Alyse Schonfeld, Ethan Freedman, Katherine Gudas Kagel, Rebecca St. James, and Robert Lugo

Columbia School of Social Work

Human Behavior and the Social Environment - Behavior Change

Dr. Victoria Frye

May 2, 2025

Acknowledgements

In introducing the following work, we would like to begin by acknowledging the traditional, ancestral, and unceded territory on which we learn, work, and resource from at Columbia University School of Social Work is land of the Lenape and Wappinger indigenous peoples. Let us commit ourselves to the struggle against the forces that have dispossessed the Lenape, Wappinger, and other indigenous people of their lands.

We would also like to acknowledge Prof. Victoria Frye and her class in Topics of Human Behavior and the Social Environment: Behavior Change (SOCWTT660C) for introducing us to pivotal social work principles of behavior change. In addition, Prof. Frye’s fruitful comments and help as we delved into this project. Moreover, our peers with whom we worked closely in discussion during class and were very influential in developing thoughts around this paper as it relates to designing interventions and approaching behavior concepts. We appreciate everyone in the class for the ideas they have assisted in generating. With these acknowledgements, we present the following work of our own.

Part 1: Identification of Setting and Problem

Identify the organization for which you are developing your intervention proposal.

Group Foster homes for youth girls within The New York City Administration for Children’s Services (ACS)

Provide a brief description of the organization and its activities.

This proposed intervention is designed for group foster home settings with youth girls in the New York City Administration for Children’s Services (ACS), the agency responsible for overseeing foster care, protective services, and child welfare initiatives across New York City (Administration for Children's Services, 2021). ACS coordinates care for thousands of youth through contracted residential placements, including group homes, transitional housing, and specialized mother-child programs. ACS protects and promotes the safety and well-being of New York City’s children and families by providing child welfare, juvenile justice, and early care and education services (Administration for Children's Services, 2025; Annie E. Casey Foundation, 2021).

In child welfare, ACS partners with private nonprofit organizations to offer preventive services that help support and stabilize families at risk of crisis while also providing foster care services for children who cannot safely stay at home (Administration for Children's Services, 2021). Each year, the agency’s Division of Child Protection conducts more than 55,000 investigations of suspected child abuse or neglect (Administration for Children's Services, 2021; Office of the New York State Comptroller, 2021). ACS manages and funds services in juvenile justice, including detention and placement, intensive community-based alternatives for youth, and support services for families. In early care and education, ACS coordinates and funds programs and vouchers for close to 100,000 children eligible for subsidized care (Administration for Children's Services, 2025; Child Welfare Information Gateway, 2020).

However, despite the agency’s expansive role and efforts, gaps persist in practice. In a residential care setting serving foster youth, where the organization receives funding from and collaborates closely with ACS, shortcomings have been observed in the provision of trauma-informed care, mental health support, and meaningful interventions for youth navigating survival under system supervision (Moss et al., 2020; Ramseyer Winter et al., 2016; Lotzin et al., 2019).

Identify a behavior problem that you will target in your intervention. Define the problem to be addressed that is specific and measurable.

This intervention focuses on youth within the ACS foster care system who have experienced sexual trauma. The behavior problem we will target is the prevalence of SUD in our target population, as measured using the DSM-5 Checklist (DSM5) diagnostic tool for substance use disorder (Addiction Research Center, 2020; American Psychiatric Association, 2013).

Part 2: Overview of the Problem

Explain the significance of the problem and how it impacts your outcome of interest

Many youths in the ACS system have experienced childhood sexual trauma (Moss et al., 2020; Administration for Children's Services, 2021). The incidence of SUD among this population is significantly higher than that within the general population (Moss et al., 2020). Within ACS, services often focus on behavioral compliance rather than healing. Youth are commonly moved, suspended, or criminalized instead of being supported through their trauma (Mirick, 2013). Despite the system's stated goals of safety, permanence, and well-being, the day-to-day reality for many youths is fragmented care and unmet emotional needs (Wurth, 2022).

A study published in Child Welfare found that 45% of foster care youth reported using alcohol or illicit drugs within the last six months, and 35% met the criteria for a substance use disorder (Vaughn, Ollie, McMillen, Scott, & Munson, 2007). Substance misuse among youth in foster care is often misunderstood as deviant or high-risk behavior when it is, in many cases, a survival strategy deeply rooted in trauma (Lotzin, Grundmann, Hiller, Pawils, & Schäfer, 2019; Moss et al., 2020).

These youth are often treated for behavior problems rather than as individuals in need of care, healing, and community. Despite their resilience, they are frequently pushed out of placements, criminalized, or left to navigate high-risk survival strategies alone (Knight, 2020; Thumath et al., 2021). Placement disruptions are a common experience for foster children. For instance, in 2020, among children in care for two years or longer, 59% experienced three or more placements (Child Welfare Information Gateway, 2020). Such instability is associated with adverse effects on psychosocial functioning and can exacerbate existing behavioral issues (Wurth, 2022). Furthermore, children initially placed in group or residential settings experience a higher number of moves on average, highlighting the impact of initial placement type on long-term stability (Child Welfare Information Gateway, 2020).

For foster youth—many of whom have experienced chronic instability, repeated displacement, sexual trauma, and systemic neglect—substance use is rarely recreational; it becomes a means of emotional regulation, a way to cope with overwhelming stress or memories, or a response to the absence of consistent caregiving and therapeutic support (Kenny et al., 2015; Stengel, 2014; Hari, 2015). As Hari (2015) argues, addiction often stems not from moral failure or lack of willpower but from disconnection—social, emotional, and relational. In this context, connection is not just a tool for recovery—it is a form of survival.

B. Identify a data source where you can gain estimates of the problem and outcomes

While we have not identified a data source providing consistently updated rates of SUD among foster youth in the United States who have experienced sexual trauma, relevant research data sets do exist. One such data source comes from Moss et al. (2020), which emphasizes that the population of foster youth experiencing adverse childhood experiences (ACEs) directly impacts developmental health and socioemotional outcomes. While many ACEs correlate to substance use among youth in foster care, specific maladaptive experiences like sexual abuse can compound developmental risks for substance use disorder (Moss et al., 2020).

We have also identified research articles examining the relationship between childhood sexual trauma and SUD and the prevalence of sexual trauma among youth in the foster care system (Lotzin et al., 2019; Ramseyer Winter et al., 2016). According to the Annie E. Casey Foundation (2021), about 10% of children in foster care have been sexually abused, underscoring the need for targeted interventions addressing sexual trauma. For those who experience increased levels of childhood trauma and sexual trauma, the possible onset of substance use can occur earlier alongside accelerated growth of maladaptive usage behaviors (Lotzin et al., 2019; Ramseyer Winter et al., 2016).

