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94–384 PDF 2005

S. HRG. 108–749

PROVIDING SUBSTANCE ABUSE PREVENTION AND

TREATMENT SERVICES TO ADOLESCENTS

HEARING

BEFORE THE

SUBCOMMITTEE ON SUBSTANCE ABUSE AND

MENTAL HEALTH SERVICES

OF THE

COMMITTEE ON HEALTH, EDUCATION,

LABOR, AND PENSIONS

UNITED STATES SENATE

ONE HUNDRED EIGHTH CONGRESS

SECOND SESSION

ON

EXAMINING SUBSTANCE ABUSE PREVENTION AND TREATMENT SERVICES FOR ADOLESCENTS, FOCUSING ON THE EFFECTS OF BINGE

DRINKING, AND MONTHLY CIGARETTE, BEER, AND MARIJUANA

USAGE, AND THE DEVELOPMENTS OF THE JUVENILE TREATMENT

NETWORK

JUNE 15, 2004

Printed for the use of the Committee on Health, Education, Labor, and Pensions

(
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

JUDD GREGG, New Hampshire, Chairman

BILL FRIST, Tennessee

MICHAEL B. ENZI, Wyoming

LAMAR ALEXANDER, Tennessee

CHRISTOPHER S. BOND, Missouri

MIKE DEWINE, Ohio

PAT ROBERTS, Kansas

JEFF SESSIONS, Alabama

JOHN ENSIGN, Nevada

LINDSEY O. GRAHAM, South Carolina

JOHN W. WARNER, Virginia

EDWARD M. KENNEDY, Massachusetts

CHRISTOPHER J. DODD, Connecticut

TOM HARKIN, Iowa

BARBARA A. MIKULSKI, Maryland

JAMES M. JEFFORDS (I), Vermont

JEFF BINGAMAN, New Mexico

PATTY MURRAY, Washington

JACK REED, Rhode Island

JOHN EDWARDS, North Carolina

HILLARY RODHAM CLINTON, New York

SHARON R. SODERSTROM, Staff Director

J. MICHAEL MYERS, Minority Staff Director and Chief Counsel

SUBCOMMITTEE ON SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES

MIKE DEWINE, Ohio, Chairman

MICHAEL B. ENZI, Wyoming

JEFF SESSIONS, Alabama

JOHN ENSIGN, Nevada

EDWARD M. KENNEDY, Massachusetts

JEFF BINGAMAN, New Mexico

JACK REED, Rhode Island

KARLA CARPENTER, Staff Director

DAVID NEXON, Minority Staff Director

(II)
CONTENTS

STATEMENTS

TUESDAY, JUNE 15, 2004

Page

DeWine, Hon. Mike, a U.S. Senator from the State of Ohio, opening statement ...................................................................................................................... 1

Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island, opening

statement .............................................................................................................. 2

Kennedy, Hon. Edward M., a U.S. Senator from the State of Massachusetts,

prepared statement .............................................................................................. 3

Curie, Charles G., Administrator, Substance abuse and Mental Health Services Administration, U.S. Department of Health and Human Services .......... 5

Prepared statement .......................................................................................... 7

Brown, Sandra A., Professor of Psychology and Psychiatry, University of

California-San Diego; Chief of Psychology Services, Veterans Affairs San

Diego Health Care Systems; Associate Director, Child and Adolescent Services Research Center, Children’s Hospital of San Diego; Roger Weissberg,

Department of Psychology, University of Illinois at Chicago, Executive Director, Collaborative for Academic, Social and Emotional Learning; Rhonda

Ramsey-Molina, President and CEO, Coalition for a Drug-Free Greater

Cincinnati; Ronald Anton, Director of Juvenile Justice and Community

Programs, Day One; and Kris Shipley, Pasadena, MD ..................................... 17

Prepared statements of:

Sandra A. Brown ....................................................................................... 19

Roger P. Weissberg, Ph.D. ........................................................................ 51

Rhonda Ramsey-Molina ............................................................................ 59

Ronald Anton ............................................................................................. 65

Kris Shipley ............................................................................................... 112

ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:

Adolescence and The Trajectory of Alcohol Use: Basic to Clinical Studies . 23

Neurocognitive Functioning of Adolescents: Effects of Protracted Alcohol

Use ................................................................................................................. 30

Neural Response to Alcohol Stimuli in Adolescents With Alcohol Use

Disorder ......................................................................................................... 41

Norman G. Hoffmann, Ph.D. Ana M. Abrantes, Ph.D. and Ronald Anton,

LCPC, LADC, MAC ...................................................................................... 70

Juvenile Automated Substance Abuse Evaluation (JASAE) ......................... 77

Practical Adolescent Dual Diagnostic Interview (PADDI) ............................ 107

The Alliance for Consumer Education (ACE) ................................................. 122

Mary Melton, Ph.D., MBA ............................................................................... 125

(III)

(1)

PROVIDING SUBSTANCE ABUSE PREVENTION

AND TREATMENT SERVICES TO ADOLESCENTS

TUESDAY, JUNE 15, 2004

U.S. SENATE,

SUBCOMMITTEE ON SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES, OF THE COMMITTEE ON HEALTH, EDUCATION,

LABOR AND PENSIONS,

Washington, DC.

The subcommittee met, pursuant to notice, at 10:17 a.m., in room

SD–430, Dirksen Senate Office Building, Hon. Mike DeWine (chairman of the subcommittee) presiding.

Present: Senators DeWine and Reed.

OPENING STATEMENT OF SENATOR DEWINE

Senator DEWINE. Our hearing will come to order.

Thank you all for being here today. My colleague, Senator Reed

from Rhode Island, will be here in a moment. Let me thank him

for his continued dedication to issues affecting children and adolescents. Senator Reed is certainly a great advocate for youth in need.

Today, we are meeting to talk about substance abuse prevention

and treatment issues concerning adolescents. We all know that alcohol and drug abuse and dependence represent major problems for

young people in this country. Providing effective services to adolescents is particularly challenging. Despite the best efforts across the

field, much remains to be learned about the types and mix of services and strategies that are most effective in preventing and treating youth with alcohol and drug problems.

Some data highlight this challenge: the most recent information

we have from the National Household Survey on Drug Use and

Health shows that 11.6 percent of youth aged 12 to 17 currently

use illegal drugs; 20.2 percent of those aged 18 to 25 currently use

illegal drugs. Marijuana is the drug used by the majority of these

young people.

Of those aged 12 to 20, 28.8 percent are current alcohol users,

with 19.3 percent of this age group having binged within the last

month—that is defined as five or more drinks on a single occasion—while 6.2 percent can be considered heavy drinkers.

Research has shown that prevention can be very effective. Comprehensive, community-based approaches, combining individually

focused strategies with more ‘‘environmental’’ approaches, have

yielded very positive results in communities around the country.
2

Yet, as we can see in the data I just mentioned, we have a lot of

work to do.

If our prevention efforts fail, we must provide treatment services

to address substance abuse among our youth. Yet, the Household

Survey reveals a crisis in this area as well. For example, 2.3 million youth aged 12 to 17, (9.1 percent of that total age group) needed treatment, yet only 187,000 (8 percent of the total) received

services.

Clearly, we need to do much better. I am glad to say that there

is some good news. Results from the 2003 monitoring and future

surveys show an 11 percent decline in drug use by 8th, 10th and

12th grade students over the past 2 years. This decline correlates

with data showing a shift in youth attitudes about drug use. The

perceived risk of using drugs, especially marijuana, continues to increase among youth.

As important as our focus on illegal drugs is and must continue

to be, we know that alcohol is the primary substance of abuse

among young people and that it is a contributor to the three leading causes of death among this population: unintentional injuries,

such as traffic crashes, homicide, and suicide.

The annual societal cost of underage drinking has been esti- mated at over $50 billion per year. That is why I am working with

Senator Dodd and five members of the House on a bipartisan, bicameral bill specifically addressing underage drinking prevention.

We hope to introduce that bill soon.

Further research now is showing that substance abuse and dependence among our youth can be characterized as a developmental disorder. The prevalence of alcohol and drug dependence actually peaks in the 18 to 25 age group, and of course, a co-occurrence of major mental health disorders such as depression and bipolar disorder is also an important factor as well.

With this important challenge, we must act on what these data

tell us. Research must continue to search for answers and services

based on what we have learned from that research must receive

adequate funding. If we fail our youth in their developmental

years, we may be condemning them to a life of difficulty and lowered expectations.

That is why I am committed to doing what I can to prevent that

from happening. I believe that from this hearing, we can learn

more specifically what the state-of-the-art is in adolescent prevention and treatment. I believe we also can learn the important gaps

in our knowledge, the particular challenges and difficulties faced by

government, providers, communities and families and what we

might do to assist or facilitate in developing a broader, more effective system focusing on adolescents’ needs.

Let me at this point turn to Senator Reed for any opening comments.

OPENING STATEMENT OF SENATOR REED

Senator REED. Thank you very much, Mr. Chairman. Let me

again commend you for holding this hearing.

You and your staff have been scheduling some very important

and very significant hearings, and I thank you for the opportunity

to participate. As we all know, the problem of adolescent substance
3

abuse is a grave one. Nearly 20 million children age 12 and older

are currently using illicit drugs. This represents almost 10 percent

of the adolescent population, and when we factor in the presence

of comorbid conditions such as depression in these children, these

statistics are staggering.

The issue here is not simply that so many adolescents are affected but that we are doing so little to help the vast majority of

these children. On average, States are only able to treat 8 percent

of those in need of substance abuse services. Access to care is a

critical issue for these adolescents.

In Rhode Island, as in most communities in this country, a lack

of providers, combined with limited substance abuse treatment programs and virtually nonexistent residential treatment facilities has

left families with nowhere to turn. Some families in Rhode Island

are forced to travel as far as Arizona and Maine because they cannot get their children into a suitable residential treatment facility

in our own State.

A particularly alarming finding is the lack of services for youth

transitioning out of juvenile justice facilities and back into the community. Despite substantial evidence that as many as 60 percent

of juvenile offenders have a substance abuse problem, and despite

evidence that proper treatment reduces recidivism by as much as

75 percent, this high risk population is left largely untreated.

In the past, we did not comprehend the prevalence of substance

abuse by our adolescents, and we certainly did not know how to

help these children. Today, however, we have made great strides

at understanding these illnesses. We have developed effective treatments, and we now can help many of these children to live much

better lives.

Although more research and medical advancement are always

needed, we must act to help youngsters currently coping with substance abuse problems. I look forward to the panel’s testimony, and

I thank the chairman again for holding this hearing.

Thank you, Mr. Chairman.

Senator DEWINE. At this time I would like to submit Senator

Kennedy’s statement for the record.

[The prepared statement of Senator Kennedy follows:]

PREPARED STATEMENT OF SENATOR EDWARD M. KENNEDY

One of our major priorities in this committee is to do more to see

that all children in communities have access to vital health services. Preventing and treating substance abuse addiction is an essential part of protecting their potential to succeed and lead productive lives.

On some health issues, the Federal, State and local response has

produced significant progress. We can see the results in lower

smoking rates and in other quantifiable ways. But alcohol and drug

use continue to plague our communities, especially college communities.

Adults who began alcohol, tobacco or drug use before the age of

21 are far more likely to become addicted. The number of young

people who initiate drug use at a very early age is alarming. In

Massachusetts, according to a recent study, 20 percent of youth

had their first cigarette, 28 percent had their first alcoholic drink,
4

and 12 percent had used marijuana before turning 13. Nationally,

one in five persons from ages 12 to 20 had engaged in binge drinking.

Reaching children and adolescents effectively means more than

just making contact. It means providing prevention services that

are science-based and effective. It means following up with later

sessions, so the lessons won’t be lost. And it means involving

schools, families and local agencies in prevention efforts.

Schools are particularly important, because children are most accessible there. Yet few schools use proven and effective prevention

curricula. Instead, they typically rely on a patchwork of programs

with no consistent approach.

Interactive programs specifically tailored to a school’s demographics are highly effective. Programs focused on single drugs are

more effective than general anti-drug programs. If we build on

proven approaches, we can have a nation-wide initiative to make

the best prevention practices available to every school in the country.

On treatment, we’re still learning what works, but we know we

have to involve communities more effectively in the effort—from

schools, to law enforcement to health providers. Research is needed

on what interventions work best. The goal is to have individualized

and age-appropriate treatment for every child and adolescent who

needs it. If necessary, treatment for substance abuse should go

hand in hand with treatment for emotional disorders. Treating one

without the other means almost certain failure. Screening and assessing are important too, so that youths are less likely to be overlooked.

Recovery has to be the goal for anyone with an identified addiction. Again, building on best practice models across the country, we

can end the shameful nationwide disparities that exist today and

make our goals a reality for far more students.

We’ll hear today from Administrator Charles Curie of the Substance Abuse and Mental Health Services Administration, which is

coordinating the Federal response through its block grant and

other programs. The continuum of care provided under those programs can change lives in every State.

We’ll also hear today from academic experts, from hands-on program directors, and from a brave former consumer who can speak

to these and other issues.

I thank all of our witnesses and I look forward to their testimony.

Senator DEWINE. For our first panel this morning, I would like

to introduce Charles Curie, Administrator of the Substance Abuse

and Mental Health Services Administration. He has served in this

role since October 2001. He reports directly to Health and Human

Services Secretary Tommy Thompson and leads the $3.2 billion

agency responsible for improving the accountability, capacity and

effectiveness of our Nation’s substance abuse prevention, addictions

treatment and mental health services.

Good to see you again.
5

STATEMENT OF CHARLES CURIE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mr. CURIE. Good to see you, Mr. Chairman.

Senator DEWINE. Thank you very much.

Mr. CURIE. Thank you so much, and thank you, Senator Reed,

as well, for this opportunity today. As you said, I am Charles

Curie, the Administrator of what is known as SAMHSA in the Department of Health and Human Services, and I do request that my

formal written testimony be submitted to the record.

Senator DEWINE. That will be made a part of the record.

Mr. CURIE. Thank you.

Again, today, we have an opportunity to describe how we are

working together to provide effective substance abuse treatment to

people who want and need it, including young Americans. Drug

abuse, as you have both indicated, is a major public health problem. Overall, there are an estimated 22 million Americans aged 12

and older struggling with a drug or alcohol problem.

Among adults 18 and older with a serious substance abuse problem, again, just over 20 percent have a co-occurring serious mental

illness. Addiction often begins during childhood and adolescence,

and research shows that while substance abuse was once thought

to be an adult onset disease, as you indicated in your remarks, Mr.

Chairman, it actually is a developmental disease. And there is a

clear correlation between the age of first use of drugs and alcohol

and the potential for developing a serious problem.

For example, one-third, 2.3 million, of alcohol-dependent adults

aged 21 or older in 2002 had first used alcohol before the age of

14. Over 80 percent, 5.8 million, had first used alcohol before they

were aged 18, and 96 percent, 6.6 million, had first used alcohol

before the age of 21.

The rate of dependence for those who first drank at age 21 or

older was only 1 percent. Conversely, 99 percent of adults 21 or

older who first drank alcohol at 21 or older do not have a dependence problem. It is plain to see why improving treatment services

for adolescents and ratcheting up prevention programs targeted at

this age group are top priorities for SAMHSA.

During my tenure, we have restructured our work around the vision of a life in the community for everyone, and our mission,

building resilience and facilitating recovery. To focus and guide our

program development and resources, we have developed a matrix

of program priorities and cross-cutting management principles.

Two priorities I want to highlight for you are prevention and treatment of adolescent substance abuse.

On our matrix, you will see Strategic Prevention Framework.

Through this framework, we are working to more effectively and efficiently align our prevention resources. Fortunately, we know more

about what works in prevention, education and treatment than

ever before. Over the years, we have shown that prevention programs can and do produce results. Currently, we have 60 model

programs listed in our National Registry of Effective Programs.

These programs yield an average of a 25 percent reduction in substance use.
6

To help provide a structured approach to prevention that is

based on the best that science has to offer, Secretary Thompson

launched SAMHSA’s Strategic Prevention Framework during the

National Healthier U.S. Prevention Summit in Baltimore on April

29th. This new $45 million competitive grant program will enable

States, territories and the District of Columbia to bring together

multiple funding streams from multiple sources to create and sustain a community-based, science-based approach to substance

abuse prevention and mental health prevention and promotion.

In the area of substance abuse treatment, this year, we launched

the President’s Access to Recovery program with a $100 million investment. The administration’s commitment to expand clinical

treatment and recovery support services to reach those in need extends beyond the immediate fiscal year.

Our 2005 request doubles Access to Recovery’s appropriation to

$200 million and increases the Substance Abuse Prevention and

Treatment Block Grant by $53 million, for a total of $1.8 billion.

Critically, Access to Recovery provides States the opportunity, if

they choose, to target resources to providing treatment for adolescents. We also support treatment for adolescents through our Targeted Capacity Expansion Grants.

Each of our efforts, whether through the block grant, Targeted

Capacity Expansion or Access to Recovery to expand treatment for

adolescents are based on the undeniable need. Key to achieving our

goals is developing an ability to report on meaningful outcomes.

These outcome measures must be concise, purposeful and useful.

They must get real outcomes for real people. We are changing the

emphasis from how did you spend the money, and did you spend

the money according to the rules, to how did you put your dollars

to work, and how did your consumers benefit.

Through an internal data strategy work group, we are conducting an examination of our data collection and analysis systems, and

a central component is the development of national outcomes.

Through collaboration with the States, we have identified a key set

of domains or national outcomes. These domains are, one, abstinence from drug use and alcohol abuse or decreased symptoms

from mental illness; two, increased or retained employment and

school enrollment; three, decreased involvement with the criminal

justice system; four, increased ability in family and housing conditions; five, increased access to services; six, increased retention in

services; and seven, increased social connectedness to family,

friends and coworkers.

These national outcomes ultimately will be aligned across all of

SAMHSA’s programs, including Access to Recovery, the Community Mental Health Services Block Grant and Substance Abuse

Prevention and Treatment Targeted Capacity Expansion Grants.

We do know, based on our experience that prevention works,

treatment works. And it helps people triumph over addiction and

leads to recovery. Mr. Chairman and Members of the Committee,

thank you for the opportunity to appear today. I will be pleased to

answer any questions you may have.

[The prepared statement of Mr. Curie follows:]
7

PREPARED STATEMENT OF CHARLES G. CURIE, M.A., A.C.S.W.

Mr. Chairman and Members of the Subcommittee, good morning. I am Charles

G. Curie, Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services

(HHS).

Thank you for providing me the opportunity to describe how SAMHSA and our

Federal, State, and local community-level partners are working to provide effective

substance abuse treatment to people who want and need it, including young Americans.

Drug abuse and mental illness are major public health problems that affect us

all. In terms of dollars, substance abuse, including alcohol, illicit drugs, and tobacco

use, costs our Nation more than $484 billion per year. The economic costs of mental

illness are also staggering. The President’s New Freedom Commission on Mental

Health reports the cost in the U.S. from both direct (treatment-related) and indirect

(productivity loss) expenses may exceed $150 billion per year with rapid annual increases, especially in the drug treatment area. Mental illnesses, including depression, account for four of the top six causes of disability among 15–44 year olds in

the Western world.

Although not as well known as the deaths due to substance abuse, mental illnesses are a substantial source of mortality. Of the 30,000 Americans who die by

suicide each year, 90 percent have a mental illness. The fact that deaths from suicide outnumber deaths from homicide (18,000) is often a surprising finding. Suicide

rates are high among several ethnic minority groups, though it remains highest in

older white males. Between 1952 and 1992, the incidence of suicide among adolescents and young adults nearly tripled; currently it is the third-leading cause of

death in adolescents. We know that substance use increases the probability of a person with mental illness attempting suicide and increases the person’s likelihood of

succeeding.

Addiction’s toll on individuals, their families, and the communities they live in is

a cumulative devastation with a ripple effect. This ripple effect leads to costly social

and public health problems including HIV/AIDS, domestic violence, child abuse, and

crime in general, as well as accidents and teenage pregnancies.

Addiction often begins during childhood and adolescence. Research has shown

that substance use dependence, while once thought to be an adult-onset disease, is

actually a ‘‘developmental disease.’’ It is developmental in terms of having its start

during the early stages of adolescence and even childhood, when children use drugs

or consume alcohol. The introduction of an illicit drug or of alcohol to the adolescent

brain has a dramatic impact because of the changes occurring in the brain during

this developmental stage.

The data from SAMHSA’s 2002 National Survey on Drug Use and Health provides the scope of the problem. In 2002, there were 2.3 million youths aged 12 to

17 who needed treatment for an alcohol or illicit drug problem. Of this group, only

186,000 received treatment. Without help, it is very likely that these young people,

at the very beginning of their lives, will continue on a destructive path of addiction,

disability, criminal involvement, and premature death.

Overall, there are an estimated 22 million Americans struggling with a drug or

alcohol problem. There is a clear correlation between age of first use of drugs and

alcohol and the potential for developing a serious problem. For example, in 2000,

18 percent of people age 26 and older who had begun using marijuana before age

15 met the criteria for either dependence or abuse of alcohol or illicit drugs, compared to 2.1 percent of adults who never used marijuana. Among past year users

of marijuana age 26 and older who had first used marijuana before age 15, 40 percent met the criteria for either dependence or abuse of alcohol or illicit drugs.

The story is very similar for alcohol. One-third, 2.3 million, of alcohol-dependent

adults age 21 or older in 2002, had first used alcohol before age 14. Over 80 percent,

5.8 million, had first used before they were age 18. And 96 percent, 6.6 million, had

first used before age 21. The rate of dependence for those who first drank at age

21 or older was only 1 percent. Conversely, 99 percent of adults 21 and older who

first drank alcohol at age 21 or older do not have a dependence problem.

It is plain to see why improving treatment services for adolescents and bolstering

prevention programs targeted to this age group are top priorities for SAMHSA.

THE SAMHSA ROLE

SAMHSA is working to improve how we approach substance abuse treatment and

prevention, not only at the Federal level, but also at the State and community levels. During my tenure, we have restructured our work around the vision of ‘‘a life
8

in the community for everyone’’ and our mission of ‘‘building resilience and facilitating recovery.’’

To focus and to guide our program development and resources, we have developed

a Matrix of program priorities and cross cutting principles that pinpoints SAMHSA’s

leadership and management responsibilities. These responsibilities were developed

as a result of discussions with Members of Congress, our advisory councils, constituency groups, people working in the field, and people working to attain and sustain

recovery.

The Matrix priorities are also aligned with the priorities of President Bush and

HHS Secretary Tommy Thompson, whose support for our vision of a life in the community for everyone we appreciate. The Matrix has produced concrete results by focusing SAMHSA staff and the field on planting a few ‘‘redwoods’’ rather than letting

‘‘a thousand flowers bloom.’’ I see my responsibility as Administrator to make solid

program and management improvements that will last beyond my tenure.

I am proud of our success over the past 21⁄2 years since I came to SAMHSA. I

believe the SAMHSA Matrix is the underpinning of our success and has helped us

to focus on solid investments in the future of mental health and substance abuse

prevention and treatment services. In particular, I will highlight the ways we support the prevention and treatment of adolescent substance abuse.

On our matrix you will see the program ‘‘Strategic Prevention Framework.’’

Through this Framework we are working to more effectively and efficiently align

our prevention resources. The Framework is aligned with the President’s and Secretary Thompson’s HealthierUS initiative. HealthierUS is a plan to improve overall

public health by capitalizing on the power of prevention to help prevent, delay, and/

or reduce disability from chronic disease and illnesses, including substance abuse

and mental illnesses.

I am pleased to report that the most recent data confirms that the President’s 2-

year goal to reduce illicit drug use among youth by 10 percent in 2 years has been

exceeded, with an 11 percent reduction in the past 2 years. This is a clear indication

that our work with our many Federal and State partners, along with schools, parents, teachers, law enforcement, religious leaders, and local community anti-drug

coalitions, is paying off. But our work is far from over, and prevention is key.

Fortunately, we know more about what works in prevention, education, and treatment than ever before. Over the years, we have shown prevention programs can and

do produce results. Currently, we have 60 model programs listed in our National

Registry of Effective Programs. These programs yield, on average, a 25 percent reduction in substance use and affect a broad range of behavioral issues, from violence

and delinquency to emotional problems. Primary access to the programs in the Registry is through the SAMHSA Model Programs website. The website describes and

provides contact information for each of the programs in the Registry

(www.modelprograms.samhsa.gov).

Unfortunately, as we all know, individuals, communities, or State and Federal

agencies do not always translate, or make it easy to translate, into action what is

known about prevention. To help provide a structured approach to substance abuse

prevention and mental health promotion that is based on the best that science has

to offer, Secretary Thompson launched the Strategic Prevention Framework during

the national HealthierUS Prevention Summit in Baltimore on April 29. This new

$45 million competitive grant program will enable States, Territories, and the District of Columbia to bring together multiple funding streams from multiple sources

to create and sustain a community-based, science-based approach to substance

abuse prevention and mental health promotion.

The Framework is based on the risk and protective factor approach to prevention.

For example, family conflict, low school readiness, and poor social skills increase the

risk for conduct disorders and depression, which in turn increase the risk for adolescent substance abuse, delinquency, and violence. Protective factors such as strong

family bonds, social skills, opportunities for school success, and involvement in community activities can foster resilience and mitigate the influence of risk factors.

Clearly, these risk and protective factors exist at several levels—at the individual

level, the family level, in schools, the community level, and in the broader environment. People working in communities with young people and adults understand the

need to create an approach to prevention that is citizen centered, cuts across existing programs and system levels, and has common outcome measures.

Just as when we are promoting exercise and a healthy diet or advancing vaccination, when we speak about abstinence or rejecting drugs, tobacco, and alcohol and

promote mental health, we really are all working towards the same objective—reducing risk factors and promoting protective factors. The challenge is to build a national framework for prevention on that common foundation.
9

Moving the framework from vision to practice will require the Federal government, States, and communities to work in partnership. Under the new grant program, States will provide leadership, technical support, and monitoring to ensure

that participating communities are successful in implementing a five-step public

health process that will promote youth development, reduce risk-taking behaviors,

build assets and resilience, and prevent problem behaviors across the life span. The

five steps are:

First, communities assess their mental health and substance abuse-related problems including magnitude, location, and associated risk and protective factors. Communities also assess assets and resources, service gaps, and readiness.

Second, communities must engage key stakeholders, build coalitions, and organize, train, and leverage prevention resources.

Third, communities establish plans that include strategies for organizing and implementing prevention resources. They must be based on documented needs, build

on identified resources, and set baselines, objectives, and performance measures.

Fourth, communities implement evidence-based prevention efforts specifically designed to reduce risk and promote protective factors identified.

Finally, communities will monitor and report outcomes to assess program effectiveness and service delivery quality, and to determine if objectives are being attained or if there is a need for correction.

The success of the Strategic Prevention Framework will be measured by specific

national outcomes that are true measures of whether our programs are helping

young people achieve our vision of a life in the community, for example, whether

they are in stable homes, in school, and are not involved with the criminal justice

system. We are rapidly moving to implement these national outcomes across all of

SAMHSA’s programs.

In the area of substance abuse treatment, we are already using National outcomes. This year we commenced the President’s Access to Recovery program with

a $100 million investment. The Administration’s commitment to expand clinical

treatment and recovery support services to reach those in need extends beyond the

immediate fiscal year, with its fiscal year 2005 request to double Access to Recovery’s appropriation to $200 million and to increase the Substance Abuse Prevention

and Treatment Block Grant by $53 million for a total of $1.8 billion.

As you may know, Access to Recovery is based on the knowledge that there are

many pathways to recovery. It empowers people with the ability to choose the path

best for them—whether it is physical, mental, medical, emotional, or spiritual. In

particular, we know that for many Americans, treatment services that build on spiritual resources are critical to recovery. Access to Recovery ensures a full range of

clinical treatment and recovery support services are available, including the transforming powers of faith. Critically, Access to Recovery provides States the opportunity to target resources to providing treatment to adolescents.

Over the years, SAMHSA, through its Center for Substance Abuse Treatment

(CSAT), has made significant strides in addressing the shortage of adolescent substance abuse treatment. Between 1970 and 1997, there were only 14 published studies of the effectiveness of adolescent substance abuse treatment. In response,

SAMHSA funded the Cannabis Youth Treatment (CYT) Study in 1997. Its purpose

was to explore whether proven adult models of intervention could be made developmentally appropriate for adolescents and achieve effective outcomes in real-world,

community-based treatment settings. The CYT study of over 600 youth randomized

to five different treatment interventions resulted in five effective treatment protocols that are now available in manuals that are in use across the country. The five

volumes of the CYT Series are based on treatment approaches specifically designed

for use with adolescents. The CYT manuals are part of SAMHSA’s larger Science

to Services Initiative that is working to speed the delivery of effective, evidencebased programs into communities where clinical intervention and treatments are

put into practice.

In 1999, a few years after the CYT study began, SAMHSA funded the Adolescent

Treatment Models program. The purpose was to identify potentially exemplary programs that existed in the field and to have them rigorously evaluated to determine

their effectiveness. The same core assessment and follow-up instruments, as well as

data collection points from CYT, were used, which afforded the opportunity to draw

critical comparisons. The outcomes of this study generated 10 treatment program

manuals that include effective programs for intensive outpatient, short-term residential and long-term residential programs that are available on-line and are being

adopted within the adolescent treatment field as we speak.

Having worked to identify effective treatment interventions, SAMHSA proceeded

to develop the Strengthening Communities—Youth (SCY) program in 2001. With a
10

$39 million investment, twelve sites were funded for 5 years to develop a continuum

of adolescent services and a system of care for youth within their communities.

Although these programs have clearly and undoubtedly strengthened treatment

programs for this age group, an identified weakness is the lack of continuing care

models for youth after they complete the active phase of treatment. For example,

too often when youth complete residential placements and return to their families

and communities, they are cut-off from treatment services and quickly resume their

substance abuse and other destructive behaviors. In response, SAMHSA awarded

grants under its program to Improve the Quality and Availability of Residential

Treatment and its Continuing Care Component for Adolescents (ART) during 2002.

As a result, numerous residential programs have developed and implemented models of providing continuing care to youth.

Along with improving after-care services for adolescents, SAMHSA launched the

Effective Adolescent Treatment (EAT) program in 2003 to assist the field in adopting a previously proven effective approach of the CYT initiative. This approach, Motivational Enhancement Therapy/Cognitive Behavioral Therapy, for adolescents with

substance use disorders is now being implemented in 22 sites around the country.

In 2004, an additional 16 sites will be funded, which will result in a total of 38 programs implementing a practice for which there is evidence of effectiveness and will

directly impact success rates for adolescents who are in a battle for their very lives.

In tandem with improving and extending the continuum of care in residential settings, which often include court-adjudicated youth from the criminal justice system,

CSAT also provides for critical treatment services through the Juvenile Justice Drug

Treatment Court. Six programs are up and running smoothly, and others will be

operational soon through our Youth Offender Re-entry Program, which will support

12–14 new programs in Fiscal Year 2004.

CSAT also supports treatment programs for adolescents through its Targeted Capacity Expansion program (TCE), Targeted Capacity Expansion/HIV (TCE/HIV),

and HIV Outreach programs. These grantees are encouraged and supported to adopt

only effective treatment practices. They are included in meetings and trainings to

further facilitate the evolution and improvement of the field of adolescent substance

abuse treatment.

Each of these efforts to expand treatment services for adolescents have been well

thought out, and each resulting program has been funded based on the underlying

and undeniable fact that all we can do to help our Nation’s youth is what must be

done—nothing less is acceptable. The treatment services afforded through the opportunities I just mentioned are improving services for adolescents, and we are improving and building upon the services for consumers of all ages—children, adolescents,

young adults, adults, and older adults alike.

I am particularly proud to tell you that improving services for all of these age

groups, from this Nation’s elderly down through and including our youngest citizens,

is the driving force behind achieving our agency goals—goals which are independent

yet interconnected and goals which are clearly outlined in our Matrix of agency priorities.

Key to achieving our goals is developing an ability to report on meaningful outcomes. These outcome measures must be concise, purposeful, and useful. They must

get at real outcomes for real people. We are changing the emphasis from, ‘‘How did

you spend the money?’’ and, ‘‘Did you spend the money according to the rules?’’ to,

‘‘How did you put the dollars to work?’’ and, ‘‘How did your consumers benefit?’’

Through an internal data strategy workgroup we are conducting a thorough examination of our data collection and analysis systems. The goal is to take steps now

to ensure that decisions related to SAMHSA’s priorities are based on the most comprehensive and accurate information available.

As I mentioned previously, an essential component of SAMHSA’s data strategy is

development of ‘‘National Outcomes’’ and related ‘‘National Outcome Measures.’’

Through collaboration with the States we have identified a set of key domains.

These domains are:

(1) abstinence from drug use and alcohol abuse, or decreased symptoms from mental illness;

(2) increased or retained employment and school enrollment;

(3) decreased involvement with the criminal justice system;

(4) increased stability in family and living conditions;

(5) increased access to services;

(6) increased retention in services for substance abuse treatment or decreased utilization of psychiatric inpatient beds for mental health treatment; and

(7) increased social connectedness to family, friends, co-workers, and classmates.

As I mentioned, these national outcomes are already being implemented through

the President’s Access to Recovery program and the Strategic Prevention Frame-
11

work. Ultimately the National Outcomes will be aligned across all of SAMHSA’s

programs, including the Community Mental Health Services Block Grant and the

Substance Abuse Prevention and Treatment Block Grant. The National Outcomes

are an attempt to provide greater flexibility and accountability while limiting the

number of reporting requirements on the State. Ultimately we are confident this approach will ensure the data collected is relevant and useful and helps to improve

services for the people we serve.

Putting the data to work is a responsibility that SAMHSA is happy to shoulder.

We can now clearly and definitively demonstrate that Federal investments in prevention and treatment are beneficial. Prevention works. Treatment works—it helps

people triumph over addiction and leads to recovery. The vital treatment and prevention efforts and programs that I have discussed today are working to improve

services for adolescents, and for people of all ages.

Mr. Chairman and Members of the Subcommittee, thank you for the opportunity

to appear today. I will be pleased to answer any questions you may have.

Senator DEWINE. Thank you very much.

Senator Reed?

Senator REED. Thank you very much, Mr. Curie, for your excellent testimony and for your good work. The SAMHSA program Access to Recovery, the voucher program, for substance abuse treatment would children and adolescents be eligible to participate in

this program? If they can, would you please walk the Committee

through this process, particularly a more challenging case of an adolescent from a family that is not able to adequately care for him

or her; how would this person get access to a voucher? Who would

make these judgments?

Mr. CURIE. Absolutely; in fact, we, in terms of Access to Recovery, a major premise of Access to Recovery is States, territories and

tribal organizations have the opportunity to shape these voucher

programs among meeting their immediate needs. We encourage

adolescents as a specialty population. So we anticipate, with the

over—I think there are about 66 applications right now we have received for Access to Recovery, and we will be making those awards

this summer as they are going through review right now.

Some of the States, territories or tribal organizations would indeed target children and adolescents through their juvenile justice

system, child welfare system, and there is a wide range of latitude

that we have given States to be able to do that so they can address

their most immediate needs. Also, it allows for adolescent treatment, be it residential, outpatient, various forms of counseling and

support.

The way it could work and the way in terms of based on our

standards is, one, an entity that receives Access to Recovery needs

to demonstrate that there will be a professional assessment conducted by a qualified professional, that they have opened more portals of entry to assessment and treatment in their system due to

Access to Recovery.

If, for example, they decided to work with their juvenile justice

system, if an individual looked as though they were having an

issue with drugs or alcohol, they would be sent to the deemed professional for an assessment. Based upon that assessment, then, a

voucher would be issued which would basically be for the treatment

based upon that recommendation and a list of qualified providers

that provide that kind of service that have been approved by the

State or by the tribal organization would be available for a decision

to be made as to where the individual would seek treatment.
12

Senator REED. And who would make that decision, Mr. Curie?

Would the youngster or someone in the social welfare service?

Mr. CURIE. We would expect in the situation of children and adolescents that, you know, if there is a parent or guardian involved

that they would be the primary ones working in making that decision. If they are under custody of the State or county in terms of

welfare that again, those decisions would be made by whoever is

responsible for that child or adolescent.

But we would encourage, obviously, if there is some sort of preference in the type of treatment that they would have input to that.

Obviously, in the adult situation, the adults would have more of a

primary choice.

Senator REED. In my view, the system is conceived such that, the

individual patient can make the judgment in terms of the type of

treatment.

Mr. CURIE. Right.

Senator REED. That is the difference. And here, in many cases,

because of the lack of family support and the situation of the child,

it is not much different than what you do today except, instead of

having one approved vendor or two from the State, you now have

a longer list.

Mr. CURIE. I think that is one point. There will be a goal of Access to Recovery, more providers being available. Second, another

goal would be using outcomes to promote accountability, and the

seven domains I mentioned——

Senator REED. Yes.

