ERIC EJ815080: Juvenile Justice and Substance Use

2008·0.27 MB·English

by  ERIC

Juvenile Justice and Substance Use
Juvenile Justice and Substance Use
Laurie Chassin
Summary
Laurie Chassin focuses on the elevated prevalence of substance use disorders among young
offenders in the juvenile justice system and on efforts by the justice system to provide treat-
ment for these disorders. She emphasizes the importance of diagnosing and treating these
disorders, which are linked both with continued offending and with a broad range of negative
effects, such as smoking, risky sexual behavior, violence, and poor educational, occupational,
and psychological outcomes.
The high rates of substance use problems among young offenders, says Chassin, suggest a large
need for treatment. Although young offenders are usually screened for substance use disorders,
Chassin notes the need to improve screening methods and to ensure that screening takes place
early enough to allow youths to be diverted out of the justice system into community-based
programs when appropriate.
Cautioning that no single treatment approach has been proven most effective, Chassin describes
current standards of “best practices” in treating substance use disorders, examines the extent to
which they are implemented in the juvenile justice system, and describes some promising mod-
els of care. She highlights several treatment challenges, including the need for better methods
of engaging adolescents and their families in treatment and the need to better address environ-
mental risk factors, such as family substance use and deviant peer networks, and co-occurring
conditions, such as learning disabilities and other mental health disorders.
Chassin advocates policies that encourage wider use of empirically validated therapies and of
documented best practices for treating substance use disorders. High relapse rates among youths
successfully treated for substance use disorders also point to a greater need for aftercare services
and for managing these disorders as chronic illnesses characterized by relapse and remission.
A shortage of aftercare services and a lack of service coordination in the juvenile justice system,
says Chassin, suggest the need to develop treatment models that integrate and coordinate mul-
tiple services for adolescent offenders, particularly community-based approaches, both during
and after their justice system involvement.
www.futureofchildren.org
Laurie Chassin is a professor of psychology at Arizona State University.
VOL. 18 / NO. 2 / FALL 2008 165
Laurie Chassin
The link between juvenile crimi- enforce nonsmoking policies consistently and
nal offending and adolescent completely.7 And substance use treatment
substance use and substance programs often overlook tobacco use because
use disorders is strong and well of the (mistaken) fear that tobacco cessation
established. Among adolescents attempts will undermine sobriety.8 In fact,
detained for criminal offending in 2000, 56 youths who decrease their smoking after
percent of boys and 40 percent of girls tested substance use treatment have been reported
positive for drug use.1 In 2002, the substance to decrease their use of other substances.9
use disorder rate among adolescents aged
twelve through seventeen who had ever been
in jail or detention was 23.8 percent—almost Among adolescents detained
triple the 8 percent rate among youth in
for criminal offending in
that age range who had never been jailed or
detained.2 National data for primarily publicly 2000, 56 percent of boys
funded substance abuse treatment pro-
and 40 percent of girls
grams show that the criminal justice system
accounted for 55 percent of male admissions tested positive for drug use.
and 39 percent of female admissions to these
programs. The criminal justice system is thus
the nation’s major referral source for adoles- Substance use among juvenile offenders is
cent substance users, causing some observers linked with other health risk behaviors. In
to conclude that it has become the de facto one sample of detained youth with substance
drug treatment system in the United States.3 use disorders, 63 percent engaged in five or
more sexual risk behaviors, producing height-
Research has also linked substance use with ened vulnerability to HIV and other sexually
continued contact with the justice system and transmitted diseases.10 Substance use is also
less desistance from criminal offending. In associated with violence and accidents and,
other words, juvenile offenders who continue among pregnant women, with harm to fetal
to use drugs are also more likely to continue development.11 Among adolescents in the
their offending careers.4 This “drug-crime” general population, substance users, par-
cycle likely reflects both the mutual causal ticularly heavy substance users, tend to have
influences between drug use and crime and less positive educational, occupational, and
the fact that substance use and offending psychological outcomes.12
share common risk factors.5 Drug treatment
thus may be one way to reduce recidivism.6 Given the important consequences of
substance use and substance use disorders
Drug treatment offers other obvious benefits. for juvenile offenders, I focus in this article
Besides being illegal, substance use has on how well the juvenile justice system
negative consequences for adolescents’ addresses substance use disorders. I survey
physical health and development. Both the prevalence of substance use problems
alcohol and illegal drug use are correlated and treatment need among offenders as well
with cigarette smoking, the negative health as the extent to which treatment needs are
consequences of which are well known. But unmet. Then I consider the effects of sub-
juvenile correctional facilities often fail to stance use treatment for juvenile offenders.
