What kinds of treatment work for Francophone youth with substance use problems?

Rapid Review

In brief

There are a number of different approaches to treating youth with substance use problems. However, it can be challenging to isolate which of these approaches are effective, and which are suitable for specific populations or treatment settings.

For this reason, a Local Health Integration Network in Ontario reached out to EENet to identify the best treatment models for addressing substance use problems in Ontario’s Francophone youth population. The purpose of collecting the following information is to assist with selecting treatment approaches for local residential treatment facilities.

EENet conducted a literature search and prepared an evidence brief of the findings. Read our evidence brief below or access the PDF here.

What you need to know

  • Research on the outcomes of specific treatment models for youth with substance use problems is limited, with research on effective treatment for Canadian Francophone youth being virtually nonexistent.  
  • Though evidence about the value of residential treatment is contradictory, a review of the current literature reveals a number of treatment models and specific features of effective treatment that can be considered best practices in residential treatment for youth substance use problems.
  • Family therapy models and motivational enhancement therapy have been found to be particularly promising practices for outpatients and can be integrated into residential treatment settings.

What’s the problem?  

There are a number of different approaches to treating youth with substance use problems. However, it can be challenging to isolate which of these approaches are effective, and which are suitable for specific populations or treatment settings.  For this reason, a Local Health Integration Network in Ontario reached out to EENet to identify the best treatment models for addressing substance use problems in Ontario’s Francophone youth population. The purpose of collecting the following information is to assist with selecting treatment approaches for local residential treatment facilities. 

What did we do?

A search of academic literature was conducted in November 2015, using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, In Process Medline, PsycINFO, and the Cochrane Database of Systematic Reviews. 

This database search was supplemented by literature recommendations from experts in the field of youth substance use treatment in Ontario. We included relevant literature on Canadian Francophone youth and substance use published in English or French since 2000. An expanded search on substance use treatment for youth in general included only review-level literature (such as systematic reviews and meta-analyses) published since 2009, since the quantity of evidence on this topic was significantly greater.

Though the primary focus of the search was on models or approaches to be used in youth residential treatment settings, literature focusing on treatment approaches used for youth in other (outpatient) settings was also reviewed, as publications about youth residential treatment are limited. It was also done in order to provide a broader picture, illustrating approaches that show promise for integration with residential treatment.    

This search excluded single studies that focused exclusively on a single treatment model, instead of comparing models, and publications that were not peer-reviewed, such as books and government reports. Other topics we deemed to be outside of scope for this particular review included: 

  • Approaches to the prevention of substance use problems in youth;
  • Internal predictors of treatment outcomes, such as personality traits or personal family history;
  • Treatment approaches for mental illness or behavioural problems; 
  • Treatment approaches applicable only in primary care, school, justice system, or emergency department settings;
  • Treatment approaches for a single substance, such as alcohol or cannabis, rather than substance use in general; 
  • Treatment approaches for adults. 

Some literature recommended by experts was included despite being published before 2009 or being classified as grey literature. Following a review of titles and abstracts, a total of 14 articles were selected as relevant for inclusion; two on substance use treatment for Canadian Francophone youth (in Quebec) and 12 on substance use treatment for youth in general.    

What did we find?

The following section begins by outlining findings specific to Francophone youth, followed by evidence on effective residential treatments for youth in general. Finally, it presents promising practices for outpatients that can be integrated into residential treatment settings.

Treatment for Francophone youth 

The literature search yielded no studies about substance use treatment for Francophone youth in Ontario. Research in Quebec found the following treatment components to be important12,13:

  • Building a strong therapeutic alliance between therapist and patient early in treatment;
  • Family involvement in treatment;
  • Focusing on retention and aftercare;
  • Use of motivational interviewing;
  • Use of group interventions to build consciousness and solidarity, and promote recovery;
  • Patient involvement in determining treatment objectives (i.e., not necessarily aiming for abstinence).

Many of these suggestions parallel other findings and are applicable to youth in general. While the lack of research in Ontario could be a gap in the literature, it is also possible that approaches to treatment do not vary significantly. It is possible that successful outcomes with this population are related more to treatment accessibility and the availability of culturally and linguistically appropriate treatment, both of which were beyond the scope of this rapid review. 

Effective residential treatment

The evidence about the value of residential treatment for youth substance use is contradictory. Some literature claims that residential treatment is empirically unjustified, citing the high costs and disruptive consequences associated with separating youth from their families and communities, the risks of maltreatment and negative peer culture formation, and the difficulty of maintaining treatment gains once youth return home1,2.  