Mr. CURIE [CONTINUING].——in my testimony would be driving

Access to Recovery. So after a period of time of being in treatment,

assessing how well is that adolescent doing in terms of staying

drug-free or alcohol-free; how well are they doing in terms of educational or employment pursuits; do they have a more stabilized

living situation; do they have access to the services they need? Are

they staying out of trouble with the juvenile justice system and

measure those real outcomes which depict recovery and which depict building resilience in the young person’s life.

And Access to Recovery is really our first program that we have

tied these particular seven domains, and our goal, then, is to make

sure all these domains are part of what we are measuring through

all of our programs, that these seven domains that reflect recovery,

whether we are talking block grant, our other Targeted Capacity

Expansion Grants, that we are measuring the same things, because

if we are funding something that is not promoting resilience or facilitating recovery, then, I question why SAMHSA is funding it.

Senator REED. Right.

Mr. CURIE. Because that is our goal. So Access to Recovery gives

us that opportunity.

Senator REED. You quite rightly have put a lot of weight on this

notion of the outcome measures, and that raises some obvious

questions. Who is collecting the data? Is there a uniform system

that is understood by everyone and that is statistically, you know,

reliable?

Mr. CURIE. Sure.
13

Senator REED. We all know that there are some systems that

purport to measure but, do not measure very well. Can you talk

about that in terms of your proposal?

Mr. CURIE. Yes; yes. In Access to Recovery, we outline the broad

domains and requirements that we are looking for, and we would

be expecting, again, whatever entity is awarded a grant, whether

it be a State, tribal organization or territory, that they would have

a uniform way of collecting this data and demonstrate that in their

proposal, because we would be looking for a way of uniformly——

Senator REED. Right.

Mr. CURIE [CONTINUING].——assessing outcomes.

Senator REED. But their uniform method might be different than

the next grantee; and theirs might be different than the next

grantee.

Mr. CURIE. Well, we would expect consistency at least within the

State, as a beginning point, because you are right: we want to see

what kind of baselines they are establishing. Again, there may be

some variance from State to State, but we would not be looking for

each grantee only to self-report on their own criteria, but there

would be some consistent uniform way of measuring these particular outcomes.

Senator REED. Some of these are necessarily subjective, like the

increase in stability in family and living conditions, etc. Are you

going to provide any, guidance? There is always the danger that

the further you move away from quantitative measures—recidivism, further engagement with law enforcement, you get into subjective areas where it may be fudged.

Mr. CURIE. Right, understood. There have been, among these

seven domains, and we have had a range of researchers examine

these domains and feel they are very valid for measuring recovery,

and there are measures within those domains which are much

more quantifiable: length of stay in a housing situation, time that

they are living with their family.

Senator REED. Right.

Mr. CURIE. You know, when did they gain employment? How

long are they staying in school? So there clearly will need to be

more precise measures within those domains.

Senator REED. Mr. Chairman, you have been very kind, but if

you would indulge me with one more question.

Why will SAMHSA not develop a framework, a national data

framework that could be applied in every State?

Mr. CURIE. Well, that is a very good question. Actually, we have

embarked this past year on what we are calling our data strategy,

because up until now, there really has been no clear national data

strategy, and I know that we have been grappling with moving in

the direction of national treatment outcome measures. And in one

sense, the data infrastructure that we have funded and developed

through the years has been State by State, as that is how the block

grants were allocated.

And to make that move from State by State to a national level,

while not impossible at all, is going to take an endeavor which we

partner clearly with the States, and we are actually looking to do

that type of data framework through what we were calling Performance Partnership Grants with the States but working with the
14

State drug and alcohol authorities and mental health authorities to

come to common agreement on the measures as a major first step.

And we are actually much further down that road than we ever

have been, and then, it is a matter of operationalizing it. So the

answer to your question is yes, we are committed to doing that.

But we want to make sure we do it in building on the infrastructure that we have already been funding with the States.

It also, as we have examined it, to start all over with some national treatment outcome measures approach, which is not connected with what we have already done, could be extremely costly,

and also, it would be experimental. So we are trying to build on

that sure footing. But you are exactly right: the more consistent we

can have national measures, the stronger we will all be.

Senator REED. Thank you very much, Mr. Curie.

Thank you, Mr. Chairman.

Senator DEWINE. One of the age-old problems, as we have discussed a little bit this morning, but I would like for you to get into

a little more detail, is to take the research into practice. Do you

want to describe how SAMHSA works with its Federal partners in

the field to move research into practice and ensure that the results

of research get used by SAMHSA, but also get used out into the

field in the most appropriate ways?

Mr. CURIE. Absolutely; in fact, you are right: age-old is a good

word for it, because it has been documented by the IOM study: 17

to 20 years’ lag time between research findings being realized on

the front line. What we have done with our partners in NIH, both

NIAAA, NIDA and NIMH, is SAMHSA has embarked with our

partners upon a course of action that we are calling our science to

services project and initiative.

And our goal is to facilitate more rapid implementation of effective evidence-based, science-based practices to the front line. And

we are doing this in several different ways, in several different avenues. And again, I see this as a process that we have really embarked upon much more formally over the past 2 years. There have

been initiatives in the past, but we have tried to bring it together

to view the science to service cycle, where the first phase is research and development by the Institutes; the second phase is dissemination and implementation; and the third phase is monitoring

and feedback.

And part of this has been in terms of moving ahead is also clarifying the roles of the Federal agencies in doing this. And I think

that had not been totally clarified previously. Obviously, the Institutes are responsible for research, and we are a services administration, so we are responsible for services.

So phase one that I described is clearly more of an Institute responsibility which they fulfill; two, dissemination and implementation is a partnership between us, and three, monitoring and feedback rests on us to bring back feedback to feed into the services

research agenda in the Institutes.

Some of the activities that we actually have done: NIMH and

SAMHSA have jointly funded programs to facilitate the State planning for implementation of evidence-based programs. We are looking to release what we call six tool kits around practices that are
15

working that we make available through both State authorities and

to providers. In partnership with NIDA, NIDA has committed $15 million for

5 years to evaluate SAMHSA’s newly-developed Strategic Prevention Framework, which I mentioned earlier, and we also are contributing $15 million to that evaluation process. We also have, as

I mentioned earlier, our National Registry of Effective Programs,

and again, we are expanding that beyond prevention programs to

include treatment programs and are working with the Institutes in

arriving at, first of all, what is an effective program? Do they meet

certain scientific thresholds of effectiveness, and then, as we list

them, how can we begin to implement them?

Also, we have addiction transfer technologies, technology transfer

centers in CSAT. We have TA centers, technical assistance centers,

in CMHS and what we call our CAPS, our TA centers in the Prevention all have partnerships with the Institutes in bringing those

practices to the field, regionally and through States.

So again, we have a framework now for the first time that we

are calling science to service. We are putting our endeavors that we

have been doing under that framework, and we are actually encouraging new endeavors as well.

Senator DEWINE. Good. We know that we face serious work force

issues which limit the expansion of treatment services. What is

SAMHSA doing to show leadership to create and also sustain a

qualified work force for adolescent treatment as well as adult treatment?

Mr. CURIE. No, absolutely. This has been a problem for quite

some time. It has been a challenge to recruit people to our fields.

It has been a challenge to keep people in our fields, and it has been

a challenge to keep qualified individuals in our fields.

Again, we have several initiatives addressing this. I mentioned

the addiction treatment technology centers as well as the CAPS

and the TA centers. Each one of them have a major focus on providing training and services to work force to both grantees and providers at the regional level. Each one of them also have partnerships with universities. For the ATTCs, for example, we have a listing on our Website of all of the universities affiliated with them

that provide ongoing certification training for professionals.

And so, we are strengthening in that area in terms of providing

ongoing certification and training. Also, we have minority fellowship grants to encourage minorities to receive education in our

field, in our area, to fund that type of training. And also, we have

$6 million for a children’s SIG, State Incentive Grant, to fund

seven States, which the purpose of that is to develop an infrastructure around—which includes developing workforce and training

workforce around services to children and adolescents, that we are

just actually issuing at this point in time.

The other thing that we must do is have an ongoing relationship.

I know I met with NAADAC, the association of drug and alcohol

certified counselors as well as Therapeutic Communities of America. These are organizations, these types of associations are consistently looking at workforce development issue, and we have got to

strengthen our partnership with the professional associations to

make sure the linkages are being made as well.
16

Senator DEWINE. Well we thank you very much, and certainly,

this subcommittee looks forward to working with you on SAMHSA

reauthorization in the future.

Mr. CURIE. Thank you, Mr. Chairman, thank you.

Senator DEWINE. We will be talking a lot in the future.

Mr. CURIE. I am looking forward to it.

Senator DEWINE. Good. Thank you very much.

Let me ask our second panel to come up, and I will begin to introduce you as you come up. On the second panel, we have Sandra

Brown from the Department of Psychology at the University of

California, San Diego. Dr. Brown is a professor of psychology and

psychiatry and also the chief of psychology services at the Veterans

Affairs San Diego Health Care Systems. She is associate director

of the Child and Adolescent Services Research Center at Children’s

Hospital of San Diego. Dr. Brown is an internationally-recognized

researcher whose work has covered many of the topics of interest

at today’s hearing.

We also have Dr. Roger Weissberg, from the Department of Psychology at the University of Illinois at Chicago. He is also the executive director of the Collaborative for Academic, Social and Emotional Learning, an international organization committed to supporting the development and dissemination of effective schoolbased programs that enhance the positive social, emotional, academic, moral, and healthy development of young people. He is a

well-respected prevention researcher who has spent much of his career focusing on issues of interest to us in this hearing.

We also have Rhonda Ramsey-Molina, who has served as president and CEO of the Coalition for a Drug-Free Greater Cincinnati

since 1999. She brings to this position over 10 years of experience

in the field of substance abuse prevention and community coalition

building. Prior to this, she directed the Monroe County Community

Prevention Coalition in Bloomington, Indiana; served on the Governor’s Commission for a Drug Free Indiana and worked as a prevention specialist for the Cincinnati Alcoholism Council.

We also have Ronald Anton, director of juvenile justice and community programs at Day One, Maine’s largest provider of substance abuse services to adolescents and families. He has over 30

years of experience as a mental health and substance abuse clinician, clinical supervisor, consultant, trainer and administrator. He

currently oversees a broad range of programs, including the Juvenile Treatment Network, which uses vouchers to assist youth in obtaining substance abuse services.

Let me also acknowledge Ann Dolan Peletier, who is the Day

One program manager of the Juvenile Treatment Network of

Maine. She has traveled with Mr. Anton to be with us today.

Finally, we have Kris Shipley, a young man who has struggled

with his own addiction and now works to help others avoid the

kind of problems he faced. Let me welcome you to the committee

Kris. Kris, thank you very much for being with us.

Let me welcome all of you to the committee, and Dr. Brown, we

will start with you, and we have received testimony from all of you.

It will be made a part of the record, and we have a 5 minute rule

for your testimony, and you can watch the light come on here, and
17

if you could keep your testimony to 5 minutes, and that will give

us the opportunity to ask you all some questions.

Dr. Brown?

STATEMENTS OF SANDRA BROWN, PROFESSOR OF PSYCHOLOGY AND PSYCHIATRY, UNIVERSITY OF CALIFORNIA-SAN

DIEGO; CHIEF OF PSYCHOLOGY SERVICES, VETERANS AFFAIRS SAN DIEGO HEALTH CARE SYSTEMS; ASSOCIATE DIRECTOR, CHILD AND ADOLESCENT SERVICES RESEARCH

CENTER, CHILDREN’S HOSPITAL OF SAN DIEGO; ROGER

WEISSBERG, DEPARTMENT OF PSYCHOLOGY, UNIVERSITY

OF ILLINOIS AT CHICAGO, EXECUTIVE DIRECTOR, COLLABORATIVE FOR ACADEMIC, SOCIAL AND EMOTIONAL LEARNING; RHONDA RAMSEY-MOLINA, PRESIDENT AND CEO, COALITION FOR A DRUG-FREE GREATER CINCINNATI; RONALD

ANTON, DIRECTOR OF JUVENILE JUSTICE AND COMMUNITY

PROGRAMS, DAY ONE; AND KRIS SHIPLEY, PASADENA, MD

Ms. BROWN. Thank you. Thank you, Mr. Chairman and Senator

Reed.

I am delighted to have the opportunity to speak with you today

on this very important topic, and I think that it will become clear

through my testimony that current research has exciting new information that can bear on the development of prevention and intervention services for adolescents, and this is a very exciting time

from a researcher’s perspective in this arena. Research that is supported by the National Institutes of Health and other agencies is

leading to a new and very common understanding about the critical

role of early onset of addictive disorders in their course, their consequences and their progression.

We are finding that these disorders begin during adolescence and

sometimes even during early childhood, and therefore, our interventions may prevent many of the social, behavioral, health and

economic consequences that are caused by alcohol and drug abuse

as well as provide us an opportunity to treat problems before they

become full-blown and to damage the lives of our youth.

I would really like to highlight three points today from a research perspective. One is that in just the past few years, it is becoming increasingly evident that these disorders start routinely

much earlier than previously appreciated. Second, that hazardous

drinking, particularly binge drinking, is on the rise, and third, that

we have a new understanding of the substantial problems that alcohol and drugs produce in adolescent brain functioning, and I

would like to highlight those in my testimony this morning.

NIAAA and NIDA-supported researchers are finding that alcohol

and drug addictions commonly start earlier than previously understood, and the earlier youth start, the greater the lifetime risk for

dependence. New findings regarding the patterns of abuse and dependence dramatically underscore the importance of reducing underage drinking and drug use. The age of most prevalent tobacco

dependence onset, for example, is 15. For alcohol dependence, age

18 is the most common period of first diagnosis of dependence.

It is now clear that most cases of alcohol dependence begin before

age 25. The epidemiological research message, I think, is obvious:

that youth is a critical window of opportunity for preventing alco-
18

hol, tobacco and other disorders. Alcohol, which is the most commonly abused substance, has found an increasing rise in hazardous

drinking over the past few years. Binge drinking, which we have

mentioned are episodes of heavy drinking of five drinks or more for

males or four drinks or more for females is a problem for people

of any age, whether or not the drinker is addicted to alcohol.

But an alarming number of children and adolescents binge drink,

and it is becoming increasingly evident. As Senator DeWine highlighted earlier, 11 percent of 6th graders and a third of high school

seniors and half of all college students binge drink just within the

past 2 weeks. Drinking too much too fast in this manner carries

substantial risks for youth, additional risks for youth beyond those

carried with this behavior among adults. They include car crashes,

injury, death, property damage, encounters with the justice system,

family, school and workplace problems.

Each drink increases the fatal crash risk for youth moreso than

adults. At a blood alcohol level of 0.08 percent at every age and

gender group, there is at least an elevenfold increase in single vehicle fatal crash risk. But among males ages 16 to 20 at that same

level of 0.08 percent, there is a 52-fold increase in single vehicle

crash risk compared to sober drivers in that same age range.

In a series of recent studies, we have begun to understand how

the exposure to alcohol and other drugs of abuse during adolescence produce substantially more adverse effects than exposure

during adulthood, in part because of very important changes that

are occurring in the brain during adolescence. Advances in science

have now brought us to the point where we can use new animal

models, modern brain imaging technology that was previously not

available and other neurobehavioral assessment tools to probe the

effects of alcohol, tobacco and other drugs on the developing brain

and determine immediate as well as long-term behavioral consequences.

Emerging findings from our neuroimaging studies demonstrate

that brain structures change substantially during adolescence, and

in particular, brains become more specialized and efficient. Our developmentally-focused research indicates that there are distinct

neurocognitive disadvantages among adolescents with alcohol and

drug use disorders compared to teens without substance involvement.

So, for example, alcohol-dependent adolescents who have 3 weeks

of abstinence still show a 10 percent decrement in their memory

skills relative to teens who do not have a history of alcohol abuse.

Neuropsychological testing following these youth throughout adolescence and into young adulthood show decreased attentional

abilities, additional memory problems, visual-spatial skills, all of

which add to the evidence of substantial brain damage to adolescents as a function of alcohol and drug involvement.

Our new directions in adolescent research can help inform us on

important aspects of cognition and decision making, emotional regulation and risk perception by adolescents that can help us determine how these factors play a role in the use and consequences of

alcohol and drugs, and armed with this knowledge about how teens

make decisions and control their impulses and desires and what

motivates their behaviors, we will be poised to improve on the cur-
19

rent prevention programs and intervention programs that are in

place.

I thank you.

[The prepared statement of Ms. Brown follows:]

PREPARED STATEMENT OF SANDRA A. BROWN

INTRODUCTION

Recent research supported by the National Institutes of Health and other agencies

is leading to a common understanding about the critical role of age of onset of addictive disorders in their course, consequences and progression. Researchers are

finding that these disorders often begin during adolescence and sometimes even during childhood; therefore early intervention may prevent many of the social, behavioral, health, and economic consequences caused by alcohol and drug abuse as well

as provide an opportunity to treat problems before they become full blown and damage in the lives of our youth.

EARLY ONSET

NIAAA and NIDA-supported researchers are finding that alcohol and other drug

addictions commonly start earlier than previously understood, and the earlier youth

start the greater the lifetime risk for dependence. New findings regarding early patterns of abuse and dependence dramatically underscore the importance of reducing

underage drinking and drug use. As shown in Figures 1 and 2, the age of most prevalent tobacco dependence onset is 15 and for alcohol dependence age 18 is the most

common period of first diagnosis of dependence. It is now clear that most cases of

alcohol dependence begin before age 25. After that age, new cases drop off precipitously. The epidemiological research message is obvious: youth is a critical window

of opportunity for preventing alcohol, tobacco and other drug disorders. Previous

studies have suggested that this is so, but the new research findings, corroborated

by independent sources, have confirmed these findings.

Ongoing research may reveal a cause-and-effect relationship between early use

and subsequent dependence, or it may reveal that common biological and environmental factors drive the risk for both use and dependence, as well as other addictive

and psychiatric disorders. In either case, these new data are a powerful indicator

of the need for more effective preventive interventions for youth.

Given the new epidemiologic findings, the fact that alcohol use is so widespread

among children and adolescents is troubling. Alcohol is the primary substance of

abuse among American children and adolescents.

• 47 percent of 8th graders, 67 percent of 10th graders, and 78 percent of 12th

graders have used alcohol.

• 11 percent of 6th graders have reported binge drinking (five or more drinks per

occasion for males; four for females) in the past 2 weeks.

• 30 percent of high-school seniors have reported binge drinking at least once a

month.

• 44 percent of college students have reported binge drinking in the past 2 weeks.

• 23 percent have reported that they binge drink frequently.

• Youth who drink alcohol before age 14 are four times more likely to become alcohol dependent in their lifetime than those who wait until age 21 or older.
20

NEURODEVELOPMENTAL STUDIES

A series of recent studies indicate that exposure to drugs of abuse during adolescence may produce more adverse effects than exposure during adulthood in part because of the important changes occurring in the brain during adolescent development.

Advances in science have now brought us to a point where researchers can use

new animal models, modern brain imaging technology and other neurobehavioral assessment tools to probe the effects of alcohol, tobacco and other drugs on the developing brain and determine immediate as well as its long-term behavioral consequences.

For example, as shown in Figure 3, emerging findings from neuroimaging studies

demonstrate that brain structures change during adolescence to become more specialized and efficient in their functioning. Our developmentally focused research indicates important neurocognitive disadvantages among adolescents with alcohol and

drug use disorders as compared to teens without substance involvement. For example, even after 3 weeks of abstinence, alcohol dependent youth display a 10 percent

decrement in delayed memory functions (Figure 4). Neuropsychological testing of

these youth followed up to 8 years demonstrates that continued heavy drinking during adolescence is associated with diminished memory of verbal and nonverbal material, and poorer performance on tests requiring attention skills. Alcohol and drug

withdrawal over the teen years appears to uniquely contribute to deterioration in

functioning in visuospatial tasks. Recent brain imaging studies of alcohol and drug

using youth compared to youth without such experience have also shown reduced

hippocarmpal volumes, white matter microstructure irregularities, and brain response abnormalities while performing cognitive tasks among those with early alcohol/drug exposure. Additionally, youth who have extensive experience with alcohol

have increased brain response when viewing alcohol advertisements compared to

other beverage advertisements.

Animal studies are consistent with the findings that alcohol or drug exposure during adolescence has more adverse consequences than delayed (adult) exposure. In

these investigations, adolescent alcohol exposure is associated with more frontal lobe

damage and poorer spatial memory. Further research is needed to understand how

age of drinking or drug use onset and duration of abstinence at the time of assessment affect cognitive and behavioral findings. Longitudinal studies are needed to

clarify neuromaturational changes associated with early alcohol and drug exposure

and patterns of resiliency. Although the magnitude of effects observed in adolescents’ neurocognition is modest, the implications are major given the prevalence of

alcohol involvement, and the important educational, occupational, and social transitions that occur during adolescence.

These new directions in adolescent research will help to inform us on important

aspects of cognition, decision-making, motivation, emotional regulation, and risk

perception during adolescence, and will help us determine how these factors play

a role in the use and consequences of alcohol and drugs. Armed with new knowledge

about how adolescents make decisions, control their impulses and desires, and what

motivates their behavior, researchers and agencies will be poised to design better

preventions and interventions to reduce alcohol, tobacco and other drug experimentation, abuse and dependence, as well as other risky behaviors. Adolescents have

in common unique neurobiological and neurocognitive developmental factors that affect risk and resiliency vis-a ́-vis substance use. Few studies have addressed these

developmentally specific neurobiological and neurocognitive mechanisms and consequences of heavy drinking/use in this group despite the importance of these for

long-term development.
21

VULNERABILITY

While early initiation of substance involvement is a powerful predictor of subsequent dependence, not everyone who uses at a young age later develops abuse or

dependence. Even among youth with two alcoholic parents, only about one-half become alcohol dependent. The outcome is determined largely by the interplay of environmental and genetic/biological factors.

Environmental factors have the biggest influence on whether a child first uses alcohol, tobacco or other substances. However, genetic factors have an influence on

whether a child continues to use. Understanding how these factors result in initiation and continuation of use or make resolution of drinking/drug use more difficult

is essential to disrupting the developmental process of addictive behavior. Thus, a

focus on genetic/biological aspect of use may clarify how variations in genes result

in differences in how our bodies absorb, distribute, and eliminate substances and

variability in tolerance.

BINGE DRINKING

Binge drinking, episodes of heavy drinking (five or more drinks for males; four

or more drinks for females), is a problem for people in any age group, whether or

not the drinker is addicted to alcohol. An alarming number of children and adolescents binge drink and that it is increasing. Drinking too much, too fast in this manner carries additional risks especially for youth. They include car crashes, injury,

death, property damage, encounters with the justice system, and family, school, and

workplace problems. Each drink increases the fatal crash risk more for youth than

adults. At a blood alcohol level of 0.08 percent in every age and gender group there

is at least a 11-fold increase in single vehicle fatal crash risk. Among males 16–20

at a blood alcohol level of 0.08 percent there is a 52-fold increase in single vehicle

crash risk compared to sober drivers the same age.

Epidemiology studies have shown beyond doubt that genes play a role in risk of

alcohol, tobacco and other drug dependence. Research toward discovering which

genes are involved, what biochemical pathways they influence in brain cells, and

how these pathways translate into specific behaviors is the next step to this line

of investigation. Such findings provide information about genetic/molecular events

in the brain that influence use, and provide potential targets for pharmacological

intervention. For example, new findings about a naturally occurring marijuana-like

substance in the brain also provide potential new molecular targets for pharmacological intervention.

PREVENTION OF ABUSE AND DEPENDENCE

Prevention of alcohol and substance use problems among youth need to be understood as a continuum of services and consequently research needs to span this continuum. This continuum ranges from universal prevention (those appropriate for all

children and adolescents who might use alcohol, tobacco or other drugs) to selective

preventative measures for subgroups with risk factors for abuse or dependence, to

indicated preventative measures for those individually at high risk for the disorder.

Preventive interventions for alcohol, tobacco, and other drug use disorders and related problems can be improved through early detection and diagnosis, and through

testing of new behavioral strategies at the individual, family, and community levels.

Of particular interest are longitudinal data on children entering the age of risk, adolescents and young adults in high-risk environments (college and the military),

youth who resolve use/problems without formal treatment, and women of childbearing age. New interventions to prevent early-onset of use can be gleaned through

studies that identify developmental and environmental features as well as biological

factors that stimulate or suppress addictive behavior.

It is important to evaluate prevention programs on an ongoing basis as well as

disseminate research findings to communities, educators, parents, and health care

providers who are the first line of defense against alcohol, drugs and other risky

behaviors. Both NIAAA and NIDA offer free educational materials designed to help

students learn about the impact of alcohol and drugs on the brain and body. Parents, educators, and community leaders can use these materials to help guide their

thinking, planning, selection, and delivery of drug abuse prevention programs at the

community level. NIAAA and NIDA also have websites that offer science-based information specifically designed for teens. The Leadership to Keep Children AlcoholFree has recruited 33 Governors’ spouses to spearhead a national prevention campaign which influences both public policy and local practices. The Task Force on College Drinking has brought together university presidents and researchers, and is
22

making headway in efforts to reduce the seemingly intractable problem of drinking

by college students.

Clearly, alcohol and substance use disorders are the result of a complex combination of genetic and environmental interactions that influence how people respond to

the substance and their initial propensity for using alcohol and drugs. Longitudinal

studies of these genetic and environmental factors are crucial for understanding (1)

early initiation of drinking and drug use, (2) transition to harmful use, abuse, and

dependence, and (3) remission and abatement of alcohol and drug related problems

in untreated populations. This is particularly critical for youth as some resolve problematic use without treatment and research in this area can teach us how to facilitate changes in alcohol and drug involvement in ways that are most developmentally appropriate and acceptable to youth. Developmentally specific research in

these areas has potential to help identify mechanisms of vulnerability and protection which can be used in prevention.

IMPROVING EFFECTIVENESS OF TREATMENT

Findings from the National Household Survey on Drug Abuse indicate that about

10 percent of 12- to 17-year-olds (about 2.3 million) are heavy users of alcohol or

drugs, yet only 187,000 (8 percent) received services. Although estimates of the costeffectiveness of early intervention are speculative, research suggests that early

treatment has the potential to be cost-effective, especially in comparison with incarceration or treatment for a long-term abuse problem. For instance, cost benefit research on drug and alcohol treatment generally (Office of National Drug Control

Policy, 2001) suggest that the range of savings is between $2.50 and $9.60 for every

dollar spent on treatment. Unfortunately, only one person in seven who would qualify for treatment was admitted to treatment in 1999 (National Institute on Drug

Abuse Community Epidemiology Work Group, 1999). The proportion of youth who

are admitted to treatment is even smaller.

Much progress has been made in developing behavioral/psychosocial interventions

for alcohol and other substance use disorders, but much remains to be investigated.

Controlled research trials provide evidence that several psychosocial treatment approaches may be effective in reducing alcohol and other drug use while also improving associated behavioral, familial, and psychosocial outcomes. These outcomes are

enhanced when a combination of modalities are offered in a comprehensive, integrated treatment plan that addresses alcohol and drug abuse and a broad range of

biopsychosocial problems, skills deficits, and comorbid psychiatric problems. For example, having families involved in the treatment program increases the likelihood

of success in youth. Brief Strategic Family Therapy (BSFT) and Cognitive Behavioral Interventions are examples of promising youth specific treatment already in

the field. The evaluation and dissemination of more evidence-based interventions in

a variety of community venues, including schools, healthcare settings, and prisons,

should be a high priority. Developing, evaluating, and improving efficacy and costeffectiveness of treatments is a central goal in alcohol, tobacco and drug research.

Adolescent focused treatment research lags behind adult treatment research. Studies are needed to develop and test new behavioral therapies; conduct clinical trials

in existing treatment settings, examine cost-effectiveness of behavioral and pharmaceutical therapies; clarify mechanisms of action that make effective treatments successful; and conduct trials of dissemination strategies, to test how effective they are

at introducing behavioral and pharmacological treatments into real-world clinical

practice.

Alcohol, tobacco and other drugs affect genders and subpopulations differently,

and some groups suffer more adverse effects of alcohol, tobacco and drugs than

other groups. For treatment of these youth problems to be optimally effective, research to study the role of gender, ethnicity, socioeconomic status, and other variables in determining the effects of various substance abuse interventions is sorely

needed. For example, we need to support studies on specific facilitators and barriers

to alcohol and drug treatment in minority and rural populations.

Clearly multifaceted longitudinal research is sorely needed to fully understand the

development and resolution of alcohol and drug use disorders in the context of child

and adolescent development. Through such focused process research (e.g., changes

in brain structure and recovery of functioning, decision making process, social and

family dynamics) can improved prevention and intervention policies emerge.

ATTACHED REFERENCES

Brown, S.A. & Tapert, S.F. (In Press). Adolescence and the trajectory of alcohol

use: Basic to clinical studies. In Dahl, R.E. and Spear, L.P. (Eds.), Adolescent Brain
23

Development: Vulnerabilities and Opportunities, Volume 1021 of the Annals of the

New York Academy of Sciences.

Brown, S.A., Tapert, S.F., Granholm, E., & Delis, D.C. (2000). Neurocognitive

functioning of adolescents: Effects of protracted alcohol use. Alcoholism: Clinical and

Experimental Research, 24 (2): 164-171.

Tapert, S.F., Cheung, E.H., Brown, G.G., Frank, L.R., Paulus, M.P.,

Schweinsburg, A.D., Meloy, M.J., & Brown, S.A. (2003). Neural response to alcohol

stimuli in alcohol use disordered adolescents. Archives of General Psychology, 60:

727-735.

ADOLESCENCE AND THE TRAJECTORY OF ALCOHOL USE: BASIC TO CLINICAL STUDIES

SANDRA A. BROWN AND SUSAN F. TAPERT

ABSTRACT

Emerging findings from developmentally focused research indicates subtle but important neurocognitive disadvantages among adolescents with alcohol use disorders

(AUD) as compared to teens without AUD. Even after 3 weeks of abstinence AUD

youth display a 10 percent decrement in delayed memory functions. Neuropsychological testing of youth followed at 4 and 8 years demonstrates that heavy drinking

during adolescence is associated with diminished retrieval of verbal and nonverbal

material, and poorer performance on tests requiring attention skills. Alcohol withdrawal over the teen years appears to uniquely contribute to deterioration in functioning in visuospatial tasks. Brain imaging studies suggest reduced hippocampal

volumes, white matter microstructure irregularities, brain response abnormalities

while performing challenging cognitive tasks, and enhanced brain response when

viewing alcohol cues (i.e., alcohol advertisements) among adolescents with AUD.

Family characteristics such as history of alcoholism and socioeconomic status as

well as personal features, including adolescent psychopathology, gender, and age of

onset, must be carefully considered when investigating the influence of teenage

drinking on neurocognition. Further research is needed to understand how age of

drinking onset and duration of abstinence at the time of assessment affect cognitive

findings. Longitudinal studies are needed to clarify neuromaturational changes associated with early alcohol exposure and patterns of resiliency. Although the magnitude of alcohol-related effects observed in adolescents’ neurocognition is relatively

modest, the implications are major given the prevalence of alcohol involvement, and

the important educational, occupational, and social transitions that occur during

adolescence. KEYWORDS: adolescence; alcohol; neurocogntition; fMRI; development.

The present chapter highlights the relation of alcohol involvement among youth

and neurocognitive functioning over the course of adolescent development. Following

a brief review of adolescent alcohol use patterns and related problems, the chapter

focuses on neurocognitive and neuroimaging studies from our research program.

Emerging evidence demonstrates the cognitive and behavioral impact of early alcohol involvement and potential deleterious effects on brain functioning.

BACKGROUND

Adolescence is the most common time for initiation of alcohol use. By the time

high school students graduate, over 80 percent will have begun drinking alcohol.

Heavy drinking (five or more drinks per occasion) is also prevalent, with 18 percent

of 10th graders and 30 percent of 12th graders reporting that they got drunk in the

past month.1 Approximately 6 percent of high school students consume quantities

of alcohol and drink in problematic patterns such that they meet diagnostic criteria

for alcohol abuse or dependence.2 Alcohol is a contributor to the top causes of death

for youth: accidents, suicides, and homicides.3 For example, the leading cause of

death for youth age 16 to 20 is unintentional injury, primarily related to motor vehicle accidents, of which one in three involve alcohol.4

The earlier alcohol use is initiated, the greater the risk for a variety of adverse

consequences. Youth that begin drinking alcohol before age 14, have a 41 percent

chance of developing alcohol dependence during their lifetime compared to individuals who wait to the legal drinking age of 21 when lifetime risk is reduced to 10

percent.5 Early use of alcohol elevates risk for a multitude of mental health and social problems.6 Rates of conduct disorder, antisocial personality disorder, nicotine

dependence, and illicit drug abuse and dependence are significantly higher among

youth that drink early.7 Cross-culturally, studies also indicate that heavy adolescent

alcohol use is associated with psychological distress, anxiety, and depression.7 Youth

with early problems such as school difficulties, personal difficulties (e.g., hyperactivity, impulsivity, and inattentiveness), or family problems are more likely of begin
24

drinking early. Although alcohol use is prevalent among adolescents, those most disadvantaged, such as the homeless, abused, or neglected, evidence high rates of alcohol use disorders (AUD), as well as behavioral and psychological symptoms.6

Youths with certain mental health disorders evident in early adolescence are more

likely to initiate alcohol use and accelerate their use throughout adolescence. Disruptive disorders, including conduct problems and aggressive or oppositional behaviors, have been most consistently associated with the early onset of alcohol use and

abuse.7 8 In girls, early anxiety disorders may also accelerate alcohol involvement,7

and girls appear more vulnerable to the adverse consequences under conditions of

low parental monitoring.

HOW ALCOHOL AFFECTS ADOLESCENT BRAIN DEVELOPMENT

Despite the prevalence of alcohol use and related disorders in adolescence, we are

just beginning to understand how protracted alcohol consumption during this period

affects brain development and cognition. Central nervous system abnormalities including neurocognitive deficits, atrophy of several brain structures, abnormal

electrophysiology, altered blood flow, abnormal brain function, and disruptive sleep

have clearly been observed in adults with chronic heavy drinking histories (e.g.,

Refs. 9-11). Although it is less clear how adolescent brains are affected, mounting

evidence from animal and human studies suggest a potentially greater impact of alcohol prior to full brain maturation. Understanding the neuromaturational implications of adolescent alcohol use is critical, since maladaptive patterns of alcohol use

during adolescent development appears to limit educational, occupational, and social

opportunities.

ADOLESCENT BRAIN DEVELOPMENT

To understand alcohol effects on adolescent brain development, it is helpful to

briefly review the maturational processes unfolding during these years. As summarized in FIGURE 1, substantial neuromaturation continues throughout adolescence.

Structural magnetic resonance imaging (MR1) studies have described disproportionate growth in the hippocampal region, and decreases in gray matter volume and

density during adolescence, particularly in frontal and parietal brain regions, which

underlies maturation of cognitive processing.12 13 14 Neuronal myelination continues

throughout adolescence and young adulthood 15 16 and is thought to be related to increases in cognitive efficiency. Stages of increased cerebral blood flow support periods of rapid brain growth.17 Synaptic pruning occurs through midadolescence, varies

in relation to environmental stimulation, and results in greater efficiency, as evidenced by decreased energy requirements and diminished glucose metabolism.18 19

Changes in functional regional activity become increasingly evident and are indicative of regional specialization and maturation.20

ANIMAL STUDIES

While human research on alcohol’s impact on the brain has mushroomed over the

past decade with the advent of more sensitive neuroimaging technology, animal

studies have previously demonstrated that alcohol affects adolescent brain development processes in several ways.21 In general, animal studies consistently show that

adolescents appear to be more sensitive than adults to the learning and memory im-
25

pairments produced by alcohol exposure, but less sensitive to the sedation and temperature regulation effects of this drug. For example, in a recent study investigators

gave adolescent and adult rats multiple exposures of large quantities of alcohol,

mimicking the binge drinking pattern characteristic of one-third of U.S. teens. Once

rats reached adulthood, those who had been given alcohol during adolescence

showed more impairments on a spatial learning memory task than those who had

been given alcohol only as adults.22 Furthermore, studies of adolescent and adult

rats reveal that chronic alcohol use during adolescence alters sensitivity to alcoholinduced motor dyscoordination.21 Another study examined the behavioral and

neuroanatomical effects of a 4-day alcohol binge on adolescent and adult rats. While

significant brain damage was found in both groups during the autopsy, several frontal brain regions were damaged only in the adolescent exposed rats, suggesting that

different brain regions vary in vulnerability to alcohol effects across development.23

NEUROPSYCHOLOGICAL STUDIES

Through a series of studies we have longitudinally examined youths with and

without alcohol abuse and dependence and monitored their alcohol and drug involvement into adulthood to investigate neurocognitive functioning over time.

