Promoting Wellness among Adolescents in Substance Abuse Treatment Programs: A Review of the Empirical Literature

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1 Promoting Wellness among Adolescents in Substance Abuse Treatment Programs: A Review of the Empirical Literature by Ana M. Abrantes, Ph.D. Butler Hospital/Brown Medical School Providence, Rhode Island This Literature Review was commissioned by the Phoenix House Foundation to inform the outcomes of a roundtable meeting on adolescent wellness in substance abuse treatment programs, held June 9, 2006 in Princeton, New Jersey. Made possible through the generous support of the Robert Wood Johnson Foundation

2 Introduction: How Do Adolescents Treatment Needs Differ from Adults? Substance use disorders (SUDs) among adolescent populations are a significant and growing public health concern in the United States. The 2003 National Survey on Drug Use and Health found that 8.9% of adolescents aged 12 to 17 approximately 1.1 million youth (US Census, 2000) - met criteria for substance abuse or dependence (SAMHSA, 2004b). Rates of SUDs are even higher for adolescents in clinical settings. In a 2001 study examining the prevalence of adolescent substance use disorders among youth ages 13 to 18 years receiving public health services, Aarons and colleagues (2001) found that 62.1% of youth in juvenile justice settings and 40.8% of those in mental health settings met diagnostic criteria for a SUD. These statistics indicate that youth with mental health disorders are significantly more likely than others to have a co-occurring substance abuse problem. Youth who become involved in the criminal justice system also have higher rates of substance use disorders. There has been a significant increase in the number of adolescents admitted to substance abuse treatment programs over the past 14 years. Data from the Treatment Episode Data Set (TEDS), an annual compilation of substance abuse treatment admissions in the United States, revealed that in the year 2002, there were 156,000 adolescents in substance abuse treatment a 65% increase in the number of admissions from the previous decade (SAMHSA, 2004a). Additionally, while less than half of the adolescent substance abuse treatment admissions had been referred from the juvenile justice system in 1992, by 2002 these referrals comprised a majority of youth addiction treatment admissions (SAMHSA, 2004a). Historically, adolescent substance abuse treatment has consisted of direct application of adult addiction treatment models. However, with the rise in adolescent substance abuse treatment admissions, there has been a concurrent increase in adolescent specialty treatment programs (M. D. Godley & White, 2005). Adolescence, the transition from childhood to adulthood, is a unique phase of development marked by biological, cognitive, and emotional changes that can influence psychosocial functioning (Brooks-Gunn & Graber, 1994; Huttenlocher & Dabholkar, 1997; Sowell, Thompson, Tessner, & Toga, 2001). There are distinct differences between adults and adolescents with respect to substance use problems, including patterns of use, associated psychiatric comorbidities, motivation for treatment, and extent of familial and peer influences (Deas, Riggs, Langenbucher, Goldman, & Brown, 2000). As a result, providing adolescents with substance abuse treatment that incorporates developmentally appropriate components has become critically important. Successful long-term treatment outcomes for adolescents have eluded clinicians and researchers. According to some studies, approximately half of adolescents 1

