This paper provides initial support for the integration of the pretreatment person-centered, environmental factors and substance use factors in predicting youth substance use outcomes at one year post-treatment. Entering treatment without concomitant Axis I disorders and a larger proportion of abstaining social supports in the peer network were associated with abstention at one year post-treatment. Among youth who relapsed during the year following treatment, younger adolescents exhibited less severe relapses. These findings support the notion that both personal and environmental factors contribute to the substance use treatment outcomes for youth. However, a different pattern emerged for substance dependence symptoms at one year. Pretreatment substance use and dependence symptoms at treatment intake predicted DSM-IV substance dependence symptoms at one year. While 61% of treated youth did not meet diagnostic criteria for dependence at one year, only 35% were abstaining at one year. These finding suggest that how we measure treatment outcome greatly determines what is considered central to success or failure after substance use treatment.
The general factors identified at the outset of this investigation (background variables, substance use, environmental influences, personal characteristics) all contributed in some way to the prediction of substance use outcomes one year after treatment. However, not all of the specific, research identified variables predicted outcome. Among background variables, age was implicated in treatment outcome while gender was not. This finding is somewhat surprising given the consistent relation between male gender and substance use patterns and relapse. It is possible that this commonly found effect was masked by the inclusion of diagnosis and psychiatric symptomatology within the model. Gender based differences in the expression of psychopathology, particularly along the internalizing- externalizing dimension, might have better explained the differences in outcome over gender. For other personal characteristics, the lack of relation between self-esteem and early treatment outcomes is consistent with other findings from this lab (Richter et al., 1991
). However, the lack of associations between alcohol expectancies and treatment outcomes were surprising. While some authors have questioned the influence of expectancies on early treatment outcomes (Jones et al., 2001
), support has been found for targeting expectancies in treatment (Brown et al., 1988
; Darkes and Goldman, 1998
The environmental influences of family history and family environment were not predictive of substance-related outcomes at one year. While family history has been found to be associated with substance use in adolescence and adulthood (Chassin et al., 2004
), investigations in this laboratory have not found family history to contribute to our understanding of treatment outcomes. However, this might be a function of the dichotomous index of family history used here. A more continuous measure of family history that incorporates the degree to which substance abuse exists in families might better convey risks associated with genetic factors (e.g., Comtois et al., 2005
). Additionally, the inclusion of nonusing social supports in our model might have mitigated the impact of family environment. As our social support measure includes families and peers, the impact of family through the mechanism of support and increased connectedness might have been overshadowed.
There are a number of procedural explanations for inconsistencies in the present findings and those of other studies. Our focus was on a competitive model whereby model components were considered simultaneously. Using this analytic strategy may mask significant value of factors that, when considered independently, may predict outcome or function as moderators. Testing this model from a process-oriented perspective requires a larger sample size. The addition of moderators capturing the impact of environmental influence across the year following treatment might significantly change the implications of these pretreatment variables on substance use outcomes. Secondly, for some variables of interest, the operationalizations used in this investigation may not have been optimal. For example, internalizing and externalizing symptoms were considered proxies for having a more harm avoidant and impulsive behavioral style. While harm avoidance and impulsivity have been consistently associated with internalizing and externalizing symptom expression, respectively (Cloninger et al., 1998
; Cooper et al., 2003
), these proxies may not sufficiently capture the trait-like characteristics of these personality styles. In addition, the use of a single measure of motivation might have limited its influence on the model.
This study has a number of strengths. First, this sample provides the opportunity to simultaneously examine a range of personal and environmental variables, assessed from the developmental perspective of adolescents, among youth after inpatient treatment for substance use disorders. In addition, the inclusion of research-supported risk and protective variables associated with substance use outcomes for SUD youth provided the opportunity to examine these factors in a sample with concomitant mental health disorders.
Given the positive impact of abstention on longer term psychosocial functioning in treated youth (Brown et al., 1994
), interventions targeting decreasing the impact of concurrent psychopathology and increasing non-using social supports could have the greatest impact on general functioning in youth. However, further research is necessary to identify the specific factors associated with treatment outcomes beyond substance use patterns. While the present study provides important information regarding predictors of youth treatment outcome, other factors beyond those in traditional treatment outcome models are needed to account for the success and failure of youth following substance abuse treatment. Many factors incorporated in these models derive from adult studies of SUD or SUD teens without concomitant psychopathology. Future investigations pitting competing developmental models for youth relapse against one another are necessary to guide model development in the future.
The overarching goal of this research is to help enhance a theoretical framework for designing relapse prevention programs for youth with substance use disorders. By better understanding the impact of risk and protective factors on substance-related outcomes, embedded within the developmental framework of adolescence, we improve the design and implementation of treatments for youth. The next step is to better understand the processes underlying how predictive factors and their interaction to impact outcomes for alcohol and drug disordered youth.