C. Develop a hypothesis for why the desired behavior/outcome is not occurring at the level you are seeking.

Foster youth who have experienced sexual trauma demonstrate a higher prevalence of substance use disorder (SUD) than the general population due to a variety of factors, including the impact of repeated trauma, system-induced instability, the lack of consistent caregiving, and punitive responses to behavior. This is further exacerbated by limited access to trauma-informed mental health services, fear of criminalization or placement disruption, and a lack of safe, nonjudgmental spaces to disclose experiences of sexual exploitation or drug use. Youth often avoid seeking help because disclosures may lead to surveillance, punishment, or further disconnection from vital supports (Thumath et al., 2021).

While foster youth who have experienced sexual trauma are at increased risk for substance use disorder due to compounding maladaptive experiences, instability, and lack of supportive services, participation in intentional and targeted group-based mental health interventions—such as Multidimensional Family Therapy (MFT) and group Cognitive Behavioral Therapy (CBT) (More research necessary for our literature review)— may reduce risks by providing safe, consistent, and trauma-informed support. We believe that by providing group-based mental health services specifically targeting youth in foster care who have experienced sexual trauma, we can reduce the prevalence of Substance Use Disorder among our target population.

Part 3: Literature Review

This literature review aims to explore the connection between sexual trauma, foster care involvement, and substance use, while evaluating the most effective interventions that could be utilized for this underserved population. The distal/intermediate factors, causal mechanisms and mediating factors identified are proposed to exacerbate risk of substance use disorder amongst teens in the foster care system who have experienced sexual trauma.

The identified distal/intermediate causes of elevated risk for substance use disorder amongst teens in the foster system is as follows: childhood sexual and physical abuse, living in the foster care system itself, peer group substance use, placement instability and group home transience, and a general lack of trauma-informed care responses available to vulnerable youth. Childhood sexual and physical abuse are recognized as significant risk factors for the later development of substance use, with particularly pronounced effects observed among females (Kobulsky, 2017; Danielson et al., 2012; Cicchetti & Handley, 2019; Valdez et al., 2014).

Living in foster care has also been strongly associated with a heightened risk of developing substance use disorder (Kim et al., 2017; Radenhausen et al., 2024; Pilowsky & Wu, 2006). Adverse childhood events and abuse incurred during childhood has been shown to exacerbate this risk (Becker et al., 2024). Youth in foster care are also more likely than their peers in the general population to be exposed to peer group substance use (Kim et al., 2017). This elevated exposure is partly due to the higher prevalence of substance use within foster care environments, which increases the likelihood of normalization and peer influence (Kim et al., 2017). Placement instability and transience within group home settings further exacerbate these risks (Anderson et al., 2019; Bederian-Gardner et al., 2018; Fairbairn et al., 2018; Kim et al., 2013; Kim et al., 2017). Frequent changes in caregiving environments disrupt the formation of secure attachments, reduce stability, and increase exposure to deviant peer groups, all of which contribute to higher susceptibility to substance use (Anderson et al., 2019; Bederian-Gardner et al., 2018; Fairbairn et al., 2018; Kim et al., 2013; Kim et al., 2017). Additionally, youth with histories of trauma often receive care that is fragmented or lacks integration across service systems (Beyerlein & Bloch, 2014). The absence of trauma-informed care responses can worsen emotional and behavioral symptoms, thereby increasing the risk of substance use as a maladaptive means of coping (Becker et al., 2014; SAMHSA, 2021).

Several causal mechanisms and mediating factors contribute to the heightened risk of substance use disorders (SUD) among youth with histories of trauma and foster care involvement. These include psychological, behavioral, and environmental factors that interact to influence long-term outcomes. Childhood abuse significantly undermines the development of secure attachments, and living in foster care further exacerbates attachment insecurity due to inconsistent caregiving and relational disruptions (Bederian-Gardner et al., 2018). Insecure attachment has been strongly associated with an increased risk of developing substance use disorders later in life (Fairbairn et al., 2018; Anderson et al., 2019). Psychiatric symptoms and emotional dysregulation are also common consequences of early trauma and foster care experiences (Dvir et al., 2014; Pilowsky & Wu, 2006). Childhood abuse is linked to a higher prevalence of emotional dysregulation, which impairs one’s ability to manage distress effectively (Dvir et al., 2014).

Furthermore, living in foster care has been correlated with increased rates of psychiatric symptoms and emotional dysregulation, adding to the psychological vulnerability of these youth (Pilowsky & Wu, 2006; Valdez et al., 2014). Externalizing behaviors, such as aggression and rule-breaking, often arise in response to trauma (Kobulsky, 2017; Cicchetti & Handley, 2019). These behaviors serve as mediators between childhood abuse and later substance use, highlighting the role of behavioral dysregulation as a developmental pathway to maladaptive outcomes (Kobulsky, 2017; Cicchetti & Handley, 2019). Maladaptive coping strategies further compound these risks; many youth turn to substance use as a coping mechanism for unresolved trauma, particularly when they lack access to effective emotional regulation strategies (Danielson et al., 2012; Underwood et al., 2007).

A deficiency in adaptive, relational, or collective coping mechanisms can reinforce continued reliance on maladaptive behaviors such as substance use (Gabrielli et al., 2017). Foster youth, in particular, often resort to asocial coping methods due to disrupted support systems (Harden, 2004). Childhood abuse may initiate patterns of maladaptive behavioral development that lead to dysregulation, which is further intensified by system-level issues such as placement instability and transience in group home settings (Cicchetti & Handley, 2019; Harden, 2004; Bederian-Gardner et al., 2018). Peer influence is another significant factor. Peer alcohol use has been consistently identified as a strong predictor of individual alcohol consumption (Anderson et al., 2019). The risk increases when youth form associations with substance-using peers, particularly in the absence of stable and supportive caregiver relationships (Kim, Buchanan, & Price, 2017).

Finally, inadequate support systems, including the lack of trauma-informed and multi-level behavioral interventions such as Risk Reduction through Family Therapy (RRFT) and Multidimensional Family Therapy (MDFT), contribute to the persistence of symptoms and risk of relapse (cite). Without comprehensive and integrated care, youth are less likely to achieve sustained recovery from trauma and substance use (Becker et al., 2024; SAMHSA, 2021).

Part 4: Explanatory Model of Behavior

Figure 1. Pathways to Substance Use Disorder Risk Among Foster Youth with a History of Childhood Sexual Abuse

Part 5: Outcome For The Targeted Behavior

The targeted behavior for this intervention plan is the reduction of substance use among foster youth in group homes within the New York City Administration for Children Services (ACS) system who have experienced sexual trauma. These youth demonstrate disproportionately high rates of substance use disorder (SUD) as a result of compounding vulnerabilities including adverse childhood experiences (ACEs), emotional dysregulation, placement instability, and lack of trauma-informed mental health care (Moss et al., 2020; Lotzin et al., 2019). The measurable outcome will be a reduction in SUD symptoms as assessed through tools such as the DSM-5 diagnostic criteria for SUD (American Psychiatric Association, 2013; Addiction Research Center, 2020). By addressing the emotional, cognitive, and structural conditions that contribute to maladaptive coping, the intervention seeks to interrupt the behavioral trajectories leading to substance misuse and instead foster pathways of healing, resilience, and sustained behavioral change.