3 receiving treatment for SUDs relapse within the first three months following treatment (S. A. Brown, Mott, & Myers, 1990; Cornelius et al., 2003). In their review of the adolescent SUD treatment literature, Mark and colleagues (2006) state that many highly regarded substance abuse programs for youth fall short of the expert panel standards (Brannigan, Schackman, Falco, & Millman, 2004) for effective adolescent SUD treatment. These and other studies highlight the gaps in current adolescent treatments that fail to address mental health, medical, developmental and cultural needs. (Jaycox, Morral, & Juvonen, 2003; Olmstead & Sindelar, 2004; Williams & Chang, 2000). The need for substance abuse treatment for adolescents that is developmentally appropriate continues to exist as admission rates rise. Future research in this area is critically important in order to improve the long-term substance use outcomes and psychosocial functioning of adolescent substance abusers. Positive Youth Development: Addressing the Whole Person in the Treatment Setting One contributing factor to poor substance abuse treatment outcomes for adolescents may be that addiction programs do not pay enough attention to positive youth development. Blum and Ellen (2002) argue that society has a responsibility toward addressing not only adolescents problems but providing them with an opportunity to develop into healthy, thriving adults. Therefore, it is not enough that we treat substance use disorders; youth substance abuse treatment programs must also incorporate programs that will foster healthy development and promote factors associated with resiliency (Blum & Ellen, 2002). As varied risk behaviors emerge in adolescence, health and development become interrelated goals (Aujoulat, Simonelli, & Deccache, 2006). As treatment programs focus on a problematic behavior (e.g., substance abuse), the likelihood of a treatment being efficacious may be increased if protective factors and positive youth development are also concurrently addressed. For many adolescents, the increase in exploration, experimentation, risk taking and independence often leads to feelings of invulnerability (Quadrel, Fischhoff, & Davis, 1993). During this stage, adolescents often begin to engage in such health risk behaviors as smoking, alcohol and drug use, physical inactivity, unhealthy eating, and risky sex (Eaton et al., 2006). There is a strong body of literature that demonstrates these health compromising behaviors are highly correlated with each other during adolescence (Grunbaum et al., 2002; Pate, Heath, Dowda, & Trost, 1996). In a large study of high school students, adolescents who engaged in problem behaviors (e.g., smoking cigarettes, using marijuana, drinking alcohol, carrying a knife or weapon, engaging in physical fights, driving while drinking, and engaging in sexual intercourse) were much less likely to engage in healthenhancing behaviors (e.g., healthy eating, exercise behaviors, use of seat belt, adequate sleep, and proper dental care) (Hawkins, 1992). 2

4 Among adolescents who use alcohol and drugs, there is a negative association between the extent of substance use and healthy eating and physical activity. In a sample of 4,636 adolescents in South Carolina high schools, those engaging in unhealthy eating practices (i.e., extreme dieting) were more likely to use cigarettes, alcohol, and/or marijuana, and less likely to engage in physical exercise (Rafiroiu, Sargent, Parra-Medina, Drane, & Valois, 2003). Other studies have consistently found that community youth engaging in regular physical activity use cigarettes and drugs at much lower levels than their sedentary counterparts (Duncan, Duncan, Strycker, & Chaumeton, 2002; Pate, Trost, Levin, & Dowda, 2000; Peretti-Watel, Beck, & Legleye, 2002; Tur, Puig, Pons, & Benito, 2003). With respect to alcohol, adolescents involved in competitive sports may actually have higher rates of alcohol consumption. However, physical activity outside of competitive sports is related to decreased alcohol consumption (Peretti-Watel et al., 2002; Tur et al., 2003). While the relationship between substance involvement and such health promoting behaviors as balanced nutritional diet and regular physical activity has been explored in community samples of adolescents, this association has been relatively unexplored in adolescent substance abuse treatment populations. In one study, Thatcher and Clark (2006) examined whether adolescents in treatment for an alcohol use disorder were more likely to have cardiovascular risk factors (i.e., smoking, physical inactivity, poor diet) compared to a control group of adolescents from the community. They found that the adolescents in alcohol abuse treatment were less likely to report exercising regularly or eating a balanced diet and more likely to report smoking. The author concluded that it is necessary to develop interventions that focus on problematic health behaviors in conjunction with addiction treatment so as to improve the long-term health outcomes of adolescents with alcohol use disorders. In fact, there is some concern that substance abuse treatment may actually pose a risk toward unhealthy eating and weight gain. In a study examining the relationship between supervised drug abstinence and increased weight gain among 215 adolescents in a residential substance abuse treatment center, Hodgkins and colleagues (2004) found that a significant gain in weight and body mass index was observed during substance abuse treatment with increasing duration of confirmed abstinence. Given that food intake also impacts the endogenous reward system in the brain (as does alcohol and drugs), abstinence from these substances may result in the use of food to serve as a substitution (Hodgkins et al., 2004). While this has not received extensive empirical study among adolescent substance abusers, weight gain after smoking cessation has been well documented with adults (Marcus et al., 2003; Perkins, Levine, Marcus, & Shiffman, 1997). Thus, it appears critical that adolescents are aided in learning new health promoting skills and behaviors around nutrition and physical activity while concomitantly receiving substance abuse treatment. 3

