With her bright pink nail polish, pancake makeup and darting, penciled eyes, Sarah looks older than 16. But being too old has never been her problem — not since the age of 11, when she sought help from a California drug treatment program for adolescents and was turned away for being too young.

By then, she had already been smoking crystal meth for at least a year. She had been expelled from the sixth grade after 17 suspensions; run away from five foster homes, and was, in her own later estimation, looking “pretty gross” — skinny as a stick, with five different hair colors and a face full of self-inflicted scars.

Ineligible for a program “developmentally targeted” for teens, an adolescent Sarah fell through the cracks. Although a social worker from Child Protective Services, familiar with her case, offered alternative counseling, it was years before Sarah quit, and then it was on her own terms.

The overwhelming fact is that of the 1.6 million young people between the ages of 12 and 18 with serious alcohol and drug problems, fewer than one in 10 receive treatment. Of the estimated 175,000 who do, only about 25 percent stay in treatment for three months, as recommended by the National Institute on Drug Abuse; less than 50 percent stay for even six weeks, according to the Office of Applied Statistics in 2005.

And there is virtually no continuing care for teenagers who struggle to stay straight once back in the larger community. Is it any surprise, then, that a 2002 study in the Journal of Substance Abuse Treatment found almost 80 percent of teenagers relapse within a year of treatment?

There is an explanation for this public health embarrassment: The epidemic of drug and alcohol abuse among young people was until recently an invisible problem, either unrecognized, ignored or wishfully dismissed as too awful to be true. Until 1997, there were only 14 studies published in the field of adolescent drug treatment, and those were widely regarded as being of questionable quality.

Today, the field is moving from an uninhabited backwater to a state-of-the-art discipline, with dozens of new federal grants, hundreds of published studies, promising new interventions and — finally — evaluated program outcomes.
 

One of the most telling developments is the rapid growth of recovery high schools and colleges — some with waiting lists — whose main focus is abstinence and recovery for students after treatment. At the high school level, there are 30 of these schools for abusers around the country, each built on a 12-Step model, offering mentorship and concrete rules for staying straight, as well as the sort of peer bonding that reinforces new patterns of positive behavior, something that generally isn't possible in a typical high school.

“To think a teenager is going to go for treatment for 30 days and then come back to his old environment — where he bought his drugs, where his peers are using, and where he was seen as a drug user ... that's not realistic for the vast majority of kids,” says Andrew Finch, executive director of the Association of Recovery Schools, which represents the 30 recovery high schools, from Alabama to Alaska. “For them, school is a danger zone,” Finch says. “It's like an adult alcoholic being required to go to work in a bar.”

Finch says the programs work: Between 20 and 30 percent of the young participants relapse, but that's a substantial improvement over the national norm of 80 percent.

The field is exploding with new knowledge about adolescence and substance abuse. It is now understood, for example, that the vast majority of teen substance abusers — more than 80 percent of girls, according to some recent academic studies — have been sexually, physically or emotionally abused. With that in mind, many experts have put out a call for routine screening for sexual abuse when young drug and alcohol users show up for treatment.

“The issue of traumatic victimization is an unspoken elephant in the counseling rooms,” writes Michael L. Dennis, a research psychologist at Chestnut Systems, a research and treatment center in Bloomington, Ill., and author of well-regarded drug assessment tests. “Physical, sexual and emotional abuse is the norm.”

Many adolescent substance abusers — federal estimates say 70 percent — also have a mental health issue, such as attention deficit disorder, bipolar disorder or post-traumatic stress disorder. In a Catch-22 scenario, mentally ill youths and adults are routinely turned away from drug and alcohol treatment centers, told, typically, that they have to get their depression under control before being treated for their addictions. The consensus among experts today is to treat it all.

Slowly, local public agencies across the country are responding, some even consolidating mental health and substance abuse agencies into single entities, its counselors expected to be trained to deal with both. Multi-tiered programs are becoming the new norm: A teen meets regularly with counselors, parents, clergy, probation officers; every one is around the same table, considering the teen's interests.

This sort of wraparound approach is partly a response to the growing body of research that unmasks the effects of alcohol and marijuana on the adolescent brain.

Among the findings on alcohol's effects: A teen with a family history of alcoholism has a 50 percent risk of becoming an alcoholic. When a teenager drinks large amounts of alcohol, his brain is changed; researchers suspect that specific proteins are activated, increasing the susceptibility to alcohol throughout life. Adolescents who begin drinking before age 15 are four times more likely to become alcohol-dependent later in life.

“And when youth drink, they tend to drink heavily,” notes a recent report from the American Psychological Association. “Underage drinkers consume on average four to five drinks per occasion about five times a month. By comparison, adult drinkers age 26 and older consume on average two to three drinks per occasion about nine times a month.”

Among kids who move from one high to another, a taste for alcohol can easily escalate to one for drugs – and there are more choices out there now than ever.

Since 1992, a new kind of drug abuse has tripled in popularity among teenagers: the mixing of controlled prescription drugs like opiate painkillers, tranquilizers and stimulants. Among adolescents, they’re known as “farming” or “trail-mix” parties, now constituting the fastest growing type of drug abuse in the United States, outpacing marijuana by a factor of two.

