Addiction professionals across the country are being asked to lead or participate in efforts to shift addiction treatment from an “emergency room” model of acute biopsychosocial stabilization to a model of sustained recovery management (RM) and to nest addiction treatment within larger recovery-oriented systems of care (ROSC). These federal, state and local innovations have focused primarily on the redesign of adult addiction treatment services. This article summarizes a technical report prepared for the City of Philadelphia on potential advantages and limitations of recovery as an organizing concept for services to children (under age 13), adolescents (age 13 to17) and transition age youth (age 18 to 25). The report offers recommendations on how services for these populations can be integrated into recovery- and resiliency-focused behavioral health care systems transformation efforts. The full report (48 pages, 182 research citations) is available at http://www.facesandvoicesofrecovery.org/pdf/White/ChildAdolescents.pdf.
Since 2004, the City of Philadelphia has been engaged in a recovery-focused behavioral health care systems transformation process that has mobilized the community to create a recovery vision and align service concepts, practices and contexts (e.g., regulatory policies, funding mechanisms) to support long-term recovery for individuals, families and neighborhoods. Federal, state and local behavioral health policy and planning bodies are evaluating the extent to which recovery can be used as an organizing concept for child and adolescent (C & A) services. There is growing interest in creating recovery-oriented systems of care for youth that are family-driven; developmentally appropriate; culturally nuanced; highly individualized; and focused on youth resilience, strengths and empowerment. However, questions remain about the potential advantages and disadvantages of the recovery concept applied to services for children, adolescents and transition age youth.
The average age of onset of AOD use of adolescents entering addiction treatment in the United States is now below age 13. This lowered age of onset of alcohol and other drug use is the most socially and clinically significant American drug trend of the past century. Lowered age of initial AOD use is linked to greater risk of developing a substance use disorder; accelerated problem development; greater severity of AOD-related consequences; and higher rates of post-treatment relapse. The concept of recovery is more applicable to children, adolescents and transition age youth today than at any previous time in the country’s history.
Child development also can be adversely affected by AOD-related problems of parents or siblings. Children in AOD-affected families are at increased risk for developing such problems as well as experiencing other adverse developmental outcomes. Conversely, the recovery of a parent with AOD-related problems enhances the health and developmental outcomes of his or her children. Adding to such positive effects are specific interventions that enhance the recovery and resilience of children who have been negatively impacted by parental substance dependence.
Recovery of adolescents and transition age youth
In 2008, 8 percent of youth aged 12 to 17 and 21 percent of transition age youth in the United States met diagnostic criteria for a substance use (alcohol or illicit drugs) disorder, but less than one in ten of these young people received specialized addiction treatment. More than 4,900 facilities in the United States currently specialize in the treatment of adolescent substance use disorders, and youth-focused recovery mutual aid meetings in the U.S. have significantly increased in recent years. The importance of these resources is underscored by the consistent research finding that earlier treatment for a substance use disorder (in terms of both age and duration of use) leads to better long-term recovery outcomes. There are evidence-based, brief therapies that have proven effective aids in recovery initiation, but most adolescents are precariously balanced between recovery and relapse in the months following such therapy. Long-term recovery stability is enhanced by sustained post-treatment monitoring and support, stage-appropriate recovery education, assertive linkage to communities of recovery and, if needed, early re-intervention. Unfortunately, such extended care and support is rare. In spite of these limitations, a growing number of young people are using recovery as a conceptual framework to reconstruct their identities and interpersonal relationships following significant and sustained AOD-related problems.
Conceptual frameworks for organizing child and adolescent services
The concepts of “system of care,” “wraparound services,” “positive youth development” and “resilience” have served as organizing frameworks for C & A services in recent decades. Resilience is the achievement of positive developmental outcomes in spite of personal and environmental risk factors. Resilience-based systems of youth development seek to reduce risk factors and increase protective factors at personal, family and environmental levels. Resistance is: an innate hardiness that allows one to be exposed to an infectious agent without becoming ill; and/or the act of refusing or ceasing AOD use as an act of cultural or political survival (particularly within historically disempowered communities of color). Recovery from a substance use disorder entails three critical ingredients: sobriety, global health (physical, cognitive, emotional, relational, spiritual) and citizenship. These elements of recovery have yet to be fully defined and measured for youth.
