CREATING SOBRIETY: FORGING THE ROAD TO RECOVERY C A Curriculum by Hailey Kivler Purpose Statement • To develop an art therapy-based curriculum for youth with substance use disorder in an effective residential group setting that addresses both the substance use and mental health concerns. Problem to be Investigated Ineffectiveness of Current Substance Use Disorder Treatment for Youth Justification Substance Use & SUD is a prevalent problem among youth •Study found that by 12th grade, two-thirds of students had tried alcohol while two out of ten students admitted to using prescription medication illegally (Johnson et al., 2014) •nearly 1 million youths (ages 12 to 17) needed treatment for SUD in 2018, although only 83,000 of them received services in a treatment center (SAMHSA, 2019). Barriers to Treatment •Barriers include racial bias, economic cost of care, and the stigma associated with SUD (Alegria et al., 2010; Earnshaw, 2020; Farhoudian et al., 2022). Current treatment methods found ineffective •“programs for adolescents using a pure abstinence-based approach (the “just say no” approach) are ineffective in reducing substance use and abuse” (Marlatt & Witkiewitz, 2002, p. 2) Untreated SUD in youth can lead to a cycle of incarceration •“contribute to an elevated risk of recidivism, which leads to further, and oftentimes more serious, involvement with the juvenile justice system” (Fisher et al, 2018, p. 3). Overall lack of research of arttherapy based treatment for youth SUD Terms Adlerian “Individual” Psychology • An approach to psychology that emphasizes a “holistic and phenomenological understanding to human behavior”, stressing the importance of viewing all aspects of an individual including lifestyle and social context (Carlson & Johnson, 2016). Human behavior is goal-oriented and is often influenced by external factors such as birth order, the family constellation, personal lifestyles, and social interest. Art therapy • “An integrative mental health and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship.” (AATA, 2022, para.1) Recovery • “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (SAMHSA, 2012, p. 3). Residential Treatment • “Are licensed, community-based facilities that provide 24-hour inpatient care for people with mental health and/or chemical dependency disorders in a residential treatment setting” (WSDOH, 2022, para. 1) Terms Substance •“This is material abused (e.g. Cocaine, alcohol, marijuana), a medicine (sedative, for example) or toxin” (Psychology Dictionary, 2013, para. 1) Substance Use Disorder (SUD) •“Characterized by recurrent use of alcohol or drugs (or both) that results in problems such as being unable to control use of the substance; failing to meet obligations at work, home, or school; having poor health; and spending an increased amount of time getting, using, or recovering from the effects of using the substance.” (Lipari & Van Horn, 2017, para 1). Overdose •“Injury to the body (poisoning) that happens when a drug is taken in excessive amounts. An overdose can be fatal or nonfatal.” (CDC, 2021, para. 24) LITERATURE REVIEW C Adlerian Major Tenants (Fong et al, 2015) • Developed by Alfred Adler in the early 1900’s as an alternative to Freud’s Psychoanalytic Theory • Focus on social, holistic, and goal-directed nature of people • Looks at people as a whole; indivisible from individual parts • Differs from Freuds separate Id, Ego, and Superego 5 Major Tasks of Life • Coping with • Coping with • Coping with • Coping with • Coping with problems of social relationships problems of work problems of love the self existence ***Unsuccessful attempts to navigate lead to psychopathology Adlerian Lifestyle • holistic pattern of beliefs and goals that the person uses for interacting with others and for measuring self-worth (Fong et al, 2015, p. 210) • Develops in childhood through experiences; influences present and future Family Constellation and Birth Order • Family is first social group and shapes later experiences • Birth order – first born, middle child, youngest, only child, ect. • being a first born male or female was a protective factor against SUD while being the youngest put the youth more at risk of developing SUD (Horner et al, 2012 Social Interest • “An internal feeling of connectedness to others and their well-being, to the well-being of the individual” and the desire to need and belong (Fong Chang et al, 2015, p. 207). • Substance use is driven from a lack of social interest and used as