Theories or Conceptual Models That Inform The Intervention Plan

The present intervention plan is grounded in an integrated theoretical framework that combines multiple models to address the complexity of trauma, systemic involvement in group home and foster care settings, and behavioral health in foster youth. Rooted in Trauma-Informed Care (TIC) frameworks that ensure all intervention components incorporate principles of safety, trustworthiness, collaboration, empowerment, and choice, this framework is critical for agents who have experienced trauma and system involvement in our target population (SAMHSA, 2014). With trauma-informed care orienting both the structure and delivery of the intervention, the outcome of reducing substance use is situated alongside mitigating the retraumatization of participants while promoting healing.

In tandem with this, Bronfenbrenner’s (1979) Ecological Systems Theory underscores the impact of multiple environmental systems through which foster youth move. Whether their immediate family, foster family, chosen family, peers, institutions, or societal structures, the development of adolescents in general and foster youth is embedded in child welfare systems as well as ecological disruptions. Whether frequent placement changes, fractured peer and adult relationships, or isolation from any broader macrosystem, foster youth are strongly associated with increased SUD risk (Bederian-Gardner et al., 2018; Kim et al., 2017).

While the situated intervention will address behaviors on many levels of influence, Cognitive Behavior Theory (CBT) will serve as a foundation for modifying the maladaptive thought patterns and emotional regulation issues that often arise from trauma (Beck; 1967). Youth who have experienced sexual abuse frequently engage in substance use as a coping mechanisms for unprocessed emotions, intrusive memories, or negative self conceptions (Danielson et al., 2012; Becker et al., 2024). CBT-informed group modules will be used to support cognitive restructuring and skills for emotional adjustment. Multidimensional Family Therapy (MDFT) is a guiding clinical model for this intervention as it integrates family level cognitive, behavioral, and system situated practices to treat adolescent substance use and related behavioral problems. Although foster youth may lack traditional familial networks, MDFT can be adapted to include chosen family, group home staff, or supportive caregivers and adults to address relational healing and behavioral change (SAMHSA, 2021). It is essential to address these family systems in tandem with Attachment Theory and an understanding of the impact of disrupted early caregiver relationships on emotional regulation (Bowlby, 1988). Foster youth often exhibit insecure attachment styles due to neglect or trauma, which can contribute to coping through substance use (Fairbairn et al., 2018; Cicchetti & Handly,  2019). Through the incorporation of practices sensitive to developing secure attachments and mitigating maladaptive forms, the present intervention aims to promote relational safety and trust for foster youth and their networks.

Lastly, The Behavioral Drivers Model (BDM; Petit, 2019) offers the most sensible and realistic framework for the structure of the intervention model. Ensuring interventions that are context sensitive by identifying individual, social, and structural drivers of behavior, the BDM aligns with the multifaceted nature of SUD in group home foster care youth by recognizing the roles of identity, belief systems, emotional states, social norms, peer influence, and service delivery systems capable of shaping substance use (Petit, 2019). With the Behavioral Drivers Model providing a global structure within which to target and integrate the various elements of our intervention, these frameworks together provide a comprehensive, trauma-sensitive, systems-informed design and implementation strategy that is developmentally appropriate and contextually grounded.

Intervention Components

The proposed intervention is a 16-week, trauma informed group therapy program designed for foster youth in group homes within the New York city Administration for Children Services (ACS) who have experienced sexual trauma and are at risk or currently experiencing Substance Use Disorder (SUD). The intervention will be structured around weekly, closed group virtual sessions that blend evidence based skills training with structured peer support, drawing from Trauma Focused Cognitive Behavioral Therapy (TF-CBT), Multidimensional Family Therapy (MDFT), and Cognitive Behavioral Therapy (CBT) approaches (Becker et al., 2024; Danielson et al., 2012; SAMHSA, 2021)

Group Composition and Facilitation

Each group will include six to eight members, with a minimum threshold of three and a maximum of twelve participants. Groups will be opt-in and closed, meaning that continued participation is at the discretion of each member and membership is fixed following a screening process led by facilitators to assess appropriateness, clinical readiness, and group dynamic fit. Two individuals will be responsible for facilitating, one Lead Facilitator and one Support Facilitator. The Lead Facilitator is responsible for session leadership, including delivering structured and skills-based content related to behavior change, providing time management, and guiding group discourse. The Support Facilitator is tasked with providing individualized support to group members during sessions, offering supplemental guidance to participants in emotional distress, and contributing to group processes when appropriate.

Recruitment Strategy

Recruitment will occur across ACS-affiliated group homes in all five New York City Boroughs, while outreach methods will include the distribution of information flyers, direct engagement with informational sessions hosted by group homes for foster youth, and referrals facilitated by staff and providers. Despite the option of focusing on a single borough or group home remaining a viable adaptation for future in-person interventions, the current iteration prioritizes outreach and accessibility through a virtual format that addresses challenges related to geographic diversity and recruitment volume.

Session Format and Structure

Group sessions will occur weekly via a secure virtual platform and will be 60 minutes in length. Each session will follow a consistent four part structure:

Check-Ins (10 minutes)

Group members will be invited to share how they are feeling and highlight any pressing issues they hope to discuss during the session. This segment fosters emotional regulation and group cohesion by integrating Trauma-Informed Care (TIC) principles of safety and empowerment through the creation of facilitator and peer created space for support focused on each member’s. individual needs (SAMHSA, 2014).

Skills Training (25 Minutes)

Led by the Lead Facilitator, this portion will include instruction and interactive engagement with one trauma-focused cognitive behavioral skill. Skills may range from emotion regulation, identifying automatic thoughts, grounding techniques, or behavioral activation. These activities are broadly grounded in the emphasis of CBT on restructuring maladaptive thoughts and behaviors (Beck, 1976) and are tailored to the emotional and relational realities of youth in foster care (Cicchetti & Handley, 2019).

Supportive Discussion (20 Minutes)

Facilitators will guide an open discussion around the themes raised during check-ins and skill integration, providing space for peer support and reflection. This portion of the intervention encourages development of positive narratives and peer normalization, consistent with narrative and group therapy models for trauma-affected youth (Bougard et al., 2016; Underwood et al., 2007).

Mode of Delivery

Given the geographic spread of potential participants ranging from all five boroughs of New York City and the complexities of travel that are required for physical participation, the present intervention will be administered in a virtual format. This approach enhances accessibility and feasibility while maintaining fidelity to trauma-informed engagement principles. Future adaptations for in-person implementation may be explored pending recruitment success and infrastructural support–as well as funding.

Change Mechanisms

The proposed intervention activates change both through skills and support-based mechanisms drawing from trauma-informed cognitive-behavioral, and group therapy models. These mechanisms directly respond to the identified behavior risks located in “Part 4: The Explanatory Model of Behavior,” and organizes behavioral change across psychological, social, and structural domains oriented by the Behavioral Drivers Model (Petit, 2019).