166 THE FUTURE OF CHILDREN
Juvenile Justice and Substance Use
Although no single treatment approach has and African Americans the lowest.16 The same
been proven most effective, I describe study found no gender differences in the
current standards of “best practices” and the prevalence of alcohol or marijuana disorders
extent to which they are implemented in the but did find that females were more likely to
juvenile justice system and conclude with have other forms of substance use disorders
some promising models of care. and to have a co-occurring (comorbid) mental
health disorder as well. Other studies have also
The Prevalence of Substance found that females with substance use disor-
Use Disorders among Juvenile der are more likely than males to have co-
Offenders occurring mental health disorders.17
It is important to distinguish between
substance use and clinical substance use Treating substance use disorders among juve-
disorders (SUDs), which reflect a more nile offenders is complicated because youths
problematic pattern of use and are associated in the juvenile justice system also face a range
with impaired functioning. Rates of substance of other serious problems, including mental
use disorders among juvenile offenders vary health disorders such as anxiety and depres-
substantially depending both on the criteria sion (especially in girls), academic failure,
used to define the disorder and on the learning disabilities, and parental substance
settings—such as juvenile detention, secure use disorders.18 To be successful, treatment
confinement, and entry into the system—that must thus address these co-occurring prob-
are sampled. Detained adolescents show high lems. Youths with co-occurring mental health
rates of substance use disorders. According to disorders tend to have more severe substance
one study, half of males, and almost half of use disorders, greater family dysfunction, and
females, in juvenile detention had an SUD, poorer treatment outcomes.19
the most common being marijuana use
disorder.13 Another study estimated that Screening and Diagnostic
two-thirds of adolescents entering the Illinois Assessment for SUDs among
juvenile corrections system met clinical Juvenile Offenders
diagnostic criteria for substance use disor- Although the negative consequences of
der.14 Rates as low as 25 percent, however, substance use (including an elevated risk for
have been reported at juvenile intake.15 Thus, continued offending) suggest the utility of
although juvenile offenders have higher rates substance abuse treatment, not every adoles-
of substance use disorders than the general cent who uses alcohol or drugs needs treat-
adolescent population, in most samples, the ment. Attempting to treat all substance-using
majority of offenders do not have a clinical juvenile offenders would be both impractical
diagnosis. Nevertheless, with rates varying and a waste of costly and much-needed
from 25 percent to 67 percent, the preva- resources.20 Rather, treatment is more
lence of substance abuse disorder is substan- appropriate for adolescents with clinical
tial, suggesting significant treatment need. substance use disorders.21 Identifying juvenile
offenders with such disorders requires
One study found that substance use disorder screening and, then, for those who screen
rates among incarcerated, detained, or secured positive, more thorough diagnostic evalua-
youth vary by race and ethnicity, with non- tions. These evaluations help determine how
Hispanic Caucasians showing the highest rates intensive treatment should be (for example,
VOL. 18 / NO. 2 / FALL 2008 167
Laurie Chassin
whether detoxification is necessary) and delivered, assessing adolescent substance use
whether treatment should take place in the and substance use disorders poses multiple
community or in a residential or secure challenges. Most standardized measures and
setting. Current “best practices” for treating structured interviews rely on self-report data,
adolescent SUDs also require a diagnostic which require youths not only to comprehend
assessment to learn whether the juvenile complex questions, but also to provide accu-
suffers from common co-occurring disorders rate and honest reports. Because substance
(see the article in this volume by Thomas use is illegal, adolescents may be unwilling
Grisso for further discussion).22 to disclose their use. Indeed, one study of
juvenile detainees found that at least half
