Associations Between School-Based Substance Use Treatment and Academic Outcomes

Abstract

Objectives:

Evaluate the association between school-based treatment of substance use disorders and academic outcomes by developing a system of simple and easily tracked academic performance metrics coinciding with an established substance use treatment program.

Methods:

This study provided treatment to 75 high school students enrolled without exclusion who voluntarily sought care for substance use disorders. Participants were enrolled in a 12-week program of individual motivational interviewing, acceptance and commitment therapy, family sessions, case management, contingency management, and psychiatric consultation at school-based health centers. We tracked distinct metrics of substance use treatment, including urine drug screens and self-reported use, along with three key metrics of academic performance referred to as the ABCs: attendance (No. of missed classes and percentage of days attended), behavior (No. of behavioral incidents per semester), and credits (grade-point average).

Results:

Participants in the study attended an average of 6.4 sessions and nearly 50% attained a negative urine drug screen. Participants demonstrated a significant reduction in behavioral incidents with an average decrease from 1.2 to 0.41 incidents per semester (p < 0.01). In addition, there was a reduction in the mean number of missed classes from 148 per semester to 127 (p = 0.001).

Conclusions:

School-based substance use treatment appears to be associated with a reduction in behavioral incidents and improved class attendance. This study provides the foundation for development of a robust school-based substance treatment program that can be rigorously evaluated against a control group for students with substance use disorders.

Introduction

Adolescent substance use is a growing problem in the United States with roughly 5% of youth aged 12–17 years with an active substance use disorder other than tobacco (Center for Behavioral Health Statistics and Quality 2016). The implications of adolescent substance use are widespread, including increased legal troubles, strained interpersonal relationships, and notable impact on academic performance and school outcomes (Townsend et al. 2007; National Institute on Drug Abuse 2014).

School performance and high school graduation can significantly impact the overall trajectory of a person's life and influence families for generations to come, as high school dropouts are more likely to earn a lower income, live in poverty, have poorer health, and be imprisoned (Levy and Murname 1992; Sum et al. 2009; Wilson et al. 2011; DuPont et al. 2013). Although the overall dropout rate in the United States is declining, the rates are still unacceptably high at 6.1% (U.S. Department of Education 2018).

Substance use among adolescents is associated with academic failure and school dropout (Yamada et al. 1996; Townsend et al. 2007; McCaffrey et al. 2010; DuPont et al. 2013; Stiby et al. 2015). The relationship between substance use and school performance appears to be bidirectional, with poor academic performance leading to increased likelihood of substance use in some students, whereas in others worsening academic performance is preceded by substance use (DuPont et al. 2013). Furthermore, adolescent substance use is correlated with decreased likelihood to attend and/or complete college (King et al. 2006).

Academic performance generally improves with cessation of substance use (Engberg and Morral 2006; DuPont et al. 2013); however, we are unfamiliar with any studies that have evaluated the relationship between substance use treatment and academic performance. These data are important for educators to evaluate if providing on-site services is worthwhile. The data are also important for clinicians to know how to best help their clients. In this study we examine the association between enrollment in school-based treatment of substance use disorders and academic outcomes, specifically measuring attendance, behavior, and credits.

Methods

Procedure

This research was approved by the Colorado Multiple Institutional Review Board. Seventy-five youth who voluntarily sought substance use treatment at select urban school-based health centers from August 2016 through December 2016 were recruited without exclusion. Baseline demographic, clinical, and academic information was collected. Clinical information was tracked during treatment. Academic information was tracked for the semester before, during, after, and up to two semesters after treatment.

Participants

Participants were 75 youth who sought substance use treatment at school-based health centers located in select urban middle and high schools in Denver, CO. Participants were tracked and were included if they participated in at least one therapy session. There were no exclusion criteria.