a “means to evade the tasks of life, including love, friendship, work, and self” (Giordano et al, 2014, p. 116) Socio-Ecological Model of Substance Use Disorder • The model “recognizes the mosaic of interactions that play a role in addiction, including society and public policy (laws and regulations); communities; organizations and personal networks; and our own individual biological, genetic, and psychological makeup” (Indiana University, 2022, para. 8). Note: Adapted from Indiana University. (2022). Understanding the Crisis: Addictions. IndianaUniversity.edu Note: Adapted from Jalali et al., (2020) The opioid crisis: a contextual, social-ecological framework Substance Use • Mind altering substances have been around since the beginning of time • the English word Drug was taken from French word Drogue which means Dry Herb and suggests that earliest drugs were taken and developed from plant sources (Wadud et al, 2007). • A substance can be considered “medicine” or a “drug” depending on the intent of the user and medicinal value • The use of substances is not considered a substance use disorder unless the use becomes disruptive or impairing to everyday life • What is considered disruptive/impairing is unique to everyone • Moralization of Substance Use & Development of Stigma • In America: Prohibition Era, Nixon’s War on Drugs • Creates social barriers to receiving help SUD: Recurrent use of alcohol or drugs (or both) that results in problems such as being unable to control use of the substance; failing to meet obligations at work, home, or school; having poor health; and spending an increased amount of time getting, using, or recovering from the effects of using the substance.” (Lipari & Van Horn, 2017, para 1). Youth SUD At least 1-in-8 teenagers (12-17) used an illicit substance in the last year (National Center for Drug Abuse Statistics, 2023) Most common substances used are alcohol, marijuana, and nicotine (National Center for Drug Abuse Statistics, 2023) Monitoring the Future (MTF) study found that vaping (marijuana, nicotine, and/or flavored liquid) resulted in the largest increase that MTF ever tracked (Johnson et al, 2014, p.1). • In 2019, 2.7% of youth had a SUD but no Major Depressive Episode(MDE); 1.7% of youth had both a SUD and MDE. (SAMHSA, 2020) • Total of 4.4% of youth having at least SUD in US • 39% of youth with SUD had a co-occurring disorder • Treatment for MDE in youth increased in 2019 (SAMHSA, 2020) • For youth with co-occurring SUD and MDE: (SAMHSA, 2020) • 62.5% received only mental health services • 2.4% received only SUD services • 1.3% received both SUD & mental health services • SUD treatment should always include mental health care Youth SUD and CoOccurring Disorders Number of drug overdose deaths and deaths involving illicitly manufactured fentanyl among persons aged 10–19 years (2019-2021) Youth SUD • Overdose: “Injury to the body (poisoning) that happens when a drug is taken in excessive amounts. An overdose can be fatal or nonfatal.” (CDC, 2021, para. 24) • Can be accidental or intentional Notes: IMF = illicitly manufactured fentanyl Adapted from Center for Disease Control (CDC). (2022). Drug Overdose Deaths Among Persons Aged 10–19 Years — United States, July 2019–December 2021. https://www.cdc.gov/mmwr/volumes/71/wr/mm7150a2.htm • Lacing is when one drug is added to another; may be done secretly by dealers to lessen their costs or make more addictive (Laguna Treatment Hospital, 2022) • Threat of overdose is what makes SUD so dangerous • “Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life.” (Finch et al, 2020, p. 2) • In 2011, SAMHSA broadened this definition even more by removing the mention of abstinence as a criterion for recovery: “a process of selfdirected change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.” (Finch et al, 2020, p. 2) • For youth with SUD, “developmental, legal, and familial context fundamentally differs in ways that render adult based conceptualizations of recovery insufficient”. (Finch et al, 2020, p. 3) • Aim of the curriculum to encourage abstinence from substances until adulthood/legal age by empowering youth with psychoeducation & autonomy to make their own choices • Tracking Success: Focus on symptom & use reduction rather than pure abstinence Recovery & Abstinence Current Treatment • Can be outpatient or inpatient; Intensive inpatient care is usually preferred due to serious nature of SUD • Residential treatment can lack addressing the issues that