harmed by an adult in one or more of six
different ways. In addition, 61 percent of females and 25 percent of males
interviewed indicated that they had been sexually victimized at least once
in their lifetimes. These reported rates should be considered conservative
estimates and may indirectly affect relapse rates.

The research strongly suggests that while no system will be able to address
each correlate noted, a balance between the optimum and possible should
be sought. Adequate consideration of the various correlates of AOD
initiation and use are essential in developing successful treatment
programs and choosing appropriate treatment modalities. Both programs
and modalities are reviewed in the following two sections of this
document.

Treatment programs. If a judge is favorable toward treatment, a juvenile
offender may receive a mandatory referral to an adolescent AOD treatment
facility. A range of more traditional nondetention options exist within
communities, although not nearly as many as are needed to meet the
demand for such services. Options include (from lesser to greater
restrictiveness): support groups such as AA or NA, outpatient, day
treatment, inpatient, and residential therapeutic communities (TCs). While
no single treatment for adolescent AOD abusers has clearly emerged as
superior to other forms of treatment, some tentative treatment patterns are
beginning to emerge.[14] Interventions which address a wide range of
AOD correlates within the context of the adolescent's natural environment
appear to demonstrate the most positive outcome effects.

Support group, outpatient, day treatment, and inpatient programs.
Henggeler (1997a) maintains that researchers know little about the
effectiveness of support groups, outpatient, day treatment, and inpatient
programs. Such programs are called traditional treatments and are the most
widely used programs for adolescent substance abuse. The Twelve-Step
approach is believed to be the most widely used intervention approach in
the United States for treating severe substance-abusing adolescents
(Hoffmann et al., 1993). However, controlled trials have not been
conducted for specialized inpatient treatments and Twelve-Step programs,
making conclusive judgments about their effectiveness inappropriate. The
Chemical Abuse/Addiction Treatment Outcome Registry (CATOR) data
base is currently the most extensive longitudinal data base on adolescent
treatment outcomes (Harrison & Hoffman, 1989; see also Jenson et al.,
1995). Results collected from 924 youth (49 percent of the eligible follow-
up sample) at a 1-year follow-up period indicate that 42 percent report
total abstinence and another 23 percent have less than monthly AOD use.
Alford et al. (1991) determined that youth who regularly attend AA and
NA groups following inpatient treatment have significantly higher
abstinence rates than adolescents who complete inpatient treatment only
(see also Jenson et al., 1995). While such findings underscore the
importance of posttreatment supports, these nonrandomized outcomes may
simply reflect higher motivation levels to remain substance-free on the
part of support group attendees.

Winters, Stinchfield, et al. (in press) recently conducted a quasi-
experimental outcome study of AOD-abusing adolescents treated with a
Twelve-Step approach. Subjects included 245 AOD clinic-referred
adolescents who were assessed with at least one substance dependence
disorder as classified by the Diagnostic and Statistical Manual of Mental
Disorders, Third Edition Revised (DSM-III-R). Outcome analyses
indicated that those who complete treatment maintain superior treatment
outcomes compared to those who do not complete treatment or are part of
a waiting group (n=66). Fifty-three percent of those who complete
treatment report either abstinence or only a minor lapse during the 12
months following treatment, compared to 15 and 28 percent for the
incompletes and waiting list groups, respectively. Treatment retention was
found to be an important contributor to outcome, with favorable treatment
outcomes for AOD abuse being two to three times more likely if treatment
was completed. No outcome differences were found between residential
and outpatient groups. Additionally, gender and age did not interact with
outcome findings. Despite the quasi-experimental nature of this study, the
findings are generally consistent with other Twelve-Step outcome studies
(Harrison & Hoffmann, 1989; Brown et al., 1989), which may indicate
that such programs are a relatively effective treatment approach.

In comparing inpatient versus outpatient treatments, the 1991 United
States Congress Office of Technology Assessment review found no clear
evidence that either setting was more effective in reducing adolescent
substance abuse. The review additionally found that treatment modalities
more clearly associated with positive outcomes for youth in treatment (e.g.
recreational, educational, social skills training, and family therapy
components) were viewed by treatment staff as secondary supports to
actual substance abuse treatment. Treatment modalities will be reviewed in
a separate section below.

2. TCs for adolescents. TCs are 24-hour settings in which
multidimensional rehabilitation services are provided, including
personality restructuring, social education, and economic and survival
skills. Adolescents who enter AOD-free TCs generally have very severe
substance abuse problems which have caused serious disfunction in their
daily lives. While the traditional TC focuses on the adult (usually male)
addict, the need to accommodate the developmental differences and use
patterns of adolescents has led to the following treatment modifications:
shorter recommended lengths of stay than for those in adult TCs due to
more rapid developmental changes in emotional and physical areas for
adolescents, participation by families in the therapeutic process, limited
use of peer pressure with a greater focus on positive influences
(pretreatment peer influences have been generally negative), less reliance
on life experiences to develop understanding of one's self and behaviors,
and participation in the daily authority structure of the TC's operations
with peers (staff maintain control over all decisions and supervision)
(Jainchill et al., 1995).

Jainchill and her colleagues (1995) have reviewed several major studies of
TC effectiveness, including the Drug Abuse Reporting Program (DARP)
study (conducted during the late 1960s and early 1970s), the Treatment
Outcome Prospective Study (TOPS, conducted from 1979 to1981), and the
Center for Therapeutic Community Research (CTCR) study (involving 6
adolescent TCs at 9 sites based on a sample of 938 adolescents between
1992 and 1994). In the past, a substantial proportion of total TC referrals
came from self, family and/or friends, and medical and substance
treatment-based referrals. In what appears to be an increasing trend, 70 to
100 percent of admissions into programs reviewed by Jainchill and
colleagues (1990) were court referrals for all but two of the programs. The
large majority of clients were males who entered treatment because of
marijuana and/or alcohol abuse problems, with the exception of Hispanic
youth who reported significant abuse of heroin.

Jainchill and her colleagues have also reported significant reductions at 6-
month posttreatment in AOD use among adolescents who were involved
in a TC. Other outcome measures, including criminal activity and
educational achievement, showed significant improvements as well (in
press; see also Winters, Stinchfield, et al., in press). In her meta-analysis
of residential programs for delinquent youth, Garrett (1985, as cited in
Catalano et al., 1990/91) reported on the effectiveness of various treatment
approaches within residential facilities. She reported that "a cognitive-
behavioral approach, a relatively recent development, seems to be more
successful than any other, even in the more rigorous studies" (304). 

The amount of time spent in a treatment program (TIP) is the largest and
most consistent predictor of treatment outcomes within TCs (Catalano et
al., 1990/91; De Leon, 1988; Jainchill et al., 1995). Positive outcomes
(e.g., no criminal activity, no AOD use, employment, and improvement in
psychological measures) are all associated with longer TIP (De Leon,
1984; Hubbard et al., 1985; Simpson & Sells, 1982; see also Onken et al.,
1997, for recent studies on general AOD treatment retention). Therefore,
while juvenile TCs advocate comparatively shorter treatment times than
adult TCs, it is essential that programs allow adequate time for treatment
effectiveness. Further support for this claim was found in the TOPS study,
which concluded that at 12-month follow-up, "residential treatment
produced more substantial and consistent reductions in drug and alcohol
use, drug-related problems, and predatory illegal acts than outpatient
treatment" (Catalano et al., 1990/91:1107). However, this finding was
confounded by the DARP study, which found that outpatient AOD-free
clients showed slightly better outcomes for reductions in alcohol and
marijuana use. High rates of dropout are the norm for TCs, with 30-day
dropout rates in the CTCR study ranging from 2 to 35 percent (reasons for
this wide dropout range were not discussed, but lower rates are likely
related to court-mandated referrals). Given the recent trend toward court-
referred TC stays, it is anticipated that high dropout rates would be
significantly lowered.

Long-term TCs: Variables which correlated negatively with retention
through 90 days include an antisocial lifestyle, high criminal involvement,
significant problems with fighting or controlling violent behavior, poor
psychological status, and relationship with friends who are strongly
involved with AOD and crime. Variables predicting retention include high
levels of self-esteem, high CMRS Index scores (a scale which measures
circumstances, motivation, readiness, and suitability for treatment), high
Environmental Risk Index scores (a scale measuring various
environmental factors which occur in treatment settings), and interviewer
impressions of client likelihood of staying in the program (Jainchill, et al.,
1995). While positive outcomes for those who remain in treatment appear
promising, a great deal more research is needed to understand the complex
and interactive relationships between client, treatment, and outcome.

Short-term TCs: Short-term residential facilities have more problematic
outcomes than their long-term alternatives. While the trend in the juvenile
justice system is to place troubled adolescents in these large and frequently
crowded residential facilities, "These facilities are often intimidating and
otherwise stressful environments, where youth educational and other
rehabilitative needs are often ignored or insufficiently addressed. Evidence
has been accumulating that these expensive programs serve primarily to
isolate youth from the general society, are ineffective, and have no
significant impact on recidivism" (Dembo et al., 1993:119).

