Teen Substance Abuse and the U.S. Mental Health Care System

Introduction: A Fractured System and Its Youngest Casualties

The mental health care system in the United States is historically fractured. A "silo"-based foundation precludes coordination among the varied and integral systems that, collectively, offer a range of services to treat the whole patient. The President's New Freedom Commission on Mental Health galvanized the mental health community around one goal: providing thorough, coherent, and appropriate treatment to Americans with mental health and substance abuse problems. Particularly in need of this form of coordinated care is one demographic: teens dealing with drug and alcohol abuse. The substance-abusing teen is caught between many cracks — between child and adult, and between the mental health system and juvenile justice. The ever-evolving mental health care system in the United States is restructuring to address this failure, approaching the teen through both SAMHSA and affiliated programs as well as through the Justice Department, using individual, family, and developmentally appropriate forms of treatment to offer a complete system of care.

An integral part of the mental health care system's provision for teens with drug and alcohol abuse is its relationship with the juvenile justice system. Frequently unacknowledged, the justice system plays a key role not only in treatment, but in the transmission of norms through the legal consequences associated with drug use and underage alcohol consumption.

Because substance abuse straddles the line between mental health and judicial concerns, it necessarily incorporates both systems. In its treatment of teens especially, the fine line between breaking the law and the biological, mental, and emotional reasons behind substance use places the issue under intense scrutiny.

The United States Department of Health and Human Services groups both substance abuse and mental health service provision together in its outreach programs, deliberately prioritizing treatment over punishment. Inherently, drug users and underage drinkers are breaking the law, but treatment is widely regarded as more critical than addressing the judicial infraction alone, given the physical, cognitive, and mental effects of abuse. To address cases of alcohol and drug abuse across all ages, SAMHSA instituted a nationwide, unified approach, including a Substance Abuse Treatment Facility locator, a Buprenorphine physician directory in many locations, and a range of self-tests to gauge drinking problems, prescription drug misuse, and illicit drug use.

For teens, many of these resources are adapted into youth-specific outreach programs with both family-oriented and individual-oriented models. The President's New Freedom Commission on Mental Health underscored the importance of treatment through the mental health community for substance abuse and also drove a systematic expansion to incorporate new science and ideas through the Mental Health Transformation State Incentive Grant Program (MHT-SIG), integration of Evidence-Based Practices through implementation resource kits, and child-oriented programs. However, two categories remain inadequately addressed in the strategic framework: those not clearly suffering from chemical or emotional imbalance — young people using drugs and thereby breaking the law — and those who understand right from wrong, have increased access to illegal substances, and are neither children nor adults: teens.

The Juvenile Justice System as De Facto Treatment Provider

Drug and alcohol abuse among the nation's adolescents is a story of struggle and reinvention — a demand for services and a necessary interaction with the law aimed at achieving safe and effective help for America's youth. "An untold story of drug and alcohol abuse among the nation's adolescents," said Laura Nissen, a social worker and grant recipient from the Robert Wood Johnson Foundation, "is the degree to which the juvenile justice system has become the de facto substance abuse treatment provider for young people in trouble with the law. As such, it struggles to reinvent itself to meet a rapidly growing demand for services that effectively help youths to change their lives."

Critics of the system argue that its largest problem is its inability to get help to those in greatest need — what the Robert Wood Johnson Foundation calls the divide between the "haves and have-nots." Estimates consistently suggest that of the youths in need of substance abuse treatment, only 1% receive appropriate help.

The consequences of leaving teens with drug or alcohol problems untreated are alarming, and this concern unites all sides of the treatment debate around the goal of the greater public good: youths abusing substances are three to four times more likely to end up in emergency departments, perform poorly in school despite their ability and encouragement, engage in disruptive behavior, and come into troubling contact with the law for reasons beyond substance abuse itself — including theft, violence, and truancy.

Despite their disregard for legal boundaries, many of these teens are not funneled directly into the juvenile justice system. Instead, they move between the mental health system and the justice system, since many youths with substance problems have co-morbid mental disorders.