This being said, published literature also reveals a number of positive outcomes for youth who have undergone residential treatment. These include increased regulation, protection from harmful or abusive home environments, and reductions in drug use and associated problems in the year following treatment. Benefits have been seen from both long-term and intensive short-term residential treatment and have been estimated to outweigh costs1,2

Despite this contradictory evidence, there is consensus that youth treatment for substance use problems should occur in the least restrictive environment possible1. Plant and Panzarella1 highlight that residential treatment should be recommended only when previous treatment efforts have been ineffective, when additional structure and supervision are needed, or when there are goals that can’t be achieved elsewhere. However, residential treatment looks different in different institutions and jurisdictions1,2. 

The following have been identified as features of effective residential treatment programs for youth1,3,4,5

  • Multimodal, holistic, and ecological approaches that address more than substance use
  • Family involvement in treatment
  • Motivational approaches focused on harm reduction
  • Culturally and linguistically competent delivery of services
  • Approaches based on knowledge of youth development, designed to meet the youth’s developmental stage 
  • Methods for promoting treatment retention and preventing drop-out
  • Capacity to treat concurrent disorders, including mood, anxiety, and trauma-related disorders
  • Strengths-based approaches focused on the youth’s positive characteristics and existing capabilities 
  • Comprehensive discharge planning and aftercare
  • Responsiveness to the unique needs of the individual youth

Table 1 lists the most common treatment models being used in youth residential settings, as of 2009. The research evidence supporting the effectiveness of each of these models varies.  

Promising practices for adoption in residential treatment

There are a number of practices from home and community (outpatient) settings that have been identified as effective, evidence-based treatment models6,1,5. Many of these show promise for integration with residential treatment and are gradually being incorporated into residential settings1. These are outlined below. 

1. Family therapy

A recent analysis of the comparative effectiveness of different outpatient youth treatment approaches found that those using family therapy yielded larger beneficial effects than other treatment approaches7

Family therapy approaches highlight the need to engage family members, including parents, siblings, and sometimes peers, in the treatment process. This is based on the assumption that families have the strongest and longest-lasting impact on adolescent development. 

Family therapy generally serves to address issues beyond youth substance use, including: 

  • family communication, problem-solving and cohesiveness;
  • other co-occurring behavioral, mental health, or learning disorders;
  • problems with school or work attendance; and 
  • relationships with peers 

Family therapy approaches are categorized into five treatment models, each highlighted by Winters et al.5 and outlined in Table 2. There is currently insufficient evidence to determine if the family therapy models differ in effectiveness. They all show statistically significant, albeit modest, effects8.

2. Motivational enhancement therapy

Outpatient treatments using motivational enhancement therapy (MET) tend to yield beneficial effects relative to other treatment approaches, especially for youth with marijuana dependence8. MET is based on motivational interviewing techniques to encourage the adolescent to engage in treatment and stop using drugs. It is typically delivered in conjunction with other treatment approaches. 

Motivational enhancement therapists use a person-centered, non-confrontational style to help the youth explore different facets of his or her use patterns. Adolescents are encouraged to examine the pros and cons of their use and to create goals to help them achieve a healthier lifestyle. 

The therapist provides personalized feedback and respects the youth’s freedom of choice regarding his or her own behavior. While generally remaining neutral, the therapist is directive in helping the youth examine and resolve ambivalence and encouraging the youth to take responsibility for selecting and working on healthy changes in behavior5.

3. Behavioural approaches 

Behavioural treatment models (see Table 3) focus on teaching and reinforcing new skills, behaviours, thinking patterns, and coping mechanisms to reduce substance use. The goal is to strengthen positive behaviours and eliminate negative or maladaptive ones5

4. Pharmacotherapy 

Pharmacotherapy refers to the use of medication to address different aspects of addiction, including reduction of cravings, aversion therapy, substitution therapy, and treatment of underlying psychiatric disorders. Medication is specifically used to treat addiction to opioids, alcohol, and nicotine, as no medications have been approved to treat cannabis, cocaine, or methamphetamine use problems. The research on pharmacotherapy for adolescents is limited and no medications have been  approved specifically for adolescents5.  

5. Integrated treatments 

Many facilities providing treatment for youth with substance use problems use an approach that integrates multiple evidence-based treatment approaches. Some well-established integrated treatments, according to Hogue et al.6 are MET and cognitive behavioural therapy (CBT), or the two combined with family therapy. 

6. Continuing care and recovery supports 

Continuing care and recovery supports are approaches that are used together with, or after, other treatment approaches. The continuing care and recovery supports in Table 45 are not intended as substitutes for other treatment models. 

7. Internet-based interventions

Internet-based interventions offer another approach to treatment that can be combined with other treatment models. Their advantage is that they can be delivered to a far greater proportion of the target population. 

A systematic review of Internet-based interventions for youth with substance use problems by Tait and Christensen9 revealed that those targeting alcohol-related problems are as effective as brief in-person interventions. In their review, Hogue et al.6 recommend the use of Web-based technology as a cost-effective way to extend the reach of substance use treatment.  