Overall treatment program evaluation issues. Many studies on adolescent
AOD treatment effectiveness have relied on quasi-experimental or one-
group pre-post designs. However, researchers (Henggeler, 1997a; Catalano
et al., 1990/91) note that reported changes in treatment conditions can
result from a number of factors unrelated to treatment effectiveness. Such
factors include: (1) statistical regression effects, which are likely because
youth who enter treatment in crisis often reduce their AOD use when
problems have diminished; (2) differential dropout rates, which may skew
results so that those with the most serious problems drop out of treatment,
leaving the less severe users to show a false overall improvement in
treatment outcomes; (3) effects of history and maturation, which are
especially important for adolescents (in 1994, Brown and her colleagues
reported that there are wide normal variations of AOD use for adolescents
over time; see also Henggeler, 1997a), and (4) AOD use patterns, which
for adolescents in no-treatment or minimal-treatment control conditions
have shown substantial decreases in substance use over time (Joanning et
al., 1992; Amini et al., 1982). In addition to the above factors, the
delinquency treatment literature has a long history of demonstrating
successful outcomes in uncontrolled studies, but these effects diminish
when submitted to controlled clinical trials (Henggeler, 1997a).

Treatment modalities. In addition to a variety of treatment levels and
settings, a variety of modalities are utilized, including family therapy,
skills training, conflict resolution, adult mentoring, and after-school
recreation programs. Although focused on in this subsection, the
modalities and concepts examined here are found at various places along
the treatment continuum. For example, one might find family therapy
interventions used in prevention settings, diversion programs, inpatient
and outpatient settings, and (in a limited way) among residential facilities.
In addition, these modalities are often used to reduce other problem
behaviors in addition to substance use. In this sense, they should be
considered integral to the various phases of any multiproblem system,
including substance abuse treatment within the juvenile justice system.

While randomized trials have provided minimal support for the
effectiveness of any specific treatment modalities for adolescent AOD
abuse (Henggeler, 1997a), several interventions have shown promise
under experimental conditions (to be reviewed below). However, despite
the overall lack of carefully controlled studies, Winters and Latimer and
colleagues (in press) maintain that adolescent substance treatment is better
than no treatment at all, with 1-year abstinence rates (between 30-50
percent) approaching those found in the adult literature. Several carefully
designed experimental studies have compared adolescent treatment
modalities: inpatient versus outpatient (Amini et al., 1982), family therapy
versus parent training (Friedman, 1989; Lewis et al., 1990), and conjoint
versus one-person family therapy (Szapocznk et al., 1983; 1986; see also
Henggeler, 1997a). For all studies, findings generally support decreased
adolescent AOD use across all paired experimental and comparison
treatment conditions, leading the authors to conclude that each compared
treatment condition was effective. However, Henggeler maintains that
"such conclusions may be in error because these studies and their results
present the same difficulties in interpretation and significant threats to
internal validity as noted for single group designs. That is, history,
maturation, and regression may have accounted for the similar decreases
in AOD use across treatment conditions" (1997a:264).

Briefly examined below are the treatment modalities of family therapy,
skills training, conflict resolution and violence prevention, peer mediation,
adult mentoring programs, and after-school recreation programs. In the
discussion of the various modalities, primary emphasis is given to reported
effectiveness.

1. Family therapy. Family therapy has been utilized extensively as a
treatment modality in the mental health and AOD abuse fields.
Researchers have been led to design and test family interventions
specifically for AOD-abusing adolescents (Liddle & Dakof, 1995) for two
reasons: (1) success of family-based interventions in other related problem
areas, such as delinquency and child behavior problems (Kumpfer et al.,
1996; Patterson, 1986), and (2) identification of consistent family-related
factors associated with development of adolescent AOD use (Brook et al.,
1990). Family therapy models include conjoint family therapy and one-
person family therapy, [15] group treatment of families versus individuals
(utilizing strengths of social networking, self-help, and mutual support that
are often part of minority group culture),[16] and integrative models.

Integrative models are the most promising family-based interventions
(Coyne & Liddle, 1992; Gurman & Kniskern, 1992). These interventions,
which recently emerged with developments in psychotherapy, emphasize
the construction of systematic and prescriptive packages, which have been
termed multisystemic (Henggeler & Bourdin, 1990) and multidimensional
(Liddle et al., 1991). Examples include Multidimensional Family Therapy
(Liddle et al., 1991), Brief Strategic/Structural Family Therapy (BSFT)
(Szapocznik & Kurtines, 1989), and Multi Systemic Therapy (MST)
(Henggeler et al., 1991). These comprehensive approaches view the family
as a system which is, in turn, part of a larger social network including
schools and peers. Within these networks, parents and other significant
primary caregivers are viewed as being the most critical influences in the
development of a child's prosocial attitudes and behaviors. 

Such interventions therefore focus on rebuilding a child's natural habitats
in ways which build upon the existing strengths of these primary support
systems. Caregivers are helped to establish boundaries and consequences
for their child's behaviors and are coached on ways to become more
involved with teachers and school activities. Parents also become more
involved with their child's peer groups and learn how to monitor peer
networks more effectively. In addition, such approaches attempt to work
with legal systems in order to educate judges and other professionals in
system collaboration models. Within this integrative framework, the use of
graduated sanctions is generally seen as a constructive way to create
carrot-and-stick incentives for reducing delinquent behaviors.

--

Research groups have recently published results of randomized clinical
trials assessing the effectiveness of family-based treatments with other
treatment modalities as evidenced by significantly lower AOD use at
termination. A few of the trials demonstrated the superiority of family
therapy over other treatments in the areas of individual counseling
(Henggeler et al., 1991), parent education and skill-building groups
(Joanning et al., 1992; Lewis et al., 1990; Liddle & Dakof, 1992), and peer
group therapy (Joanning et al., 1992; Liddle & Dakof, 1992). Studies have
demonstrated that family-based models can engage and retain cases in
AOD treatment (Santisteban et al., 1996). This is especially important
given the traditionally high dropout rates in the field of substance abuse.
Home-based MST has demonstrated a particularly strong ability to reduce
and, in some cases, almost completely eliminate program dropouts
(Henggeler et al., 1991; 1996; 1998).

The most systematically evaluated integrative model is MST, a
comprehensive family- and community-based treatment approach
embedded within the Family Preservation Model of service delivery. MST
attempts to address the multiple determinants of youth and family
problems by targeting the individual, family, peer, school, and community
factors associated with serious antisocial behavior. MST practitioners meet
with juveniles and their families in the home, school, neighborhood, and
community as these are the areas where AOD use and delinquency
behaviors are most likely to occur. Interventions are intensive, highly
individualized, comprehensive, and include a team approach to service
delivery. Therapeutic contacts emphasize positive aspects of the family
and use these strengths as levers for change. Interventions are present-
focused and action-oriented. "The therapist's task is to identify the 'fit' of
identified problems with the strengths and needs of the multiple systems
within which the youth is embedded and to collaborate with family
members in using these strengths to create and maintain changes in the
individual behavior and social ecology of the youth (e.g., family
interactions, access to negative peers, school-family interactions, etc.)"
(Schoenwald et al., 1996:435).

MST has recently shown promise in reducing a number of AOD-related
delinquency behaviors, including fewer arrests, fewer criminal offenses,
and 10 fewer weeks in juvenile detention during a 59-week follow-up
period (Henggeler, 1997a). Two studies focusing on AOD-using juvenile
offenders demonstrate significantly lower incarcerations, out-of-home
placements, and soft- and hard-AOD use at posttreatment. In addition,
reductions in soft-AOD use have been maintained at 6-month
posttreatment follow-up for males (Henggeler et al., 1991; 1997b).
Another multisite randomized trial (Henggler et al., 1997b) compared
MST with the usual juvenile justice services among a population of
violent and chronic juvenile offenders and their families. Findings indicate
that MST produced a 47 percent reduction in days incarcerated at a 1.7
year follow-up. MST also significantly reduced self-reported alcohol,
marijuana, and other substance use at posttreatment, although these
differences disappeared at 6-month follow-up. Researchers concluded that
MST's effectiveness appears to be reduced when the therapists who
administer the intervention do not carefully adhere to treatment protocols
(Henggeler et al., in press). Finally, in a recent meta-analysis of family-
based treatments of substance abuse (Standon & Shadish, 1997), MST
effect sizes were among the highest of those reviewed.

MST appears to be more effective than usual community treatment for
inner-city juvenile offenders, specifically in improving family warmth and
cohesion and decreasing youth behavioral difficulties, such as aggression
with peers. "The relative efficacy of MST was neither moderated by
demographic characteristics--ethnicity, age, social class, gender, arrest,
and incarceration history--nor mediated by psychosocial variables
including family relations, peer relations, social competence, behavior
problems, and parental symptomatology. Thus, MST was equally effective
with youth and families of divergent backgrounds" (Henggeler, 1997b:4).
Positive findings were replicated in an MST intervention with rural
African-American and white families (Scherer, 1994).

Cost comparisons made between MST and usual services (outpatient
substance abuse referral received over a 1-year period) show that "the
incremental costs of MST were nearly offset by the savings incurred as a
result of reductions in days of out-of-home placement during the year"
(Schoenwald et al., 1996:431). Cost savings are estimated to be much
greater if youth are at risk of out-of-home placement (Henggeler et al., in
press; Schoenwald et al., 1996). Supporting this claim, the Washington
State Institute for Public Policy conducted an economic study of 16
programs and concluded that MST was the most cost-effective
intervention for juvenile offenders (Washington State Institute for Public
Policy, 1998).

