Much of the rhetoric in the War on Drugs revolves around protecting children, and nearly all prevention activities are geared toward youth. Yet experts at the annual meeting of the American Society of Addiction Medicine (ASAM) pointed out that most treatment programs are designed for adults, and that the research base on adolescent treatment is astonishingly thin.

"There really isn't much knowledge" about treatment matching, medication dosing, stages of change, or other facets of adolescent care, said Marc Fishman, M.D., an assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine.

Fishman, a faculty member on a Center for Substance Abuse Treatment (CSAT) multi-site project to test adolescent treatment models, said that while there are well over 1,000 studies on adult addiction treatment, less than 100 studies of adolescent treatment have been published. Furthermore, Fishman said, few controlled studies have been conducted, and many have problems with dropout, viewing treatment experiences as discrete episodes ("which doesn't make a lot of sense with a chronic, relapsing condition," he noted), and viewing treatment as one-size-fits-all.

Randolph Muck, M.Ed., co-project officer for CSAT's Adolescent Treatment Models (ATM) project, said that even under the most optimistic projections, only one in five adolescents who need treatment are getting it. CSAT has attempted to use its targeted capacity-expansion grants to boost treatment resources for adolescents, said Muck, but the effort has been undermined to some extent by the dearth of research and lack of dissemination. "Most applicants don't even have a rudimentary knowledge of what we know works," said Muck. "It's rather astonishing."

Even when adolescents are enrolled in treatment, they are likely to be placed in programs that were designed for adults. Progression of alcohol and other drug abuse among adolescents, however, is often quite different than among adults.

Fishman described this progression as "counterintuitive;" for example, risk-taking and experimentation is seen as normative for adolescents, and dependence symptoms sometimes precede abuse symptoms. Nor can adolescent treatment be viewed as a monolith: Fishman points out that the treatment needs of a 12-year-old are far different from those of a 14-year-old.

The research conducted to date at least shows that some treatment is better than no treatment for adolescents. An overview of the research literature conducted by Fishman shows that an average of 32 percent of adolescents remain abstinent one year after treatment, while 44 percent are either completely abstinent or suffer only minor relapses. But knowledge about the comparative effectiveness has been completely lacking, according to Fishman.

CSAT's Cannabis Youth Treatment (CYT) program, launched in 1997, represents one of the most significant attempts to assess different theory-based treatment models in terms of their effectiveness. According to Muck, the CYT project found a number of models were effective in an outpatient setting, including motivational-enhancement therapy, cognitive-behavioral therapy, family support networks, adolescent community approaches, and multidimensional family therapy.

The ATM project is more ambitious, with 11 sites being funded over three years to evaluate the relative cost-effectiveness and outcomes of a variety of adolescent treatment modalities. The programs funded under the project -- each identified as "promising" by addiction researchers -- include:

• Phoenix Academy, a long-term therapeutic community (TC) in Los Angeles
• Thunder Road, a long-term TC/medical model program in Oakland, Calif.
• Dynamic Youth, a long-term TC in New York
• Mountain Manor, a short-term intensive outpatient program in Baltimore, Md.
• La Canada, a short-term intensive outpatient program in Tucson, Ariz.
• The Village, a family-centered outpatient program in Miami, Fla.
• Epoch Consulting Center, an outpatient program in Cantonville, Md.
• Chestnut Health System, an intensive and residential outpatient program in Bloomington, Ill.
• Four Corners Residential Adolescent Treatment Center, a Native-American centered moderate-term residential program in Shiprock, N.M.
• Teen Substance Abuse Treatment an outpatient program in Phoenix, Ariz.

Fishman added that research is also needed on treatment for subpopulations of adolescents, including youths with dual diagnosis, those who abuse specific types of drugs, and those who are cognitively impaired.

Given that 41 percent of all adolescents currently in the treatment system are referred from the juvenile-justice system, research on this population also is seen as critical. Muck and other researchers are looking for the Reclaiming Futures project, funded by the Robert Wood Johnson Foundation, to greatly increase the field's knowledge of treatment of young people involved in the criminal-justice system.

The project, which encourages collaboration between the juvenile-justice and addiction treatment systems, will spend at least $5 million on identifying and evaluating promising treatment programs for juvenile offenders.

The ASAM annual meeting was held April 19-22 in Los Angeles, Calif.