Feature Article_693 437..

444
Retention of adolescents with substance
dependence and coexisting mental health
disorders in outpatient alcohol and drug
group therapy
Bronwyn Pagey,
1
Daryle Deering
2
and Doug Sellman
2
1
Youth Speciality Service, Canterbury District Health Board and
2
National Addiction Centre (Aotearoa New
Zealand), University of Otago, Christchurch, New Zealand
ABSTRACT: The aim of this study was to investigate characteristics that might enhance retention
among adolescents attending outpatient alcohol and drug group therapy within a youth mental health
setting. An important goal was to provide information for nurses and other clinicians who work with
adolescents with coexisting substance use and mental health disorders. A retrospective le audit
reviewed the les of 64 adolescents who attended a weekly alcohol and drug group between 2002 and
2004. Five characteristics were shown to have a signicant impact on enhancing participant group
retention. These were Ma ori and Pacic Island ethnicity, past or current legal charges, youth drug
court (YDC) involvement, having a diagnosis of cannabis dependence, and a diagnosis of conduct
disorder. Logistic regression found that YDC involvement on its own signicantly predicted treatment
retention. In an area of limited research, the ndings from this study expand the literature on
enhancing treatment retention for a vulnerable and hard-to-engage adolescent group with complex
treatment needs, and highlight the need for further investigation of the potential role of the YDC. From
a practice perspective, the ndings support group therapy interventions as a cost-effective treatment
modality for assisting adolescents with coexisting substance use and mental health issues, including
those with conduct disorder and YDC involvement.
KEY WORDS: adolescent, alcohol and drug treatment, group therapy, treatment retention, youth
drug court.
INTRODUCTION
Adolescence is a critical developmental stage, the transi-
tional period between childhood and adulthood, when
adolescents develop essential skills for functioning
independently in society. Difculties in this stage of devel-
opment can be particularly damaging and have lifelong
impacts (Rutter & Taylor 2002). Substance use-related
problems experienced by adolescents include mental and
physical health problems, academic and vocational failure,
legal charges, nancial problems, and family and social
difculties (Copeland 2004; Dennis et al. 2004; Sellman &
Deering 2002).
Although the increasing prevalence of substance-
related problems and dependence among adolescents
has led to the development of a number of treatment
modalities, research is limited in this area (Brown 2004;
Correspondence: Bronwyn Pagey, Youth Speciality Service, Canter-
bury District Health Board, Private Bag 4733, Christchurch, New
Zealand. Email: bronwyn.pagey@cdhb.govt.nz
Bronwyn Pagey, RN, MHSc.
Daryle Deering, RN, PhD.
Doug Sellman, MBChB, PhD, FRANZCP, FAChAM.
Accepted June 2010.
International Journal of Mental Health Nursing (2010) 19, 437444 doi: 10.1111/j.1447-0349.2010.00693.x
2010 The Authors
International Journal of Mental Health Nursing 2010 Australian College of Mental Health Nurses Inc.
Bukstein & Winters 2004; Dennis et al. 2004; Liddle
2004; Schroder et al. 2007). Furthermore, due to meth-
odological issues, such as differing diagnostic criteria
and treatment programme denitions, it is difcult to
draw specic conclusions from the literature as to which
interventions are more effective for specic adolescent
populations, particularly those with coexisting psychopa-
thology (Bukstein & Winters 2004).
Nevertheless, there are a number of general conclu-
sions that can be reached from considering the adolescent
treatment literature. For example, the ndings from the
Drug Abuse Treatment Outcome Study for Adolescents
(DATOS-A) involving 23 sites in the USA (n = 1167) indi-
cated that, in general, both residential and outpatient
drug abuse treatments were effective, and that longer
stays in treatment were associated with favourable out-
comes (Hser et al. 2001). Favourable outcomes included
reduction in substance use, improved school perfor-
mance, and decreased criminal activity (Hser et al. 2001).
These DATOS-A ndings are consistent with a number of
reviews of adolescent alcohol and drug treatment
research, which have supported the general effectiveness
of treatment and highlighted family therapy as having the
highest evidence base (Liddle 2004; OLeary-Tevyaw &
Monti 2004; Vaughn & Howard 2004).