Such multidimensional family therapy models have proven to be
particularly effective at engaging, retaining, and reducing problem
behaviors among minority youth. Szapocznik et al. (1990) designed the
Structural Strategic Systems Engagement (SSSE) approach to engage
Hispanic/Latino substance abusers and their families more effectively.
SSSE is based on the premise that the same dysfunctional interactional
patterns which create and maintain the presenting problem will emerge in
the engagement phase as resistance to beginning treatment. "The goal of
SSSE is to begin the work of diagnosing, joining, and restructuring the
family with the very first contact, thereby facilitating the engagement of
the entire family into therapy" (Santisteban et al., 1996:35). Overall results
in controlled experiments indicate that 81 percent of experimental group
families were successfully engaged compared to 60 percent of control
group families. Further, SSSE was more successful in engaging non-
Cuban Hispanics (97 percent) than Cuban Hispanics (64 percent). In
addition, dropout rates in therapy were up to three times lower for families
that had received the SSSE intervention compared to control group
families.

Regarding other integrative models, once engaged in the therapeutic
process, BSFT has been effective in preventing or reducing problem
behaviors in Hispanic/Latino youth (Szapocznik, 1995; Coatsworth et al.,
in press; Santisteban et al., 1996). MST has shown considerable success in
engaging and retaining both African-American and white families in
treatment. As stated earlier, findings from clinical trials also show that
MST has been equally effective in obtaining favorable clinical outcomes
with these cultural groups (Brondino et al., 1997). Another family-based
intervention, Multidimensional Family Therapy (MDFT) (Liddle, 1995),
has been developed and refined for inner-city adolescent substance
abusers. Controlled randomized clinical trials have demonstrated MDFT's
superiority to adolescent group therapy and a multifamily educational
condition in reducing substance use as well as improving grades. Current
clinical trials are comparing MDFT to an individual-based cognitive
therapy condition.

One final family-based intervention showing initial promise is the Youth
Support Project (YSP), a 5-year study funded by NIDA. The purpose of
the project's Family Empowerment Intervention (FEI) is to improve family
functioning by empowering parents. This is accomplished through nine
goals: restore the family hierarchy; restructure boundaries between parents
and children; encourage parents to take greater responsibility for family
functioning; increase family structure through implementation of rules and
consequences; enhance parenting skills; have parents set limits,
expectations, and rules that increase the likelihood that the target youth's
behavior will improve; improve communication skills among all family
members; improve problem-solving skills, particularly with the problem
youth; and where needed, connect the family to other systems (e.g. school,
church, and community activities) (Dembo et al., 1998).

Families involved in the project were randomly assigned to either the
Extended Services Intervention (ESI) or the Family Empowerment
Intervention. Families in the ESI group received monthly phone contacts
and, if indicated, referral information; FEI group families received three 1-
hour, home-based meetings per week from a clinician-trained
paraprofessional. Twelve month follow-up analysis (Dembo et al., in
review, a) of participating families (n=303) indicated that youth and
families who completed the FEI experienced significantly lower rates of
new charges and significantly fewer new arrests than youth not completing
the FEI. An earlier 12-month follow-up analysis (Dembo et al., in review,
b) (n=272) also found that youth completing the FEI had lower rates of
delinquency (self-reported crimes against persons, substance sales, and
total delinquency) and substance use (measured by self-reports and hair
test results) than juveniles who did not complete the FEI. Dropout rates for
the FEI were quite high (47 percent), largely due to families moving from
the area or parents/guardians who were unwilling or unable to commit to
participating in family meetings.

2. Skills training. Skills training (also referred to as interpersonal skills,
life-skills, or social skills training) has been recommended for a number of
problems including adolescent substance abuse. While the definition of a
skill varies across studies and program reports, a skill can be defined as
"the exact words to say, the way to say them, and the hand movements
needed to convey a message" (Hall, 1995:255). These programs are often
integrated into school-based prevention programs using cognitive-
behavioral strategies. One common difficulty with skills training is that
the existence of many models make agreement on a common intervention
and set of skills difficult. Skills training often includes such components as
assertiveness training, communication skills, anger management, peer-
resistence training, problem solving, and relapse prevention skills
(Hawkins et al., 1992; Catalano et al., 1990/91). Specific treatment
techniques which are often used to teach skills include providing
information, demonstrating desired behaviors by appropriate modeling,
role playing desired behaviors by teens, giving structured and supportive
feedback, and assigning homework to practice skills in the teen's natural
environment.

While skills training is found in many clinical programs and prevention
model descriptions, few evaluation studies are available. Hall (1995) has
identified only seven studies where skills training was either the sole
treatment approach or a major component of treatment. Hawkins and
colleagues (1991) provide the only study which utilized skills training as
the primary treatment with incarcerated adolescents to increase resistance
to AOD use. In both studies, investigators found strong evidence that
youth in the experimental group improved their skills in AOD use
avoidance, social interaction, self-control, and problem solving from
pretreatment to posttreatment when compared to control group teens.
However, few studies demonstrate long-term effects of acquired skills on
reductions in AOD use (Jenson et al., 1995), and attrition rates are quite
high with high-risk youth (Botvin et al., 1990). While such interventions
show promise, more controlled studies using well-defined intervention
techniques are needed in this area.

3. Conflict resolution and violence prevention. Conflict resolution and
violence prevention programs use curricula developed to improve student
social, problem solving, and anger management skills, promote beliefs
favorable to nonviolence, and increase knowledge about conflict and
violence. The curricula address risk factors such as early and persistent
aggressive behavior and association with delinquent and violent peers,
factors which are also correlates of substance use. Content and
instructional methods vary considerably between programs.

While many such curricula have been developed in recent years, few have
undergone controlled evaluation. Evaluations that have been done show
mixed results (Brewer et al., 1995). While various programs have been
generally effective in improving student social skills in hypothetical
conflict situations, only one (Gainer et al., 1993) of the four controlled
studies measuring attitudes about violence has shown reduced student
attitudes about violence. Two studies show reductions in self-reported
violent behavior (Bretherton et al., 1993; Spiro et al., cited in Webster,
1993). Several of the curricula were designed and tested with minority,
low-income adolescents (Gainer et al., 1993; Hammond & Yung, 1991).
While a variety of methodological problems and lack of random
assignment make interpretations of these findings problematic, such
programs appear to merit more careful study and controlled
implementation among high-risk juvenile populations.

4. Peer mediation. Peer mediation programs are often offered in
conjunction with conflict resolution curricula. Students in conflict agree to
involve a peer mediator to help resolve the dispute. The mediator
examines various aspects of the problem, recommends changes and
compromises, and develops a mutually agreed upon solution. Peer
mediation may address risk factors such as early and persistent antisocial
behaviors, association with peers who are involved in violence, and
delinquent behaviors such as substance abuse.

Lam (1989, as cited in Brewer et al., 1995) reviewed 14 evaluations of
peer mediation programs in North America. While qualitative and
anecdotal reports were positive, none of the controlled studies showed
significant impact on observable student behaviors (e.g., disciplinary
referrals, fighting). One other noteworthy school-based study conducted
by Tolson et al. (1992) found that peer mediation participants are
significantly less likely to be referred again within 2.5 months to school
authorities for interpersonal conflicts than are individuals receiving
traditional discipline. More controlled studies are needed in this area.

5. Adult mentoring programs. Adult mentoring programs typically involve
nonprofessional volunteers who spend time with individual adolescents
acting as nonjudgmental, supportive role models. These programs are
designed to address risk factors, such as alienation, academic failure, low
commitment to school, and association with delinquent or violent peers.
Mentoring programs are also designed to provide protective factors, such
as opportunities for prosocial involvement, bonding with prosocial adults,
and development of healthy beliefs and clear standards for behavior
(Brewer et al., 1995).

In their review of 10 available evaluations, Brewer and his colleagues
determined that "noncontingent, supportive mentoring relationships do not
have desired effects on outcomes such as academic achievement, school
attendance, dropout, various aspects of child behavior (e.g. misconduct),
or employment" (1995:99). However, one small short-term study found
that when mentors use behavior management techniques such as
contingency contracting, student school attendance improves. This is
consistent with findings from studies of school behavior management
interventions (Brewer et al., 1995). More evaluations with randomized
designs are needed in this area before firm conclusions can be reached.

6. After-school recreation programs. After-school recreation programs are
designed to address risk factors, such as alienation and association with
delinquent and violent peers, as well as provide protective factors, such as
skills for leisure activities and opportunities for involvement and bonding
with prosocial youth and adults. While few evaluation studies have been
conducted in this area, Jones and Offord (1989) found statistically
significant reductions in antisocial behaviors during the program, perhaps
indicating that participants who are involved in structured activities have
less free time on their hands to become involved in delinquent behaviors.
No changes were reported in home or school behaviors, and positive
program effects declined significantly after the intervention concluded.
Given the lack of evaluations of these types of programs, more research
designs using random assignment are needed (see Brewer et al., 1995, for
a comprehensive review of these programs and their effectiveness).

Meta-analysis of treatment effectiveness. Lipsey and Wilson (1998)
recently conducted a meta-analysis of experimental or quasi-experimental
studies of intervention programs for serious and violent juvenile offenders.
This analysis reviewed 200 programs divided into interventions with
noninstitutionalized juveniles (n=117) and interventions with
institutionalized juveniles (n=83). The great majority of the juveniles in
these studies were reported to be adjudicated delinquents, and most or all
had a record of prior offenses usually involving person or property crimes.
While this comprehensive analysis did not specifically look at AOD use
reductions, it provides very useful insight into which intervention
programs showed the greatest impact on outcomes closely related to
substance use, such as reductions in police contacts/arrest recidivism rates,
officially recorded contacts with juvenile courts, offense-based probation
violations, or other similar categories. Evidence from the analysis clearly
shows that intervention programs are generally capable of reducing the
reoffending rates of serious juveniles. The more important question for
this report, however, is which types of programs are the most effective and
which have proved to be ineffective.