5 Given that substance-abusing youth are likely to be concurrently engaged in other health compromising behaviors, the success of addiction treatment may hinge upon whether these issues are addressed. Recently, researchers have suggested that those substance abuse interventions which simultaneously address multiple health risk behaviors may prove to be more successful strategies for improving adolescent substance abuse outcomes (Werch, Moore, DiClemente, Bledsoe, & Jobli, 2005). Addressing Healthy Living in Youth Substance Abuse Programs Over the last decade there has been an increase in the number of interventions specifically designed for adolescent substance abusers that are being developed and tested by academic researchers. The extent to which these interventions will be deemed worthy of dissemination into the community is still currently unknown. The field of evidence-based interventions for adolescent substance abusers is still in its infancy. To address the need for more evaluation of adolescent substance abuse programs and interventions, SAMHSA s Center for Substance Abuse Treatment (CSAT) has sponsored a movement toward manualizing and empirically testing existing adolescent substance abuse treatment programs in the United States. CSAT s national evaluation study includes 10 exemplary models of adolescent substance abuse treatment (Stevens & Morral, 2003). Across each of these treatment programs, the primary drugs of abuse were alcohol and marijuana and clients were predominantly males referred from the juvenile justice system. Most of these exemplary models included some treatment component to promote healthy living in adolescents. For example, the Teen Substance Abuse Treatment (TSAT) program in Arizona, a 3-month intensive outpatient program included health topics such as HIV and STDs, depression, physical exercise and fitness, healthy living, positive feedback, and sober fun/natural highs, in their group therapy curriculum (Stevens et al., 2003). They also sponsor monthly sober-fun activities such as rock climbing, laser tag, hiking, basketball and bowling. In the Chestnut Health Systems program in Illinois, treatment included life skills, self-esteem, and leisure education groups which combined didactic instruction with therapeutic recreational activities (S. H. Godley, Risberg, Adams, & Sodetz, 2003). The Epoch outpatient program in Maryland incorporates educational groups on STDs/HIV and physical health into their 20-week group based program (R.J. Battjes et al., 2003). Adolescents at the 12-step based Mountain Manor Treatment Center in Baltimore, a short-term residential program, all participate in a series of health recovery groups that focus on such topics as: STDs/HIV, sexual abstinence and safety, injury prevention, and nutrition (Fishman, Clemmey, & Adger, 2003). At Our Youth, Our Future, Inc. in New Mexico, treatment is culturally-relevant and geared toward helping substance abusing American Indians and Native Alaskans identify physical, emotional, and 4

6 spiritual strengths in order to develop a sense of self-esteem and resiliency (Stewart-Sabin & Chaffin, 2003). Early morning runs are part of the treatment program. The 3-year multiphasic therapeutic community, Dynamic Youth Community in New York, holds seminars on health topics with some sporting activities on the weekends (Perry et al., 2003). Lastly, the Phoenix Academy in Los Angeles is a long-term residential program with an onsite public school. Their modified adolescent therapeutic community model places greater emphasis on recreation, less confrontation than in adult programs, more supervision by staff, greater family involvement in treatment, and more assessment for psychological disorders (Morral, Jaycox, Smith, Becker, & Ebener, 2003). As part of the treatment program, residents spend 2 hours per day on recreational activities such as physical education, sports, singing, games, dramatic arts, arts and crafts, and religious activities. Although the healthy living components of these adolescent substance abuse treatment programs have not been specifically evaluated and tested, each of these programs as a whole is being examined for efficacy and preliminary results appear promising. For example, over a 12-month period of time, participation in Phoenix Academy was associated with superior substance use outcomes compared to other group home and probation placements (Morral, McCaffrey, & Ridgeway, 2004). Further, participation in the Epoch program was related to reduced 6- and 12-month marijuana use although not to reduced alcohol use or criminal behavior (R. J. Battjes et al., 2004). Need For More Research There have been very few attempts to empirically study the integration of structured health promotion programs into substance abuse treatment, with most of the research in this area focusing on adult substance abusers. In one study, Sinyor and colleagues (1982) reported on 58 adult participants receiving inpatient alcohol rehabilitation treatment. Participants engaged in six weeks of tailored exercise, consisting of progressively more rigorous physical exercise including stretching, calisthenics and walking/running. Results revealed that these subjects demonstrated better abstinence outcomes post-treatment than did nonexercising subjects from two other small comparison groups. Significant differences between exercisers and non-exercisers continued at 3-month and 18- month follow-up. Among adolescents, a preliminary study was conducted in a residential facility treating adolescents with SUDs to examine the efficacy of an aerobic exercise intervention alone and with nutrition education to prevent weight gain during addiction treatment (Hodgkins, 2004). One hundred and twenty male adolescents were randomly assigned to one of the following: an exercise intervention, exercise plus nutrition intervention, or a treatment-as-usual condition. Adolescents who participated in the intervention conditions, compared to a 5

