Treatment of Adolescents
with Substance Use Disorders
Chapter 2 -- Tailoring Treatment to the Adolescent's Problem
Determining the appropriate level of treatment for an adolescent is no small task. In addition to factors normally considered when placing an individual in treatment for a substance use disorder, such as severity of substance use, cultural background, and presence of coexisting disorders, treatment programs must also examine other variables such as age, level of maturity, and family and peer environment when working with adolescents. Once these factors are assessed and the problems are understood, the treatment program can then match the adolescent with the proper type of treatment.
Understanding the Problem
The Severity Continuum
Researchers and treatment professionals have found it useful to characterize adolescent substance use behavior on a continuum of severity. The Classification of Child and Adolescent Mental Diagnoses in Primary Care (American Academy of Pediatrics, 1996) views substance use disorders as occurring on a continuum that extends from the developmental variation of experimentation with substances through problem use, to the disorders of abuse and dependence. The degree of substance involvement is an important determinant of treatment, as are any coexisting disorders, the family and peer environment, and the individual's stage of mental and emotional development. This information should be used to refer to the appropriate treatment.
It is useful to consider a substance use continuum with these six anchor points (Knight, in press):
- Abstinence
- Use: Minimal or experimental use with minimal consequences
- Abuse: Regular use or abuse with several and more severe consequences
- Abuse/Dependence: Regular use over an extended period with continued severe consequences
- Recovery: Return to abstinence, with a relapse phase in which some adolescents cycle through the stages again
- Secondary Abstinence
Treatment interventions fall along a continuum that ranges from minimal outpatient contacts to long-term residential treatment; all levels of care should be considered in making an appropriate referral (see Figure 2-1). Any response to an adolescent who is using substances should be consistent with the severity of involvement. Although no explicit guidelines exist, it stands to reason that the most intensive treatment services should be devoted to youths who show signs of dependency--that is, a history of regular and chronic use, with the presence of multiple personal and social consequences and evidence of an inability to control or stop using substances.
Factors Affecting Treatment Placement
Developmental Stages
Youth treatment providers should be sensitive to the developmental differences among adolescents and make the necessary adjustments to accommodate such differences. The treatment of a 13-year-old should not be identical to that of an 18-year-old. Figure 2-2, below, provides some general developmental features that tend to distinguish younger from older adolescents, as well as some guidelines pertaining to professional behavior and attitudes that reflect these differences. This is an adaptation of the Adolescent Development Table created by the Advisory Council of Adolescent Health and the Colorado Department of Public Health and Environment (1998).
Ethnicity
Understanding substance use and abstinence within the client's cultural context will flow most naturally from a broad base of knowledge about the client. The provider will be better prepared, however, with some specific information about that culture. First, the provider should find out if the client's parents are first generation immigrants. Any intervention with a teenager from an immigrant family will be enhanced by the provider's knowledge about the background of the youth and his family. Norms, values, and health beliefs may differ across cultures, and these factors can have a significant impact on treatment; for example, people from some cultural groups may see therapy as invasive, and others may want the extended family included in family therapy sessions.
Programs to which non-English speakers are referred should be able to provide services in the language of clients and their families. This includes bilingual staff and written materials on topics ranging from program policies to bibliotherapy (a self-learning procedure by which the client reads and studies appropriate self-help material). Cultural competence is far more than bridging language barriers, however.
Treatment settings and providers should incorporate cultural traditions (e.g., special holidays) into their treatment regimens. Also, cultural concerns should be addressed in clinical staff meetings, through interagency collaborations, and at all levels of the organization in order to enhance cultural sensitivity and competence.
Gender
Many gender-related factors have a bearing on the extent of the adolescent's involvement in treatment and on the treatment approach that is most likely to be effective and appropriate. Adolescent females, for example, may need more attention in regard to family problems; it has been found empirically that female adolescent substance users have often experienced severe parental rejection and sexual or physical abuse (Gross and McCaul, 1990-1991). Family dysfunction, therefore, may be a more critical component and indicator of substance use disorders in adolescent females and may require more attention in treatment. Females also often need highly specialized services, such as those for pregnant and parenting young women. Intervention for domestic abuse also may be required for females.