1. Interventions with noninstitutionalized juveniles. Lipsey and Wilson
calculated treatment effectiveness by using a mean effect size for each
treatment. Treatments were then grouped into similar effect sizes. The top
group consists of those treatment types which show consistently positive,
statistically significant treatment effects. This group includes interpersonal
skills training, individual counseling (including MST and reality therapy),
and behavioral programs (e.g., family counseling and contingency
contracting). Overall, these treatments have been found to reduce
recidivism rates by about 40 percent, a considerable reduction considering
the expense and social damage caused by juvenile delinquents.

Close behind this top group is a second tier of treatment types for which
evidence is also statistically significant and quite convincing. These
programs include multiple services, such as intensive case management
and multimodal service as well as restitution programs for juveniles on
probation or parole.

The bottom group of treatments "show the strongest and most consistent
evidence that they were not effective in reducing the recidivism of
noninstitutionalized serious juvenile offenders" (Lipsey & Wilson,
1998:323, authors' italics). This group includes wilderness/challenge
programs, early release from probation or parole, deterrence programs
(mostly shock incarceration), and vocational training or career
counseling/job search programs. While strong arguments can be made that
job skills and access to jobs are crucial, existing studies do not indicate
much success. Perhaps at the program level, job training is not of
sufficient intensity or does not take place within sufficient collaboration to
be effective. In addition, job opportunities at a macro level must be
available for any vocational training to be effective.

The largest proportion of effect size variance has been associated with the
characteristics of juveniles who receive treatment, especially prior offense
histories. The influence of treatment type and amount shows intermediate
effect sizes, with general program characteristics only weakly related to
effect size. Interestingly, the largest intervention effect sizes have been
seen with the more serious offenders rather than with less serious
offenders, offering good reason to believe that such interventions would be
at least equally effective if used exclusively with more serious offenders.

2. Interventions with institutionalized juveniles. Again, mean effect size
for each treatment type was calculated and findings were grouped into
similar effect sizes. However, there were too few total studies in each
group to make any firm conclusions about the relative effectiveness of
different treatment types. Treatment types in the top two groups with the
strongest treatment effects include interpersonal skills training (such as
social skills, aggression replacement, and cognitive restructuring),
teaching family homes (including small behavior modification group
homes with teaching parents and token economies), behavioral programs
(such as cognitive mediation training and stress inoculation training),
community residential programs or TCs, and multiple services within
residential settings. The most effective of these treatments reduced
recidivism rates by 15-20 percent, a considerable decrease given the
relatively serious offenses of involved juveniles.

The largest proportion of effect size variance has been associated with the
general characteristics of the intervention program, especially the age of
the program and whether services are administered by juvenile justice or
mental health personnel (programs run by mental health professionals are
significantly more effective than those provided by juvenile justice
personnel). Type and amount of treatment show only moderate effects, and
juvenile characteristics show little effect. This is the reverse of the pattern
shown by noninstitutionalized offenders.

3. Summary. Based on the findings from the meta-analysis by Lipsey and
Wilson (1998) and the review of the range of AOD treatment and
supervision options available to judges, the following summary represents
three levels of knowledge about what is known regarding the effectiveness
of AOD supervision and treatment programs/modalities. The first level
shows programs or modalities with the strongest empirical evidence of
effectiveness. The second level highlights existing programs which need
further research before conclusions can be made about their effectiveness
(particularly related to program costs). The final level shows programs
which appear to show little or no evidence of success based on current
empirical studies. Both nonincarceration and institutionalization program
summaries are provided.

What works: Within noninstitutionalized programs, program options
which show good evidence of effectiveness include individual counseling,
behavioral programs (family counseling and contingency contracting),
multiple services (including intensive case management and multimodal
services), restitution programs (parole- and probation-based), and
interpersonal skills training. Among institutionalized programs, evidence
of effectiveness has been demonstrated for behavioral programs (cognitive
mediation and stress inoculation training), longer-term community
residential programs (therapeutic communities with cognitive-behavioral
approaches), multiple services within residential communities (case
management approach), interpersonal skills training (social skills,
aggression replacement, and cognitive restructuring), and teaching family
homes.

Program options which require more research to document effectiveness:
Among noninstitutionalized programs, the following require additional
research: employment-related programs, academic programs,
advocacy/casework, family counseling, and group counseling. For
institutionalized programs, more research is required for individual
counseling, guided group programs, and group counseling.

Program options which do not show evidence of effectiveness:
Effectiveness has not been demonstrated for the following
noninstitutionalized programs: deterrence programs, vocational training or
career counseling/job search, early release from probation or parole, and
wilderness challenge programs. Institutionalized programs without
evidence of effectiveness are milieu therapies.

Amidst the discussion of treatment modalities and effectiveness, it is
important to recognize that while knowledge of general effectiveness
exists to varying degrees, there is very little information on the
relationship between treatment program outcomes among different
ethnic/cultural groups. In planning and implementing treatment programs,
it is crucial to develop interventions based on the specific characteristics
and needs of the ethnic/cultural groups that will be served by the program.

Culturally sensitive intervention and treatment programming.
Interventions at any point of system contact (diversion, disposition, and
sentencing) may have differential effects on adolescents based on their
ethnic association. Ethnicity can affect family relationships, self-esteem,
achievement orientation, and perceptions of authority structures and
treatment providers (Canino & Spurlock, 1994; Paniagua, 1994). Care
must be taken to address considerations of ethnicity in developing
interventions which are effective with adolescents from a broad range of
backgrounds or that meet the specific needs of a given population.

One intervention option involves improving intergroup relations. This
could be done in the context of treatment, supervision, therapy, or
community-building activities. In their discussion of designing and
implementing effective strategies of this kind, Hawley and his colleagues
(1995) provide the following principles, stating that effective strategies:

1. Address individual and institutional sources of prejudice and
discrimination in a context relevant to the population targeted for change.

2. Consider diversity within and across groups, acknowledging all to be of
equal importance.

3. Should receive support from those who have authority and power within
the structure where they are being implemented.

4. Are periodically reinforced with old members of the group and
explained to new members.

5. Should be implemented across related systems as appropriate.

6. Need to examine diversity of ethnicity, socioeconomic status, gender,
and language, appreciating and acknowledging the strengths inherent in
each as well as the challenges.

7. Should dispel myths which perpetuate stereotypes and prejudices.

8. Recognize that experience of prejudice and discrimination is unique at
the level of the individual and the ethnic group of association, and
therefore does not necessarily apply to others.

When developing interventions, it is also important to consider that
minority populations may have experienced problems accessing health and
mental health services, barriers to education (such as language differences
or inappropriate placement in special education programs), and other
discrimination based on their ethnicity. Very little research has been done
to assess the effectiveness of various treatment modalities with minority
adolescent substance abusers; however, there are various compilations of
available literature which suggest general guidelines for treating specific
minority populations (for further information, please see Canino &
Spurlock, 1994; Ho, 1992; Paniagua, 1994).

Continuing care services: beyond and within the juvenile justice system

As mentioned previously, dropout rates (percent of clients discontinuing
treatment before program completion) from voluntary substance abuse
services are quite high (up to 35 percent in methadone maintenance
programs, 82 percent in outpatient drug-free programs, and 90 percent in
TCs) (Anglin & Hser, 1990; Bale et al., 1980; Hubbard et al., 1989; Mejita
et al., 1997; McLellan et al., 1983). Regardless of the progress clients
make in residential AOD treatment facilities, research suggests that it is
difficult to maintain these gains following discharge (Hayes, 1988;
Hubbard et al., 1989; see also Godley et al., 1994). Brown et al. (1989;
Godley et al., 1994) found that 60 percent of adolescent substance abusers
had relapsed within the first 3 months of discharge, with relapse rates
climbing to 80 percent in the first 12 months following discharge.
Similarly, Spear and Skala (1995) found that 92 percent of adolescents had
relapsed at least once during the first year after discharge from a
residential facility, with 76 percent using primarily alcohol or marijuana at
least monthly by the end of the first year. Adolescents were found to be
most vulnerable to relapse during the first 2 months following treatment.
Perhaps this is not surprising given that adolescents often return to the
familiar peer, family, and school stressors which supported and promoted
their initial AOD use.

Continuing care services are a vital link in the service continuum, but such
services are infrequent, underdeveloped, and tend to focus on only single
problem areas such as peer networks or school placements (Armstrong,
1991; see also Dembo et al., 1993). While many programs are well
intentioned, services which are provided are often fragmented. In an
OJJDP-commissioned study on community-based continuing care
services, Altschuler and Armstrong (1991) found that a relatively small
proportion of programs focus on juveniles, and that reported outcomes are
often anecdotal, impressionistic, and descriptive. In addition, the design
and operations of most programs are not clearly spelled out, explained, or
implemented.

Several recent studies have more systematically evaluated aftercare
treatment programs for juveniles and have come to mixed conclusions
about the effectiveness of continuing care services. Sontheimer and
Goodstein (1993) evaluated an intensive aftercare probation program for
juveniles with a primary focus on reintegrating serious, habitual male
juvenile offenders from a State training school back into the community.
Individuals were randomly assigned to an experimental intensive aftercare
probation group or a traditional probation control group. The study found
that the incidence of rearrest was significantly lower for the aftercare
group than the parole group, but this effect disappeared when controlling
for follow-up. When examining rearrest frequency, however, the aftercare
group showed a significantly lower number of rearrests than the control
group, and these differences were maintained when controlling for follow-
up period length.