Neuropsychological studies of adults with AUD have consistently revealed

visuospatial, executive functioning, psychomotor, and memory impairments secondary to heavy alcohol exposure.6 24 However, until recently it was unclear whether

the neurocognition of teenagers might be affected by protracted alcohol consumption. The limited number of studies that have examined neurocognition in adolescents with AUD have generally demonstrated modest functional decrements. For example, an early neuropsychological study by other investigators recruited teens with

AUD from treatment centers, and demonstrated subtle deficits in verbal skills

among youths with AUD compared to nonabusing controls, as well as problem-solving errors among girls with AUD relative to control girls.25 Tarter and colleagues 26

examined cognition among 106 female youths with AUD, most of whom met criteria

for other substance use disorders as well. Compared to 74 control girls, those with

AUD performed poorly in several domains, including language, attention, perceptual

efficiency, general intelligence, and academic achievement.

In a series of studies, our group has assessed AUD youths recruited from alcoholand drug-treatment facilities and nonabusing control teens from the same communities who were matched for gender, age, socioeconomic status, and family history

of alcohol and substance use disorders. In one study of 15–16 year olds with at least

100 episodes of heavy alcohol use (M=753), youths with an AUD and 3 weeks of abstinence used fewer learning strategies to acquire new information and showed a

10 percent deficit in the ability to retrieve verbal and nonverbal information compared to control teens.24 While both abusing and nonabusing youths were able to

learn verbal and nonverbal (visual-spatial) information, as shown in TABLE 1, delayed recall was reduced approximately 10 percent across tasks (e.g., Wechsler

Memory Scale-Visual Reproduction, California Verbal Learning Test) for those with

a history of AUD.

We followed samples of abusing and nonabusing youths longitudinally, and readministered a neurocognitive testing battery at 4 and 8 years subsequent to initial

testing.27 28 Among those who continued substance involvement after treatment, alcohol withdrawal symptoms experienced at any point during the follow-up period

predicted poorer with visuospatial functioning at 4 years after treatment discharge,

and those with recent use and a past history of withdrawal evidenced the poorest

neurocognitive outcomes.27 Further, at 8 years post initial assessment (average

age=24 years) greater cumulative lifetime alcohol experiences predicted poorer attention functioning as well as poorer working memory scores at the 8-year followup.28 A history of alcohol withdrawal symptoms predicted reductions in visual-spatial functioning as measured by the Wechsler Memory Scale-Visual Reproduction as

well as Rey-Osterrieth figure, These predictions remained significant even after excluding youths who had drank heavily (≥4 drinks/occasion for females, ≥5 drinks for

males) and used other substances in the 28 days prior to testing. Together, these

studies indicate that heavy alcohol involvement during adolescence is associated

with cognitive deficits that worsen as drinking continues into late adolescence and

young adulthood. Specifically, adolescents who by age 15–16 years of age have over

100 heavy drinking episodes and meet criteria for an AUD, use fewer strategies to

learn new information and demonstrate significantly reduced memory skills. For

those who continue alcohol involvement during the next 4 years and experience any

withdrawal symptoms, deterioration in attention and visual-spatial functioning continues. By young adulthood these skills continue to deteriorate relative to the

youth’s own baseline and those not abusing. These findings suggest that use and
26

withdrawal differentially affect neurocognitive functioning across this stage of development.

As part of our longitudinal program of research we have examined the complex

relationship between neurocognitive skills and onset and persistence of AUDs.

Neurocognitive functioning appears to moderate outcome through its relation with

coping skills and alcohol reinforcement expectancies. Adolescent coping skills significantly predict less alcohol and other drug use after treatment for those with lower

levels of cognitive functioning, while coping skills do not predict outcomes for youths

with higher levels of cognitive functioning.23 In contrast, for youths with above average language skills, having more favorable alcohol expectancies predicted more alcohol and drug use and dependence symptoms after treatment, while expectancies

played a smaller role for young people with lower levels of language ability.24 These

longitudinal investigations highlight changing neurocognitive functioning in relation

to clinical course as well as the adverse cumulative effect of prolonged alcohol use

during the course of adolescent development. Finally, neurocognition plays an active

role in promoting or retarding alcohol involvement, depending on personal and environmental characteristics.

BRAIN-IMAGING STUDIES

The recent advent of noninvasive neuroimaging techniques has provided unique

opportunities to examine the influence of alcohol involvement on brain structure and

function in adolescents. De Bellis and colleagues used MRI to quantify volumes of

several brain structures among youths ages 13 to 21 years.29 Those with adolescentonset AUD had reduced hippocampal volumes, but similar cortical gray and white

matter, amygdala, and corpus callosum sizes compared to controls. We have used

diffusion tensor imaging to investigate corpus callosum microstructure integrity

among teenagers with AUD and nonabusing controls.30 All participants were free

from psychiatric disorders, and had limited experience with other drugs. Preliminary results indicated that AUD youths exhibit subtle white matter abnormalities,

particularly in the splenium of the corpus callosum. Thus, although adolescents with

AUD show normal corpus callosum volumes, subtle abnormalities in white matter

micro-structure may represent the beginnings of a more profound disruption than

is observed in chronic heavy drinking adults.

Functional brain changes have also been demonstrated among youths with AUD.

Young women, ages 18–25, who started drinking heavily during adolescence and

had a lifetime history of an AUD showed significantly diminished frontal and parietal functional MRI (fMRI) response as well as less accurate performance during a

spatial working memory task relative to demographically similar young women with

comparable family histories of alcoholism.31 We used the same paradigm to examine

brain activation among adolescents, ages 14–17, with little alcohol experience and

age and gender-matched teens with AUD but without histories of other psychiatric

disorders or heavy drug use. In contrast to our findings with young adult women,

AUD boys and girls showed increased parietal response during spatial working
27

memory compared to control teens, despite similar task performance.30 These findings, if replicated, suggest that in the early stages of AUD, youth may be capable

of compensating for subtle alcohol-induced neuronal disturbances by recruiting additional resources and more intense and widespread neuronal activation. However, the

neurocognitive and fMRI findings among young adult women suggest that, as heavy

drinking continues, neural injury may increase,32 the brain may be less able to

counteract alcohol-related disruption, and behaviors may begin to show signs of impairment.

Functional neuroimaging has also been used to evaluate response to alcohol cues

among adults with AUD and adolescents.33 In our study of 14–17 year olds, teens

were shown pictures of alcoholic beverage advertisements and visually similar nonalcoholic beverage ads during fMRI. The images presented were individualized

based on personal drinking experiences and preference in order to ensure familiarity

with cues. Compared to youth with limited alcohol experience, teens with AUD demonstrated increased brain response to alcohol pictures in left anterior, limbic, and

visual regions commonly associated with emotion, visual processing, and reward circuitry. Although family history of AUD was a significant predictor of responsivity,

personal alcohol use was a stronger predictor of brain response to visual alcohol

cues.

Moreover, AUD teens reporting greater monthly alcohol consumption and more intense desires to drink showed the greatest extent of’ neural response to the alcohol

advertisements. Given the strong neural response to alcohol beverage advertisements among teens with AUD, it is possible that these media images may influence

continued drinking among teens with alcohol problems, and may interfere with effective coping strategies in youths attempting to stop using.

DEVELOPMENTAL CONSIDERATIONS

Several factors are critical in the consideration of alcohol’s influence on the

neurocognitive and neuroanatomical functioning of youth. First, while adverse behavioral and social trajectories are evident with the onset AUDs during adolescence,

it remains unclear whether the adolescent brain is ultimately more vulnerable to

this toxin or will be more resilient and capable of recovery than adults (e.g., Refs.

6 and 24). Evidence with animals suggests greater vulnerability to adverse learning

consequences and our human studies suggest cumulative neurocognitive impairment

over the course of middle to late adolescence. However, neuroimaging findings are
28

consistent with early compensation, and only prospective longitudinal studies can

resolve this apparent discrepancy.

Gender differences have been evident in studies of AUDed adults, with females

more susceptible to alcohol-related brain injury than males.34 Hormonal fluctuations, differences in alcohol metabolism, and gender-specific drinking patterns, may

partially account for the mounting evidence that adolescent girls suffer greater alcohol-related neurocognitive deficits than adolescent boys. Girls with AUDs show more

perseveration errors than nonabusing girls, while boys with AUDs show fewer perseverative errors than control boys, suggesting that this component of frontal lobe

functioning may be more adversely affected by heavy alcohol use in girls.25 In our

longitudinal research of 70 adolescents followed over 8 years, young women demonstrated more adverse cognitive effects related to alcohol and other drug use, especially in working memory and visuospatial functioning, whereas young men showed

a greater relationship between verbal learning and substance involvement. Further,

while alcohol withdrawal and hangovers were associated with poorer performance

in both males and females, this effect was stronger in females.28 Additionally, our

recent fMRI spatial working memory investigations have shown greater magnitude

of response change in girls than boys. Gender differences in fMRI response may reflect gender-specific disruptions in brain development related in part to hormonal

changes or dysregulation in puberty,35 which may ultimately influence subsequent

neural development and functioning.

Studies of alcohol-related neurocognitive and neural sequelae, need to consider

other sources of abnormalities that may predate the onset of heavy drinking among

youth. Two such factors are familial alcoholism and personal comorbid psychopathology, both of which are risk factors for developing an AUD and have been associated with unique neurocognitive features. Youths with multigenerational and

dense family histories of alcoholism have shown modest neuropsychological differences compared to youths without such family histories independent of personal

substance intake and maternal drinking during pregnancy.36 Adolescent males who

do not personally abuse alcohol or other drugs, but have family histories of alcohol

dependence commonly perform worse on tests of language functioning and academic

achievement, organization of new information, executive cognitive functioning,

perseveration, working memory, nonverbal memory, visuospatial skills, and attention (e.g., Ref. 37). In our studies, family history of alcohol dependence and adolescent alcohol/substance use operate as separate risk factors for poorer neuropsychological performance in youth.36

Disruptive disorders (e.g., conduct disorder, attention deficit hyperactivity disorder) and certain internalizing disorders are also associated with specific

neurocognitive disadvantages that elevate risk for adolescent AUDs. Conduct disorder and related behavior disorders, characterized by disinhibition (e.g., ADHD)

have been associated with poorer performance on academic achievement and IQ

tests, and are more likely to show deficits on measures of executive functioning, including sequencing, cognitive flexibility, selective attention, and initiating planned

strategies, including nonverbal tests.38 Internalizing disorders, some of which parallel adolescent AUD results, have also been associated with alterations in cognitive

performance and brain functioning in adolescents, Youths with familial alcoholism

often show a low amplitude P3 component of the event-related potential, which has

a slow rate of change during adolescence. However, in girls, this neurophysiological

developmental pattern is also associated with childhood internalizing and

externalizing psychopathology as well as psychiatric diagnoses in young adulthood.39

YOUTH RECOVERY OF NEUROCOGNITIVE ABILITIES

It remains uncertain to what extent the observed abnormalities in cognition of

heavy drinking youth repair with sustained abstinence, and, if such abnormalities

are repaired, how much sobriety is required until performance and brain integrity

measures resume predrinking levels. Adults with histories of chronic heavy drinking

have been shown to improve even after extended (i.e., multiple years) abstinence on

neuropsychological testing, magnetic resonance spectroscopy, and brain volume indices (e.g., Refs. 43 and 44). In our studies, measurable memory deficits (10 percent)

are evident after 3 weeks of abstinence, and neurocognitive functioning after 4 years

of abstention appears comparable to baseline (e.g., Refs. 24 and 27). It remains to

be seen if recoverability of brain integrity and cognitive function might be more

complete in youth, whose brains are more plastic, or if recovery is less likely because neurotoxic insult may have adversely affected the course of neuromaturation.
29

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NEUROCOGNITIVE FUNCTIONING OF ADOLESCENTS: EFFECTS OF PROTRACTED

ALCOHOL USE

SANDRA A. BROWN, SUSAN F. TAPERT, ERIC GRANHOLM, AND DEAN C. DELIS

Background: The present study examined associations between alcohol involvement in early to middle adolescence and neuropsychological (NP) functioning.

Methods: Alcohol-dependent adolescence (n=33) with over 100 lifetime alcohol

episodes and without dependence on other substances were recruited from alcohol/

drug abuse treatment facilities. Comparison (n=24) adolescents had no histories of

alcohol or drug problems and were matched to alcohol-dependent participants on

age (15 to 16 years), gender, socioeconomic status, education, and family history of

alcohol dependence. NP tests and psychosocial measures were administered to alcohol-dependent participants following 3 weeks of detoxification.

Results: Alcohol-dependent and comparison adolescents demonstrated significant

differences on several NP scores. Protracted alcohol use was associated with poorer

performance on verbal and nonverbal retention in the context of intact learning and

recognition discriminability. Recent alcohol withdrawal among adolescents was associated with poor visuospatial functioning, whereas lifetime alcohol withdrawal was

associated with poorer retrieval of verbal and nonverbal information.

Conclusions: Deficits in retrieval of verbal and nonverbal information and in

visuospatial functioning were evident in youths with histories of heavy drinking

during early and middle adolescence.

Key Words: Adolescence, Alcohol Dependence, Withdrawal, Neuropsychology,

Memory.
31

DOMAINS OF NEUROPSYCHOLOGICAL (NP) functioning most commonly studied in conjunction with alcohol dependence do not isomorphically map with

neuroanatomical effects, but reflect prevalent behavioral indices of neurocognitive

integrity. Language functioning has emerged as a risk factor in children of alcoholics (Najam et al., 1997), although it is not generally affected by personal heavy

drinking. Visuospatial, executive, psychomotor, and memory functioning yield the

most robust performance decrements associated with substance use disorders in

adults (Grant, 1987).

Impaired NP performance may be associated with changes in superior frontal and

parietal cortices, mesial temporal lobe structures, and subcortical regions (e.g., diencephalon and caudate nucleus). Although some NP studies have suggested that

the right hemisphere is selectively vulnerable to ethanol effects, most studies report

no lateralization (Kwon et al., 1997; Nicolas et al., 1993). Executive functioning

seems to have the slowest neurocognitive recovery from central nervous system

(CNS) exposure to ethanol due to increased likelihood of neural death in the frontal

lobe relative to other brain regions (Fein et al., 1994). However, only 30–60 percent

of adults with alcohol dependence evidence significant deficits on NP tests (Grant

et al., 1984). In addition, drinking variables rarely account for significant variance

in NP functioning when demographic factors are appropriately controlled. This has

lead some researchers to explore specific mechanisms linking alcohol use to NP

decrements.

Sullivan and colleagues (1996) found that adult patients with histories of alcoholwithdrawal related seizures evidenced greater white matter volume loss in temporal

regions, relative to both normal controls and alcohol-dependent adults without seizure histories. Repeated withdrawal experiences may increase the risk of alcoholrelated seizures, which may in turn compound cerebral abnormalities. Animal models of alcohol dependence (e.g., Eckardt et al., 1992) have reported that cerebral glucose utilization is increased in gray and white matter regions among alcohol-dependent rats during withdrawal, suggesting that certain brain regions have abnormal

physiologic responding during withdrawal.

This abnormal physiology could lead to longer term or permanent cellular alterations, influencing subsequent neurocognitive performance. Alcohol withdrawal has

also been shown to induce depressed mood symptoms in adults (Brown and

Schuckit, 1988).

Recent studies have begun to evaluate neurocognitive functioning patterns in alcohol-dependent adolescents (Giancola et al., 1998; Moss et al., 1994; Tapert and

Brown, 1999; Tarter et al., 1995). Problems that have been detected pose a threat

to healthy development, as significant neuromaturation continues during adolescence. For example, synaptic connections disappear as a function of redundancy and

environmental stimulation up until about age 16 (Huttenlocher, 1990). Continued

myelination in frontal and parietal association areas (Kolb and Pantic, 1989) suggests that speed of information transfer in these regions is less efficient before age

15. Cerebral metabolic rates increase greatly during childhood and taper toward

adult levels by approximately age 20 (Harris, 1995).

CNS exposure to neurotoxins such as ethanol during adolescent development has

undetermined consequences. Thus, adolescence is a period of potential differential

impact of ethanol exposure compared with adulthood, when such neuroanatomical

changes have stabilized. At present, the. NP impact of alcohol dependence during

early and middle adolescence, and the pattern of NP impairment in contrast with

alcohol-dependent adults, is relatively unknown. Several processes may influence

the adolescent risk of neurocognitive damage. First, adolescent brains may have

more resilience: maturation is not fully complete, allowing more opportunity for

compensatory development. Second, neurological development and/or cognitive maturation may be disrupted, altered, or impeded by exposure to neurotoxins during

this time in development. Neurotoxins may also accelerate other risks, such as head

trauma and academic drop-out.

This study examined associations between protracted alcohol involvement during

early to middle adolescence and the neurocognitive functioning in middle adolescence. Youths with repeated alcohol exposure were predicted to evidence difficulties

in aspects of verbal and nonverbal memory and visuospatial functioning, based on

results from the adult literature. In addition, repeated alcohol withdrawal experiences were predicted to be associated with deficient performance on measures of

these neurocognitive domains.
32

METHODS

Participants

Participants were recruited from treatment programs and surrounding communities as part of an ongoing longitudinal study (e.g., Brown et al., 1994). The alcohol-dependent participants were recruited from adolescent inpatient alcohol and

drug abuse treatment programs in metropolitan San Diego, and met DSM-111-R criteria (American Psychiatric Association, 1987) for a lifetime diagnosis of alcohol dependence. Alcohol-dependent participants with more than 100 lifetime alcohol use

episodes and one or more heavy drinking episodes in the past 3 months were selected to test hypotheses for the present study. The alcohol-dependent participants

drank alcohol heavily during early and middle adolescence, when maturational

changes (e.g. myelination of frontal and parietal association areas; Kolb and Pantie,

1989) would normally take place.

TABLE 1. DEMOGRAPHIC CHARACTERISTICS OF ALCOHOL-DEPENDENT AND

COMPARISON ADOLESCENTS

Alcohol-dependent mean (SD)

(n¥33)

Comparison

mean (SD)

(n=24)

Male (%) ................................................................................................................................. 58 58

Age (range, 15–16 yr) ............................................................................................................ 16.2 (0.56) 15.9 (0.59)

Caucasian (%) ........................................................................................................................ 71 74

Grades completed ................................................................................................................... 9.5 (0.66) 9.2 (0.82)

Hollingshead socioeconomic status ........................................................................................ 31.2 (11.6) 32.5 (14.3)

Family history of alcohol dependence (%) ............................................................................. 57 71

Frequency mothers drank during pregnancy (%):

No drinking ..................................................................................................................... 52 50

Less than once per month ............................................................................................ 30 32

1-3 times per month ..................................................................................................... 6 14

More than 4 times per month ....................................................................................... 12 5

Average drinks mother consumed per occasion .................................................................... 0.88 (1.17) 0.86 (1.04)

Maximum drinks mother consumed ....................................................................................... 1.00 (1.46) 1.45 (2.36)

Note: all conparisons nonsignificant (ex¥0.05).

Range 11–77; higher score reflects lower socioeconomic background.

Age-appropriate comparisons across NP tests were facilitated by scores from a

comparison group of community adolescents without histories of alcohol or other

drug use disorders. These comparison adolescents were recruited through advertisements in the same communities from which the clinical sample was drawn and via

parents who were in adult alcohol treatment programs. Comparison adolescents had

no history of alcohol or other drug problems and were recruited to match the age,

gender, socioeconomic status, education, and family history of substance-dependence

characteristics of the alcohol dependent teens.

Clinical and comparison adolescents were excluded if they: (1) did not have a resource person (parent) who independently consented to participate for corroboration

of biographical and substance involvement information; (2) lived over 50 miles from

the research facility; (3) had an Axis 1 psychiatric disorder (predating the onset of

regular substance use); (4) had a history of significant head trauma with loss of consciousness > 2 min or neurological condition that could compromise NP performance

(e.g., seizure disorder); (5) did not speak English; or (6) had a history of drug dependence or heavy recent drug use. Analyses were performed on 33 alcohol-dependent and 24 comparison adolescents. The nonabusing sample was comparable to the

alcohol-dependent sample on gender, age (15–16 years), ethnicity, years of education, Hollingshead socioeconomic index (mostly lower middle class), family history

of alcohol and other drug dependence, and maternal drinking during pregnancy (see

Table 1). Informed consent, approved by the University of California, San Diego institutional review board and clinical agencies, was independently obtained from all

youths and parents.

Measures

Structured Clinical Interview. This 90-min interview (Brown et al., 1987) assessed

demographic information, social and academic functioning, physical and emotional

health, behavioral intentions and attitudes regarding substance use, and maternal

alcohol use during pregnancy. Mood was assessed with the Profile of Mood States

(POMS; McNair et al., 1981). Family history of alcohol and other drug dependence

was assessed with DSM-111-R criteria and Schuckit’s problem list (Schuckit et al.,
33

1988) for all biological first- and second-degree relatives. For purposes of the present

study, a minimum of one alcohol-dependent biological parent was required for classification as positive for family history.

Customary Drinking and Drug Use Record (CDDR). The lifetime version of the

CDDR (Brown et al., 1998) was administered to obtain information on lifetime and

recent (past 3 months) involvement with alcohol (beer, wine, liquor) and eight types

of drugs (i.e., marijuana, amphetamines, barbiturates, hallucinogens, cocaine,

inhalents, opiates, and prescription medications or other substances not previously

specified), life problems related to alcohol and drug use, DSM-III-R and DSM-IV

substance abuse and dependence criteria, and alcohol and other drug-withdrawal

symptoms. The CDDR incorporates the Cahalan drinking classification procedure

(Cahalan, 1970), Drug Indulgence Index (Lee, 1974), and Alcohol Dependence Scale

(Skinner and Horn, 1984). Good internal consistency, test-retest reliability, Interrater reliability, and convergent and discriminant validity have been demonstrated

with adolescents (Brown et al., 1996; Stewart & Brown, 1995).

TABLE 2. DESCRIPTION OF NEUROPSYCHOLOGICAL TEST BATTERY

Measure Ability tested

WISC-R Subtests

Vocabulary ........................................................................ Language development; general intelligence.

Information ....................................................................... Store at general knowledge.

Similarties ........................................................................ Abstract reasoning.

Arithmatic ......................................................................... Mental tracking and computation.

Digit Span ........................................................................ Auditory attention.

Block Design .................................................................... Visual-motor organization; visual-spatial reasoning.

Coding .............................................................................. Psychomotor processing and speed.

California Verbal Learning Test-Children’s Version (CVLT-C)

List A trial 1 .................................................................... Words recalled on first learning trial.

List A total ....................................................................... Words recalled on five learning trials.

Long-delay free recall (LDF) ............................................ Target words recalled after 20-minute delay.

Samantic clustering ......................................................... Ratio of observed to expected semantic grouping on recall

trials.

Retention (LDF/List A Trial 5) .......................................... Proportion of words recalled on fifth learning trial also recalled on LDF.

Recognition discriminability ............................................. Proportion correct on recognition testing of target words embedded among distractor words.

WMS Visual Reproduction

Immediate recall (IR) ....................................................... Visual stimuli reproduced after initial presentation.

Delayed recall (DR) .......................................................... Visual stimuli reproduced after 10-minute delay.

Retention (DR/IR) ............................................................. Proportion of visual stimuli reproduced on IR also recalled

on DR.

Trail Making Test

Part A time ....................................................................... Psychomotor processing speed.

Part B time ...................................................................... Cognitive flexibility and speeded processing.

B-A time ......................................................................... Part B time minus Part a time (subtracting out simple

motor speed).

Embedded Figures Test ............................................................. Visual memory: visuoperception: contour analysis.

Boston Naming Test .................................................................. Word finding: confrontation naming.

Letter Fluency ............................................................................ Letter-specific verbal fluency.

Category Test ............................................................................ Nonverbal concept formation and deductive reasoning.

Neuropsychological Test Battery. This 2-hr battery was designed to measure

verbal and nonverbal learning and memory, visuospatial functioning, language

skills, attention, and problem solving skills, based on literature indicating impairment among adults with alcohol and drug dependence (see Table 2), The battery

consisted of the following tests: Wechsler Intelligence Scale for Children-Revised

(WISC-R; Wechsler, 1974) subtests of Vocabulary, Information, Similarities, Arithmetic, Digit Span, Block Design, and Coding; Wechsler Memory Scale Visual Reproduction subtest (WMS-VR; Wechsler, 1945); Trail Making Test (Reitan and Wolfson, 1985); Embedded figures Test (Witkin et al., 1971); an adapted 30-item Boston

Naming Test (Kaplan et al., 1983); Controlled Oral Word Association Test (Benton

et al., 1983); Booklet Category Test (DeFillippis and McCampbell, 1979); and California Verbal Learning Test-Children’s version (CVLT-C; Delis et al., 1994).

Administration of the CVLT-C involved oral presentation of a list of 15 words

(List A) over five trials. After each trial, participants were asked to recall as many

words from the list as possible. The clustering of words into semantic categories was
34

trucked. An interference word list (List B) was presented and asked to be recalled.

Next, participants were asked to recall List A in a free recall format, then in a cued

recall format in which semantic category names were provided. After a 20-min

delay, participants recalled List A in free and cued formats again, then were asked

to discriminate List A words from distractor words on a yes-no recognition trial.

Procedure

Youths were administered the battery of NP tests, structured clinical interview,

and CDDR by Bachelors- and Masters-level psychometrists trained to criterion. Alcohol-dependent adolescents were interviewed and tested during the 3rd week of

their inpatient treatment programs, and thus were detoxified from alcohol and other

drugs at the time of testing. Comparison adolescents were administered assessments at the research facility. A resource person (typically a parent) was separately

interviewed for corroboration of historical, family history, and substance use information. Separate psychometrists interviewed adolescents and parents to enhance

self-disclosure and to ensure confidentiality. In cases of discrepant information, additional data were obtained from other family members (see Brown et al., 1996).

RESULTS

Lifetime and current alcohol and drug use characteristics differed greatly between

alcohol-dependent and comparison teens (see Table 3). Alcohol-dependent adolescents reported an average of 753 alcohol use episodes spanning approximately 5

years, as well as larger quantities of alcohol per drinking episode and more alcohol

withdrawal symptoms in their lifetimes than nonabusing comparison participants.

Although alcohol-dependent youths with lifetime or current dependence on other

drugs were excluded, the alcohol-dependent group reported exposure to other drugs,

primarily cannabis and stimulants.

WISC-R Vocabulary (p<0.01), information (p<0.01), Similarities (p<0.05), and Coding (p<0.01) subtest scores were significantly worse in the alcohol-dependent sample

(see Table 4). The group difference in Coding scores remained statistically significant (p<0.05) after covariation for Vocabulary as a proxy for IQ (Kaufman, 1975).

TABLE 3. ALCOHOL AND OTHER DRUG INVOLVEMENT CHARACTERISTICS OF

ALCOHOL DEPENDENT AND COMPARISON ADOLESCENTS

Alcohol-dependent

mean (SD) (n=33)

Comparison mean

(SD) (n=24)

Lifetime

Age of first alcohol use* ..................................................................................... 10.93 (3.46) 12.89 (2.49)

Age of first weekly alcohol use* ......................................................................... 13.45 (2.05) 13.83 (1.17)

Total times drank*** .......................................................................................... 753.21 (658.38) 82.38 (185.63)

Alcohol dependency symptoms*** ...................................................................... 6.67 (3.66) 0.29 (0.55)

Alcohol withdrawal symptoms*** ....................................................................... 2.06 (2.19) 0.36 (0.72)

Have used any alcohol (%) ................................................................................. 100 80

Have used any drugs (%)*** ............................................................................. 100 8

Have used marijuana (%)*** ............................................................................. 94 4

Have used amphetamines (%)*** ...................................................................... 78 0

Have used cocaine (%)* ..................................................................................... 33 4

Have used hallucinogens (%)*** ....................................................................... 18 4

Have used Inhalants (%)** ................................................................................ 6 4

Past 3 months

Drinking days per month*** ............................................................................... 18.76 (17.15) 1.79 (2.15)

Drinks per day*** ............................................................................................... 5.13 (6.33) 0.19 (0.16)

Maximum drinks on an occasion*** .................................................................. 16.33 (9.62) 2.63 (3.44)

Drinks per month*** ........................................................................................... 154.00 (189.93) 3.38 (4.61)

Alcohol withdrawal symptoms* ........................................................................... 1.48 (1.79) 0.25 (0.68)

* Includes only recent (past 3 month) drinkers.

* p<0.05;** p<0.01;*** p<0.001.

TABLE 4. WISC-R SCORES FOR ALCOHOL-DEPENDENT AND COMPARISON

ADOLESCENTS

Test

Alcohol-dependent mean (SD)

(n=33)

Comparison

mean (SD)

(n=24)

Verbal
35

TABLE 4. WISC-R SCORES FOR ALCOHOL-DEPENDENT AND COMPARISON

ADOLESCENTS—CONTINUED

Test

Alcohol-dependent mean (SD)

(n=33)

Comparison

mean (SD)

(n=24)

Vocabulary** .................................................................................................................. 9.30 (2.01) 10.88 (2.31)

Information** ................................................................................................................. 8.79 (2.00) 10.75 (3.31)

SImilarities* ................................................................................................................... 10.15 (2.85 11.92 (2.76)

Arithmetic ....................................................................................................................... 10.45 (3.32) 10.38 (2.30)

Digit Span ...................................................................................................................... 9.27 (2.80) 10.25 (2.88)

Performance

Block Design .................................................................................................................. 10.91 (2.94) 11.33 (2.32)

Coding** ........................................................................................................................ 8.94 (3.26) 11.54 (3.62)

* p<0.05;** p<0.01.

New learning of verbal material was not associated with exposure to ethanol, as

evidenced by comparable group performances on CVLT-C learning trials (see Table

5). However, alcohol-dependent youths employed fewer semantic learning strategies

than comparison youths (p<0.05), and retention rates were significantly worse

among the alcohol-dependent adolescents (p<0.05). However, when asked to discriminate between words previously presented and distractor words, both groups

fared equally well, and alcohol-dependent youths were often able to correctly recognize words they had failed to recall.

TABLE 5. NEUROPSYCHOLOGICAL TEST SCORES FOR ALCOHOL-DEPENDENT

AND COMPARISON ADOLESCENTS

Measure Alcohol-dependent

mean (SD) (n=33)

Comparison mean

(SD) (n=24)

CVLT-C

List A trial 1 ...................................................................................................... 7.15 (1.79) 6.68 (1.70)

List A total ......................................................................................................... 54.12 (8.21) 55.12 (8.15)

Long-delay free recall ........................................................................................ 11.30 (2.80) 12.60 (2.27)

Semantic clustering* ......................................................................................... 1.84 (0.60) 2.18 (0.63)

% Retention* ..................................................................................................... 85.84 (17.90) 96.16 (16.15)

% Recognition discriminability ......................................................................... 95.36 (3.47) 95.58 (4.48)

Visual Reproduction:

Immediate recall ................................................................................................ 10.03 (2.39) 11.13 (1.73)

Delayed recall** ................................................................................................ 8.82 (2.70) 10.75 (1.85)

% Retention** ................................................................................................... 87.85 (16.40) 97.79 (9.42)

Embedded Figures Test time ...................................................................................... 442.00 (256.98) 415.38 (207.18)

Trail Making Test, Part B time ................................................................................... 61.70 (25.78) 56.68 (18.75)

Trail Making Test B-A time ........................................................................................ 33.45 (19.77) 29.46 (13.14)

Boston Naming Test (correct without cue, Max=30) ................................................. 24.36 (2.97) 25.92 (3.94)

Latter Fluency ............................................................................................................. 35.39 (9.09) 34.83 (9.14)

Category Test errors .................................................................................................... 19.82 (10.71) 16.79 (10.44)

* p<0.05;** p<0.01.

Visual reproduction retention rates were significantly lower in the alcohol-dependent sample (p<0.01). Although alcohol-dependent and nonabusing youths were similar on immediate delay reproductions, alcohol-dependent adolescents reproduced less

nonverbal information after the 10-min delay period, and their delayed recall performances were proportionately worse than what they had recalled immediately

after exposure to the stimuli.

Verbal and nonverbal retention rates were not significantly related to gender,

family history of alcohol/drug dependence, or maternal drinking during pregnancy.

To examine the hypothesis that alcohol withdrawal is associated with

neurocognitive functioning during early to middle adolescence, correlations between

alcohol withdrawal symptoms and NP scores were evaluated (see Table 6). A modest

but statistically significant pattern of correlations was evident in that 20 of 22 lifetime withdrawal-NP correlations and 19 of 22 recent withdrawal-NP correlations

were in the predicted direction (p<0.01; Ghahramani, 1996, p. 241). In particular,

more lifetime alcohol-withdrawal experiences were associated with poorer performance on delay trials of the CVLT-C (r=¥0.28,p<0.05) and WMS-VR (r=¥0.32,p<

0.05), WMS-VR retention rates (r=¥0.33,p<0.05), and scores on WISC-R Informa-
36

tion (r=¥0.27,p< 0.05). Recent withdrawal symptom counts were associated with

poorer WISC-R Block Design scaled scores (r=¥0.26,p<0.05) and Embedded Figures

Test completion times (r=0.26,p<0.07). Moderate correlations were found with between both lifetime and current withdrawal symptom counts and a task involving

multiple brain systems (Trail Making Test, p’s<0.07).

NP performances were associated with other drinking variables, although to a

lesser extent than lifetime alcohol withdrawal, and with POMS depression scale

scores (see Table 7). Frequency of drinking was correlated with WISC-R Information

and Block Design scores, and DSM-IV alcohol dependence criteria were correlated

with WMS-VR delay and retention rates (p’s<0.05). Depressed mood was related to

CVLT-C and WMS-VR delay trials, WMS-VR retention (p’s 0.05 to 0.01), and also

with lifetime (p<0.01) and current (p<0.05) alcohol withdrawal. Because alcohol

withdrawal commonly involves depressed mood, and depressed mood may affect

neurocognition, two mediational models were tested: (1) to see if depressed mood

mediates the relationship between withdrawal and poor retention, and (2) to see if

withdrawal mediates the relationship between depressed mood and poor retention.

Hierarchical regressions suggested the former: that depressed mood mediates the relationship between withdrawal and poor WMS-VR retention rates in a mixed gender

sample F(2,51)=5.58, p<0.01; R2∆=15%, p<0.05).

TABLE 6. CORRELATIONS BETWEEN WITHDRAWAL SYMPTOMS AND NEUROPSYCHOLOGICAL TEST SCORES FOR ALCOHOL-DEPENDENT AND COMPARISON ADOLESCENTS (N=57)

Measure

Alcohol Withdrawal

Lifetime Recent

WISC-R

Vocabulary .............................................................................................................................. ¥0.12 0.18

Information ............................................................................................................................. ¥0.27* ¥0.24

Similarities ............................................................................................................................. ¥0.04 ¥0.23

Arithmetic ............................................................................................................................... ¥0.14 ¥0.21

Digit Span .............................................................................................................................. 0.21 0.13

Block Design .......................................................................................................................... ¥0.18 ¥0.26*

Coding .................................................................................................................................... ¥0.20 ¥0.17

CVLT-C

List A trial 1 .......................................................................................................................... 0.05 0.05

List A total ............................................................................................................................. ¥0.10 0.07

Long-delay free recall ............................................................................................................ ¥0.28* ¥0.17

Semantic clustering ............................................................................................................... ¥0.19 ¥0.18

Retention rate ........................................................................................................................ ¥0.22 ¥0.04

Recognition discriminability .................................................................................................. 0.06 0.01

WMS Visual Reproduction

Immediate recall .................................................................................................................... ¥0.14 ¥0.15

Delayed recall ........................................................................................................................ ¥0.32* ¥0.17

Retention rate ........................................................................................................................ ¥0.33* ¥0.07

Embedded Figures Test time a ........................................................................................................ 0.08 0.26**

Trail Making Test, Part B time ....................................................................................................... 0.25** 0.13

Trails B-A time ............................................................................................................................... 0.22 0.25**

Boston Naming Test ....................................................................................................................... ¥0.10 ¥0.07

Letter Fluency .................................................................................................................................. 0.06 0.13

Category Test errors* ...................................................................................................................... 0.07 0.04

Correlations In predicted direction (p<0.01) 20/22 19/22

a Positive correlations predicted; all other correlations predicted to be negative.

* p< 0.05; ** p<0.07.

To see if the pattern of scores might be affected by the inclusion of both boys and

girls, analyses were tested on boys only (n=19 alcohol-dependent and n=15 comparison). The same pattern of results emerged for group differences on NP tests and for

NP correlations with withdrawal symptoms as were found with the full sample. Of

note, boys’ lifetime alcohol-withdrawal symptoms correlated highly with CVLT-C retention (r=¥0.49,p< 0.005) and WMS-VR retention (r=¥0.55,p<0.001) rates. In contrast to the mixed gender analyses, boys’ lifetime alcohol-withdrawal symptoms predicted retention rates independent from the influence of depressed mood in hierarchical regressions (coefficient p’s<0.05). Withdrawal mediated the relationship between depressed mood and CVLT-C retention (B=¥0.37,p<0.05), whereas de-pressed
37

mood did not mediate the relationship between alcohol withdrawal and retention

rates.