Coexisting Disorders
A coexisting disorder (also called a dual diagnosis) most commonly refers to the coexistence of a substance use disorder and a psychiatric disorder. Adolescents with substance use disorders are much more likely than their abstinent peers to have such psychiatric disorders (Kleinman et al., 1990; National Institute on Drug Abuse [NIDA], 1998). The behavioral or mental conditions of childhood most often associated with substance use disorders are conduct and oppositional disorders, attention deficit/hyperactivity disorder (AD/HD), affective disorders (unipolar and bipolar depression), and anxiety disorders, including posttraumatic stress syndrome from sexual or physical abuse (NIDA, 1998).
There is growing evidence that the presence of conduct and oppositional disorders in childhood are particularly predictive of later adolescent substance use (Crowley and Riggs, 1995). Also, the coexistence of more than one childhood psychiatric disorder greatly enhances the risk for later substance use. In particular, the coexistence of externalizing (behavioral) and internalizing (emotional) disorders constitutes a high risk for substance use (NIDA, 1998). Other disorders associated with a higher risk for substance use include learning disorders (Latimer et al., 1997) and eating disorders (Harrison and Hoffman, 1989). A complete assessment--including a lifetime diagnostic evaluation, treatment trials, and clinical progress over time--will help to establish whether an adolescent has such a disorder in addition to the substance use disorder.
Coexisting disorders can interfere with treatment for substance use disorders, and if they are left untreated, the client is more vulnerable to relapse. The ability of treatment staff members to identify and either treat these disorders or provide appropriate referrals for treatment can help guard against this possibility.
For example, a consultant may be needed to conduct mental health assessments and to evaluate the need for pharmacotherapy, and the adolescent may be referred to an outpatient mental health program. It is important for staff members to be aware of the distinctive problems of the young person who is diagnosed with substance use and other disorders. It is vital for the treatment team to perform the functions of gathering and sharing clinical data, formulating a diagnosis, and planning intervention for these clients with coexisting disorders.
To treat adolescents with coexisting disorders, substance use disorder treatment providers and mental health providers must develop programs together and ensure that staff members are cross-trained. Each program can maintain its individuality, but services should be provided in one location and arrangements made to accommodate each program's requirements. (see Chapter 7 for more discussion on youths with coexisting disorders)
Pharmacotherapy
When treating adolescents with coexisting disorders, it is paramount for programs to consider the client's need for appropriate medication. For example, substance use disorder treatment facilities should suspend "no-medication" rules for depressed adolescents who have been prescribed antidepressants. Of course, medication, whether for detoxification or the treatment of psychiatric disorders, must be prescribed and dispensed under the direction of a physician. It is recommended that youths with coexisting disorders receive supplemental counseling regarding their psychiatric medication. Discontinuation of any medication is a decision that should be made only in consultation with a medical doctor. Abrupt discontinuation of certain psychotropic medications can be extremely dangerous. However, if the patient continues to use illicit substances, the medication regimen should be reassessed. The relative risks and benefits of a temporary discontinuation of pharmacotherapy (until abstinence is achieved) should be carefully considered.
The use of stimulant medication (for AD/HD) or minor tranquilizers (for anxiety disorders) is still controversial for adolescents with substance use disorders. Some of these medications have significant potential for addiction or abuse. Nonaddictive medications, as well as behavioral and psychotherapeutic interventions, should be considered before medications with the potential for addiction or abuse are prescribed. For cases in which these medicines must be used, regular urine testing for substances of abuse, and/or serological determination of therapeutic drug levels, is usually indicated.
Family Factors
The risk of adolescent health and behavioral problems, including substance use disorders, rises with lack of parenting skills, high levels of family conflict, and poor bonding between parents and children. Recent national data of adolescent health identified the importance of connectedness to parents and family as a key factor that protects adolescents, in a cross-cutting manner, from many problem behaviors, including substance use (Resnick et al., 1997). When parents have unclear expectations of their children's behavior, apply discipline inconsistently, or fail to reward their children for positive or desirable behavior, their children's risk for substance use disorders increases. Both permissiveness and excessively harsh parenting practices can lay the groundwork for adolescent behavioral problems and substance use disorders (Patterson, 1982).
