Drug Treatment for Teens - The ASAM Adolescent Levels of Care, with Case Study Examples

If your teen son or daughter needs substance abuse treatment, it’s essential that you find an appropriate level of care. You’d never want to send a teen to residential treatment if she could get treated while staying in the family home, but on the other hand, you’d never want to under react and keep an in-danger teen from getting the intense residential care that could make all the difference.

But though as a parent you generally know what's best for your child, you probably don't have addiction treatment expertise and you probably don't know what kind of treatment your son or daughter needs most.

So this puts you in a pretty tough spot. How are you suppose to make the right decision?

Well, as a starting point, consider the following two, somewhat contradictory truths that can help to guide your decisions.

1. Since you’re not an expert, it makes sense to seek out an experienced professional for a comprehensive assessment of the problem and a recommendation for a starting-point level of care. Your doctor can likely recommend a behavioral health assessment professional in your area.
   
2. Though you’re not a treatment expert, you are the world’s leading authority on your child and his or her needs and wants. You should accept expert advice, but always filter it through your own expertise and gut-sense of what’s most needed.

If you get a professional assessment you will probably get a recommendation that’s based on the American Society of Addiction Medicine’s (ASAM) levels of care. Before you can evaluate for yourself the appropriateness of this treatment recommendation, you need to understand how experts determine treatment needs and know what’s involved with each level of care.

Read on to:

1. Learn about the different levels of care and about how a teen gets matched to an appropriate level.
2. Find case-study examples that illustrate situations that match with outpatient, intensive outpatient and residential treatment levels of care
3. Learn about what happens at the end of treatment – does it just end or do you step-down to less intensive treatment?

ASAM – The 5 Levels of Addiction Treatment

According to the widely used ASAM adolescent placement criteria, there are 5 basic levels of teen addiction treatment.

The 5 levels of care are:

1. Level 0.5 – Early intervention
2. Level 1 – Outpatient
3. Level 2 – Intensive outpatient treatment or partial hospitalization
4. Level 3 – Residential or intensive inpatient treatment
5. Level 4 – Medically managed intensive inpatient treatment

To determine an appropriate level of care, professionals look at the situation across 6 assessment dimensions, which are:

• Acute intoxication and withdrawal – looking at how much medical management of withdrawal might be needed, for example.
• Biomedical complications – assessing for other health conditions that might complicate the recovery process.
• Emotional, behavioral and cognitive conditions or complications – looking for other mental health, developmental or behavioral conditions that might complicate the recovery process and lead to a higher level of care requirement.
• Readiness to change – the more ready and motivated for change the lower the treatment intensity that is required.
• Relapse or continued use potential – teens able to control use and maintain abstinence for moderate periods require less intensive treatment than teens unable to stop for even short periods of time.
• Recovery environment – Teens without a safe and stable recovery environment may require higher intensity care, such as residential treatment, to make lasting gains.

Case Studies

To illustrate how the placement criteria translate, in real-world terms, into level of care recommendations, here are three case-study examples: one for a teen who would benefit most from outpatient care, one for a teen who would benefit from an intensive outpatient program and one for a teen who would benefit most from a residential program.

Case Study 1 – Outpatient

Outpatient programs generally provide 3 or more hours per week of therapeutic programming.

Jesse is a 16 year old teen with a marijuana problem. He has been grounded on numerous occasions for breaking house rules but he continues to use. The school guidance counselor tried a brief intervention conversation, but behaviors haven’t changed for the better.

Although his repeated drug use is worrisome, he is not yet physically dependent and is in no risk of serious withdrawal. His current level of use doesn't put him in serious physical danger and his social and cognitive functioning is not yet affected. He has no physical or mental health problems that would complicate treatment.

Jesse says he can quit if he wants to but he has not yet demonstrated an ability to do so. Though he is ambivalent about behavioral change, he has promised his parents that he is willing to try. Jesse’s parents are involved in the treatment process and willing to do what they can to facilitate a good outcome.

By evaluating this situation across the assessment dimensions you would come to a recommendation of outpatient as a most appropriate starting point. Should outpatient treatment fail to help, Jesse would probably need to progress up to intensive outpatient treatment.

Case Study 2 – Intensive Outpatient

Intensive outpatient programs provide a minimum of 6 hours per week of therapeutic programming. The next step-up in intensity would be a partial hospitalization or day treatment program, which provides a minimum of 20 hours of programming per week^.1

Laura is a 15 year old regular marijuana user and binge drinker.

Though she’s not drinking every day Laura says she feels anxious when she can’t get drunk or high. She’s not drinking at a level that puts her in immediate risk of harm but she is not motivated to quit – her parents are forcing treatment - and though her social functioning isn’t yet affected, her school performance has dropped significantly in the last few months.

Her parents say they’ve tried everything, including family therapy, but nothing has helped. Although her parents are well-meaning, there is significant conflict in the home and home-stress contributes to the problem.

Because of her lack of motivation to stop (she says she doesn’t have a problem), because she continues to use and because she doesn’t have a totally stable/supportive  home-environment, she requires more frequent interventions and motivation help than she’d get in an outpatient program.

Case Study 3 – Medium Intensity Residential Treatment

Rob is a 17 year old meth user.

Rob is at risk of moderate withdrawal symptoms but these aren’t expected to be severe enough to require medical monitoring. He has no mental or physical impairments that would complicate treatment but he has been engaging in multi-day drug binges that put him at moderate risk of harm and which compromise his ability to function socially and at school (he has dropped out). Rob has no interest in recovery but is court-mandated to participate.

Rob has no proven ability to maintain abstinence. His family is supportive but Rob typically stays with other drug using friends in a very unstable environment.²

When Does Treatment End?

It takes as long as it takes.

Behavioral change isn’t easy and it doesn’t always happen on a 28 day treatment schedule. When starting with treatment, it’s best to consider starting with the lowest intensity treatment that’s likely to work, but to also consider an open-ended treatment timeline – treatment doesn’t end on a schedule, it ends with the resolution of the problem.

When reassessing the situation at the completion of any scheduled treatment:³

1. If the person hasn’t yet resolved their difficulties but is making progress or seems about to make progress, and the person is working hard at achieving treatment goals, continue on with more treatment at the same intensity.
2. If the person has achieved their treatment goals, either end treatment or transfer down to continuing care treatment of a lower intensity.
3. If the person does not improve, despite legitimate effort and/or modifications of treatment plans at any given intensity, consider intensifying the treatment level.
4. If the problem behavior worsens, consider intensifying the treatment level.

Cause for Concern - Reason for Hope

Teens do better when parents get involved in the treatment process, so get involved right from the start by learning all you can about treatment needs and by making sure that whatever level you start with makes the most sense for your situation.

Adolescence is a time of continuing brain development (this continues into the early twenties). This continuing development has both positive and negative implications.

• Drug and alcohol abuse can affect essential developmental tasks and so substance use during adolescence can have greater consequences than it would during adulthood. This underscores the importance of addressing the situation as quickly as possible.
• But though the stakes are high, teens have such an innate capacity for change – it’s really what defines adolescence – that with help and guidance they can make enormous gains in a short period of time.

So though the stakes are high, with appropriate treatment, you can be very hopeful for a positive outcome.