DISCUSSION

This study identified subtle to modest NP deficiencies associated with repeated

heavy alcohol use and withdrawal during early to middle adolescence. In particular,

alcohol-dependent adolescents with a minimum of 3-weeks of abstinence differed

from sociodemographically and family history-matched nonabusers on several NP

measures. As hypothesized, aspects of memory functioning and visuospatial cognition were poor, compared with the demographically and family history-matched

controls. Verbal skill deficiencies were also found in the alcohol-dependent group.

The pattern of memory functioning results was internally consistent and suggested deficits among heavy drinking adolescents. New learning did not appear to

be affected by alcohol involvement when measured after 3-weeks of abstinence, but

alcohol-dependent youths, especially those with histories of alcohol withdrawal

symptoms, failed to reproduce some words or figure components that they had recalled on trials administered immediately after exposure to the stimuli (see Fig. 1).

This retrieval deficiency was mediated by depression scores for the full sample, but

for boys, withdrawal had an independent contribution to poorer retention and withdrawal that mediated the mood-retrieval relationship. As participants were screened

for primary mood disorders, the relationship between depression and withdrawal

suggests that alcohol-dependent adolescents may have experienced alcohol-induced

mood changes that affected neurocognition. This mood change seems to have affected boys and girls differently.

In examining the process of learning, alcohol-dependent youths were found to

underutilize semantic clustering strategies, which may have hampered efficient recall performance. When asked to discriminate between words previously presented

and distractor words, both alcohol-dependent and nonabusing groups performed

equally well. This resembled a pattern of NP performance observed in patients with

mild frontal-subcortical dysfunction (review Butters et al., 1995). However, the reduced level of recall on delay in alcohol-dependent adolescents relative to controls

contrasts with studies of alcohol-dependent adults. In a study of access, availability,

and efficiency of verbal information processing, alcohol-dependent adults demonstrated comparable recall relative to controls (Nixon and Bowlby, 1996). One possible explanation for this developmental difference is that deficits in recall may be

compensated over time, whereas efficiency of recall may become increasingly impaired with continued years of drinking.

The association between visuospatial functioning and substance withdrawal found

in the present study was also reported by Tapert and Brown (1999) using other statistical procedures. Youths who experienced alcohol-withdrawal symptoms performed more poorly on tests of visual motor integration and visuoperception. These

functions appeared more related to withdrawal histories than to other indices of

substance involvement. A complex substitution task involving speeded scanning and

processing was performed significantly slower in the alcohol-dependent sample, as

reported in studies of alcohol-dependent adults (e.g., Brandt et al., 1983).

TABLE 7. INTERCORRELATIONS BETWEEN RETENTION RATES, MOOD, AND

SUBSTANCE INVOLVEMENT IN ALCOHOL-DEPENDENT AND COMPARISON

ADOLESCENTS (N¥57)

Variable 1 2 3456 7

1. CVLT-C retention rate

2. Visual Reproduction retention rate ............... 0.34*

3. POMS Depression scale ................................ ¥0.26 0.41**

4. Drinking episodes per month ....................... 0.02 ¥0.08 0.38**

5. DSM-IV Alcohol Dependence criteria ............ ¥0.17 ¥0.30* 0.49** 0.67**

6. Alcohol withdrawal symptoms, lifetime ........ ¥0.22 ¥0.34* 0.58** 0.54** 0.57**

7. Alcohol withdrawal symptoms, recent .......... ¥0.04 ¥0.07 0.33* 0.69** 0.51** 0.73**

* p<0.05;** p<0.01
38

Vocabulary and Information scores were lower in the alcohol-dependent sample.

Environmental, economic, or family factors can adversely affect language functioning (e.g., Rourke et al., 1983). Language skills may have been inferior among alcohol-dependent adolescents because substance use prevented adequate attendance,

attention, and/or participation in or processing of educational experiences. Alternatively, verbal IQ deficits that commonly mark academic problems and conduct disorder (review Moffitt, 1993) may have been associated with CNS differences that

predated the use of alcohol. The association between tests of language functioning

and alcohol involvement differentiated these adolescent findings from those of adult

alcoholics.

The present study has several limitations. First, the carefully selected but small

sample size prohibited exploration of gender and family history differences. Second,

the use of other drugs may have independently affected cognitive performance (e.g.,

Beatty et al., 1997), but could not be explored in this relatively small sample. Third,

there was no recognition trial on the nonverbal memory test, so we cannot distinguish between pictorial retention and retrieval processes. Fourth, although a relationship between alcohol dependence and NP difficulties was indicated by this and

other cross-sectional studies, the directionality can be determined only by longitudinal studies. Although protracted alcohol or drug involvement may cause NP impairment, cognitive deficits may also be a risk factor or marker for the development

of substance use disorders. For example, aggressive youths (Giancola et al., 1998)

and those with family histories of alcohol dependence (Harden and Pihl, 1995;

Najam et al., 1997) have demonstrated executive and language dysfunction and selfregulation deficiencies (Henry et al., 1996) before the onset of substance use. Although not exclusively an alcohol-dependent sample, one longitudinal study has suggested that continued substance involvement in adolescence leads to greater

neurocognitive difficulties (Tapert and Brown, 1999).

In summary, these results, taken with other studies (Giancola et al., 1998; Moss

et al., 1994; Tapert and Brown, 1999; Tarter et al., 1995), suggest that NP deficits

are detectable among middle-aged adolescents with histories of extensive alcohol

use. Limitations in the retrieval of recently acquired information put alcohol-dependent adolescents at risk for falling farther behind in school, thus compounding

their risk for social problems (Newcomb and Bentler, 1988). Treatment programs

may improve outcomes by measuring teens’ memory capacities and using efficacious

methods of presenting new information that consider impaired retention. Future

studies could determine if multi-modal learning, repetition, and active learning procedures (e.g., role playing) help to successfully teach coping skills and appraisal of

post-treatment relapse risks (Myers et al., 1993; Roehrich and Goldman, 1993;

Tapert et al., 1999).
39

Deficits on visuospatial and retention measures suggest that underlying brain

mechanisms may be affected by ethanol exposure, even after 3 weeks of abstinence.

These results share a consistent pattern with adult studies in that verbal and visual

memory deficits suggest potential mesial temporal lobe, caudate nucleus, and/or

diencephalic damage, regions implicated in studies of adult alcohol-dependent patients (e.g., Jernigan et al., 1991). Overall, lifetime alcohol withdrawal symptoms

were associated with poorer retrieval functioning (mesial temporal lobe and

diencephalic regions and frontal-subcortical circuits), whereas recent withdrawal

was associated with lower levels of visuospatial functioning (frontal-parietal regions). Structural and functional neuroimaging studies may help examine these

hypotheses.

ACKNOWLEDGMENT

Appreciation is expressed to San Luis Roy Hospital, Mesa Vista Hospital,

Harborview Medical Center, and Scripps Memorial Hospital for their participation

in the project.

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49

Senator DEWINE. Dr. Weissberg?

Mr. WEISSBERG. Good morning, Chairman DeWine and Senator

Reed. I would like to thank you and Senator Kennedy for inviting

me here today to comment as a psychologist, researcher and practitioner on effective substance abuse prevention for young people. I

am Roger Weissberg, a professor of psychology and education at the

University of Illinois at Chicago. I also serve as president of the

Collaborative for Academic, Social and Emotional Learning, or

CASEL. CASEL is a national organization of researchers and educators with the mission of establishing and disseminating evidencebased social and emotional learning as an essential part of preschool through high school education.
50

Recently, I co-chaired the American Psychological Association

Task Force on Prevention and subsequently coedited a special issue

of the American Psychologist on prevention that works for children

and youth. Building from our findings, my testimony briefly highlights some research-based principles of effective prevention programming and offers a few key recommendations for prevention

practice and policy.

As detailed in my written testimony, too many adolescents still

engage in substance use, and significant percentages experience

mental health problems, engage in other risky behaviors and lack

social and emotional competencies such as stress management,

problem solving and relationship skills. Given these high rates of

substance use and related problem behaviors, our society urgently

needs effective prevention and youth development approaches that

are broadly disseminated and implemented with high quality.

A convincing research base now shows that well-designed and

well-implemented school-based prevention programs can reduce

substance use, enhance mental health and improve academic performance. The best school-based efforts are multiyear, skill-based

and coordinated. They are school-wide and involve families and

communities as partners. They help schools coordinate and unify

categorically-funded prevention programs that are often fragmented. They offer developmentally and culturally appropriate instruction and clear learning objectives at each grade level.

In addition to preventing the negative, they promote the positive,

such as teaching children to apply social and emotional skills and

ethical values in daily life through service learning. They build connection to school through caring people and engaging classroom

and school practices. They address the effective and social dimensions of academic learning. They provide high-quality staff development and administrative support, and they incorporate continuing

evaluation and improvement. Finally, in this era of No Child Left

Behind pressures for academic accountability, there is a new generation of research indicating school-based prevention can also enhance academic performance.

Unfortunately, despite scientific advances, there is still a wide

gap between prevention research and practice. Most schools still do

not use prevention programs of proven effectiveness. Even when

schools select research-based programs, the majority of them do not

implement those programs with fidelity and thus fail to obtain

their expected benefits.

Furthermore, there is widespread fragmentation and lack of coordination among prevention programs. No matter how many prevention programs schools have, those programs will not achieve

their intended effects when they are introduced in a categorical

manner targeting one negative outcome at a time.

There are a variety of steps that could improve prevention practice and benefit more children. At the State level in Illinois, our

governor recently signed the Children’s Mental Health of 2003,

which makes mental health promotion integral to education. It requires the Illinois State Board of Education to incorporate social

and educational development standards as part of the Illinois

Learning Standards, and it requires every school district to develop
51

a policy for incorporating social and emotional development into

the district’s plan.

The Illinois legislation can serve as a national model for innovative education that fosters social and emotional learning to enhance

students’ academic performance, health, character and citizenship.

For school-based prevention to succeed, it is crucial that schools

have prevention coordinators who are explicitly responsible for the

selection, effective implementation, coordination, evaluation and

continuous improvement of evidence-based programming.

We are finding that providing training and technical assistance

to National Safe and Drug Free School coordinators improves practice and benefits children. This investment is starting to pay off

and should be continued.

Finally, I applaud SAMHSA’s leadership to translate rigorous

science into effective practice. Recently, SAMHSA announced that

it will provide $45 million to support States in implementing the

new Strategic Prevention Framework to prevent substance abuse

and promote mental health. The SAMHSA framework will facilitate collaboration among different prevention programs across

schools, families and communities.

This promising prevention initiative requires new and substantial funds if we are to reduce significantly the number of young

people who develop substance abuse and mental health problems.

In closing, I also thank the Committee and Senator DeWine even

asked today about the importance of encouraging stronger interagency linkages between Federal agencies such as the U.S. Department of Education, Health and Justice. Such collaboration is critical both to improve coordinated prevention through practice

through research and to understand factors that influence high

quality dissemination and utilization of prevention programs and

policies.

Once again, thank you, Mr. Chairman, for the opportunity to

present this testimony and for holding this timely hearing. I would

be glad to answer any questions the Subcommittee may have for

me.

[The prepared statement of Mr. Weissberg follows:]

PREPARED STATEMENT OF ROGER P. WEISSBERG, PH.D.

Good morning, Chairman DeWine, Senator Kennedy, and Members of the Subcommittee. Thank you for inviting me here today to comment from my 30-year perspective as a psychologist, prevention researcher, and practitioner addressing the

challenges facing school and other community-based prevention programs as they

work to prevent youth substance abuse.

I am Roger Weissberg, Professor of Psychology and Education at the University

of Illinois at Chicago, where I direct a Prevention Research Training Program in

Urban Children’s Mental Health and AIDS Prevention funded by the National Institute of Mental Health. I also serve as President of the Collaborative for Academic,

Social, and Emotional Learning (CASEL), an organization dedicated to the development of children’s social-emotional competencies and the capacity of schools, parents, and communities to support that development. CASEL’s mission is to establish

integrated, evidence-based social and emotional learning (SEL) as an essential part

of preschool through high school education (for information on advances research

and practice in this area see www.CASEL.org).

Recently, I co-edited a Special Issue of the American Psychologist on ‘‘Prevention

that Works for Children and Youth’’ (Weissberg & Kumpfer, 2003). The articles in

the Special Issue are an outgrowth of an American Psychological Association Presidential Task Force on ‘‘Prevention: Promoting Strength, Resilience, and Health in

Young People’’ that I co-chaired. The task force members concluded that prevention
52

research has matured substantially in recent decades, synthesizing new knowledge

and offering important findings to guide prevention practice and policy. Part of my

testimony will highlight some common features of effective prevention programming

identified by scholars representing diverse perspectives. I am pleased to emphasize

that there is great overlap between our views and the principles emphasized in the

new Strategic Prevention Framework to advance community-based programs for

substance abuse prevention and mental health promotion announced by the Substance Abuse and Mental Health Services Administration (SAMHSA).

In Part I of this testimony, I briefly introduce findings about trends in adolescent

substance use and other risky behaviors and comment on the implications of these

findings for coordinated prevention and youth-development programming. In Part II,

I review results from recent large-scale studies and reviews on effective school-based

prevention programs. Part III presents some of the challenges and difficulties that

schools face in administering school-based prevention programs. In Part IV, I share

with you some of the work CASEL is doing to reduce the gap between research and

practice. In the last part, I comment on SAMHSA’s ‘‘Strategic Prevention Framework’’ as a powerful tool towards collaboration and coordination among multiple prevention programs.

I. Trends in Adolescent Substance Use and Other Risky Health Behaviors

The news regarding recent national trends in adolescent substance use is mixed.

Perhaps the simplest set of headlines is ‘‘During the past 12 years, tobacco and alcohol use has declined; marijuana, cocaine, and illegal steroid use has increased; and,

overall, too many students engage in all forms of substance use.’’ To support this

summary, I highlight some findings recently reported by the Centers for Disease

Control and Prevention (CDC) from the 2003 Youth Risk Behavior Surveillance System (www.cdc.gov/yrbss). The National Youth Risk Behavior Survey is conducted

every 2 years during the spring semester and provides data gathered from students

in grades 9–12 in public and private schools throughout the United States. The

chart below summarizes changes in percentages of self-reported substance use between 1991 and 2003.

Behavior 1991 2003

Lifetime cigarette use ............................................................................................................. 70.1 58.4

Current cigarette use (last 30 days) ..................................................................................... 27.5 21.9

Lifetime alcohol use ................................................................................................................ 81.6 74.9

Current alcohol use (last 30 days) ........................................................................................ 50.8 44.9

Episodic heavy drinking (last 30 days) ................................................................................. 31.3 28.3

Lifetime marijuana use .......................................................................................................... 31.3 40.2

Lifetime cocaine use ............................................................................................................... 5.9 8.7

Lifetime illegal steroid use ..................................................................................................... 2.7 6.1

Defying some commonly held stereotypes, substance use crosses geographic and

economic boundaries. For example, studies comparing substance use between adolescents from affluent suburban versus low-income urban families show that high

rates of teens from affluent families use substances (Luthar & Becker, 2002; Levine

& Coupey, 2003). Such findings speak to the importance of universal (i.e., targeting

all children) rather than selective approaches to prevention. Targeting only selective

groups of children and youth in our prevention efforts may result in ignoring substantial numbers of children and youth who are in urgent need of prevention programs. Some may argue that broadly targeted prevention programming may not be

appropriate for at-risk groups. However, research findings suggest that as long as

we provide programs with fidelity, that is, implement them in a way that is faithful

to the original program design, most programs are equally beneficial for all students

(Griffin, Botvin, Nichols, & Doyle, 2002). Furthermore, Caulkins and his colleagues

(2002) recently examined whether the benefits of a model school-based prevention

program exceed its costs. According to their best estimates, they concluded that society would currently realize quantifiable benefits of $840 from a student’s participation compared with a program cost of $150 per participating student, a saving of

almost $6 for every $1 invested.

It may sound as though I am making an argument that early and effective substance abuse prevention for young people should be our highest priority. But, actually, I will argue that a broader perspective is needed. Preventing substance abuse

is a worthy endeavor, but it is a limited goal. It is indisputable that young people

who are not drug abusers may still lack the resources to become healthy adults, car-
53

ing family members, responsible neighbors, productive workers, and contributing

citizens (Pittman, Irby, Tolman, Yohalem, & Ferber, 2001). In addition to having

drug-free sons and daughters, parents across the United States want children who:

1. are intellectually reflective and committed to lifelong learning;

2. interact with others in socially skilled and respectful ways;

3. practice positive, safe, and healthy behaviors;

4. contribute ethically and responsibly to their peer group, family, school, and

community; and

5. possess basic competencies, work habits, and values as a foundation for meaningful employment and engaged citizenship.

Although the prevalence of substance use calls for action, there is also reason for

concern about high rates of related adolescent risk behaviors in domains such as

violence, sexual behavior, depression, and suicide. Consider the following percentages of student involvement in problem behaviors from the 2003 CDC Youth Risk

Behavior Surveillance System:

Behavior 2003

Threatened or injured with a weapon on school property (last 12 months) ...................................................... 9.2

Engaged in a physical fight on school property (last 12 months) .................................................................... 12.8

Currently sexually active partners (lifetime) ....................................................................................................... 34.3

Had 4 or more sex partners (lifetime) ................................................................................................................ 14.4

Felt so hopeless almost every day 2 weeks or more in a row that they stopped doing some usual activities

(last 12 months) ............................................................................................................................................. 28.6

Made a suicide plan (last 12 months) ............................................................................................................... 16.5

Attempted suicide (last 12 months) ................................................................................................................... 8.5

When we look at the broader picture of adolescent functioning, it is clear that,

beyond substance use, significant percentages of young people experience mental

health problems, engage in other risky behaviors, and lack social-emotional competencies. The 1999 Surgeon General’s report on mental health indicated that 20

percent of children and adolescents experience the symptoms of a mental disorder

during the course of a year, and that 75–80 percent of these children do not receive

appropriate services (U.S. Department of Health and Human Services, 1999).

Dryfoos (1997) estimated that 30 percent of 14 to 17 year-olds engage in multiple

high-risk behaviors, and that another 35 percent, considered to be at medium risk,

are involved with one or two problem behaviors. Approximately 35 percent have little or no involvement with problem behaviors, but even these young people require

strong and consistent support to avoid becoming involved.

Such a constellation of multiple high-risk behaviors points to the importance of

moving beyond the problem-focused approach and especially beyond targeting only

one problem behavior at a time. Ripple and Zigler (2003) argued that such approaches fail to take into consideration the complicated etiology of individual target

problems and the significant overlap of multiple problems. The design of prevention

programs should be guided by the theoretical knowledge on risk and protective factors commonly underlying multiple problem behaviors. Furthermore, programs

should not merely aim at reducing risk conditions; they also should explicitly promote personal and environmental assets that will decrease problem behaviors and,

more important, serve as foundations for healthy development (Greenberg et al.,

2003; Kumpfer & Alvarado, 2003; Wandersman & Florin, 2003).

In assessing the functioning of young people and families, I draw three major conclusions that have relevance for prevention policy and practice. First, a significant

proportion of children will fail to grow into contributing, successful adults unless

there are major changes in the ways they are taught and nurtured. Second, families

and schools must work together more systematically and effectively to enhance the

social-emotional competence, character, health, and academic learning of all children. Finally, new kinds of community resources and arrangements are needed to

support the positive development of young people into responsible, healthy, productive workers and citizens.

II. Principles of Effectiveness Based on Meta-Analyses and Large-Scale Reviews of Prevention Programs

The No Child Left Behind Act has prompted heightened awareness of educational

accountability as well as the need for evidence-based programs to improve student

performance. Federal and State government agencies are mandating that only programs proven to be effective should receive public funds. Due to significant advances
54

in prevention science, there have been increasing efforts to identify effective prevention programs and the characteristics that underlie such programs (Nation et al.,

2003).

A number of institutions, both public and private, including the Centers for Disease Control and Prevention, the Center for Substance Abuse Prevention, the Office

of Juvenile Justice and Delinquency Prevention, the U.S. Department of Education,

and CASEL have put forth lists of model programs. However, there have been growing concerns about the gap between scientific knowledge about prevention programs

and actual practice (Wandersman & Florin, 2003). Therefore, with the intention to

inform practitioners about the availability and characteristics of effective programs,

several researchers have conducted reviews and meta-analyses of prevention programs. These studies have yielded noteworthy principles of successful prevention

programming (Catalano et al., 2002; Durlak, 1998; Eccles & Appleton, 2002; Greenberg, Domitrovich & Bumbarger, 2001; Kumpfer & Alvardo, 2003; Nation et al.,

2003; Tobler, 2000; Wilson, Gottfredson, & Najaka, 2001).

In their meta-analysis of 207 universal prevention programs published between

1978 and 1998, Tobler et al. (2000) found that programs that only emphasized information and lacked an interactive approach were minimally effective. Among three

types of programs categorized under interactive approaches—interpersonal skills

training programs, comprehensive life skills training programs, and school-wide restructuring programs—system-wide restructuring showed the strongest impact. As

researchers have consistently pointed out, thoughtful school-based prevention and

youth development interventions should enhance students’ personal and social assets and at the same time improve the quality of the environments in which students are educated (Catalano et al., 2002; Eccles & Appleton, 2002; Greenberg et

al., 2003). Given that peer social influences are the most salient determinant of substance use, no one will doubt the crucial role that refusal skills (the ability to ‘‘say

no’’ and mean it) play in preventing teens from using tobacco, alcohol, and other

substances. However, skills training alone is not sufficient. Considering that many

youth involved in substance use lack a sense of connectedness to school and family,

instruction of skills and knowledge should take place in tandem with changes in

school-wide culture that help children feel more engaged, safe, and supported.

Weissberg, Kumpfer, and Seligman (2003) highlighted six characteristics of effective prevention programming across school, family, and community levels for young

people:

1. Uses a research-based risk and protective factor framework that involves families, peers, schools, and communities as partners in coordinated programming that

targets multiple outcomes;

2. Is long-term, age-specific, and culturally appropriate;

3. Fosters development of individuals who are healthy and fully engaged by teaching them to apply social-emotional skills and ethical values in daily life;

4. Aims to establish policies, institutional practices, and environmental supports

that nurture optimal development;

5. Selects, trains, and supports interpersonally skilled staff to implement programming effectively; and

6. Incorporates and adapts evidence-based programming to meet local community

needs through strategic planning, ongoing evaluation, and continuous improvement.

Despite advances in scientific knowledge about ways to make prevention programs effective, there still is a wide gap between research and practice—what we

know and what we do. In the case of school-based prevention programs, many

schools still do not use programs of proven effectiveness (Gottfredson & Gottfredson,

2001). Even when schools select research-based programs, the majority of them report that they do not implement those programs with fidelity. Bolstering the quality

of schools so that they work effectively with families to foster both the social-emotional development and academic performance of all students must be the top priority of any comprehensive prevention strategy for young people (Osher, Dwyer, &

Jackson, 2002).

III. Barriers to Successful Implementation of School-Based Prevention Programs

Several observations can help to explain the disparity between research and practice. Taken together, they represent a set of barriers to the successful implementation of beneficial school-based prevention programs.

First, there is widespread fragmentation and lack of coordination among prevention programs. In most cases, schools are flooded with programs covering such topics

as character education, substance abuse prevention, and HIV/AIDS awareness, with

no effort to coordinate what are in fact closely interrelated realms. No matter how

many prevention programs schools have, those programs are not likely to achieve
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their intended effects as long as they are introduced in a piece-meal and uncoordinated manner.

A second challenge is the lack of administrator-teacher support and professional

development opportunities. Bombarding principals and teachers who are already

overburdened by academic duties with a succession of new programs with minimum

support and guidance is likely to raise educators’ resistance and ultimately result

in ineffective program results. As seen in the work of Osher et al. (2002) and

Adelman and Taylor (2000), for a prevention program to achieve maximum impact,

the entire school community should embrace the program’s mission and goals, thereby changing whole school culture. However, without the ownership of the school

community, active leadership of administrators, and high-quality implementation by

teachers and student-support staff, the program is not likely to be successful.

A third challenge is the lack of an accountability system. I have already noted

that the majority of the programs are not implemented with fidelity. The problem

is exacerbated by the absence of accountability systems through which both the implementation and the impact of a prevention program is assessed and shared publicly in an ongoing fashion. Therefore, to achieve faithful and successful implementation of prevention programs, we should adopt accountability systems for children’s

social-emotional development and health with the same vigor as we do for their academic performance.

IV. The Social and Emotional Learning Framework: Bridging the Gap Between Science and Practice

In 1994 a group of educators, school-based prevention researchers, and child advocates came together to address the ineffective nature of so many prevention and

health promotion efforts. The result was the formation of the Collaborative for Academic, Social, and Emotional Learning (CASEL) Since its inception, CASEL has

been working toward the goal of establishing social and emotional learning (SEL)

as an essential element of education from preschool through high school. SEL is the

process of acquiring the skills to recognize and manage emotions, demonstrate caring and concern for others, make responsible decisions, establish positive relationships, and handle challenging situations effectively. SEL is fundamental to children’s social and emotional development, health and mental well-being, ethical development, citizenship, motivation to achieve, and academic learning.

Developmentally and cultury appropriate SEL-focused classroom instruction in

the context of a safe, caring, well-managed, and participatory school environment

enables young people to learn, practice, and apply SEL skills. It also enhances students’ connection to school through caring, engaging classroom and school practices.

Learning social and emotional skills is similar to learning other academic skills in

that the effect of initial learning is enhanced over time to address the increasingly

complex situations children face. SEL outcomes are best accomplished through effective classroom instruction; student engagement in positive activities in and out of

the classroom; and broad student, parent, and community involvement in program

planning, implementation, and evaluation. Ideally, planned, systematic SEL instruction should begin in preschool and continue through high school. We at CASEL believe that the rationale for SEL can serve as a powerful framework to facilitate coordination and integration of multiple fragmented prevention efforts (Greenberg et

al., 2003) and thus address more effectively some of the most pressing problems facing prevention and health promotion programs today.

There is growing evidence that school-based SEL programming can successfully

enhance students’ academic performance as well as reduce substance use and address other problem behaviors (Greenberg et al., 2003; Zins, Weissberg, Wang, &

Walberg, 2004). In spite of the fact that most schools’ mission statements embrace

the notion of the whole child, most schools do not make systematic efforts to institutionalize promotion of social and emotional competencies and creation of environments supporting their development.

CASEL believes that schools should explicitly address children’s social and emotional development as an educational priority. We are conducting a variety of activities to help educators and prevention professionals create and sustain more effective

approaches to prevention programming. These activities include:

• Disseminating scientific knowledge about the conceptual framework for SEL

and evidence-based SEL programs through CASEL’s publications, web site, and

monthly electronic newsletters;

• Providing support and technical assistance for the pre-service and in-service

training of teachers and administrators to ensure fidelity and sustainability of

school-based SEL prevention programs;

• Promoting school-family-community partnerships; and
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• Developing and facilitating local, State, and national networks of educational

leaders who are concerned about effective prevention and positive youth development programming

At the State level in Illinois, our Governor recently signed the Children’s Mental

Health Act of 2003 (Public Act 93-0495). Section 15 (Mental Health and School) requires the following:

1. The Illinois State Board of Education shall develop and implement a plan to

incorporate social and emotional development standards as part of the Illinois

Learning Standards for the purpose of enhancing and measuring children’s school

readiness and ability to achieve academic success.

2. Every Illinois school district shall develop a policy for incorporating social and

emotional development into the district’s educational program. The policy shall address teaching and assessing social and emotional skills and protocols for responding to children with social, emotional, or mental health problems, or a combination

of such problems, that impact learning ability.

CASEL is currently working with the Illinois State Board of Education and the

Illinois Children’s Mental Health Partnership to implement this legislation. The Illinois effort can serve as a national model for fostering educational systems that focus

on student competencies that serve as foundations for successful academic performance, health, character, and citizenship.

At the national level, CASEL trains school building-level and school district-wide

coordinators who support the implementation, evaluation, and continuous improvement of evidence-based school safety and substance use prevention programs. Specifically, we, as a team with three other groups (the American Institutes for Research, the Education Development Center, and the National Association of School

Psychologists) provide training and technical assistance to the National and Middle

School Prevention Coordinators under the Office of Safe and Drug-Free Schools in

the U.S. Department of Education. The coordinators play a critically important role

in their schools and districts by ensuring successful implementation of evidencebased programs. Their roles include: (1) integrating and coordinating multiple programs, (2) conducting needs assessments and establishing baseline data related to

prevention and youth-development programming, (3) conducting implementation

and outcome assessments, and (4) overseeing and facilitating prevention-related

school staff development.

We applaud the Office of Safe and Drug-Free Schools for its effective leadership

in conceptualizing and advancing efforts to train and support Safe and Drug-Free

School Coordinators. Given the crucial role that they play in successful implementation of programs and the host of tasks for which the coordinators are responsible,

more funding should be provided for training the coordinators and selecting and hiring more individuals to join in this important endeavor. For school-based prevention

to succeed, it is crucial that districts and schools have staff members who are explicitly responsible for assuring the selection, effective implementation, coordination,

evaluation, and continuous improvement of evidence-based programming.

Another important avenue for informing and supporting educators to implement

research-based SEL programming is through the Regional Education Laboratories.

CASEL is effectively collaborating with the Mid-Altlantic Regional Educational Laboratory for Student Success at Temple University to disseminate information and

provide supports to thousands of educators who implement school-family prevention

programming (CASEL, 2003; Zins et al., 2004).

V. Toward Further Collaboration and Coordination: The SAMHSA Strategic

Prevention Framework

In recent years, SAMHSA has provided groundbreaking and high-quality national

leadership in translating rigorous science into effective practice. For example,

through its Model Programs initiative, Training and Technical Assistance Centers,

and informative publications, SAMHSA has focused on making sure that the highest

quality, evidence-based programs are provided effectively and broadly to American

children and families. Given the common risk and protective factors for substance

abuse and mental health problems, it is good to see increased coordination between

CSAP and CMHS so that their science-based interventions focus simultaneously on

the fundamental and common factors that influence both types of outcomes. The

best payoff from these efforts will come from programming that begins in early and

middle childhood and works with schools, families, and communities to create integrated systems of prevention and treatment in which prevention is seen as the front

line of defense to reduce the number of new cases as well as an important offensive

strategy to enhance the competence of all young people.

SAMHSA has recently announced that it will provide $45 million to support

States in implementing the new ‘‘Strategic Prevention Framework (SPF)’’ to prevent
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substance abuse and promote mental health. The Framework is based on the belief

that effective prevention programs must (1) involve individuals, families, and entire

communities, (2) acknowledge the importance of health promotion as well as problem prevention, (3) emphasize common risk and protective factors among multiple

problems, and (4) have accountability systems through which program implementation and impact are monitored in an ongoing fashion.

The SPF recognizes the lack of collaboration and coordination among multiple

prevention efforts and the absence in too many cases of a comprehensive theoretical

framework. I applaud SAMHSA for creating this comprehensive framework. It has

tremendous potential to, in SAMHSA’s own words, ‘‘bring together multiple funding

streams from multiple sources to create the true cross-program and cross-system approach that health promotion and disease prevention demand.’’

The newly proposed SAMHSA Framework will facilitate collaboration among different prevention programs in multiple settings that include schools, families, and

communities, a crucial component for effective prevention strategies. SAMHSA’s

strategic planning represents an exciting set of directions, but their prevention initiatives require new and substantial funds if we are to reduce significantly the number of young people who develop substance abuse and mental health problems. I

urge you to provide more funding for SAMHSA’s prevention efforts. In addition, I

hope that you will encourage stronger interagency linkages between Federal agencies—such as the U. S. Department of Education, SAMHSHA, and the National Institutes of Health—both to improve practice and to understand factors that influence high quality dissemination and utilization of effective prevention programs and

policies.

Once again, thank you, Mr. Chairman and Senator Kennedy for the opportunity

to present this testimony and for holding this timely hearing. I would be glad to

answer any questions the subcommittee may have.

Senator DEWINE. Good. Doctor, thank you very much.

Ms. Ramsey-Molina?

Ms. RAMSEY-MOLINA. Good morning, Chairman DeWine, Senator

Reed.

As president of the Coalition for a Drug Free Greater Cincinnati,

it is truly my pleasure to be here today. Thank you for the opportunity to speak.

The Coalition was founded in 1996 by Congressman Rob

Portman as a long-term effort to mobilize all sectors of the community to address the issue of adolescent substance abuse. He understood that to be successful, we must convene the community at

large to deal with each child as an individual while changing the

community norms, attitudes and standards of conduct.

I want to, before I start my testimony, I want to share a story

about why I do what I do. Many years ago, several years ago, I was

providing direct service to the Coalition through the Alcoholism

Council of Cincinnati, and I worked with children of single, crackaddicted mothers within the city. I had a group of young girls, and

one of the girls said to me, when I grow up, I am not going to do

drugs. And I said that is great. She said let me tell you what I am

going to do: when I grow up, I am going to have a baby, and then,

I am going to get married, and my boyfriend is going to sell drugs

so we can be rich.

And I took a step back, and I said my goodness, we have an issue

here. And I said, well, it is against the law to sell drugs. What happens to men who sell drugs and women who sell drugs? And she

said, well, they go to jail for 30 or 90 days. When they get out, we

have a party.

And so, I took another step back and said, well, if that is what

your boyfriend is going to do to be rich, what do you want to do?

Well, she had recently lost her grandfather, who was her only consistent male influence, positive male influence in her life to heart
58

disease. She wanted to grow up and be a cardiologist. She wanted

to work on people with sick hearts.

I did not last in direct service much longer after that. I moved

into community coalition building, because I realized that one single program intervening with that small child for 50 minutes over

the course of 10 weeks was not going to get us where we needed

to be. We needed to convene the community at large. The individual programs are extremely important, but we had to intervene

with the systems and the messages she was receiving throughout

the community the other 23 hours of the day.

We must address the community at large. Coalitions do this. We

must look at community norms, attitudes and behavior. Coalitions

are uniquely positioned to engage all sectors and to create community change that supports all youth, including this young little girl.

Coalitions develop a broad base of support and collaboration.

They promote shared resources so that together, we can achieve

more. Linda Verst, a volunteer in Northern Kentucky, in the rural

parts of Northern Kentucky, they were having challenges meeting

the adolescent treatment needs; had limited resources, many youth

were going untreated. She convened roundtables as a member of

the Coalition for a Drug Free Greater Cincinnati to look at what

are our resources, local, State and national, and how do we work

together?

After the course of 18 months’ studying and looking at the issues,

the result is increased access and utilization of adolescent treatment spots in Northern Kentucky. Collaboration works through

coalitions. Coalitions implement data-driven processes that ensure

that our limited resources have maximum impact, making sure

that we understand the data, and we understand the issue, so that

we can focus what it is that we are doing.

Coalitions apply the science of prevention and treatment through

all sectors of the community. Coalitions work within communities,

with community members, take the science and implement through

the fabric, through the culture of the individual community. Coalitions engage multiple individuals across the community to decrease

drug use by increasing protective factors and decreasing risk factors for individual youth. Coalitions do work.

Our comprehensive efforts through the Coalition for a Drug Free

Greater Cincinnati has allowed us the opportunity to surround the

issue and to provide a single message, a single, unified community

that says to kids, it is not okay, it is not healthy; we can make better choices. The result? Fewer kids in Greater Cincinnati are using.

Southwest Ohio boasts lower use rates among adolescents than the

State and the national averages.

Why and how does it work? Tammy Sullivan, a single parent

from Greater Cincinnati, chaired our parent school-youth task force

and implemented the Strong Voices, Smart Choices campaign,

which put parenting for prevention tips into the hands of over

750,000 parents in Greater Cincinnati. This contributed to a 54

percent reduction in use among adolescents whose parents talked

to them about the issue and set and enforced clear and consistent

rules.

Rob Matucci, working in global hair care for Procter and Gamble,

oversees the implementation of the local anti-drug media campaign
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for the Cincinnati market. As a volunteer, he facilitates over $1

million worth of donated air time. The result? A 19 percent decrease in adolescent use among youth who see or hear anti-drug

commercials. Mike Hall, the principal at a local suburban high

school, implements the Coaches, Kids and Chemicals clinic. The result, a 42 percent decrease in use among adolescents who are active in schools that have athletic programs that implement substance abuse prevention.

Pastor Wilkins, from the Faith Community Alliance, implements

the Reviving the Human Spirit project. The result? A 50 percent

decrease in use among kids who are actively involved in prevention

programs through their church. I could provide many examples of

individuals from throughout Greater Cincinnati who have dedicated their time and talent to the table of coalition building and

shared that with our resources.

Since our inception in 1996, we have grown to include 31 neighborhoods and coalitions in communities throughout Greater Cincinnati. We see greater decreases in use, adolescent drug use, in

these communities than similar communities that do not have coalitions.

I am a firm believer in the power of communities to come together as a coalition and decrease adolescent substance abuse. I do

it; I work it; and I have seen it. It works.