8. Interventions for concurrent disorders 

Almost all treatment models for youth with substance use and concurrent psychiatric disorders result in modest reductions in symptoms10. However, they also share difficulties maintaining treatment gains and high relapse rates10

According to Hulvershorn et al.10, the National Registry of Evidence-Based Programs and Practices of the U.S. Substance Abuse and Mental Health Services Administration contains ten evidence-based treatment programs for youth with concurrent disorders. These include the following programs: 

  • Seven Challenges;
  • Adolescent community reinforcement approach (A-CRA);
  • Family behavior therapy; 
  • Multisystemic therapy;
  • Multidimensional family therapy;
  • Parenting with Love and Limits; 
  • Phoenix House Academy;
  • Family Support Network; 
  • Seeking Safety;  
  • Chestnut Health Systems-Bloomington Adolescent Outpatient and Intensive Outpatient Treatment Model.

Through their critical review of treatment models, Hulvershorn et al. found the following components of existing psychosocial treatment models to be effective in addressing concurrent disorders:

  • Behavioural therapies, such as CBT and treatment derived from CBT (e.g. Dialectical Behaviour Therapy)
  • Goal-directed techniques, such as role-playing, modeling, behavioural exposures, self-monitoring of behaviour outside of therapy, and challenging maladaptive beliefs (combined with CBT)
  • Motivational interviewing, combined with skill building and CBT or equivalent
  • Family/systems interventions, incorporating parental training and monitoring skills

9. Early interventions 

A review of nine studies by Carney and Meyers11 revealed that early interventions reduce substance use and associated behavioural outcomes, with small but significant effect sizes. Interestingly, early interventions were more effective if they were delivered over multiple sessions and in an individual, rather than group, format. 

Teen Intervene was the intervention that was associated with the largest effect sizes. It was the only one of the nine that included a session with the youth patient’s parents11.  

What are the limitations of this review?

Only 14 studies met our inclusion criteria. The findings are limited by the parameters of our methods, including the research question and the timeframe of the search strategy. As a result, this rapid review may not present a comprehensive view of knowledge on this topic. The findings reveal a number of research gaps on the topic of best practices in treatment for youth with substance use problems.

The body of evidence on what types of treatment work best for which youth, and to what extent, is small. This is especially true in comparison to studies looking at adult treatment. A recent systematic review of evidence-based treatment guidelines for substance use problems among adolescents found that most were of low quality, with sparse evidence to support their recommendations and many recommendations based on adult studies14.  

Evidence from randomized, controlled trials is particularly limited, and trials done to date have shown relatively modest effect sizes10. In addition, there are virtually no well-controlled studies on long-term treatment outcomes for youth10

At this time, it is difficult to determine which components are responsible for the successful treatment outcomes observed by some researchers. This is because most youth treatment programs use a variety of approaches that incorporate multiple treatment models, and because most researchers are not specific about all the components of the treatment approaches they studied2

Most importantly, perhaps, for the purposes of this rapid review, research on effective treatment for Francophone youth in Ontario with substance use problems has yet to be done. Also, very little research exists on treatment for Francophone youth in Quebec. For this reason, the treatment models outlined above as best or promising practices might not be entirely applicable to Ontario’s Francophone youth population.

What are the conclusions?

Based on the limited number of studies meeting the inclusion criteria for this rapid review, there appear to be several promising evidence-based treatment approaches that can lead to positive outcomes for youth with substance use problems. However, it remains unclear to what extent these interventions would be effective within a residential treatment program for Ontario’s Francophone youth. It is important to note that several publications have identified features of effective treatment for youth that are not specific to any treatment model and that also may be incorporated into various treatment settings. These include family involvement in treatment, motivational approaches focused on harm reduction, and developmentally-appropriate services that attend to the comprehensive needs of each individual. 

Table 1: Common Treatment Models in Youth Residential Treatment

Table 2: Family Therapy Approaches(5)

Table 3: Behavioural Treatment Models(5)

Table 4: Continuing Care and Recovery Supports(5)

