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Key Results: Barriers to Treating Alcohol and Drug Problems Among Adolescents
Citations Listed in Key Results
- For adolescents whose substance use escalates into substance use disorders (SUDs), receipt of formal treatment services is rare.
Use of illicit drugs, misuse of prescription medications, and alcohol consumption are common among adolescents (Johnston et al., 2009; Miller et al., 2007). Data from the Monitoring the Future study shows rates of past month illicit drug use of 7.6%, 15.8%, and 22.3% among eighth, tenth, and twelfth graders, respectively (Johnston et al., 2009). Rates of having "been drunk" in the past month were 5.4%, 14.4%, and 27.6% in these three grade-based groups.
Recent research about the relationship between early onset of substance use and the development of substance use disorders (SUDs) heightens concerns about substance use during adolescence (Hingson et al., 2006; Lynskey et al, 2003; Volkow & Li, 2005). In their analysis of data from the National Survey on Drug Use and Health (NSDUH), Winters and Lee (2008) found that the risk of developing a SUD after recent onset of use is particularly acute for adolescents when compared to young adults. While substance use should not be conflated with substance abuse, this research demonstrated that the relationship between recent onset of use and developing an SUD was stronger for adolescents than for adults. Furthermore, individuals who begin drinking early in adolescence are more likely than their peers to hurt themselves or others unintentionally after drinking even as adults (Hingson & Zha, 2009).
For about 10% of American adolescents, substance use escalates into the development of an SUD. In 2007, 5.4% of adolescents met criteria for past-year alcohol abuse/dependence, and 4.3% of adolescents reported past year abuse of/dependence on illicit drugs (SAMHSA, 2008). SUDs pose risks to both physical and mental health for adolescents (Delaney et al., 2001; Dennis et al., 2003; Diamond et al., 2002). There is an extremely high rate of co-occurrence between SUDs and mental health conditions, with 76-90% of youth having an SUD also having at least one co-occurring psychiatric disorder (Kandel et al., 1999; Chan et al., 2008).
Although SUD treatment is associated with clinical improvements in a range of outcomes (Azrin et al., 2001; Brown et al., 2001; Dennis et al., 2004; Henggeler et al., 1999; Hser et al., 2001; Liddle et al., 2001; Muck et al., 2001; Winters, 1999; Winters et al., 2000), there is a treatment gap between the number of teens with SUDs and the relatively small number who actually receive treatment services. Just 11.3% of adolescents needing drug treatment actually receive treatment services, and the rate of treatment for alcohol use disorders (8.1%) is even lower (SAMHSA, 2008).
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- Adolescents with SUDs are unlikely to recognize their need for treatment services, so systems that serve adolescents should adopt and implement the screening, brief intervention, and referral to treatment (SBIRT) model.
The barriers to treatment faced by adolescents with substance use disorders (SUDs) are multiple and complex. There are clear gaps in problem recognition, help-seeking, and motivation for treatment among adolescents with SUDs. Data from the National Survey of Drug Use and Health (NSDUH) reveals that between 87% and 91% of adolescents with SUDs do not perceive that they need treatment services (SAMHSA, 2006). Many youth do not know where to seek help, fear being socially stigmatized for seeking help, and do not believe that services will actually benefit them (Johnson et al., 2001). They may lack the motivation to enter treatment or engage in the treatment process (Battjes et al., 2003; Broome et al., 2001; Mensinger et al., 2006). However, it is precisely because adolescents are often unable to recognize the shift from substance use to SUDs that organizations serving adolescents need to adopt the SBIRT model in order to better connect adolescents to needed treatment services (McLellan & Myers, 2004).
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- National guidelines recommend the implementation of the SBIRT model in general medical settings, but low adherence to these guidelines creates barriers to adolescent SUD treatment.
