Research Paper

Drug Strategies
Literature Review for Bridging the Gap

Substance abuse today is a widespread problem for youth as a whole, and presents an especially important challenge for those involved in the juvenile justice system. To help inform research related to substance abuse treatment in the juvenile justice system, we conducted a 10-year literature review guided by the framework of the 9 key elements to effective adolescent substance abuse treatment identified by Drug Strategies in Treating Teens: A Guide to Adolescent Drug Programs (Drug Strategies, 2003). These 9 elements were developed with the assistance of a distinguished advisory panel of nationally recognized adolescent substance abuse experts, and consist of: Assessment and Treatment Matching; Comprehensive, Integrated Treatment Approach; Family Involvement in Treatment; Developmentally Appropriate Program; Engage and Retain Teens in Treatment; Qualified Staff; Gender and Cultural Competence; Continuing Care; and Treatment Outcomes. This literature review is part of a process that we hope will lead to the identification of the key elements that are needed to effectively treat substance abusing adolescents involved in the juvenile justice system. The articles discussed in this review were located by conducting Internet searches using the Office of Juvenile Justice and Delinquency Prevention, Pub Med and Google search engines, consulting with a number of experts in both fields, and reviewing bibliographies of prominent articles on both the juvenile justice system and substance abuse treatment.
Overview of Substance Abuse Treatment in the Juvenile Justice System More than one-third of all arrests in the U.S. are related to drug and alcohol use, and almost $24 billion was spent in 2000 to incarcerate 1.2 million nonviolent offenders (Kumpfer & Alvarado, 1998; Schiraldi et al., 2000). Due in part to the rate of illicit drug use among youth, in recent years there has been an increasing burden on the juvenile justice system, (Dickinson & Crowe, 1997). Between 1986 and 1996, there was a 291% increase in the rate at which young people were incarcerated because of drug involvement (Schiraldi et al., 2000). Interviews and drug tests from 1998 with more than 3,500 recent juvenile arrestees had over half testing positive for marijuana use (NIJ, 1999). Research suggests that a relatively small group of serious and violent juvenile offenders who are serious drug users accounts for a disproportionate amount of all serious crimes committed by delinquents (VanderWaal, 2001). Substance abuse and delinquency are often closely related. Research indicates that juvenile drug use is connected to recurring, chronic and violent delinquency that can continue well into adulthood (VanderWaal, 2001). Furthermore, a 1999 Australian study found that substance use variables do predict involvement in violent crime (Lennings, 2003). Common factors such as school and family problems, negative peer groups, a lack of neighborhood social controls, and a history of physical or sexual abuse can lead to higher risk for both drug abuse and delinquency (Dickinson & Crowe, 1997). Despite this prominence of substance abuse problems among juvenile delinquents, the research literature suggests that there is far from unanimous agreement as to what constitutes effective treatment for young offenders. While a meta-analysis by Lipsey & Wilson (1998) of 200 studies found that intervention programs can reduce the reoffending rates of serious delinquents, VanderWaal (2001) concluded that few interventions have demonstrated consistently positive scientific outcomes in breaking the juvenile drug-crime cycle. Butts and Mears (2001) argue that the earlier an intervention occurs, the more likely it is to be cost-effective and to reduce negative outcomes such as criminal behavior. Yet in a 1997 survey of short- and long-term juvenile correctional facilities, the Substance Abuse and Mental Health Services Administration (SAMHSA) found that only 36% offered some type of substance abuse treatment (Altschuler & Brash, 2004). In addition, there is a shortage of slots for treatment in correctional facilities as well as in the community, making it all the more important that treatment be designed effectively and efficiently (Altschuler & Brash, 2004). In this review, we have organized experts’ views on substance abuse treatment for young offenders according to Drug Strategies’ 9 key elements for adolescent substance abuse treatment. For each element, we will examine what the literature has to say regarding its importance in treating the drug problems many juvenile delinquents face, the key themes and issues regarding the element, and some strategies for how to effectively address the element.

Assessment and Treatment Matching
Importance of This Element In Treating Teens, Drug Strategies (2003) argued that a standardized, in-depth assessment “provides a basis for determining if the adolescent’s needs match the services available at the particular program as well as the level of treatment intensity” (p. 5). Upon intake into the juvenile justice system, there are a number of problems that can be present with high-risk youth, including: substance abuse; physical abuse; poor emotional and psychological functioning; and educational difficulties (Dembo et al., 1997). Co-morbid psychiatric disorders are a particularly prevalent health problem among young offenders (Prescott, 1997), as Abram et al. (2003) state that about 60% of male and 70% of female juvenile detainees have a psychiatric disorder upon entry into the juvenile justice system. Yet many jurisdictions lack the resources to effectively identify and intervene with high-risk youths at their first contact with the juvenile justice system (Dembo et al., 1997). Furthermore, on an average day, approximately 15% of incarcerated youth are housed in adult facilities that may lack adolescent mental health services (Abram, et al., 2003).
Key Themes Increasingly, certain elements within the juvenile justice system, such as juvenile drug courts (which will be further discussed later), are realizing the importance of earlier and more comprehensive intake assessments (Drug Court Clearinghouse, 1997). However, as is true for noninstitutional adolescent treatment programs, there does not appear to be much consistency with regards to the types of assessment offered in the juvenile justice system (Drug Strategies, 2003). In general, there is a strikingly low priority given to needs assessment for juvenile offenders, as well as widespread ambiguity about the purposes of assessment (Mears, 2003). If the youth is not properly assessed and matched for services at intake, a number of issues can arise that may hinder effective treatment, such as girls with less visible signs of psychological distress not being referred properly or being overmedicated without the necessary psychotherapy (Prescott, 1997). There are a large number of screening and assessment instruments being used in the juvenile justice system, and this lack of standardization can negatively influence the youth’s treatment pathway. For example, Prescott (1997) argues that determining the prevalence rates of co-occurring disorders among adolescents is difficult due to the lack of uniform assessment guides. In addition, a study of a juvenile assessment center in Florida found that very few clients or their families were engaged in the assessment process (Dembo et al., 1997). One common screening method is urinalysis, which was first used to assess the drug status of people in jail in 1977. In the juvenile justice system, however, it is neither applied consistently nor to the degree that it has in the adult criminal justice system. (Crowe & Sydney, 2000). Crowe and Sydney (2000) further contend that while drug testing can help identify needs and suggest appropriate referrals, it can also increase demands on the juvenile justice system because of a higher number of technical violations and increased costs in the short-term.