contribute to SUD • Failing to address Co-Occuring Disorders • At time of aftercare check in one year after residential treatment, “47 percent of the youth with mental health issues used marijuana weekly compared to 39 percent of the other youth, 32 percent used hallucinogens compared to 18 percent of others, and 17 percent had suicidal thoughts compared to 12 percent of the others” (Foxhall, 2001, para. 6). • Focusing on only abstinence • Marlatt & Witkiewitz (2002), “programs for adolescents using a pure abstinence-based approach (the “just say no” approach) are ineffective in reducing substance use and abuse” (p. 2) Barriers to Treatment Racial Barriers Economical Barriers Stigma •Minorities in the US are less likely to receive effective treatment •“Black adolescents with SUD reported receiving less specialty and informal care, and Latinos with SUD reported less informal services” (Alegria et al, 2010). •Found to be one of the most expensive types of care in the United States, limiting the availability of treatment depending on economic status and insurance coverages (Farhoudian et al, 2022). •$25,000 and up for at least 30 days (not counting insurance) •stigma has been defined as a social process that exists when labeling, stereotyping, separation, status loss, and discrimination occur within a power context (Link & Phelan, 2001 •“leads to the development of substance use disorders (SUDs), undermines SUD treatment efforts, and drives persistent disparities within these crises (Earnshaw, 2020, p. 1300)” Individual • Youth’s biological predisposition to developing SUD and personality/temperament factors (Youth.gov, 2022). • Stress and Trauma • Pain Interpersonal Risk Factors • Lack of social support, isolation • Exposure through Family • “approximately 1 in 8 children in the US were living in a household with at least one parent with SUD” (Lipari & Van Horn, 2017, para. 15). Community/Peers • Peer Pressure in Schools • Availability of care • Accessibility to substances Society • Public Opinion on Substances/Media • Laws and norms that are favorable towards substances, such as the more recent nicotine vaping marketing advertisements towards teenagers, can impact a youth’s perception about the dangers of drug use (Youth.gov, 2022). Youth SUD & COVID-19 Lockdown increased risk factors but lowered access to substances (Lundahl & Cannoy, 2021) Opioid overdoses skyrocketed due to lack of in-person treatment and social supports (Richter, 2022) Vulnerable Youth • Foster Care • Group Homes: Foster youth congregate care lacks family-based care; increases risk factors (Watson, 2016) • Juvenile Justice System • Juvenile Justice System fails to address SUD or provide treatment while in juvenile detention (The National Center on Addiction and Substance Abuse at Columbia University, 2004) • Low reliance on adolescent self-reporting utilized by most of the research, the failure of justice and other systems to routinely assess youth for either current drug use or indicia of drug use (e.g., “resiliency” or “protective” factors), and confidentiality and other restrictions pertaining to access to juvenile justice system information. (Cooper, 2009, p. 2) • “Art therapy is an integrative mental health and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship” (AATA, 2022). • Art therapy offers a non-judgmental means of expression that explores the deeper issues behind substance use in an alternative manner than traditional talk therapy. • benefits art therapy brings in SUD treatment include decrease in denial, reducing opposition towards treatment, providing an outlet for communication and lessening shame (Aletraris et al, 2014) • helps to target rigid defenses and denial, fostering insight and awareness, encouraging emotional expression, enhances self-esteem and promotes creativity and problem solving in SUD clients (Hanes & Rojas, 2022). Art Therapy and Youth SUD Curriculum Structure • 10 Week Curriculum; 1h 30 mins • Begins with Introduction, Ends with Termination • 8 weeks in-between based upon elements of the socio-ecological model of substance use C disorder • Individual, Interpersonal, Community/Peers, and Society • Intended to be used in a residential setting, assuming youth are receiving other services including individual therapy and psychoeducation on mental health & substances • Facilitated by Master’s leveled art therapist Week 1 (Introduction) Forging Direction: The Road Drawing Activity •Intro: Introductions, Rules •Check-in: “Tell us