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are the two names I most associate with groundbreaking studies aimed at enhancing long-term recovery outcomes for adolescents following addiction treatment. They have done this through development of an approach to adolescent treatment (the Adolescent Community Reinforcement Approach) that seeks among other things to create a post-treatment family and social environment conducive to recovery and by pioneering assertive approaches to post-treatment continuing care for adolescents and their families. My own work conceptualizing a model of sustained addiction recovery management has been profoundly shaped by their respective studies and by our writing collaborations. The study below exemplifies the scientific rigor and clinical importance of their work. William

This study evaluated the effectiveness and cost-effectiveness of two types of outpatient treatment with and without Assertive Continuing Care (ACC) for 320 adolescents with substance use disorders. Study participants were randomly assigned to one of four conditions: (a) Chestnut’s Bloomington Outpatient Treatment (CBOP) without ACC; (b) CBOP with ACC; (c) Motivational Enhancement Therapy/Cognitive Behavior Therapy-7 session model (MET/CBT7) without ACC; and (d) MET/CBT7 with ACC. All study conditions attained high rates of participant engagement and retention. Follow-up interviews were completed with over 90% of the adolescents at three, six, nine, and twelve months after treatment admission. There was a significant time by condition effect over 12 months, with CBOP having a slight advantage for average percentage of days abstinent. Unlike previous findings that ACC provided incremental effectiveness following residential treatment, there were no statistically significant findings with regard to the incremental effectiveness of ACC following outpatient treatment. Analysis of the costs of each intervention combined with its outcomes revealed that the most cost-effective condition was MET/CBT7 without ACC.

Objective Most adolescents relapse within 90 days of discharge from residential substance use treatment. We hypothesized that Contingency Management (CM), Assertive Continuing Care (ACC), and their combination (CM+ACC) would each be more effective than Usual Continuing Care (UCC). Method 337 adolescents were randomized to 4 continuing care conditions following residential treatment: UCC alone, CM, ACC, or CM+ACC. UCC was available across all conditions. Outcome measures over 12 months included percentage of days abstinent from alcohol, heavy alcohol, marijuana, and any alcohol or other drugs (AOD) using self-reports and toxicology testing and remission status at 12 months. Results CM had significantly higher rates of abstinence than UCC for heavy alcohol use (t(297)= 2.50, p<.01, d = 0.34), any alcohol use (t(297)= 2.58, p<.01, d = 0.36), any AOD use (t(297)= 2.12, p=.01, d = 0.41), and had a higher rate in remission (Odds Ratio [OR]=2.45 [90% CI: 1.18 to 5.08], p=.02). ACC had significantly higher rates of abstinence than UCC from heavy alcohol use (t(297)= 2.66, p<.01, d = 0.31), any alcohol use (t(297)= 2.63, p<.01, d = 0.30), any marijuana use (t(297)= 1.95, p=.02, d = 0.28), any AOD use (t(297)= 1.88, p=.02, d = 0.30), and had higher rates in remission (OR=2.31 [90% CI: 1.10 to 4.85], p=.03). The ACC+CM condition was not significantly different from UCC on any outcomes. Conclusions CM and ACC are promising continuing care approaches after residential treatment. Future research should seek to further improve their effectiveness.

Summary Research shows that many adolescents who enter treatment for substance use do not complete the recommended program, and after discharge, do not connect with continuing care services. Furthermore, the majority of adolescents will return to some level of substance use either during or after participation in treatment. Our review found 10 outcome studies of continuing care treatment for adolescents. Five of six studies with randomized designs resulted in significant clinical improvement for youth receiving the experimental continuing care approaches. Key findings of these trials are that more assertive approaches can increase continuing care initiation rates and that rapid initiation of continuing care made a difference in reducing substance use. Findings suggest that continuing care is not only appropriate for those who successfully complete treatment but also for many individuals who do not. Although there are no randomized controlled studies of adolescent participation in mutual aid groups, evidence is accumulating suggesting that matching adolescents to age-appropriate 12-step and other mutual aid groups can support recovery. Research employing adaptive treatment designs holds promise for establishing decision rules as to which adolescents need low-intensity continuing care services and which need more intensive care.