7 treatment-as-usual control group, experienced significantly less weight gain. While this program was implemented successfully in the youth substance abuse treatment programs, it is unknown whether the exercise/nutrition intervention was associated with improved alcohol and drug use outcomes. Much of the work done in the area of introducing structured health promotion to adolescent substance abuse treatment has been conducted by Collingwood and colleagues (Collingwood, 1997; Collingwood, Reynolds, Kohl, Smith, & Sloan, 1991; Collingwood, Sunderlin, & Kohl, 1994; Collingwood, Sunderlin, Reynolds, & Kohl, 2000). Collingwood (1997) designed a structured physical training program called First Choice to reduce substance use among at-risk youth in prevention settings (e.g., schools and YMCAs), substance abuse treatment programs, and juvenile justice settings and correctional institutions. The program was designed to be implemented in a structured manner with a formal curriculum consisting of lesson plans and manuals so that trained staff could effectively execute the program at each site. One of the program components included both group exercise classes and educational classes where physical fitness was taught as a life skill, so that in addition to weight training, running, stretching, and calisthenics, youth learned about nutrition, stress management, goal setting, the value of respect, responsibility and self-discipline. An additional component of the First Choice program consists of leadership training where staff at each site is trained on how to implement the program and how to continue to sustain it. Evaluation of the First Choice program has demonstrated a positive impact on both fitness and substance involvement. Collingwood and colleagues (1991) conducted a study of an 8-week structured fitness program with adolescent substance abusers in either a school-based at risk prevention program, a community substance abuse treatment program, or an inpatient hospital for substance abuse. All participants received the same physical fitness program and exercise prescription. Overall, participants showed improved physical fitness, reduced polysubstance use, and increased abstinence rates. In another larger scale study, Collingwood, Sunderlin, and Kohl (1994) evaluated the effects of an 8 16 week physical fitness skills training program on substance use in a sample of approximately 1500 at-risk adolescents. Participants were recruited from substance abuse residential treatment centers, community service agencies, junior high and high schools, and a juvenile correction center. Outcome data revealed general improvements in fitness and self-concept and in reduced use of cigarettes, alcohol, and other drugs. By 1997, over 4,000 adolescents had participated in the First Choice program (Collingwood, 1997). In general, the outcomes suggest that youth improve their activity levels and fitness (including increased cardiovascular endurance, strength and flexibility), selfconcept, mood (i.e., depression and anxiety) with significant observed reductions in substance involvement. Furthermore, youth themselves, parents, and treatment staff rate the value of the program very highly. 6