Evaluations of youth drug courts (YDC) have shown
that they are an effective intervention for adolescents
involved in the court system, and contribute to reduced
substance use and criminal behaviour (Belenko & Logan
2003; Carswell 2004; Henggeler 2007; Henggeler et al.
2006). Research trials have also demonstrated that group
therapy is a cost-effective alcohol and drug treatment
modality for adolescents (Dennis et al. 2004), and that
cognitive behaviour and psychoeducation approaches
within group therapy are effective in assisting adolescents
to reduce their substance use and associated problems
(Kaminer et al. 2002; Waldron & Kaminer 2004).
Because longer time in treatment is associated with
improved client outcomes, the retention of adolescents in
treatment is critical (Hser et al. 2001; Joe et al. 1999; Stark
1992; Williams & Chang 2000). However, high adolescent
attrition rates remain a widely recognized problem(Grella
et al. 1999; Orlando et al. 2003; Schroder et al. 2009).
Studies that have addressed adolescent treatment reten-
tion have particularly focused on xed or unchangeable
client characteristics, such as age, ethnicity, sex, substance
use, mental health status, criminal history, family relations
and parental substance use, and educational and employ-
ment history (De Leon et al. 1997). Although xed client
characteristics have not consistently been found to be
associated with treatment retention in either outpatient or
residential treatments (Galaif et al. 2001; Schroder et al.
2009), the presence of conduct disorder and attention
decit hyperactivity disorder (ADHD) has been found to
be associated with decreased retention (Horwood & Fer-
gusson 1998; Siegal et al. 1993; Wise et al. 2001), and court
referral and involvement in the court system to be associ-
ated with improved treatment retention (Melnick et al.
1997; Pompi & Resnick 1987).
As well as examining the inuence of xed factors on
adolescent treatment retention, dynamic client character-
istics, such as level of motivation (De Leon et al. 1997;
Schroder et al. 2009) and programme factors (Friedman
& Glickman 1987; Hser et al. 2001; Schroder et al. 2009),
have been investigated. Internal motivation (Hser et al.
2001; Melnick et al. 1997; Schroder et al. 2009) and
expectations about treatment (Schroder et al. 2009) have
been shown to be associated with treatment retention, as
have staff ratios and staff experience (Friedman & Glick-
man 1987), client/staff relationships (Hser et al. 2001;
Schroder et al. 2009), perceived involvement in treatment
planning (Schroder et al. 2009), and comprehensiveness
of the issues addressed (Stark 1992).
Research on adolescent treatment retention in group
therapy is limited. In the one study identied in the litera-
ture review, Battjes et al. (2004) examined client and pro-
gramme characteristics that predicted length of time in
treatment. No associations were found between xed
client characteristics and treatment retention. Factors that
were associated with retention included type of substance
use, absence of emotional problems, perception of coun-
sellors skills, and type of therapy received. However, the
authors cautioned careful interpretation of the results due
to the low severity of substance use among the sample.
The overall aim of the present study was to investigate
characteristics that might enhance retention among ado-
lescents attending outpatient alcohol and drug group
therapy within a youth mental health setting. An impor-
tant goal was to provide information for mental health
nurses and other clinicians who work in mental health and
addiction treatment settings with adolescents who have
coexisting substance use and mental health disorders, in
the hope that such information could contribute to
improving treatment retention for this group of high-risk
adolescents.
METHOD
Setting
The Youth Specialty Service (YSS) is located in
Christchurch, New Zealand, and is a government-funded
438 B. PAGEY ET AL.
2010 The Authors
International Journal of Mental Health Nursing 2010 Australian College of Mental Health Nurses Inc.
outpatient mental health service of the Specialist Mental
Health Service of the Canterbury District Health Board.
Adolescents aged between 13 and 18 years are referred to
the service by a range of health, justice, welfare, and
educational organizations, as well as other community
groups.