Greenwood et al. (1993) conducted a 4-year evaluation of two
experimental aftercare programs for juvenile offenders. At the conclusion
of residential placement, approximately 100 youth from each site were
randomly assigned to a 12-month experimental aftercare group or a control
group. The aftercare model included multiple contacts between the
juvenile and his or her caseworker, improved family functioning, and
linkages to appropriate educational or employment programs. Control
group participants were released into the community with no services.
Researchers did not find significant differences in self-reported offenses,
substance use, school involvement, or official arrest data when comparing
the two groups. Some positive effects were observed on self-report
measures, such as personal goals, sense of self-efficacy, and coping skills,
although these effects were not consistent between the two programs.
Researchers concluded that "surveillance and casework" (32) was
insufficient to overcome the multiple negative influences of peers, family,
and environmental deficits. They recommended refocusing the program on
cognitive-behavioral techniques that would provide more concrete tools
for community reentry.

Only one quasi-experimental study has focused on the effectiveness of
treatment-oriented aftercare following residential substance treatment for
addicted offenders. Sealock and Gottfredson (1997) evaluated 700
substance-abusing juvenile offenders who were assigned by a judge to
either a 2-month residential substance abuse treatment program group or a
comparison group. At the conclusion of the residential program,
participants reported significantly decreased substance use and
delinquency as well as increased cognitive decision-making skills.
Participants also demonstrated a longer period of time from entry into the
study until rearrest than the comparison group . Following program
completion, residential program participants were assigned to a treatment
(n = 120) or comparison group (n = 132) for a 4-month community
aftercare phase. Aftercare services included improving discipline and
reducing enabling negative behaviors within the youths' families,
increasing youth involvement in productive community activities, and
reducing negative peer influences. Results from this program indicated
that the positive gains which were made in treatment were not maintained
through aftercare. Aftercare youth reported more delinquent behaviors and
demonstrated more participation in substance-related crime than the
comparison group. Aftercare juveniles did, however, show less
participation in interpersonal crimes. The researchers concluded that
" this research provides yet another case in which the positive results of
residential treatment are short-lived .Future efforts to provide treatment-
oriented aftercare services must grapple with the difficult issue of client
attrition. and with the basic problem that treatment services of the type
provided in aftercare programs do not seem able to compete with the
temptations of street life" (13).

One important exception to this trend is the Wraparound process.
Wraparound is not a program or type of service, but an approach to
developing a system of care for children and their families (vs. an
interagency network) among formal and informal resource providers based
in individual communities (VanDenBerg, 1998). Wraparound is a
strengths-based, needs-driven, unconditional approach to developing
individualized family-centered plans involving "a combination of existing
or modified services, newly created services, informal supports, and
community resources, and should include a plan for a step-down of formal
services" (Ottawa-Carleton Wraparound, 1998). A community team
accepts family referrals, and, if a family is accepted based on local
priorities, sends the case to a broker agency. While not the Wraparound
agency, the broker agency facilitates the case as part of the process
involving all community resources. In developing a service plan, a child
and family team is composed of four to ten individuals (plus the child and
family); this team must have a membership of at least 50 percent
nonprofessional individuals representing both formal and informal
resources (Ottawa-Carleton Wraparound, 1998). While each community
defines the population to be targeted by the Wraparound process, some
communities have chosen to include adolescents who could be returned
from residential treatment centers to the community through the
availability of Wraparound services (Milwaukee County Mental Health
Division, 1998). The process seeks to find the least restrictive, most
normative environment possible for an adolescent while providing access
to a variety of services and community supports (VanDenBerg, 1998).
Continuing care services available through processes such as Wraparound
might be optimum methods of providing ongoing care once a juvenile has
completed juvenile justice system processing.

According to Catalano and associates (1989), a strong continuing
care/aftercare program must include elements which deal rapidly with
relapse to substance abuse, respond to those relapses in ways that
discourage continued use, and support a return to abstinence. As
mentioned in the Treatment Correlates subsection above, strong predictors
of relapse include the presence of AOD cravings and the inability of
treatment clients to establish non-AOD-using social contacts in work and
school settings. Specific interventions which appear to have the greatest
promise of addressing these multiple factors include multidimensional
family therapies and cognitive-behavioral skill training. Skill training
"seeks to alter skills by actively developing new ways of interpreting and
responding to inter- and intrapersonal situations....Because skill training
seeks to alter individuals' methods of coping, and to instill self-control, it
should be effective in helping adolescents maintain treatment gains and
negotiate their post-treatment environment" (Catalano et al.,
1990/91:1130). While well-controlled studies are needed to evaluate the
long-term effectiveness of cognitive-behavioral skill training programs,
evidence is accumulating which supports such interventions in other
related areas (see Catalano et al., 1990/91 for a review of these studies).

Internal evaluations of Wraparound services have shown positive results.
A critical component of the Wraparound process is to design outcome
indicators and collect outcomes information. In Wraparound Milwaukee
(Milwaukee County Mental Health Division, 1998), 65 percent of youth
served were delinquent. Youth and their families were enrolled in
Wraparound Milwaukee and assigned to a broker agency. A strengths
inventory was built, and a child and family team was convened to develop
the Wraparound plan, including establishing goals, identifying and
prioritizing needs, and developing strategies to meet identified needs
(including identifying both formal and informal resources). While a
comparison group evaluation has apparently not been undertaken yet,
results from a before-after comparison study showed a 40 percent
reduction in utilization of residential treatment services, and an almost 50
percent drop in the utilization of inpatient psychiatric Medicaid hospital
days. In addition, children enrolled in the process showed a 40 percent
drop in the number of felonies committed between intake and 1 year of
services, and a 31 percent drop in misdemeanors committed. Clinical
outcomes were also positive, with improvements in functional assessment
scale and behavior scores, as well as decreases in reported restrictions in
living situations.

General Recommendations for Future Intervention Research

Recommendations for future research on adolescent AOD treatment have
been made by a number of prominent researchers (Henggeler, 1997a;
Greenbaum et al., 1996; Dembo, personal interview; Szapocznik &
Williams, in review; Winters, Latimer et al., in press). The following
provides a summary of what the authors consider to be especially relevant:

1. Develop consistent assessment and outcome measures for use in
national demonstration projects of program effectiveness.

2. Conduct well-controlled trials, preferably with random assignment, so
that the relative effectiveness of different modalities can be more
adequately tested. This includes exploring which treatments work best at
various developmental periods in an adolescent's life.

3. Develop and evaluate multisystemic interventions that can be used with
a variety of cultural groups or which can be differentially used to engage,
retain, and treat specific cultural groups.

4. Explore factors which relate to treatment retention.

5. Compare the cost-effectiveness of various treatment modalities.

6. Examine the mechanisms which support positive changes in adolescent
substance use behaviors, including the role of the environment and health
service options.

7. Establish prevalence of co-occurring mental disorders and AOD abuse
among adolescents using general population samples.

Summary and Recommendations

Based on a review of the juvenile drug-crime cycle with all of its
correlates as well as a review of the various interventions used to break
this cycle, it is essential to develop successful interventions as a
comprehensive system, not merely a series of components. The evaluation
data strongly suggest that an integrated, collaborative system that includes
comprehensive assessment, referrals to appropriate services, case
management along a continuum of care, and system collaboration has the
greatest probability of yielding successful outcomes.

Throughout this report, several systems and services have been cited as
examples of juvenile justice programs that have shown some success in
combating the juvenile drug-crime cycle (such as drug courts, TASC, and
Target Cities). These programs and services have all been developed to
assist in ameliorating the serious problems associated with the cycle to a
greater or lesser extent. It is the authors' position that each of the
successful programs and services discussed in this publication should be
looked at as a potential source for developing community-specific
programming. If a community has an existing TASC service that is
functioning well and has the support of community members, it would
likely be best to build improved service provisions around TASC. The
same principal holds true for drug courts, Target Cities, or other programs.
If communities have existing resources on which to build, those resources
should be looked at as essential assets; it is expedient to not waste time
reinventing the wheel.

A Conceptual Model

As a result of extensive literature review, input from juvenile justice and
adolescent substance abuse experts, and analysis of available data, the
guidelines below are recommended in developing community-based
collaborative infrastructures capable of intervening in the juvenile drug-
crime cycle. Interventions designed to meet these guidelines should
recognize the balance of the very real needs for public safety, juvenile
treatment, and the importance of reintegrating the juvenile into the
community. This statement implies a primary importance of protecting the
public. Today, society expects the justice system to protect us from future
crimes that may be committed. There is also a recognition that, at some
point, a juvenile leaves the supervision of the juvenile court and an
expectation that the court will help ensure that services are provided to
change/rehabilitate the juvenile. 

As has also been noted in this report, the juvenile justice system is
increasingly concerning itself with reintegration into the community -
often the community that has been damaged by the juvenile's behavior.
Such interventions can be successfully accomplished through a local
collaborative system using graduated sanctions addressing public safety,
rehabilitation, and community reintegration. However, all key
stakeholders within the collaborative should recognize that as the party
responsible for the safety of the community, the juvenile justice system
must hold final authority in supervision and treatment decisions. At the
same time, it is crucial that the juvenile court recognize the importance of
collaborative input from appropriate service agencies and the community
if goals are to be successfully addressed through comprehensive
assessment, informed collaborative judicial decision making that results in
public safety, and successful treatment/rehabilitation ending in continuing
care and community reintegration.