your name, where you are from, and one unique fact about yourself”. •“For this project, I would like for you to create an image of a road. There are no right or wrong responses to this prompt. Some things to think about: What is your road made of? Where does your road lead to? What surrounds the road?” Processing Prompts: • • • • What was your road made of and where did it lead to? Were there any signs that assisted the road? What about any hazards surrounding the road? Where do you believe you are on this road right now? How do you feel this could be related to your personal journey and recovery? Goals •Begin to envision what recovery looks like for each participant •Evaluate where participants are in road to recovery Materials •Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Construction Paper, Plain Paper, Paint, Textile Fabric Week 2: (Individual) Looking Back – Timeline of My Life Activity •Check-in: “Think about a high and low of the last week. Take about five minutes to think and then we will share.” •“For this activity, I would like you to create a timeline of your life. Think about moments in your life that have defined you, from birth to this point in time. There are no right or wrong ways to develop this timeline.” Goals Processing Prompts: • • • • What are the most impactful events that happened in your life? Are there any patterns that you notice? Have there been events that have made you stronger? Are there any events that have made you feel vulnerable? Try to identify when you first started using substances. Was this related to any particular event? •Examine specific events that have influenced substance use • Identify protective and risk factors developed through participants experiences Materials •Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Construction Paper, Plain Paper, Paint Paper, Air Dry Clay, Modeling Clay, Clay Tools, Textile Fabric, String, Beads, Week 3: (Individual) Processing Trauma – Body Map Activity •Check-in: “If you were an animal, what animal would you be and why?” •“For this activity, we will be creating a body map. Chose a partner to help trace your body on a life sized sheet of paper. After this, take a moment to close your eyes and envision how your body feels. Use art materials to map out the different feelings.” Goals Processing Prompts: • • • • How did this activity feel? Were there any parts that surprised you? Were there any areas that you feel pain? Has substance use influenced any parts of your body? •Show how trauma impacts the physical body •Examine how drugs impact the body •Encourage social support Materials •Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Large Rollable Paper Week 4: (Interpersonal) Family of Origin – Genogram Activity •Check-in: “Now that we’ve been meeting for a few weeks, I’m wondering what are your goals from these sessions?” •“Take a moment to think about your family, whether biologically related to you or people you consider like family. Including yourself, create a genogram or family tree including yourself and how these important people are connected to you. Use patterns, words, lines, shapes to identify specific connections. You can include a legend that depicts what each symbol means, if you’d like too. Try to include as many people as you can that have come to impact your life”. Goals Processing Prompts: • • • Who are some of the people that you included in your genogram? Are there any patterns or similarities between the people and yourself? Any differences? Are there any relationships you consider toxic? Any relationships that are healthy and supportive? •Explore familial connections •Create a physical representation of family systems •Understand impact of family relationships and drug use Materials •Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Large Rollable Paper, construction paper, colored tape, stickers Week 5: (Interpersonal) Birth Order – Kinetic Family Drawing/Sculpture Activity •Check-in: “What is your earliest memory from childhood? Take a few minutes to write or draw this memory.” •“For this activity, I would like you to create a drawing or sculpture of you and your family doing something together. Think of your immediate family and the household you grew up in. Include yourself, siblings, parental figures or other family members/family friends that were impactful to you and that you lived with.” Goals Processing Prompts: • • • Who is in the drawing/sculpture and what are you doing together? Looking at Adler’s