Nissen identifies not only the co-occurring presence of mental health problems as a complicating factor in targeting, treating, sustaining, and preventing relapse among teens with substance abuse disorders, but also a set of local-level factors that further undermine systematic efforts. Among these are the high availability of drugs and underage access to alcohol, financial cutbacks that reduce school and community youth programs, an increasing scarcity of safe and supervised adolescent activities, economic instability in the family setting, and the ever-increasing reliance on the justice system to treat juveniles punitively in an effort to deter future offenses.

Further problems exist at the national level, where preoccupation with international affairs draws attention away from domestic concerns in an already polarized environment. These difficulties include rising rates of delinquency and the growing costs of substance abuse interventions, which intersect with efforts to maintain public safety and build strong schools.

In this state of turbid confusion, youths needing help are caught in the debate between service-focused and safety-focused perspectives. Without proper intervention, acceptance of emerging evidence-based practices, and accessible systems of help, many teens risk falling deeper into substance abuse, untreated mental disorders, addiction, and possible criminal activity to sustain their habits. "Providing substance abuse and related comprehensive services for juvenile offenders is a bargain compared to the long-term costs of the alternative," Nissen urges.

Escalating Incarceration and the Burden on Justice

The ties between the juvenile justice system and the mental health system are strong because teens interact with both, but the confusion of a two-part system with dual administration, competing recommendations, and differing goals prevents consistent progress. Within the Justice Department's data lies the troubling reality that many teens desperately in need of mental health support are instead being cycled through detention environments that only deepen their mental health struggles. By 1999, the U.S. Department of Justice was already noting a broad increase in juvenile involvement in the justice system due to substance abuse — specifically, a 144% increase in juvenile drug abuse violations and a 183% increase in drug abuse cases among previously processed juvenile offenders.

These teens either entered the juvenile justice system for the first time at increasingly high rates or were returned as repeat offenders. Not only are rates of interaction with the system rising, so are rates of incarceration. One study found that between 1990 and 2000, incarceration in drug-related cases rose by 291%.

Proponents of the justice system's approach argue that incarceration rates have increased in recent years partly because the system has become the front line for addressing treatment needs among teens dealing with substance abuse and addiction. Nissen suggests that this data reveals that "the juvenile justice system has found itself as the largest single referral source for youths in publicly funded substance abuse treatment."

SAMHSA concurs, lamenting that because consistent screening, assessment, and substance abuse treatment — including attention to co-occurring disorders — remains so fractured and uneven nationwide, the justice system is forced to bear the brunt. Without proper treatment, underage addicts and abusers are more likely to come into contact with the justice system than with available treatment resources. Even juvenile probation departments are feeling the pressure, citing substance abuse treatment programs as one of their four top expansion needs.

Ultimately, the system is overwhelmed. Before the expansion of the New Freedom Commission in 2001, the justice system was forced to operate as the nexus between juvenile justice and public health, mental health, and substance abuse programs. As a result, the juvenile justice system has been actively involved in expanding community-based treatment programs across the nation, particularly best-practice models aimed at future reform — including community assessment centers, juvenile drug courts (already in place in Florida, most notably Miami-Dade), integrated case management, graduated sanctions, and strength-based approaches. These actions not only revitalized local capacity but also attracted national attention, propelling the system toward a more comprehensive and integrated network of care.

Conclusion: Toward an Integrated Web of Care

Teens with drug and alcohol problems are in a systematic Catch-22: they are almost adults, but still children. Caught between two ages, they are also caught between two systems — that of Juvenile Justice and that of Mental Health. As a result, the mental health care system in America is structured to include substance abuse treatment and has made adolescent abuse a particular focal point. The mental health care system is currently in a state of transition, as fostered by the President's New Freedom Commission on Mental Health, that shifts the structure from singular, silo-based treatment opportunities to an integrated web of approaches that treat the whole teen — from family to individual, from addiction to underlying disorder.

With the support of foundations like the Carter Center and the Robert Wood Johnson Foundation, communities nationwide are able to translate the President's challenges into action, providing a coherent and complete system of treatment for teens with substance abuse problems within the broader mental health care system.