Suggested Strategies There are a number of obstacles to implementing standardized, comprehensive assessments in the juvenile justice system. These include the need to clarify the purposes and appropriate uses of assessments, improve their reliability and validity, and enhance the feasibility of conducting assessments (Mears, 2003). In general, most experts seem to agree that whichever assessment is used, it should at least be conducted upon intake, be individualized, and be comprehensive so that youths do not receive inappropriate referrals, duplicate services, or unnecessarily restrictive placements (VanderWaal, 2001; Butts and Mears, 2001; Greene et al., 1998; Nissen et al., 1999). Two American Probation and Parole Association projects, funded by the Office of Juvenile Justice and Delinquency Prevention (OJJDP), recommended a combination of three methods for screening juveniles for illicit drug use: assessment instruments and techniques; drug recognition techniques; and chemical testing (Dickinson & Crowe, 1997). Many experts also insist that the youth should be repeatedly reassessed throughout the treatment process (Butts and Mears, 2001). Volume 31 of the TIP series produced by the Substance Abuse and Mental Health Services Administration (SAMHSA) argues that screening and assessment of juveniles should be conducted repeatedly at different stages, including an initial screening within 24 hours of entry to the agency or facility. Family Functional Therapy, a multisystemic, short-term prevention and intervention approach that has become a widely used program in juvenile justice settings, conducts an assessment at each of three phases: engagement and motivation; behavior change; and generalization (Alexander et al., 2000; Sexton & Alexander, in press). Family Empowerment Intervention, which is a systems-oriented, low-cost intervention for high-risk youths who have been arrested, uses two standardized instruments, the POSIT and PEI, for a preliminary screening and in-depth assessment, as well as referral outcome data (Dembo et al., 1997; Dembo & Schmeidler, 2002). Juvenile drug courts involve frequent drug testing and match for participation in appropriate treatment and counseling programs (Drug Court Clearinghouse, 1997). Since co-occurring disorders are so common among delinquent youths, research also stresses the importance of including mental health screenings for youth in the juvenile justice system as part of the assessment process (Cocozza & Skowyra, 2000). Mears (2003) insists that interventions be premised on an understanding of the multiple pathways and linkages, including as co-occurring disorders, that contribute to a wide range of negative outcomes for delinquent youth. Drug testing is a common tool, and some experts recommend it when necessary for the initial screening and assessment, as well as monitoring treatment compliance (Nissen et al., 1999; Crowe & Sydney, 2000). To be administered correctly, this screening method requires developing policies and procedures, training staff, and evaluating the program to ensure that it is appropriately implemented and legally defensible. Drug testing may be conducted either: offsite (at a certified laboratory); onsite using an instrument operated by trained staff; or onsite using noninstrument-based tests at the point of contact with the youth (Crowe & Sydney, 2000). An important recent development regarding assessment and matching is the statewide establishment of juvenile assessment centers (JAC) in Florida, which provide a centralized intake process based on multidisciplinary screening and assessment (Mears, 2003). Thanks to their focus on the importance of assessment, JAC facilities could foster the development of innovative strategies to improve the availability, accessibility, and delivery of services to young offenders and their families (Dembo et al., 1997). Butts and Mears (2001) view JACs as an approach that could go a long way towards solving some the present problems involved in juvenile justice assessments.

Comprehensive, Integrated Treatment Approach
Importance of This Element To avoid duplication of services, provide necessary referrals and ensure that treatment is targeted to the specific needs of each substance-abusing adolescent, services should be comprehensive and coordinated across agencies throughout the duration of the treatment process (Drug Strategies, 2003). However, one of the most common themes in the juvenile justice and substance abuse literature is the lack of integration and systems collaboration with agencies that deal with treating the drug problems of young offenders (Butts and Mears, 2001; VanderWaal, 2001; Altschuler & Brash, 2004; Nissen et al., 1999). Studies show that frequently one system will refuse to become involved with youths until exclusive jurisdiction has been established, as there are still strong institutional barriers between the rehabilitative and correctional orientations (Mears, 2003). Traditionally, service providers for juveniles have been plagued by poor coordination, large caseloads of multiple-need families, poor cross-system communication, increased specialization, and inadequate funding (VanderWaal, 2001). The lack of information-sharing among agencies is attributed to factors including: real and perceived confidentiality issues; lack of communication structures; prohibitive policies and procedures; and technological barriers (Nissen et al., 1999). As a result of these challenges, the diverse agencies supposed to be serving the needs of young offenders with drug treatment needs, including the juvenile justice, mental health, school and social service systems, are insulated from each other (Blechman, et al., 2001).
Key Themes Some experts stress that one reason for this lack of coordination is that institutional and community corrections each have cultures and orientations that in certain ways are often fundamentally at odds (Altschuler, 1999). Altschuler and Brash (2004) argue that divergent objectives are in large part to blame for this divide; they describe institutional corrections as focused primarily on the young offender, rather than social networks or community-based resources, while depicting community corrections as being designed to focus on addressing the delinquent’s ecology. Those who focus on a restorative justice approach, which will be discussed in more detail later, view this lack of a coordinated approach as a result of adolescent treatment having become increasingly interventionist, which undercuts the historically stronger informal control provided by communities (Bazemore et al., 2000). Research by Butts and Mears (2001) suggests that the evolution of the juvenile justice system over the past half century has contributed to this lack of a comprehensive, integrated approach. They describe the development of juvenile courts in the early 1900s as an effort to increase the rehabilitative potential of the criminal court for youths, protect adolescents from adult prisoners and control juvenile crime. In the 1960s and 1970s, as the criminal justice system overall became more bureaucratic and formalized, they argue that the juvenile court’s jurisdiction was increasingly limited. In the 1980s and 1990s, they see an increasingly get-tough environment as having led the juvenile court to become increasingly aligned with the values and philosophical orientation of the criminal court, which saw a growing number of juveniles to be transferred to criminal courts, including many for drug violations. One important effort that has been made within the juvenile justice system to address the lack of comprehensive, integrated case management is the growth of juvenile drug courts, which have grown in prevalence in recent years. They seek to modify behavior by tracking youths objectively and applying meaningful consequences, as well as integrate community-based substance abuse treatment for the youths (Randall et al., Manuscript). Juvenile drug courts take a continuous and intensive supervisory case management role for juveniles with nonviolent drug or drug-related offenses and moderate-to-severe substance usage, and increasingly are aware of the importance of greater coordination between the court and the school system and other community agencies (Drug Court Clearinghouse, 1997). Multisystemic therapy (MST) is an example of a treatment strategy focusing on an integrated case management approach that has been adapted and integrated with juvenile drug courts in a number of locations (Randall et al., Manuscript). There are a number of other efforts being made to remedy some of these structural problems. Altschuler (1999) argues that, for those young offenders to whom it applies, parole can be responsible for the challenging task of bridging the gap between the institutional and community services. MST, which involves intensive, community-based treatment for youths with serious behavioral and emotional problems, focuses on providing treatment where the youths’ problems are, in order to change the ecology surrounding the youth (Randall et al., Manuscript; Randall et al., in press). This is based on the belief that expensive, out-of-home placements such as residential treatment facilities, psychiatric inpatient treatment, incarceration, outpatient and clinic-based services have failed to demonstrate results in reducing serious behavioral problems of juvenile offenders (Henggeler, 1997). MST therefore focuses on improving the psycho-social functioning of youth and their families in order to reduce or eliminate the need for out-of-home placements (Henggeler, 1997).
