Adolescent community reinforcement approach

The adolescent community reinforcement approach (A-CRA) is a behavioral treatment for alcohol and other substance use disorders that helps youth, young adults, and families improve access to interpersonal and environmental reinforcers to reduce or stop substance use.^[1][2]

Description

A-CRA is a variant of the adult CRA model, which has a history of development and effectiveness research starting in the 1970s.^[3] A-CRA was adapted to be developmentally appropriate for adolescents, which included adding sessions for parents/caregivers.^[4] The goal of A-CRA is to improve or increase access to social, familial, and educational/vocational reinforcers for adolescents to achieve and sustain recovery. That is, therapists assist adolescents with learning how to lead an enjoyable and healthy life without using alcohol or other drugs.^[5] The treatment manual describes an outpatient curriculum that is intended for adolescents (ages 12 to 17) and young adults (ages 18–25). with DSM-5 alcohol and/or other substance use disorders.^[1][2] A-CRA also has been implemented in intensive outpatient and residential treatment settings.^[6][7] A-CRA includes three types of clinical sessions: adolescent alone, parents/caregivers alone, and family (adolescent with parents/caregivers).^[1][2] To address the adolescent's needs, goals for treatment, and reinforcers, clinicians select from 19 A-CRA procedures (e.g., communication skills, problem-solving, and participation in positive social activities), all with the goal of improving life areas and supporting abstinence from alcohol and other drugs.^[8] Practicing skills during sessions is an important aspect of A-CRA counseling, and every clinical session ends with a homework assignment (mutually-agreed upon by adolescent and clinician) to apply skills learned during the session.^[1][4] Clinicians practicing A-CRA are trained in all 19 procedures and complete an extensive certification process.^[8] A-CRA has been widely implemented in the U.S.,^[8] Canada,^[9] and Brazil.^[10]

Evidence-based outcomes

As of 2017, five randomized clinical trials of A-CRA have been published. The Cannabis Youth Treatment (CYT) study, which was funded by the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT), was a randomized controlled study of five manual-guided treatment models for adolescents with cannabis-related disorders.^[11] All five models demonstrated significant pre-post treatment improvements in number of days abstinent and the percent of adolescents in recovery during the 12-month follow-up period.^[12] Within its study arm, A-CRA was the most cost-effective model; across both study arms, A-CRA was the most cost-effective model to involve parents in treatment.^[12] Additional randomized clinical trials have shown A-CRA to be effective for homeless, street-living youth and young adults,^[7] youth with juvenile justice involvement,^[13] and as a continuing care approach for adolescents after residential treatment.^[14][15] Secondary evaluation studies suggest that A-CRA shows potential to be an effective treatment for adolescents with co-occurring psychiatric disorders^[16] and youth with opioid use problems.^[17]

Treatment cost

In a 2002 article assessing the economic costs of A-CRA, the average cost per completed treatment event was $1,237 at one site and $1,608 at another site.^[18] Using U.S. Bureau of Labor Statistics data to adjust for inflation, the 2017 cost per A-CRA treatment episode ranges from $1,683 to $2,188.^[19]

Treatment manual

The original A-CRA treatment manual was published in 2001.^[1] An updated version of the A-CRA manual was published in 2016.^[2]

Therapist fidelity to A-CRA treatment manual

Although therapist fidelity to an evidence-based treatment manual is believed to predict treatment outcome, this relationship has been difficult to prove.^[20] A 2017 study found that higher ongoing fidelity (model competence) ratings of 91 A-CRA therapists' clinical sessions predicted improved adolescent substance use outcomes.^[21] This finding suggests that the A-CRA model of clinical certification and supervision, which rates A-CRA counseling sessions using a standardized rubric, is a central part of model effectiveness.^[21]

See also

• Behavior therapy
• Behaviorism
• Cognitive behavioral therapy
• Community reinforcement and family training
• Drug rehabilitation
• Mental health disorders
• Opioid use disorder