Adolescents held in juvenile justice sys- of adolescent cocaine users (as detected by
tem facilities are commonly screened for bioassay) denied recently using cocaine; self-
substance use problems. Among facilities reports may thus be more accurate for past
reporting data on screening in the Office of use than for current use.27 Several guidelines
Juvenile Justice and Delinquency Prevention’s on drug abuse treatment recommend moni-
(OJJDP) 2002 Juvenile Residential Facility toring drug use through urinalysis or other
Census, 61 percent (holding 67 percent of objective methods.28 In the 2002 OJJDP data,
juvenile offenders) screened all of the youth, 73 percent of facilities (holding 77 percent of
with the highest screening rates reported adolescent offenders) reported conducting
by reception and diagnostic centers and by urinalysis and 37 percent reported random
long-term secure facilities.23 Between 6 and drug testing. But even biological analysis has
22 percent of facilities reported no screening its limits, and different analyses (for example,
at all. But although the facilities commonly of urine, saliva, and hair) vary in terms of
did some screening, they less commonly used their expense, the time it takes to receive
standardized screening instruments; 55 per- results, and the time window of use that
cent of programs in the OJJDP Census data is detectable. Thus, a combination of self-
and 48 percent in another national sample reports and biological measures is probably
used such instruments.24 Thus, it is unclear necessary to evaluate thoroughly the sub-
whether programs are screening effectively stance use disorders of young offenders.
enough and early enough to be maximally
useful. Sixty percent of facilities (holding Assessing substance use disorders (using
64 percent of offenders) that reported on standard American Psychiatric Association
screening in the 2002 OJJDP Census did their criteria) requires characterizing substance
screening within the first week.25 But if youths use–related social consequences, dependence
can be screened even before they are admit- symptoms, and the associated impairment.
ted to the facilities, they may be able to enter Current psychiatric practice is to diagnose
diversion programs instead, which may allow adolescents using the same criteria as adults,
them the opportunity for community treat- although the developmental appropriateness
ment. One review has suggested that a lack of of this practice has been questioned.29 Many
case management and initial intake evaluation adolescents have been labeled “diagnostic
has led diversion programs to be under-used.26 orphans” because they show symptoms of
a disorder that fall just short of diagnostic
Even if standardized screening and diag- thresholds, making treatment decisions
nostic evaluation services can be promptly difficult.30 Moreover, the current taxonomy
168 THE FUTURE OF CHILDREN
Juvenile Justice and Substance Use
distinguishes between substance abuse and Another estimate of unmet need was based
substance dependence disorders. Substance on a sample of youths entering the Juvenile
dependence is presumed to be more severe Division of the Illinois Department of
than substance abuse and to require treat- Corrections.35 Of all the youths who had a
ment. However, recent research suggests substance use disorder and thus needed
that some symptoms of dependence are less treatment, only 48 percent reported ever
severe than those of abuse, making it difficult having been treated. (There were no gender,
to base treatment decisions on the distinction racial and ethnic, or educational differences.)
between abuse and dependence diagnoses.31 The level of unmet need here too was
substantial, but because these youths were
Finally, diagnosing and assessing adolescent just entering the justice system, their lack of
substance use disorders is particularly treatment does not necessarily reflect their
complicated for juvenile offenders. For experience in the system. In fact, youths with
example, being confined in a correctional prior arrests and with a history of childhood
facility can influence the likelihood that neglect were more likely than others to have
particular substance use–related negative been treated, suggesting that the juvenile
consequences can occur (such as negative justice and child welfare systems provided
effects on romantic relationships). Thus, for treatment.