An adolescent's family also provides a crucial background to the child's substance use for reasons both genetic and environmental. Children of parents with substance use disorders are at increased risk of developing substance use disorders themselves compared with children with nonsubstance-abusing parents (Cotton, 1979; McGue et al., 1992; Schuckit, 1987). An assessment of the family's history of substance use will provide some insights into the possible role of genetic factors in the family lineage. Perhaps even more relevant to the adolescent patient's immediate concern is the need to evaluate the family environment for risk and protective factors that pertain to substance use. Salient environmental factors include parental modeling of substance use behaviors, permissive parental attitudes toward substance use, and substance use by siblings (Hawkins and Fitzgibbon, 1993).
Clinicians working with adolescents with substance use disorders should consider the degree of stability and commitment in the patient's family in determining the most appropriate treatment type and approach for each individual. Ideally, the family should be involved in all phases of the adolescent's treatment, but in families characterized by extreme instability, conflict, physical or sexual abuse, and/or domestic violence, this may not be possible or even advisable. It is important for providers to remember that "family" may include a broad spectrum of members, such as grandparents, older siblings, and foster parents.
Social and Community Factors
School life, peer influences, the community, and the media may also exert an influence on the adolescent's risk to initiate and maintain substance use (Newcomb and Bentler, 1989). Understanding their influences on an individual can help a service provider pinpoint areas of intervention relevant to the client's recovery.
Peer Influences
Association with peers who use alcohol and/or illicit drugs, including involvement in gangs, is a very prominent risk factor associated with adolescent substance use (Winters et al., in press). Adolescents in cohesive peer groups make substances available to each other, substance use is modeled by friends in the group, and peer group support and norms favor substance use (Oetting and Beavais, 1986). Also, because the role of substance use and other delinquency behaviors may influence the selection of friends, it is possible that substance use behavior may contribute to selecting peers who are delinquent and happen to already be using alcohol and/or illicit drugs as well (Farrell and Danish, 1993).
Environmental Influences
The socioeconomic level of a young person's community is one important determinant for his risk of substance use. Rates of substance use are higher in areas where alcohol and/or illicit drugs are more easily available and where local norms are more tolerant of their use. Substance use in these areas is also more likely to be associated with crime. In addition, positive role models for young people are often scarce or lacking. Not surprisingly, youths who identify with individuals engaging in substance use and criminal activities are more likely to engage in these activities themselves. Youths who grow up in communities where there is little or no social cohesiveness and attachment, a high population density, and disorganized neighborhoods are at greater risk of using alcohol and illicit drugs, as well as developing other behavioral problems (Hawkins and Fitzgibbon, 1993).
School Factors
No relationship has been found between intelligence level and the risk of substance use. Performance in school, however, does affect this risk (Friedman et al., 1985). Academic failure beginning in the late elementary grades increases the likelihood that substance use will develop in adolescence (Hawkins et al., 1992). This is true regardless of whether academic failure stems from learning or behavioral disorders, family conflict, or poor educational quality. Lack of success and academic commitment, as evidenced by problems such as truancy and insufficient time spent on homework, is predictive of later substance use, which in turn increases the risk of substance abuse (Newcomb and Bentler, 1989).
The Continuum of Treatment
The various types of treatment approaches for adolescents with substance use disorders are described in detail in upcoming chapters. Regardless of the modality or the setting in which it takes place, treatment can be seen as taking place on a continuum starting with outreach, screening, and assessment to identify youths who are at risk or who are already engaging in substance use. It continues through the stages of counseling and treatment to continuing care and support to reinforce abstinence.
Linking Assessment and Treatment Placement
The variety of options for the treatment of substance use disorders--outpatient, inpatient, and residential, as well as services that support independent living--can be subdivided into specific services for adolescents with substance use disorders. These services can be viewed as a continuum ranging from pretreatment services for at-risk adolescents and those in the early phases of substance use to more intensive treatment for youths already having substance use disorders.
The differences among these levels of treatment are both qualitative and quantitative; that is, the variation in intensity of service is only one aspect of the continuum. Treatment programs also may differ considerably in their individual philosophies and approaches to treatment, in the treatment components they offer, and in the types of professionals employed. Regardless of the specific elements, any program's services must match the needs of the adolescents it intends to serve, and the levels of treatment and service options must respond to the internal and environmental realities of at-risk or substance-using adolescents. To that end, the original Consensus Panel developed the continuum shown in Figure 2-3, Client Assessment Criteria, bearing the following in mind:
- Levels of treatment and service options must respond to the internal and environmental realities of an adolescent who is at risk for or who already has a substance use disorder.