Nearly 75% of adolescents visit a primary care physician each year (Newacheck et al., 1999), and studies have shown that adolescents want to talk about their substance use with physicians but often fail to do so (Klein & Wilson, 2002; Stern et al., 2007). Primary care clinicians and other health care providers have enormous potential to screen adolescents for SUDs, engage in brief office-based interventions, and make appropriate referrals to treatment (SBIRT). However, the available evidence suggests that many opportunities for intervention are missed (Levy & Knight, 2008).
Clinicians often fail to routinely implement the SBIRT model during health care visits, despite recommendations for universal screening in the American Medical Associations Guidelines for Adolescent Preventive Services (Elster & Kuznets, 1994). A national survey found that less than 20% of physicians provide alcohol screening and education to all of their adolescent patients (Marcell et al., 2002). Physicians in a California health maintenance organization reported higher universal screening, with about 40% of physicians screening all of their adolescent patients (Halpern-Felsher et al., 2000). Even in emergency departments where substance use is often implicated in traumatic injury, implementation of screening is low, with one study documenting that just 13% of adolescents hospitalized for traumatic injury were screened for alcohol use (Mader et al., 2001).
This low rate of routine screening is particularly disappointing because researchers have developed and validated brief standardized screening tools (Winters & Kaminer, 2008). One validated tool, known as the CRAFFT, has been tested in a variety of primary care settings. Researchers found that nearly 15% of adolescents presenting for a routine medical visit screened positive for substance abuse (Knight et al., 2007), pointing to a need for additional assessment and brief intervention or referral to treatment.
Use of standardized screening tools is particularly important because clinicians often miss SUDs when they rely solely on their clinical impressions. One study found that clinicians only successfully identified 10% of adolescents who met formal criteria for SUDs (Wilson et al., 2004). Given increasing demands to reduce the length of office visits, technological innovations such as personal digital assistants (PDAs) can be used to screen youths, with adolescents completing the screening questions before meeting with the physician. PDA-based screening tools have been shown to significantly increase the percentage of office visits in which teens discuss substance use with their physicians (Olson et al., 2009).
Diagnosis of an SUD by a physician does not guarantee referral to treatment services. Pediatricians are two times more likely to ask an adolescent with an SUD to return to their own office for an additional visit than to make a referral to a mental health counselor (Hassan et al., 2009). A recent review of medical charts of 400 adolescents with SUDs found that just 16% of medical charts included a written documentation of referral to SUD treatment; about 30% of medical charts had a written referral to mental health treatment (Scott et al., 2004). Taken together, these findings suggest that primary care clinicians need to be prepared to help adolescents with SUDs. More tools and training resources may be necessary in order to adequately prepare the primary care workforce to routinely implement the SBIRT model.
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- Adolescents involved with the criminal justice system have significant treatment needs, but juvenile justice organizations inconsistently implement screening tools and the availability of treatment services is variable.
Epidemiological studies indicate that substance use disorder (SUD) treatment needs among adolescents involved with the juvenile justice system are high. In a study of adolescents in San Diego County, California, about 37% of adolescents involved with juvenile justice met criteria for at least one SUD in the past year (Aarons et al., 2001). Data collected from adolescents entering a juvenile detention center in Cook County, Illinois, indicated that about 50% of males and 45% of females had at least one SUD in the past six months (Teplin et al., 2002); about one-fifth had more than one SUD (McClelland et al., 2004). A recent study of youth entering the Illinois juvenile correction system found that about two-thirds met criteria for SUDs and needed treatment (Johnson et al., 2004).
Despite the high rates of treatment need, there is evidence of inadequate assessment and lack of access to treatment services within the juvenile justice system. A large national survey of 141 juvenile justice organizations found that only 48% of the juvenile justice facilities use standardized assessments to diagnose SUDs, which means that treatment needs may remain unidentified for a significant proportion of youth (Young et al., 2007). Second, the availability of treatment services is highly variable. While 66% of residential juvenile justice facilities offer some type of SUD treatment, just 20% of jails offer SUD-related counseling (Young et al., 2007). Even in facilities offering treatment, the use of evidence-based treatment practices is lower in juvenile justice organizations than in community-based treatment facilities (Henderson et al., 2007).