Suggested Strategies To effectively treat the substance abuse problems of juvenile delinquents, the adoption of effective interagency collaborations and integrated case management is critical (Nissen et al., 1999; VanderWaal, 2001; Mears, 2003). Covington (1998) argues for a systemic change that embraces a holistic treatment model that addresses addiction and gender-specific psychological development and trauma in a safe and supportive all-female environment. Other research emphasizes collaboration with representatives from a number of organizations involved in the youths’ welfare, including the juvenile justice system, the community, and mental health and social services providers (SAMHSA, TIP31). Continuity of care literature, for example, stresses the importance of establishing consistency, coordination and collaboration between institutional and community corrections (Altschuler & Armstrong, 2002). Other literature urges the various public and private agencies and programs involved in treating juvenile offenders to network and coordinate their activities. VanderWaal (2001) suggests having a single point of entry that would house a comprehensive management information system and could also provide screening and assessment services. A well-organized, collaborative structure could be part of the behavior change process by linking the youth to prosocial groups and ensuring that the schedules of these services do not conflict (Nissen et al., 1999). Still Nissen et al. warn that it can take a significant amount of time before they can become full partnerships since these collaborative relationships are often plagued by organizational challenges, and they will need to built carefully. There have been a number of partnerships between the juvenile justice system and the substance abuse treatment system in recent years, including Juvenile TASC Programs, Juvenile Integrated Treatment Networks, Juvenile Drug Courts, and Short-Term Youth Detention and Diversion (Nissen et al., 1999). The Prosocial Communities Solution (PSC) builds an infrastructure among the various systems serving young offenders that is based on information sharing, coordinated supervision and involvement in prosocial activities (Blechman, et al., 2001). Family Empowerment Intervention stresses the interrelatedness of problems facing young offenders and argues that holistic, rather than sequential, services be developed for these juveniles and their families (Dembo & Schmeidler, 2002). Since co-morbidity is so prevalent among this population, the mental health needs of juvenile offenders must also be appropriately addressed by interagency collaboration (Mears, 2003; Cocozza & Skowyra, 2000). However, the organizational and structural functions of the mental health and juvenile justice systems often conflict when attempting to address the needs of adolescent offenders, due in part to the dilemma of focusing on the issue of “appropriateness” for the adolescent in one system or the other (Prescott, 1997). Greene et al. (1998) argue that treatment programs should provide comprehensive health services that promote physical and mental wellness, as well as positive community involvement. Furthermore, Abram et al. (2003) insist that mental health professionals collaborate with the juvenile justice system to improve screening, increase diversion and linkage and reduce barriers to service in the community. There are some relatively new strategies recommended by the research literature to address the lack of collaboration and integration in the juvenile justice system. An alternative to the traditional focus of the juvenile justice system is the restorative justice approach, which seeks to shift the focus towards the needs of crime victims and community members, and affirms the central role of community social support and the importance of strong relationships with law-abiding adults and local institutions (Bazemore et al., 2000; Butts and Mears, 2001). Restorative justice attempts to balance offender accountability, competency development and community safety (VanderWaal, 2001). By emphasizing that crime involves a violation of individuals, communities and relationships, restorative justice attempts to repair the harm caused by the crime (Bazemore et al., 2000; Bazemore 2001). Blechman, et al. (2001) argue that communities should use local resources to build an infrastructure compatible with restorative justice ideals. However, thus far, restorative justice has not been widely used in the substance abuse context (Bazemore, 2001; Braithwaite, 2001). Altschuler and Brash (2004) are proponents of what they call the reintegration model, which will be further discussed under the section on Continuing Care. They assert that reintegration can serve as the bridge between institutional and community corrections, since it addresses both offender change and offender ecology. Nevertheless, they worry about whether reintegration can be implemented in a “get tough” climate focused on deterrence or zero tolerance.

Family Involvement in Treatment
Importance of This Element Families clearly play a crucially important role in the lives of most adolescents, and institutions such as juvenile drug courts are increasingly realizing the importance of addressing family problems as well as the specific needs of the young offender (Drug Court Clearinghouse, 1997). Important family indicators that influence juvenile substance abuse include: parents with a history of substance abuse; favorable family attitudes toward substance abuse and deviant behavior; and lack of parental involvement or appropriate supervision (Nissen et al., 1999). While peer influence is often cited as a major reason to initiate drug use or delinquency, parental disapproval is also a major reason not to engage in delinquent acts or to use drugs (Kumpfer & Alvarado, 1998).
