ADOLESCENTS AND COLLEGE STUDENTS

Helping Students, Educators, and Administrators Understand Substance Use Disorders and Overcome Stigma and Discrimination

After growing up a fairly "normal" kid, my focus shifted from school, family, sports, and church to going to parties and getting drunk when I turned 16. My alcoholism and drug use led me down a road to drop out of two colleges, quit playing sports, and separate myself from all the good people in my life who cared about me. Several years later, I reached out to my family for help. They found a place that was a non-traditional treatment program and truly helped me save my life. Things have changed since then. Not only did I clean myself up, but each day gets better. I decided that I wanted to give back and help others and started working in the drug prevention and treatment field. This has become my passion, from working with kids and adults to educating elected officials and community leaders. I have communicated anti-drug messages to millions of people through the media. I have even published a book with the hope of helping even more people escape the downward spiral of substance abuse or avoid it altogether. Lucas A. Catton Recovery Advocate		Substance use disorders affect millions of Americans, many of whom are under 21 years old. Approximately 8.8 percent of people aged 12 to 17 (or 2.2 million) and 21.2 percent of people aged 18 to 25 (or 6.8 million) suffer from substance dependence or abuse.1 Overall, as many as 74 percent of Americans in general say that addiction to alcohol has had some impact on them at some point in their lives, whether it was their own personal addiction, that of a friend or family member, or any other experience with addiction.2 Substance use disorders can have an enormous impact on young adults and college students, making it difficult for them to relate to their peers and have successful academic careers. But young people who receive treatment and enter recovery can go on to lead successful lives. Substance use disorders involve the dependence on or abuse of alcohol and/or drugs. Dependence on and abuse of alcohol and illicit drugs, which include the nonmedical use of prescription drugs, are defined using the American Psychiatric Association's criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Dependence indicates a more severe substance problem than abuse; individuals are classified with abuse of a certain substance only if they are not dependent on the substance.3 For more information on the criteria used in defining dependence and abuse, consult the 2004 National Survey on Drug Use and Health, which is available on the Web at www.oas.samhsa.gov/nsduh.htm. Much has been written about substance abuse, dependence, and addiction; many studies have used different terminology to explain their findings. To foster greater understanding and avoid perpetuating the stigma associated with these conditions, the phrase "substance use disorders" is used as an umbrella term to encompass all of these concepts.

Adolescence and young adulthood is a time of growth and experimentation, and many young people experience a curiosity or pressure to use alcohol and/or drugs. The 2004 National Survey on Drug Use and Health:  National Findings, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), found:

• Among youths ages 12 to 17, 10.6 percent (2.7 million) are current illicit drug users.⁴
• Of young people ages 12 to 17 who said they currently used illicit drugs, 7.6 percent (1.9 million) used marijuana, 0.5 percent (126,000) used cocaine, 1.2 percent used inhalants (312,000), and 0.8 percent (211,000) used hallucinogens.⁵
• Among youths ages 12 to 20, 19.6 percent (nearly 7.4 million) were binge drinkers and 6.3 percent (2.4 million) were heavy alcohol drinkers.⁶ Binge use is defined as 5 or more drinks on the same occasion at least once in the past 30 days. Heavy use is defined as 5 or more drinks on the same occasion on at least 5 different days in the past 30 days. A "drink" is defined as a can or bottle of beer, a glass of wine or a wine cooler, a shot of liquor, or a mixed drink containing liquor.⁷
• Young adults aged 18 to 22 enrolled full time in college were more likely than young adults not enrolled full time to use alcohol, binge drink, and drink heavily. Within the past month, 62.4 percent of full-time college students (or 5 million) reported using alcohol, compared with 55.7 percent of people of the same age who were not full-time students (or 7 million).⁸
• In 2004, the rate of current illicit drug use among full-time college students was 20.2 percent (1.6 million people), which is lower than the rate among other people aged 18 to 22, including part-time students, students in other grades, and non-students.⁹