Thank you for the opportunity to speak today.

[The prepared statement of Ms. Ramsey-Molina follows:]

PREPARED STATEMENT OF RHONDA RAMSEY-MOLINA

Good Morning Chairman DeWine and other distinguished Members of the Subcommittee. My name is Rhonda Ramsey Molina and I serve as the President of the

Coalition for a Drug Free Greater Cincinnati.

The Coalition for a Drug Free Greater Cincinnati was founded in 1996 by Congressman Rob Portman as an effort to mobilize all sectors of the community to address adolescent substance abuse and the effects on neighborhoods throughout

Greater Cincinnati. Our mission—promoting drug free environments for youth and

mobilizing and supporting local anti-drug coalitions is served through implementation of multiple strategies through multiple sectors aimed at changing community

norms, attitudes and standards of conduct. Hailed as a national model for coalitions

with its innovative approach to adolescent substance abuse, the Coalition has grown

dramatically since its inception to include 31 local coalitions in neighborhoods

throughout Greater Cincinnati.

I begin my testimony by sharing a brief story of why I am committed to coalitions

as an integral part of adolescent substance abuse prevention and treatment.

Several years ago, prior to joining the coalition field, I provided direct services to

children of chemically dependent parents within the city of Cincinnati. One day with

a group of five 4th grade little girls who were all daughters of single, crack addicted

mothers, I realized the importance of coalitions. One of the girls in the group stated,

‘‘When I grow up I am not going to use drugs.’’ She said, ‘‘When I grow up I am

going to have a baby, then get married and my boyfriend is going to sell drugs so

I can be-rich.’’Astonished by her thought pattern, I took a deep breath and step back

and shared with her that it is against the law to sell drugs. I asked her what happens to people who sell drugs. She stated, ‘‘They go to jail for 30 or 90 days then

they get out and you have a party.’’ Again, astonished by her thought process, I said

that that may be what your boyfriend does to make money, but what do you want

to do. Come to find out, she wanted to be a heart surgeon. Recently, her grandfather, the only constant, positive male influence in her life, had died of a heart attack and she wanted to help people like her grandfather who had sick hearts.

The reality is that any program, provided only once a week for 50 minutes over

a 10-week period, while valuable, is not able to address the larger community issues

that adolescents face the other 23 hours a day they are not participating in the program. Direct service programs focus on individuals, not the community at large. The
60

messages adolescents receive in their community are not necessarily the same messages they receive in the program. • Coalitions address the community at large. In an effort to support every

child and enhance the effectiveness of individual programs, coalitions build a community consensus of non-use so that youth receive a consistent message regardless

of what system they interact with in the community. • Coalitions develop a broad base of support and collaboration. They convene the energy and resources of multiple sectors to enhance the effectiveness of individual approaches. • Congressman Rob Portman initiated the Coalition in Cincinnati because he realized that he could not simply legislate away the drug problem from Washington.

He needed to partner with the community at large so that together we could attack

the issue from all sides. We could collaboratively legislate, educate, recreate, arrest,

intervene, treat, etc. • We mobilize more talents, resources and approaches to influence an issue than

any single organization could achieve alone. • Coalitions implement data driven planning processes to define the

issue within their community and then program accordingly. • In 1996 the Coalition For a Drug Free Greater Cincinnati implemented the Student Drug Use Survey in an effort to provide the region the most current and reliable source of validated information on youth substance abuse. In 2004, this survey

gathered drug use data from nearly 70,000 7th through 12th grade students in

Greater Cincinnati. • Data from this survey and other surveys were used to identify key risk and protective factors present in Greater Cincinnati and to develop a comprehensive community plan to address the issues using strategies that enhance protective factors

and reduce risk factors. • The community plan is implemented through partnerships and collaboratives

with the many partners who make up the coalition. • Example—Linda Verst, a prevention specialist, partnered with the Coalition to

sponsor community roundtables to assess community needs regarding adolescent

substance abuse treatment. In a large, rural geographic area of Northern Kentucky,

treatment services were scarce and needs were going unmet. The roundtables promoted the spirit of collaboration among providers who in turn shared resources and

planned cooperatively. This resulted in increased access to adolescent substance

abuse treatment throughout Northern Kentucky. • Given their collaborative approach, coalitions are uniquely positioned

to plan and implement a diverse set of strategies to change community

norms, attitudes and standards of conduct. • Example—Tamie Sullivan, a parent in the community, chaired our Parent Task

Force and facilitated the implementation of the ‘‘Strong Voices, Smart Choices’’ parent education campaign. This campaign partnered with businesses, doctors, pharmacies, the local media, and the Ohio National Guard to put parenting tips into the

hands of over 750,000 parents in Greater Cincinnati. The campaign changed community attitudes and norms. Middle school parents often pull away from the issue

at this critical time, this campaign under Tamie’s leadership, changed the standard

so that the expectation is that parents become increasingly involved during the middle school years. The result, a 57 percent decrease in drug and alcohol use among

youth who report that parents talk to them and set clear rules regarding substance

abuse.

• The coalition focuses on increasing protective factors and decreasing

risk factors. And we are moving the needle.

• Examples of measurable impact (see attached table)

• Rob Matteucci, a Vice President at Procter & Gamble volunteers to oversee the

implementation of the anti-drug media campaign in our market. The result, a 12

percent decrease in drug use among youth who have seen or heard anti-drug advertisements.

• Mike Hall, Principal at a local high school, partners with businesses, a local

hospital and professional athletes in Greater Cincinnati to implement the ‘‘Coaches,

Kids and Chemicals’’ program. Over 1,200 coaches, principals and athletic directors

have been trained to incorporate substance abuse prevention into their athletic programs. The result, a 34 percent decrease in drug and alcohol use among youth involved in school sports.

• Pastor Wilkins, Chair of the Faith Community Alliance, partners with local

service providers and other faith leaders to implement the ‘‘Reviving the Human

Spirit’’, a faith-based initiative aimed at increasing the effectiveness of faith based

programs in our region. The result, a 55 percent reduction in drug and alcohol use

among youth involved in these programs.
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• Marty Herf , with the Ohio Bureau of Workers Compensation worked with the

Drug Free Workplace Task Force to convene local businesses, EAP (Employee Assistance Program) providers and State representatives to implement the ‘‘Say Yes

To A Drug Free Workplace’’ program. This program initiated the creation of a statewide incentive for businesses who implement a qualified drug free workplace program. The result, southwest Ohio has the highest percentage of drug free workplaces in the State.

By working through multiple systems within the community to address adolescent

substance use and abuse the Coalition for a Drug Free Greater Cincinnati has positively impacted the issue. All of the strategies that have been implemented to enhance protective factors, that the Coalition has organized the community around,

have become increasingly more effective for the last 6 years. And, for the first time

in over a decade, drug use is declining in Greater Cincinnati. In fact, for the first

time since the 80’s, data indicate that less than 20 percent of the combined 7th

through 12th population are 30-day users of alcohol, tobacco and marijuana.

I am a firm believer in the power of communities to reduce the use and abuse

of illicit drugs and alcohol among adolescents. Communities that attack their drug

problems in a comprehensive way, involve as many individuals, groups and institutions as possible have the greatest likelihood of success. With such strong coalitions

working to convene the community to work collaboratively, Southwest Ohio boasts

adolescent use rates that are significantly lower than State and national averages,

which are also declining. Additionally, we see much greater reductions, by as much

as 41 percent, in adolescent drug and alcohol use in communities where strong coalitions exist than in control communities where there are no coalitions.
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Senator DEWINE. Great. Thank you very much.

Mr. Anton?

Mr. ANTON. Chairman DeWine and Senator Reed, good morning.

My name is Ronald Anton, and I am the director of Juvenile Justice and Community Programs for Day One in Cape Elizabeth,

Maine.

First of all, I would like to recognize you, Mr. Chairman, for your

leadership in assisting people across the country who have addiction problems. Thank you for the opportunity to offer testimony

today on behalf of Day One, the Maine Association of Substance

Abuse Programs and the State Association of Addiction Services,

the national organization of State alcohol and drug abuse treatment and prevention provider associations, whose mission is to ensure the availability and accessibility of quality drug and alcohol

treatment, prevention, education and related services.
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Day One has been making a difference in the lives of youth for

over 30 years. Our spectrum of care provides prevention, intervention, treatment and after-care services for youth and their families

throughout Maine. Today, we are Maine’s premier agency dealing

with adolescent substance abuse. We use a variety of evidencebased prevention and treatment programs, and we are respected as

a resource and authority in the field.

Maine is a frontier State with a population of approximately 1.2

million people, and geographically, it is the size of all of the rest

of New England combined. Maine’s publicly-supported substance

abuse service system is complex and community-based, providing

education, prevention, early intervention and treatment services.

Now, I could talk about many of those programs, but I really

want to focus on one in particular today. Our most innovative approach to treatment has been through the creation of a systems approach to identifying adolescents with the potential for substance

abuse and accessing and providing services for them. Our collaborations began in 1996. And then, thanks to the impetus provided

by a SAMHSA CSAT Treatment Capacity Expansion Grant that

Maine received in 1998, Day One worked to formally develop the

Juvenile Treatment Network.

The Juvenile Treatment Network is a coordinated, State-wide

initiative whose goal is to identify, screen and refer adolescents

with substance abuse issues to State-approved treatment providers

of their choice. The Juvenile Treatment Network works to increase

access to substance abuse treatment services by providing a system

to coordinate a last resort funding for these services while identifying and addressing barriers to adolescent substance abuse treatment services.

The Juvenile Treatment Network is a collaboration of the Office

of Substance Abuse, substance abuse treatment providers, Maine

juvenile drug treatment courts, the Maine judiciary, the Department of Corrections, schools, police, the Native American tribes,

and other community agencies. Day One is contracted by the Office

of Substance Abuse to staff and manage the network.

It is with thanks to Annie Peletier, the program manager of the

network, who is here with me today, and to her staff, that this program has reached its high level of success and acceptance in

Maine. Prior to the Juvenile Treatment Network, although many

treatment providers existed, few provided any significant substance

abuse treatment services to adolescents. Now, identification,

screening, assessment and treatment services to adolescents and

their families are available through more than 50 provider agencies

at more than 80 locations across the State of Maine.

The Juvenile Automated Substance Abuse Evaluation Screening

and Referral Process, which was implemented in January 1998 as

part of the Juvenile Treatment Network: results to date include

close to 10,000 adolescents have been identified in the State of

Maine as being at risk for developing a substance abuse problem,

and more than 10,000 screenings have been conducted.

Of these, about 57 percent of the screenings recommended a further substance abuse evaluation to determine to what extent services were needed. Through this process, Maine reaches 18 percent

of kids in need of treatment, exceeding the national average of 8
65

percent by more than double. Between 1996 and 2003, adolescent

admissions to Maine’s substance abuse treatment services increased by 137.5 percent, compared to only 21.7 percent for adults.

Now, the benefits of this voucher program model that we have

has demonstrated the following: it provides a structure that has

helped to increase access to substance abuse treatment services

and recovery support services for adolescents. It provides client

choice and informed selection of treatment providers through the

State of Maine; provides an effective infrastructure through which

to distribute last resort funds for substance abuse treatment services. It maintains the professional integrity of licensing and certification standards. It provides for performance accountability of

treatment providers, and it offers funding for a limited range of recovery support services that can readily be expanded when appropriate.

Additionally, the network funds will cover transportation costs

for adolescents to get them to and from treatment appointments as

well as providing child care support. Day One continues to strive

for quality and comprehensiveness in all of its prevention and

treatment services. Equally as important, we work diligently to address barriers to treatment and systems issues that negatively affect the ability of Maine’s youth and families to access these needed

treatment and recovery support services.

We believe that our model, the only Statewide model in the Nation to build a system for adolescents that identifies youth in need

of services, expands access to and improves treatment Statewide

and engages all collaborative partners positively has produced positive results in a relatively short period of time. Surveys from our

members support this direction and approach. We hope that the

subcommittee will continue to study this model and encourage and

support the expansion of adolescent prevention and treatment services nationwide.

Thank you for listening to this testimony today. I would be

happy to answer any questions.

[The prepared statement of Mr. Anton follows:]

PREPARED STATEMENT OF RONALD ANTON

Introduction

Chairman DeWine and Members of the Subcommittee, thank you for the opportunity to present testimony on behalf of Day One, the Maine Association of Substance Abuse Programs, and the State Associations of Addiction Services, a national

organization of State alcohol and drug abuse treatment and prevention provider associations whose mission is to ensure the availability and accessibility of quality

drug and alcohol treatment, prevention, education, and related services. Day One

has been making a difference in the lives of youth for over 30 years. Our spectrum

of Care provides prevention, intervention, treatment and aftercare services for youth

and their families throughout Maine. Today, we are Maine’s premier agency dealing

with adolescent substance abuse and we are respected as a resource and authority

in the field. Our innovative programs and collaborative ethos provided adolescents,

parents, schools and communities the training, treatment, and support needed to

bring hope, healing and recovery to Maine youth and their families. Our mission

is to dramatically reduce substance abuse among Maine youth to help them live productive, healthy, and rewarding lives.

Overview

We would like to present you with information about adolescent treatment in

Maine and to share with you highlights of Day One’s Juvenile Treatment Network,
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our ‘‘voucher system’’ for adolescent services. But first, here is some information

about our State.

Maine is a frontier State with a population of approximately 1.2 million and geographically the size of all of the rest of New England combined. Maine has the largest county east of the Mississippi River (equal to the size of Connecticut and Rhode

Island combined), and this county is in the most northern and rural part of the

State. Maine’s Office of Substance Abuse (the State’s Single State Authority) has

stated that it maintains a viable treatment continuum of services in the State that

includes: shelters, extended shelters, detoxification, extended care, residential rehabilitation, halfway houses, non-residential rehabilitation, outpatient care, as well as

facilities for treating adolescents. This range of services is designed to help clients

receive the level of care they need.

Maine’s publicly supported substance abuse service system is complex and community based, providing education, prevention, early intervention, and treatment

services. Currently, OSA has 45 contracts for services with 33 substance abuse

treatment agencies. Our Juvenile Treatment Network has reached beyond these

contracted treatment agencies in an attempt to reduce barriers, and provide access

and choice to adolescent substance abuse treatment services.

In State Fiscal Year (SFY) 2003, 14,747 clients and 19,784 admissions were reported through OSA’s Treatment Data System. This was a 12.4 percent increase in

clients served since the previous fiscal year. Of those clients admitted for services

in State Fiscal Year 2003, 66.3 percent were males and 33.7 percent were females,

continuing a similar pattern from past years. Eighty-five percent were adults and

15 percent were youth, continuing a growing pattern in serving youth.

Day One’s Adolescent Treatment is Research-Based

As an agency dedicated to providing services to adolescents and families affected

by adolescent substance abuse, we constantly have been aware of the uniqueness

of adolescents, and the special needs that they present. Adolescents are not just

young adults. They present with varying and different issues than do adults, and

need to have an ability to look at their specific risk and protective factors as they

address their substance use and other life issues in treatment. Consequently, the

challenges in providing services are to find and utilize effective prevention and

treatment strategies. Day One supports the ongoing professional development of our

staff in the various programs that we operate.

Treatment through Day One is available across the full continuum, from outpatient services and intensive outpatient, to long-term residential and transitional

housing for youth in need. In the last 6 years, as more and more research has become available, we have (through both our Day One programming and through

training sponsored or provided by our Juvenile Treatment Network) introduced and

reinforced the use of evidence-based and other ‘‘best-practices’’ in prevention and

treatment services to youth. We have worked collaboratively with the Office of Substance Abuse in all of these endeavors. In the prevention area, Day One currently

provides a number of science-based and model prevention programs, including

‘‘Guiding Good Choices’’ and ‘‘Reconnecting Youth.’’

In addition, in the assessment and treatment area, for the past number of years

we have worked with Dr. Norman Hoffmann, on the faculty of Brown University,

and an international expert on screening and assessment instruments, in the use

of the ‘‘Practical Adolescent Dual Diagnosis Interview’’ (PADDI) as part of a co-occurring assessment in most of our Day One treatment services. Our studies of the

results of the use of the PADDI have been published in a number of professional

journals, including Addiction Professional and Offender Substance Abuse Report.

Other publications are pending and our use of the PADDI continues. Also, our outpatient treatment services here at Day One are recent participants as a ‘‘Center of

Excellence’’ in a private foundation grant award that will bring strong collaborations

and additional skills development in the area of services to youth presenting with

co-occurring substance abuse and mental health issues. This grant initiative will

allow Day One the opportunity to work closely with Dr. Ken Minkoff, a psychiatrist

and specialist in the development of service systems for people with both substance

abuse and mental health issues. Day One will also participate as a founding member in the Maine Institute for Quality Behavioral Health Care.

Day One’s juvenile corrections programs utilize the evidence-based treatment modalities found to be most effective with adolescents in the juvenile justice system.

Consequently our substance abuse treatment programs in the two State juvenile

correctional facilities and in our Statewide Juvenile Drug Treatment Courts system

make use of these approaches. Research conducted with our Juvenile Drug Treatment Courts demonstrate that adolescents in that program are less likely to return

to the justice system with new offenses, and more likely to address their substance
67

use and abuse issues in a positive manner than adolescents in the juvenile justice

system that do not participate in this program.

Development of the Juvenile Treatment Network or ‘‘Voucher Program’’

Our most innovative approach to treatment has been through the creation of a

systems approach to accessing and providing services for youth. The initial collaborations that ultimately resulted in the formation of the Juvenile Treatment Network

began in 1996 with the receipt of a small State grant. Then, thanks to the impetus

provided by a CSAT Treatment Capacity Expansion Grant that Maine received in

1998, Day One worked to formally develop what is called the Juvenile Treatment

Network. The Juvenile Treatment Network is a coordinated Statewide initiative

whose goal is to identify, screen and refer adolescents with substance abuse issues

to State approved treatment providers of their choice and to increase access to substance abuse treatment services by providing a system to coordinate a last resort

funding for these services. The Network is a collaboration of the Office of Substance

Abuse (OSA), substance abuse treatment providers, Maine Juvenile Drug Treatment

Courts and Judiciary, the Department of Corrections, schools, police and other community agencies. Day One is contracted by the Office of Substance Abuse to staff

and manage the Network.

Prior to the Juvenile Treatment Network substance abuse treatment services to

adolescents in Maine were provided by only a handful of agencies across the State.

Resources were scarce, and so our approach to treatment capacity expansion was

to develop a system of services for adolescents that could be accessed across the

State. Screening, assessment and treatment services are now available through

more than 50 provider agencies at more than 80 locations across Maine.

The Juvenile Treatment Network utilizes the ‘‘Juvenile Automated Substance

Abuse Evaluation’’ (JASAE), a standardized tool to screen adolescents and to provide information to determine if and to what extent further substance abuse assessment and treatment services are needed. These screening services are available

throughout Maine and are conducted by a cadre of individuals who are trained by

the Network to administer this screening instrument. If it is determined that further services are needed the adolescent is referred to one or more of over 50 participating treatment providers Statewide. In addition, the Network coordinates and distributes last resort payment funds for adolescents referred to Network member substance abuse treatment providers and who meet funding eligibility criteria.

The JASAE screening and referral process was implemented in January 1998 as

part of the Juvenile Treatment Network. Results to date include:

• Close to 10,000 JASAE surveys have been administered which translates to just

under 10,000 adolescents being identified in the State of Maine as being at risk for

developing a substance abuse problem.

• Of those, about 57 percent of the screenings recommended a further substance

abuse evaluation to determine to what extent services are needed. Through this

process, Maine reaches 18 percent of kids in need of treatment, exceeding the

national average of 8 percent by more than double.

• Adolescents identified as needing treatment were given the choice to select one

of the 50 participating treatment providers for services in over 80 locations throughout the State. Maine is the only State to have a Statewide coordinated system of

care for adolescent substance abuse screening, assessment and treatment services.

• Through a combination of Federal Targeted Capacity Expansion Grant funds

(SAMHSA/CSAT funds) and State funds, over $750,000 was distributed through the

Juvenile Treatment Network to pay for screening and treatment services.

• Provided five treatment capacity expansion loans to treatment providers in 1999

as incentives to begin additional treatment services in underserved areas of the

State.

• Provided five treatment capacity expansion start-up grants in 2002 for new and/

or innovative substance abuse treatment programs totaling over $70,000.

• Additional data from the JASAE administrations is included at the end of this

testimony.

The Juvenile Treatment Network has demonstrated success in implementing an

effective centralized identification, screening, referral and last resort funding system

to increase access to substance abuse treatment services for adolescents. This model

is an effective ‘‘Voucher program’’ and shares common goals and objectives for implementation. In a January 2004 report, prepared by the Office of Substance Abuse,

and presented to the Maine Legislature Joint Standing Committee on Health and

Human Services regarding ‘‘An Act to Obtain Substance Abuse Services for Minors,’’

it was stated that ‘‘Capacity to treat adolescent substance abuse has expanded dramatically over the past few years, particularly at the outpatient level because of the

creation of the Juvenile Treatment Network.’’
68

The benefits that this ‘‘voucher program’’ model has demonstrated include:

• Providing a structure that has helped to increase access to substance abuse

treatment services and recovery services for adolescents;

• Providing client choice and informed selection of treatment providers throughout the State of Maine;

• Providing an effective infrastructure through which to distribute last resort

funds for substance abuse treatment services;

• Maintaining professional integrity of licensing and certification standards;

• Providing for performance accountability of treatment providers;

• Offering funding for a limited range of recovery support services that can readily be expanded when appropriate; and

• Providing assessment and treatment services at an average cost of $1,597 per

adolescent admitted to treatment.

The Programs

There are two programs the Network manages: the Juvenile Corrections Substance Abuse Treatment Network (JCSATN) and the more recently created (2002)

Substance Abuse Treatment Network for Adolescents (SATNA).

The Juvenile Corrections Substance Abuse Treatment Network was created in response to the increasing number of juvenile offenders who have substance abuse

issues and who need and cannot obtain substance abuse treatment. In January of

1998, substance abuse treatment providers throughout the State formally applied

for membership in the Network and a standardized screening tool, the Juvenile

Automated Substance Abuse Evaluation (JASAE), was chosen for the purpose of

screening and referring juvenile offenders in the State of Maine.

Because of the success of the Juvenile Corrections Substance Abuse Treatment

Network, and to implement recommendations from the Third Year Evaluation Report (conducted by the University of Southern Maine, Department of Social and Behavioral Research) of the Juvenile Treatment Network and Juvenile Drug Treatment Courts, the Substance Abuse Treatment Network for Adolescents was created

to address the needs of adolescents with substance abuse issues before they became

involved with the juvenile justice system. This program began on July 1, 2002, and

identifies adolescents who may have a substance abuse problem through participating schools and other community-based organizations Statewide. The Substance

Abuse Treatment Network for Adolescents also uses the Juvenile Automated Substance Abuse Evaluation for screening and assessment purposes.

In addition to screening and referral services, the Network also has a last-resort

payment source for adolescents in both programs who meet certain eligibility guidelines and are accessing further evaluation/substance abuse treatment as a result of

their JASAE recommendations.

The Treatment Providers

Network member treatment providers are selected based on the following criteria:

• Agency must be licensed by the State Office of Substance Abuse.

• Agency must be Medicaid Eligible.

• Agency must provide outpatient and/or intensive outpatient substance abuse

services in one or more services locations.

• Agency must adhere to Network policies.

Participating treatment providers commit to the following:

• Participation in Network-sponsored training and attendance at a minimum of

three Network meetings per year.

• Incorporation of best practices into treatment programs for adolescents, with

best practices defined by the Network in collaboration with the State Office of Substance Abuse and demonstrated by research;

• Use of Network-developed protocols and forms for communication between the

Juvenile Treatment Network, Network Member Treatment Providers, Department

of Corrections, schools and other community organizations;

• Collaboration with other Network members and participants to identify gaps in

treatment services and work cooperatively to fill those gaps;

• Participation in a Network screening and referral system designed to match client needs with provider strengths;

• Development of program admission and discharge criteria consistent with best

practices for adolescents; and

• Participation in Network development of policy, procedures and training designed to implement Network goals and encourage provider compliance; and

• Timely completion of required State Office of Substance Abuse Admission and

Discharge forms with the appropriate Network Code.

Members of the Juvenile Treatment Network receive the following benefits:
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• Last resort outpatient treatment reimbursement eligibility for providers;

• Free registration for Network-sponsored trainings;

• Participation in the Network screening and referral system;

• Input into the development of Network policy and a system of comprehensive

continuum of care for adolescents;

• Participation in a data collection system that will assist in identifying barriers

to substance abuse treatment services throughout the State; and

• Improved communication between referral sources and treatment providers

through attendance at quarterly Network meetings.

Last Resort Funding Distribution

Network funds are available to pay for substance abuse treatment for adolescents

that have no other means of payment. Adolescents must meet identified criteria to

be considered eligible for last resort payment funds.

The goal of the Network is to reduce barriers to treatment services and partial

funding is available if a hardship or barrier that would prevent the adolescent from

accessing treatment services has been identified by the treatment provider.

Eligible adolescents must not have private insurance that will cover substance

abuse treatment services. If an adolescent’s coverage does not include substance

abuse treatment services, or the juvenile has exceeded the allowable benefits, Network funds may be an option. If an adolescent and his/her parents do have insurance but paying their co-pay would be a financial hardship, the Network funds may

be an option. This is also true if the family has a deductible that must be met before

the insurance will cover services.

Any adolescent who is eligible for Medicaid is not eligible for Network funds until

Medicaid resources are exhausted or if a particular service is not covered by Medicaid (e.g. assessment and other transitional services from institutional care to community-based services).

If a client can pay a certain amount per session, Network funds may be able to

fund part of the session providing that the total amount does not exceed the maximum allowance listed on the Substance Abuse Treatment Network for Adolescents

billing form.

By accepting Network funds for treatment services the provider agrees not to bill

the adolescent/family for any fees over and above the maximum reimbursement paid

by the Substance Abuse Treatment Network for Adolescents.

The Network funds will cover transportation costs for adolescents to get to and

from treatment appointments. This option is available regardless of payment source.

If, in the provider’s judgment, transportation is a barrier to treatment, the Network

funds will cover bus or cab fare, or pay mileage to the adolescent or friend/family

member that drives the adolescent to and from treatment.

As with transportation costs, the Network funds will cover childcare regardless

of the funding source for treatment.

Additional Services

In addition to the centralized identification, screening, referral and payment system in place, the Network also functions to facilitate collaboration between the Department of Corrections, Office of Substance Abuse, Maine Department of Behavioral and Developmental Services, Maine Juvenile Drug Treatment Courts, substance abuse treatment providers, schools, police and other community agencies. To

facilitate this collaboration the Network annually hosts 28 meetings throughout the

State. Representation from all of the above mentioned agencies are typically

present. These meetings are a place where individuals and agencies can and do discuss barriers to treatment services and how to address these issues. The meetings

also serve to provide a forum to disseminate information as it relates to the Network or the field. In addition, the Network will provide training in response to provider and other partners’ needs.

The Network has a comprehensive database in which data is recorded from the

JASAE assessment tool, information related to the referral for the JASAE and further evaluation as well as data relating to the last resort payment source. To date

the Network has information pertaining to close to 10,000 JASAEs. This information is used in a number of ways by various agencies. This information has been

used to identify trends and barriers, gauge service capacity needs and support grant

proposals.

In addition, the Network has developed Policy and Procedure Manuals for all of

the Network operations and has shared these manuals with other States and agencies looking to implement a similar structure to address substance abuse treatment.
70

Closing

Day One continues to strive for quality and comprehensiveness in all of its prevention and treatment services. Equally as important, we work diligently to address

barriers to treatment and systems issues that negatively affect the ability of Maine’s

youth and families to access these needed treatment and recovery support services.

We believe that our model, one of the first Statewide models in the Nation to build

a system for adolescents that identifies youth in need of services, expands access

to and improves treatment Statewide, and engages all collaborative partners, has

produced positive results in a relatively short period of time. Surveys from our members support this direction and approach. We hope that the subcommittee will continue to study this model and encourage and support the expansion of adolescent

prevention and treatment services nationwide. Thank you for listening to this testimony today. I would be happy to answer any questions.

Additional JASAE Screening Data

Percentage of those referred for further evaluation: 57 percent

(Percentages below based on total number of JASAE’s screened)

Male/Female ratio: 65 percent Males, 35 percent Females

Percentages regarding living status:

Living at home with both parents: 41 percent

Living at home with mom: 26 percent

Living at home with dad: 8 percent

Living with relatives: 3 percent

Living with sister/brother: <1 percent

Living with non-family: 3 percent

Living in foster home: <1 percent

Other: 6 percent

Unknown (pre-data collection for this variable): 12 percent

Percentages regarding educational status:

In school full time: 66 percent

In school part time: 5 percent

Suspended: 2 percent

Quit school: 9 percent

Kicked out of school: 4 percent

Finished school: 2 percent

Unknown (pre-data collection for this variable): 12 percent

Most frequently used drug:

Alcohol: 48.5 percent

Marijuana: 34.8 percent

None: 10.7 percent

Sedatives/Hypnotics: 1.2 percent

Barbiturates, Amphetamine, Cocaine, Crack,

Hallucinogens, Heroin, Inhalants, Tranquilizers, Other: Each <1 percent

PREPARED STATEMENT OF NORMAN G. HOFFMANN, PH.D. ANA M. ABRANTES, PH.D.

AND RONALD ANTON, LCPC, LADC, MAC

ABSTRACT

The PADDI (Practical Adolescent Diagnostic Interview) is a structured diagnostic

interview, designed to gather basic information about substance use disorders, other

mental health conditions, and related experiences. It is used for the evaluation of

all adolescents committed to juvenile detention centers in Maine. Anonymous data

from 230 adolescents interviewed as part of routine clinical assessments in the detention centers were analyzed to assess the prevalence and severity of problem

areas of importance to correctional officials.

Results demonstrated that the majority of individuals manifested multiple problems. Relative prevalence rates and implications of the findings for clinical services

and case management are discussed. The case is made for pragmatic routine intake

assessments for adolescents entering the juvenile justice system.

INTRODUCTION

Observed prevalence rates for co-occurring mental health and substance use disorders vary from setting to setting, but consistently show levels suggesting a necessity for routine assessment. Estimates tend to range from about 50 percent in adolescent psychiatric populations (Grilo, Becker, Walker, Levy, Edell, & McGlashan,

1995) to as high as 80 percent among adolescents receiving services for substance

dependence (Stowell & Estroff, 1992). Such differentials may be consistent with ob-
71

servations in adult populations that many co-existing mental health conditions may

be substance-induced (Lehman, Myers, Corty, Thompson, 1994).

Concomitant psychopathology among substance abusing adolescents has been associated with significant negative consequences including more severe substance involvement, greater suicidal ideation, academic problems, and family difficulties.

While it has been well established that concomitant psychopathology is associated

with poorer treatment outcomes among adult substance abusing populations, recent

evidence points to similar findings among adolescent substance abusers as well.

Findings from the Drug Abuse Treatment Outcome Study for Adolescents (DATOSA) showed greater substance involvement and illegal acts among adolescents with

a concomitant mental health disorder compared to those without a co-occurring disorder (Grella, Hser, Joshi, Rounds-Bryant, 2001). In addition, conduct disorder

among substance abusing adolescents has been associated with greater alcohol and

drug involvement and poorer psychosocial functioning in young adulthood (Myers,

Stewart, & Brown, 1998). Therefore, given the prevalence and clinical correlates of

co-occurring disorders among adolescents, accurate identification and assessment of

these disorders is crucial for the development of effective treatment interventions

and reducing criminal recidivism.

While some structured interviews such as the Diagnostic Interview Schedule for

Children (DISC) have been developed for evaluating co-occurring conditions, they

were initially developed for research and have limitations for routine clinical applications (Shaffer, Fisher, Dulcan, et al., 1996). For example, administrations of the

DISC are time consuming, averaging over one hour to complete. Extensive assessment instruments such as the GAINS (Dennis, et al., 1999) are also too time consuming to be used as an initial screening or assessment instrument for juvenile justice settings. Given the limited resources available in juvenile justice environments,

these measures, while well suited for research or treatment applications, are not the

optimal choice for use in these settings.

A practical instrument to accurately assess adolescents with co-occurring conditions should be adolescent-specific, developmentally appropriate, and obtain a continuous measure of symptomatology to provide indications of severity. The instrument should also demonstrate strong psychometric properties across a wide range

of mental health problems, including substance use disorders. In addition, the instrument should be able to be capable of providing a foundation for diagnostic documentation in accordance with current diagnostic criteria (APA, 1994, 2000). To date,

we are not aware of an assessment instrument that has demonstrated all of these

characteristics.

The Practical Adolescent Dual Diagnostic Interview (PADDI) was developed as a

pragmatic clinical assessment tool to standardize diagnostic assessments of adolescents (Estroff & Hoffmann, 2001). The structured questions are designed to collect

information about specific symptoms and behaviors in an objective and value neutral tone. It does not attempt to cover all possible diagnoses, nor does it attempt

to probe every aspect of some of the covered conditions. Rather, it is designed to

address the more common symptoms and indications of problems in the context of

an interview limited to approximately 30 to 45 minutes. The PADDI has demonstrated its utility in clinical populations (Hoffmann, Estroff, & Wallace, 2001) and

in initial assessment of adolescents in juvenile justice settings (Hoffmann, Abrantes,

& Anton, 2003). The present study considers the presenting problems for both males

and females committed to juvenile detention centers. These adolescents are expected

to be under the supervision for some time so that proper care and case management

are likely to be an ongoing concern for juvenile justice officials.

METHODS

The PADDI is a structured diagnostic interview that covers indications of prevalent mental health conditions and substance use disorders. It is designed explicitly

for use with adolescents and is not an adaptation of an adult tool. The PADDI is

structured for routine clinical administration facilitated by a detailed manual (Hoffmann & Estroff, 2001). Therefore, juvenile justice personnel, trained technicians, or

behavioral health professionals can administer the interview.

Interpretation of findings or making diagnostic determinations requires a professional or team of professionals with the appropriate training and expertise covering

both mental health and substance use disorders. Professionals who may not have

expertise in both mental health and substance use disorders can gather pertinent

information to aid in determining diagnoses within their areas of competence and

making focused and appropriate referrals to other professionals for those areas in

which they might not practice. Juvenile justice staff can use the interview to gather
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sufficient information to inform referrals to professionals for further evaluation or

services.

The interview includes questions related to depressive and manic episodes, mixed

states, psychosis, PTSD, panic attacks, generalized anxiety and phobias, obsessivecompulsive disorder, conduct and oppositional defiant disorders, and possible paranoid and dependent personality disorders in addition to substance use disorders.

Questions about dangerousness to self and others as well as victimization (physical,

sexual, and emotional abuse) are also included. As mentioned, the design and

branching allow the interview to be administered in a relatively short amount of

time-30 to 45 minutes depending upon the extent of problems reported.

Procedures

The study obtained anonymous data consisting of the item responses to PADDI

interviews conducted in routine assessments from the two detention centers in

Maine. The organization providing the behavioral health coverage for the detention

centers uses the PADDI as part of the standard clinical assessment. The staff removed names and unique identifiers from copies of the protocol for all consecutively

admitted committed adolescents to be processed for statistical analyses of problem

prevalences. These data and analyses facilitate administrative oversight of the services and comparisons of prevalences between the two facilities. They also provide

the information for this report.

Sample

Data from a total of 230 adolescents (199 males and 31 females) were analyzed.

Ages ranged from 13 to 18, and the average age of the sample was 16.3 (S.D.=1.10).

Approximately 64 percent of the adolescents were between the ages of 16 and 17.

The vast majority of the adolescents were Caucasian (88 percent), and Native Americans (5 percent) constituted the only minority ethnic group with more than 10

cases. The remainder of the sample was from other ethnic groups or of mixed ethnicity.

Educational achievement appears low for a number of these adolescents. Although

more than 75 percent were over the age of 15, 38 percent had passed no higher than

the 8th grade in school. Approximately 30 percent were at least 1 year behind the

expected grade level for their age group. Although only 13 percent reported substantial reading difficulties, more than 50 percent had been in special classes for academic or behavioral problems.

A large number of the sample had been prescribed medication for either a medical

or mental health condition. Almost two in five (37 percent) reported being on medications at the time of the interview and an additional 23 percent reported receiving

medications previously.

Non-violent offences were cited as the most frequent issue related to the admission (55 percent), followed by substance related issues (42 percent). Violent offenses

were acknowledged by 27 percent. There were no significant differences between

males and females for the prevalence of either violent or non-violent offenses. A statistically significant differential for substance related offenses was noted with males

reporting more (44 percent vs. 23 percent) than females (p<.05).

Analyses

Item responses from the PADDI forms were entered and verified into Excel spread

sheets and converted into SPSS (Statistical Packages for the Social Science) system

files for analyses. Algorithms for scoring the scales related to conditions for which

the PADDI captures sufficient information to suggest a specific diagnosis. Thus the

scales for symptoms of psychosis and generalized anxiety and phobias were not analyzed for placement into diagnostic groups because these scales serve more as

screens than documenting diagnostic indications.