Intervention

Participants received a manual standardized intervention consisting of individual motivational interviewing, acceptance, and commitment therapy (ACT), family sessions, case management, psychiatric consultation as needed, and urine drug screens with contingency management (Thurstone et al. 2017). The intervention is described in detail in Thurstone et al. (2017), and the treatment manual is available at on Dr. Thurstone website Sessions typically lasted a class period, or 45 minutes. They began with a 15 minute check-in and data collection about substance use and emotional well-being. The next 15 minutes focused on practicing new ACT processes. ACT is an emerging third-wave cognitive behavioral therapy focused on improving psychological flexibility so that youth can take action consistent with what matters to them (Hayes et al. 2013). Randomized controlled trials support ACT as an evidence-based intervention for anxiety, depression, and substance use (Swain et al. 2013; Ost 2014; Lee et al. 2015; Hacker et al. 2016; Twohig and Levin 2017). ACT also has evidence to support its use as a transdiagnostic intervention that targets various processes underlying both substance and psychiatric disorders (Dindo et al. 2017). The final 15 minutes of the session focused on developing relevant at-home practice, completing the urine drug screen, and the contingency management. The contingency management was modeled after the MEIDAR study, which uses an escalating positive intermittent reinforcement schedule to reward negative urine drug screens (Petry et al. 2005). Participants received individual and family sessions. The intervention did not use group sessions. Up to three family sessions were offered. Family sessions included the same ACT processes as the individual sessions to help family members increase actions aligned with their chosen values. Therapists also provided case management as needed. Participants were offered 12 weekly sessions to complete within 16 weeks. The intervention was delivered by three different Licensed Clinical Social Workers, who completed an 8-hour training in the intervention and had ongoing monthly supervision with a certified ACT trainer. Sessions were not audio-recorded or rated for adherence. Medication management was performed by two board-certified child psychiatrists.

Measures

At baseline, demographic information related to age, ethnicity, and race was collected. Baseline clinical information included diagnoses from clinical interview using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association 2014). The clinical interview was conducted by a licensed clinical social worker or a board-certified child psychiatrist. Instant urine drug screens were collected at weekly psychotherapy visits and tested for amphetamine, benzodiazepine, cocaine, marijuana, methamphetamine, and opioids. Urine drug screens supported self-report of past 7-day substance use at each therapy session. Seven-day point prevalence abstinence is a common outcome measure in smoking cessation trials, and we found it to be more feasible to implement in this clinical setting than a 30-day outcome measure (Cheung et al. 2017). Utilization and tracking of the timeline followback interview, urine drug screening, and session attendance was useful in assessing the effectiveness of our interventions in helping students achieve abstinence. Academic outcomes were measured with attendance, behavior, and credits. Attendance was measured by the number of classes missed per semester. Behavior was measured as the number of behavioral incidents (e.g., expulsion, suspension) per semester. Credits were measured by semester grade-point average (GPA). Academic outcomes were recorded from an online school portal by semester for the semester before treatment, during treatment, and for three semesters after treatment.

Statistical analyses

Data were extracted and checked by the primary (M.J.L.) and senior authors (C.T.). Descriptive statistics were used to describe the overall sample. Linear mixed models fit with restricted (residual) maximum likelihood estimation were implemented to assess effects of interest related to missed classes, behavioral incidents, and GPA. Each model included age and seasonality (i.e., “spring” or “fall”) as covariates and student as the random factor. The effects of interest were time points (e.g., “baseline,” “one semester post-treatment”), proportion of negative urine drug screens, and total therapy sessions attended. Analysis of variance was performed with Satterthwaite's method and post hoc analyses of significant results were completed using Tukey's HSD (honestly significant difference). These analyses were calculated with the lme4 module in R (v. 3.5.1) (R Core Team 2018).

Results

Seventy-five youth (51 males, 24 females) of average age 15.5 years from select urban high schools in Denver, CO, were enrolled in the study. In total, 18 (24%) of the sample was prescribed a psychotropic during treatment or follow-up. Medications included antidepressants (n = 8), psychostimulants (n = 5), antipsychotics (n = 3), and sleeping medication (n = 3). Participants met with school-based therapists with mean session attendance of 6.4 (standard deviation = 3.0) for the course of the 16-week treatment period. Nearly half of participants attained negative urine drug screens during treatment with 49% of participants reaching a negative urine drug screen. The baseline average number of days used for the previous 7 days was 2.0. Descriptive details, including co-occurring psychiatric and substance use disorder diagnoses, are provided in Table 1.