Additionally, SAMHSA found that 2.2 million youths aged 12 to 17 (or 8.8 percent) used prescription drugs nonmedically in 2004.¹⁰

High school and college students with substance use disorders are different from their adult counterparts, with their problems stemming from various causes. Stronger peer influences, physical and mental developmental issues, the presence of other disorders, and diverse value sets all need to be considered when treating youth with substance use disorders. Because of this, young people in treatment for substance use disorders need more specialty support than others.¹¹

Treating Substance Use Disorders

Like other chronic disorders that affect young people, substance use disorders are medical conditions that can be treated.^{12, 13} A major study published in the Journal of the American Medical Association in 2000 is one of several that demonstrate the success of treatments for substance use disorders.¹⁴ In addition, the treatment of both mental and substance use disorders can help prevent the exacerbation of other health problems, including cardiac and pulmonary diseases, according to SAMHSA's Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Health Disorders in 2002.¹⁵ People with both a substance use disorder and a mental health disorder at the same time are said to have a co-occurring disorder.

Admissions to treatment programs among youth have risen. Between 1992 and 2002, the number of adolescents aged 12 to 17 admitted to treatment increased 65 percent, compared to the number of people of all ages admitted to treatment, which increased 23 percent in the same period.¹⁶

Treatment Programs Designed for Youth

There is no one method of treatment that is best for youth. To increase successful outcomes, treatment programs should be specifically designed to meet the needs of young people who suffer from substance use disorders.^{17, 18} Distinctive programming options for youth can include:  family programming, psychiatric services, recreational activities, coordination of care, and other health care services. By providing flexible and available options, communities can help more young people with substance use disorders find a recovery path that is better suited to their individual needs.¹⁹

One barrier to achieving recovery is the limited availability of treatment programs designed particularly to meet young people's intricate needs.²⁰ The reality is that teens with substance use disorders have generally been overlooked.²¹ Communities can help reduce this barrier by promoting progressive assessment systems; providing additional funding to increase treatment capacity; implementing ongoing checkups to ensure a supportive recovery environment and encourage early re-intervention if necessary; and improving outreach to schools and health care professionals.²²

Specifically, new research has identified nine key elements of effective substance use disorder treatment for adolescents:

1. Assessment and matching - Assessment helps determine if the youth's needs match the services available, as well as the level of treatment intensity needed.
2. A comprehensive and integrated treatment approach - An effective treatment plan should address the adolescent's problems broadly, rather than focus solely on the substance use disorder.
3. Family involvement in treatment - Engaging parents or other family members increases the likelihood that a teen will stay in treatment and that progress will be sustained after the treatment program has ended.
4. Developmentally appropriate programs - Adolescent programs cannot simply be modified adult programs. Programs must address the many contexts that shape the teen's environment, such as school, recreation, peers, welfare, and medical care.
5. Engaging and retaining teens in treatment - Many teens who enter treatment do not think they have a problem. Finding ways to make treatment resonate with adolescents can make them more motivated to change behavioral patterns.
6. Qualified staff - To effectively address the unique needs of adolescents with substance use disorders, treatment programs should engage staff with specialized training and experience in diverse areas.
7. Gender and cultural competence - There are significant differences between males and females who have substance use disorders. Programs should recognize both gender and cultural differences in their treatment approach.
8. Continuing care - Adolescents' progress in treatment can quickly vanish if they do not have consistent support at home and in the community. Continuing care can include relapse prevention training and follow-up plans.
9. Treatment outcomes - Evaluations of treatment programs can offer crucial, in-depth insight into their effectiveness.²³

These recommendations are from a manual titled Treating Teens:  A Guide to Adolescent Drug Programs, published by Drug Strategies, a nonprofit research institute that promotes effective approaches to the nation's drug problems. This can be ordered through the organization's Web site at www.drugstrategies.org/teens/indexbottom.html. Also included on the Web site are listings of youth-centered programs and research about adolescents with substance use disorders.