Key Themes It is often difficult to get families of young offenders involved in their treatment, and states differ on whether family participation in court proceedings is required (Drug Court Clearinghouse, 1997). In a study of over 1,800 juvenile detainees in an Illinois detention center, Abram et al. (2003) found that despite repeated attempts to contact a parent or guardian for consent to participate in the study, none could be found for 43.8% of participants. Thus, when family participation is required, strategies for dealing with a noncompliant parent need to be further explored (Drug Court Clearinghouse, 1997). Since the family can be a positive or a negative influence on juvenile delinquents, experts are split as to whether families should be required to participate in the substance abuse treatment process. Nissen et al. (1999) argue that family involvement is a critical component of effective adolescent treatment, and programs should implement family-based treatment if relatives are abusing substances. Furthermore, Kumpfer & Alvarado (1998) describe comprehensive family programs as having a greater impact on a broader range of family risk and protective factors than programs that ignore context and work only with youth. Dembo & Schmeidler (2002) believe that court-ordered participation in intervention services can increase family engagement in the treatment process as well as the period of time that families receive services. Kumpfer and Alvarado (1998) point out that family conflict and reduced family involvement significantly predict associations with deviant peers, which can promote delinquent behavior. On the other hand, since not all dysfunctional families will change sufficiently to support the child’s needs, some experts argue that the youth must also be equipped with skills to get along apart from their family (Drug Court Clearinghouse, 1997). Since the family’s impact on the youth can vary widely, Nissen et al. (1999) argue that it is important to have a variety of options in terms of the intensity at which the family participates in the young offender’s treatment. Another important and often difficult issue is how to define the child’s “family” (Drug Court Clearinghouse, 1997). The traditional definition of a family is not necessarily applicable to every juvenile, so alternative and functional family arrangements should be considered during intervention efforts, as well as attempts to have problematic families enter treatment (SAMHSA, TIP31).
Suggested Strategies Research has not pointed to a single best family intervention program (Kumpfer & Alvarado, 1998). The Strengthening Families Initiative conducted a national search of 500 programs that found 25 effective family strengthening programs taking a variety of approaches to family involvement (Kumpfer & Alvarado, 1998). Kumpfer and Alvarado (1998) argue that family-focused prevention programs should not only decrease risk factors, but also increase ongoing family protective mechanisms. They identify 5 major types of family protective factors: supportive parent-child relationships; positive discipline methods; monitoring and supervision; families who advocate for their children; and parents who seek information and support. To achieve these goals, they argue for long-term, family-focused intervention programs that should be: highly structured; comprehensive; tailored to the youth’s developmental stage and the family’s risk factors; and designed to produce changes in ongoing family dynamics and environment. Greene et al. (1998) further support the notion that treatment programs should involve the parents in the treatment plan and build positive family support. There are specific programs that have been shown in some evaluation studies to have a positive impact on the family. Functional Family Therapy, which requires 8 to 26 hours of direct service time with at-risk youths and their families, has demonstrated process changes with family communication patterns, especially in terms of negative communications and silent treatment (Alexander et al., 2000). Multisystemic therapy has made progress using a family preservation model to deliver services that address the psychological, social and educational needs of families in which a child is in imminent danger of out-of-home placement (Henggeler, 1997). A well-publicized review conducted by the University of Maryland in 1996 found that for delinquents and at-risk youth, family therapy and parent training have demonstrated success, while diversion from court to job training as a condition of case dismissal, boot camps, “scared straight” programs, and “wilderness programs” do not work (Sherman et al., 1998).

Developmentally Appropriate Program
Importance of This Element While there are data to show that treatment programs can be effective among adolescents, no one approach has been shown to work with all youth; therefore, it is critical to have the treatment process be developmentally appropriate for each adolescent it serves (Muck et al., 2001). Developmentally appropriate treatment takes into account issues that many delinquent youth face in addition to substance abuse, including mental health and emotional problems, risk level and educational difficulties (Drug Strategies, 2003). Research has shown that delinquent youth tend to be developmentally behind their nondelinquent peers (Altschuler & Brash, 2004). In a study of over 1,800 juvenile detainees in an Illinois detention center, Abram et al. (2003) found that more than one in ten detainees had both major mental and substance use disorders (rates as high as adult detainees), and that detainees with any substance use disorder had significantly greater odds of having a major mental disorder. Furthermore, Mears & Travis (2004) found that incarcerated youth are more likely to have some type of mental illness, and upwards of 36% suffer from some type of learning disability. Nissen et al. (1999) thus argue that the most important guideline for adolescent treatment programs is that the design must reflect the developmental stage of the youth. Despite this need for appropriate services, recent “get tough” changes in the criminal justice system have increased the likelihood that youths will be transferred into the adult correctional system, which creates even greater challenges for the application of developmentally appropriate services (Altschuler & Brash, 2004). Mears and Travis (2004) argue that because of the lack of developmentally appropriate services in the juvenile justice system, most youth released from custody have not developed skills to successfully participate in the work force and independent living, lack interpersonal relationships and social functioning skills, and are unable to develop a positive sense of self-worth and an ability to set and achieve personal goals.
Key Themes Research shows that risk and protective factors affecting recidivism vary depending on the age and developmental stage of the youth (Altschuler & Brash, 2004). Early problems such as family dysfunction and abuse may well be linked in a “developmental pathway to delinquency” that leads to later behavioral problems (Greene et al., 1998). Studies have found that preventing delinquency requires accurate identification of the risk factors that increase the likelihood of delinquent behavior and those factors that promote positive youth development (Huizinga et al., 2000). In fact, Lipsey and Wilson (1998) found that treatment for delinquent behavior seems to be most effective when those receiving the treatment have appreciable risk of actually reoffending. According to Altschuler and Armstrong (2002), however, risk is frequently misunderstood in terms of development of policy and practice in corrections, and they argue that high risk is established by criminal history along with the presence of criminogenic needs. They further assert that misclassifying offenders by enrolling lesser-risk youths in intensive programs may be in part responsible for the poor performance of some reintegration programs.
Suggested Strategies There are a number of areas that researchers suggest should be covered by developmentally appropriate methods. These include inadequate coping skills and resiliency, poor decision-making and planning skills, lack of support for more positive behaviors, and low self-esteem (Nissen et al., 1999). Butts and Mears (2001) recommend relying on cognitive-behavioral treatment modalities that address the particular needs and abilities of specific youth. Kumpfer & Alvarado (1998) argue that developmentally appropriate risk and protective factors should be addressed in family intervention programs. Recent studies have emphasized the importance of identifying and addressing the unique needs of individual youth, rather than processing them under the assumption that all offenders require similar treatment, to most effectively prevent and reduce serious, chronic delinquency (Huizinga et al., 2000).