Table 1.

Demographics

Category	Mean (SD)
Age	15.5 (1.5)
Gender	51 M/24 F
Ethnicity	44 Hispanic/Latin(x)/Spanish Origin; 11 Mexican/American/Chican(x); 12 none; 8 unknown
Race	5 Black or AA; 43 White; 10 other; 7 declined; 10 unknown
Number of sessions	6.4 (3.1)
Number of school transitions^a	0.77 (1.03)
Proportion negative urine drug screens	0.49 (0.55)
TLFB score during therapy	2.0 (2.3)
Average number of diagnosed substance use disorders	1.8 (1.2)
Co-occurring diagnoses
ADHD	29
CD	9
GAD	27
Social anxiety	5
MDD	38
ODD	4
PTSD	28
NOS	13
Psychotic disorder	2
Substance use disorder diagnoses
Cannabis	71
Alcohol	36
Other	27

School transition is defined as either a move from MS to HS or between school settings.

ADHD, attention-deficit/hyperactivity disorder; CD, conduct disorder; GAD, generalized anxiety disorder; MDD, major depressive disorder; NOS, not otherwise specified; ODD, oppositional defiant disorder; PTSD, post traumatic stress disorder; SD, standard deviation; TLFB, timeline followback.

As outlined in Table 2, the number of missed classes was significantly decreased for the course of the treatment (F _296,75 = 6.19, p < 0.001). Class attendance improved with the average number of missed classes per semester decreasing from 148 at baseline to 115 during treatment (p = 0.034), which remained stably decreased from baseline to two semesters post-treatment at 127 missed classes per semester (p = 0.001). Behavioral issues were also significantly different between time points (F _296,75 = 6.12, p < 0.001). The number of behavioral incidents continually decreased relative to baseline (1.2 incidents per semester) showing significant reduction by post-treatment (0.61, p = 0.022) and remaining decreased one semester (0.40, p = 0.001) and two semesters later (0.41, p = 0.001). Average GPA showed a marginal increase from 1.5 to 1.62 although was not statistically significant (F _296,75 = 1.6, p = 0.18). However, when stratifying by abstinence status, we found that those achieving abstinence had a higher GPA than students who continued to use (F _229,59 = 4.4, p = 0.017).

Table 2.

Attendance, Behavior, and Credits of School

	Baseline	Treatment	Post-treatment	One semester post-treatment	Two semesters post-treatment	Significance	Tukey's HSD post hoc
Attendance: missed classes	148 (106)	115 (89)	158 (123)	99 (93)	127 (108)	F _296,75 = 6.19, p < 0.001	Tx < baseline, p = 0.03; tx < post-tx, p = 0.001; one semester later < baseline, p = 0.026; one semester later < post-tx, p = 0.001
Behavioral incidents	1.2 (2.0)	0.95 (1.3)	0.61 (1.2)	0.40 (0.91)	0.41 (1.0)	F _296,75 = 6.12, p < 0.001	Two semesters later < baseline, p = 0.001; one semester later < baseline, p = 0.001; tx < baseline, p = 0.022; one semester later < tx, p = 0.043; two semesters later < tx, p = 0.048
GPA	1.5 (0.89)	1.27 (0.96)	1.47 (1.01)	1.53 (1.08)	1.62 (1.0)	F _296,75 = 1.6, p = 0.18

Statistical significance based on linear mixed effects and estimations from Satterthwaite's method on analysis of variance, seasonality, and age were covariates.

GPA, grade-point average; HSD, honestly significant difference; Tx, treatment.

The total number of therapy sessions attended was significantly associated with decreased behavioral issues (t = 2.6, p = 0.011), but not the number of missed classes (p = 0.83) or GPA (p = 0.92). The proportion of negative urine drug screens for the course of therapy was not associated with missed classes (p = 0.60), behavioral incidents (p = 0.11), or GPA (p = 0.46).