youths in secure confinement, assessing only
current symptoms (rather than past symp- One study, using the 2002 OJJDP data,
toms) may be misleading. Moreover, there is estimated that 66 percent of juvenile justice
some evidence that juvenile offenders system facilities provide treatment services,
under-report their own substance use–related the most common being drug education
impairment and that they may not have the (97 percent).36 Approximately two-thirds of
judgment and maturity to appraise accurately the facilities provide group counseling by a
such impairment.32 professional, and 20 percent provide all youth
in the facility with onsite counseling. Because
Unmet Need for Treatment these figures exclude facilities that did not
in Juvenile Justice Settings provide data on substance use treatment,
Getting precise figures for the extent of however, they may over-estimate the treat-
“unmet need” for substance use disorder ment provided.
treatment in the juvenile justice system is
difficult. One study, based on 1999 data, esti- A study by Dennis Young, Richard Dembo,
mated that 30 percent of juveniles arrested, and Craig Henderson found that most facili-
or a total of 840,000 adolescents, needed ties (75 percent) provided drug and alcohol
treatment. That figure is six times the num- education classes, which were attended (on
ber of publicly funded treatment slots.33 Like average) by 21 percent of residents.37 Educa-
the data presented earlier—that 25 percent tion alone, however, is not enough for youth
to 65 percent of adolescents in various justice with substance use disorders, and only 44.6
system settings meet diagnostic criteria for a percent of programs provided some other
substance use disorder—the figure suggests form of treatment. Treatment varied widely
that many youths who need treatment go by type of setting, with low rates of treatment
untreated. A similar unmet need has been in jails and detention centers. Of course,
reported among adolescents more generally.34 assessing unmet need requires knowing not
VOL. 18 / NO. 2 / FALL 2008 169
Laurie Chassin
only the rates of services provided by particu- courts significantly reduced subsequent
lar settings but also the individual treatment arrests, though adult courts reduced arrests
needs of the adolescents in these settings. All by an average of 9 percent, as against only 5
current available estimates, however, suggest percent for adolescent courts.42 Moreover,
substantial unmet treatment need among the positive effects of drug courts decline
juvenile offenders. when court supervision ends.43
The Role of Drug Courts One limitation of drug court services is that
Juvenile drug courts first appeared during the often they do not use empirically validated
1990s based on the premise that more treatments.44 Some researchers have tried to
intensive assessment, monitoring, and treat- address this problem by introducing treat-
ment would reduce offending for adolescents ments such as multidimensional family
with alcohol and drug problems. By 2006, 350 therapy and Multisystemic Therapy (MST).45
of these drug courts were in session, with Both these therapies target social environ-
another 160 being planned.38 These courts mental factors that maintain adolescents’
monitor drug use (including drug testing) and antisocial behavior. Their aim is to improve
offer a team of professionals who can refer or family relationships and disciplinary practices,
provide services including education, voca- increase youths’ associations with prosocial
tional training, recreation, mentoring, com- peers, and improve school or vocational
munity service, health care, and drug and outcomes (see the article in this volume by
mental health treatment. Compared with Peter Greenwood for further discussion of
typical courts, juvenile drug courts provide these therapies).
earlier assessments, better integration
between assessments and court decisions, One recent clinical trial randomly assigned
more emphasis on families, more continuous juvenile offenders with substance use disor-
supervision, and more immediate use of ders to four groups: family court and usual
sanctions and rewards.39 A recent review community services, drug court and usual
suggests that the adolescents in these courts community services, drug court plus MST,
are demographically similar to other juvenile or drug court plus MST plus vouchers for
offenders: most typically use alcohol or “clean” urine samples.46 The trial found that
marijuana, typically have past justice system juveniles in the drug court (as well as the
involvement (but limited past treatment), and drug court plus MST) significantly reduced
often have co-occurring mental health prob- substance use, as measured by urine drug
lems as well as family histories of substance screens during the first four months. How-
use or criminal justice involvement, or both.40 ever, drug courts were not found to improve
rates of re-arrest or re-incarceration, probably
Relatively few researchers have examined because of the heightened surveillance in
the effectiveness of juvenile drug courts. In the courts.