A number of researchers stress the importance of individualized treatment based on an early assessment of the risk factors and correlates of the youths’ substance abuse, in order to devise developmentally appropriate services (Randall et al., Manuscript). Butts and Mears (2001), for example, highlight the need to target factors in high-risk offenders that predict recidivism, including drug use. The research literature indicates that combining strategies that address multiple risk factors is necessary for effectiveness (Morehouse & Tobler, 2000). Altschuler (1999) argues that risk level should determine the intensity of treatment, suggesting that those offenders who pose a high risk to public safety be placed on intensive supervision, while most everyone else be kept on a standard caseload. This is based largely on his assertion that some individuals, particularly adolescents, tend to react negatively to the pressures created by highly intrusive supervision. His research has shown that providing high levels of supervision to lower risk offenders results in poorer performance, due in large part to the accompanying increase in technical violations One recent and increasingly common approach promoted by a number of experts is known as adaptive treatment strategies (Murphy & McKay, 2003; Collins, et al., 2004). Rather than utilizing the same fixed treatment plan for each client, adaptive treatment strategies individualize and adjust programming according to the youth’s need (Murphy, in press). The type of treatment and level of intensity are varied, both across individuals and within an individual over time, in order to promote the best strategy to deal with the varying needs of young substance abusers. While there is a lack of significant research on the subject thus far, proponents of adaptive treatment strategies argue that they can increase treatment effectiveness, improve adherence to the plan, reduce waste of resources, and decrease negative side effects associated with inappropriate treatment programming (Murphy & McKay, 2003; Collins, et al., 2004). An increasingly popular method of addressing developmental appropriateness in fields such as prevention and education is the strength-based approach. This approach – in contrast to the traditional problem solving model - looks at adolescents’ strengths and competencies and seeks to discover how these personal resources can be applied to dealing with the situation (Clark, 1999). Clark (1999) points out that the approach also views accountability as being realized through behavioral change, not through passive admission of guilt, so it does not look for causation. Nissen et al. (1999) stress the importance of a strengths-based perspective for young offenders because of its restorative and redemptive vision. However, the juvenile justice system has not yet rallied to strengths-based work to the extent of other disciplines (Clark, 1999; Nissen, under review).

Engage and Retain Teens in Treatment
Importance of This Element While substance abusing youth in the juvenile justice system differ from youth in community treatment programs in that their participation is mandatory, there is still a clear need to engage adolescents in their own treatment process in order to promote positive results. Nevertheless, the articles included in our literature review generally avoided much discussion of the need to engage young offenders in their own treatment, or specific strategies to achieve this goal.
Key Themes One effort currently in place in the juvenile justice system to engage adolescents in treatment is graduated sanctions, which are applied in juvenile drug courts in order to hold juveniles accountable for their actions and reward them for positive ones (VanderWaal, 2001). These positive or negative sanctions should be consistently and predictably implemented in order help youth take responsibility for their actions (Drug Court Clearinghouse, 1997).
Suggested Strategies There are a number of tactics suggested in the research literature regarding ways of engaging young offenders. Proponents of the strength-based approach in the juvenile justice system call for clients to have an equal - or better - partnership in their treatment process, and suggest having treatment focus on the times when the problem does not happen in order to show that the youth is not all bad (Clark, 1999). Nissen et al. (1999) propose that programs incorporate strategies to orient new clients and control group dynamics in order to provide treatment in a more comfortable and supportive environment. Multisystemic therapy, however, clearly proscribes group treatment for delinquent adolescents, even though such group interventions may well account for the vast majority of substance abuse services provided to adolescents (Randall et al., Manuscript). Clark (1999) points to research that suggests that staff belief in the ability of the client to change can influence their behavior, and is a significant determinant of treatment outcomes. Battjes et al. (1999) define crucial aspects of engaging and motivating substance abusers in treatment as: flexibility in terms of program rules; confluence between treatment and client goals; and a reduction in barriers to treatment. Also, Henggeler, et al. (1996) promote the use of services that increase accessibility and place greater responsibility for engagement on service providers to reduce high dropout rates in the substance abuse field.

Qualified Staff
Importance of This Element Of the nine key elements identified by Drug Strategies as crucial to effective adolescent substance abuse treatment, the one that was probably least discussed in the research we reviewed was qualified staff. Yet if the staff who work directly with the young offender are not properly qualified and trained to address the myriad issues that delinquent youths with substance abuse face, the success of the entire treatment process can be at risk (Drug Strategies, 2003).
Key Themes One of the few consistent themes in the research literature regarding qualified staff is that there should be ongoing training provided. Alexander et al. (2000) point out that Family Functional Therapy (FFT) includes a rigorous training period for staff. Multisystemic therapy also has an extensive training program for staff (Henggeler, 1997). Crowe and Sydney (2000) recommend that staff involved in drug testing programs receive ongoing training. Family Empowerment Intervention has a rigorous training period for staff, who report that their success is predicated in part on their own self-directedness, ability to tolerate ambiguity, nonjudgmental and accepting, communication skills, empathy, orientation toward action and self-awareness (Dembo & Schmeidler, 2002).