The YSS is staffed by a multidisciplinary mental health
team and provides comprehensive mental health and
alcohol and drug assessments and treatment for adoles-
cents with a variety of substance use and coexisting mental
health disorders. Interventions include individual, family,
and group therapy. Mental health nurses and social
workers comprise the majority of the clinical case manag-
ers who conduct assessments, coordinate individualized
treatment plans, and facilitate access to or directly provide
psychosocial interventions for an assigned number of ado-
lescents. The clinical case managers are supported by
consultant psychiatrists, psychologists, and other specialist
staff. One of the teams within the YSS is a specialist alcohol
and drug team, which accepts referrals of adolescents with
complex substance use andcoexisting mental healthissues.
Highly-experienced mental health nurses with addiction-
related postgraduate qualications are a core component
of the alcohol and drug team stafng.
The alcohol and drug therapy group was an open-
ended group. Participants attended for an undetermined
duration, depending on individual need. The weekly
group was of 1-hour duration and was facilitated by two of
the team members: a mental health nurse (female) and a
social worker (male). A mix of psychoeducation, motiva-
tion enhancement, and cognitive behaviour strategies,
including relapse prevention, were utilized within ses-
sions, underpinned by a harm-reduction approach
(Lenton & Single 1998). A parallel weekly group for
parents and other caregivers was provided. The group
facilitators had observed that adolescents who attended
four or more sessions were more likely to continue attend-
ing, reecting a model of engagement in alcohol and drug
treatment in which session attendance is an important
factor (Simpson & Joe 2004).
Design and sample
The study was a retrospective le audit of the clinical
records of 64 adolescents who attended the YSS outpa-
tient alcohol and drug group therapy group between 2002
and 2004. All adolescents met criteria for substance
dependence according to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV)
(American Psychiatric Association 1994), as this was a
requirement to attend the group. Retention was dened
as attendance of four or more group sessions. Ethical
approval was granted by the Canterbury Ethics Commit-
tee. The committee determined that the study was a ret-
rospective clinical le audit and anonymity was being
maintained; therefore, written individual or parental
consent was not required.
Data collection
Data were collected using templates that were developed
following a focused literature review on adolescent treat-
ment retention. The data collection templates were then
trialled on 10 les and adjusted as required. The
individual adolescent data were largely obtained from
the initial comprehensive assessment and discharge
summary. These included sociodemographic characteris-
tics, physical health status, legal status, substance use,
level of motivation, substance use and other mental health
diagnoses, mental health and addiction treatment history,
outcome of treatment, and reason for discharge.
The group data were obtained from the group atten-
dance register. These included attendance, weekly group
focus, sex mix of attendees, and facilitator sex. Retention
was dened as attending four or more group therapy
sessions.
Analyses
Data were entered and analysed using the Statistical
Package for the Social Science (SPSS) version 13.0 (SPSS
1999). Descriptive statistics were used to describe the
sociodemographic, substance use, and mental health
characteristics of the study sample and the prole of the
alcohol and drug group. Cross-tabulation c
2
-tests were
utilized to analyse the relationship between retention and
participants characteristics. The following categories
were condensed and/or recategorized to enable data
analysis: ethnicity, referral source, living circumstances,
vocational activity, and past and current substance use.
P-values were examined in order to establish the sta-
tistical signicance of the relationship between character-
istics and retention. P < 0.05 was chosen as the level of
statistical signicance. Multiple logistic regression involv-
ing all the variables that were signicant in the initial
univariate analysis using c
2
-tests was undertaken to iden-
tify which variables remained signicant predictors of
retention when considered in the context of the other
signicant variables as a group.
RESULTS
Participant prole
Table 1 outlines the sociodemographic, substance use,
and mental health characteristics of the 64 participants
ADOLESCENTS WITH SUBSTANCE DEPENDENCE 439
2010 The Authors
International Journal of Mental Health Nursing 2010 Australian College of Mental Health Nurses Inc.
who attended the YSS alcohol and drug group. As can be
seen from this Table, one-quarter were of Ma ori and
Pacic Island descent; only a minority (14.1%) were living
with both parents, and nearly two-thirds (64.1%) had legal
charges. Just over 70% (71.9%) had family involvement in
their assessment, and for 23.4%, a caregiver attended the
parallel caregivers group. In addition to a substance use
problem, participants met criteria for a range of mental
health disorders, particularly conduct disorder (43.8%)
and depression (21.9%). Diagnoses in the other category
(21.9%) included adjustment disorder, parentchild con-
ict, oppositional deant disorder, post-traumatic stress
disorder, and social phobia.