Treatment and recovery programs tailored to meet young people's needs make a considerable difference in treatment outcomes. For example, a national study of treatment programs for adolescents in four U.S. cities found a decrease in drinking, illicit drug use, and criminal involvement among those who obtained treatment-in addition to better psychological and behavioral adjustments and improved school performance.²⁴ Family member involvement is also crucial to a young person's recovery because of their possible role in the origins of the problem and their ability to change the youth's living environment.²⁵

Counselors who want to help improve treatment for young people can become a member of a national learning community for the improvement of the field. The Society for Adolescent Substance Abuse Treatment Effectiveness, a SAMHSA program, links researchers and practitioners interested in improving the practice of adolescent treatment. For more information about how to get involved, please see the resources section at the end of this document.²⁶

Defining Stigma's Impact on Young People

Even though substance use disorders are medical conditions, and treatment is highly effective, stigma and discrimination can plague young people. Despite the effectiveness of treatment, stigma and discrimination present a barrier for people with substance use disorders who wish to access treatment. They also inhibit the ongoing recovery process. Stigma detracts from the character or reputation of a person. For many people, stigma can be a mark of disgrace.²⁷ In 2004, 21.6 percent of the 1.2 million people who felt they needed treatment but did not receive it indicated it was because of reasons related to stigma.²⁸

When I started doing drugs, my life as I knew it came to a sudden halt. Since I was 13 years old, drugs robbed me of having a chance to learn how wonderful life can be. My dad found me a rehabilitation program, and while in the program, I finally realized that there was actually a solution to my immediate problem-there is life after drugs! I learned to live without drugs. Many do it. Many fail. You have to look at it as a fight for your life because that's what you are fighting to get back. You have to know that you are in control of your life. Being a heroin addict is not what I was destined to be. I just got sidetracked along the way. Now, I am happily married and work to help others fight this difficult battle. Erica Catton Senior Director for Administration

Stigma directed against young people with substance use disorders can occur when a young person's own family has a negative perception of the teen's disorder. For example, one study found that many parents are less willing to tell people in a group setting that their child uses illegal substances than to admit a child has depression or attention deficit disorder.²⁹

Discrimination, on the other hand, is an act of prejudice. It can include denying someone employment, housing, accommodation, or other services based on the revelation that the person is receiving treatment or has previously been treated for a substance use disorder.³⁰ Discrimination ignores the fact that substance use disorders can strike people of any age, gender, race, ethnicity, education level, and geographic area.³¹

Sometimes fear of discrimination can also act as a barrier to seeking treatment. Many young people fear disclosing substance use because of the potential legal consequences that may stem from admitting illegal drug or alcohol use. However, this delay in revealing a substance use disorder can actually lead to encounters with the legal system. Studies have shown that if families openly discuss their child's substance use without fear of any legal ramifications, more may be willing to share their story.³²

Discrimination can also continue to haunt young people long after they have begun their path to recovery. Some policies have delayed and/or denied financial aid for students who have been convicted of a misdemeanor or felony drug offense. Nearly 130,000 students applying for financial aid have been denied assistance because of such policies.³³ According to a survey for Faces & Voices of Recovery, 52 percent of American adults surveyed believe this type of policy is problematic.³⁴ Recently, President Bush took action to fight this type of discrimination by signing a bill that will help people with prior drug convictions regain eligibility for federal student financial aid.³⁵

More than any other group, young people are exposed to pressure to experiment with alcohol and
drugs-but staff members in schools and health care settings are sometimes hesitant to openly confront young people with substance use disorders because of the potential damage of stigma, uncertainty about the severity of their disorder, and a lack of resources to help the students.³⁶ Focusing specifically on peer influences during treatment and on educational programming for youth can help them better understand substance use disorders.³⁷

The Importance of Educators

Fortunately, teachers, school administrators, and family members can have a positive impact by helping young people obtain treatment and eroding the societal stigma against youth in recovery by celebrating their successes. In fact, one-fifth of public school students received some type of school-supported mental health services in the year prior to a recent survey.³⁸ Teachers, coaches, and school nurses in particular have a valuable role in recognizing the symptoms of substance use disorders, which could include:

• Strained relationships
• Legal problems
• Money problems
• Motor vehicle collisions related to substance use or "driving while intoxicated" (DWI) citations
• Health problems
• School/work problems
• Depression/suicide attempts^{39, 40}

Education also is needed to ensure the public understands that trauma can be a factor in substance use. In turn, this outreach can assist victims of traumatic events. Among students from 7th to 12th grade in New York who knew someone killed or injured in the 9/11 terrorist attacks, 40,000 more students used alcohol, 24,000 more students used an illicit drug or a prescription drug nonmedically, and 15,000 more students sought help for alcohol or other drug problems. This underlines the importance of education about substance use disorders.^{41, 42}

Since school nurses participate in many aspects of prevention activities in schools, they may appear more approachable to students who face substance use disorders. In a recent survey, school nurses said they spent approximately a third of their time providing mental health services.⁴³ They can recognize the symptoms and provide counsel on treatment options and methods of care.⁴⁴

College administrators also can play an important role. According to a national survey, nearly 31 percent of college students met the accepted criteria for a diagnosis of alcohol abuse.⁴⁵ Many schools have "sober" or "wellness" floors, and to help students in recovery, some schools have set up specific "Recovery Dorms" to help them on their path through recovery. For example:

• At Case Western University, students have the option to reside in a substance-free, recovery-based house. This housing community assists students in developing healthy life skills while abstaining from alcohol and drugs. Residents also develop their own plans for continuing their recovery along with other personal health objectives. Students are encouraged to support each other by creating a safe place to live, study, and socialize without using substances.⁴⁶
• Rutgers University provides recovery housing where students can live with others who are in recovery to receive emotional, social, and environmental support. Emphasis is placed on school goals and socializing without alcohol and drugs. The recovery housing is confidential and anonymity is protected. The program has been in effect since 1988 and was developed by students in recovery.⁴⁷
• The StepUP Program at Augsburg College provides ongoing support to students in recovery who are willing and able to progress toward an academic degree through separate chemical-free housing, weekly individual support meetings, and community activities.⁴⁸

Other resources that help educators support students with substance use disorders are:

• The Office of Safe and Drug-Free Schools (OSDFS), a division of the U.S. Department of Education, provides financial assistance to educators for prevention activities and programs that promote the health and well being of students in elementary and secondary schools, as well as colleges and universities.
• The National Student Assistance Association (NSAA), the national membership organization of student assistance professionals, offers early intervention and training on alcohol- and drug-related problems in thousands of schools across the country. It also provides a broad range of prevention and support services for students affected by substance use disorders-either their own or that of a family member. For complete contact information, please see the resources listed at the end of this document.
• The Association of Recovery Schools (ARS) combines the support of students, secondary and post-secondary schools, and professionals to help students in recovery from substance use disorders. ARS also advocates for strengthening and expanding both high school and college programs committed to both academic and recovery goals.⁴⁹
• The March/April 2004 issue of Counselor Magazine:  The Magazine for Addiction Professionals offers insight and tips for those working with young people with substance use disorders and helping them obtain specialized treatment and recovery. This issue can be accessed on the Web at www.counselormagazine.com/.

Many communities have started anti-drug parent peer groups and anti-drug coalitions that are bringing together new allies-such as schools, businesses, faith communities, and youth groups-to help stop drug use and underage drinking in young people.⁵⁰ Community coalitions are an excellent way to focus on issues particular to youth and college students. For more information on how to join or develop a coalition in your community, please refer to the "Building Your Recovery Month Coalition or Community Team" document in the "Resources" section of this planning toolkit.

Making a Difference:  What Can I Do?