Suggested Strategies When discussed in the research literature, there is no consensus on how much training staff should have. Functional Family Therapy (FFT) is provided by one and two person teams that may include para-professionals under supervision, trained probation officers, mental health technicians and degreed mental health professionals (Alexander et al., 2000). Evaluation studies have shown that FFT can be implemented by people without graduate level education (Alexander et al., 2000). The RSAP uses highly trained (MSW) counselors to provide prevention and intervention services to high-risk teens (Morehouse & Tobler, 2000). Family Empowerment Intervention is delivered by trained non-therapists, uses trained paraprofessionals as the Field Consultants and has supervisory personnel play a key role in treatment (Dembo et al., 1997; Dembo & Schmeidler, 2002). One of the reasons for this, as Dembo and Schmeidler (2002) argue, is that there is some research to indicate that at least for some treatments, paraprofessionals produce outcomes that are similar to those produced by professional therapists. In a study of a juvenile assessment center in Florida, Dembo et al. (1997) found that more assessor staff need training in psycho-social functioning and substance abuse. The few recommendations offered in the literature regarding qualified staff tend to be fairly non-specific. Clark (1999) agues that since most practitioners have been trained in the problem solving model, juvenile justice workers have become preoccupied solely with offenders’ faults and failures, rather than their strengths. Greene et al. (1998) believe that programs should have a charismatic and diverse program staff and incorporate effective gender-specific training for staff. Nissen et al. (1999) suggest that good staff selection, training, supervision and retention policies are crucial for a successful, integrated approach. According to Altschuler (1999), the various roles assumed by staff for community supervision must be carefully delineated, and staff should be committed to the goals and approaches that characterize the unique aspects of the intermediate sanctions working environment and culture. Morehouse and Tobler (2000) report that RSAP counselors unanimously agreed that the most important ingredient for program success was access to adolescents

Gender and Cultural Competence
Importance of This Element A relatively recent trend in the research literature, but one that has gained much traction in the past few years, is the idea that substance abuse treatment should be based on gender-specific and culturally competent issues. VanderWaal (2001), for example, argues that taking into account ethnicity and culture is important in treating the needs of young offenders. Juvenile drug courts are also increasingly taking into account issues related to gender and cultural diversity (Drug Court Clearinghouse, 1997). Traditionally, in the juvenile justice system gender-related issues were generally not considered, and girls were placed in programs that were designed for delinquent boys - even though the limited research on female interventions suggests that delinquent girls are more difficult to work with than boys (Covington, 1998; Bloom and Covington, 2001). This is due in part to the fact that in most cases, delinquent girls were victims themselves before they became offenders—girls are three times as likely as boys to have experienced sexual abuse, and an estimated 70% of girls in detention facilities have been abused (Greene et al., 1998). In the early 1990s, trends showed an increase in female delinquency and arrests, taking place at an even higher rate than male adolescents (Prescott, 1997). This fast pace of girls arrests in the 90s was due in part to the tendency of girls to be detained for less serious offenses than boys (Bloom and Covington, 2001). Although their offenses are typically less violent, girls are twice as likely to be detained as boys, since there are fewer community-based services for girls – with detention lasting five times longer for girls than boys (Greene et al., 1998). Girls are also more likely to commit substance abuse-related offenses and be arrested and detained for status offenses (Covington, 1998). As girls increasingly entered the justice system at younger ages and for increasingly violent offenses, the traditionally boy-oriented juvenile justice system began to examine gender-specific programming (Greene et al., 1998). The 1992 reauthorization of the Juvenile Justice and Delinquency Prevention Act of 1974, for example, required states to include an analysis of gender-specific services and encouraged them to make changes in their overall programming for girls (Greene et al., 1998). However, few attempts have been made to include adolescent females in research studies on delinquent behavior (Bloom and Covington, 2001). Prescott (1997) points out that there is a startling lack of research on comorbidity, treatment and violence pertaining to girls in the juvenile justice system. While the articles covered in our literature review did not address cultural competence as much as gender issues, it still was occasionally mentioned as an important issue in dealing with substance abuse. Nissen et al. (1999) stress the importance of providing culturally relevant substance abuse treatment for juvenile offenders. De La Rosa (2002) points to early and unsophisticated research on acculturation and Latino mental health that contentiously concluded that Latinos who were more acculturated to American society were more likely to experience mental health problems. Schiraldi et al. (2000) point out that while blacks make up about 13% of regular drug users in the U.S., they make up 62.7% of all drug offenders admitted to prison; blacks were incarcerated for a drug offense at a rate 14 times that of whites (Schiraldi et al., 2000).
Key Themes There are a number reasons why experts suggest the specific needs of girls and various cultures be addressed in treating a young offender’s substance abuse. Girls tend to be at greater risk because of factors such as: abuse and victimization; substance use; teen pregnancy; poor academic performance; mental health needs; societal factors; and additional special needs such as pregnancy (Greene et al., 1998; Prescott, 1997). Research does point to a strong link between victimization, trauma and female delinquency, with childhood abuse and neglect being significant factors in girls’ delinquency, especially if that abuse occurs within the family (Bloom and Covington, 2001). Also, female juvenile offenders are more likely to be poor, uneducated, unskilled, of color, and with histories of trauma and abuse (Covington, 1998). A study by Abram et al. (2003) of over 1,800 juvenile detainees in an Illinois detention center, found that significantly more females (56.5%) than males (45.9%) had multiple co-occurring disorders. In addition, according to Mears and Travis (2004), young female offenders may be held to different standards than young male offenders by the community they reenter after institutionalization. Prescott (1997) states that the need for gender-specific programming initiatives for girls in correctional settings exists in part because girls lack viable, safe outlets to express their true selves, which leads to self-destructive acts. Despite this need, girls’ needs are not being served in a number of different areas. Female delinquents have fewer placement options than their male peers in the juvenile justice system (Greene et al., 1998). Prescott (1997) argues that in the juvenile justice system, there is a lack of sensitive and uniform assessments tailored to girls’ needs, and therefore adolescent girls who act unusually or engage in high risk behaviors are more likely than boys to be placed in mental health settings. Prescott (1997) further argues that in the juvenile justice system, there is an overemphasis on symptom reduction, rather than trying to understand and change the underlying etiology of the problems that girls face. Covington (1998) contends that current services for delinquent girls are often fragmented, inconsistent and contradictory. Bloom and Covington (2001) state that the juvenile justice system has not adequately developed gender-specific programming for girls that addresses crucial issues such as sexual, physical and emotional abuse, substance abuse, and reproductive health. In terms of cultural competence, while black and Hispanic youth are overrepresented in the juvenile justice system (Abram et al., 2003), studies done on minority status have shown that bias can occur at any stage of juvenile processing and that, in some instances, small racial differences accumulate and become more pronounced as the minority youth proceed through the system (Nissen et al., 1999).
Suggested Strategies The research literature offers a variety for suggestions as to how to develop more gender-specific treatment policies in the juvenile justice system. Covington (1998) argues for a systemic change that embraces a holistic treatment model addressing addiction, female psychological development and trauma. This holistic model should place an emphasis on females’ need for social relationships, and take place in a safe and supportive all-female environment. Bloom and Covington (2001) further propose comprehensive, integrated gender-specific programs for girls that focus on relationships and offer ways for girls to master their lives. This gender-specific programming should also take place in an environment conducive to a therapeutic change process, and should take into account developmental theory and trauma theory. Nissen et al. (1999) state that programs aiming to serve girls must provide equitable treatment that consciously explores the underlying causes of female delinquency. Some best practices for the gender-specific programs they describe include: self-esteem building; assertiveness skills; female health education; recognition of the importance of relationships to women; positive images of women; women as role models; and vocational counseling in nontraditional areas such as engineering. Greene et al. (1998) likewise support a comprehensive gender-specific approach that includes primary prevention, early intervention, treatment and aftercare. This approach, they argue, should teach positive relationship-building skills, decision making and life skills, and acknowledge the effects of sexism, victimization, poverty and racism in girls’ lives. They believe that it should include: a physically and emotionally safe space; time for girls to talk; opportunities to develop relationships of trust and interdependence; tap cultural strengths rather than focusing primarily on the individual; mentors; education about women’s health; opportunities to create positive individual change; giving girls a voice in program design, implementation and evaluation; adequate financing; and involvement with schools. Through these strategies, they argue that the programs can change girls’ negative behavior by fostering gender identification, interpersonal relations, self-esteem, individualism, future orientation, physical development, and family-school-community support. While a significant number of strategies have been offered in the literature for gender-specific program development, there are far fewer recommendations for culturally competent policies. Greene et al. (1998) suggest that programs seek outside support and services when dealing with hard-to-reach ethnic youths. Also, Kumpfer and Alvarado (1998) argue that family intervention programs should be tailored to the family’s cultural traditions.