birth order roles, what do you feel like your role was? Does the personality description resonate with you or do you feel like you connect with a different description? Who do you have the best relationship with? Who do you have a strained relationship with? •Examine the roles and relationships within immediate family • Understand how birth order affect’s youth personality and personal experience • Examine how personality factors and familial role contributes to substance use Materials •Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Paper, Construction Paper, Clay, Fabric, Textiles, Beads, Aluminum Foil Week 6: (Community/Peers) Exploring Supports – The Tree of Life Activity • Check-in: “How do you want to be perceived or thought of by others?” • “For this activity, we will be creating a Tree of Life representing social connections. The first step is to envision and draw a tree with roots, a trunk, and a crown. In the roots sections, include pictures and/or words that represent social connections, any people/groups/organizations/places that have influenced who you are as you were growing up. On the trunk, write your name and include anything you feel represents you in the present. On the crown of the tree, include leaves/branches of social connections that you would like to keep, ones that you would like to form, and ones that you would like to disconnect or fall off like dead leaves.” Goals Processing Prompts: • • • • What connections have defined you to this point in your life? How do you feel others view you now in the present? What connections would you like to form or keep? What connections would you like to severe? Have you noticed any connections that are positive, neutral, or negative? • Explore social connections and supports • Determine if connections are positive, neutral, or negative • Explore social impacts of substance use Materials • Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Paper, Construction Paper Week 7: (Community/Peers) Recovery Groups – Group Mural Activity •Check-in: “Think of the people that you were close with before joining this group. How will they influence your newfound view of recovery? How will they support your recovery?” •“For this activity, I want you all to image what your recovery looks like. Work collaboratively to share this wall space for your creation. You may work together or independently, but try to be aware of how the space you chose impacts and relates to what others are creating around you.” Goals Processing Prompts: • • • • How did this activity feel? What was it like working with others in this process? Were there any conflicts or any compromises? How can working with others support your recovery? •Provide new perspectives on recovery • Encourage social connection •Model healthy relationships Materials •Acrylic Paint, Paintbrushes, Wall Space (inside or outside), Sidewalk Space or Large Cloth (at least 10ft x 8ft) Week 8: (Society) Self-Concept vs Social Identity – Dual Self-Portrait Collage Activity • Check-in: “What is your role in society? Take a few minutes to write or draw your ideas.” • “Today we will be creating a dual-self portrait based on our ideas of self-concept and social identity. Self-concept is the ideas you have about yourself, while social identity is how you feel you fit into the world around you. To start the portrait, create an outline of yourself being as detailed or as vague as you prefer. Once finished, draw a line up and down through the center of the outline. Label one side “How I view myself” and the other side “How others view me”. Take the rest of the time using art materials and collage materials provided to fill in the space within your outline.” Goals Processing Prompts: • • • • • Examine self-concept vs. social Identity • Compare aspects of self-concept and social identity • Make connections to protective and risk factors of substance use in both self-concept and social identity How are the sides of your portrait similar? How are they different? How does substance use influence the sides of your portrait? If you could change anything about the portraitMaterials for the future, what would you change and • Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Paper, why? Construction Paper, Magazines, Old Books, Text Cut Outs, Pictures It can be hard when our idea of self and social identity do not match or are not similar. How can your ideas of self and how others view you change to become more aligned with one another? Week 9: (Society) Overcoming