one study, of only six evaluations of the courts
that included both a control or comparison Available evidence thus suggests that drug
group and data on post-program recidivism, courts have reduced adolescents’ substance
five found significantly lower recidivism for use, at least while the youths are under
drug court clients.41 A recent meta-analysis supervision. The data base, however, is small,
found that both adult and adolescent drug and more evidence is needed, particularly
170 THE FUTURE OF CHILDREN
Juvenile Justice and Substance Use
about long-term outcomes and whether Cocaine use, however, significantly increased.
greater use of empirically validated treat- And because the study lacked an untreated
ments can improve outcomes in the drug control group, its findings are not conclusive.
courts. Research is also needed to determine
the effect of matching the intensity of The Cannabis Youth Treatment Study
supervision and intervention to the individual included two randomized trials with 600
needs of the adolescent offender.47 marijuana users, a majority of whom were
under the supervision of the criminal justice
The Effects of Treatment system. The studies compared the effects
on Substance Use and Criminal of motivational enhancement therapy plus
Offending cognitive-behavioral therapy, both with and
A small but rapidly growing empirical litera- without family support and with and without
ture demonstrates that treatment can reduce either community reinforcement or multidi-
substance use among adolescents in general mensional family therapy.50 All the treatments
and among juvenile offenders in particular. increased significantly the days the youths
Conducting research in this area is challeng- abstained from using marijuana, but no
ing, and methodological problems include single treatment proved more effective than
having to take into account the case-mix of another. One year later, the share of adoles-
adolescents who are treated, the length of cents who were in recovery—that is, living
the follow-up period, the time during the in the community without current substance
follow-up that adolescents spend in insti- use or substance use problems—ranged from
tutional placement or controlled environ- 17 percent to 34 percent, but, again, did
ments, whether the treatment is delivered not differ across different treatments. The
as intended, the need to verify self-reported subgroup of adolescents involved with the
substance use, and the ability to retain the justice system also reduced substance use.51
adolescents to measure substance use during However, because results were the same for
the follow-up period. Despite these formida- different types and intensities of treatment,
ble obstacles, however, adolescent substance only limited claims can be made for treat-
use treatment appears to reduce substance ment effects.
use, at least to some extent and at least in the
short term. Studies of residential programs have also
shown some positive but mixed effects. In one
Yih-Ing Hser and colleagues analyzed the study, adolescents on probation who received
DATOS-A data collected on adolescents (58 nine to twelve months of residential treatment
percent of whom were involved with the and professional counseling showed better
criminal justice system) from residential or substance use outcomes at one-year follow-up
outpatient drug treatment programs in four than did those on probation who did not
U.S. cities.48 After treatment, the youths receive residential treatment.52 However, the
significantly reduced frequent marijuana use, study found no effects on criminal offending.
heavy drinking, other illegal drug use, crimi- Another study examined a therapeutic
nal activities, and arrests; the longer they community that had been developed specifi-
were in treatment, the better the outcome. cally for adolescents in the justice system and
Moreover, the reductions in substance use that used cognitive-behavioral techniques,
were linked with reductions in offending.49 contingency management, and education.53
VOL. 18 / NO. 2 / FALL 2008 171
Laurie Chassin
The study found no significant self-reported rather than as acute disorders. The new view
decreases in substance use, although it did brings with it a corresponding emphasis on
find significant self-reported decreases in aftercare and long-term management.57
criminal behaviors. The lack of a comparison Analysts now see substance use disorders as
group, the need to rely on self-report data, being similar to other chronic conditions such
and the failure of many in the group to as diabetes or hypertension, for which
participate in the follow-up make the findings outcomes are positive as long as patients
less than conclusive. adhere to prescribed treatment, but not when
treatment stops.