Discussion

These results show improvements in attendance, behavior, and grades for students simultaneously enrolled in school and school-based substance use disorder treatment. We observed significant and stable reductions in the number of behavioral incidents and missed classes per semester. Regarding academic performance, we found subtle but insignificant improvements in GPA in the pretreatment versus all post-treatment periods. By design, this intervention targets behavioral and emotional regulation, whereas attendance and grades were not directly targeted. This focus may explain why bigger changes in GPA were not observed. In addition, no changes were made to the schooling regimen to directly influence academic performance and outcomes. As the nature of formal education is to build on previously attained knowledge in a stepwise manner, we would not expect substance use disorder treatment alone to be sufficient to significantly improve the GPAs of students whose grades may be the result of years of poor academic performance. Although we observed an association between treatment and a reduction in the number of behavioral incidents and missed classes, the nature of this study does not allow us to conclude a causative relationship.

There are some limitations of the data presented here as a result of the preliminary staging of this study. First, participants receiving treatment were not compared against a control group and, thus, it cannot be definitively concluded that the academic improvements were the direct result of our substance treatment intervention. Second, due to the logistics of data access and study design, we were able to track the targeted academic metrics for indefinite periods before and after interventional treatment. Although this is a relative strength of the study, tracking data pertaining to substance use was limited to the period directly surrounding the duration of treatment. As a result, we do not have substance use data (e.g., proportion of days used and urine drug screens) corresponding to all the same time periods of academic data. Thus, we cannot directly correlate the reduction in behavioral events and missed classes with sustained abstinence from drugs and alcohol. Despite the lack of long-term substance use data, we see a clear trend of significant reductions in behavioral incidents and missed classes that persists for up to two semesters after treatment.

These results show promise for the potential impact that timely substance use disorder treatment might have on academic achievement. Providing substance use disorder treatment in school-aged individuals may have important implications, as academic performance and high school graduation are indicators of other successful life outcomes (Levy and Murname 1992; Sum et al. 2009; Wilson et al. 2011; DuPont et al. 2013). School-based intervention provides unique advantages for treatment by improving access to care and likelihood of program completion (Jaycox et al. 2010). Modest changes in GPA suggest that abstinence and therapy alone are not sufficient to impact this measure of academic performance. Contingency management is highly effective in promoting abstinence in treatment of substance use disorders (Prendergast et al. 2006), and may be beneficial in facilitating greater achievement in certain aspects of academic performance as well. Future implementations of school-based substance use disorder treatment may be tailored to target academic performance using contingency management protocols in a similar manner to its role in substance use disorder treatment. Another point of improvement may be in the timing of intervention. Programs geared toward earlier intervention may have a greater influence on behavioral changes in consideration of long-term goals of academic achievement. These questions warrant further investigation and will be addressed in future adaptations of this study.

Conclusions

This study demonstrated a favorable relationship between school-based substance use disorder treatment with the reduction in behavioral incidents and an increase in class attendance. However, based on the preliminary staging of this study, a causative relationship has yet to be established and future studies will aim to address this limitation. Increasing positive interactions with teachers and the raw number of encounters with required educational content by addressing underlying ongoing substance use disorders may contribute to a higher potential for successful academic outcomes. Indeed, these preliminary results provide a foundation for the development of a robust school-based substance use disorder treatment program that can target both abstinence from controlled substances and improved academic outcomes. Development of this and similar programs may contribute to improving graduation rates that are otherwise precluded by ongoing substance use disorders.

Clinical Significance

As previously mentioned, substance use disorders in adolescents can have a profound impact on academic performance which may subsequently set the tone for their short- and potentially long-term futures. By treating these disorders in a timely manner via school-based programming, treatment is more accessible to individuals and increases the likelihood of having a noticeable impact on their daily lives. In addition, substance use is not without consequences to an individual's health. Addressing these disorders can minimize this burden on individuals, the health care system, and society at large.

Availability of Data and Material

The treatment manual is available on request. The data sets from this study are not publicly available to preserve the confidentiality of the research participants. However, they may be available on request from the corresponding author.

Footnotes

Acknowledgments

We are grateful to the youth and therapists who provided valuable feedback to develop this treatment. We also thank Alicia Chance and her team of research assistants for helping with literature review.

Disclosures

No competing financial interests exist.

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