Continuing Care
Importance of This Element While significant gains can be made during the treatment process, adolescents can still relapse upon release unless there is a clear and effective continuing care plan. Successful relapse prevention and continuing care programs help maintain treatment gains, ensure good transition in the community and keep the youth engaged and involved in treatment after reentry (Nissen et al., 1999). Mears and Travis (2004) point out that aftercare can be critical for reducing crime and improving youth outcomes. For adolescents in the juvenile justice system, positive drug tests during probation can result in severe sanctions that can discourage the young offender’s progress towards abstinence (Drug Strategies, 2003). The research literature suggests that aftercare programs in the juvenile justice system are currently far from ideal. Approximately 100,000 juveniles under the age of 18 leave secure juvenile correctional facilities or state and federal prisons and return home each year, and up to two-thirds of these youth will be rearrested and up to one-third will be reincarcerated within a few years after release (Mears & Travis, 2004).
Key Themes Some authors argue that continuing care in the juvenile justice system has fundamental problems that need to be addressed. Aftercare is frequently funded and staffed at levels far below what is required to provide truly intensive supervision and enhanced service delivery (Altschuler et al., 1999). One of the most prominent challenges to implementing successful continuing care strategies, according to Mears and Travis (2004), is the lack of systematic aftercare services across multiple agencies and institutions. Altschuler and Armstrong (2002) lament that design and implementation problems in juvenile justice aftercare are unfortunately more the rule than the exception. Altschuler (1999) argues that it has been difficult to change the professional orientation and culture of traditional probation and parole, as it tends to focus more on surveillance and consequences than on treatment and services. Altschuler and Brash (2004) further note that aftercare programs historically have primarily been supervision-focused, addressing what happens following release from prison but not what takes place during confinement. Altschuler and Brash (2004) also criticize recent “get tough” changes that have increased the likelihood that youths will be transferred into the adult correctional system, which creates even greater challenges for their reintegration into the community. Juvenile offenders on standard probation and aftercare routinely do not receive the level of community supervision that they need (Altschuler, 1999). Furthermore, Altschuler and Brash (2004) note that community aftercare frequently fails to sufficiently provide services and treatment, instead relying primarily on surveillance and monitoring. They also point to research showing that risk and protective factors affecting recidivism vary depending on the age and developmental stage of the youth. Mears and Travis (2004) thus insist that psychological development is critical to understanding and improving the reentry process
Suggested Strategies There are a number of strategies that experts recommend regarding how to improve juvenile justice aftercare. Crowe and Sydney (2000) recommend that ongoing drug testing and program evaluation be conducted and taken into account in the continuing care plan. VanderWaal (2001) supports continuing care that deals rapidly with relapse, responding in ways that discourage continued use and support a return to abstinence. Nissen et al. (1999) contend that for youths with short-term or uncertain lengths of stay, programs should ensure transfer to community-based treatment programs after their release. Altschuler et al. (1999) point out that proper aftercare requires formal assessment procedures to determine which offenders are in need of a more intensive level of intervention. They also believe that community-based aftercare must be preceded by parallel services in the corrections facility and must include careful preparation for aftercare to follow. Consistent with their focus on gender-specific services, Greene et al. (1998) argue that programs should prepare girls for reentry into the community with relapse prevention support that addresses the specific challenges that the young females face in their community. One recent model proposed in the research literature to address continuing care problems in the juvenile justice system is the concept of reintegration, or reintegrative confinement (RC). This concept seeks to address both offender change and offender ecology, and is contrary to the deterrence or zero tolerance orientation of a “get tough” approach (Altschuler & Brash, 2004). Successful RC requires that, upon admission to a correctional facility or shortly thereafter, risk and protective factors affecting recidivism are identified (Altschuler & Brash, 2004). In general, RC should emphasize 3 things: preparing confined offenders for reentry into their community; making necessary arrangements and linkages with community agencies and individuals regarding known risk and protective factors; and ensuring the delivery of required services and supervision (Altschuler et al., 1999). In 1998, the Office of Juvenile Justice and Delinquency Prevention initiated the Intensive Aftercare Program (IAP) model, which identifies specific program components and services that address essential aspects of RC (Altschuler et al., 1999). IAP was specifically designed to address 2 deficiencies within institutional corrections: the idea that institutional confinement does not adequately prepare youth for return to the community; and the notion that lessons and skills learned in confinement are not systematically monitored, much less reinforced, upon reentry into the community. (Altschuler & Armstrong, 2002). IAP-related research envisions RC as comprised of 3 distinct but overlapping phases: institutional services and programming tied directly to pre-release planning; structured transition experiences before and after community reentry; and longer-term normalization in the community (Altschuler & Armstrong, 2002). Despite its promise, corrections approaches incorporating RC are not widespread, and few have been rigorously evaluated (Altschuler et al., 1999). Bazemore et al. (2000) promote a restorative model of reintegration, which focuses on promoting positive social relationships as a buffer against recidivism. This concept of “social support” attempts to address the damage that acts of crime have caused in the community in order to reduce ongoing harm. They argue that treatment programs can promote reintegration by supporting restorative justice objectives through incorporating victim awareness, conflict resolution, apprenticeship components and restorative community service into their continuing care strategies.