the Stigma of Addiction – Group Mandala Activity • Check-in: “Are there any stigma’s that exist for individuals that use substances? Have you ever felt judged by others? What did this feel like?” • “Each of you will receive a part of a piece of paper that together form a circle. For this activity, I want you to think about what your have brought to this group over the course of weeks we’ve been meeting. What parts did you play? How did you impact others? What was your overall role in our group? Please draw or paint your response to these questions on the piece of paper. At the end, we will attach all of the pieces to form a circle or mandala that represents our group.” Goals Processing Prompts: • • • What do you think your role was in this group? How have you overcome the negative stigmas you’ve faced? How does this group defy the social stigmas put against us? • Show how each individual impacts the group • Display how each individual part put together creates meaning and connection • Encourages connection and social interest Materials • Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Paper, Construction Paper Week 10: (Termination) Letting Go of Addiction – Torn Paper Transformation Activity • Check-in: “What was your favorite thing we did during these sessions? How do you feel ending the sessions? What does recovery look like for you?” • “For this activity, I want you to write, draw, and/or paint what you felt like when you first entered into group therapy. Think about your mindset and thoughts of substance use. When finished, rip or cut up this piece of paper into smaller pieces. Use these pieces, art materials, and a new sheet of paper to create your current mindset. Think about what you’ve learned about yourself, substance use, and what recovery is like.” Goals Processing Prompts: • • • How has your mindset transformed from the first session to now? What are the most important insights you’ve learned about yourself? Do you feel like you will still use substances after this group? • Examine past before engaging in group therapy • Examine present values and beliefs • Leave group with a clear understanding of what recovery looks like for each individual Materials • Pencils, Colored Pencils, Pens, Markers, Acrylic Paint, Watercolor Paint, Paintbrushes, Paper, Construction Paper Discussion Personal Experience witnessing SUD in Family Members Working in an Adolescent Residential Facility for youth SUD Not officially test; validity and reliability not assessed Limitations Not all may connect with Art Therapy Modality Intended for use within a residential setting Curriculum relies on social aspect of group therapy Areas for Future Research Could curriculum be used with adults? Further research into art therapy with SUD Differences of the socio-ecological model of substance use from youth vs adult Q&A References • Aletraris, L., Paino, M., Bond Edmond, M., Roman, P.M., Bride, B.E. (2014, December 17). The Use of Art and Music Therapy in Substance Abuse Treatment Programs. J Addict Nurse, 25(4): 190-196. doi:10.1097/JAN.0000000000000048 • American Art Therapy Association (AATA). (2022). About Art Therapy. AATA. https://arttherapy.org/about-art-therapy/ • Alegria, M., Carson, N. J., Goncalves, M., & Keefe, K. (2011). Disparities in Treatment for Substance Use Disorders and Co-Occurring Disorders for Ethnic/Racial Minority Youth. Child and Adolescent Psychiatry, 50 (1), 22-31. https://doi.org/10.1016/j.jaac.2010.10.005 • Carlson, J., & Johnson, J. (2016). Adlerian therapy. In I. Marini & M. A. Stebnicki (Eds.), The professional counselor’s desk reference., 2nd ed. (pp. 225–228). Springer Publishing Company. • CDC. (2022, January 18). The Social-Ecological Model: A Framework for Prevention. Centers for Disease Control and Prevention; CDC. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html • CDC. (2021). Commonly Used Terms. Centers for Disease Control and Prevention; CDC. https://www.cdc.gov/opioids/basics/terms.html • CDC. (2022). Drug Overdose Deaths Among Persons Aged 10–19 Years — United States, July 2019–December 2021. Centers for Disease Control and Prevention; CDC. https://www.cdc.gov/mmwr/volumes/71/wr/mm7150a2.htm • Cooper, C. S. (2009). Adolescent Drug Users: The Justice System Is Missing an Important Opportunity. Family Court Review, 47(2), 239–252. https://doi.org/10.1111/j.1744-1617.2009.01251.x • Earnshaw, V. A. (2020). Stigma and substance use disorders: A clinical, research, and advocacy agenda. American Psychologist, 75(9), 1300–1311. https://doi.org/10.1037/amp0000744 • Farhoudian, A., Razaghi, E., Hooshyari, Z., Noroozi, A., Pilevari, A., Mokri, A., Mohammadi, M. R., & Malekinejad, M. (2022). Barriers and Facilitators to Substance Use Disorder Treatment: An Overview of Systematic Reviews. Substance Abuse: Research & Treatment. Sage Journal, 1–11. https://doi.org/10.1177/11782218221118462 • Finch, A. J., Jurinsky, J., Anderson, B. M. (2020). Recovery and Youth: An Intergrative Review. Alcohol Research Current Reviews. 