8 The extent to which adolescent substance abuse treatment programs currently incorporate intervention components which focus on positive youth development and promote healthy living remains limited. In those substance abuse treatment programs where attempts are being made to address this, program implementation has generally not been conducted in a structured fashion nor have they included formal evaluation components to empirically test the effectiveness of the intervention. Future Directions: Examining the Integration of Wellness Programming in Treatment Settings Efforts toward continuing this line of investigation will face the challenge of integrating developmentally appropriate interventions that address positive, healthy youth development among adolescents in substance abuse treatment and juvenile justice settings. Despite the enormity of the task ahead, the potential benefit to society will be substantial. Addressing healthy living in adolescent substance abuse treatment settings may prove to be quite cost effective and potentially increase treatment success rates. Werch and colleagues (2005) have argued that physical fitness should be considered a positive theme when designing substance abuse prevention programs that also integrate various health behaviors, with physical exercise being an important focal point. Substance abusing adolescents have been characterized as experiencing low self-esteem (Abernathy, Massad, & Romano- Dwyer, 1995) and adolescent physical activity has been consistently associated with increased self-esteem (Collingwood, 1997; Finocchiaro & Schmitz, 1984; Koniak-Griffin, 1994; Modrcin-Talbott, Pullen, Ehrenberger, Zandstra, & Muenchen, 1998). To the extent that positive self-esteem is associated with adaptive responses to life s challenges, it may be an important mechanism by which adolescents achieve wellness and recovery from drugs and alcohol (Modrcin-Talbott et al., 1998). In addition to self-esteem, there may be other mechanisms by which physical activity can influence substance use outcomes among adolescents in addiction treatment. Adolescent substance abusers have high rates of comorbid psychiatric disorders (Armstrong & Costello, 2002) with studies reporting that 68% (Novins, Beals, Shore, & Manson, 1996) and 82% of adolescents in inpatient substance abuse treatment (Stowell & Estroff, 1992) also meet criteria for a co-occurring psychiatric disorder. Along with this is a growing body of evidence which suggests that physical exercise improves adolescent psychological well-being. Studies have found that increased physical activity is associated with decreases in stress (Norris, Carroll, & Cochrane, 1992; Yin, Davis, Moore, & Treiber, 2005), depression (S. W. Brown, Welsh, Labbe, Vitulli, & Kulkarni, 1992; Koniak-Griffin, 1994; Norris et al., 1992), self-efficacy (S. W. Brown et al., 1992; Bungum, Pate, Dowda, & Vincent, 1999; Holloway, Beuter, & 7

9 Duda, 1988) as well as improved general psychological well-being (Colchico, Zybert, & Basch, 2000; Steptoe & Butler, 1996). Because concomitant mental health problems are a risk for poor substance use outcomes among adolescent substance abusers (Grella, Hser, Joshi, & Rounds-Bryant, 2001; Tomlinson, Brown, & Abrantes, 2004), improvements in these domains due to interventions promoting physical fitness will greatly enhance the recovery process and contribute to successful treatment outcomes. Given the numerous benefits of promoting healthy living in adolescent substance abuse treatment programs, the logical next step is to move toward research in designing and evaluating effective interventions. In doing so, we can look toward the adolescent intervention literature more generally as a guide. There are examples of successful smoking cessation programs (Myers & Brown, 2005) and STD/HIV prevention programs (St Lawrence, Crosby, Brasfield, & O'Bannon, 2002) that have been integrated into adolescent substance abuse treatment, as well as examples of structured exercise and nutrition programs that have been implemented in school and community settings (Shilts et al., 2004; Takada, Guerra-Walter, & Agron, 2001). Drawing on this literature will prove useful in designing interventions that attempt to integrate multiple health behaviors among adolescents. There are certain factors that should be considered when developing health promoting interventions for adolescents. In general, psychoeducational approaches has typically not been effective (Wagner, Meusel, & Kirch, 2005). Therefore, interactive approaches that incorporate adolescents perspectives may result in better outcomes (Peterson-Sweeney, 2005). In addition, environmental factors can play a significant role in whether youth will engage in healthy behaviors (Kubik, Lytle, Hannan, Perry, & Story, 2003). For example, adolescents are more likely to eat healthy if nutritionally healthy choices are available to them and if treatment facilities remove or minimize snack vending machines (Evans, Wilson, Buck, Torbett, & Williams, 2006). Similarly, the availability of athletic and sporting equipment, gyms, tracks, and fields in treatment programs are important toward maximizing the likelihood adolescents will adopt healthy behaviors. Lastly, involving parents, guardians, and staff as role models for practicing healthy behaviors may also prove beneficial in promoting healthy living. Before any intervention can be widely disseminated, it is critical for there to be demonstrated empirical evidence of both efficacy and effectiveness. An intervention is considered efficacious if, after repeated trials, it is found to be significantly better than treatment-as-usual or another established treatment. An intervention is considered effective if participants adhere and follow through with the treatment. At this point, there is a lack of health promoting interventions that enhance youth development in adolescent substance abuse programs that have demonstrated efficacy or effectiveness. While Collingwood (1997) has done preliminary work in this area, that research was limited due to a lack of a control 8

