This research extends the existing literature on adolescent-only substance abuse treatment by examining service delivery within existing national random samples of publicly and privately funded programs. Consistent with the work of Mark et al. (2006)
, these data revealed a low prevalence of adolescent-only treatment services. Similar to the results of the 2003 N-SSATS (SAMSHA, 2004b), a substantial percentage of treatment organizations excluded adolescents from admission as a matter of program policy. Additionally, a significant percentage of organizations did not offer an adolescent-only program, but instead integrated adolescents into programs serving adults. Such integration is contrary to the recommendations of CSAT (1999)
This research then considered whether organizational characteristics were associated with the odds that adolescents were excluded from admission or integrated into a program with adults, relative to the odds of offering an adolescent-only program. Several organizational characteristics were relevant. First, organizational size was significant, such that smaller organizations were more likely to either exclude adolescents from admission or to combine them with adults. Smaller numbers of staff likely place practical limits on the number of programs that can be delivered within a single organization. Location within a hospital setting appeared to be an access barrier in two ways. Hospital-based treatment centers were more likely to exclude adolescents from admission, and they were more likely to have closed. To some extent, hospitals may admit adolescents needing inpatient care to psychiatric units that are separate from their substance abuse treatment units; unfortunately, these data cannot assess how frequently this was the case. The finding regarding heightened risk of closure in hospital-based addiction programs is consistent with previous research (Knudsen, Roman, & Ducharme, 2005
). Additionally, center accreditation reduced the likelihood that adolescents were excluded from admission, although it was not associated with the odds of the integration of adolescents with adults. While twelve-step programs were no more or less likely to exclude adolescents from admission, twelve-step programs were more likely than programs based on other models to integrate adolescents with adults.
The most prevalent levels of care were standard and intensive outpatient treatment, which is consistent with broader trends in the substance abuse treatment system. Adolescent-only standard outpatient, intensive outpatient, and partial hospitalization were offered by 69%, 51%, and 13% of these organizations. Data from the 2006 N-SSATS places the facility-level prevalence of these levels of care at 74%, 45%, and 15% (SAMHSA, 2007
). These similarities provide support for the representativeness of these data.
There were more frequent clinical sessions in the more intensive levels of care. With increasing treatment intensity, the number of weekly group sessions and psycho-educational sessions became particularly frequent, raising two issues. The first issue relates to the use of group therapy for adolescents. Some have argued that group therapy may actually be detrimental for certain adolescents, although the average main effect for group treatment interventions is often in the positive direction (Waldron & Kaminer, 2004
). For example, Battjes et al. (2004)
found that while a group treatment intervention was beneficial for marijuana users with more severe use histories, the intervention was associated with greater marijuana use at follow-up for those adolescents who entered treatment with less severe use histories. While there is more research needed on group therapies (Kaminer, 2005
), future health services research should also consider what steps are taken, if any, when treatment programs organize therapy groups, such as dividing groups into high or low intensity users. Alternatively, it may be important to study if treatment programs actively train counselors in group facilitation in order to reduce potential iatrogenic effects.
The second issue raised by these data on clinical sessions relates to the content of the psycho-educational sessions, which represents an important direction for future research. It is not known what topics were covered in these educational sessions and whether such sessions utilize active versus passive models of learning. To some extent, the data on the indicators of developmental appropriateness suggest that some attention is paid to creating a more interactive learning environment in which skills are practiced. However, these measures only offer indirect information about the educational components of adolescent substance abuse treatment. Given the increased frequency of educational sessions in the more intensive levels of care, future research should explore in greater detail what types of information are being communicated and whether the communication methods used are indicative of good clinical practice.
The aggregation of data on the 43 components into nine domains of treatment quality revealed medium levels of quality, with most of these scales having averages near their midpoints. The aggregate measure consisting of all 43 components similarly had an average of about half of the components. None of the programs approached the maximum possible value of this scale. The greatest number of actual components reported by a program was 34, representing about 79% of the possible components. These data suggest that there is room for continued efforts for quality improvement the treatment sector that serves adolescent clients.