Treatment Outcomes
Importance of This Element Formal outcome evaluations are critical to determine whether treatment efforts are actually effective in dealing with young offenders’ substance abuse. However, this is arguably the element that is receiving the least amount of attention. There is a very clear lack of sufficient outcome studies conducted among substance abuse treatment programs (Drug Strategies, 2003). VanderWaal (2001) agrees that well-designed evaluation studies documenting program effectiveness are important. Greene et al. (1998) argues that programs should have an effective evaluation strategy.
Key Themes Due to the lack of quality outcome data, there is no clear expert consensus about what works with treating young offenders. Although recent research provides strong evidence that rehabilitation can effectively change offenders (Altschuler et al., 1999), without reliable outcome studies, it will continue to be difficult to determine what works with treating substance-abusing young offenders. Randall et al. (Manuscript) argue that few of the substance abuse treatments utilized by juvenile drug courts have demonstrated effectiveness. When they are conducted, outcome studies can highlight successful treatment strategies. Morehouse and Tobler (2000) point to outcome data that has shown the Residential Student Assistance Program (RSAP) to be effective in preventing and reducing substance use among high-risk participants. The finding is based on a five-year outcome evaluation documenting the program’s effectiveness in both preventing and reducing substance use among participants. In a widely cited meta-analysis, Lipsey and Wilson (1998) found that the best intervention programs were capable of reducing recividism rates by as much as 40 percent. Thirteen evaluations of Functional Family Therapy show significant treatment effects, as rates of offending and foster care or institutional placement have been reduced at least 25% and as much as 60% in comparison to the randomly assigned or matched alternative treatments (Alexander et al., 2000). In outcome studies on Family Empowerment Intervention (FEI), which seeks to provide sustained effects - rather than producing positive outcomes that last only a few months - youths completing FEI had significantly lower self-reported rates of crimes against persons, drug sales, and total delinquency than youths not completing FEI (Dembo & Schmeidler, 2002). FEI also had statistically significant lower drug counts for getting very high/drunk on alcohol, reported marijuana use and hair test results for marijuana. Unfortunately, only 58% of 130 youths and their families receiving FEI completed the intervention. Multisystemic therapy (MST) has demonstrated a particularly strong record in reducing long-term rates of rearrest and incarceration among chronic and violent juvenile offenders (Randall et al., in press). A study of the Simpsonville South Carolina Project found that youth receiving MST had significantly fewer arrests and weeks incarcerated than youth receiving usual services; also, the cost per client for treatment in the MST group was $3,500 – versus $17,769 for incarceration (Henggeler, 1997). In addition, a study examining the effects of MST on 118 substance-abusing juvenile delinquents found that while 98% of those families chosen to receive MST completed a full course of treatment, 78% of those families assigned to treatment through the usual community services received no mental health or substance abuse treatment in the 5 months after referral (Henggeler, et al., 1996).
Suggested Strategies The few outcome studies that have been conducted do point to some successful treatment strategies for young offenders. In their meta-analysis, Lipsey and Wilson (1998) concluded that for noninstitutionalized offenders, interpersonal skills, individual counseling and behavioral programs were the most effective types of treatment. For institutionalized offenders, interpersonal skills and teaching family home proved to be most effective. MST, which has proven effective with chronic juvenile offenders in studies conducted in Missouri, defines success in terms of reduced recidivism rates among participating youth, improved family and peer relations, decreased behavioral problems and decreased rates of out-of-home placements (Henggeler, 1997). Schools in Minnesota, which use restorative justice practices statewide, report significant reductions (27%) in the number of suspensions and expulsions (Karp & Breslin, 2001). A well-publicized review conducted by the University of Maryland in 1996 also showed that family therapy and parent training, as well as drug courts, intensive supervision and aftercare of juvenile offenders, and drug treatment in jails followed by urine testing in the community are all promising strategies for juvenile delinquents (Sherman et al., 1998). The review also concluded that diversion from court to job training as a condition of case dismissal, boot camps, “scared straight” programs, and “wilderness programs” have not proved to be successful strategies. Lastly, Altschuler et al. (1999) contends that the quality of implementation of a program is tremendously important to its outcome results. MST likewise strongly focuses on treatment adherence and program fidelity (Henggeler, 1997).

Conclusions The research literature on dealing with substance abuse in the juvenile justice system clearly suggests that Drug Strategies’ nine key elements of effective adolescent treatment are not being adequately addressed. Considering its high importance in setting the course for an effective treatment strategy, our review suggests that assessment and matching in the juvenile justice system is in dramatic need of review. The lack of standardized assessment instruments and of coordinated case management strategies, required in part to treat the widespread incidence of comorbidity among delinquent youth, are particularly prominent problems. The literature also highlights the absence of a comprehensive, integrated approach to treating substance-abusing delinquent youths, due in large part to poor coordination among agencies serving the juvenile justice system. While experts are split on the extent to which families should be involved in their child’s treatment, there do appear to be a number of promising developments regarding family involvement, partly because of a significant amount of recent research on the topic. Due to the high rate of co-occurring disorders and educational problems among young offenders, crafting individualized, developmentally appropriate treatment is clearly needed, but numerous experts assert that it has been hindered by a “get tough” focus in the juvenile justice system. The quantity of research into how to engage and retain teens in treatment, as well as how to ensure that staff are qualified to deal with substance-abusing young offenders, appears to be fairly minimal. These two elements are nonetheless quite important to successful treatment, and should be the subject of future studies and articles. On the other hand, many recent articles have focused on treating female juvenile delinquents. This research has pointed to a definite need for addressing girl-specific issues in treatment, and suggests some promising strategies for fostering gender and cultural competence. Continuing care research has likewise recently highlighted important new approaches, such as reintegrative confinement, to ensure that treatment gains are maintained after the young offender’s release from residential confinement. The literature on treatment outcomes, however, mostly bemoans the lack of scientifically rigorous outcome data, and is therefore not able to offer much discussion in terms of what has been proven to work in treating substance abuse among young offenders. However, a number of initiatives, such as multisystemic therapy, Family Empowerment Intervention, and Family Functional Therapy, which all seek to address various elements that treatment in the juvenile justice system has all too frequently ignored, do collect outcome data and can form the basis for future studies into what works. While there is a significant amount of research literature that points to promising strategies to improve certain aspects of substance abuse treatment in the juvenile justice system, very few studies have attempted to address the entire treatment process. We hope that this literature review serves as a first step towards developing a set of key elements that, when properly implemented, can function as guidelines for the successful treatment of young offenders.
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