Hatice Han Er

INTERVENTIONS FOR SUBSTANCE USING ADOLESCENTS

The issue of substance abuse is a prevalent global problem affecting the health

of many people all over the world (Lineberry & Bostwick, 2006; McMurran, 2007).

However, apart from being a social problem, the abuse of alcohol and drugs also

raises many questions in the field of criminology (Weekes, 1997; McMurran, 2007).

Although numerous empirical research have studied the causes of substance abuse

(Hawkins et al., 1987; Wilson & Howell, 1993), its prevention and management

(Bukstein, 1995; National Institute on Drug Abuse 1998; Ghodse, 2002;), the increase

in the number of substance abusing juvenile offenders remains to be a serious issue

(Fazel et al., 2006; Sabol et al., 2007). This essay will focus on substance using

adolescents and attempt to illustrate how Social Learning Theory explains and

predicts behavior amongst this specific offending group. Furthermore, this essay will

then assess the most appropriate and effective treatments for substance using juvenile

offenders and provide an evidence-based treatment plan that will address the problem

behavior. Finally, the essay will explore the possible process issues involved with this

treatment plan for juvenile offenders who abuse substances like alcohol and drugs.

Sutherland’s (1947) theory of Differential Association in relation to criminal

behavior consists of nine points that explores the notion that crime is a learned

behavior through the interactions with other persons. This process of learning not only

includes learning through a process of communication but also the techniques of

criminality as well as behavior that is favourable to the violation of law (Sutherland,

1947). However, through the evolution of Sutherland’s theory of differential

association solely within intimate groups and the process of learning ideas, Akers

(1973, 1998) further developed this theory of learning deviant and criminal behavior

by integrating operant conditioning and behavioural reinforcement (Skinner, 1953;

Rotter, 1954) in developing Social Learning Theory. Akers (1985) further

demonstrated that learning deviance can occur through the direct or indirect

interaction with the environment without associating with other individuals as well as

modeling, and social reinforcements for such behaviours.

Akers’ (1985) theory of Social Learning has been extensively used in the

study of various crimes including childhood and adolescent aggression, intimate

partner violence, drug and alcohol use, terrorism and violent and non-violent criminal

behavior (Akers & Silverman, 2004; Akers et al., 1989; Barak, 2004; Boeringer et al.,

1991; Jensen & Akers, 2003; Silverman, 2002). The research conducted using social

learning theory has studied the differential association (Akers et al., 1979; Arriaga &

Foshee, 2004; Clingempeel & Henggeler, 2003; Conway & McCord, 2002; Daigle et

al., 2007; Herrenkohl et al., 2001; Losel et al., 2007) as well as gaining support for the

aspects of definitions, imitations and differential reinforcement in social learning

(Baron et al., 2001; Bellair et al., 2003; Graham & Wells, 2003; Herrenkohl et al.,

2001; Huang et al., 2001). Over a few decades, Akers used his theory to explain why

adolescents smoke, deviance amongst males and females (Akers & Lee, 1996) and in

drinking and drug use amongst both elderly and young groups (Akers et al., 1989;

Lanza-Kaduce et al., 1984). In relation to deviancy and criminality, Social Learning

Theory attempts to establish a connection between both the macro and micro social

variables that may explain why some people commit crimes (Jensen & Akers, 2003).

In his own words, Akers describes the process of learning deviancy as he states: “the

probability that persons will engage in criminal and deviant behavior is increased

and the probability of their conforming to the norm is decreased when they

differentially associate with others who commit criminal behavior and espouse

definitions favourable to it, are relatively more exposed in person or symbolically to

salient criminal/deviant models, define it as desirable or justified in a situation

discriminative for the behavior, and have received in the past and anticipate in the

current or future situation relatively greater reward than punishment for the

behavior.” (Akers, 1998:50).

In the area of substance use, abuse and dependence, research has shown that

adolescent and youth abuse of a variety of substances and drugs is a widespread

problem (Johnston et al., 2004; Dembo et al., 1993) and has been on the rise since

1992 (Dickinson & Crowe, 1997). Furthermore, substance and drug abuse is one of

the leading factors for the levels of adolescent morbidity rates in the United States

(Brannigan et al., 2004; Newcomb & Bentler, 1988a; Sussman et al., 1997). The

consequences of adolescent substance use leads to an array of other major problems

including health problems (McCaig, 1995), academic issues (Hawkins et al., 1992), a

decay on peer and family relations (Nowinski, 1990), mental health issues as well as

delinquency that may lead to an involvement with the criminal justice system.