- The table must be comprehensible to treatment providers with different levels of clinical sophistication.
- The table must be internally consistent and reliable in making placement decisions.
In the model presented in Figure 2-3, the following assessment criteria can be used to determine the level and type of service that is most appropriate for each individual. For example, assessment of an adolescent's recent substance use might indicate that she has a toxicity level that requires more than outpatient medical management but is not severe enough to require life support and intensive medication.
This would suggest that the adolescent requires care as a medically monitored inpatient. On the other hand, her emotional well-being might reveal a great deal of distress, requiring 24-hour continuous psychiatric monitoring. The following areas can be evaluated in order to arrive at appropriate treatment placement decisions:
- Use pattern: Pressure of consequences and problems resulting from substance use, and level and recency of substance consumption
- Medical concerns: Toxicity, withdrawal, and other medical sequelae resulting from substance use, as well as medical problemsunrelated to substance use, such as pregnancy, HIV/AIDS, domestic violence, and child abuse and neglect
- Intrapersonal--Cognitive: Substance-induced impairment in cognition and thinking, both chronic and acute, including neurological deficits as well as memory problems such as blackouts, short-term memory deficits, and poor concentration
- Intrapersonal--Emotional: Emotional functioning, which may range from an inability to experience emotions to extremely negative emotional states
- Interpersonal--Social: Interpersonal relationships, social development, and social concerns such as employment, family, friends, and legal matters
- Environmental: External influences, including living conditions, housing, gang influence, and family and school influences
The continuum of treatment underscores the importance of understanding all of the factors that bear on the adolescent's substance use. These factors must be included in a comprehensive assessment, which must in turn incorporate information collected from the adolescent's self-report, standardized assessments, reports from family members, and other collateral sources of information whenever possible in order to obtain a complete picture of the adolescent's social and environmental situation.
Placement Guidelines
The following guidelines indicate how the continuum can be used in making a decision regarding the placement of the adolescent. The Revision Panel created the guidelines based on clinical experience.
- In making placement decisions, practitioners should choose the most intensive level of care indicated by any single assessment criterion.
For example, an adolescent who is not currently using substances but who is actively psychotic would require inpatient treatment.
- When an assessment indicates the need for a particular level of care that is not available, it is desirable to refer the adolescent to the next higher level of care, unless the assessment indicates that such a placement would be counterproductive. For example, if intensive outpatient treatment is indicated but unavailable, day treatment should be the next recommendation, unless it is contraindicated. Naturally, a higher level of care may not be practical or available.
- Assessment is an ongoing process. Decisions about level of care should be based on the adolescent's progress and changes in his environment. Clients should have the opportunity to move back and forth across the level-of-care continuum on the basis of changes in these factors.
- There is as much, if not more, variability among treatment programs within a single intensity level as there is across treatment intensity levels. The assessor should incorporate this understanding when making placement decisions. Assessors should have an indepth knowledge of available services and the intensity of any particular treatment or service option.
- The assessment criteria shown in Figure 2-3 are interrelated and can be viewed together as an integrated system. This point is important in considering the most appropriate treatment level and the ability of the adolescent to move along the level-of-care continuum as treatment progresses or regresses. Prior to each program change, indepth reassessment must be completed in order to update information on the client's status and to obtain a current clinical picture of his situation.
The American Society for Addiction Medicine is also in the process of developing placement guidelines for adolescents with substance use disorders.
Levels of Treatment
Outpatient Treatment
Outpatient services provide a broad range of intensity-of-care levels without overnight accommodation. Some of these levels may be used subsequent to inpatient treatment. It is common for some levels of outpatient counseling to implement the same treatment strategies as in inpatient counseling. Outpatient counseling as a treatment option is composed of sublevels of treatment characterized by increasing levels of intensity.