Guiding principles

Intervention must take place early when it has the best chance of reversing
or ameliorating problem behaviors.

1. Adolescents entering the system must undergo a comprehensive needs
assessment in order to tailor interventions to each juvenile's unique needs.

2. Adolescents entering the system must undergo a comprehensive needs
assessment in order to tailor interventions to each juvenile's unique needs.

3. Once needs have been identified, adolescents must be provided with a
flexible and comprehensive continuum of care which offers a full range of
relevant services needed for effective intervention. Recognizing that a full
range of treatment services may not be available in all communities, an
important collaborative role is to advocate for additional services.

4. Collaboration between and across systems relevant to juveniles
(families, schools, the courts, and communities) must be in place, and
there must be an agent or agency accountable for establishing and
maintaining collaboration between components of the care continuum.

5. Case management through one agent or agency should be provided to
help juveniles and their families successfully navigate the continuum of
care.

6. Consistent with principles of client confidentiality and juvenile justice
system responsibility, an MIS should be in place in which all relevant
information would be available to those involved in service provision.

7. Continuing care services should be developed to provide continuing
support for the juvenile following release from formal AOD treatment.

8. Programs must undergo consistent, ongoing, rigorously designed
evaluation including cost-benefit analysis. Such evaluation should result in
modifications to strengthen what works and change what does not.

9. Effective interventions must be related to the school, peer, and family
systems where adolescents routinely socialize and receive reinforcement
for their substance-using behaviors.

10. Program interventions and staff training must be sensitive to the
unique and culturally specific needs of adolescents.

11. It is important to recognize that interventions occur within specific
national and local community, educational, and economic opportunity
structures. A successful intervention should include attempts to ensure
high quality educational and job opportunities for those at risk. Job
opportunity issues here refer to a macro-level concern for environments
that provide positive alternatives to delinquency and substance use for
youth.

12. Given the general lack of experimental evidence supporting more
restrictive services, treatment dollars should be targeted toward programs
which are less restrictive and are more likely to address juvenile problems
in the context in which they occur and are reinforced: the family, the
school, and peer groups of the adolescent.

These guiding principles provide a reasonable framework for developing a
suggested model program that could contribute to local intervention
program development. Following is a brief description of the broad
categories that a model program would incorporate using the previously
outlined guiding principles.

Systems flow: what a model program might look like

Acknowledging that each community system for breaking the juvenile
drug-crime cycle will be uniquely tailored to the locale's needs and
resources, the following section provides a brief description of the flow in
a comprehensive system.

Single point of entry

From a cost-efficiency standpoint, adolescents would enter the system at a
single-point-of-entry such as a JAC or Target Cities-modeled CIU. This
location would be able to utilize a comprehensive MIS (consistent with
principles of client confidentiality and juvenile justice system
responsibility) and might be ideally colocated with an appropriate
substance abuse treatment facility providing adolescent detoxification and
stabilization (Dembo & Rivers, 1996). The point-of-entry would provide
assessment and screening, assign a CM trained in both effective
assessment and juvenile justice system management, and make
recommendations for services based on assessment.

Immediate and comprehensive assessment

At the point-of-entry, immediate and comprehensive assessment would be
provided. Identification of key needs and problem areas is required to
avoid inappropriate referrals, duplication of services, and unnecessarily
restrictive placements. Assessment should be consistent with protecting
the community. Recommendations to the judicial system for services
would be made based on this assessment (including dismissal, diversion,
or disposition/detention, as well as initial psychosocial and treatment
suggestions). Assessors would have training in the specific instruments
used, be culturally sensitive, and aware of the role of cultural differences.

Cross-systems case management

Case management identifies needs, service gaps, and preliminary
outcomes through the following functions: ensuring involvement with
assessment, supporting compliance with recommendations, tracking
treatment progress, forging linkages with service providers, and
monitoring random substance testing, such as urinalysis. All those
involved in service provision would have access to relevant information
through the MIS (again recognizing client confidentiality and juvenile
justice system responsibility). Case management would be coordinated by
one agent or agency. Specific functions of case management could be
contracted or reassigned with the understanding that the coordinating
agent would oversee how various aspects connect and work for the best
interest of the juvenile.

Continuum of care

Recognizing that many delinquent youth have multiple factors which
affect their decisions to use substances, a continuum of care providing
links to service providers in a variety of areas is crucial. Services provided
within the continuum of care would be community-based whenever
possible, involve the family (nuclear and extended), identify and address
risk factors, identify and effectively utilize protective factors and
resources, be comprehensive and flexible, empower families and
communities, aim at modifying personal characteristics and developing
competencies, and build positive peer networks.

Judicial decision making

While judicial involvement and decisions may occur at other points,
judges would typically become involved after assessment and perhaps
after the initiation of case management. Judges would retain sanction
imposition authority, and would play an active role in ensuring the
juvenile's adherence to treatment services as recommended by both the
CM and other treatment collaborative partners as well as ensure
supervision requirements under a graduated sanctions framework.
Sanctions would be clearly stated and defined, provided in list format for
the juvenile to sign at program entry with the understanding that any
infractions would have clearly defined repercussions. Collaborative
members would agree on the sanction process and support judicial
decisions. The least restrictive supervision option still consistent with
community protection would be utilized.

Systems collaboration

As has been shown, breaking the juvenile drug-crime cycle is a complex
process that draws upon a wide variety of community agencies and
systems. Therefore, it is crucial that the juvenile justice system provide
linkages between all of the community systems that can contribute to
breaking the cycle. For example, in a family based intervention, linkages
would occur with agencies and systems such as schools, communities of
faith, social service, and public health agencies and employers (including
job training and skill development).

Treatment

Treatment programming is complex due to the need to address factors
involved in substance abuse initiation, continuation, and relapse. In order
to increase the probability that treatment will be effective, factors such as
those previously identified as correlating to substance use would be
considered and programming would be based on individual case
requirements. Programs showing the strongest evidence of treatment
effectiveness would be given highest treatment priority. Ideally, a core of
treatment services would be provided at a clearly specified point in the
care continuum under the guidance of a CM who would then connect the
adolescent and his or her family to other needed services.

Utilization of traditional services

While many traditional AOD services such as inpatient programs,
outpatient services, and half-way houses fail to show long-term treatment
successes, these services will continue to be needed within the continuum
of care. However, these alternatives would begin to incorporate the
approaches shown to have the greatest likelihood of success in enhancing
long-term outcomes as they sought to remain viable parts of the juvenile
justice process.

Continuing care

The juvenile justice system and the juvenile would maintain contact after
formal systems processing is completed. To maintain ongoing evaluation
efforts, the juvenile justice system would benefit from continued
monitoring of and involvement with the client system. For the juvenile,
continuing care would help maintain treatment and programming gains
during his or her transition from treatment to community. This view is
consistent with both the BARJ model, which stresses the importance of
community reintegration, and the concept of reentry courts that is
emerging within the drug court movement. 

In the BARJ model, it is strongly suggested that a type of closure be
sought where the offender is reintegrated into the community, generally
under the care or supervision of a community organization. In the drug
court model, a more formal system is suggested that includes judicial/court
supervision of an offender (juvenile or adult) after they complete their
court imposed sentence, including all required treatment and auxiliary
services, as reported at the 1999 National Association of Drug Court
Professionals Annual Training Conference in Miami, Florida.
Reintegration would link the juvenile to community supports and
reenforce positive modeling. Continuing care would include an exit
posttreatment assessment conducted by the CM (within the framework of
the BARJ model, reentry court or similar structure) to identify unmet or
ongoing service needs, as well as link the juvenile to community supports
and educational, vocational, and economic opportunities. Four official
reports (at approximately 1, 3, 6 and 12 months after treatment completion
of formal systems processing) by the specified community services to the
CM would be planned, allowing the juvenile justice system to intervene
early and appropriately with observed problems, thus reducing recidivism
and problem escalation. Such intervention would include judicially
recommended referral to relevant human service agencies and available
publicly or privately funded treatment programs. Continuing care
monitoring would also help collaborative partners not only better inform
national and local policymaking bodies about the local juvenile
community but also advocate needed macro-level changes.

Evaluation

As has been noted throughout this report, scientifically well-designed
evaluation studies documenting program effectiveness are generally
absent. This occurs for a variety of reasons ranging from a lack of
resources to limited expertise to conduct such studies. It would likely be
impossible for each program to conduct major scientific outcome studies.
However, at the program level, a number of things could be done that
would provide important evaluation information. First of all, local
programs need to engage in formative and process evaluation. This would
involve careful documentation regarding initial goals and objectives, the
process of program implementation, and structural changes that occurred
during implementation. Perhaps the most important program level
evaluation activity would be the development and implementation of an
MIS. An MIS would allow programs to document programmatic and client
characteristics as well as important baseline, change, and outcome data
that would allow for a basic level of evaluation (a before-after
comparison). Carefully designed scientific outcome studies would likely
be beyond the resources of any local program; however, such efforts
should be encouraged by funding agencies and could be conducted under
the auspices of a wide variety of Federal funding agencies. Large-scale
evaluation impact studies are an important part of documenting the
effectiveness of the collaborative intervention program alternatives
advocated in this report. Continued funding of collaborative programs
designed to break the juvenile drug-crime cycle likely will depend on the
provision of data documenting a well-managed program serving at-risk
populations who show levels of behavioral change significantly greater
than would have occurred without the collaborative intervention program.
As noted, funded programs should be required to utilize an MIS system
that supports formative, process, and before-after evaluation. Participation
in larger scale scientific comparison group studies that would provide
valid data on cost-effective outcomes of the program should also be
encouraged.