The algorithms placed individuals into one of five priorities defined categories: no

symptoms, sub-diagnostic, meeting minimal criteria, exceeding minimal criteria, and

far exceeding minimal criteria. The sub-diagnostic category includes individuals who

reported at least one positive response, but not enough to meet the minimal indications for a diagnosis. Those in the ‘‘exceeds criteria’’ group report positive indications on at least one additional criterion beyond the minimum, and those in the last

group typically endorsed 70 percent to 85 percent of the possible criteria items. For

substance use disorders, only substance dependence was considered since it has

been shown to be the more severe (Hoffmann, DeHart, & Campbell, 2002; Hoffmann, & Hoffmann, 2003) and chronic condition (Schuckit, Smith, Danko, Bucholz,

Reich, & Bierut, 2001).
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RESULTS

General prevalence rates for various problem areas and disorders are presented

for male and female adolescents in Table 1. Although these adolescents have committed offenses resulting in commitment to a juvenile detention center, many have

been victims of various forms of abuse. Abuse categories as determined by the

PADDI are very conservative and require substantial indications of maltreatment.

Physical abuse is defined as being hit so hard or so as to result in marks or fear

of the perpetrator or to have resulted in the need for medical attention in an emergency room. Sexual abuse is identified as unwanted physical contact or coercion to

engage in sexual acts. Emotional abuse is defined as being persistently ridiculed or

humiliated over a period of time. Given these definitions, almost 75 percent of the

females and 45 percent of the males have been subjected to some form of abuse.

Emotional and physical abuses are the most common for both genders. The majority of females (52 percent) report emotional abuse followed by sexual abuse (45 percent). For males, physical and emotional abuses are reported by about 30 percent

of the adolescents. The overall prevalences for emotional and sexual abuse are

greater for females at statistically significant levels.

For both genders, sexual abuse is highly related to other forms of abuse. From

36 percent to 40 percent of all sexual abuse victims report all three forms of abuse

regardless of gender. Fifty percent of females and 67 percent of males who were sexually abused also report other forms of physical abuse.

TABLE 1: PROBLEM PREVALENCES† BY GENDER

Problem Area Females N=31 Males N=199

Physically abused ........................................................................................................................... 36% 30%

Sexually abused ** ......................................................................................................................... 45% 11%

Emotionally abused * ...................................................................................................................... 52% 28%

Any prior suicide attempts ............................................................................................................. 39% 24%

Multiple prior suicide attempts ...................................................................................................... 26% 18%

Considered killing someone ............................................................................................................ 13% 18%

Auditory plus other hallucinations ** ............................................................................................. 23% 4%

Major depressive episodes ** ......................................................................................................... 64% 24%

Manic episodes ............................................................................................................................... 40% 19%

Panic attacks .................................................................................................................................. 13% 8%

PTSD ................................................................................................................................................ 36% 15%

Conduct Disorder ............................................................................................................................ 74% 83%

Oppositional Defiant Disorder ......................................................................................................... 61% 51%

Substance Dependence ................................................................................................................... 69% 60%

* p<.01; ** p<.001. † All prevalences exclude apparent substance induced indications.

Suicidal ideation and possible suicide risks appear to be of concern with a substantial minority of cases. Overall, 26 percent of females and 18 percent of males

report a history of more than one suicidal attempt or gesture. A substantial number

have considered specific ways in which they might kill themselves, which may serve

to increase concerns in this area.

Compared to a history or thoughts of self-harm, serious consideration of harming

others appears to be considerably lower. Fewer than 20 percent of males and 15 percent of females acknowledged thoughts of serious harm to others. Positive responses

to the question of harming others were positively related to confinement for a current violent offense, to acknowledging initiation of fights and to having used a weapon in a fight.

Conduct disorder and substance dependence are the most prevalent of the behavioral health conditions. However, it is probable that some behaviors associated with

the substance dependence may account for a portion of the conduct disorder indications. For example, some theft or initiation of fights may be related to getting

money for drugs or related to alcohol or other drug use.

Before considering some of the severity indications, for these conditions, a discussion of the other mental health areas is appropriate. The indications for psychoses,

affective and anxiety disorders are of significance in that many of these conditions

require medications for their proper treatment and management. While some of

these disorders could be substance induced, many are likely to exist as independent

conditions and will contribute to relapse to substance misuse if left unaddressed.

Indications of psychosis are problematic to assess from responses to structured

questions because many of the indications of these disorders include observational

information. However, acknowledgment of hallucinations does provide in indication
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that this area warrants further consideration. This is particularly true for auditory

hallucinations in the absence of substance use or when they occur at times other

than when the individual is drifting off to sleep or awakening. Of the females, 23

percent reported both auditory and other hallucinations in the absence when obvious associations with substances or sleep are excluded. In contrast, only 4 percent

of males report such events.

Another area of major concern involves affective disorders because these too may

indicate a need for medications for proper management of such conditions. When

only a constellation of symptoms consistent with major depressive episodes is considered and exclusions for obvious substance induced instances are excluded, a majority (64 percent) of females and almost a fourth of males report such a constellation of symptoms. Manic episodes are also relatively common as can be seen in

Table 1. Of particular concern are those cases where both manic and major depressive episodes are both reported by the same individual. This would suggest the possibility of an emerging bipolar disorder in which the individual alternated between

depressive and manic episodes. Of the entire cohort, 13 percent report both depressive and manic episodes with symptoms levels that exceed the DSM-IV requirements for both types of episodes. This suggests that as many as one in ten of the

adolescents committed to the detention centers may require mood stabilizing medications if the bipolar condition is confirmed by a psychiatrist.

Anxiety disorders may take many forms. The PADDI conducts a brief screening

for generalized anxiety, phobias, and obsessive-compulsive indications, but covers

panic attacks and posttraumatic stress disorder (PTSD) in greater depth. Females

are more likely to reach levels of symptoms for concern for the various anxiety indicators; however, PTSD shows the greatest and most significant differential. This is

not surprising in light of the level of abuse reported by females. That is, given the

levels of physical, emotional, and sexual abuse, among females, it is expected that

a significant number of them would report experiencing indications of PTSD.

If only the more prevalent conditions are considered (major depressive episodes,

mania, PTSD, conduct disorder, and substance dependence), 92 percent of the consecutive admissions report positive indications suggesting a possible diagnosis. Even

when the thresholds for each disorder is increased so as to exceed the criteria of

the DSM-IV so as to decrease the likelihood that the findings might include falsepositive indications, 77 percent still emerge as positive for one or more conditions.

Using the more stringent requirements, almost 25 percent of the consecutive admissions are positive for only one condition, but most (52 percent) are positive for multiple conditions. Not surprisingly, the combination of substance dependence and conduct disorder is one of the most prevalent (10 percent of the cohort), but these estimates do not include possible psychoses or anxiety disorders.

For those who meet diagnostic criteria, the extent of symptoms and the pattern

formed by the number of diagnostic indications provide both an indication of severity and validity for several of the diagnostic formulations. The distributions for the

number of positive diagnostic indicators are in Table 2. The diagnostic and severity

of seven conditions presented in the table suggest that for most conditions, the

PADDI items make a relatively clear distinction for those who meet diagnostic criteria. Major depression, manic episodes, and substance dependence produce profiles

where the majority of cases fall into either the category for no symptoms or the one

indicating extensive symptomatology. These conditions appear more categorical

while conditions such as conduct disorder appear more dimensional with more of a

normal distribution of problems.

TABLE 2: SYMPTOM PROFILES FOR SELECTED CONDITIONS N=230

Condition (Lifetime) No Symptoms Sub-diagnostic

Minimal

Criteria

Exceeds

Criteria

Far Exceeds

Criteria

Major Depressive Episode * ................................. 62% 8% 9% 10% 11%

Manic Episode * ................................................... 73% 5% 5% 8% 9%

Panic Attacks ** .................................................. 81% 10% 3% 5% 1%

Posttraumatic Stress Disorder ............................. 64% 18% 1% 10% 7%

Conduct Disorder ................................................. 3% 15% 35% 27% 20%

Oppositional Defiant Disorder ............................. 12% 35% 14% 7% 32%

Substance Dependence † ..................................... 19% 20% 5% 8% 48%

* Substance induced conditions are counted as sub-diagnostic.

** Only symptoms for attacks in the previous 12 months are considered.

† Diagnosis considered only if use is reported in the past 12 months; abuse cases are counted in the sub-diagnostic category.
75

Several points need to be made concerning the categorizations in the tables. First,

those individuals denying any substance use in the previous 12 months were placed

into the ‘‘no symptom’’ category for substance dependence and those meeting abuse

criteria only were placed into the ‘‘sub-diagnostic’’ category. Second, oppositional defiant disorder is subsumed by conduct disorder in the DSM-IV criteria. That is, if

the individual meets both criteria, only the conduct disorder diagnosis is given. This

is ignored in the present analyses to illustrate the profile of symptoms for both sets

of items. Finally, conditions such as depression and mania that might be substance

induced are placed in the ‘‘sub-diagnostic’’ category if the individual reports the

symptoms to be associated only with use.

As can be seen in Table 2, a number of conditions present relatively clear syndromes while others do not. That is, for clear syndromes those who meet at least

the minimum number of diagnostic criteria fall into the moderate to high range of

symptoms while those who do not meet criteria usually have no symptoms. This results in a bimodal where the majority of individuals fall either into the no symptom

category or into the moderate or above range of symptoms, and the fewest cases are

seen in the sub-diagnostic or minimal criteria categories. When a clear syndrome

is not found, or sees more of a normal distribution where most cases are in the subdiagnostic to minimal criteria categories.

In the case of substance dependence, the majority of cases (67 percent) fall either

in the no symptom or highest symptom groups. When the abuse only cases are considered as sub-diagnostic, 20 percent are seen in this category and only 5 percent

of the cases fall into the dependence with minimal criteria met. In contrast 48 percent of the entire sample fall into the high symptom category meaning that they

are positive for at least five of the seven dependence criteria. Similarly, major depressive and manic episodes appear to be categorically distributed. Most cases meeting at least minimal diagnostic criteria tend to be in the higher ranges of symptoms

while the majority of cases are in the no symptom category.

On the other hand, conduct disorder symptoms appear to be distributed much differently. In this example, conduct symptoms are approaching a normal distribution

with most cases falling into the minimal diagnostic category and few cases in the

no symptom and highest symptom categories.

These general distributions are similar for both males and females although the

exact percentages vary between the genders. Since the number of females is relatively small, no specific comparisons are made at this time.

DISCUSSION

The results of this study suggest a number of issues that merit specific discussion.

First, the distribution of scores across the five diagnostic categories (no symptoms,

sub-diagnostic, meeting minimal criteria, exceeding minimal criteria, and far exceeding minimal criteria) is such that, for most problem areas, a clear distinction

exists between those individuals meeting DSM-IV diagnostic criteria from those that

do not. This finding supports the utility of the PADDI as a screening instrument

with the ability to discriminate between adolescents likely to meet diagnostic criteria for a given disorder and those who are not.

Second, the prevalence and extent of problems noted in these consecutive admissions to juvenile centers suggest that routine screening and assessment should be

conducted for both mental health and substance use disorders. Many of these conditions require professional services and in some cases medications for proper care

and case management.

This analyses as to most have some limitations. First, these data from the PADDI

cannot definitively rule out the possibility of substance induced mental health problems and the instrument is not intended to make comprehensive diagnostic determinations on all conditions. Thus, while a positive indication on the PADDI may be

a clear signal of a need for further evaluation, it is by itself not a diagnosis. Additionally, concurrent validity cannot be assumed, as no data exists to corroborate how

often the PADDI’s impressions are confirmed with a firm clinical diagnosis. Second,

the participants in this study may not be representative of all potential users of the

instrument. The study is based on consecutive admissions from facilities in a State

where the number of minority individuals is small. This precludes generalizing to

inner city populations where minority subcultures might influence reporting.

Despite the limitations, these analyses do provide basic statistical information on

the PADDI and support for its use. Information on the severity of diagnostic conditions and forms of victimization also support the argument for routine assessment

of youths entering juvenile facilities. Further research with other populations and

concurrent validity measures will provide more definitive perspectives on this critical area.
76

REFERENCES

American Psychiatric Association (1994). Diagnostic and Statistical Manual of

Mental Disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition, Text Revision.Washington, DC: Author.

Dennis, M. L., Titus, J.C., White, M., Unsicker, J., & Hodgkins, D. (2002). Global

Appraisal of Individual Needs (GAIN) Administration guide for the GAIN and related measures. Bloomington, IL Retrieved from http//www.chestnut.org/li/gain/

gadm1299.pdf.

Estroff, T. W. & Hoffmann, N.G. (2001). PADDI: Practical Adolescent Dual Diagnosis Interview. Smithfield, RI: Evince Clinical Assessments.

Grella, C.E., Hser, Y., Joshi, V., & Rounds-Bryant, J. (2001). Drug treatment outcomes for adolescents with comorbid mental and substance use disorders. Journal

of Nervous and Mental Disease, 189, 384-392.

Grilo, C.M., Becker, D.F., Walker, M.L., Levy, K.N., Edell, W.S., & McGlashan,

T. H. (1995). Psychiatric comorbidity in adolescent inpatients with substance use

disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 34,

1085-1091.

Hoffmann, N.G., Estroff, T.W., & Wallace, S.D. (2001). Co-occurring disorders

among adolescent treatment populations. The Dual Network,2 (1), 10-13.

Hoffmann, N.G., DeHart, S.S., & Campbell, T.C. (2002). Dependence: Whether a

disorder or a disease; it is not a ‘‘concept.’’ Journal of Chemical Dependency Treatment,8 (1), 45-56.

Hoffmann, N.G. & Hoffmann, T.D. (2003). Construct validity for alcohol dependence as indicated by the SUDDS-IV. Journal of Substance Use and Misuse,38 (2),

293-305.

Lehman, A.F., Myers, C.P., Corty, E., & Thompson, J.W. (1994). Prevalence and

patterns of ‘‘dual diagnosis’’ among psychiatric inpatients. Comprehensive Psychiatry,35, 106-112.

Myers, M.G., Stewart, D.G., & Brown, S.A. (1998). Progression from conduct disorder to antisocial personality disorder following treatment for adolescent substance

abuse. American Journal of Psychiatry, 155, 479-485.

Schuckit, M.A., Smith, T.L., Danko, G.P., Bucholz, K.K., Reich, T., & Bierut, L.

(2001). 5-year clinical course associated with DSM-IV alcohol abuse or dependence

in a large group of men and women. American Journal of Psychiatry, 158(7):1084-

1090.

Shaffer, D., Fisher, P., Dulcan, M.K., Davies, M., Piacentini, J., Schwab-Stone, M.

E., Lahey, B.B., Bourdon, K., Jensen, P.S., Bird, H.R., Canino, G., & Regier, D.A.

(1996). The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC2.3): description, acceptability, prevalence rates, and performance in the MECA

Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders

Study. Journal of the American Academy of Child and Adolescent Psychiatry, 35(7),

867-877.

Stowell, R.J. & Estroff, T.W. (1992). Psychiatric disorders in substance-abusing

adolescent inpatients: A pilot study. Journal of the American Academy of Child and

Adolescent Psychiatry,31, 1036-1040.
77
78

Appendix A

Authorization for Release of Information (JASAE)

Region I

Region II

Region III

Region IV

Appendix B

JASAE Administrators

Region I

Region II

Region III

Region IV

Appendix C

Participating Schools

Region I

Region II

Region III

Region IV

Appendix D

Network Member Treatment Providers

Region

Region II

Region III

Region IV

Appendix E

Profile of Network Member Outpatient Substance Abuse Services

Region I

Region II

Region III

Region IV
79

Appendix F

Instructions for Administering the JASAE

Appendix G

JASAE Screening

Introduction

The Substance Abuse Treatment Network for Adolescents is modeled on the successful Juvenile Corrections Substance Abuse Treatment Network. In 2002, the Office of Substance Abuse contracted with Day One to manage the expansion of the

Juvenile Corrections Substance Abuse Treatment Network to adolescents not currently in the Department of Corrections System.

The Juvenile Corrections Substance Abuse Treatment Network is a coordinated

Statewide system providing a centralized screening and referral process to identify

juvenile offenders with substance abuse issues. The Office of Substance Abuse and

the Department of Corrections collaborated on this project and the Office of Substance Abuse contracted with Day One to staff and manage the Network.

In January 1996, treatment providers throughout the State formally applied for

membership in the Network and a standardized screening tool, the Juvenile Automated Substance Abuse Evaluation (JASAE), was chosen for the purpose of screening and referring juvenile offenders in the State of Maine.

Since the JASAE screening and referral process was implemented in January

1998, 5,461 juvenile offenders have been screened. Of those 2,968 (54 percent) were

referred on for a further substance abuse evaluation. The Network, as a collaborative program of the Office of Substance Abuse and the Department of Corrections,

is committed to its goals of expanding the capacity of the State to provide substance

abuse treatment to juveniles, and to enhance the continuum of care as juveniles

move in the justice and treatment systems.

The Juvenile Treatment Network employs two Regional Support Coordinators to

work within the four Department of Corrections regions and provide support for

JCCOs and Network providers within their respective regions. The Substance Abuse

Treatment Network for Adolescents will continue to work within these four regions

to maintain a continuity of services. The Regional Support Coordinators schedule

and facilitate quarterly meetings within each region to allow for discussion between

JCCOs, community based organizations and Network providers on a variety of

issues including problems/issues identified by the JASAE, best practice approaches

to treatment, communication and information sharing, and other community issues.

Mission Statement

To foster collaboration throughout the State of Maine between community based

organizations and providers of adolescent substance abuse treatment services, so

that adolescents can access appropriate levels of assessment and treatment that

match client needs with provider strengths.

Maine Department of Behavioral and Developmental Services, Office of Substance

Abuse, Marquardt Building, 3rd Floor—AMHI Complex, 159 State House Station,

Augusta, ME 04333-0159, Phone (207) 287-2595, FAX (207) 287-4334 or 287-8910,

http://www.state.me.us/bds/osa.

Network Administrator: Day One, Juvenile Treatment Network, 525 Main St.,

South Portland, ME 04106, PHONE (207) 842-3637, FAX (207) 842-3639, http://

www.JuvenileTreatmentNetwork.org.

SCREENING AND ASSESSMENT

Screening

The purpose in using the Juvenile Automated Substance Abuse Evaluation

(JASAE) standardized screening tool is to identify adolescents that may have a

problem abusing substances, or the potential for developing a problem. Adolescents

identified by the JASAE screening (see Appendix G) as having a problem, or the

potential for one, will be referred to a Network Member Treatment Provider for a

full substance abuse evaluation to determine whether or not further services are

needed.

The Juvenile Substance Abuse Treatment Network for Adolescents has in place

a centralized screening and referral system. Network affiliated schools have access

to a Network trained JASAE administrator (hence forth referred to as JASAE administrator) who will administer the JASAE to juveniles referred by a Network authorized school contact (hence forth referred to as school contact). Once the juvenile

has taken the JASAE screening the Network Coordinator will contact the juvenile

and parent or guardian, if authorized by the juvenile, of the JASAE screening referral recommendations. If the juvenile scores high enough he/she will be referred to

a Network Member Treatment Provider for a further substance abuse evaluation.
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In addition, the Network will communicate with the school contact to give recommendations for further substance abuse evaluation and school based services follow up based on the JASAE screening results.

Criteria for Referring Adolescents for JASAE Screeninq

When referring a juvenile for the JASAE screening please use the following criteria:

1. AGE:

Refer adolescent if between the ages of 12 and 20 and currently enrolled or attempting to enroll in school (does not apply to post secondary education). Ages 11

and under refer directly to provider for evaluation.

2. NOTICEABLE SUDDEN CHANGES IN ADOLESCENTS:

Refer the adolescent for a JASAE screening if any sudden changes have occurred

in:b School performance b School attendance b Change in peers b Interest in extra curricular activities b General disposition or personality

3. VIOLATION OF CHEMICAL HEALTH POLICY HAS OCCURRED

Refer the adolescent for a JASAE screening if the juvenile has violated the school

chemical health policy.

SUBSTANCE ABUSE TREATMENT NETWORK FOR ADOLESCENTS

IDENTIFICATION, SCREENING AND REFERRAL FLOW CHART

1)

• Adolescent is identified by nurse, primary teacher, guidance counselor or other

school personnel and referred to school contact.

• School contact administers JASAE screening or refers juvenile to JASAE administrator for JASAE screening.

2)

• JASAE administrator gives the JASAE in school setting or outside agency location.

• JASAE administrator has adolescent sign consent for release form and contact

form.

• JASAE administrator sends bubble sheet, consent for release of confidential information and JASAE referral form to the Network office.

3)

• Network office scores JASAE.

• Network office records data and creates file.

• If adolescent scores high enough on the JASAE, adolescent will be referred for

further substance abuse evaluation to a Network Member Treatment Provider.

• A full copy of the screening is sent to the Network Member Treatment Provider.

• Network Coordinator communicates JASAE referral recommendations by mail

and/or phone follow up with parent/legal guardian.

4)

• Network will communicate with the school contact to give recommendations for

further substance abuse evaluation based on the JASAE screening results.

KEY PARTICIPANTS AND ROLES

Network Affiliated Schools

• Identification of adolescent by school personnel who may refer adolescents to

take the JASAE.

School Contact

• Timely and appropriate referral to a Network trained JASAE administrator.

• Collaborates with Network Member Treatment Provider to coordinate appropriate services.

• May be trained by Network staff to administer the JASAE.

Network Member Treatment Providers

• May be trained as JASAE administrator by Network staff.

• Receive referrals for further substance abuse evaluation and outpatient substance abuse treatment services.
81

• Collaborate with the school contact to coordinate appropriate services.

The Juvenile Treatment Network

• Scoring of JASAE screening.

• Data collection and record keeping.

• If the adolescent scores high enough, referral to a Network member treatment

provider for a further substance abuse evaluation.

• If authorized, shares JASAE screening results with Network Member Treatment Provider.

• Communicates with school contact to give recommendations for further substance abuse evaluation.

• Shares recommendations for further substance abuse evaluation with parent or

legal/guardian.

JASAE ADMINISTRATION

JASAE Administrators must have completed a training session with ADE Inc.,

the developer and owner of the JASAE screening tool, or a Network staff person.

The JASAE Administrator will have documentation of JASAE training completion

on file. Please see Appendix F for step-by-step instructions on how to administer the

JASAE.

JASAE Administrators administering the JASAE on behalf of agencies participating in the Network will receive $15 per individual JASAE screening or $20 per

group JASAE screening. The Network will pay for up to two JASAE no-shows on

one adolescent for an individual JASAE screening if the agency schedules the adolescent for a third time and he/she does not show, the Network will not cover the

no-show fee.

JASAE Administrators will receive timely JASAE screening referrals from school

contacts. The JASAE administrator will conduct the screening per Network policy

and forward the JASAE screening answer sheet, Authorization for Release of Information and JASAE referral form to the Network office for scoring within 5–7 days

of completion. The Network will score and distribute results (or inform the school

contact and/or JASAE administrators of problems with the completed JASAE) within 1–2 days after receipt of the completed JASAE. If the juvenile scores high enough

he/she will be referred to a Network Member Treatment Provider for a further substance abuse evaluation. In addition, the Juvenile Treatment Network will communicate with the school contact to give recommendations for further substance abuse

evaluation based on the JASAE screening results.

Recommendations based on the JASAE screening will be shared with the parent/

legal guardian. Once a client has signed the Authorization for Release of Information there should not be any changes made to the form without the client’s permission.
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83

INTERAGENCY REFERRALS AND CASE MANAGEMENT

Network members provide not only a variety of services but have differing service

capacities. Some of these treatment providers serve overlapping geographic areas.

To maximize resources and provide for proper client/service matching, Network

members are encouraged to refer clients they are either unable to serve (e.g., limited

space) or who require specialized service provided by another Network member.

Adolescents will be referred to treatment programs that meet their individual profiles. To assist Network members, a list of member services for each region is provided (see Appendix A). This list will be updated on an annual basis.

The treatment provider performing the evaluation or providing treatment services

is responsible for recommending new or additional services and any transitional programming. Recommendations will be made to the client.

The client and the treatment provider resolve payment for treatment services.

Medicaid and private insurance will be utilized whenever possible. Client self-pay

will be used according to the provider’s individual scale. When none of these payment sources are available, the provider may access OSA Contract Funds, managed
84

by the Network, in accordance with policy and procedures established by the Office

of Substance Abuse. Please see the section titled, ‘‘Billing Policies and Procedures’’

for more information on these funds.

RIGHTS OF CLIENTS

The client has the final choice of services and provider. Network treatment providers will inform clients that, although Network members are recommended service

providers, other choices do exist. When requested by the client, Network members

will inform the client of other treatment providers.

Participation by the juvenile in the Substance Abuse Treatment Network for Adolescents is voluntary. Information about the juvenile may only be shared with the

juvenile’s consent in the form of a signed, initialed and witnessed authorization for

release of information meeting CFR 42 criteria. Under no circumstances should the

juvenile be coerced to participate in the Juvenile Treatment Network at any level,

against their wishes.

NETWORK MEMBERSHIP GUIDELINES

Members of the Juvenile Treatment Network commit to the following:

• Participation in Network-sponsored training and attendance at a minimum of

three Network meetings per year (Network members failing to attend at least three

meetings will not receive free registration for Network-sponsored trainings and will

not receive Network referrals);

• Incorporation of best practices as defined by the Network and demonstrated by

research, into treatment programs for adolescents;

• Use of Network-developed protocol and forms for communication between the

Juvenile Treatment Network, Network Member Treatment Providers, Department

of Corrections and community organizations;

• Collaboration with other Network members and participants to identify gaps in

treatment services and work cooperatively to fill those gaps;

• Participation in a Network screening and referral system designed to match clients and providers;

• Development of program admission and discharge criteria consistent with best

practices for adolescents; and

• Participation in Network development of policy, procedures and training designed to implement Network goals and encourage provider compliance; and

• Timely completion of required TDS Admission and Discharge forms with the appropriate Network Code.

Members of the Juvenile Treatment Network receive the following benefits:

• Last resort outpatient treatment reimbursement eligibility for providers;

• Free registration for Network-sponsored trainings;

• Participation in the Network screening and referral system;

• Input into the development of Network policy and a system of comprehensive

continuum of care for adolescents;

• Contribute to data collection that will assist in identifying barriers to substance

abuse treatment services throughout the State; and

• Improved communication between referral sources and treatment providers

through attendance at quarterly Network meetings.

Network membership criteria:

• Agency must be licensed by the Office of Substance Abuse.

• Agency must be Medicaid eligible.

• Agency must provide outpatient and/or intensive outpatient substance abuse

services in one or more service locations.

• Agency must adhere to Network policies.
85

NETWORK MEMBER CRITERIA EXCEPTION

The Juvenile Treatment Network will accept membership from individual practitioners who are not OSA agency licensed and who work in a rural area where there

is no other Network Member Treatment Provider Agency within a 30-mile radius.

If a treatment provider who meets Network criteria for membership joins the Juvenile Treatment Network within the 30-mile radius, the individual practitioner will

no longer receive referrals from the Juvenile Treatment Network.

The Juvenile Treatment Network will continue to fund juveniles currently on that

individual practitioner’s caseload who meet Juvenile Treatment Network criteria for

funding. The Juvenile Treatment Network will not extend this exception to any Substance Abuse Treatment Agency that is eligible for OSA agency licensure and Medicaid seed.
86
87

BILLING POLICIES AND PROCEDURES

In 2002 the Juvenile Treatment Network received continued and expanded funding from the Office of Substance Abuse in anticipation of the conclusion of the Targeted Capacity Expansion grant from the Center for Substance Abuse Treatment.

Network funds are available to pay for substance abuse treatment for adolescents

that have no other means of payment. The Network funds are to be used as a

last resort for payment, therefore, Network providers will be asked to provide information about the juvenile’s household income and/or insurance

to ensure that only eliqible juveniles are receiving Network funds. It is the

Network Member Treatment Provider’s responsibility to exhaust all other

funding sources with the client before submitting bills for Network funds.

Following are the criteria that adolescents must meet in order to be considered

eligible for Network funds. If there is any question as to whether or not an adolescent is eligible for Network funds, please call the Network Coordinator at 842–3637.

Under no circumstances should a family member or insurance agency be
88

referred to the Network regarding payment. The Network funds are for providers to access for eligible adolescents.

Client does not have private insurance that will pay for outpatient substance abuse treatment services. Eligible adolescents must not have private insurance that will cover substance abuse treatment services. If an adolescent’s coverage does not include substance abuse treatment services, or the juvenile has exceeded the allowable benefits, Network funds may be an option. If an adolescent’s

insurance will cover certain ‘‘in-network’’ providers, and there are no Network providers in the geographic area, Network funds may be an option. However, if there

is a Network agency within the geographic area that is considered ‘‘in-network’’ by

the insurance company, the adolescents may be referred to that provider. If an adolescent and his/her parents do have insurance but paying their co-pay would be a

financial hardship, the Network funds may be an option. This is also true if the

family has a deductible that must be met before the insurance will cover services.

Approved documentation of insurance denial must be submitted with the billing

form for Network funds.

Client is not eligible for Medicaid. Any adolescent who is eligible for Medicaid

is not eligible for Network funds. There is space on the billing form for providers

to report the number of people in an adolescent’s household and that household’s

income. If the income falls between 100–150 percent of the Federal poverty level,

the adolescent may be eligible for Medicaid and that option will need to be explored

by the client before Network funds can pay for services. Although this is not the

only indication of whether or not an adolescent is eligible for Medicaid, it is currently the only feasible way for the Network to determine if an adolescent is eligible

to receive Network funds to cover treatment. If the family has applied for Medicaid

and been denied, approved documentation of denial must be submitted with the billing form for Network funds.

Client cannot pay the full cost of treatment based on the provider’s sliding fee scale. If a client can pay a certain amount per session, Network funds may

be able to fund part of the session providing that the total amount does not exceed

the maximum allowance listed on the Substance Abuse Treatment Network for Adolescents billing form. For example, if a Juvenile Treatment Network provider’s hourly rate for family counseling is $85 per hour, and the family can afford to pay $20

per hour, the Network funds may be able to cover $55 per hour, as the maximum

allowable reimbursement for Network funding is $75 per hour for family counseling.

Client has taken the JASAE screening. An adolescent is not considered part

of the Substance Abuse Treatment Network for Adolescents until he/she has taken

the JASAE screening by referral through their high school.

Please keep in mind:

• Any incomplete billing forms will be returned to the provider, e.g., the household size and income has not been filled out; and

• By accepting Network funds for treatment services the provider agrees not to

bill the adolescent/family for any fees over and above the maximum reimbursement

paid by the Substance Abuse Treatment Network for Adolescents.

Transportation

The Network will cover transportation costs for adolescents to get to and from

treatment appointments. THIS OPTION IS AVAILABLE REGARDLESS OF

THE ADOLESCENT’S FUNDING SOURCE FOR TREATMENT. If, in the provider’s judgment, transportation is a barrier to treatment, the Network funds will

cover bus or cab fare, or pay mileage ($.30/mile) to the adolescent or friend/family

member that drives the adolescent to and from treatment. While the Network funds

will cover mileage to and from treatment appointments, it will not cover mileage

for a friend or family member to drive back home, or somewhere else, while waiting

for the adolescent.

The Juvenile Treatment Network provider is responsible for reimbursing the adolescent or friend/family member at the appointment and submitting a Substance

Abuse Treatment Network for Adolescents billing form to the Juvenile Treatment

Network for the amount. If this is a hardship for the Network Member Treatment

Provider and creates a barrier to outpatient substance abuse treatment services for

adolescents, please apply for a Transportation Loan (see table of contents).

In order to be eligible for transportation reimbursement from the Network funds,

the adolescent must have had a JASAE. The Juvenile Treatment Network provider

is required to complete a TDS admission and discharge form.
89

Child Care

As with transportation costs, the Network funds will cover childcare (up to $10

per treatment session) for adolescents REGARDLESS OF THE FUNDING

SOURCE FOR TREATMENT.

In order to be eligible for childcare reimbursement from the Network funds, the

adolescent must have had a JASAE and the treatment provider is required to complete a TDS admission and discharge form. The Juvenile Treatment Network provider is responsible for reimbursing the adolescent at the appointment and submitting a Substance Abuse Treatment Network for Adolescents billing form to the Juvenile Treatment Network for the amount.

Please Include the following when submitting for billing:

• (Required) Completed Juvenile Treatment Network Billing Form.

• (Required) Copy of Completed TDS admission Form for client with appropriate

Network code-23021-99.

• Any relevant supportive documentation for last resort payment source.
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JUVENILE TREATMENT NETWORK

TRANSPORTATION LOAN

BILLING POLICIES AND PROCEDURES

The Juvenile Treatment Network transportation loan is available for providers to

access when current Juvenile Treatment Network transportation reimbursement

procedures are a barrier to treatment services. Upon submission of a check request

form from the Network provider to the Juvenile Treatment Network office, Day One

will issue a check to the provider to be used for transportation expenses as they

occur for clients eligible for transportation funds. Day One will create a debit account in an amount not to exceed $200 in the provider’s name. THE PROVIDER

WILL CONTINUE TO BILL FOR CLIENTS, using the Transportation Billing

Form but instead of receiving payment, the billable amount will be subtracted from

the debit account until a zero balance is reached. At that time the provider may

request another Transportation loan.

Transportation loan funds may be used to cover transportation costs for juveniles

to get to and from treatment appointments. THIS OPTION IS AVAILABLE REGARDLESS OF THE JUVENILE’S FUNDING SOURCE FOR TREATMENT.

If, in the provider’s judgment, transportation is a barrier to treatment, the transpor-
91

tation funds can cover bus or cab fare, or pay mileage ($.30/mile) to the juvenile or

friend/family member that drives the juvenile to and from treatment. While the

Transportation Loan Funds can cover mileage to and from treatment appointments,

it will not cover mileage for a friend or family member to drive back home, or somewhere else, while waiting for the juvenile.

KEEP IN MIND THAT IN ORDER FOR CLIENTS TO BE ELIGIBLE FOR SETASIDE FUNDS, THE FOLLOWING CRITERIA MUST BE MET:

• The client must have had a JASAE.

• A TDS admission form must be completed for the adolescent.

To obtain a Transportation Loan, providers must submit a Juvenile Treatment

Network Transportation Fund Check Request Form to the Juvenile Treatment Network office at:

JUVENILE TREATMENT NETWORK

525 MAIN ST.

SOUTH PORTLAND, ME 04106
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93
94

Appendix A

Authorization for Release of Information (JASAE)

Region I

Region II

Region III

Region IV

Appendix B

JASAE Administrators

Region I

Region II

Region III

Region IV

Appendix C

Juvenile Community Corrections Officers

Region I

Region II

Region III

Region IV

Appendix D

Network Treatment Providers

Region I

Region II
95

Region III

Region IV

Appendix E

Profile of Network Member Outpatient Substance Abuse Services

Region I

Region II

Region III

Region IV

Appendix F

Instructions for Administering the JASAE

Appendix G

JASAE Screening

Juvenile Corrections Substance Abuse Treatment Network

INTRODUCTION

The Juvenile Corrections Substance Abuse Treatment Network is a coordinated

Statewide system providing a centralized screening and referral process to identify

juvenile offenders with substance abuse issues. The Office of Substance Abuse and

the Department of Corrections collaborated on this project and the Office of Substance Abuse contracted with Day One to staff and manage the Network.

In January 1998, treatment providers throughout the State formally applied for

membership in the Network and a standardized screening tool, the Juvenile Automated Substance Abuse Evaluation (JASAE), was chosen for the purpose of screening and referring juvenile offenders in the State of Maine.

The referral for the JASAE is made by the Juvenile Community Corrections Officer (JCCO) and is administered by a Network agency or the JCCO in some cases.

The screening is scored at the Network office, where it is determined, based on the

JASAE results, whether or not the juvenile should be referred to one of the 60 Network providers for a substance abuse evaluation. Many times, the JCCO refers for

the JASAE even if he/she has no further action with a juvenile. Therefore, we believe we are able to identify substance abuse problems early on in a juvenile’s contact with the justice system.

Since the JASAE screening and referral process was implemented in January

1998, 5,427 juvenile offenders have been screened. Of those 5,427, 2,950 (54 percent)

were referred on for a further substance abuse evaluation. The Network, as a collaborative program of the Office of Substance Abuse and the Department of Corrections, is committed to its goals to expand the capacity of the State to provide substance abuse treatment to juveniles, and to enhance the continuum of care as juveniles move in the justice and treatment systems.

The Network employs two Regional Support Coordinators to work within the four

Department of Corrections regions and provide support for JCCOs and Network providers within their respective regions. The Regional Support Coordinators schedule

and facilitate quarterly meetings within each region to allow for discussion between

JCCOs and Network providers on a variety of issues including problems/issues identified by the JASAE, best practice approaches to treatment, communication and information sharing, and other community issues.