Juvenile justice-involved adolescents with SUDs are rarely referred to treatment programs when they re-enter their communities. National data reveal that only 31% of adolescents with SUDs when released from jails are referred to community treatment services; the rate is somewhat higher (51%) for adolescents released from residential correctional facilities (Young et al., 2007). Despite these sub-optimal rates of referral, criminal justice remains the largest source of referrals for adolescents who are admitted to treatment programs (SAMHSA, 2007a).
Taken together, these studies suggest that adolescents involved in the juvenile justice system are highly likely to need SUD treatment services. Barriers to treatment, however, are multiple and include lack of appropriate assessment, lack of treatment services within facilities, sub-optimal use of effective treatment practices, and insufficient referrals to treatment when youth re-enter their communities. The Robert Wood Johnson Foundation-funded Reclaiming Futures initiative is a major attempt to address these barriers faced by juvenile offenders in ten U.S. communities. Interim results from the project suggested that systems of care can be re-engineered to promote greater access to treatment and increase positive community involvement in that process (Nissen et al., 2006).
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- Involvement by schools in identifying SUDs and providing services reduces barriers to care, but the availability of school-based services has been decreasing over time.
Schools can help adolescents with substance use disorders (SUDs) by referring adolescents to community-based treatment services and offering school-based counseling. However, schools are reducing their involvement in referring adolescents to treatment and providing on-site counseling services. Federal data from the 2000 Treatment Episode Data Set (TEDS) showed that about 15,000 admissions came from referrals made by schools, down from the 19,000 referrals made by schools in 1992 (SAMHSA, 2004a). A study of 855 secondary schools found a similar decrease over time in the percentage of students attending schools where any students with SUDs had been referred to external counseling services (Terry-McElrath et al., 2005).
Direct service provision is another method for helping adolescents with SUDs, but the availability of counseling services within schools has declined over time. In 2003, about a quarter of students attended a school with on-site SUD treatment counseling, which is a 35% decrease in availability when compared to data from 1999 (Terry-McElrath et al., 2005).
One model of care that dramatically increases utilization of treatment services are school-based health care centers (SBHCs). SBHCs, numbering about 1,700 in 2005, are sites that deliver primary care, behavioral health care, and preventive services to students in a confidential setting (Lear, 2007). About 57% of SBHCs offer individual substance abuse counseling, and 41% provide prevention and treatment (Brindis et al., 2003). A study of commercially insured adolescents demonstrated much greater utilization of SUD-related services among students with access to a SBHC relative to students without SBHC access (Kaplan et al., 1998).
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- The lack of high-quality community-based treatment programs is a significant barrier faced by adolescents who need SUD treatment. Many communities have insufficient high-quality and developmentally appropriate treatment programs to meet the needs of adolescents.
Adolescents needing SUD treatment face a set of barriers related to the availability of high-quality treatment services in their community. Nationally, only 52% of treatment facilities admit adolescents with SUDs into treatment (SAMHSA, 2004b). Some evidence suggests that the number of adolescent treatment slots within organizations is limited. When Mark and colleagues (2006) sought to identify the percentage of programs that had at least ten adolescent clients currently receiving treatment, they found that only 18.3% of facilities met this criterion.
An additional barrier faced by adolescents with SUDs is the lack of developmentally appropriate treatment services. Adolescents differ from adults in terms of psychological development and treatment needs (Etheridge et al., 2001), so national guidelines recommend that adolescents be separated from adults during the treatment process (CSAT, 1999). Data collected from 770 treatment organizations across the United States revealed that 40% of organizations did not admit adolescents and 22% admitted adolescents into treatment but integrated them with adults (Knudsen, 2009).