Studies over the past twenty years have proven the strong relationship between

juvenile delinquency and substance use (Held, 1998; Center for Substance Abuse

Treatment/ Department of Juvenile Justice, 1999; Dembo et al., 1993). Apart from

substance abuse being a grave concern for the health of adolescents, it has been

proven that it also is a prevalent issue in regards to substance related crime

(McMurran, 2007). Studies have illustrated that 8% of Americans aged 12 and older

have used an illicit drug, while 9% of youths aged 12 and 17 and 20% aged 18 and 25

had used an illicit drug in the past month (Substance Abuse and Mental Health

Services Administration, 2009). On the other hand, an analysis of prisoners in the

USA have revealed that 73% used drugs before their incarceration (Petersilia, 2005)

and 50% were under the influence of drugs or alcohol at the time of committing a

crime (Karberg & James, 2005). Overall, one of the main reasons for the 400%

increase in US imprisonment rates were due to incarcerations for drug offences

(Blumstein & Beck, 2005). Research has shown that the abuse of drugs leads to

acquisitive crime like shoplifting, burglary, prostitution and fraud in order to maintain

the habit of drug abuse while alcohol abuse leads to crimes related to violence and

disorder (Richardson & Budd, 2003; Leonard, 2001; McMurran, 2007).

The grave portrait of the prevalent use of drugs and alcohol amongst juveniles

and its relation to incarceration rates and crime draws the need for effective treatment

programs for offenders (Chassin, 2008). There have been numerous studies into

various treatment programs for substance using adolescents in order to control and

decrease the use of substances and prevent recidivism of crimes (MacKenzie, 2000;

Seiter & Kadela, 2003; Sherman et al., 2002; Wormwith et al., 2007). One of the most

effective treatment programs that are administered to substance abusing offenders

include cognitive-behavioural therapy that involves the restructuring of attitudes and

the development of interpersonal skills (Milkman & Wanberg, 2007; Anglin & Hser,

1990) through the active involvement of tasks and activities that encourage and

develop skills (Lowenkamp et al., 2009). Studies have shown that substance using

offenders treated with CBT programs were less likely to abuse drugs and recidivate

(Pelissier et al., 2001; Hall et al., 2004; Budney et al., 2006; Carroll et al., 2006;

Easton et al., 2007; Kadden et al., 2007; Rawson et al., 2006; Dutra et al., 2008;

Magill & Ray, 2009) and overall, this framework has been empirically considered to

be one of the most effective techniques in treatment of substance abusing adolescents

(Andrews et al., 1990; Cullen & Gengreau, 2000; Landenberger & Lipsey, 2006;

Lipsey et al., 2001; MacKenzie, 2006).

Another effective treatment used with adolescents with drug abuse is

Contingency Management (CM). This intervention involves positive reinforcement

through rewards. In other words, adolescents who abstain from drugs are rewarded

with various prizes or vouchers for the purposes of encouraging further abstinence.

Studies evaluating the effectiveness of CM as a treatment program has shown that

those who received rewards for abstinence were more likely to abstain from drugs

compared to those who did not receive any form of rewards (Budney et al., 2006;

Rawson et al., 2006; Epstein et al., 2009; Olmstead & Petry, 2009; Predergast et al.,

2006).

Multidimensional family-based and Multisystemic Drug Treatments (MST) in

the use of treatment for adolescent substance abusers have also proven to be an

effective form of intervention (Rowe et al., 2007; Henggeler et al., 2006). The

framework of these forms of treatments involves the targeting of the social

environmental factors that surround adolescents. The other purposes of MST are to

change the relationships between the adolescents and their family, implement

disciplinary frameworks, promote pro-social peer relations and improve skills in areas

of vocation and school (Greenwood, 2008).

The population of adolescent substance abusers is not a homogenous group.