MISSION STATEMENT

Structured collaboration between substance abuse treatment providers and Juvenile Community Corrections Officers in every region of the Department of Corrections to provide access to treatment that matches client needs with provider

strengths for all juvenile offenders.

(Maine Department of Behavioral and Developmental Services, Marquardt Building,

3rd Floor—AMHI Complex, 159 State House Station, Augusta, ME 04333–0159,

Phone (207) 287–2595; FAX (207) 287–4334 or 287–8910, http://www.state.me.us/

bds/osa.) (Maine Department of Corrections, Juvenile Services Division, 111 State

House Station, Augusta, ME 04333-0111, Phone (207) 287–2470, FAX (207) 287–

5150.) (Network Contractor/Administrator: Day One, Juvenile Treatment Network,

525 Main Street, South Portland, ME 04106, PHONE (207) 842–3637, FAX (207)

842–3639, http://www.JuvenileTreatmentNetwork.org.)

SCREENING AND ASSESSMENT

Screening

The purpose in using the Juvenile Automated Substance Abuse Evaluation

(JASAE) standardized screening tool is to identify juvenile offenders that may have

a problem abusing substances, or the potential for developing a problem. Juvenile
96

offenders identified by the JASAE screening (see Appendix G) as having a problem,

or the potential for one, will be referred to a Network provider for a full substance

abuse evaluation to determine whether or not further services are needed.

The Juvenile Corrections Substance Abuse Treatment Network has in place a centralized screening and referral system. All Juvenile Community Corrections Officers

(JCCOs) have access to a provider who will administer the JASAE (Appendix B) to

juveniles referred by the Department of Corrections. The JCCO may refer a juvenile

for the JASAE at any point during the juvenile’s contact with the justice system,

including informal adjustment, probation, and aftercare. Juvenile Community Corrections Officers may administer the JASAE themselves if they choose. In many

cases this will be more efficient and result in quicker referral for services than relying on a middle person for JASAE administration. Juvenile Community Corrections

Officers are asked to use the following criteria when referring a juvenile for the

JASAE screening.

CRITERIA FOR REFERRING ADOLESCENTS FOR JASAE SCREENING

1. Age—Refer adolescent if between the ages of 12 and 18. If juvenile is under

12, refer directly to a Network provider for an assessment.

2. Peer Group—Refer adolescent if it is known that he/she has peers who are

involved in substance use.

3. History—Refer adolescent if it is known that he/she or a family member has

a history of substance use and/or abuse.

4. Change—Refer adolescent if any sudden changes in the following have occurred: school performance/attendance, change in peers, interest in extracurricular

activities and general disposition/personality.

5. Arrest—Refer adolescent if his/her arrest involved substances directly or indirectly.

6. Unsure—Refer adolescent if there is any doubt at all.

7. Previous JASAE Screening—Refer adolescent if he/she took the JASAE

screening more than 6 months ago. In some cases it may be appropriate to refer

the juvenile for another JASAE if it has been less than 6 months since the last one

(see #4 above, ‘‘Change’’).

JASAE Administrators must have completed a training session with ADE Inc.,

the developer and owner of the JASAE screening tool, or a Network staff person.

The JASAE Administrator will have documentation of JASAE training completion

on file. Please see Appendix F for step-by-step instructions on how to administer the

JASAE.

JASAE Administrators will receive $15 per individual JASAE plus mileage if necessary, or $20 per group JASAE administration (not to exceed 5 juveniles). The

Network will pay for up to two JASAE no-shows on one juvenile for each individual

JASAE administration—if the agency schedules the juvenile for a third time and he/

she does not show, the Network will not cover the no-show fee.

All completed JASAEs are forwarded to the BDS contractor, Day One, for scoring

within 5–7 days of completion. The Network/Day One will score and distribute the

results, or inform JCCOs and/or JASAE administrators of problems with the completed JASAE, within 1–2 days after receipt of the completed JASAE. The full results and a summary are sent to the Juvenile Community Corrections Officer. With

the client’s written consent a summary is sent to the parents or guardian with recommendations for follow-up evaluation when indicated by the screening results. All

referrals for follow-up services will be made to regional Network members (see Appendix D) when indicated by the client on the Authorization for Release of Information (see Appendix A). Once a client has signed the Authorization for Release of Information there should not be any changes made to the form without the client’s

permission.

If a juvenile is referred for a full evaluation, the parent/guardian will receive a

phone call from the Network Coordinator to ensure that there are no questions or

concerns about the screening and/or results. Any parent/guardian not able to be contacted by phone will receive a letter from the Network Coordinator with a reference

sheet including frequently asked questions about the JASAE and the answers to

those questions.
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RESTRICTIONS ON REDISCLOSURE

Notice prohibiting redisclosure must accompany any disclosure made with patient’s consent (42 CFR § 2.32). Each disclosure made with the patient’s written consent must be accompanied by the following statement:

Prohibition on Redisclosure of Information Concerning Client in Alcohol or

Drug Abuse Treatment

This notice pertains to any disclosure of information concerning a client in alcohol/

drug abuse treatment, made to you with consent of such client. This information has

been made to you from records protected by Federal confidentiality rules (42 CFR

Part 2). The Federal rules prohibit you from making any further disclosure of this

information unless further disclosure is expressly permitted by the written consent

of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A

general authorization for the release of medical or other information is NOT suffi-
99

cient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

INTERAGENCY REFERRALS AND CASE MANAGEMENT

Network members provide not only a variety of services but have differing service

capacities. Some of these treatment providers serve overlapping geographic areas.

To maximize resources and provide for proper client/service matching, Network

members are encouraged to refer clients they are either unable to serve (e.g., limited

space) or who require specialized service provided by another Network member.

Juveniles will be referred to treatment programs that meet their individual profiles. To assist Network members, a list of member services for each region is provided (see Appendix E). This list will be updated on an annual basis.

The treatment provider performing the evaluation or providing treatment services

is responsible for recommending new or additional services and any transitional programming. Recommendations will be made to the Juvenile Community Corrections

Officer and the client.

The client and the treatment provider resolve payment for treatment services.

Medicaid and private insurance will be utilized whenever possible. Client self-pay

will be used according to the provider’s individual scale. When none of these payment sources are available, the provider may access Targeted Capacity Expansion

grant funds, managed by the Network, in accordance with policy and procedures established by the Office of Substance Abuse. Please see the section titled, ‘‘Billing

Policies and Procedures’’ for more information on these funds.

RIGHTS OF CLIENTS

Notwithstanding conditions for probation imposed by the Juvenile Community

Corrections Officer, the client has the final choice of services and provider. Network

treatment providers and Juvenile Community Corrections Officers will inform clients that, although Network members are recommended service providers, other

choices do exist. When requested by the client, Network members will inform the

client of other treatment providers.

NETWORK MEMBERSHIP GUIDELINES

Members of the Juvenile Treatment Network commit to the following:

• Participation in Network-sponsored training and attendance at a minimum of

three Network meetings per year (Network members failing to attend at least three

meetings will not receive free registration for Network-sponsored trainings and will

not receive Network referrals);

• Incorporation of best practices as defined by the Network and demonstrated by

research, into treatment programs for adolescents;

• Use of Network-developed protocol and forms for communication between the

Juvenile Treatment Network, Network Member Treatment Providers, Department

of Corrections and community organizations;

• Collaboration with other Network members and participants to identify gaps in

treatment services and work cooperatively to fill those gaps;

• Participation in a Network screening and referral system designed to match clients and providers;

• Development of program admission and discharge criteria consistent with best

practices for adolescents; and

• Participation in Network development of policy, procedures and training designed to implement Network goals and encourage provider compliance; and

• Timely completion of required TDS Admission and Discharge forms with the appropriate Network Code.

Members of the Juvenile Treatment Network receive the following benefits:

• Last resort outpatient treatment reimbursement eligibility for providers;

• Free registration for Network-sponsored trainings;

• Participation in the Network screening and referral system;

• Input into the development of Network policy and a system of comprehensive

continuum of care for adolescents;

• Contribute to data collection that will assist in identifying barriers to substance

abuse treatment services throughout the State; and

• Improved communication between referral sources and treatment providers

through attendance at quarterly Network meetings.

Network membership criteria

• Agency must be licensed by the Office of Substance Abuse.
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• Agency must be Medicaid eligible.

• Agency must provide outpatient and/or intensive outpatient substance abuse

services in one or more service locations.

• Agency must adhere to Network policies.

NETWORK MEMBER CRITERIA EXCEPTION

The Juvenile Treatment Network will accept membership from individual practitioners who are not OSA agency licensed and who work in a rural area where there

is no other Network Member Treatment Provider Agency within a 30-mile radius.

If a treatment provider who meets Network criteria for membership joins the Juvenile Treatment Network within the 30-mile radius, the individual practitioner will

no longer receive referrals from the Juvenile Treatment Network.

The Juvenile Treatment Network will continue to fund juveniles currently on that

individual practitioner’s caseload who meet Juvenile Treatment Network criteria for

funding. The Juvenile Treatment Network will not extend this exception to any Substance Abuse Treatment Agency that is eligible for OSA agency licensure and Medicaid seed.
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BILLING POLICIES AND PROCEDURES

In 2002 the Juvenile Treatment Network received continued and expanded funding from the Office of Substance Abuse in anticipation of the conclusion of the Targeted Capacity Expansion grant from the Center for Substance Abuse Treatment.

Network funds are available to pay for substance abuse treatment for adolescents

that have no other means of payment. The Network funds are to be used as a

last resort for payment, therefore, Network providers will be asked to provide information about the juvenile’s household income and/or insurance

to ensure that only eligible juveniles are receiving Network funds. It is the

Network Member Treatment Provider’s responsibility to exhaust all other

funding sources with the client before submitting bills for Network funds.

Following are the criteria that adolescents must meet in order to be considered

eligible for Network funds. If there is any question as to whether or not an adolescent is eligible for Network funds, please call the Network Coordinator at 842-3637.

Under no circumstances should a family member or insurance agency be

referred to the Network regarding payment. The Network funds are for providers to access for eligible adolescents.

Client does not have private insurance that will pay for outpatient substance abuse treatment services. Eligible adolescents must not have private insurance that will cover substance abuse treatment services. If an adolescent’s coverage does not include substance abuse treatment services, or the juvenile has ex-
102

ceeded the allowable benefits, Network funds may be an option. If an adolescent’s

insurance will cover certain ‘‘in-network’’ providers, and there are no Network providers in the geographic area, Network funds may be an option. However, if there

is a Network agency within the geographic area that is considered ‘‘in-network’’ by

the insurance company, the adolescents may be referred to that provider.

If an adolescent and his/her parents do have insurance but paying their co-pay

would be a financial hardship, the Network funds may be an option. This is also

true if the family has a deductible that must be met before the insurance will cover

services.

Approved documentation of insurance denial must be submitted with the billing

form for Network funds.

Client is not eligible for Medicaid. Any adolescent who is eligible for Medicaid

is not eligible for Network funds. There is space on the billing form for providers

to report the number of people in an adolescent’s household and that household’s

income. If the income falls between 100-150 percent of the Federal poverty level, the

adolescent may be eligible for Medicaid and that option will need to be explored by

the client before Network funds can pay for services. Although this is not the only

indication of whether or not an adolescent is eligible for Medicaid, it is currently

the only feasible way for the Network to determine if an adolescent is eligible to

receive Network funds to cover treatment. If the family has applied for Medicaid

and been denied, approved documentation of denial must be submitted with the billing form for Network funds.

Client cannot pay the full cost of treatment based on the provider’s sliding fee scale. If a client can pay a certain amount per session, Network funds may

be able to fund part of the session providing that the total amount does not exceed

the maximum allowance listed on the Substance Abuse Treatment Network for Adolescents billing form. For example, if a Juvenile Treatment Network provider’s hourly rate for family counseling is $85 per hour, and the family can afford to pay $20

per hour, the Network funds may be able to cover $55 per hour, as the maximum

allowable reimbursement for Network funding is $75 per hour for family counseling.

Client has taken the JASAE screening. An adolescent is not considered part

of the Substance Abuse Treatment Network for Adolescents until he/she has taken

the JASAE screening by referral through their high school or JCCO.

Please keep in mind:

• Any incomplete billing forms will be returned to the provider, e.g., the household size and income has not been filled out; and

• By accepting Network funds for treatment services the provider agrees not to

bill the adolescent/family for any fees over and above the maximum reimbursement

paid by the Substance Abuse Treatment Network for Adolescents.

Transportation

The Network funds will cover transportation costs for adolescents to get to and

from treatment appointments. THIS OPTION IS AVAILABLE REGARDLESS

OF THE ADOLESCENT’S FUNDING SOURCE FOR TREATMENT. If, in the

provider’s judgment, transportation is a barrier to treatment, the Network funds

will cover bus or cab fare, or pay mileage ($.30/mile) to the adolescent or friend/family member that drives the adolescent to and from treatment. While the Network

funds will cover mileage to and from treatment appointments, it will not cover mileage for a friend or family member to drive back home, or somewhere else, while

waiting for the adolescent.

The Juvenile Treatment Network provider is responsible for reimbursing the adolescent or friend/family member at the appointment and submitting a Substance

Abuse Treatment Network for Adolescents billing form to the Juvenile Treatment

Network for the amount. If this is a hardship for the Network Member Treatment

Provider and creates a barrier to outpatient substance abuse treatment services for

adolescents, please apply for a Transportation Loan (see table of contents).

In order to be eligible for transportation reimbursement from the Network funds,

the adolescent must have had a JASAE. The Juvenile Treatment Network provider

is required to complete a TDS admission and discharge form.

Child Care

As with transportation costs, the Network funds will cover childcare (up to $10

per treatment session) for adolescents REGARDLESS OF THE FUNDING

SOURCE FOR TREATMENT.

In order to be eligible for childcare reimbursement from the Network funds, the

adolescent must have had a JASAE and the treatment provider is required to complete a TDS admission and discharge form.
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The Juvenile Treatment Network provider is responsible for reimbursing the adolescent at the appointment and submitting a Substance Abuse Treatment Network

for Adolescents billing form to the Juvenile Treatment Network for the amount.

Please Include the following when submitting for billing:

• (Required) Completed Juvenile Treatment Network Billing Form.

• (Required) Copy of Completed TDS admission Form for client with appropriate

Network code-23021-99.

• Any relevant supportive documentation for last resort payment source.
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JUVENILE TREATMENT NETWORK

TRANSPORTATION LOAN

BILLING POLICIES AND PROCEDURES

The Juvenile Treatment Network transportation loan is available for providers to

access when current Juvenile Treatment Network transportation reimbursement

procedures are a barrier to treatment services. Upon submission of a check request

form from the Network provider to the Juvenile Treatment Network office, Day One

will issue a check to the provider to be used for transportation expenses as they

occur for clients eligible for transportation funds. Day One will create a debit account in an amount not to exceed $200 in the provider’s name. THE PROVIDER

WILL CONTINUE TO BILL FOR CLIENTS, using the Transportation Billing

Form but instead of receiving payment, the billable amount will be subtracted from

the debit account until a zero balance is reached. At that time the provider may

request another Transportation loan.

Transportation loan funds may be used to cover transportation costs for juveniles

to get to and from treatment appointments. THIS OPTION IS AVAILABLE REGARDLESS OF THE JUVENILE’S FUNDING SOURCE FOR TREATMENT.

If, in the provider’s judgment, transportation is a barrier to treatment, the transportation funds can cover bus or cab fare, or pay mileage ($.30/mile) to the juvenile or

friend/family member that drives the juvenile to and from treatment. While the

Transportation Loan Funds can cover mileage to and from treatment appointments,

it will not cover mileage for a friend or family member to drive back home, or somewhere else, while waiting for the juvenile.
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KEEP IN MIND THAT IN ORDER FOR CLIENTS TO BE ELIGIBLE FOR SETASIDE FUNDS, THE FOLLOWING CRITERIA MUST BE MET:

• The client must have had a JASAE

• A TDS admission form must be completed for the adolescent

To obtain a Transportation Loan, providers must submit a Juvenile Treatment

Network Transportation Fund Check Request Form to the Juvenile Treatment Network office at: Juvenile Treatment Network, 525 Main St., South Portland,

ME 04106.
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107

CRIMINALS, TROUBLED YOUTH, OR A BIT OF BOTH

MULTIPLE DISORDERS SEEN IN JUVENILE POPULATION PRESENT TREATMENT

CHALLENGES

Crime, especially violent crime, is a frequently voiced concern and often a hot political topic during elections. According to Federal statistics, juveniles accounted for

17 percent of all arrests in 2000, and for 16 percent of all violent criminal arrests.1

Crimes committed by adolescents are particularly troubling since rearrest rates

have been found to range from 37 percent to over 50 percent within 2 years 2 and

up to 67 percent within 4 to 5 years.3

Unfortunately, most of the recidivism reports not only ignore substance use disorders in adolescent populations, they also ignore other co-occurring conditions.

Even among the treatment studies, there is a tendency to focus on a single problem

or diagnosis. But as Weisz and Hawley 4 point out, ‘‘. . .adolescent problems do not

come in such neat, one-diagnosis units, but in bundles. . .’’ According to their literature review, it is not unusual for adolescents in clinical populations to average

three or more diagnoses.

Adolescents in the juvenile justice system resemble clinical populations in the elevated prevalence of co-occurring conditions. One general literature review found that

about 60 percent of adolescents with a substance use disorder had a co-occurring

mental health diagnosis as well.5 Teplin and colleagues found that, even when con-
108

duct disorder is ignored, 60 percent of males and 65 percent of females in juvenile

justice populations had one or more diagnoses.6

The prevalence of co-occurring conditions appears to apply to minorities as well

as whites. For example, a study of American Indian detainees found that more than

20 percent met diagnostic criteria for two or more disorders.7

In Maine, Day One is the program responsible for assessing all juveniles committed to the State’s two detention centers or entering its various adolescent drug treatment courts. In order to standardize the assessment procedure across all sites, the

Practical Adolescent Dual Diagnostic Interview (PADDI), a structured diagnostic

interview, is administered to each juvenile. The PADDI covers a number of mental

health domains in addition to substance use disorders. It also inquires about suicidal ideation, thoughts of harming others, and victimization (physical, sexual and

emotional).

An analysis of the first 218 consecutive admissions (187 males and 31 females)

ranging in age from 13 to 18 revealed that almost 90 percent of the cases were between ages 15 and 17. The majority were Caucasian (89 percent), and American Indians (5 percent) constituted the only other group with more than 10 cases. Most

came from single-parent homes, with fewer than 20 percent living with both parents.

Educational attainment appeared low for these adolescents. Although almost 75

percent were over the age of 15, 65 percent had not passed beyond the 8th grade

in school. Half of the adolescents had been in special classes for behavioral or academic problems, and 15 percent reported reading difficulties that caused serious

problems. This is consistent with other reports indicating that while more than 70

percent of delinquent juveniles have some reading or spelling problems, slightly over

10 percent of the problems were considered serious.8

When asked about the reason for incarceration or being in adolescent court, most

(61 percent) responded that it was due to a nonviolent offense, but 24 percent acknowledged violent offenses. A substantial proportion (43 percent) reported substance abuse as being a factor in their current detention.

Almost three out of four adolescents (73 percent) reported that they had been in

trouble for the same problem before. Of those reporting nonviolent offenses, 73 percent reported prior problems, compared to 77 percent for the violent offenders and

85 percent for those indicating a substance use problem. This is consistent with the

rates of recidivism in other juvenile samples.23

Although they had committed either a criminal or statutory offense, these adolescents were often themselves victims of abuse. More than 75 percent of the females

and about half of the males reported physical, sexual and/or emotional abuse. For

females, emotional abuse (61 percent) was the most prevalent, followed by sexual

abuse (42 percent) and physical abuse (39 percent). For males, physical and emotional abuse were most common (33 percent and 29 percent, respectively), and sexual abuse was least prevalent (11 percent).

Multiple disorders

In addition to the prevalence of victimization, the pattern of diagnostic disorders

in this population is staggering. More than 90 percent appear to meet at least minimal criteria for a mental health or substance use disorder, and 80 percent meet

such criteria convincingly. Of the five most prevalent conditions (substance use disorder, conduct disorder, oppositional defiant disorder, major depressive episode, and

manic episode), 75 percent appear to meet diagnostic criteria for more than one of

these conditions.

Of the adolescents in this juvenile sample, 80 percent met criteria for conduct disorder and 71 percent met criteria for substance dependence. An additional 14 percent meet criteria for substance abuse only, so that a total of 85 percent appear to

meet criteria for a substance use disorder. Because substance dependence is the

more severe and chronic condition,9 we chose to focus on this condition rather than

including abuse, or misuse.

There are two notable differences in the severity indications between substance

dependence and conduct disorder. The first is that if both abuse and dependence are

considered, substance use disorders would be the most prevalent conditions. Secondly, when the extent of diagnostic indicators is examined, 65 percent of the entire

sample reported events and behaviors that exceeded the minimal criteria for substance dependence. In contrast, 35 percent of the sample met only minimal criteria

for conduct disorder and 45 percent substantially exceeded the minimal criteria for

this condition. Furthermore, it is probable that some of the apparent conduct disorder behaviors were a consequence of substance dependence rather than an independent co-occurring condition.
109

For major depression and mania, the PADDI attempts to identify those episodes

that are related to substance use. This identified 7 percent of the sample as having

apparent substance-induced episodes. When these cases are excluded, almost 30 percent of the youths provide indications of a major depressive episode and about one

in four reports symptoms consistent with a manic episode.

Approximately 13 percent meet at least minimal DSM-IV criteria for both depression and mania, and about half of those clearly exceed minimal criteria for both conditions. These findings highlight the possibility of emerging bipolar conditions

among a substantial minority of delinquent adolescents.

Indications of anxiety disorders are also common. Given the victimization histories, it is not surprising that more than 20 percent of the youths indicate symptoms compatible with post-traumatic stress disorder (PTSD). Almost one-fourth of

the cases endorsed more than half of the symptoms for generalized anxiety or phobias. Approximately 10 percent reported panic attacks and associated physiological

experiences compatible with a panic disorder.

Because of the varied presentation for anxiety disorders and the need to carefully

rule out other possible causes, these prevalences should be considered tentative.

However, the level of reported symptoms does suggest that a substantial portion of

these youths may suffer from a range of anxiety disorders.

Treatment Recommendations

The results of this study point toward strong indications that a majority of adolescents entering juvenile justice systems merit mental health and/or substance abuse

treatment services.

More than half of the adolescents in this cohort report positive indications for at

least five of the seven dependence criteria, and 36 percent exceed diagnostic criteria

for a mental health condition other than conduct disorder or oppositional defiant

disorder. Even if we were to assume that half of the mental health conditions were

substance-induced beyond those already identified as such, we would still be left

with a substantial proportion of adolescents with serious mental health conditions

that are likely to require attention.

In addition to conduct disorder, substance dependence and conditions such as bipolar disorder are likely to be related to recidivism. Therefore, failure to identify

and treat these mental health and substance use problems is likely to further contribute to the recidivism issue. However, caution should be exercised when considering treatment options or other solutions, as the politically popular boot camps for

juvenile offenders have often yielded disappointing outcomes and, in one case, higher-than-expected recidivism.10

The findings from this systematic assessment of consecutive admissions to the

Maine juvenile justice system provide support for several recommendations. First,

and most obvious, routine assessments and not simply perfunctory screening should

be undertaken with all new cases entering the juvenile justice system. This would

include admissions to detention centers and cases considered for diversion courts.

The present study has shown that such initial assessments can be conducted in less

than an hour using a structured interview process.

The second recommendation involves the allocation of resources for treatment in

order to address the identified conditions. Treatment services should be available

not only in the juvenile institutions but also in the community upon release to adequately address both chronic and acute conditions. To the extent that such services

reduce recidivism, they are likely to pay for themselves in overall cost savings. The

costs for incarcerating a juvenile for a year have been estimated to range from

$34,000 to $64,000.11 Thus, if treatment can reduce recidivism for a portion of cases,

it may more than pay for itself.

Finally, due to the prevalent academic problems in juvenile populations, remedial

educational services and vocational counseling are necessary investments to facilitate the path toward productive citizenship instead of career recidivism in the adult

correctional system. ■

Norman G. Hoffmann is president of Evince Clinical Assessments and clinical associate professor of community health at Brown University. Ana M. Abrantes is a

post-doctoral fellow at Brown University’s Center for Alcohol and Addiction Studies.

Ronald Anton is director of juvenile justice and community programs at Day One

for Youth and Families, in Maine.

Hoffmann may be contacted at Evince Clinical Assessments, P.O. Box 17305,

Smithfield, RI 02917; phone (401) 231-2993; fax (401) 231-2055; e-mail

evinceassessment@aol.com. For more information, visit www.evinceassessment. com.
110

References 1Snyder, H.N. (2002). Juvenile Arrests 2000. Juvenile Justice Bulletin, NCJ

191729, Washington, DC: OJJDP, U.S. Department of Justice. 2 Blechman, E.A., Maurice, A., Buecker, B., & Helberg, C. (2000). Can mentoring

or skill training reduce recidivism? Observational study with propensity analysis.

Prev Sci, 1(3), 139-155. 3Steiner, H., Cauffman, E., & Duxbury, E. (1999). Personality traits in juvenile

delinquents: relation to criminal behavior and recidivism. Journal of the American

Academy of Child and Adolescent Psychiatry, 38(3), 256-262. 4Weisz, J.R. & Hawley, K.M. (2002). Developmental factors in the treatment of

adolescents. Journal of Consulting and Clinical Psychology, 70(1), 21-43. 5 Armstrong, T.D., Costello, E.J. (2002). Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. Journal of Consulting

and Clinical Psychology, 70, 1224-1239. 6Teplin, L.A., Abram, K.M., McClelland, G.M., Dulcan, M.K., & Mericle, A.A.

(2002). Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59(12) , 1133-1143. 7Duclos, C.W., Beals, J., Novins, D.K., Martin, C., Jewett, C.S., & Manson, S.M.

(1998). Prevalence of common psychiatric disorders among American Indian adolescent detainees. Journal of the American Academy of Child and Adolescent Psychiatry, 37(8), 866-873. 8Svensson, I., Lundberg, I., & Jacobson, C. (2001). The prevalence of reading and

spelling difficulties among inmates of institutions for compulsory care of juvenile

delinquents. Dyslexia, 7(2) , 62-76. 9 Hoffmann, N.G. (2003). Distinguishing ‘‘Dependence’’ from ‘‘Abuse.’’ Addiction

Professional, 1(2) , 19-21. 10Greenwood, P.W. (1996). Responding to juvenile crime: Lessons learned. Future

Child, 6(3), 75-85. 11Kumpfer, K.L., Alexander, J.F., McDonald, L., & Olds, D.L. (1998). Family-focused substance abuse prevention: What has been learned from other fields. In Drug

Abuse Prevention Through Family Intervention (NIDA Research Monograph 177,

pp. 78-102). Washington, DC: NIDA.

Senator DEWINE. Thank you very much.

Mr. Shipley?

Mr. SHIPLEY. Thank you. Chairman DeWine, Senator Reed, distinguished Members of the Substance Abuse and Mental Health

Services Subcommittee, thank you for holding this hearing.

There is no greater issue impacting families in America today

than teenage drug use and abuse. I am here today before you as

a client of the Second Genesis Residential Treatment Program. My

name is Kris Shipley. I am 28 years old and began my use of alcohol and drugs at the age of 11. I appear before you proud today

that I have been clean for 4 years; am gainfully employed as an

administrative assistant, but every day is a challenge.

I have a 7-year-old son, and I pray every night that I can give

him the necessary tools and mentoring to stay drug free and not

follow in the footsteps of myself or those of his grandfather. My recovery is part of my child’s prevention.

I began my substance abuse drinking beer and moved to hard

liquor when I was 12. My substance abuse escalated when I got my

driver’s license and could spend time roaming the streets. I graduated to harder drugs, including marijuana, cocaine, ecstasy and

PCP. I unfortunately fell between the cracks and weaved in and

out of the juvenile criminal justice system, bouncing between my

parents’ home and living on my own.

My parents were divorced, middle-class and skilled employees.

My father loved to party, which included drug use. Often, when I

stayed at his house, he would return from a night of partying and

wake me up to join him and his friends in the living room to continue the party. His house became a haven for my friends and me
111

to use and abuse drugs. My only goal was to party with him, with

my friends, and to get high with whatever was available.

My mother enabled my use and was helpless to intervene with

my behaviors. When I started getting into trouble, she took me to

family therapy and one-on-one counseling sessions, but nothing

worked. At age 16, I quit school. I got to the point where no one

could intervene, because I was completely engulfed in this lifestyle.

Nothing was more important than getting high, hurting people and

selling drugs. I got comfortable with my negative behaviors. It became a way of life.

As an adult, I weaved through the court system many times until

I got caught and sentenced to a 20-year sentence in prison. The

treatment program that I am in is a residential program that predominantly serves individuals who are in the criminal justice system. I came to Second Genesis from prison. After serving 3 years

of my sentence, I was sent to Second Genesis in the fourth year of

my sentence. Sixteen years of my sentence will be suspended when

I successfully complete treatment.

I have been very motivated to change after realizing what my

losses have been and could be. I have since found out that Second

Genesis also runs an adolescent program, but I was not lucky

enough as a youth to have been mandated to that level of treatment and care during those years.

I am committed to helping at risk adolescents because I know

what they are going through. As part of Second Genesis’ education

and community prevention outreach program, residents are asked

to speak to kids in local schools. Because of our history from living

in the lifestyle and progressing through treatment, we can easily

identify those kids that are potentially at risk. These are the same

kids that an untrained eye will not identify until it is too late. We

try hard to reach these kids and deter the larger group.

The more I give these high school testimonies, the more I realize

it cannot just be a one-time effort, but efforts must be available to

students constantly and continuously. Youth feel invincible and

think that what has happened to me could never happen to them.

I tell them differently. To this day, the damage to my body and

mind is irreversible, and the most evident damage is my short-term

memory loss due to my excessive use of ecstasy.

But I am still lucky that I am living to tell my story. I did not

die from my substance abuse habit. I could have overdosed, committed suicide, been in an accident while driving, or even worse,

killed an innocent bystander.

I know most people wonder what could my school, family or I

have done differently to intervene and stop my downward cycle.

That is a difficult question. My best advice to you is to please keep

funding substance abuse treatment and educational programs.

Drug education for America’s youth should start at a young age.

Intervention should come early in an adolescent’s life, whether

through prevention or mandated treatment.

It is also important that education, prevention and treatment

services are provided both to adolescents and their parents. I know

everything in policy is based on statistics, so you should be aware

that the University of Maryland conducted a study on the Second

Genesis program and found that 79 percent of clients that com-
112

pleted residential treatment while continuing care remained drug

free. Fewer than 10 percent were arrested after 6 months.

We all must share the success of treatment and let communities

and individuals know that treatment works. Other prevention programs can help youth from starting or sustaining a lifestyle of drug

use, programs including outreach and education in the schools,

community-based programs, peer counseling, tutoring and mentoring programs.

We must focus on an adolescent’s strengths to facilitate healing.

We come into treatment at all levels of ability to be open to treatment. Adolescents need more than one-on-one and family counseling. For treatment to work, you need to improve major life domains

for clients while they are in treatment. Treatment supports and

helps clients achieve permanent sobriety.

The goal is to support adolescents to develop necessary skills and

confidence to be drug free. Kids need structure and support to develop their personal growth necessary to stay drug free and for

lasting recovery. The therapeutic community treatment model is

created to provide treatment services that adapt to the individual’s

needs. These services include assessment and treatment planning,

therapeutic drug testing, health education and intervention, family

education and counseling, parenting skills and family support

groups, individual and group counseling for adolescents, vocational

counseling, recreational programs, anger management, social skills

building, educational programs and services, relapse prevention,

transitional services and continuing care and followup.

The components of an adolescent program must address the developmental issues of an adolescent and be holistic in approach. I

thank you for your interest and commitment. Your job is not an

easy one; your leadership is desperately needed. Never give up on

trying to keep America’s youth free from substance abuse through

prevention and treatment. I am a living testament that your leadership has helped me to remain in recovery, and hopefully, we can

empower youth like my son and generations to come not to start

a life of drug abuse.

[The prepared statement of Mr. Shipley follows:]

PREPARED STATEMENT OF KRIS SHIPLEY

Introduction

Chairman DeWine and distinguished Members of the Substance Abuse and Mental Health Services Subcommittee, Senate Committee on Health, Education, Labor

and Pensions, thank you for holding the hearing ‘‘Providing Substance Abuse Prevention and Treatment Services to Adolescents.’’ I am here today before you as a

client of the Second Genesis Residential Treatment Program. My name is Kris Shipley. I am a 28-year old parent and began using alcohol and drugs at age 11.

Second Genesis is a nonprofit drug and alcohol rehabilitation program with residential and outpatient centers in Maryland, Virginia, and Washington, DC. Second

Genesis is a member of Therapeutic Communities of America, a nonprofit membership association that represents over 500 therapeutic community programs throughout the United States. TCA members are predominately funded through public

funds.

Second Genesis, is a therapeutic community, designed to help individuals empower themselves and to lead healthy, responsible drug free lives. Treatment is holistic in nature and incorporates not only treatment for individuals’ addictions but

also understands the importance of habilitation. It includes vocational services, educational services, social skill building, relapse prevention, family services, transitional living services and continuing care to help transition an individual back into

their community.
113

I have been drug free for 4 years and I am now gainfully employed as an administrative assistant but every day is challenging. I will forever live with the possibility

that I will use again. My 7-year-old son lives with me. I appreciate the committee’s

commitment to helping future generations of Americans not to abuse drugs and alcohol. I pray every night that I can give my son the necessary tools and mentoring

to stay drug free and not follow in my footsteps. With my sobriety, I hope that my

son has a better chance than I was given, and I hope to see a day when all adolescents have access to substance abuse prevention and treatment services. One of the

most difficult problems facing American families today is teen drug use. The most

important action you can take is to help parents know where to turn when their

kids are at risk of using by making prevention and treatment services readily available.

Journey to Recovery

I am going through a residential treatment program that predominately serves individuals who are in the criminal justice system. I came to Second Genesis from

prison. I had served 3 years of my jail term and was sent to this community residential substance abuse treatment for the 4th year of my 20-year sentence. As a condition of successfully completing treatment, the remaining 16 years, will be suspended. For the first time, I was motivated for treatment when I entered the program.

I began using drugs when I was 11 years old. My parents are divorced, middle

class skilled employees. I started my substance abuse drinking beer and progressed

to harder drugs including marijuana, cocaine, ecstasy, and PCP. Due to my drug use

I have significant short-term memory loss that has been directly related to my extensive use of ecstasy.

But I am still here to tell my story. A significant number of adolescent drug abusers loose their lives to overdose, suicide or motor vehicle fatalities, to name a few.

Second Genesis also runs an adolescent program, but I was not lucky enough in

my youth to have been mandated to that level of care. My drug abuse has cost me,

my family and society immeasurable amounts of heartache and money. I unfortunately fell between the cracks and weaved in and out of the criminal justice system

bouncing between my parent’s homes, and quitting school at the age of 16. I had

one parent who liked to party and another parent that enabled my use and seemed

unable to intervene with my behaviors.

I started drinking hard liquor when I was 12, but my substance abuse escalated

when I got my driver’s license and I could spend time ‘‘roaming’’. My goal was to

party with my friends. I used to take my friends to my dad’s house, which allowed

us an environment to abuse drugs. My dad also liked to party, that included drug

use. Often times when I stayed over at my dad’s place, he would get home from

partying with his friends and wake me to join them in the living room to continue

the party.

My mother took me to family and individual counseling when I started getting

in trouble with the law but no one directly intervened with my drug use. In the 10th

grade, my mother sent me to a private school because I was having fights in public

school. I dropped out of that school after one quarter. I got to a point where no one

could intervene because I was completely engulfed in this lifestyle. Nothing was

more important than getting high, hurting someone, and selling drugs. Nothing was

more important than my drugs and my life style. As an adolescent you violate your

values in stages and you get more and more comfortable with negative behaviors.

My mother would buy me cars and tell me that I had to pay for them, but I would

wreck them when I was high and she would replace the car without any consequence. I went through 11 cars from 16—21 years of age.

I went through the juvenile court system 5 times for such offenses as assault and

served time on 3 of those occasions but I was never mandated to treatment. At 17

I was arrested running in the streets in my boxer shorts with a meat cleaver in

my hand, high out of my mind on PCP, ready to assault anyone. I thank the police

officers that subdued me for sparing my life and not shooting me. I lived independently in my own apartment and had lots of money from drug sales. I had several

arrests after that until at 24, I was sent to prison and then sent to long-term residential care for the 4th year of my jail sentence.