Skills-Based Mechanisms

The skills component of the intervention is designed to address individual level drivers such as emotional well being, agency, self-efficacy, mindset, and beliefs, while also strengthening concrete behavioral tools. Drawing on elements of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Dialectical Behavioral therapy (DBT), the group will introduce and practice skills that have shown efficacy in reducing emotional distress and substance use in adolescents who have experienced trauma (Becker et al., 2024; Danielson et al., 2012). These include: emotional regulation skills (reduction on the reliance of substances as a means of coping with trauma symptoms), cognitive restructuring (challenging and shifting internalized shame, negative images of self, and beliefs related to trauma), tolerance for distress (borrowed from DBT, this particularly supports youth during emotional activation), clarification of values, and commitment to action (informed by acceptance and commitment therapy (ACT), to reinforce aspirations and goal setting amidst adversity) (Beck, 1976; Becker et al., 2024; Cicchetti & Handley, 2019; Dvir et al., 2014; Underwood et al., 2007). These mechanisms also align with the Behavioral Drivers Model emphasis on internal psychological drivers like mindset, past experience, and identity, as well as enabling conditions such as awareness, knowledge, and confidence that mediate behavior change motivation. (Petit, 2019)

Support-Based Mechanisms

The supportive group process initiates interpersonal and relational drivers of behavior that include social norms, self-image, sense of belonging, and relational safety. These mechanisms draw directly from Irvin Yalom’s therapeutic factors of group therapy, which are especially important in populations impacted by shame, isolation, and systemic disconnection (Yalom & Leszcz, 2020). The incorporated support-based mechanisms are as follows: connectivity, affirmations and validation, rewriting the emotional experience, and informed harm reduction. Participants will experience connectivity by encountering shared experiences of trauma, system involvement, and substance use, reducing feelings of alienation and reinforcing the belief that change is possible. This particularly addresses identity related drivers like internalized stigma and low self worth. Members will support one another by validating each other’s experiences, thus building agency, relational trust, and positive regards for self, something critical to countering trauma induced helplessness (Gabrielli et al., 2017). By sharing stories that have been previously silenced due to fear or shame (especially around sexual violence or drug use), participants will receive nonjudgemental feedback that from facilitators and peers and in so doing, rewrite their emotional experiences in more productive and empowered ways. Facilitators will be tasked with managing the feedback of peers at this time.

This helps to foster new relational and narrative scripts that assist in reconditioned internal belief systems (Bougard et al., 2016). Finally, facilitators and peers will exchange accurate information on safety planning, substance use risks, coping alternatives, and navigating the foster care group home system. This targets the knowledge gaps between agents, promotes informed agency, and helps reduce risky behaviors in environments with large repercussions (SAMHSA, 2021). These mechanisms are crucial for healing in a system that emphasizes compliance with regulations rather than connection with those who have similar experiences. Through centering mechanisms of support like belonging, confidence, and shared values, the intervention cultivates a sense of purpose and relational resilience that are extreme protective factors against substance use and large components of youth development.

Specific Steps And Strategies To Change Behavior And Address The Problem

Program Development

First, the curriculum will be established using principles derived from the TF-CBT and DBT programs as elaborated on above, with a specific focus on harm reduction and the needs of foster youth with a history of sexual trauma (Becker et al., 2024; Danielson et al., 2012; SAMHSA, 2021).

Facilitators

Lead facilitators will be recruited and screened for relevant certifications in clinical work (eg. LCSW or PhD Clinical Psychology), experience in trauma-informed clinical work and adolescent mental health as well as group therapy. Support facilitators will be recruited using similar screening criteria, however, there may be more leniency around education level (eg. LMSW, group home workers, or social work interns). Facilitators will be trained in the proposed intervention in order to prepare them for work with this specific population and to fill in any gaps in their previous experience and training. Competence in working with multiethnic groups with sensitivity and humility is also of great importance (Center for Substance Abuse Treatment, 2005). The authors of this intervention note that recruiting directly from counselors involved in group homes themselves may be especially beneficial due to their experience with the target population. ACS workers will assist in participant recruitment, program referrals, technology access, and scheduling. Both ACS workers and group home leaders will be instrumental in ensuring digital resource needs are met, and in enforcing fidelity to group structure and ethics.

Participants

The target population comprises adolescent girls (assigned female at birth or who self-identify as female) ages 13-18 struggling with SUD as a result of sexual trauma incurred in the foster system. Participants are also required to be living in group homes in New York City for the duration of their treatment and are expected to be of a variety of racial and ethnic backgrounds.

Participants will be screened for the above criteria as well as group treatment readiness in accordance with industry best practices (Center for Substance Abuse Treatment, 2005). Recruiters will determine the prospective participant’s present stage of recovery and capacity for placement and collaboration with individuals of diverse ethnic, racial, religious and other protected backgrounds (Center for Substance Abuse Treatment, 2005). Preliminary biopsychosocial assessments will be administered in order to discern this information.

Furthermore, placement into a group will be guided by an assessment of the client’s unique traits, individual needs, personal preferences, and where they are in their recovery process. Decisions will reflect the resources the program has available, as well as the purpose and structure of the groups offered. These guidelines ensure that each client is matched with a group environment that aligns with and supports their path toward recovery and personal growth (Center for Substance Abuse Treatment, 2005).

Expected Challenges And Obstacles To Program Implementation

Systemic

The implementation of this group intervention will likely face both systemic and interpersonal challenges. Systemically, logistical barriers such as inconsistent access to technology, difficulty scheduling across multiple group homes, and variability in staff availability present as potential obstacles. High turnover among staff, social work interns, and facilitators due to placement rotations, burnout, or broader life changes, could disrupt the program continuity and group dynamic. The volatility of group home environments may further complicate consistent program delivery. There is a necessity for sustainable funding to support staffing, training, and implementation oversight, as well as to ensure the training and supervision is ongoing to maintain quality of care. Moreover, there is potential for incompatible Motivational Interviewing (MI) principles in group settings, as MI is often individually tailored and may be less effective in a collective setting (Wendt & Gone, 2018).

Interpersonal

There could be difficulty with client recruitment for a variety of reasons including lack of interest, resistance to structured treatment, and mistrust of institutions. This is coupled with stigma surrounding trauma, sexual abuse, substance use, and mental health treatment. As a result, feelings of shame and self-protection may arise which could lead to non-disclosure or disengagement intensified by the group dynamic. Further client attrition may result from non-cohesion with group members, relapse, or regression in treatment or recovery. In-program challenges will likely involve managing confrontation, redirecting dominant or off-topic members, and ensuring equal participation from all clients. This may show up as an issue especially for withdrawn youth or clients with social anxiety and other comorbid problems (Wendt & Gone, 2018). These factors could limit the efficacy of individualized care, a limitation commonly found in group-based models (Wendt & Gone, 2018).