10 or comparison group. However, Collingwood (1997) highlights the importance of developing structured programs. In order for interventions to be empirically evaluated, it is important that they can be implemented by other research groups. Thus, interventions should be structured and manualized. In addition, as interventions are being developed and evaluated, it will be useful to refer to a theoretical model or potential mechanisms of actions to help inform intervention components. Lastly, while it is expected that these interventions will promote positive health behavior change, ultimately what we are interested in is whether this will result in successful substance treatment outcomes. Therefore, future research should also focus on defining and standardizing the definition of successful treatment outcomes (e.g., abstinence, reduced days using drugs, recidivism rates, reduction in substance-related negative consequences). Conclusion Over the last decade there has been increased interest in developing specialized substance abuse treatment for adolescent populations. Given the significant negative consequences associated with substance involvement in youth coupled with high relapse rates after treatment, developing effective substance abuse interventions that address the unique developmental needs of adolescents is critically important. One area that is insufficiently explored among the currently available adolescent substance use treatment programs is that of promoting healthy living. Integrating structured physical activity and nutritional intervention programs along with developmentally appropriate pro-social activities in substance abuse treatment for youth may result in significantly improved treatment outcomes. The emotional and psychological benefits of these interventions may have a direct impact on substance use recovery in adolescents. Future research efforts can be guided by existing adolescent intervention research in designing and evaluating effective programs that can be implemented in existing adolescent substance use treatment programs. 9

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14 Myers, M. G., & Brown, S. A. (2005). A controlled study of a cigarette smoking cessation intervention for adolescents in substance abuse treatment. Psychol Addict Behav, 19(2), Norris, R., Carroll, D., & Cochrane, R. (1992). The effects of physical activity and exercise training on psychological stress and well-being in an adolescent population. J Psychosom Res, 36(1), Novins, D. K., Beals, J., Shore, J. H., & Manson, S. M. (1996). Substance abuse treatment of American Indian adolescents: comorbid symptomatology, gender differences, and treatment patterns. J Am Acad Child Adolesc Psychiatry, 35(12), Olmstead, T., & Sindelar, J. L. (2004). To what extent are key services offered in treatment programs for special populations? J Subst Abuse Treat, 27(1), Pate, R. R., Heath, G. W., Dowda, M., & Trost, S. G. (1996). Associations between physical activity and other health behaviors in a representative sample of US adolescents. Am J Public Health, 86(11), Pate, R. R., Trost, S. G., Levin, S., & Dowda, M. (2000). Sports participation and health-related behaviors among US youth. Arch Pediatr Adolesc Med, 154(9), Peretti-Watel, P., Beck, F., & Legleye, S. (2002). Beyond the U-curve: the relationship between sport and alcohol, cigarette and cannabis use in adolescents. Addiction, 97(6), Perkins, K. A., Levine, M. D., Marcus, M. D., & Shiffman, S. (1997). Addressing women's concerns about weight gain due to smoking cessation. J Subst Abuse Treat, 14(2), Perry, P. D., Hedges, T. L., Carl, D., Fusco, W., Carlini, K., Schneider, J., et al. (2003). Dynamic Youth Community, Incorporated: A multiphase therapeutic community for adolescents and young adults. In S. J. Stevens & A. R. Morral (Eds.), Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study (pp ). New York, NY: Hawthorn Press, Inc. Peterson-Sweeney, K. (2005). The use of focus groups in pediatric and adolescent research. Journal of Pediatric Health Care, 19, Quadrel, M. J., Fischhoff, B., & Davis, W. (1993). Adolescent (in)vulnerability. Am Psychol, 48(2), Rafiroiu, A. C., Sargent, R. G., Parra-Medina, D., Drane, W. J., & Valois, R. F. (2003). Covariations of adolescent weight-control, health-risk and healthpromoting behaviors. American Journal of Health Behavior, 27(1), SAMHSA. (2004a). The DASIS Report: Adolescent Treatment Admissions: 1992 and 2002 October 15, SAMHSA. (2004b). Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD. Shilts, M. K., Horowitz, M., Townsend, M. S., Shilts, M. K., Horowitz, M., & Townsend, M. S. (2004). An innovative approach to goal setting for adolescents: guided goal setting. J Nutr Educ Behav, 36(3),