The most recent Monitoring the Future report, the continuing study of teenage drug use conducted by the University of Michigan and the National Institutes of Drug Abuse, found that 5.5 percent of 12th graders have abused the prescription drug Oxycontin, up 4 percent since 2002.
In the past five years, methamphetamine has become a severe problem throughout the West and mid-West. In a recent survey, 70 percent of county and regional hospitals in the Midwest attributed 10 percent of all emergency room visits to methamphetamine.

“We’re really in an epidemic,” says Brent Kelsey, assistant director of the Utah Division of Substance Abuse and Mental Health. “Methamphetamine is now the No. 1 drug of choice for people between 26 and 35, and the public health consequences are enormous.”

While treatment for meth addiction has been shown to work, it is typically more intensive than that for other drugs; experts often liken the damage from meth to a brain injury requiring unique and long-term treatment needs. In fact, meth addicts’ needs have begun to crowd out treatment for alcoholism.

“In Utah, the number of alcoholics entering treatment is much smaller and I don’t think it’s because there are fewer alcoholics,” says Kelsey. “What’s happening is that – because of the criminalization of drugs – it’s become harder and harder for the alcoholic to get services in our system. Methamphetamine and other drug users are really squeezing them out."

Despite the flood of information pouring in from academia, families and adolescents with problems all too often face questionable practices and scant alternatives. Parents can go broke looking for help, since private insurers don't cover the cost of treatment. Even for the few who can afford to pay the typical $20,000 cover charge of a 30-day private residential treatment program, there are few effective programs available and no guarantees from those that do exist.

In 2004, an expert panel evaluated 144 of the “most highly regarded” drug programs for adolescents and concluded that most of them failed to address the key elements of successful treatment: individual assessment at the start of treatment, tailored therapy for teens with psychiatric disorders, gender and cultural differences, continuity of care, staff evaluation and treatment outcomes.

What the study neglected to mention is that there are, in fact, no licensing standards for adolescent drug counselors. A handful of states, including California, Washington and Colorado, are now working to establish them.

“If I were a parent trying to navigate something for my child, even I — knowing everything I do — would have a very hard time trying to figure it out,” admits Yolanda Perez-Logan, project director of the Reclaiming Futures program in Santa Cruz, Calif.

Introduced in 10 cities, Reclaiming Futures is a five-year initiative funded by the Robert Wood Johnson Foundation in response to the “treatment gap” that occurs when an increasingly drug-dependent teen winds up in trouble with the law. The gap is more like a canyon: Four out of five teenager arrests involve the use of drugs or alcohol, while 80 percent receive no treatment for the problem that got them there.

The juvenile justice system serves as a kind of laboratory for what works, since most young drug and alcohol abusers first enter treatment through its doors. Which means they don't come willingly. By far, the majority of youths in residential treatment are sent there through the criminal justice system. Even then, parents have to shoulder a huge part of the financial burden.

In California, for example, the cost for court-ordered residential treatment is nearly $6,000 a month. Individual counties then bill families for about 60 percent of that cost. At that rate, a six-month stay can easily cost a family — one already likely living on a financial precipice – over $20,000.

For those who can get to private treatment, many youth programs are now moving away from the classic 12-Step model, as embodied by Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). A philosophical split has emerged in the treatment community, with some on-the-ground programs endorsing alternatives to 12 Step and its insistence on total abstinence.

“Many treatment programs are using new evidence-based practices that meet youth where they are with their current substance abuse and help them make a decision what they’re going to do about it,” says Randy Muck, lead public health advisor for Adolescent Treatment Programs at the federal Substance Abuse & Mental Health Services Administration.

Many experts argue that the language of 12 Step programs, with their starting point of sobriety, grew out of a therapeutic model aimed at adult males. Its requisite call to a “higher power” is often a major sticking point to teens who, in the words of one probation officer, often “think they are the higher authority."

“For years, the problem we've encountered is that treatment for kids is basically treatment for adults repackaged,” says Scott Reiner, program development manager in the Virginia Department of Juvenile Justice. “They changed a couple words, perhaps, but never addressed the developmental needs of kids.”

Small wonder, then, that an 11-year-old girl like Sarah could be told to come back for treatment when she turned 14.

Sarah now takes classes at The New School, an alternative high school largely comprised of former gang members and drug addicts in Watsonville, Calif., that offers some services you won’t find at your typical high school — including rides to nearby AA and NA meetings, after-school 12-Step classes, routine urine testing, and a dog who comes in to sniff backpacks a few times a year.

Like many of her peers at the school, Sarah claims she had to find a way to get clean on her own, without professional treatment. She says it happened like this:

“I'd run away from a group home and no one knew where I was for a month. One day I came home and my niece asked me, ‘Are you going back to jail?’ That made me feel really bad because she was only 6 years old.

“I saw my niece going through the same exact thing I went through. Fighting with her mom, her mom always hitting her,” Sara says. “And I thought, how am I going to help her if I don't stop?”

(Richard Scheinin is a reporter for The San Jose Mercury News.)
 

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