An integrated model

A wide variety of material has been reviewed in this report, and an attempt
has been made to examine effective intervention programs and their
elements at each stage of the juvenile justice system. This has been done
within the broad framework of existing conceptual and structural models
from the BARJ model to drug courts to TASC. In their review of
promising drug treatment programs, Nissen and her colleagues (in press)
have made many model program recommendations which are similar to
those in this report, thereby providing independent corroboration from
practitioners. 

Figure 1 attempts to both summate and integrate the suggested model
elements that have been discussed and illustrates the relationship between
graduated sanctions, case management, and systems collaboration as a
juvenile progresses through the juvenile justice system. As noted earlier in
this report, the juvenile justice system is held responsible for maintaining
public safety, while at the same time acting as an advocate for
rehabilitation of the offending juvenile with the goal of effective
community reintegration. Graduated sanctions provide the direction and
energy for such movement. However, in order for the adolescent to receive
appropriate and comprehensive services, interconnected linkages (systems
collaboration) must exist between service providers. CMs both assess the
juvenile and help him or her move through and between judicial, AOD
treatment, and social service systems. In this way, juveniles receive the
most appropriate and comprehensive services a community can offer while
still remaining firmly under juvenile justice system supervision.

Implementation at the local level

In order to successfully implement the strategies outlined above at the
local level, support from all relevant components of the juvenile justice
system and the community is mandatory. Although mandated treatment
can be successful for adolescents, gains made need to be sustained once
the adolescent returns to his or her community. The following steps
comprise a suggested strategy for implementing model programs at the
local level.

First

Planners should conduct a community assessment in order to identify
juvenile justice system willingness to participate and provide leadership
(especially judicial willingness), identify potential resources, understand
community expectations, determine level of community support for
program goals and objectives, and identify existing collaborative
structures. Judicial buy-in and support of the recommended strategies is
essential. As judges provide final authority in the juvenile justice system,
attempts to develop a collaborative systems approach to juvenile justice
substance abuse treatment simply will not be successful without sustained
judicial support.

Second

All major systems in which the adolescent interacts (schools, communities
of faith, families, etc.) need to be invited to participate with the courts in
the development of strategies and services. This establishes points of
contact, opens communication channels, promotes integrated approaches
to problem solving, and increases community buy-in to the process.

Third

The juvenile justice system at the local level must be committed to making
referrals a reality. In maintaining the delicate balance between
accountability and rehabilitation, the juvenile justice system serves as the
link between the needs of the juvenile and the needs of the larger
community. Enforcement of treatment plans, engagement of the family
unit, and support of collaborative action are all roles which can be filled by
judges, probation officers, and other law enforcement officials.

Fourth

Those responsible for implementing any element of the overall plan
should receive necessary training prior to implementation. Supervisors
should support professional development activity enhancing employee
effectiveness in their assigned roles.

Fifth

Mechanisms must be put in place to ensure that collaborative program
efforts are sustainable. Transitions into new initiatives should be planned
and gradual, allowing time for necessary training and problem solving.
Alternative strategies and processing options should be available as often
as possible for staff charged with implementing new programs. At all
levels (administrative, management, and direct service staff), commitment
to cross-systems collaborative principles is needed to sustain effort and
create an environment in which collaboration can occur. Appropriate
resource development activities should be directed to sustain and replenish
resources. Ongoing feedback and support mechanisms should also be in 

place.

Sixth

The implementation phase of any project potentially involves conflict,
which can result in wasted resources and energy or even lead to program
destruction. Within a collaborative system, successful conflict mediation
involves taking various perspectives of the problem situation into account
and then attempting to reach consensus on how best to resolve them.
Additional strategies to resolve conflict include avoiding or delaying
action, deciding by majority rule, encouraging those in conflict to develop
alternative solutions on their own, or even using directive processes by
which those in positions of authority gain compliance with their views and
wishes (Kindler & Leigh, 1996).

Kindler and Leigh (1996) suggest that no single approach to conflict
resolution will be effective in every case. Rather, they note that effective
mediators of conflict do the following: explore the issue to identify the
source of conflict and those who should be involved in resolving it;
determine the level of resource commitment (time, effort, etc.) to devote to
resolution; and implement a conflict resolution strategy based on these
considerations, learning from the process through follow-up after the
conflict is resolved.

Finally

It is critical that planners monitor and evaluate community collaborative
processes and outcomes, as well as implement evaluations of the overall
attempts to intervene with juvenile delinquency treatment. The knowledge
gained from such monitoring and input from various community units
should be shared with local and national decisionmakers with the goal of
informed advocacy at the macro-level.

Conclusion

The nature of juvenile AOD use, AOD treatment, and crime is complex.
Future programmatic attempts to break the juvenile drug-crime cycle must
be based on knowledge gained from past work and methodologically
sound evaluation research. This report has been an attempt to summarize
such knowledge and suggest a model that would be useful to communities
attempting to develop intervention programs. The focus has been on
general principles rather than on specific organizational structures,
recognizing that local communities must use any models suggested or
information provided within the framework of local resources and
possibilities. The authors are hopeful that the information presented here
will provide a useful contribution to the work of collaborative partners in
the juvenile justice system, AOD treatment programs, and a wide variety
of community agencies as they search for ways to intervene with the
juvenile drug-crime cycle.

Endnotes

1. These researchers found a correlation of .53 between delinquency and
substance use (see also Johnson et al., 1991).

2. It should be noted that the definition of the age of offenders covered by
the juvenile court increasingly depends on State law and, at times, the
discretion of the district attorney. That is, many States have differing ages
that define juvenile status; even within State definitions, specific violent
crimes may either require trial as an adult or leave decisions of adult or
juvenile status up to the discretion of the district attorney (Sickmund,
1994; Strom et al., 1998).

3. Please refer to Schaefer (1995), Leccese & Waldron (1994), and
Winters & Stinchfield (1995) for a comprehensive review of adolescent
substance abuse measurement instruments, including detailed validity and
reliability information.

4. For further information on use of the PESQ, as well as reliability and
validity estimates, see Winters, 1991,1992,1993.

5. Interrater reliability on diagnoses ranged from Kappa = .53 to .86. Test-
retest reliability on diagnoses over a 1-week period ranged from Kappa =
.80 to .83. Evidence for criterion validity was found in clinician ratings
which were generally in agreement with the ADI scores, ranging from
Kappa = .71 to .82 (Winters et al., 1993).

6. See the National Drug Court Institute (1999b) publication Federal
Confidentiality Laws and How They Effect Drug Court Practitioners for a
more complete overview of confidentiality laws.

7. Children and Family Services Act, 20 ILCS 505/35.1

8. Dembo et al., (1993) describe one promising preadjudication program:
the Family Education Program, run by the Prevention and Intervention
Center for Alcohol and Drug Abuse (PICADA) in Madison, Wisconsin.
PICADA is a diversion program which provides a variety of intervention
services, including screening, assessment, education, and referrals to youth
and their families. Goals include: increase knowledge about AOD;
increase clients' ability to identify and communicate attitudes about AOD;
promote attitude change; increase clients' abilities to more accurately
assess their substance use/abuse; and increase clients' willingness to
accept referrals to other programs. Pre- and posttest measurements, in the
absence of a control or comparison group, indicated changes in
knowledge, attitudes, and feelings regarding substance use when assessed
shortly after program participation. Literature reporting formal evaluation
of this program was not located.

9. For a history of the involvement of the court with AOD abuse, see
Inciardi et al., 1996.

10. For a recent description of drug courts, see Drug Strategies, 1999.

11. For a comprehensive discussion of the issue and application of
graduated sanctions, see Krisberg and Howell, 1997.

12. For a description of intensive juvenile probation, see Wiebush, 1993.

13. For an overview of a urine-monitoring program, see Crowe, 1998 and
Inciardi, 1994.

14. Nissen and her colleagues (in press) recently completed a CSAT
monograph which reviews innovative and promising practices and
programs which attempt to integrate substance abuse treatment with the
juvenile justice system. The document reviews specific program models
which are being used with some level of success, are meeting most of their
program goals, and have gained increasing popularity. All the programs
which were reviewed were demonstration projects associated with CSAT
over the course of the 6 years prior to publication. This document should
prove to be a valuable resource for reviewing the "best practices" of
programs which are currently showing the greatest promise of effectively
intervening in the drug-crime cycle of juvenile offenders.

15. For example, the Strategic-Structural Systems Engagement technique
(Santisteban et al., 1996; Szapocznik et al., 1988). This modality has
proved particularly promising with Hispanic families due to traditionally
strong family ties.

16. An example of this modality is the Multiple Family Group Treatment
(MFGT). Due to the large client base, the MFGT decreases the impact of
differences in ethnicity/socioeconomic status and power between the
facilitator and the clients. The MFGT model provides a supportive
network for families engaged in addressing similar problems, and
promotes the use of community as a resource for at-risk children and
parents. Rather than focusing on individual pathology, the group addresses 
areas which are of concern to all families (McKay et al., 1995).