Additionally, the differences of trauma histories and varying levels of readiness to change among participants could complicate creating a cohesive and mutually supportive group environment. Some participants may also present with disruptive behaviors, such as aggression, intoxication, or lethargy, which could affect group dynamics during sessions (Wendt & Gone, 2018). These systematic and interpersonal challenges underscore the need for adaptive strategies, highly-trained staff, and a flexible program designed for the realities of this high-need, high-risk population.

Solutions

Systemic

To address the technological barriers faced by group home youth, funding must be allocated to ensure each site has the digital infrastructure necessary to provide care. This may include the distribution of necessary technology, such as tablets, headphones, and stable Wi-Fi hotspots, to ensure clients can meaningfully participate in telehealth sessions. To account for potential scheduling challenges across various group homes, programming should be designed to avoid conflicts with school hours, meal times, and other high-demand periods. Prior to rollout, data collection across partner group homes could be helpful in identifying common windows of downtime, thus maximizing consistency and minimizing disruption to daily routines. To address staff availability, the program will utilize aggressive and targeted recruitment strategies. Outreach would be focused on recent graduates with relevant clinical expertise, direct recruitment from ACS and group home staff, and clinicians from outside agencies seeking additional part-time work. The issue of staff turnover could be reduced by developing contracts that commit staff for the full duration of each 16-week group session. To secure sustainable funding, the program will apply for city, state, and federal government grants, drawing on models like those proposed by Baylor (2019).

It will additionally be important to aggressively pursue private donors who are invested in youth mental health, trauma recovery, and systems-involved populations. Proper continuity and rigor of staff training will be addressed by designating dedicated training leads to develop and deliver a standardized training curriculum. These same trainers will offer weekly supervision to clinicians administering the programs directly, along with the option of group supervision for all clinicians. This continuous supervision will work to ensure continuity of care, as well as provide ongoing support for facilitators. Finally, to account for challenges in implementing MI principles in group settings, the program’s training curriculum will build alternative approaches that are more adaptable to group dynamics. This will involve narrative practices and community agreements that allow for multiple truths and individualized engagement within a collective space.

Interpersonal

In order to address interpersonal challenges that may arise, flexibility within group sessions is essential to meet the varying needs of those they are working with. As noted by Wendt & Gone (2018), effective group therapy often involves making adaptations and accommodations based on individual and group needs, providing multiple approaches and allowing individual clients to “glean” from the various approaches and “find what works for them.” This leads to the importance of maintaining dialogue between clinicians and group members, allowing the group to shape its own direction. This collaborative approach encourages group autonomy and ensures that the therapeutic processes are relevant and responsive to the group’s evolving needs, even if that means sometimes departing from planned material (Wendt & Gone, 2018). For client recruitment, a strong referral system is important. This will involve close collaboration with ACS, group home staff, and existing mental health providers to identify youth who are both clinically appropriate and potentially ready for this type of group work. To address client attrition, which could be a result of mismatched group dynamics, relapse, or disengagement, group norms and safety plans will be established during the first session and reinforced throughout the program’s continuation. Youth who struggle to engage or experience issues will have the opportunity to try again with a new group. If participants experience challenges that go beyond the scope of the group model, referrals will be made for one-on-one counseling that address interpersonal issues for those who are chronically shy, anxious, disengaged, or confrontational. Facilitators will also be trained to understand signs of comorbid conditions (e.g., mood disorders, PTSD, SUDs) and to flag cases that may require additional individualized treatment. Ultimately, addressing the challenges that could arise with this program will require flexibility, accommodation, and adaptation as core guiding principles for the success of this therapeutic intervention.

Figure 2. Model for Reducing Substance Use and Supporting Trauma Recovery Among Foster Youth: A Comprehensive Intervention Approach

Part 6: A Gender Theory Lens and Intervention Assessment Plan

Integrating a Gender Theory Lens

In addition to the trauma-informed and ecological frameworks guiding the intervention, the program explicitly integrates a gender-responsive framework informed by Gender Schema Theory (Bem, 1981) and Relational-Cultural Theory (Jordan, 2017). Gendered socialization, structural sexism, and gender-based trauma, such as sexual violence, shape the emotional regulation patterns, coping mechanisms, and relational needs of adolescent girls in foster care, making a gendered lens critical for both content development and facilitation strategies (Bloom, Owen, & Covington, 2003).

Gender Schema Theory explains how individuals internalize societal expectations about gender from an early age, which can influence trauma processing and coping (Bem, 1981). Relational-Cultural Theory further emphasizes that disconnection and relational violations, common experiences for foster youth with histories of sexual trauma, are key drivers of psychological distress and maladaptive behaviors such as substance use (Jordan, 2017). Using a

gender-specific lens, the intervention fosters relational resilience by building authentic, empowering, and mutual relationships within the group setting.

Facilitators model mutual empathy, emphasize collaboration over compliance, and create group norms that affirm diverse gender identities and lived experiences. Integrating gender theory into the intervention ensures that mechanisms of change, such as cognitive restructuring, emotional regulation, and relational healing, are communicated in a way that acknowledges the systemic oppressions shaping participants' lives. Gender-responsive programming has demonstrated effectiveness in improving substance use outcomes and mental health among trauma-exposed youth populations (Bloom et al., 2003).

Intervention Assessment Plan

The evaluation strategy measures clinical outcomes, participant experience, and implementation fidelity using a multi-method approach. Pre-test, post-test, and follow-up assessments allow for both immediate and longitudinal evaluation of intervention impact. The assessment design draws from the Behavioral Drivers Model (Petit, 2019), which emphasizes the influence of internal, social, and structural behavioral determinants.

Two weeks before the start of the intervention, participants complete baseline assessments using three validated clinical tools: the Drug Abuse Screening Test (DAST-10), the Brief Michigan Alcohol Screening Test (Brief MAST), and the Patient Health Questionnaire (PHQ-9). These instruments assess baseline substance use and depression symptoms. At the end of the 16-week program, participants complete the same tools to measure clinical change.

Midway through the intervention, participants complete a short process evaluation survey using Likert-scale items to assess perceived safety, facilitator support, and relevance of the group content. At program completion, a more comprehensive feedback survey evaluates satisfaction, group cohesion, and perceived impact. All responses are anonymous and aggregated before being shared with facilitators. Semi-structured participant interviews are offered to capture qualitative insights into group dynamics and personal growth that may not be reflected in quantitative assessments.

Three months post-intervention, participants are asked to complete the DAST-10, Brief MAST, and PHQ-9 again to assess the sustainability of outcomes.

Assessment Tools Rationale

The DAST-10 is a validated, reliable measure of substance misuse risk used widely among adolescents and adults (Skinner, 1982). The Brief MAST is effective for assessing alcohol-related problems in clinical and youth populations (Selzer, Vinokur, & van Rooijen, 1975). The PHQ-9 reliably measures depression severity and has demonstrated sensitivity among trauma-exposed youth (Richardson et al., 2010).