Retention
Based on the retention criterion of attending the group
for four sessions, Figure 1 shows the percentage of the 64
participants who were retained and not retained in the
group during the study period (n = 40 retained; n = 24 not
retained).
Characteristics associated with retention
Chi-square tests were utilized to examine relationships
between predictor characteristics and retention. Table 1
highlights those characteristics that were signicantly
associated with retention. A larger number of Ma ori and
Pacic Island participants were retained compared to
European participants (87.5% vs 54.2%, c
2
= 5.69,
degrees of freedom (df) = 1, P = 0.017), and a higher pro-
portion who were referred by the YDC were retained
compared to participants from other referral sources
(84% vs 48.7%, c
2
= 13.23, df = 3, P = 0.004). There were
no statistically-signicant differences found in regard to
age, sex, living circumstances or vocational activity, and
retention, nor were there any statistically-signicant dif-
ferences found in respect to health status and treatment
retention.
Almost three-quarters of the participants with legal
charges (past or current) were retained (73.2%,
c
2
= 5.54, df = 1, P = 0.019), as were more participants
who were involved in the YDC (85.2%, c
2
=10.26,
df = 1, P = 0.001). Examining the relationship between
substance use disorders and treatment retention showed
that signicantly more participants with cannabis depen-
dence were retained compared to those without can-
nabis dependence (70.8%, c
2
= 5.69, df = 1, P = 0.017).
No signicant associations were found for nicotine
dependence, cannabis abuse, or alcohol dependence or
abuse in this regard, nor were any signicant associa-
tions found in relation to participants past and current
substance use and treatment retention, although there
TABLE 1: Sociodemographic, substance use, mental health charac-
teristics, and retention rates of the participants who attended the Youth
Specialty Service alcohol and drug group, 20022004 (n = 64)
Age (years) (mean, SD) 15.3 (1.0)% Retained (%)
Younger (1315) 64.9
Older (1618) 59.3
Male 65.6 59.5
Ethnicity
European 75.0 54.2
Ma ori/Pacic Island 25.0 87.5*
Referral source
Youth drug court 39.1 84.0*
Other 25.0 68.8
General practitioner 23.4 40.0
School guidance counsellor 12.5 25.0
Living circumstances
Single parent 54.6 65.7
Both parents 14.1 55.6
Other 31.3 60.0
Vocational activity
Course 34.4 72.7
School 29.7 42.1
Unemployed 26.5 64.7
Employed 9.4 83.3
Legal charges
Yes 64.1 73.2*
Youth drug court involvement 42.2 85.2*
Family involvement
At assessment 71.9 63.0
Caregiver group 23.4 66.7
Substance use diagnoses
Cannabis dependence 75.0 70.8*
Nicotine dependence 57.8 62.2
Alcohol dependence 42.2 66.7
Alcohol abuse 32.8 52.4
Cannabis abuse 7.8 40.0
Mental health diagnoses
Conduct disorder 43.8 78.6*
Depression 21.9 42.9
Attention decit hyperactivity disorder 12.5 25.0*
Other 21.9 55.6
*P < 0.05. SD, standard deviation.
Retained
P
a
r
t
i
c
i
p
a
n
t
s

(
%
)
Not retained
0
20
40
60
80
FIG. 1: Percentage of retained and not retained participants in the
Youth Specialty Service alcohol and drug group, 20022004 (n = 64).
440 B. PAGEY ET AL.
2010 The Authors
International Journal of Mental Health Nursing 2010 Australian College of Mental Health Nurses Inc.
was a trend shown for past daily use of cannabis and
treatment retention (P = 0.052).