Brief Intervention
Brief intervention generally takes less time than more formal treatment approaches. It is usually delivered by nonspecialists or paraprofessionals, emphasizes self-help and self-management, reaches large numbers of individuals, and is considerably less expensive than conventional treatment. Brief interventions, notably those based on motivational enhancement theory, have proven successful with adult alcohol users (Institute of Medicine, 1990; see also Rollnick et al., 1992; Miller et al., 1993). Typically, a brief intervention would include brief screening, anticipatory guidance, and psychoeducational interventions. This option is primarily appropriate for adolescents in the low-to-middle range of the severity continuum (experimental, regular, and problem use). This approach has also been demonstrated to be very effective in the emergency medical care setting by significantly increasing the likelihood that clients will keep followup appointments for subsequent treatment (CSAT, 1995a). See the forthcoming TIP, Brief Interventions and Brief Therapies for Substance Use Disorder Treatment, for a description of brief interventions and therapies that can be used in various treatment settings(CSAT, in press).
Intervention in primary care settings
Within the health care sector, there is a growing interest in primary care providers to practice brief interventions. Primary care providers are well situated to practice primary prevention of substance use disorders and to intervene when they suspect the possibility of substance use by adolescents under their care for other medical problems. The developmental model of substance use disorder progression, diagrammed in Figure 2-1, is useful for understanding the development of substance use disorders in teenagers and the type of intervention that is most appropriate at each stage.
The time pressure in a managed care environment makes many primary care physicians reluctant to screen for substance use although health care guidelines recommend screening every adolescent patient for substance use disorders as part of routine medical care. Screening and intervention can be done in minutes--for example, during an office visit--using any of a number of screening instruments designed for adolescents (see the companion TIP 31, Screening and Assessing Adolescents for Substance Use Disorders [CSAT, 1999]).
In geographic areas where substance use is highly prevalent, it is often useful to bring substance abuse counselors in routinely to meet with adolescents as part of the screening. These workers can establish a rapport with young patients and can arrange subsequent meetings with those who screen positively for problems. This approach helps to bridge the gap between primary care and substance use disorder treatment programs, where the risk of losing patients to followup is greatest, and obviates the need to make referrals to a treatment center.
When substance use disorders are identified in an adolescent patient by a primary care provider, it is important to make the connection to a treatment program as quickly and directly as possible. Resources can be mobilized more immediately by having an established contact with a substance use disorder treatment provider who is willing to call or meet with adolescents, or even to visit those admitted to inpatient treatment. Making a direct and immediate contact with a treatment provider is highly preferable to merely giving an adolescent patient a referral card, name, or phone number, none of which may ever be used. However, making direct contact with a treatment provider requires the consent of the adolescent and may also require the consent of the parent. See Chapter 8 for information on legal and consent issues.
Physicians treating adolescents should become familiar with treatment resources in the community and their approaches to treatment. Programs vary in intensity and philosophy, but abstinence is normally the goal; it will also help if the physician is familiar with several therapeutic communities that may be available, even if they are a distance away (Knight, 1997).
The physician can recommend that the parents take part in treatment with the youth. Individual and family counseling may be needed, and the physician can refer the parents and youth to child-centered support groups, such as Alateen and Alatot. Also, if parents have a substance use disorder, they should be referred for an assessment.
The physician should also inform the patient that she will continue to check the patient's progress in future visits and encourage the youth to discuss any substance use problems with her. Formal treatment interventions are generally indicated for adolescents who have progressed to abuse or dependency. Such problem users require more than a brief intervention during an office visit, and should be referred to a substance use disorder treatment specialist. The bottom line is that primary care staff members should be encouraged to consult with substance use disorder professionals about how they might best support treatment during ongoing contact with adolescents being seen for primary care. For a further discussion on brief interventions in primary care settings, see TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT, 1997).
Outpatient counseling includes professionally directed evaluation and treatment typically for fewer than 9 hours per week in regularly scheduled sessions. In less intensive programs, 2 to 3 hours per week is common. Nonintensive outpatient treatment also may address related psychiatric, emotional, and social concerns. Intensive outpatient programs may be after-school or evening programs, often include some weekend programming, and may involve 9 to 20 hours of treatment per week.
Day treatment programs, sometimes referred to as partial hospitalization, provide professionally directed evaluation and treatment in a structured program. This is the most intensive of the outpatient treatment options and can be used for adolescents who demonstrate the greatest degree of dysfunction but do not require inpatient treatment. Day treatment may range from several hours per week to more focused and directed sessions for up to 5 days a week. Sessions may take place after school, in the evenings, or on weekends. The treatment provided may be some combination of individual, group, and family therapy.