Feedback surveys are essential for capturing participants’ perceptions of program safety, relevance, and facilitator effectiveness. A midpoint survey offers real-time feedback to allow responsive adaptation, while an end-of-program survey informs long-term program development. Likert scales provide a user-friendly format that supports completion among youth participants. Semi-structured interviews offer rich, contextual data on individual experiences and relational change, particularly important in gender-responsive, trauma-informed group therapy.

Evaluation of Effectiveness and Implementation

The intervention’s success is defined by measurable reductions in substance use and depressive symptoms from pre-test to post-test and follow-up. These reflect changes in key behavioral drivers such as emotional regulation, cognitive restructuring, and help-seeking behavior. Implementation fidelity is evaluated through weekly facilitator checklists reviewed by clinical supervisors. These include tracking delivery of skills-based content, use of relational-cultural facilitation techniques, and overall adherence to the intervention model.

If 80% of participants report feeling safe, heard, and supported in the group, and if facilitator fidelity ratings remain at 90% or above, implementation will be considered successful. Additionally, alignment with the Behavioral Drivers Model is assessed by tracking agency shifts, affect tolerance, and relational trust, factors that serve as proximal indicators of behavior change.

Summary

The infusion of a gender-responsive lens strengthens the intervention’s trauma-informed foundation by ensuring that therapeutic strategies account for the gendered realities shaping participants’ lives. Through a structured, theory-driven evaluation strategy that includes clinical tools, participant feedback, and qualitative interviews, the program will yield a comprehensive understanding of its impact. This data will inform continuous improvement and ensure that interventions for system-involved youth are both relevant and responsive to the complex interplay of trauma, identity, and behavioral health.

Appendix

Assessment Tool Samples: Feedback Surveys

Purpose:

To assess participant satisfaction and group dynamics at the midpoint of the program. This survey captures feedback on content relevance, facilitation quality, and group cohesion.

Midpoint Feedback Survey:

The midpoint survey asks group members how much they agree or disagree with a set of statements regarding the group experience. Questions are stated in accessible, casual language to encourage engagement. Responses are captured using a five-point Likert scale ranging from Strongly Disagree to Strongly Agree. Participants are also presented with an optional, open-ended question to provide additional feedback. Responses are collected anonymously through a free-text entry field.

Survey Introduction:

This short, 7-question survey is designed to gather feedback on how our group is going so far. Your answers will be kept completely anonymous from group leaders and other members. Our goal is to gauge how well things are going so that we can make adjustments if needed. We want to make this group as valuable as possible for you and your fellow members.

Survey Questions:

1. Do you agree or disagree with the following statements about our group?
• The skills and topics discussed in a group are useful.
• The skills and topics discussed in a group are relevant to my life.
• [Facilitator 1] is good at teaching us skills and strategies.
• [Facilitator 1] is good at leading group discussions.
• [Facilitator 2] is good at supporting group members when they need it.
• Our group works well together.
• I am glad I joined this program.
2. Open-ended feedback:
• Is there anything else you would like to tell us about how the group is going so far?

Figure 1. Feedback Survey, Program Midpoint Evaluation.

Administration Details:

The midpoint survey is administered digitally using a secure Google Form. A sample version is available for review upon request.

Post-Intervention Feedback Surveys

Purpose And Post-Intervention Feedback Survey

The post-intervention survey gathers participant feedback on their overall experience in the group after program completion. The survey uses a five-point Likert scale ranging from Strongly Disagree to Strongly Agree to assess perceptions of content relevance, facilitator effectiveness, group cohesion, and personal growth. An open-ended question is included to allow participants to share additional reflections or suggestions. All responses are anonymous.

Survey Introduction:

This short, 8-question survey asks for your thoughts about the group experience now that the program is ending. Your answers are anonymous and confidential. Your feedback will help us understand what went well and what could be improved for future groups.

Survey Questions:

1. Do you agree or disagree with the following statements about the group?
• I felt emotionally safe participating in this group.
• The skills and topics covered in this group were helpful to me.
• The group content reflected experiences that were relevant to my life.
• [Facilitator 1] created an environment where I felt respected and heard.
• [Facilitator 2] created an environment where I felt respected and heard.
• Group discussions helped me feel more connected to others.
• I built or strengthened coping skills through this program.
• I would recommend this group to others in similar situations.
2. Open-ended feedback:
• Is there anything else you would like to share about your experience in the group?

Figure 2. Feedback Survey, Program Post-Intervention Evaluation.

Administration Details:

The post-intervention survey is administered digitally via a secure Google Form link distributed during the final session. This is available upon request

Assessment Tool Samples: Clinical Screening Instruments

Drug Abuse Screening Test – 10 Items (DAST-10)

Purpose And Introduction:

The DAST-10 is a validated tool designed to assess drug misuse severity and behavioral change over the course of the intervention. It provides a measurable indicator of substance use risk reduction, a central focus of this program. The DAST-10 evaluates drug abuse behaviors over the past 12 months, excluding alcohol and tobacco, through 10 yes/no questions. These questions help identify individuals who may require further assessment or intervention for drug use.

Instructions:

Participants are introduced to the DAST-10 with the following instructions:

1. I’m going to read you a list of questions concerning your potential involvement with drugs, excluding alcohol and tobacco, during the past 12 months.
2. When the words "drug abuse" are used, they refer to the use of prescribed or over-the-counter medications/drugs beyond directions, and any non-medical use of drugs. This includes cannabis (e.g., marijuana, hash), solvents, tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD), or narcotics (e.g., heroin).

Please answer each question based on your experience in the past 12 months. Choose the response that best fits. You may decline to answer any question.

DAST-10 Questions

The following questions are based on the past 12 months:

Figure 3. DAST-10 questions (DAST-10, n.d.)

Administration Details:

The DAST-10 is administered in a clinical or counseling setting. The questions are asked in person or on a secure digital platform, depending on the assessment's context. A sample version is available upon request.

Assessment Tool Samples: Clinical Screening Instruments

Brief MAST

Purpose And Introduction:

The Brief MAST is a screening tool designed to assess alcohol use and its impact. The following questions focus on your drinking behavior, its consequences, and whether it has led to problems in your personal, social, or professional life over time.

Instructions:

Participants are introduced to the Brief MAST with the following instructions:

1. I’m going to read you a list of questions concerning your alcohol use.

Please answer based on your experience in the past 12 months. Choose the response that best fits your situation. You may decline to answer any question.

Survey Questions:

These questions refer to the past 12 months.

Figure 3. Brief MAST Questions (Brief MAST, n.d.)

Administration Details:

The Brief MAST is administered in a clinical or counseling setting. The questions can be asked in person or on a secure digital platform, depending on the assessment's context. A sample version is available upon request.

PHQ-9 (Patient Health Questionnaire-9)

Purpose And Introduction

The PHQ-9 is a widely used screening tool to assess the presence and severity of depression symptoms. It asks participants to report how often they have been bothered by specific problems over the past two weeks. The tool helps in identifying individuals who may need further assessment or intervention for depression.