Thus, a single proposal of treatment for all adolescent substance abusers cannot be

effective for all of this population (Watson, 2004; Weekes 1997). However, for

offender rehabilitation to be effective the Risk, Needs and Responsivity principles of

adolescent substance use offenders need to be addressed (Andrews & Bonta, 2003).

As the initial step of effective treatment, priority needs to be given to the highest risk

offenders and thus, the program intensity will be appropriately determined with the

level of risk of the offenders. Secondly, the designed intervention will be effective

only if it clearly addresses the criminogenic needs of the individuals. With this, the

factors that research proves to be related to the problem of substance abuse amongst

adolescents will be addressed and an attempt to change the dynamic risk factors will

be effective in preventing recidivism. Finally, the principle of responsivity will

determine which program will be more effective to the type of offender and his/her

characteristics.

In accordance with the Risk Principle (Andrews & Bonta, 2003), the initial

step that needs to be taken for effective therapy is dependent on the screening of

adolescents who become involved with the criminal justice system. As there are

currently problems in relation to the structuring and standardization of the procedures

for screening adolescents for substance abuse (Callahan, 2001; Chassin, 2008;

Physician Leadership on National Drug Policy, 2002), what needs to be achieved is to

ensure and improve screening methods during the first contact with the juvenile

justice system in order to direct the adolescent offenders either out of the justice

system into a community based program or, depending on their level of risk, to prison

that accommodates more intensive and multimodal programs (Flanzer, 2005). A

thorough diagnostic evaluation during the screening stage will also determine the

range of other co-occurring problems like mental health disorders the adolescents may

have, the level of risk of the offender and thus, the second stage of designing an

appropriate intervention and where it will take place can be determined (Grella et al.,

2001; Rowe et al., 2004).

The literature has illustrated numerous times that a single type of intervention

may not achieve the desired results (Chassin, 2008). Various research has also proven

that the combination of certain treatment programs have shown more success in

preventing substance abuse amongst offenders as well as in preventing crimes that

may be born as a result of drug and alcohol abuse (Duwe, 2012; Jacobs & Western,

2007; Lattimore & Visher, 2010; Sample & Spohn, 2008; Zhang et al., 2006). It is for

this reason that for medium-high risk substance using adolescents, cognitive therapy

is one of the most successful treatment programs that are applied in various contexts.

Whether it be during imprisonment or detention in juvenile centres, substance using

adolescents ought to take Cognitive Behavioural Therapy for the purposes of

changing their ideas and behaviours in relation to substance use. In accordance with

Akers’ Social Learning Theory (1985), as learning takes place through differential

associations, imitations and modeling, the patterns of favouring illegal definitions of

behaviours that develop as a result of these thinking processes, these can be reversed

through the use of CBT programs. These CBT programs can also be offered both

within prison/secure settings, residential communities or in community based

programs.

One of the major loops in relation to the failure of effective treatment and

rehabilitation of substance using adolescents is the lack of aftercare services that may

follow (Henderson et al., 2007; Young et al., 2007). As aftercare services involve the

period in which a juvenile may have served his/her imprisonment or juvenile

rehabilitation sentences, the lack of supervision may provide the opportunity for

relapse (Flanzer, 2005; Belenko & Dembo, 2003). It is crucial, for this reason that,

adolescents continue to take aftercare services like Multisystemic Treatments (MST).

This intervention has been proven to have positive results in terms of reducing

antisocial behavior and preventing both recidivism of crimes and substance abuse

amongst adolescents (Randall & Cunningham, 2003; Schaeffer & Bordum, 2005).

From the theoretical perspective of the Social Learning Theory, MST will be able to

effectively control the social environmental factors of the adolescents that may lead to

antisocial behavior, as well as to also improve relations with family, considering

disciplinary practices within these relations as well as in increasing associations with

pro-social peers (Greenwood, 2008). The intervention to the social environment of the

substance-abusing adolescent will ensure that the criminogenic needs and factors of

the offender are controlled and eliminated, which will limit the risk to abuse

substances.

Adolescent substance users are a group that is difficult to provide services for

and treat as resistance to treatment and attrition are common with this sub-group

(Chandler et al., 2009; Pelissier et al., 2007). The reason for this attitude has been

determined because of the failure of past interventions and lack of success of these

interventions (Dennis et al, 2005; Hser et al., 1997; Malik-Kane & Visher, 2008).