Comparisons of publicly funded programs and privately funded programs only yielded a few significant differences. The first difference was in the nearly exclusive concentration of inpatient and partial hospitalization programs within the privately funded treatment sector. There was also a significant difference in the overall number of quality components reported by these two samples of programs. While significant and indicating higher average quality in privately funded programs, the difference was not particularly large in magnitude; the difference was about two components. This finding is consistent with recent work by Schackman et al. (2007)
who found a positive association between private insurance referrals and a 20-component quality scale among outpatient treatment providers. This public-private difference, however, was no longer significant once levels of care, organizational size, and center accreditation were controlled.
There was evidence of treatment quality being positively associated with more intensive levels of care. The strongest difference was for residential programs, with those offering this level of care scoring significantly higher than programs without residential services. Inpatient and partial hospitalization levels of care were also positively associated with quality. These levels of care are nearly exclusively represented within the privately funded sample, which may explain why the public-private difference at the bivariate-level was no longer significant in the multivariate regression model. Notably, these more intensive levels of care were much less available than standard outpatient treatment, which was the predominant level of care.
Several limitations of this research should be noted. First, the response rate was lower than desired, which raises the risk of bias due to non-response. This issue was evaluated in the multinomial logistic regression analysis, which did not reveal significant differences in basic organizational characteristics between refusing centers and those that participated. However, there may be other characteristics associated with research participation, so it is not possible to fully resolve the issue of response bias.
A second limitation is that these results are not directly comparable to Brannigan et al. (2004)
because of some differences in the specific indicators used to measure treatment quality. This study was not intended to directly replicate the design of that survey. Similar to the approach taken by Mark et al. (2006)
, Brannigan et al.’s nine domains were used as a framework for organizing a large number of items into conceptual dimensions. Despite these differences in measurement, these data are quite similar to Brannigan et al.’s survey of 144 “highly regarded” adolescent treatment programs. These data from random samples of programs revealed a mean of 21.6 out of 43 components, or 50.2% of the possible components. The average quality rating for Brannigan et al.’s highly regarded programs was 23.8 out of a maximum of 45 components, or 52.9% of the possible components. Both studies suggest that more attention should to be paid to the quality of adolescent-only addiction treatment.
The third notable limitation is that all data were self-reported by program managers, which raises issues related to the validity of their recall and potential bias due to over-reporting of program components. Perhaps the only way to fully avoid this source of bias would be to apply an ethnographic approach of site visits where “treatment as usual” was observed by an external observer; such an approach would be extremely intensive in terms of time and resources. The reliance on self-reports in this study is consistent with the federal surveys of treatment programs (e.g. N-SSATS) and studies conducted by other researchers (Brannigan et al., 2004
; Henderson et al., 2007
). Furthermore, the data do not lend empirical support to an argument of vast and widespread over-reporting, since the highest ratings on the quality scale only reached about 80% of the maximum score that was possible. Continued attention to how to improve methodologies used by health services researchers is warranted.
Previous research on adolescent treatment has been limited by a reliance on either non-random samples of programs or the federal N-SSATS datasets which do not offer detail on the content of adolescent-only treatment programming. In many ways, these data from random samples of publicly funded and privately funded addiction programs support aspects of the conventional wisdom about adolescent treatment services. The availability of adolescent-only treatment is limited, which raises a significant barrier to helping adolescents who have substance use disorders. Much of the available treatment is delivered on an outpatient basis with group therapy being the most frequent type of clinical session, regardless of the level of care. The average program endorsed only half of the quality components, suggesting the need for continued efforts to improve the quality of usual care in adolescent treatment. Future research is needed to continue to explore the organizational, regulatory, and environmental barriers to the delivery of high quality adolescent-only addiction treatment.