There were no signicant differences found between
type of past treatment, concurrent YSS treatment, or par-
ticipant level of motivation, and group treatment reten-
tion. With respect to coexisting disorders and retention,
participants with conduct disorder were more likely to be
retained (78.6%, c
2
= 5.49, df = 1, P = 0.019). Conversely,
participants with a diagnosis of ADHD were less likely to
be retained (25%, c
2
= 5.49, df = 1, P = 0.019). However,
this result should be considered with caution, given sta-
tistical issues that emerge relating to small cell counts for
these characteristics (<5). There were no signicant dif-
ferences found in relation to the presence of other mental
health disorders and retention.
A large number of the participants had a known
family history of addiction (71.9%), with 59.4% having a
rst-degree relative with addiction and 12.5% having a
second-degree relative with addiction. There was no sig-
nicant difference found between those participants
with a family history of substance use disorders and
those without such a family history, with respect to
treatment retention in the alcohol and drug group.
Almost 60% of participants had a known family history
of mental health disorders. Again, there was no signi-
cant difference found in this regard, or in relation to
family involvement and retention.
The relationships between the statistically-signicant
characteristics were examined using cross-tabulation
c
2
-tests. The P-values of respective c
2
-test analyses are
presented in Table 2. The referral source was removed
from further analysis due to YDC being the referral
source that was most signicantly related to retention.
Table 2 shows that involvement with YDC was strongly
associated with almost all factors.
Finally, both forward and backward logistic regressions
found that involvement in YDC in its own right was sta-
tistically signicant (odds ratio = 6.7765, 95% condence
interval: 1.95123.450, df = 1, P = 0.003) in predicting
treatment retention among participants attending the
alcohol and drug group.
DISCUSSION
The aim of this study was to investigate characteristics
that might enhance adolescent retention in outpatient
alcohol and drug group therapy. As such, this study
appears to be the rst investigation focusing specically
on the retention of adolescents with coexisting substance
use and mental health disorders in outpatient alcohol
and drug group therapy. Consistent with other studies
on adolescent treatment retention, the present study
found that the majority of xed client characteristics
were not signicantly associated with treatment reten-
tion (Feigelman 1987; Friedman & Glickman 1987;
Galaif et al. 2001; Mossman 2005; Orlando et al. 2003;
Schroder et al. 2009). These included age, sex, living cir-
cumstances, vocational activity, health status, current
and past substance use, past alcohol and drug and
mental health treatment, family history of addiction and
other mental health disorders, and family or caregiver
involvement in treatment.
However, in contrast to other studies (Blood & Corn-
wall 1994; Galaif et al. 2001; Melnick et al. 1997; Orlando
et al. 2003; Pompi & Resnick 1987; Schroder et al. 2009),
the present study found that Ma ori or Pacic ethnicity,
having a diagnosis of cannabis dependence, and having a
diagnosis of conduct disorder were found to enhance
treatment retention. The most likely explanation for these
results was the signicantly strong relationship found
between these client characteristics and YDC involve-
ment. Consistent with other studies (Horwood & Fergus-
son 1998; Siegal et al. 1993; Wise et al. 2001), the present
study found a negative association between ADHD and
treatment retention.
TABLE 2: Relationships between the signicant factors associated with retention in the Youth Specialty Service alcohol and drug group, 20022004
(P-values) (n = 64)
Conduct
disorder
Cannabis
dependence
Youth drug
court
Legal
status
Ma ori and Pacic
Island ethnicity ADHD
ADHD 0.253 1.000 0.069 0.376 0.081
Ma ori and Pacic Island ethnicity 0.081 0.505 0.000* 0.024*
Legal status 0.000* 0.011* 0.000*
Youth drug court 0.002* 0.028*
Cannabis dependence 0.081
Conduct disorder
*P < 0.05. ADHD, attention decit hyperactivity disorder.
ADOLESCENTS WITH SUBSTANCE DEPENDENCE 441
2010 The Authors
International Journal of Mental Health Nursing 2010 Australian College of Mental Health Nurses Inc.