This problem is addressed by the Responsivity Principle (Andrews & Bonta, 2003) as

the appropriateness of the interventions devised for the offenders with the

considerations of risk and needs, will help in designing the most effective treatment

program for the adolescent. This, in return, will ensure higher success for relapse

prevention. One form of achieving the hindrance of relapse with adolescent substance

abusing individuals will be through motivational interviewing techniques and

implementing these throughout the CBT and MST treatment programs (Waldron et

al., 2007; McClellan & Meyers, 2004).

Although studies have shown that juvenile offenders are more responsive to

rehabilitation (Fox, 1998), the process issues that may arise in the treatment of

adolescent substance users is a serious concern that affects the treatment of juveniles.

The issue of substance abuse amongst adolescents brings with it more problems

during the processing of this sub-group of offenders within the juvenile justice system

(Belenko & Logan, 2003; Chassin, 2008; Grisso, 2004). One of the most serious of

these problems includes the lack of appropriate treatment programs and interventions

that match the criminogenic needs of the offender (Mumola & Karberg, 2006). This is

particularly seen during the assessment and screening stages of juvenile offenders as

diversion programs are underused as a result of appropriate assessments and

screenings. Another serious issue in relation to the assessment of juvenile substance

users is the problem of non-completion rates. Research has shown that these rates are

very high and remains to be serious concern in the effective treatment of juveniles as

they become more likely to reoffend compared to untreated offenders (Hough et al.,

2003; Hollin et al., 2004; Rodriguez & Webb, 2004; McMurran & Theodosi, 2007).

One approach in dealing with this issue will be to inject motivational interviewing

techniques into programs like CBT and MST in order to prevent non-completion of

interventions as the use of motivational techniques in programs have shown to

influence the treatment of outcomes (Simpson & Joe, 1993) and is a significant

predictor of participation in treatment (Hiller et al., 2002).

Another serious process problem in the use of CBT programs for adolescent

substance users includes the possibility of its effectiveness due to factors such as

mental health problems. For instance, studies have shown that individuals suffering

from antisocial personality disorder have a sense of inflated self, demonstrate serious

behavior problems and lack empathy for others and such attitudes of asocial juveniles

have negative treatment outcomes (Fals-Stewart & Lucente, 1994; Woody et al.,

1985; Richards et al., 2003). The failure of CBT programs for such individuals will be

unsuccessful as such asocial offenders show resistant behavior to these forms of

therapy (Pankow & Knight, 2012; Ogloff et al., 1990).

Although MST programs have been proven to be an effective intervention

program, an issue of family involvement eventually may surface. For example, the

involvement of family member in MST treatments may have a negative effect on the

adolescent if family members are also involved in substance misuse. This eventually

will reverse the aim of the intervention. Another serious process issue that may

surface is also in placing antisocial adolescents in group settings during therapy as it

may have a negative influence (Paulin et al., 2001; Burleson et al., 2006). Therefore,

it is an important issue that when matching effective programs for adolescents, special

vigilance must be adopted against potential effects of worsening the conditions of the

adolescents.

In conclusion, this essay has focused on how Social Learning Theory explains

the behavior of substance abusing juveniles through the notion that this sub-group of

offenders learns to abuse substances like drugs and alcohol through differential

associations, operant conditioning and behavioural enforcements. Akers (1973, 1998)

theory also stresses how the interaction through the environment of juveniles as well

as modeling, imitation and social reinforcements play a crucial role in the deviance of

these juveniles. Based on this theoretical framework, studies support the fact that

there is a serious relationship between juvenile substance abuse and criminality,

which has increased the need to prevent recidivism both in substance use and crime

through various effective treatment programs such as CBT, CM and MST. As these

interventions have the purpose to target the behavioural and psychological processing

of juveniles as well as the social and environmental factors, they have became the

most popular and effective forms of treatment for this sub-group of offenders.

However, these treatment programs are not without its process issues. These problems

include issues of screening and appropriate assessment, mental health considerations,

the high rates of non-completion and other social factors like substance using

offenders in same treatment groups or family that may deteriorate the treatment

outcomes of juveniles instead of preventing recidivism in both crime and substance

use.

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