Finally, family-based and multisystemic drug
treatments have also produced positive
findings. Because both these forms of therapy
These findings suggest that
are also used to reduce antisocial behavior,
they could reduce offending and recidivism as a substantial proportion
well as substance use (again, see the article by
of adolescent offenders is
Peter Greenwood in this volume). A review of
research showed that Multisystemic Therapy released into the community
(MST, described earlier) significantly reduced
without appropriate aftercare
substance use among juvenile offenders.54
One study of MST also found long-term to manage their substance
effects on criminal activity: the re-arrest rate
use disorders.
for the MST-treated group was 50 percent, as
against 81 percent for the individual therapy-
treated group.55 These adolescent offenders,
however, were not referred for substance use Successful treatment must also meet other
disorders. One long-term (four-year) follow-up challenges. One is the broad array of co-
of Multisystemic Therapy with adolescent occurring conditions, including poor educa-
offenders diagnosed with substance use tional and vocational achievement, mental
disorders found mixed results. Biological health disorders, and physical and legal prob-
measures of marijuana use declined but other lems, among adolescents with substance use
substance use measures did not.56 disorder. Achieving positive outcomes takes
comprehensive interventions (see the article
These findings are consistent with research by Thomas Grisso in this volume for a fuller
on substance use treatment generally, which discussion) that require collaboration by, and
shows statistically significant short-term financing from, multiple service delivery sys-
effects, but inconsistent findings across tems, such as juvenile justice, mental health,
different outcomes and also substantial child welfare, and education.58 It is also chal-
relapse. Thus, it is unrealistic to think that lenging to implement treatment in real-world
any one episode of treatment will produce a settings, where treatment may not always be
permanent “cure.” This pattern of short-term delivered as intended.
moderate success but long-term relapse after
treatment has led to a re-conceptualization of Another difficulty is that adolescents rarely
substance use disorders as chronic disorders, perceive a need for treatment, making it
characterized by remission and relapse, hard to engage and retain them in treatment.
172 THE FUTURE OF CHILDREN
Juvenile Justice and Substance Use
Drop-out and failure to take advantage of The need to improve aftercare has led
aftercare services is a problem, even for ado- researchers to test innovative models of after-
lescents in the justice system. One possible care services. One study examined “assertive
solution to this problem is to use strategies aftercare,” in which a case manager linked
such as motivational interviewing techniques. multiple services.64 Among a sample of ado-
Another is to help families to facilitate their lescents in residential drug treatment, most
adolescent’s entry into treatment.59 However, of whom were involved with the criminal
although family involvement may be advanta- justice system, assertive aftercare increased
geous, families of adolescents in the juvenile both linkages to treatment services and
adherence to continuing care. But although
justice system are themselves more likely
assertive aftercare reduced marijuana use at
to be involved in substance use or crimi-
nine-month follow-up, it had no effects on
nal activity. And including these families in
other substance use.
treatment is particularly difficult if treatment
takes place in geographically distant residen-
Because environmental risk, including family
tial settings. One final challenge to treatment
substance use and deviant peer networks,
is that placing antisocial adolescents together
affects aftercare outcomes, aftercare services
in a group setting can worsen outcomes as
might benefit from using family-based
these adolescents negatively influence each
interventions (or multisystemic interventions)
other’s behavior.60 Although no evidence of
to help target these risk factors and maintain
this phenomenon was found in the Cannabis
positive treatment outcomes.65 At the time of
Youth Study, any group-based substance use
this writing, researchers are testing a family-
disorder interventions must be vigilant in
based intervention to help young offenders in
guarding against potential iatrogenic effects.61
juvenile detention rejoin the community.66
Another approach involves training probation
Aftercare and Substance Use
officers to provide adolescent probationers
in Juvenile Justice
with cognitive interventions (that is, strategies
Given the short-term effects of treatment
to change reasoning processes and beliefs
and the concomitant importance placed on
about substance use and offending).67 One
aftercare, it is striking that a recent national
final promising strategy, recently imple-
survey of program directors providing treat-
mented in general substance abuse treatment,
ment for juvenile offenders found that only
is adaptive interventions, which adjust the
26 percent of secure institutions and 25 per-
type and intensity of the treatment over time
cent of community-based programs included
to the changing needs of the individual.68
aftercare services.62 An analysis of the same
Given the difficulty of retaining adolescents
data set found that only 51 percent of sub- in substance abuse treatment, aftercare
stance-abusing youth in residential facilities treatments that likewise vary in their intensity
and 31 percent in jails were referred to a may improve long-term adherence to treat-
community-based treatment provider when ment. Two important policy questions are
they were discharged.63 These findings sug- how to implement (and fund) continuing
gest that a substantial proportion of adoles- aftercare when an adolescent leaves justice
cent offenders is released into the community system supervision and which, if any, formal
without appropriate aftercare to manage their system of care would be responsible for
substance use disorders. providing such services.