15 Sinyor, D., Brown, T., Rostant, L., & Seraganian, P. (1982). The role of a physical fitness program in the treatment of alcoholism. J Stud Alcohol, 43(3), Sowell, E. R., Thompson, P. M., Tessner, K. D., & Toga, A. W. (2001). Mapping continued brain growth and gray matter density reduction in dorsal frontal cortex: Inverse relationships during postadolescent brain maturation. J Neurosci, 21(22), St Lawrence, J. S., Crosby, R. A., Brasfield, T. L., & O'Bannon, R. E., 3rd. (2002). Reducing STD and HIV risk behavior of substance-dependent adolescents: a randomized controlled trial. J Consult Clin Psychol, 70(4), Steptoe, A., & Butler, N. (1996). Sports participation and emotional wellbeing in adolescents. The Lancet, 347, Stevens, S. J., Estrada, B. D., Carter, T., Reinardy, L., Seitz, V., & Swartz, T. (2003). The teen substance abuse treatment program: Program design, treatment issues, and client characteristics. In S. J. Stevens & A. R. Morral (Eds.), Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study (pp ). New York, NY: Hawthorn, Press, Inc. Stevens, S. J., & Morral, A. R. (2003). Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study. Binghamton, New York: Hawthorn Press. Stewart-Sabin, C., & Chaffin, M. (2003). Culturally competent substance abuse treatment for American Indian and Alaska native youths. In S. J. Stevens & A. R. Morral (Eds.), Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study (pp ). New York, NY: Hawthorn Press, Inc. Stowell, R. J., & Estroff, T. W. (1992). Psychiatric disorders in substanceabusing adolescent inpatients: a pilot study. J Am Acad Child Adolesc Psychiatry, 31(6), Takada, E., Guerra-Walter, C., & Agron, P. (2001). Jump Start Teens: interactive, cross-curricular lessons for high school adolescents. J Nutr Educ, 33(1), Thatcher, D. L., & Clark, D. B. (2006). Cardiovascular risk factors in adolescents with alcohol use disorders. Int J Adolesc Med Health, 18(1), Tomlinson, K. L., Brown, S. A., & Abrantes, A. (2004). Psychiatric comorbidity and substance use treatment outcomes of adolescents. Psychol Addict Behav, 18(2), Tur, J. A., Puig, M. S., Pons, A., & Benito, E. (2003). Alcohol consumption among school adolescents in palma de mallorca. Alcohol Alcohol, 38(3), United States Census. Sex by single year of age Wagner, N., Meusel, D., & Kirch, W. (2005). Nutrition education for children--results and perspectives. Journal of Public Health, 13,

16 Werch, C. C., Moore, M. J., DiClemente, C. C., Bledsoe, R., & Jobli, E. (2005). A multihealth behavior intervention integrating physical activity and substance use prevention for adolescents. Prev Sci, 6(3), Williams, R. J., & Chang, S. Y. (2000). A comprehensive and comparitive review of adolescent substance abuse treatment outcome. Clinical Psychology -- Science and Practice, 7, Yin, Z., Davis, C. L., Moore, J. B., & Treiber, F. A. (2005). Physical activity buffers the effects of chronic stress on adiposity in youth. Ann Behav Med, 29(1),

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18 Phoenix House is one of the nation s largest nonprofit providers of substance abuse treatment and prevention services, operating more than 100 programs in nine states.

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