If you are a teacher, school administrator, or someone who spends time with young people or college students regularly, there are many ways you can help them on a path of recovery, starting with overturning misconceptions surrounding substance use disorders:

1. Learn about recovery schools and how to create one in your school district or university. Please visit the Association of Recovery Schools Web site at www.recoveryschools.org for more information.
2. Become a mentor or enlist a trained adolescent to mentor another youth with a substance use disorder. In addition to providing educational support, a mentor can provide advice, emotional support, and a caring relationship.⁵¹ Formal mentoring programs have become extremely popular, with 4,500 organizations that support mentoring activities, according to the National Mentoring Database.⁵² Mentoring relationships should be integrated into more comprehensive treatment to best meet the needs of at-risk youth.⁵³
3. Offer student assistance programs, such as educational support groups, treatment referrals, and counseling, to intervene and support both students with substance use disorders and students whose parents or siblings suffer from them.
4. Provide strong drug education programming from preschool through 12th grade, molded to each age group, culture, and the sophistication level of the students. Develop portions that specifically address stigma and discrimination. Tell students that substance use disorders are treatable, just like any other chronic disease. Take notice of the myths students believe about alcohol and drug use.
5. Develop and enforce substance-free policies.
6. Research various efforts in your community to determine if committees exist to improve the amount, coordination, and quality of services offered to youth with substance use disorders. Develop a strategic plan for making changes to build a more effective system.⁵⁴
7. Create an environment that engages parents and guardians in each youth's education, and specifically in matters dealing with substance use.
8. Become a meeting place for 12-step fellowships designed for youth.⁵⁵
9. Create a recovery floor or recovery dorm on campus.

Making a Difference:  How Can I Contribute to Recovery Month?

Parents, teachers, coaches, counselors, school administrators, and other people who interact with young people can use the following tools to contribute to the 17th annual National Alcohol and Drug Addiction Recovery Month (Recovery Month) in September. The theme for this year's Recovery Month is "Join the Voices for Recovery:  Build a Stronger, Healthier Community." Here are some ideas you may consider:

1. Invite youth who have shown long-term commitment to their recovery to share with fellow students their stories of treatment and the hope and promise their recovery gives them for the future. Ask them to present their stories at an assembly or to other schools or write an article for the school paper. Consult each school and district's guidelines regarding the sharing of sensitive and personal information by the students. If students are not of legal age, obtain the consent of the parent or legal guardian before publishing the article or allowing the student to present.
2. Raise awareness among parents, guardians, and young people in your community by educating them about substance use disorders, treatment effectiveness, and recovery. You can do this by setting up educational tables or booths at shopping centers, grocery stores, libraries, county or state fairs, movie theaters, or other areas that are frequented by young people and their families.
3. Establish a drug-free day at a school or youth center. You can make the drug-free day a launching pad for an entire drug-free initiative in your school. Also, try to make the youth center easily accessible during students' free periods and after school.
4. Role play in health class so students can experience what it would feel like if they had a substance use disorder and the issues they would face, such as stigma and discrimination.
5. Create a task force in your community or develop a larger initiative to dispel myths and educate others that substance use disorders are treatable conditions and recovery is possible. Education and community outreach can help reduce stigma and discrimination and encourage those in need of services to seek help.
6. Build a coalition by working with local youth-focused organizations to develop broader initiatives for Recovery Month. Tips for creating a local community coalition are located in the "Resources" section of this planning toolkit.
7. Plan a concert or rally with local musicians. Have them educate young people about substance use disorders.
8. Sponsor a health and community fair with other schools and youth organizations in your area. Set up booths for local treatment centers specifically focused on young people with substance use disorders. Provide information on how your school works to prevent substance use disorders and the programs it provides to support young people in recovery, such as student assistance programs. Invite local politicians to speak about substance use disorders and discrimination. If your community already sponsors a fair of this kind, contact the organizers about including your organization in the festivities.

For additional National Alcohol and Drug Addiction Recovery Month (Recovery Month) materials, visit the Recovery Month Web site at www.recoverymonth.gov or call 1-800-662-HELP.

For additional information about substance use disorders, treatment, and recovery, please visit SAMHSA's Web site at www.samhsa.gov.

Youth and College Student Resources

This list is not exhaustive of all available resources. Inclusion does not constitute endorsement by the U.S. Department of Health and Human Services, the Substance Abuse and Mental Health Services Administration, or its Center for Substance Abuse Treatment.