Having a past or current legal charge was another char-
acteristic found in the present study to signicantly
enhance treatment retention. Studies that have examined
the association between criminality and treatment reten-
tion have shown mixed results. A number of studies have
found a negative association between retention and crimi-
nal involvement (Feigelman 1987; Friedman et al. 1986;
Galaif et al. 2001), whereas other studies have found no
such relationship (Battjes et al. 2004; Schroder et al.
2009). However, it is important to note that the criminal-
ity focus has varied across studies. In the present study,
the signicant association found in this respect concerned
participants with past and current legal charges and YDC
involvement.
The most signicant nding in the present study was
the statistically-signicant relationship between YDC
involvement and treatment retention. When considered
together in a multivariate analysis, the YDC on its own
was the one signicant predictor of participant treatment
retention in the outpatient alcohol and drug therapy
group. No other studies were found that have focused on
YDC involvement and treatment retention. There has
been a number of other studies on court-mandated treat-
ment, and the ndings from the present study are consis-
tent with the ndings from these studies (Melnick et al.
1997; Orlando et al. 2003; Pompi & Resnick 1987).
More specically, it would appear that YDC involve-
ment enhanced the treatment retention of participants
with conduct disorder. This is a critical point to highlight,
given the frequently found negative association between
having a diagnosis of conduct disorder and treatment
retention (Horwood & Fergusson 1998; Siegal et al. 1993;
Wise et al. 2001). The ability of the YDC to inuence the
treatment retention of high-risk adolescents is of consid-
erable importance, as retention in treatment improves
treatment outcomes (De Leon et al. 1997; Hser et al.
2001; Stark 1992). Attendance over time facilitates the
engagement by experienced staff of adolescents with sig-
nicant personal vulnerabilities who typically nd it dif-
cult to engage in helping relationships.
We acknowledge the study limitations. These include
a relatively small sample size from a single-site mental
health service and the focus on one treatment modality,
thereby limiting the ability to generalize the ndings to
other population groups and treatments. However, a
number of similarities were noted between the charac-
teristics of the sample in the present study and those of
other retention study samples. Limitations associated
with retrospective le audits could include age of data,
as well as the accuracy, reliability, and availability of
data. Due to the YSS team comprising highly-skilled cli-
nicians and their use of a standardized comprehensive
assessment format and diagnostic system (DSM-IV), as
well as standardized assessment and clinical review pro-
cesses, these limitations were minimized. Therefore,
taking into account these limitations, and in the context
of an area of very limited research, this small study
should be considered an important step. As such, the
ndings from the present study expand the research evi-
dence on enhancing treatment retention for a vulnerable
and hard to engage adolescent group with complex
treatment needs.
In light of the limited adolescent treatment research
and the emerging evidence that factors inuencing treat-
ment retention can vary with treatment modalities (Galaif
et al. 2001), the ndings from the present study highlight
the need for further quantitative and qualitative research
on specic treatment modalities, including group therapy
approaches for adolescents with coexisting substance use
and mental health disorders. These ndings also add to
the growing evidence of positive outcomes for the role of
the YDC (Belenko & Logan 2003; Carswell 2004;
Henggeler 2007; Henggeler et al. 2006), thereby warrant-
ing further investigation of this intervention in enhancing
treatment retention among adolescents involved in crimi-
nal activity.
With respect to clinical and practice implications, the
ndings from the present study support alcohol and drug
group therapy as a cost-effective treatment modality
within outpatient service provision, including adolescents
with conduct disorder involved in the YDC. Lastly, they
provide important information for mental health nurses
who work in a variety of treatment settings and are
involved in assessment and treatment planning with ado-
lescents who experience a complex array of substance use
and coexisting mental health, education/vocational, and
social issues (Clancy et al. 2007).
ACKNOWLEDGEMENTS
This research was supported by the Canterbury District
Health Board and the National Addiction Centre
(Aotearoa New Zealand). The authors acknowledge the
support of the Youth Speciality Service staff, in particular,
Shirley McKinney, Nigel Loughton, and Lynne Yardley.
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