Assertive outreach strategies for narrowing the adolescent substance abuse treatment gap: implications for research, practice, and policy
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This entry is our analysis of a review or synthesis of research findings considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original review was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the review.

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Assertive outreach strategies for narrowing the adolescent substance abuse treatment gap: implications for research, practice, and policy.

Ozechowski T.J., Waldron H.B. et al.
Journal of Behavioral Health Services and Research: 2010, 37(1), p. 40–63.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Ozechowski at You could also try this alternative source.

This comprehensive US-focused review addresses the need to enrol more young problem substance users in treatment even if they at first refuse, validated methods for identifying such young people and engaging them in treatment with the help of family and others, and ethical and financial considerations involved in implementing these methods.

Summary The Gateway Provider Model of youth service access hinges on equipping providers within so-called gateway service systems for youth with the knowledge and tools to recognise substance use problems, and to work in a coordinated manner across agencies to link youth exhibiting such problems with appropriate treatment services. Primary gateway service systems for adolescent substance abusers include juvenile justice, child and adolescent mental health, school-based counselling and other special programmes, emergency rooms, hospitals, and primary medical care settings, child welfare and related social services, as well as shelters and other facilities serving runaway and homeless youth.

However, specialised strategies may be warranted for the subpopulation of adolescents whose substance use disorders are unaccompanied by other emotional or behavioural disorders. In the USA, about one third to one half of the population of adolescents with substance use disorders may be relatively free of diagnosable comorbid conditions, which, some evidence suggests, may be associated with the likelihood of receiving substance abuse treatment. Specialised assertive outreach strategies may benefit this subpopulation given that such adolescents are unlikely to make contact with existing services and systems that could provide an entryway into substance abuse treatment, are relatively unlikely to have their substance use problems detected even if such contact is made, and may have parents who are not fully aware of the severity of their substance use problems and who may be unmotivated or unable to persuade or compel them to enter substance abuse treatment. The remainder of this review discussed some promising directions for developing assertive outreach strategies for this subpopulation which may also be useful for young people who do have other diagnosable comorbid conditions.

Main findings

Identification refers to the process of detecting and making contact with adolescents with substance use disorders in order to provide information about and to advocate for their entry into substance abuse treatment. Schools offer direct access to the largest numbers of young people potentially in need. Multiple gating screening is one way to identify them. It encompasses a comprehensive tiered assessment protocol implemented in the school setting which gathers information from teachers, students, and their parents to identify youth who are candidates for a given type of intervention or service. The initial assessment tier is typically a broad and relatively inexpensive screen administered to teachers who are asked to identify pupils exhibiting certain types of emotional or behavioural risk factors. Progressively, more detailed screenings are conducted with the initial set of identified youth as well as their parents. Information collected across informants and levels of assessment is used to delineate a final pool of youth who are likely candidates for specialised services. Individual youth and their parents in the final candidate pool are recruited to participate in appropriate services as indicated across the multiple levels of assessment.

Screening for substance abuse is arguably more complicated than screening for delinquent or aggressive behaviour, given that delinquency and aggression are observable whereas substance abuse tends to be more covert and is often kept hidden from parents, teachers, and other authority figures. 'Indirect' assessments may be warranted to identify adolescents exhibiting characteristics known to be risk factors for substance abuse such as academic problems and truancy, aggressive and delinquent behaviour, depression, and personality traits consistent with high-sensation-seeking, extroversion, and disinhibition.

Once a candidate pool of adolescents has been delineated based on behavioural assessments derived using teacher and parent reports (perhaps in conjunction with school records), a more direct assessment administered to adolescents regarding substance use-related attitudes, traits, and behaviours is recommended. Next task is to work in coordination with parents to conduct a more formal substance abuse intake assessment with the adolescent.

Efforts then move on to trying to enrol the youth in treatment involving addressing barriers to participating in treatment, fostering motivation for change, and securing a commitment to enter treatment. Recommended methods which have been successfully trialled include StructuralStrategic Systems Engagement (SSSE) and Community Reinforcement and Family Training (CRAFT). SSSE involves the outreach worker forming a strategic alliance with one or more family members deemed to have significant power in the family system. SSSE interventions are basic family therapy techniques (eg, joining, reframing, restructuring) implemented in ways that capitalise on influential family members' abilities to get resistant family members to participate in treatment.

If this does not lead to treatment enrolment, CRAFT should be initiated. Relative to SSSE, CRAFT is a more intensive 12-session intervention originally designed to engage resistant adult drug users into treatment by working directly with a 'concerned significant other', usually a spouse or parent. Fundamentally, CRAFT is a behavioural family therapy intervention conducted with one or more close associates of treatment-refusing individuals with substance use disorders where the primary objective is to persuade such individuals to enter treatment. Core components include: education regarding the consequences of substance abuse and benefits of treatment; contingency management training for associates so they reward non-drug using behaviour and discourage drug use; social skills training to improve interpersonal communication and problem-solving; planning and practicing activities to interfere with the target person's drug use; and encouraging and reinforcing participation in drug abuse treatment. A version of CRAFT has been developed and tested for adolescents with substance use disorders who despite parents' and others' best efforts refuse to enter treatment.

This featured review concludes with a discussion of some of the substantive ethical and financial considerations surrounding policy changes needed to undergird the assertive outreach innovations outlined earlier.

The authors' conclusions

The widespread and systematic adoption of school-based screening procedures to identify and engage youth at risk for (or already exhibiting) emotional and behavioural disorders is rapidly gaining popularity across sectors of child and adolescent mental health research, practice, and policy, and is routinely recommended as a means of fortifying current prevention and treatment infrastructures. Against this backdrop, this article has attempted to make the case for developing specialised school- and family-based assertive outreach strategies to identify and enrol a greater proportion of substance-abusing or dependent adolescents into treatment.

The implications and recommendations for practice and policy proposed in this paper are in keeping with overarching ecological frameworks for child and adolescent clinical services. While the bulk of contemporary ecologically focused clinical literature focuses on intervention design and implementation, the critical 'pre-intervention' processes of identification and enrolment deserve fuller consideration and should be regarded as components of the overall treatment process for adolescent substance abuse. Ultimately, the integrative development, testing, and dissemination of effective identification, enrolment, and intervention procedures is essential for enhancing the public health impact of the adolescent substance abuse treatment system.

Last revised 06 February 2013. First uploaded 06 February 2013

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