Giving Back

As part of a Second Genesis prevention outreach program, I and other residents

go to local high schools and speak with students in their classrooms about drug use

and abuse. We help them identify options for help and try to deter other kids from

even beginning to use drugs.
114

Months after visiting a local high school we returned to speak once again, we

were amazed at the number of kids from the previous session that asked to participate in the second session. The more I give these testimonies, the more I realize

it cannot just be a one time effort but our efforts must be available to students on

a continuous basis. Drug use is a disease of denial and stigma and we must give

adolescents an avenue to make informed decisions so they do not use or abuse

drugs. Kids feel invincible and believe that what has happened to me could never

happen to them. I tell them differently. Peer counseling and mentoring must be important services of any prevention program.

When we speak to kids in school, we can easily spot those kids that are already

at risk. Because of our histories we can identify them through body language and

other identifying markers that a ‘‘blind eye’’ cannot. These are the same students

who are at risk of falling between the cracks and being identified too late. Within

our schools and the community, there should be avenues available to every at risk

child, and options to reach out to that child’s positive behaviors to steer them away

from drugs. Adolescent drug use is inevitably a downward cycle. There is no such

thing as a safe drug. A parent allowing a child to drink instead of using illegal

drugs is signing that child a blank check to abuse.

I know you are wondering what my school, my family or I could have done to stop

my future cycle of drug abuse when I was 11 years old. This is a difficult question.

I watched some kids in my school experiment with drugs and never become addicted, yet many of us who used drugs seemed to cross over that invisible line to

enormous consequences. It is difficult for adolescents to comprehend that they may

have to face the ultimate consequence ‘‘death’’.

Observations and Recommendations

My best advice to you is do not give up on prevention and treatment services for

adolescents. Please keep funding treatment and prevention programs. If you save

just one life from drug use, you have taken responsible actions for both the adolescent and society.

It is important that prevention and treatment services are provided to both the

adolescent and their parents. I am scared that my son will not listen to me. He may

already be damaged from the first 7 years of his life. He and I together need services so I can continue my recovery and he can make healthy choices, and not follow

the role model that he knew in his formative years. Kids from homes where there

is drug use are at a high risk of using. Public funds need to be spent on both adult

and adolescent treatment and prevention services. My treatment is part of my

child’s prevention.

Drug education to America’s youth must be continuous and constant and it should

start with children at a very young age. High school is too late. It is important to

ask questions and listen to what they are saying. Once an adolescent crosses that

line to the drug life style they become hardened and only severe intervention might

get their attention. Intervention should come early in an adolescent’s life, whether

through prevention or mandated treatment.

Treatment works and society knows that it works but the stigma against substance abuse is more powerful than common sense. A University of Maryland study

found that 79 percent of clients who completed Second Genesis programs with continuing care remained drug free. In addition, fewer than 10 percent were arrested

after 6 months. As Americans we must stop being cynical about treatment’s success

and let our communities and individuals know that treatment works.

Prevention services are also important and might include talks like the ones I

conduct in local high schools. It is important to reach out and educate youth about

their options with the hope that the information helps them make healthy decisions.

Outreach and education in the schools and community based programs, peer counseling, tutor and mentoring programs can all help to prevent a youth from starting

or sustaining a lifestyle of drug use.

Adolescents must be placed in the most appropriate care for the severity of their

illness and their treatment should be client based. When treating the adolescent,

you need more than simply one-to-one and family counseling. You need to provide

the appropriate level of treatment for each client. You must improve major life domains for clients while they are in treatment, help the client develop healthy lifestyles, and help the client achieve permanent sobriety.

We must focus on an adolescent’s strengths to facilitate healing. Whether it is

through a structured after-school program specifically designed to for outreach to

high-risk children or a residential adolescent treatment program, the goal is to support adolescents to develop necessary skills and confidence to be drug free. Kids

need structure and support to develop the personal growth necessary for recovery.
115

The model of therapeutic community treatment adapts to the special needs of adolescents. Treatment services offered include: assessment and treatment planning,

therapeutic drug testing, health education and intervention, family education and

counseling, parenting skills and family support groups, individual and group counseling for the adolescent, vocational counseling, recreational programs, anger management, social skills building, educational programs, relapse prevention, transitional services, continuing care and follow-up. The components of an adolescent program must address the developmental issues of an adolescent and be holistic in approach.

I thank you for your interest and commitment. Your job is not easy as you use

your leadership to empower Americans to make choices, which enable them to be

alcohol and drug free and to lead responsible healthy productive lives. With your

help, as an individual, I can remain in recovery and empower my son not to start

a life of drug use. You can help by never giving up on trying to sustain an America

that is free from substance abuse by recognizing the importance of treatment and

prevention services. If you would like specifics on adolescent programs across the

United States, Therapeutic Communities of America and/or Second Genesis, would

be glad to supply you with that information.

Senator DEWINE. Mr. Shipley, what was the—first of all, let me

thank you very much for your testimony and for being here today.

We appreciate it very, very much. What, if there was one turning

point for you, what was the turning point?

Mr. SHIPLEY. For me?

Senator DEWINE. For you. Yes, was it when you went to prison

or jail? Or what was the turning point for you?

Mr. SHIPLEY. For me it was prison.

Senator DEWINE. OK.

Mr. SHIPLEY. That is what it took for me.

Senator DEWINE. And then, that was pretty much it, and then,

what happened then? Did you get the treatment in prison, or was

the condition that if you got treatment, they would suspend the

rest of it? Is that——

Mr. SHIPLEY [CONTINUING]. For me, prison was—I lost everything

in prison. There were no phone calls; there were no family visits;

there were no—there was nothing. That is when I actually sat by

myself without any drugs, without any alcohol, without any anything; had to deal with all of the emotions and thoughts and everything that came along with life and realized that there was not any

treatment available other than just a 12-step program.

At that point, I was not open for that. It actually took for me to

sit and be without everything to realize that this was not the way

I wanted to live my life.

Senator DEWINE. Ms. Ramsey-Molina, you have put together a

very good program in Cincinnati. It has gotten a lot of attention.

I have followed it, and we are very proud of what you all have been

able to do. For other communities that would like to replicate that,

what advice would you give to them?

Ms. RAMSEY-MOLINA. Convene the stakeholders. In the process of

convening the stakeholders, really ensuring that you have broad

representation of the community; some of those folks even that we

consider to be strangers to prevention or strangers to the field,

make sure that they are at the table. A skilled convener, influential

leader is very important. And then, my other piece of advice would

be make sure that the work of the coalition is data-driven.

So many times, we do things in communities, schools, neighborhoods because it looks good, feels good, those sorts of things, but

does not really meet the needs of the community. When a commu-
116

nity member, regardless of who they are, comes to a table, knows

what they are doing is data-based and can be measured, the success can be measured over time, they are far more motivated to

stay involved.

So convene the stakeholders carefully and comprehensively for

the community and make sure that your efforts are data-driven.

Senator DEWINE. OK; good.

Senator Reed?

Senator REED. Thank you very much, Mr. Chairman, and I thank

Mr. Shipley for a very compelling and candid response to Senator

DeWine’s question; that was my question also.

Mr. Anton, congratulations to you and to Maine, because you

have a higher record of success compared to the rest of the Nation,

and you have also created a statewide program. Let me ask some

questions, some of which are the ones I addressed to Mr. Curie.

First on, the issue of vouchers, to what extent do vouchers result

in decreased funding for other substance abuse programs?

Mr. ANTON. In the current system, after the CSAT Treatment

Capacity Expansion Grant ended, the State found that the program

was so successful that they fully supported its continuation and expanded it beyond its initial scope. Initially, we did business with

a juvenile correction substance abuse treatment network that identified adolescents in the juvenile justice system that needed services. We have since been able to expand that to schools and communities across the State, so that we are trying to access places

where kids are and where this resource can be made available.

We have not fully developed that piece yet because it is only 2

years old, but we are really looking to move in that direction. So

the State is supportive, and they fund us through a variety of the

mechanisms they have available.

Senator REED. Let me return to the question I posed to Mr.

Curie: who is actually making the choices of provider, the vendor,

the client or the social worker?

Mr. ANTON. Generally, it’s a collaboration between the client, the

adolescent, their family member and the people helping them with

the screening process. Obviously, the adolescent and the family do

not necessarily know everything there is to know about all of the

treatment providers, so we provide them information about who is

available in their geographical area, what their specialties are.

We allow them to make the choice, however. The treatment providers do not make that choice. They provide information; they provide resources, but the choice is really up to the adolescent and

their family. Our family program helps to facilitate that. We make

family contact through our network with over 80 percent of the

families of the adolescents who take the screening instrument.

Senator REED. And a final question, Mr. Anton. You pointed out

in your testimony that all of these providers are certified by the

State of Maine.

Mr. ANTON. Yes, they are.

Senator REED. And they meet high standards and——

Mr. ANTON. They meet all of the licensing requirements that the

State has in place.

Senator REED [CONTINUING]. Very good. Thank you. Ms. RamseyMolina, thank you, and congratulations on your success in Cin-
117

cinnati. It speaks well of your, our efforts, and Mr. Portman’s efforts in getting this program off the ground.

This is sort of a mundane question, but how are you funded? I

mean, that is usually the major issue for any coalition of community activists.

Ms. RAMSEY-MOLINA. We are funded—we are actually gifted

within Greater Cincinnati; about 50 percent of our budget is local

dollars; local foundations, corporate donations and individual donations. The other 50 percent comes from local, State and Federal

dollars.

Senator REED. And the governance of the coalition, do you have

a board of citizens that represents all of the stakeholders?

Ms. RAMSEY-MOLINA. Yes, we do. We have a Board of Directors,

it is actually a 40-member board of directors that oversees the activities of the coalition. It was actively headed by Congressman Ron

Portman since its inception in 1996. In July of last year, he stepped

down as active chair; still comes to all the meetings; cannot quite

take himself away. But we have a new chairman who is senior

market researcher with Procter and Gamble. The membership of

the board includes the faith community, the business community,

the schools, parents, youth, media, a broad representation.

Senator REED. And this is a question I think Senator DeWine

posed, so I will pose it slightly differently. What other cities or

communities in Ohio or elsewhere have replicated your approach?

Ms. RAMSEY-MOLINA. Well, one of our goals within—we have a

10-county service region. It is 10 counties in Ohio, Indiana and

Kentucky. And we work with individual neighborhoods and communities to replicate what we do on the regional level within their

local neighborhood, and we have been able to build 31 neighborhood community-based anti-drug coalitions. They have replicated

the process, the same kind of planning and convening process, and

we see greater reduction in those neighborhoods than we do in

similar comparison neighborhoods where coalitions do not exist.

Senator REED. Are these neighborhoods in Cincinnati, statewide

or regional?

Ms. RAMSEY-MOLINA. We work with these 31 within our region,

within our 10 counties.

Senator REED. Thank you.

Dr. Weissberg, Senator Kennedy asked me to pose two questions

of you. In your testimony, you point out that many schools do not

use programs of proven effectiveness. Which programs are you referring to, and why are they still being used if they are not effective?

Mr. WEISSBERG. Well, there would be a variety of home grown

programs that do not have effectiveness. I think over time, DARE

has become less-used now in schools because of some of the work

there, but more importantly, there are well-intentioned efforts

going on that do not make use of well-evaluated programs that

have demonstrated impact.

Senator REED. You suggest by your answer and also by your

statement of the need for accountability systems that will evaluate

these programs. We also broached that subject with Mr. Curie in

terms of his performance parameters. Can you speak for a moment
118

about the accountability systems and what has to be done in this

area?

Mr. WEISSBERG. There are two types of accountability systems

right now that we are bringing together researchers and educators

and policy makers to develop. One has to do with practice assessment: are you implementing high-quality programming? And are

you structured in ways to support the programming through staff

development of teachers, through effective outreach and things like

that? The other accountability system would be on student outcomes, and there, there can be a variety of things ranging from

health behaviors to connection of kids to schools. There may be behavior ratings that teachers or parents also can be providing with

the system.

Senator REED. Thank you, Dr. Weissberg.

Dr. Brown, again, thank you for your testimony. With regard to

research, one of its uses is to help form a strategy. So, based on

your research and your colleagues’ research, what should be the

strategy to deal with this problem? Is the Federal Government employing the right strategy? I realize this is a pretty broad question,

but your comments would be appreciated.

Ms. BROWN. You saved the biggest question for me. Actually, I

have been really impressed with Committee Members and the

speakers who have been here who have represented a diversity of

approaches, which is what really needs to happen for prevention

and for intervention.

I think everyone here has advocated that alcohol and drug problems for youth are a developmental problem, and so, because of

that, we need to have a diversity of approaches. What might work

in one community might not work in another community, but there

needs to be a diversity of options.

Consistent with the Institute of Medicine’s perspective on early

prevention, universal, targeted and indicated prevention efforts, it

is really critical that youth have a choice in the types of prevention

or intervention opportunities that they engage in and that there be

sufficient diversity across settings; that we will not have situations

where individuals, where it is clear that there is a problem, but we

will have missed them in one system; we could pick them up in another.

And so, I guess I am saying to you yes, it is really critical that

small organizations, families, businesses, communities are involved. It is critical that there is involvement at the State level,

and of course, the Federal involvement is essential. This would not

be possible without that.

Senator REED. May I pose one more question Mr. Chairman?

Senator DEWINE. Oh, yes.

Senator REED. This question is open to the entire panel. What

I have taken from our disscusion this morning is that we are discovering—that substance abuse is in many ways a developmental

problem. Its onset is very early; that usually, young people sort of

stumble into the system of help and care when they have an obvious problem.

Which begs the question, of whether or not there should be some

screening of children for these predispositions, if it is urgent to
119

treat youngsters very young. Is that something that is being considered at all?

Mr. Anton, you are the——

Mr. ANTON [CONTINUING]. We have an ability through our process

to look at children as young as 12.

Senator DEWINE. But they present themselves to the system.

Mr. ANTON. Well, they do in some fashion. Now, to the system

could be through the schools; through guidance; through day care;

through, I mean, you know, through wherever they happen to be

within family situations or in public situations where they present

with problems or issues. So yes, that has to happen first.

Unless we see something publicly that leads us to believe there

is something going on—there is no—at least in our State, there is

no universal screening right now that looks at every child at a very

young age to see if they are predisposed. I am not sure if we have

all the tools to do that.

Senator REED. I think that is a fair response.

Ms. BROWN. I would like to also make a——

Senator DEWINE. Dr. Brown?

Ms. BROWN [CONTINUING].——comment about that.

I think that there are some natural venues in which screening

can unfold; for example, in primary care medicine. Pediatricians

are taught to look for these kinds of problems in late adolescence,

but they are not necessarily focusing on this sort of thing in the

age range where the youth of greatest risk would obviously present

themselves.

If kids are starting to use at 11, we need to be sure that pediatricians are asking these questions long before that, so it becomes

routine. So there are some natural settings.

Senator REED. That is a good point, Dr. Brown.

Dr. BROWN. Yes.

Senator REED. Dr. Weissberg?

Mr. WEISSBERG. I think the key argument that all of us would

make is that if you want to have adolescent prevention of substance abuse, you have to begin much earlier. And there is screening that I think can go on that you can identify very early on who

is at risk for substance abuse, but you would not necessarily target

it to a narrow substance abuse screening instrument, that maybe

children who are overly aggressive, who are overly active in school,

who have poor peer relations, who are poorly motivated to achieve.

So there are a number of markers that I think you can use to

identify children who may be at risk and in a general way, also,

the strategy of promoting positive behavior and connection in kids

early on from the start is something that should be happening to

prevent substance abuse later on.

Senator REED. Thank you.

Ms. Ramsey-Molina, if you have a comment.

Ms. RAMSEY-MOLINA. To echo some of the kind of naturally-occurring opportunities that happen in communities, with the Coalition, one of our emphases and efforts is to increase awareness of

folks in multiple systems so that if there is a young person who

presents some of the problem behaviors, there is an obvious avenue

for intervention, whether it is through the faith-based community,

through schools, you know, through parents. We say all the time
120

through our Coalition to monitor closely, catch it early and make

a big deal out of it if it happens. Pay attention to the behavior.

So many times, we have school personnel, we have faith leaders

who—they do not do this every day, so it is not natural for them

to pay attention and to refer it to a source who could do the official

assessment or official intervention. So part of what we do is empowering all members of the community to understand this is an

issue we must all take part in.

Senator REED. Thank you.

Anyone else?

Mr. ANTON. I think to build on what Dr. Weissberg said, I think

our experience has taught us, especially early on with our work

with the corrections system, the juvenile corrections system, that

there are key risk and protective factors that can identify

criminogenic behavior as well as substance abuse and mental

health-related issues. Dr. Weissberg mentioned many of those, but

I think we can always be looking at that, and we can be helping,

through our systems, to be more collaborative around how that

happens, because I think there are still—there is a lot of fragmentation, and I agree that, you know, primary care physicians,

family physicians are a place where that can happen; however,

very honestly, they do not always have the training they need to

do this kind of work.

Having been on the faculty at a medical school for a number of

years, I know how little they have as a focus on substance abuse

and mental health issues in their training.

Senator REED. All right, thank you very much.

Thank you, Mr. Chairman.

Senator DEWINE. Good questions.

I have a couple of questions from Senator Sessions that I would

like to ask the panel, and anyone who would like can respond.

Senator Sessions asks is there comprehensive information about

how well drug treatment works; in other words, are the current

treatment plans working, and if not, what can be done?

Who would like to respond?

Dr. Brown, I will start with you.

Ms. BROWN. Well, there are a number of agencies that are developing collaborative networks to evaluate the effectiveness of interventions for youth. And typically, what happens is that these are

done in a—as I would consider it a somewhat disjointed fashion;

that is, these are interventions for youth that are in one type of

system or another rather than comprehensively across systems,

distinctively for intervention versus for prevention.

With that background, there are a number of interventions for

youth, some of which have been already articulated today, that

have remarkable outcomes, outcomes that we would consider better

outcomes than if we were treating major health disorders, diabetes

or multiple sclerosis.

So I think these things need to be thought of in this broader context, that we have ways, and we have strategies to reduce alcohol

and drug problems. Part of the key is dissemination; that is, empirically-validated interventions need to be optimally implemented

in communities, and there is often a disjuncture there between
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what we know works and what actually is carried out in communities.

Senator DEWINE. Anyone else?

Yes, Mr. Anton?

Mr. ANTON. I think prior to the last 4 or 5 years, there has

frankly been very little research on adolescent substance abuse and

mental health issues that has proven to have much validity.

Senator DEWINE. Really?

Mr. ANTON. In my opinion.

Senator DEWINE. Really?

Mr. ANTON. In my opinion.

I think that we have seen an explosion almost of that research

in the last 5 years, newer research that has really helped to identify model programs, evidence-based and science-based research

programs. SAMHSA and Mr. Curie’s department publishes a prevention model program manual that also includes prevention and

intervention types of programming. Treatment programming is

more and more being able to identify specific models of treatment

that work effectively for different populations.

But that is all very recent, in the last 4 or 5 years. I mean, I

think we are not—you know, especially on the adolescent side, I

mean, I really believe that from a—you know, going back to the

science to service piece that Mr. Curie spoke about, that is also

very recent, you know, looking at connecting what happens in

science to the everyday real world of what clinicians and programs

have to work with on a day-to-day basis in the communities they

live and work in.

And I think there has been tremendous progress in the last recent years to help that happen, and so, I fully support the continuation of that and hope the committee would, too.

Ms. BROWN. Senator DeWine, I would like to just highlight——

Senator DEWINE. Sure, Doctor.

Ms. BROWN [CONTINUING].——NIAAA, National Institute of Alcohol Abuse and Alcoholism approximately 6 or 7 years ago instituted

a program to facilitate the development of interventions for adolescents with alcohol and drug problems. NIDA has a program that

is a clinical trials network that focuses on adolescents as well. And

so, there is research that is going on. It lags substantially behind

the decades of research that we have on effective interventions for

adults.

And so, it is really critical that we have sufficient funding for implementation in communities of interventions that we know are effective and for research in this area to promote the most optimally,

to design and develop and refine interventions that are most optimal for youth.

Senator DEWINE. Well, let me thank you all very much. It has

been a very good panel, very good session, and I think we have

learned a lot, and we appreciate all of you coming in.

Thank you very much.

[Additional material follows.]
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ADDITIONAL MATERIAL

PREPARED STATEMENT OF THE ALLIANCE FOR CONSUMER EDUCATION

The Alliance for Consumer Education (ACE) is a Washington, D.C.-based

501(c)(3) nonprofit foundation dedicated to advancing community health and wellbeing. It is comprised of a volunteer Board of Trustees who represent a unique

blend of safety advocates, consumer groups, nonprofit organizations, public health

officials and household product manufacturers.

Inhalant Abuse Education is the flagship initiative of ACE. In partnership with

the American School Counselor Association, the Inhalant Abuse Prevention Program

recently completed a six-State pilot education program. Elementary and middle

school counselors provided Inhalant Abuse education seminars to parents, community leaders and other adult influencers. This year, a total of 25 States across the

Nation will receive Inhalant Abuse Prevention kits to help empower parents to discuss the dangers of Inhalants with their children. The goal of the foundation’s program is to increase awareness of Inhalant Abuse from 47 percent to 80 percent by

2007.

With recent data (June, 2004) from the Partnership for a Drug-Free America, we

know that abuse of Inhalants has increased as much as 44 percent over a 2-year

period, driven by fewer children seeing any risk in this dangerous behavior. New

analysis reports that over the past 2 years Inhalant Abuse has increased by 18 percent (from 22 to 26 percent) among 8th graders and by 44 percent (from 18 to 26

percent) among 6th graders.

Honorary Chairman of the Alliance for Consumer Education, US Senator Mike

DeWine (R-OH), states, ‘‘There’s a strong lesson learned from this recent data and

that’s the need to remain vigilant in addressing the threat of Inhalant Abuse among

our children. Better tracking to document incidence and better outreach to educate

parents about risks and symptoms are imperative, since the real impetus for prevention begins at home.’’

What is Inhalant Abuse?

Inhalant Abuse is the deliberate inhalation by ‘‘sniffing’’ or ‘‘huffing’’ of fumes, vapors or gases from common products for the purpose of ‘‘getting high.’’ To achieve

this ‘‘high,’’ more than 1,400 household products are misused—products that are

found under the sinks, in the cabinets, in the garage, and throughout the house.

These household products are chosen because they are inexpensive, easily accessible

and legal to purchase.

Inhalant Abuse is a less-recognized form of substance abuse than use of marijuana, club drugs, cocaine and others, but it is no less dangerous. Inhalant users

can die the very first time, or any time, they inhale a substance. The number of

children that are involved in this dangerous activity is surprisingly large. Nearly

26 percent of all eighth graders in the U.S. have experimented with some form of

Inhalant—that’s more than 2.6 million children. In addition, the age of initiation

to Inhalants is younger than that for any other substance, with reported cases of

Inhalant users as young as 6 years old.

Reporting, however, involves some significant challenges, and as a result, the true

magnitude of the problem can only be estimated at this time. Parents are often completely unaware of Inhalant Abuse, or they refuse to believe or admit that their

child might be involved in this activity—‘‘Not my child!’’ Emergency rooms and doctor’s offices have no standard review criteria, or intake protocol, that helps determine if the problems of a young patient arise from Inhalant Abuse. This lack of

knowledge, open recognition, and documentation of the disastrous results of Inhalant Abuse enables the problem to continue unchecked among our youth today.

Status

Who Uses Inhalants?

The 2002 Youth Risk Behavior Surveillance System Survey showed that race or

ethnicity is not an indicative factor of Inhalant Abuse. ‘‘White’’ is listed as the predominate group abusing Inhalants (16.3 percent), but is closely followed by ‘‘Hispanic’’ at 15.2 percent. ‘‘Others’’ are listed at 14.5 percent, and ‘‘African Americans’’

at 5.8 percent.

As for gender differences, boys tend to have slightly higher use rates than girls

(in grades 4 through 6 and 10 through 12). Between grades 7 through 9, however,

girls and boys tend to use Inhalants at relatively the same rate. After 18 years of

age, males are more than twice as likely as females to use Inhalants.

The survey also showed that between 2000 and 2001, the number of people

age 12 and older having used Inhalants at least once in their lifetime rose
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by roughly 1.5 million, to nearly 23 million users. This means that there are

more Inhalant users than users of Ecstasy and OxyContin combined, but sadly, nine

out of ten parents are unaware or are in denial that their children may have used

Inhalants.

What Products Can Be Abused?

There are more than 1,400 products which are potentially dangerous when inhaled—things like typewriter correction fluid, air conditioning coolant, gasoline, felt

tip markers, spray paint, air freshener, butane, cooking spray, paint, and glue—all

common products that can be found in the home, garage, office, school, or as close

as a neighborhood convenience store. A complete list can be found and downloaded

from the ACE website that specifically addresses this problem—www.inhalant.org.

Listed below are some of the most common products that are used as Inhalants:

Gases Solvents and Gases Aerosols

Nitrous oxide ........................................... Nail polish remover ............................... Spray paint

Butane .................................................... Paint thinner .......................................... Hairspray

Propane ................................................... Paint remover ........................................ Air freshener

Helium .................................................... Correction fluid ...................................... Deodorant

Ether ....................................................... Toxic magic markers ............................. Fabric protectors

Chloroform .............................................. Pure toluene ........................................... Computer cleaning spray

Halothane ............................................... Cigar lighter fluid ..................................

Gasoline .................................................

Carburetor cleaner .................................

Octane booster .......................................

Fuel gas .................................................

Air conditioning coolant (Freon) ............

Lighters ..................................................

Fire extinguishers ..................................

Cleaning Agents Food Products Adhesives

Dry cleaning fluid ................................... Vegetable cooking spray ........................ Model airplane glue

Spot removers ......................................... Whipped cream ...................................... Rubber cement

Degreaser ................................................ Whippets ................................................ PVC cement

* Please note that this is not an all-inclusive list.

How Are Inhalants Used?

Inhalants are breathed in through the mouth or nose using various methods:

• ‘‘Sniffing’’ or ‘‘Snorting’’—Inhalants can be ‘‘sniffed’’ from a container or sprayed

directly into the nose or mouth.

• ‘‘Huffing’’—A chemically soaked rag is held to the face or stuffed in the mouth

and the substance is inhaled.

• ‘‘Bagging’’—Substances are sprayed or deposited into a plastic or paper bag and

the vapors are inhaled. Using a plastic bag may result in suffocation if the individual passes out and his or her nose and mouth are covered.

• Inhalants are placed on sleeves, collars, or other items of clothing and are

sniffed over a period of time. This is a particularly popular method of disguising inhalation of gasoline fumes.

• Fumes are discharged into soda cans and inhaled from the can.

• Users inhale from balloons filled with nitrous oxide and helium.

To maximize the effect of the Inhalant, the substance is inhaled deeply and then

several more short breaths are taken.

Why are Inhalants Dangerous?

When an individual, child or adult, inhales the chemicals in common products as

described above, the concentration of the fumes are much greater than the maximum amount that is permitted by safety standards in industrial settings. Inhaled

chemicals are rapidly absorbed through the lungs into the bloodstream and quickly

distributed to the brain and other organs. Within minutes, the user experiences intoxication, with symptoms similar to those produced by drinking alcohol. With

Inhalants, however, intoxication lasts only a few minutes, so some users seek to prolong the high by continuing to inhale repeatedly.

Short-term effects include: headache, muscle weakness, abdominal pain, severe

mood swings and violent behavior, belligerence, slurred speech, numbness and tingling of the hands and feet, nausea, hearing loss, visual disturbances, limb spasms,
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fatigue, lack of coordination, apathy, impaired judgment, dizziness, lethargy, depressed reflexes, stupor, and loss of consciousness.

The Inhalant user will initially feel slightly stimulated and after successive

inhalations will feel less inhibited and less in control. Hallucinations may occur and

the user can lose consciousness. Worse still, he or she may even die. Please see Sudden Sniffing Death Syndrome.

Long term Inhalant users generally suffer from: weight loss, muscle weakness, disorientation, inattentiveness, lack of coordination, irritability and depression.

Regular abuse of these substances can result in serious harm to vital organs. Different Inhalants produce different harmful effects. Serious but potentially reversible

effects include liver and kidney damage. Harmful irreversible effects include: hearing loss; limb spasms; bone marrow and central nervous system (including brain)

damage.

Sudden Sniffing Death Syndrome

Children can die the first time, or any time, they try an Inhalant. This is

known as Sudden Sniffing Death Syndrome, and while it can occur with many types

of Inhalants, it is particularly associated with the abuse of toluene, butane, propane,

and the chemicals in aerosols.

Sudden Sniffing Death is due to cardiac arrest:

• The Inhalant can force the user’s heart to beat rapidly and erratically until he/

she goes into cardiac arrest.

Death due to Inhalant Abuse is attributed to the following:

• Sudden Sniffing Death Syndrome: cardiac arrest.

• Suffocation: blocking air from entering the lungs when inhaling from a plastic

bag over the head (huffing).

• Choking: inhalation of one’s own vomit after Inhalant use.

• Fatal injury: accidents involving motor vehicle fatalities suffered after Inhalant

use, falls while under the influence, fires due to the inflammatory nature of

Inhalants, drowning accidents.

Signs and Symptoms

While several warning signs may point to occasional problems most teens or preteens experience at some point, don’t be fooled. Parents and caregivers should know

what specific signs may signal real trouble for a child.

Common Inhalant Abuse warning signs include:

• Drunk, dazed, or dizzy appearance.

• Glassy, glazed, or watery eyes.

• Behavioral mood changes.

• Slurred or disoriented speech.

• Lack of physical coordination.

• Red or runny eyes and nose.

• Spots and/or sores around the mouth.

• Unusual breath odor or chemical odor on clothing.

• Nausea and/or loss of appetite.

Chronic inhalant abusers may exhibit symptoms such as hallucinations, anxiety,

excitability, irritability, restlessness or anger.

In addition, there are material signs of Inhalant Abuse that parents should be

aware of. The material signs are important to note because some of the physical

symptoms may not last a long time.

Material signs of Inhalant Abuse include:

• Traces of paint or other products where they wouldn’t normally be, such as on

face, lips, nose or fingers.

• Fingernails painted with magic markers or correction fluid.

• Pens or markers held close by the nose.

• Constant smelling of clothing sleeves.

• Hair scrunchies smelled repeatedly.

• Uncharacteristic problems in school.

• Numerous butane lighters, empty or partially filled, in room, backpack or locker.

• Chemical odors on the breath or clothing.

• Spots or sores around the nose or mouth.

• Gasoline, paint-soaked rags, or used spray paint cans in a child’s room or other

peculiar location. Hidden rags, clothes or empty containers of potentially abused

products in closets, under the bed, or in the garage.

• Missing household products.
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Preventative Steps

Studies show that strong parental involvement in a child’s life makes a child less

likely to use Inhalants. Partnership for a Drug-Free America studies have found ‘‘if

you talk to your kids about the risks of drugs, it is 36 percent less likely

they will abuse an Inhalant.’’ However, parents are not talking to children about

the deadly issue of Inhalant Abuse because many know very little about it and most

do not realize that their children can die the very first time they try an Inhalant.

According to a research study by the Alliance for Consumer Education, Inhalant

Abuse falls behind alcohol, tobacco and marijuana use by nearly 50 percent in terms

of parental knowledge and concern.

Take a few minutes to educate yourself about Inhalant Abuse. Learn the behavior

patterns and warning signs to watch for so you can talk to your children about this

issue because parents can make a tremendous impact on the choices their children

make.

1. Educate yourself about this issue

• Learn what products can be harmful if intentionally abused as Inhalants. • Understand the long-term and short-term effects of Inhalant use. • Learn what slang words are used to describe Inhalants. • Learn the methods of inhalation and their more common names. • Visit the various websites. • Ask your pediatrician or family doctor about Inhalant Abuse. • Talk with other parents about this issue.

2. Preventative measures you can take

• Discuss Inhalant Abuse with your child. • Be aware of what your child is doing at all times, especially after school and

on weekends. • Know your child’s plans and activities. • Meet your child’s friends and playmates. • Reinforce age-appropriate peer resistance skills. • Talk with your child’s teachers, guidance counselors and coaches. • Keep products stored safely away from young children.

• Talk to your child about the proper use of household products.

• Be clear and firm about risky behavior, set limits and consequences.

• Tell your child you love them and that their safety is your number one priority.

In conclusion, the Alliance for Consumer Education (ACE) would like to emphasize the need for increased education methods to stem the tide of Inhalant Abuse

across the Nation. The statistics prove there is a ‘‘Silent Epidemic’’ of increased Inhalant Abuse among our youth today. We simply cannot turn away and permit new

cohorts of children to enter school and be faced with the temptations to experiment

with this dangerous activity. We believe that it is the responsibility of parents and

caretakers everywhere to become educated about Inhalants and to talk with their

children at age-appropriate times.

The Alliance for Consumer Education (ACE) stands ready to help with the education process and we look forward to working together with the subcommittee on

this important issue. For more information, visit the Alliance for Consumer Education at www.ConsumerEd.org or www.Inhalant.org.

PREPARED STATEMENT OF MARY MELTON, PH.D. MBA

Mr. Chairman, thank you for the opportunity to submit written testimony to your

committee regarding adolescent prevention and treatment issues. I also want to

commend you for your leadership and compassion regarding the issue of Addictive

Disorders.

In Ohio, the challenge for Addiction Professionals is always to do more with less.

With adult clients, these forced economies make the work difficult, but not always

impossible. For adolescents, the lack of resources is devastating. Ten years of my

31-year career in addictions and mental health were spent as the administrator of

an adolescent treatment center that offered both residential and outpatient services.

Over those years many of the adolescents who received services visited us to give

us their thanks and to share their stories of success; these nearly always included

jobs, and schools and, most meaningful to me, family reconciliations. They communicated clearly, that without the intervention and treatment services that they received from us, their lives would have taken a different path. They offered their

gratitude for our ability and willingness to somehow understand that they both

needed and could benefit from those services. Our faith in them gave them belief

in themselves.

Still in Ohio, addiction professionals have to rely on a patchwork of Federal, State

and local programs to meet the growing demand for prevention, intervention and
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treatment services for adolescents with alcohol, drug and other addictive disorders.

It is unclear how many adolescents are served through public and private efforts

and which of the available initiatives are best at meeting the needs of adolescents

and their families. It is difficult to determine whether Ohio families know where

intervention and treatment resources are located. In addition, we do not know how

many requests for services are denied due to the lack of resources.What is known

is that there are not enough services or appropriately trained staff available to meet the needs and that each untreated adolescent grows into an

adult with serious issues.

There is a critical need for the Nation to devise and implement a coordinated effort to meet these challenges. There is a need for more adolescent prevention and

treatment workforce training as well as a specific coordinated effort to deal effectively with this challenge in Ohio and other States across the Nation. One of the

ways this could be accomplished is through regional adolescent prevention and

treatment workforce development centers that would focus on such initiatives as (1)

the development of an Internet-based system to collect data on adolescent alcohol

and drug abuse treatment and prevention needs, challenge areas, available local resources, and gaps in care; (2) the development of additional education and training

resources for the addiction professional workforce targeting adolescents; (3) the undertaking of a national assessment of randomly selected school-based programs in

the United States that offer alcohol and other drug prevention initiatives geared toward adolescents; (4) a survey of randomly selected school districts to review common practices following the identification of use by a student. This assessment of

services within school systems would determine the backgrounds, experience, training, certification, and continuing education needs of professionals who are working

with a school-based population.

Federal support for a national initiative is warranted when one examines the national trends, statistics, and other factors that indicate a growing need to support

the addiction professionals through better training, research, and data collection on

adolescent related issues. If we do not address the issues and needs of adolescent

prevention and treatment endeavors, we are ignoring the next generation of those

suffering from alcohol and other drug addiction issues and the problems surrounding them.

The Problem on a National Level

• The Centers for Disease Control and Prevention (CDC) reported that more than

two million youth in the U.S. have diagnosable dependence on illegal drugs and alcohol. The CDC also found that alcohol is associated with the three main causes of

death for teens: accidents including motor vehicles, suicide, and homicide.

• The White House Office of National Drug Control Policy reported that more

than 20 percent of adolescents have been drunk before the 8th grade.

• According to the latest Substance Abuse for Mental Health Services Administration (SAMHSA) Drug Abuse Warning Network report, from 1999 to 2000, total

drug-related emergency department visits increased 20 percent for patients age 12

to 17 (from 52,783 to 63,448).

Adolescent alcohol and drug addictions do not manifest themselves the same way

as these issues in adults. The physical, mental and emotional damage is lifelong and

has a profound impact on their future. Addiction Professionals need to receive training designed to address those issues that are specific to adolescent intervention and

treatment efforts.

I submit this written testimony to you today filled with gratitude and hope.

Through the intervention and support of adults who cared, I was able to go from

being a high school drop out, living on the streets, to being a professional person

with four degrees and the opportunity to help other young people avoid a similar

fate. I understand that it is never too late, that adolescents can change, that we

have to help them and that the smallest of gestures in their lives can truly make

the difference.

[Whereupon, at 11:42 a.m., the subcommittee adjourned.]

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