Instructions

Participants are introduced to the PHQ-9 with the following instructions:

1. Over the last 2 weeks, how often have you been bothered by any of the following problems? Please select the response that best reflects your experience during this time.

Figure 4. PHQ-9 (Stanford Medicine, 2005)

Administration Details

The PHQ-9 is administered in a clinical setting, typically during routine mental health screenings. Participants may answer the questions verbally or via a secure digital platform. A sample version is available upon request.

Works Cited

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Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press.

Becker, T. D., Castañeda Ramirez, S., Bruges Boude, A., Leong, A., Ivanov, I., & Rice, T. R. (2024). Interventions for prevention and treatment of substance use in youth with traumatic childhood experiences: A systematic review and synthesis of the literature. European Child & Adolescent Psychiatry, 33(12), 3419–3438. https://doi.org/10.1007/s00787-023-02265-x

Bederian-Gardner, D., Hobbs, S. D., Ogle, C. M., Goodman, G. S., Cordón, I. M., Bakanosky, S., Narr, R., Chae, Y., & Chong, J. Y. (2018). Instability in the lives of foster and non-foster youth: Mental health impediments and attachment insecurities. Children and Youth Services Review, 84, 159–167. https://doi.org/10.1016/j.childyouth.2017.10.019

Bem, S. L. (1981). Gender schema theory: A cognitive account of sex typing. Psychological Review, 88(4), 354–364. https://doi.org/10.1037/0033-295X.88.4.354

Beyerlein, B. A., & Bloch, E. (2014). Need for trauma-informed care within the foster care system: A policy issue. Child Welfare, 93(3), 7–22. https://www.jstor.org/stable/48623435

Bloom, B., Owen, B., & Covington, S. (2003). Gender-responsive strategies: Research, practice, and guiding principles for women offenders. National Institute of Corrections. https://nicic.gov/gender-responsive-strategies-research-practice-and-guiding-principles-women-offenders

Bougard, K. G., Laupola, T. M. T., Parker-Dias, J., Creekmore, J., & Stangland, S. (2016). Turning the Tides: Coping with trauma and addiction through residential adolescent group therapy. Journal of Child and Adolescent Psychiatric Nursing, 29(4), 196–206. https://doi.org/10.1111/jcap.12164

Brief MAST . (n.d.). https://preventionforme.org/wp-content/uploads/2017/09/BriefMAST.pdf

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Chanell Baylor. (2019, April 22). Block grants. SAMHSA. https://www.samhsa.gov/grants/block-grants

Cicchetti, D., & Handley, E. D. (2019). Child maltreatment and the development of substance use and disorder. Neurobiology of Stress, 10, 100144. https://doi.org/10.1016/j.ynstr.2018.100144

DAST-10. (n.d.). https://gwep.usc.edu/wp-content/uploads/2019/11/DAST-10-drug-abuse-screening-test.pdf

Danielson, C. K., McCart, M. R., Walsh, K., de Arellano, M. A., White, D., & Resnick, H. S. (2012). Reducing substance use risk and mental health problems among sexually assaulted adolescents: A pilot randomized controlled trial. Journal of Family Psychology, 26(4), 628–635. https://doi.org/10.1037/a0028862

Department of Health and Human Services. (1999). Substance Abuse and Mental Health Services Administration: Notices: Center for Mental Health Services; Center for Substance Abuse Treatment; Fiscal Year 1999 funding opportunity [FR Doc # 99-14228]. Federal Register, 64, 30350–30352.

Dvir, Y., Ford, J. D., Hill, M., & Frazier, J. A. (2014). Childhood maltreatment, emotional dysregulation, and psychiatric comorbidities. Harvard Review of Psychiatry, 22(3), 149–161. https://doi.org/10.1097/HRP.0000000000000014

Fairbairn, C. E., Briley, D. A., Kang, D., Fraley, R. C., Hankin, B. L., & Ariss, T. (2018). A meta-analysis of longitudinal associations between substance use and interpersonal attachment security. Psychological Bulletin, 144(5), 532–555. https://doi.org/10.1037/bul0000141

Gabrielli, J., Jackson, Y., Huffhines, L., & Stone, K. (2017). Maltreatment, coping, and substance use in youth in foster care: Examination of moderation models. Child Maltreatment, 23(2), 175–185. https://doi.org/10.1177/1077559517741681

Harden, B. J. (2004). Safety and stability for foster children: A developmental perspective. The Future of Children, 14(1), 30–47. https://doi.org/10.2307/1602753

Heindel, C. (2011). Group therapy with adolescent girls in foster care: A treatment manual for clinicians at the Rutgers Foster Care Counseling Project [Doctoral dissertation, Rutgers University]. https://doi.org/10.7282/t3f76bzh

Jordan, J. V. (2017). Relational-Cultural Theory: The power of connection to transform our lives. Journal of Humanistic Counseling, 56(3), 228–243. https://doi.org/10.1002/johc.12054

Kelly, J. F., Myers, M. G., & Brown, S. A. (2005). The effects of age composition of 12-step groups on adolescent 12-step participation and substance use outcome. Journal of Child & Adolescent Substance Abuse, 15(1), 63–72. https://doi.org/10.1300/j029v15n01_05

Kim, H. K., Buchanan, R., & Price, J. M. (2017). Pathways to preventing substance use among youth in foster care. Prevention Science, 18(5), 567–576. https://doi.org/10.1007/s11121-017-0800-6

Kim, H. K., Pears, K. C., Leve, L. D., Chamberlain, P. C., & Smith, D. K. (2013). Intervention effects on health-risking sexual behavior among girls in foster care: The role of placement disruption and tobacco and marijuana use. Journal of Child & Adolescent Substance Abuse, 22(5), 370–387. https://doi.org/10.1080/1067828X.2013.788880

Kobulsky, J. M. (2017). Gender differences in pathways from physical and sexual abuse to early substance use. Children and Youth Services Review, 83, 25–32. https://doi.org/10.1016/j.childyouth.2017.10.027

Lotzin, A., Hauptmann, A., Wesselmann, U., & Stroeber, J. (2019). Profiles of childhood trauma in women with substance use disorders and comorbid posttraumatic stress disorders. Frontiers in Psychiatry, 10, 674. https://doi.org/10.3389/fpsyt.2019.00674

Moss, H. B., Choi, C., King, K. M., & Vanyukov, M. M. (2020). Risk for substance use disorders in young adulthood: Associations with developmental experiences of homelessness, foster care, and adverse childhood experiences. Comprehensive Psychiatry, 100, 152175. https://doi.org/10.1016/j.comppsych.2020.152175

Petit, V. (2019). The behavioural drivers model. UNICEF. https://www.unicef.org/mena/media/5586/file/The_Behavioural_Drivers_Model_0.pdf