VOL. 18 / NO. 2 / FALL 2008 173
Laurie Chassin
Does Treatment in Juvenile Justice problem severity, recovery stage, and level
Settings Use “Best Practices?” of supervision that is required by the justice
Researchers who have examined substance system). Drug use during treatment should be
use treatment have found that no single carefully monitored. Drug treatment in the
treatment produces the best outcome. justice system should target factors that are
Instead, several treatments, including associated with criminal behavior (including
Multisystemic Therapy, cognitive-behavioral beliefs and attitudes that promote criminal
therapy, contingency management, family offending), and criminal justice supervision
therapy, motivational enhancement, and should incorporate treatment planning. The
residential therapeutic communities, have NIDA principles recognize the importance of
shown some (although mixed) success. continuity of care during community re-entry
Because no one method of treatment is and the use of a balanced mix of rewards and
clearly superior, recommendations for “best sanctions to encourage treatment participa-
practices” have focused on the treatment tion and prosocial behavior. Medications are
dimensions associated with more favorable thought to be an important part of treat-
outcomes. These “best practices” have been ment for many offenders, and those with
derived from a combination of empirical co-occurring mental health problems require
evidence and professional consensus. an integrated treatment approach. Finally,
because of the link between substance use
In 2006 the National Institute on Drug Abuse and broader risk behaviors, treatment plan-
(NIDA) issued thirteen principles of drug ning should include strategies to prevent and
abuse treatment for criminal justice popula- treat medical conditions such as HIV/AIDS,
tions, including both adults and adolescents.69 hepatitis B and C, and tuberculosis.
These principles begin with the premise that
drug addiction is a brain disease because drug These NIDA principles apply to criminal
use changes neural mechanisms associated justice populations, but are not specific to
with reward and self-regulation, and these adolescents. For example, little is known
changes in turn increase the likelihood of about the use of medications to treat adoles-
relapse. The NIDA principles also state that cent substance use disorders, and medica-
recovery from addiction requires effective tions are less commonly used in adolescent
treatment followed by management of the than in adult treatment.
problem over time (often including multiple
treatments). Treatment must last long enough The American Academy of Child and Ado-
to produce stable behavioral changes, and lescent Psychiatry (AACAP) has also issued a
individuals with severe drug problems and set of minimum standards of care for the
co-occurring disorders may require longer treatment of adolescent substance use dis-
treatment (three months or more) as well as orders, which include: an appropriate level
requiring more comprehensive services. The of confidentiality, screening older children
NIDA principles propose that assessment of and adolescents for substance use, formal
the problem (including mental health evalu- evaluation (including biological measures) for
ation) should be the first step in treatment those with positive screens, specific treatment
planning and that treatment must then be tai- for disorders of those who meet diagnostic
lored to the needs of the individual (including criteria, treatment in the least restrictive
differences in age, gender, ethnicity, culture, setting that is safe and effective, family
174 THE FUTURE OF CHILDREN