Recovery management (RM) is a philosophy of organizing addiction treatment and recovery support services to enhance pre-recovery engagement, recovery initiation, long-term recovery maintenance and the quality of personal/family life in long-term recovery.
Recovery-oriented systems of care (ROSC) encompass the complete network of indigenous and professional services and relationships that can support the long-term recovery of individuals and families affected by AOD problems as well as the creation of values and policies in the larger cultural and policy environment that are supportive of these recovery processes. Approaches to RM and ROSC for adults and for youth share many elements in common. Efforts are currently underway to identify distinctive changes in services for children, adolescents and transition age youth that need to occur within the movement to RM and ROSC.
Rather than think of recovery, resilience and resistance in either/or terms, it is helpful to think of systems transformation guided by all of these concepts. Many child and family advocates are embracing these concepts as complementary.
Primary Prevention, Early Intervention, Treatment and Recovery Support
Addiction treatment and recovery support services for parents constitute a strategy of prevention for their children. The impact of these services can be further amplified by involving children in the treatment of their parent and by providing specialized services designed to enhance the child’s recovery from the developmental insults of parental addiction and to enhance the child’s future resilience and resistance to AOD-related problems. Some programs (e.g., the Betty Ford Center) have invested considerable resources in the development of services to children affected by parental substance dependence. The treatment of every adult parent should include child-focused prevention and early intervention services aimed at breaking the intergenerational transmission of AOD-related problems. RM and ROSC involve an integration of primary prevention, early intervention, treatment and recovery support services aimed collectively at breaking the intergenerational transmission of AOD problems.
Advocates and critics
Advocates of applying the recovery concept to C & A services extol the concept’s holistic, developmental perspective; emphasis on hope, empowerment and choice; integration of spirituality as a healing/protective force; emphasis on thriving rather than just symptom remission; compatibility with system of care and positive youth development approaches to youth service design; inclusion of such issues as historical trauma and social stigma; and its emphasis on the role of social connectedness in adolescent health. Critics of applying the recovery concept to C & A services contend that recovery is misapplied to children because it: implies returning to a previous level of functioning; brings with it the social stigma attached to addiction; lacks a holistic, developmental perspective because of its “disease” trappings; and works only if integrated with the concept of resilience. Efforts to transform C & A services as part of RM and ROSC initiatives should capitalize on those added values recovery brings to the organization of C & A services while seeking to minimize any unforeseen harm that could come from applying this concept to children and adolescents (e.g., risk of over-diagnosis, coerced treatment and financial exploitation of families by the “troubled teen industry”). Embracing and integrating resilience and recovery may be the best means of achieving this added value while minimizing any potential misapplication or exploitation of the concept of recovery.
The Philadelphia Focus Groups
Members of focus groups (providers, parents and youth) conducted in the City of Philadelphia felt that recovery and resilience were compatible concepts that called for developmentally-informed models of care; family inclusion/direction and leadership; peer support and leadership; a continuum of support; community integration and mobilization of community recovery/resiliency support resources; trauma-informed care (and addressing violence within the trauma framework); and culturally competent care. A particular group of youth much discussed in the Philadelphia focus groups was transition age youth who were “aging out” of the child service system and were no longer eligible for continued C & A services. Hope was expressed that new approaches to such transition planning could be developed given the ROSC emphasis on long-term, stage-appropriate recovery support. Voices from the youth focus groups pleaded for a system of care that would see them as individuals rather than as a disorder and relate to them from a position of respect and authenticity.
Summary and recommendations
The report ends with a set of recommendations in the following areas:
Addiction professionals working with children and adolescents will find much in the report that will help them respond to these issues as they arise within their local communities.
Acknowledgements: Work on this paper was supported by the Great Lakes Addiction Technology Transfer Center/Center for Substance Abuse Treatment/Substance Abuse and Mental Health Services Administration, the Philadelphia Department of Behavioral Health and Mental Retardation Services (DBH/MRS), and the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment (HHSS2832007006I/TO HHSS28300003T Subcontract No: s8440). The opinions expressed are the views of the authors and do not necessarily reflect the official positions of DBH/MRS, CSAT, SAMHSA, DHHS, or the Federal Government.
Feedback on this article or the full report can be sent to [email protected].
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