40(3):06. https://doi.org/10.35946/arcr.v40.3.06 • Foxhall, K. (June, 2001). Adolescents Aren’t Getting the Help They Need. Monitor, 32(7). https://www.apa.org/monitor/jun01/adolescents • Fong Chan, P. C., Norman L. Berven, P., & Kenneth R. Thomas, De. (2015). Counseling Theories and Techniques for Rehabilitation and Mental Health Professionals: Vol. Second edition. Springer Publishing Company. • Giordano, A. L., Clarke, P. B., & Furter, R. T. (2014). Predicting Substance Abuse Relapse: The Role of Social Interest and Social Bonding. Journal of Addictions & Offender Counseling, 35(2), 114–127. https://doi.org/10.1002/j.2161-1874.2014.00030.x • Hanes, M. J., & Rojas, J. (2022). Modified Bridge Drawings With a SUD Population in a Residential Setting. Art Therapy: Journal of the American Art Therapy Association, 39(3), 138–145. https://doi.org/10.1080/07421656.2021.1986328 • Horner, P. S., Andrade, F., Delva, J., Grogan-Kaylor, A., & Castillo, M. (2012). The Relationship of Birth Order and Gender with Academic Standing and Substance Use Among Youth in Latin America. Journal of Individual Psychology, 68(1), 19–37. • Indiana University. (2022). Understanding the Crisis: Addictions. IndianaUniversity.edu https://addictions.iu.edu/understanding-crisis/understandingaddiction.html#:~:text=The%20socioecological%20model%20of%20addiction%20and%20substance%20use,our%20own%20individual%20biological%2C%20genetic%2C%20and%20psychological% 20makeup • Jalali, M.S., Botticelli, M., Hwang, R.C. et al. The opioid crisis: a contextual, social-ecological framework. Health Res Policy Sys 18, 87 (2020). https://doi.org/10.1186/s12961-020-00596-8 • Johnson L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J. E., Miech, R.A. (2014). Monitoring the Future national survey results on drug use, 1975-2013. Institute for Social Research, University of Michigan, 1, 32-36. • Laguna Treatment Hospital. (2022). How Dangerous is Marijuana When Lace with Another Drug. https://lagunatreatment.com/drug-abuse/marijuana/lacingdanger/ • Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385. https://doi.org/10.1146/annurev.soc.27.1.363 • Lipari, R.N. & Van Horn, S.L. (2017, August 24). Children living with parents who have a substance use disorder. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD. https://www.samhsa.gov/data/sites/default/files/report_3223/ShortReport-3223.html • Lundahl LH, Cannoy C. COVID-19 and Substance Use in Adolescents. Pediatr Clin North Am. 2021 Oct;68(5):977-990. doi: 10.1016/j.pcl.2021.05.005. Epub 2021 May 18. PMID: 34538307; PMCID: PMC8445753. • Marlatt G. A., Witkiewitz K. (2002). Harm reduction approaches to alcohol use: health promotion, prevention, and treatment. Addict Behavior, 27: 867-86. • National Center for Drug Abuse Statistics. (2023). Drug Use Among Youth: Facts and Statistics. https://drugabusestatistics.org/teen-druguse/#:~:text=Substance%20Abuse%20Among%20Youth%201%202.08%20million%20or,illicit%20drugs%20in%20the%20last%20month.%20More%20items • National Center on Addiction and Substance Abuse at Columbia University. (2004). Criminal Neglect: Substance Abuse, Juvenile Justice and the Children Left Behind. • Richter, L. (2022). Taking Stock of the Downstream Effects of COVID-19 on Youth Substance Use Risk. Journal of Adolescent Health. 71(6). https://doi.org/10.1016/j.jadohealth.2022.09.007. • Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/ • Substance Abuse and Mental Health Services Administration (SAMHSA). (2019). Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. • Watson, A. E. (2016). Foster Children and Youth in Congregate Care Settings : Overview, Issues, and Reduction Efforts. Nova Science Publishers, Inc. • Wadud, A., Prasad, P., V., Rao, M., M., Narayana A. (2007). Evolution of drug: a historical perspective. Bull Indian Inst Hist Med Hyderabad, 37(1):69-80. PMID: 19569453. • Youth.gov. (2022). Risk and Protective Factors. https://youth.gov/youth-topics/risk-and-protective-factors