References 

  1. Plant, R.W., & Panzarella, P. (2009). Residential treatment of adolescents with substance use disorders: Evidence-based approaches and best practice recommendations. In Adolescent Substance Abuse (pp.135-154). Springer US. 
  2. Betterman, J. E. & Jasperson, R. A. (2009). Adolescents in residential and inpatient treatment: A review of the outcome literature. Child Youth Care Forum, 38, 161-183.
  3. Settles, R.E. & Smith, T.G. (2015). Toward a Developmentally Centered Approach to Adolescent Alcohol and Substance Use Treatment. Current drug abuse reviews, 8(2), 134-151.
  4. Winters, K. C., Botzet, A. M., & Fahnhorst, T. (2011). Advances in adolescent substance abuse treatment. Current psychiatry reports, 13(5), 416-421.
  5. Winters, K. C., Tanner-Smith, E. E., Bresani, E., & Meyers, K. (2014). Current advances in the treatment of adolescent drug use. Adolescent health, medicine and therapeutics, 5, 199.
  6. Hogue, A., Henderson, C. E., Ozechowski, T. J., & Robbins, M. S. (2014). Evidence base on outpatient behavioural treatments for adolescent substance use: updates and recommendations 2007-2013. Journal of Clinical Child & Adolescent Psychology, 43(5), 695-720.
  7. Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). The comparative effectiveness of outpatient treatment for adolescent substance abuse: A meta-analysis. Journal of Substance Abuse Treatment, 44(2), 145-158.
  8. Baldwin, S. A., Christian, S., Berkeljon, A., & Shadish, W. R. (2012). The Effects of Family Therapies for Adolescent Delinquency and Substance Abuse: A Meta‐analysis. Journal of Marital and Family Therapy, 38(1), 281-304.
  9. Tait, R. J. & Christensen, H. (2010). Internet-based interventions for young people with problematic substance use: a systematic review. Medical Journal of Australia 192(11), S15-S21.
  10. Hulvershorn, L. A., Quinn, P. D., & Scott, E. L. (2015). Treatment of Adolescent Substance Use Disorders and Co-Occurring Internalizing Disorders: A Critical Review and Proposed Model. Current drug abuse reviews, 8, 41-49.
  11. Carney, T., & Myers, B. (2012). Effectiveness of early interventions for substance-using adolescents: findings from a systematic review and meta-analysis. Substance Abuse Treatment, Prevention and Policy, 7(1), 25.
  12. Bertrand, K., Brunelle, N., Richer, I., Beaudoin, I., Lemieux, A., & Ménard, J. M. (2013). Assessing Covariates of Drug Use Trajectories Among Adolescents Admitted to a Drug Addiction Center: Mental Health Problems, Therapeutic Alliance, and Treatment Persistence. Substance Use & Misuse, 48, 117-128.
  13. Brunelle, N., Bertrand, K., Tremblay, J., Arseneault, C., Landry, M., Bergeron, J., & Plourde, C. (2010). Impacts des traitements et processus de rétablissement chez les jeunes toxicomanes québécois. Drogues, santé et société,  9(1), 211-247.
  14. Bekkering, G. E., Aertgeerts, B., Asueta‐Lorente, J. F., Autrique, M., Goossens, M., Smets, K., van Bussels, J.C.H., Vanderplasschen, W., Van Royen, P. & Hannes, K. (2014). Practitioner Review: Evidence‐based practice guidelines on alcohol and drug misuse among adolescents: a systematic review. Journal of Child Psychology and Psychiatry, 55(1), 3-21.

Resources for Further Reading

  1. Alberta Alcohol and Drug Abuse Commission. (2006). Youth detoxification and residential treatment literature review: Best and promising practices in adolescent substance use treatment. Edmonton, Alberta, Canada. Retrieved from http://www.albertahealthservices.ca/assets/Infofor/Researchers/if-res-yo...
  2. Drug Strategies (2002). Treating Teens: a Guide to Adolescent Drug Programs. Washington, DC: Drug Strategies.
  3. National Institute on Drug Abuse, United States of America. (2014). Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide. Retrieved from https://teens.drugabuse.gov/sites/default/files/podata_1_17_14_0.pdf 
  4. Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP). Retrieved from http://nrepp.samhsa.gov/01_landing.aspx 
  5. Health Canada (1999). Best Practices: Substance Abuse Treatment and Rehabilitation. Ottawa, ON: Health Canada. Retrieved from http://www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/bp-mp-abuse-abus/index-eng.php

Acknowledgements

The authors of this rapid review are EENet’s Samantha DeLenardo, Regional Knowledge Exchange Lead, and Emma Firsten-Kaufman, Knowledge Broker. The authors would like to acknowledge: Sheila Lacroix, CAMH Library Coordinator, for assistance with the database search; Kate Stechyshyn, Knowledge Broker, for assistance with assessing articles for relevance; Jason Guriel, EENet Supervisor, and Rossana Coriandoli, Communications Coordinator, for editorial support. 

Disclaimer

Rapid reviews are time-limited ventures carried out with the aim of responding to a particular question with   policy or program implications. The information in this rapid review is a summary of available evidence based on a limited literature search. EENet cannot ensure the currency, accuracy or completeness of this rapid review, nor can we ensure the efficacy, appropriateness or suitability of any intervention or treatment discussed in it.

 

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