Inpatient Treatment
Inpatient treatment may include 24-hour intensive medical, psychiatric, and/or psychosocial treatment and residential care. The levels of the residential care continuum include a high level of supervision by professional staff members at the most intensive end and group home living with minimal professional involvement or supervision at the least intensive end.
Detoxification generally refers to a 3- to 5-day inpatient program with 24-hour intensive medical monitoring and management of withdrawal symptoms. Although physiological withdrawal symptoms are uncommon among adolescents, this level of care may be mandated by psychosocial circumstances, personal characteristics, or a history of using significant amounts of a substance associated with life-threatening withdrawal symptoms (e.g., benzodiazepines, barbiturates, heavy chronic alcohol use). Detoxification should be monitored by appropriately trained personnel under the direction of a physician or other personnel with specific expertise in management of addiction and abstinence syndromes. It is appropriate for adolescents with multiple problems, including those who need habilitation or with coexisting personality and substance use disorders. See Appendix B for information on medical management of substance use disorders.
Residential treatment is a long-term treatment model that includes psychosocial rehabilitation among its goals. It may be directed by physicians or other professionals, and it is appropriate for adolescents with multiple problems, especially those with coexisting personality and substance use disorders. The duration of residential treatment can range from 30 days to as much as 1 year in some cases (as in the case of therapeutic communities), although managed care requirements continue to chip away at the maximum length of treatment allowed.
Continuing Care
The period right after completion of a treatment program, when the youth returns to family, peers, and the neighborhood, is often the time of greatest risk for relapse. It is for this reason that all forms of treatment should include some provision for continuing care. A continuing care program often takes the form of a structured and time-limited outpatient program and planning process that can provide ongoing support to the adolescent. Many continuing care programs have specialized groups that focus on making the transition from intensive treatment to a lower level of care.
Most treatment programs also have specialized groups for relapse prevention. Having a history of relapse is common for adolescents in treatment for substance use disorders (Hoffman et al., 1993). If an adolescent in treatment experiences relapse, it is best viewed not as a failure of the treatment or the client, but rather as a common part of the early recovery process that needs to be factored into the treatment plan. As in chronic physical diseases such as leukemia or diabetes, relapse is an indication not for punishment or discontinuation of treatment, but for additional or intensified treatment. Relapse (or the lesser version known as a minor slip or lapse) should be viewed by treatment professionals as an opportunity for learning; for example, it can help teach young people that they do not have control over their substance use.
Because an adolescent who has relapsed in the past is at greater risk for further relapses, it is important to evaluate those factors that are precipitants for relapse and to adjust treatment accordingly. An adolescent's coping style (i.e., the use of skills gained through treatment) and social resources are among the known protective factors for alcohol relapse (Brown, 1993).
Self-Help and Peer Support Groups
Self-help groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Al-Anon, and Alateen are valuable adjuncts to outpatient services and residential programs for teenagers during the recovery process, both during and after primary treatment. Self-help groups offer positive role models, new friends who are learning to enjoy life free from substance use, people celebrating sober living, and a place to learn how to cope with stress and other relapse triggers. Teenagers should ideally be referred to youth-oriented groups, led by responsible individuals, with a membership that is appropriate for the age, gender, and culture of the client. (see Chapter 4)
Group Homes
Sometimes referred to as halfway houses or independent living, group home living is a transitional living arrangement with different levels of specificity of treatment planning and staff supervision. Residents may work and/or receive educational or training services or treatment outside the group home. House responsibilities are shared, and the youths are involved in the house governance. Therapeutic foster home placements, a type of group home, involve a small group of adolescents being placed in a family situation, often with foster parents, who themselves may be recovering from substance use disorders.
"Booster" Sessions
In the cognitive-behavioral model of treatment, recovering adolescents periodically return to the treatment program to meet with clinicians and review their skills for relapse prevention, self-management, and independent living. Recommendations and supportive and encouraging feedback are provided during these monitoring sessions. Consistent with the need for continuing care, booster sessions, often known as aftercare sessions, are important for any treatment experience.
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 99-3283
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Additional Information
Teens
and Alcohol
Teen
Alcohol Use
Alcohol
and Families
Anabolic
Steroids
Effective
Parenting
Fostering
Responsibility
Fostering
Confidence
Problem
Solving
Adolescent
Substance Abuse
Successful
Dialogue
Fathers and
Discipline
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