Even if adolescents are able to surmount the many barriers to treatment, existing services often fall short on indicators of quality. Brannigan and colleagues (2004) conducted one of the first studies on the quality of adolescent-only SUD treatment by focusing on 144 programs recognized as "highly regarded" in the field. Of the 43 elements of treatment quality, the average program had adopted only about 50% of the treatment elements. A later study found a similar level of quality in national random samples of treatment programs (Knudsen, 2009).
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- Certain sub-populations of adolescents, such as racial and ethnic minorities and street-involved youth, may be particularly vulnerable to barriers to treatment services.
Research suggests that there may be some differences in SUD treatment utilization based on race and ethnicity. Research by Wu and colleagues (2002; 2003) examined data from the National Household Survey on Drug Abuse for racial and ethnic differences in service utilization. Even after controlling for severity of alcohol treatment need, white adolescents were more likely to receive alcohol treatment services than minority adolescents (Wu et al., 2002). Findings of racial/ethnic differences in utilization are less clear for adolescents who use illicit drugs. Although Wu et al. (2003) found initial differences in receiving treatment by race and ethnicity, differences in indicators of problem severity and treatment need accounted for racial and ethnic differences in utilization.
State-level studies have also found differences in utilization. Disparities in utilization of Medicaid-funded SUD treatment services and age of first treatment service between black adolescents and white adolescents have been documented in Tennessee (Heflinger et al., 2006). In San Diego County, California, Garland et al. (2005) found racial and ethnic differences in utilization of outpatient mental health/SUD services, including lower utilization among African American and Asian American/Pacific Islander adolescents.
One population of adolescents who are particularly vulnerable to both SUDs and barriers to treatment are street-involved or homeless youth (Mallett et al., 2005). Rates of substance use among street-involved youth are much higher than among adolescents with stable housing (Greene et al., 1997). Studies have shown low rates of service utilization (De Rosa et al., 1999; Slesnick et al., 2001). In one study of Canadian street-involved youth who attempted to access treatment, about 22% were unable to access services and 21% reported challenges in access although they were ultimately successful in obtaining services (Hadland et al., 2009); the most widely cited barrier was lengthy waiting lists. Street-involved youth may fear that treatment-seeking will result in stigmatization and may face substantial pressures from other street-involved peers to not seek treatment (Brands et al., 2005).
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- Insufficient private insurance coverage is an additional barrier faced by adolescents who need SUD treatment services.
About two-thirds of adolescents are insured through their parents employer-based insurance (Fox et al., 2003), but adolescents are less likely than younger children to have health insurance (English et al., 2009). Using data from the National Household Survey on Drug Abuse, Wu et al. (2003) found privately insured adolescents were no more likely than those without health insurance to utilize SUD treatment. However, adolescents covered by public insurance (e.g., Medicaid) were more likely to enter treatment than privately insured or uninsured adolescents. Medicaid eligibility is also associated with increased utilization of mental health services among adolescents who are in SUD treatment (Deck & Vander Ley, 2006). Interestingly, research has shown that family income may not be related to the likelihood that adolescents receive SUD treatment services (Wu et al., 2003; Wu & Ringwalt, 2006).
The disadvantage faced by adolescents with private insurance relative to publicly insured adolescents (e.g., those having Medicaid) may be explained by the findings of Fox and colleagues (2003), who analyzed coverage for adolescent SUD treatment services in the most widely sold health maintenance organization (HMO) and preferred provider organization (PPO) plans. Their analysis of these insurance products revealed that highly intensive residential treatment was rarely covered and that the majority of plans only partially covered outpatient SUD treatment. These limitations on coverage result in higher out-of-pocket costs, which may reduce access to treatment services.
Recently passed federal parity legislation may reduce some of these financial barriers by prohibiting out-of-pocket expenses and treatment limitations for SUD treatment that are more restrictive than insurance coverage for other medical conditions (Shern et al., 2009). Research is needed on the implementation of this legislation and whether it increases adolescents access to SUD treatment.
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