SOURCES

¹  Results From the 2004 National Survey on Drug Use and Health: National Findings. DHHS Publication No. (SMA) 05-4062. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, September 2005, pp. 70, 268.
²  Rivlin, A., presentation at Community Anti-Drug Coalitions of America Science Writers' Briefing, Pittsburgh, PA, September 29, 2005, slide #4. Survey data collected August 2005 by Peter D. Hart Research Associates.
³  Results From the 2004 National Survey on Drug Use and Health: National Findings, pp. 155, 160.
⁴  Ibid, p. 14.
⁵  Ibid.
⁶  Ibid, p. 25.
⁷  Ibid, p. 23.
⁸  Ibid.
⁹  Ibid.
¹⁰  Ibid.
¹¹  Treatment Improvement Protocol (TIP) Series 32. DHHS Publication No. (SMA) 99-3283. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1999, section entitled "Executive Summary and Recommendations."
¹²  Pathways of Addiction: Opportunities in Drug Abuse Research. National Academy Press. Washington, D.C.: Institute of Medicine, 1996, section entitled "Executive Summary," p. 9.
¹³  Kleber, H.D., O'Brien, C.P., Lewis, D.C., McLellan, A.T. "Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation." Journal of the American Medical Association, 284 (13), Chicago, IL: American Medical Association, October 4, 2000, p. 1689.
¹⁴  Ibid.
¹⁵  Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Health Disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2002, p. ix.
¹⁶  The DASIS Report: Adolescent Treatment Admissions: 1992 and 2002. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, October 15, 2004, p. 1.
¹⁷  Treatment Improvement Protocol (TIP) Series 32, section entitled "Executive Summary and Recommendations."
¹⁸  Adolescent Substance Abuse: A Public Health Priority. Providence, RI: Physician's Leadership on National Drug Policy, Center for Alcohol and Addiction Studies, Brown University, August 2002, p. 32.
¹⁹  Ibid.
²⁰  Treatment Improvement Protocol (TIP) Series 32, section entitled "Executive Summary and Recommendations."
²¹  Treating Teens: A Guide to Adolescent Drug Programs. Washington, D.C.: Drug Strategies, 2003, p. 1.
²²  Adolescent Substance Abuse: A Public Health Priority, p. 32.
²³  Treating Teens: A Guide to Adolescent Drug Programs, pp. 4-11.
²⁴  Hser, Y., Grella, C., Hsieh, S., Anglin, M.D. "An evaluation of drug treatment for adolescents in four U.S. Cities." Archives of General Psychiatry, 58, July 2001, pp. 689-695.
²⁵  Treatment Improvement Protocol (TIP) Series 32, section entitled "Executive Summary and Recommendations."
²⁶   Muck, Randolph D., M.Ed. and Butler, Jutta, B.S. "Adolescent Treatment Excellence: Connect to a Growing Movement." Counselor, The Magazine for Addiction Professionals, 5(2), February 2004, pp. 12-17.
²⁷  Faces & Voices of Recovery Public Survey. Washington, D.C.: Peter D. Hart Research Associates, Inc., and Coldwater Corporation, May 4, 2004, p. 2.
²⁸  Results From the 2004 National Survey on Drug Use and Health: National Findings, pp. 78-79.
²⁹  Lambert, Lisa. Substance Use in Children and Adolescents with Mental Health Needs. Boston, MA: Parent/Professional Advocacy League, September 2004, p. 2.
³⁰  Concurrent Disorders: Beyond the Label. An Educational Kit to Promote Awareness and Understanding of the Impact of Stigma on People Living with Concurrent Mental Health and Substance Use Problems. Toronto, ON: Centre for Addiction and Mental Health, 2005, slide #7.
³¹  Results From the 2004 National Survey on Drug Use and Health: National Findings, pp. 67-72.
³²  Lambert, Lisa. Substance Use in Children and Adolescents with Mental Health Needs, pp. 2, 5.