-------------------------------

Appendix A: Conducted Interviews

Foster Cook, M.A.
Director, Substance Abuse Program, University of Alabama
Interview Subject Expertise: Treatment services for drug-using offenders.

Peter Delaney, D.S.W.
National Institute on Drug Abuse
Interview Subject Expertise: Services needed by adolescent AOD users.

Richard Dembo, Ph.D.
Comprehensive Assessment Center, University of South Florida
Interview Subject Expertise: Single-point-of-entry.

James Hall, Ph.D.
University of Iowa
Interview Subject Expertise: Skills training and strengths-based case
management.

David Hawkins, Ph.D.
Director and Professor, Social Development Research Group, University
of Washington
Interview Subject Expertise: Prevention and early intervention with at-risk
families, children, and juvenile delinquents.

Scott Henggeler, Ph.D.,
Clinical Psychologist, Family Services Research Center, Medical
University of South Carolina
Interview Subject Expertise: Multi Systemic Family Therapy, adolescent
AOD use, and chronic juvenile offender interventions.

Carl Leukefeld, D.S.W.
University of Kentucky
Interview Subject Expertise: Treatment services, including mandated
treatment, in the justice system.

Ethel Mull, M.A.
Executive Vice-President, Chicago TASC Program
Interview Subject Expertise: Juvenile treatment and community services.

Laura Burney Nissen, Ph.D., M.S.A., CAC III
Codirector, Center for High Risk Youth Studies, Metropolitan State
College of Denver
Interview Subject Expertise: Strengths-based treatment of juvenile 
delinquents.

Elizabeth Rahdert, Ph.D.
Research Psychologist, Division of Clinical and Services Research,
Treatment Research Branch, NIDA
Interview Subject Expertise: Adolescent AOD abuse assessment and
interventions.

Richard Rapp, M.S.A., A.C.S.
Wright State University
Interview Subject Expertise: Case management and the continuum of care.

Harvey Siegal, Ph.D.
Wright State University
Interview Subject Expertise: Strengths-based case management.

Randy Stinchfield, Ph.D.
Associate Director, Center for Adolescent Substance Abuse, University of
Minnesota
Interview Subject Expertise: Adolescent addiction instruments.

Jose Szapocznik, Ph.D.
Professor and Director, Center for Family Studies, University of Miami
School of Medicine
Interview Subject Expertise: Strategic/Structural Family Therapy, client
retention.

Beth Weinman, M.A.
United States Bureau of Prisons
Interview Subject Expertise: Treatment services in incarcerated settings.

Ken Winters, Ph.D.
Director, Center for Adolescent Substance Abuse, University of Minnesota
Interview Subject Expertise: Adolescent addiction assessment, AOD
treatment for juvenile offenders.

-------------------------------

Appendix B: Assessment Tools

The information below summarizes some of the most frequently utilized
and empirically validated screening and mid-range assessment instruments
for screening and comprehensively assessing AOD problems in
adolescents. Special attention has been paid to those instruments which
have been commonly used with juvenile delinquent populations.

Screening tools

Several instruments offer brief, nonintegrated system measures which
screen for AOD use. However, the majority of these instruments are either
normed on non-juvenile-delinquent populations or have limited
psychometric data available. One notable exception is the Client
Substance Index-Short (CSI-S) (Thomas, 1990), which offers promise as a
screening protocol being developed through the National Center for
Juvenile Justice. The CSI-S is a 15-item, yes/no self-report instrument
designed to identify juveniles in the court system who are in need of
additional AOD abuse assessment. Reliability and validity information
were not available at the time of this writing.

Other screening instruments with the most psychometric data include the
Adolescent Alcohol Involvement Scale (AAIS) (Mayer & Filstead, 1979),
the Adolescent Drug Involvement Scale (ADIS) (Moberg & Hahn, 1991),
and the Adolescent Drinking Index (Harrell & Wirtz, 1990). Since it is
relatively rare for a substance-abusing juvenile delinquent to use only one
substance, alcohol indexes may be of limited value. For a more
comprehensive list of adolescent substance abuse instruments, refer to
Leccese and Waldron's (1994) or Winters and Stinchfield's (1995) review
of adolescent AOD assessment instruments.

Mid-range comprehensive assessment instruments

Several multiscale tools provide strong assessment information. These
tools often include both paper-and-pencil and interview formats and
address a range of content domains. Due to variations in
comprehensiveness, many of these tools can be described as mid-range
instruments.

Comprehensive Addiction Severity Index for Adolescents (CASI-A)

The CASI-A is a 45- to 90-minute semistructured clinical interview to
assess the "multidimensional nature of problems experienced by those
adolescents who present for treatment at various provider agencies"
(Meyers, et al., 1995:183). The length of the interview is dependent upon
the extent of the adolescent's AOD involvement. The CASI-A is patterned
after the well-established, adult-oriented Addiction Severity Index (ASI)
(McLellan, et al., 1980) to assess symptoms in areas of adjustment which
either result from or contribute to the addiction. It measures risk factors,
ongoing symptoms, and consequences of AOD use in seven areas of
functioning: education status, AOD use, family relationships, peer
relationships, legal status, psychiatric distress, and use of free time. The
instrument incorporates results from a urine screen and observations from
the assessor.

Reliability and validity information, while preliminary, is encouraging
(alpha ranges between 0.48 and 0.80 for individual sub-scales). Revisions
are being made to those areas where the coefficient alpha dropped below
0.60 or where correspondence with clinical records fell below 75 percent.
Adolescents were highly satisfied with the structure and format, feeling
the instrument was easily understood and allowed them to express
themselves clearly. The CASI-A is suitable for repeat administration at
posttreatment follow-up evaluations.

Adolescent Chemical Dependency Inventory--Corrections Version II
(ACDI-CVII)

The ACDI-CVII is designed for juvenile courts, probation and parole
departments, and community corrections programs for troubled youth. It
contains 143 items presented in a computerized or paper-and-pencil self-
report format, and requires 25 minutes to complete. Items are based on a
sixth grade reading level. The six measures include: truthfulness,
adjustment (coping, adapting, and functioning), violence, alcohol, other
substances, and distress (anxiety and depression). Gender specific norms
have been established for the Alcohol Scale and the Distress Scale (the
remaining scales did not have significant gender differences). The
instrument's developers (Risk and Needs Assessment, Inc.) have reported
strong reliability and validity information, although their reports do not
appear to be validated by external sources. Validity coefficients for the
ACDI and selected MMPI scales ranged between 0.59 and 0.69. Internal
reliability coefficients ranged between 0.85 and 0.92 over repeated
administrations with large regional samples (Risk and Needs Assessment,
Inc., 1997). The company attempts to re-standardize the instrument on a
State-by-State basis.

Other comprehensive assessment instruments

The Adolescent Problem Severity Index (APSI) (Metzger et al., 1991) has
good psychometric information but has not been normed on juvenile
offender populations. Other assessment instruments which have more
limited psychometric information are reviewed in Leccese and Waldron's
(1994) or Winters and Stinchfield's (1995) review of adolescent AOD
assessment instruments.

-------------------------------

List of Abbreviations

AA Alcoholics Anonymous

AAIS Adolescent Alcohol Involvement Scale

AARS Adolescent Assessment/Referral System

ACDI-CVII adolescent Chemical Dependency Inventory--Corrections
Version II

ADAM Arrestee Drug Abuse Monitoring Program

ADHD Attention Deficit/Hyperactivity Disorder

ADI Adolescent Diagnostic Interview

ADIS Adolescent Drug Involvement Scale

AOD. Alcohol and Other Drugs

APSI Adolescent Problem Severity Index

ASI Addiction Severity Index

BARJ Balanced and Restorative Justice

BSFT Brief Strategic/Structural Family Therapy

CAB Comprehensive Assessment Battery

CASI-A Comprehensive Addiction Severity Index for Adolescents

CATOR Chemical Abuse/Addiction Treatment Outcome Registry

CIU Central Intake Unit

CM Case Manager

CME Case Management Enhancements Project

CPHQ Client Personal History Questionnaire

CSAT Center for Substance Abuse Treatment

CSI-S Client Substance Index--Short

CTCR Center for Therapeutic Community Research

DARP Drug Abuse Reporting Program

DHHS Department of Health and Human Services

DSM-III-R Diagnostic and Statistical Manual of Mental Disorders, Third
Edition Revised

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition

ESI Extended Services Intervention

FAM Family Assessment Measure

FEI Family Empowerment Intervention

GAO Government Accounting Office

IPS Intensive Probation Services

JAC Juvenile Assessment Center

MCDAAP Minnesota Chemical Dependency Adolescent Assessment
Package

MDFT Multidimensional Family Therapy

MIS Management Information System

MOU Memorandum of Understanding

MST Multi Systemic Therapy

NA Narcotics Anonymous

NDCI National Drug Court Institute

NIDA National Institute on Drug Abuse

NIJ National Institute of Justice

OJJDP Office of Juvenile Justice and Delinquency Prevention

OJP Office of Justice Programs

PEI Personal Experience Inventory

PESQ Personal Experience Screening Questionnaire

POSIP Problem Oriented Screening Instrument for Parents

POSIT Problem Oriented Screening Instrument for Teenagers

PTS Person Tracking System

SSA Single State Agency

SSSE Structural Strategic Systems Engagement

TASC Treatment Alternatives for Safe Communities

TC Therapeutic Community

TIP Time Spent in Treatment Program

TOPS Treatment Outcome Prospective Study

YES Youth Evaluation Services

YSP Youth Support Project

-------------------------------

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