³³  Higher Education Act (HEA) Provision Denying or Delaying Federal Financial Aid for Students Convicted of Drug Offenses. New York: Legal Action Center, March 24, 2005, p. 1.
³⁴  Faces & Voices of Recovery Public Survey, p. 2.
³⁵  United States. Cong. Senate. 109th Congress, 2nd Session. S. 1932, Deficit Reduction Act of 2005 [introduced in the U.S. Senate; 27 October 2005]. 109th Congress. Congressional Bills, GPO Access. 10 February 2006 http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_bills&docid=f:s1932enr.txt.pdf.
³⁶  Adolescent Substance Abuse: A Public Health Priority, p. 32.
³⁷  Ibid, p. 34.
³⁸  Foster, S., Rollefson, M., Doksum, T., Noonan, D., Robinson, G., Teich, J. School Mental Health Services in the United States: 2002-2003. DHHS Publication No. (SMA) 05-4068. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2005, p. 2.
³⁹  A Family Guide: Is There A Substance Abuse Problem in Our Family? Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Clearinghouse for Alcohol and Drug Information Web site: http://ncadi.samhsa.gov/nongovpubs/phd757/#PROBLEM, section entitled "Do We Have a Problem in Our Family?" Accessed September 16, 2005.
⁴⁰  Beers, Mark, M.D. "Drug and Substance Use and Abuse." Whitehouse Station, NJ: Merck Manual Second Home Edition, 2004-2005, "Problems in Adolescents" chapter, section entitled "Children's Health Issues."
⁴¹  New York State Office of Alcoholism and Substance Abuse Services, 2005.
⁴²  Policy Brief: Trauma and Substance Use. Washington, D.C.: National Association of State Alcohol and Drug Abuse, September 2005, pp. 1, 2.
⁴³  Foster, S., et. al. School Mental Health Services in the United States: 2002-2003, p. 2.
⁴⁴  Issue Brief: School Health Nursing Services Role in Health Care. National Association of School Nurses Web site: www.nasn.org/briefs/2003briefsubstance.pdf. Accessed September 19, 2005.
⁴⁵  Knight J.R., et. al. "Alcohol abuse and dependence among U.S. college students." Journal of Studies on Alcohol, 63, May 2002, pp. 263-270.
⁴⁶  "Case Recovery House." Case Western University Web site: www.case.edu/stuaff/mind-body/recovery/recovery-house.html. Accessed September 19, 2005.
⁴⁷  Recovery Housing." Rutgers, The State University of New Jersey Web site: http://health.rutgers.edu/adaps/recoveryhousing.htm. Accessed September 19, 2005.
⁴⁸  "The StepUP Program at Augsburg College." Augsburg College Web site: www.augsburg.edu/stepup/#. Accessed November 15, 2005.
⁴⁹  "Mission." Association of Recovery Schools Web site: www.recoveryschools.org/mission.htm. Accessed September 19, 2005.
⁵⁰  Keeping Your Kids Drug Free: A How-to Guide for Parents and Caregivers. Washington, D.C.: White House Office of National Drug Control Policy, National Youth Anti-Drug Media Campaign, November 1, 2001, p. 45.
⁵¹  Treatment Improvement Protocol (TIP) Series 32, section entitled "Chapter 7."
⁵²  Rhodes, J.E. Stand by Me: The Risks and Rewards of Mentoring Today's Youth. Cambridge, MA: Harvard University Press, 2002.
⁵³  DuBois, David L., Ph.D. and Silverthorn, Naida, Ph.D. "Natural Mentoring Relationships and Adolescent Health: Evidence from a National Study." American Journal of Public Health, 95 (3), March 2005, p. 518.
⁵⁴  Nissen, Laura Burney, Ph.D. "Reclaiming the Futures of Teens in the Juvenile Justice System: A New Vision for Success." Counselor, The Magazine for Addiction Professionals, 5(2), April 2004, pp. 69-73.
⁵⁵  Malignant Neglect: Substance Abuse and America's Schools. New York: National Center on Addiction and Substance Abuse, Columbia University, August 1997, pp. 7-8.