Pilowsky, D. J., & Wu, L.-T. (2006). Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents. Journal of Adolescent Health, 38(4), 351–358. https://doi.org/10.1016/j.jadohealth.2005.06.014

Richardson, L. P., McCauley, E., Grossman, D. C., et al. (2010). Evaluation of the PHQ-9 for detecting major depression among adolescents. Pediatrics, 126(6), 1117–1123. https://doi.org/10.1542/peds.2010-0852

SAMHSA. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf

SAMHSA. (2021). Treatment considerations for youth and young adults with serious emotional disturbances and serious mental illnesses and co-occurring substance use (Publication No. PEP20-06-02-001). https://library.samhsa.gov/sites/default/files/pep20-06-02-001.pdf

Selzer, M. L., Vinokur, A., & van Rooijen, L. (1975). A Self-Administered Short Michigan Alcoholism Screening Test (SMAST). Journal of Studies on Alcohol, 36(1), 117–126. https://doi.org/10.15288/jsa.1975.36.117

Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behaviors, 7(4), 363–371. https://doi.org/10.1016/0306-4603(82)90005-3

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Bem, S. L. (1981). Gender schema theory: A cognitive account of sex typing. Psychological Review, 88(4), 354–364. https://doi.org/10.1037/0033-295X.88.4.354

Bloom, B. E., Owen, B., & Covington, S. (2003). Gender-responsive strategies: Research, practice, and guiding principles for women offenders (NIC Accession No. 018017). National Institute of Corrections. https://nicic.gov/gender-responsive-strategies-research-practice-and-guiding-principles-women-offenders

Jordan, J. V. (2017). Relational-cultural theory: The power of connection to transform our lives. Journal of Humanistic Counseling, 56(3), 228–243. https://doi.org/10.1002/johc.12055

Petit, V. (2019). Behavioral drivers model: A conceptual framework for social and behavior change programming. UNICEF. https://www.unicef.org/mena/reports/behavioural-drivers-model

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Selzer, M. L., Vinokur, A., & van Rooijen, L. (1975). A self-administered short Michigan Alcoholism Screening Test (SMAST). Journal of Studies on Alcohol, 36(1), 117–126. https://doi.org/10.15288/jsa.1975.36.117

Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behaviors, 7(4), 363–371. https://doi.org/10.1016/0306-4603(82)90005-3

Part 3 Resources: Annotated Bibliography for Literature Review

Anderson, Laura E., Jason P. Connor, Joanne Voisey, Ross McD. Young, and Matthew J. Gullo. “The Unique Role of Attachment Dimensions and Peer Drinking in Adolescent Alcohol Use.” Personality and Individual Differences 149 (October 2019): 118–22. https://doi.org/10.1016/j.paid.2019.05.048.

Keywords: Attachment, adolescents, drinking behavior

Anderson, et al explore the relationship between attachment, peer alcohol use, and alcohol use among adolescents in a group of 120 adolescents aged 18 to 21. It also examined how attachment patterns relate to self-reported alcohol use. The results showed that attachment anxiety, but not attachment avoidance, was a significant predictor of both reported and observed alcohol care consumption. Peer drinking behavior did not alter this relationship. These findings highlight the need to consider both dimensions of attachment—anxiety and avoidance—in research, and point to the importance of identifying the underlying mechanisms that connect attachment anxiety to alcohol use in young adults.

Becker, T. D., Castañeda Ramirez, S., Bruges Boude, A., Leong, A., Ivanov, I., & Rice, T. R. (2024). Interventions for prevention and treatment of substance use in youth with traumatic childhood experiences: A systematic review and synthesis of the literature. European Child & Adolescent Psychiatry, 33(12), 3419–3438. https://doi.org/10.1007/s00787-023-02265-x

Keywords: trauma, SUD, RRFT, integrated care, youth treatment

Becker et al. (2024) systematically review interventions for youth with traumatic childhood experiences, highlighting behavior change as a central goal of trauma-informed therapy. The most effective interventions, including RRFT (Risk reduction through family therapy) and trauma-focused CBT, combine emotional regulation, exposure techniques, and social support to address co-occurring PTSD and substance use. Behavior change occurs by helping youth develop new coping mechanisms and relational patterns that reduce reliance on substances. These approaches often result in sustained reductions in substance use and mental health symptoms. The review reinforces the necessity of integrated behavioral health care in settings like foster group homes. Outcomes include improved emotional regulation, decreased relapse risk, and greater engagement in treatment.

Bederian-Gardner, D., Hobbs, S. D., Ogle, C. M., Goodman, G. S., Cordón, I. M., Bakanosky, S., Narr, R., Chae, Y., & Chong, J. Y. (2018). Instability in the lives of foster and non foster youth: Mental health impediments and attachment insecurities. Children and Youth Services Review, 84, 159–167. https://doi.org/10.1016/j.childyouth.2017.10.019

Keywords: Foster care, life instability, PTSD, youth

This study examined how life instability impacts mental health outcomes in both foster and non-foster youth. Comparisons between the groups showed that instability was linked to symptoms of posttraumatic stress disorder (PTSD) among foster youth, but not among their non-foster peers. These results align with earlier research on the subject. The authors emphasize that instability in areas such as school and living placements is a stronger predictor of PTSD symptoms than placement in the foster care system itself.

Beyerlein, B. A., & Bloch, E. (2014). Need for Trauma-Informed Care Within the Foster Care System: A Policy Issue. Child Welfare, 93(3), 7–22. https://www.jstor.org/stable/48623435

Keywords: trauma, foster care, awareness, trauma-informed care

This article aims to raise awareness among key stakeholders—including policymakers and funding bodies— of the problems faced by children entering the foster care system by emphasizing the widespread nature and impact of trauma. It presents existing efforts as illustrative examples and identifies critical areas where further progress and targeted improvements are needed.

Bougard, K. G., Laupola, T. M. T., Parker-Dias, J., Creekmore, J., & Stangland, S. (2016). Turning the Tides: Coping with Trauma and Addiction through Residential Adolescent Group Therapy. Journal of Child and Adolescent Psychiatric Nursing, 29(4), 196–206. https://doi.org/10.1111/jcap.12164

Keywords: PTSD, SUD, adolescents, females, in-patient, group therapy

This article provides an overview of a new evidence based program, Turning the Tides, targeting substance addiction in teen females in an in-patient setting. The article itself explores the usefulness of the program in treating both post traumatic stress disorder and substance abuse. The model drew on previously-established interventions for these issues, including: the Skills Training in Affective and Interpersonal Regulation (STAIR) model, a model of trauma recovery established by Judith Herman, VOICES, by Stephanie Covington, and Seeking Safety, by Lisa Najavits. The sources listed provided both a theoretical foundation and inspiration for group activities and topics. Reported and observed outcomes as a result of participation in the Turning the Tides program included a decrease in PTSD symptoms, overall, and lower rates of functional impairment as determined by the Child PTSD Symptoms Scale. While an increase in prescriptions for as-needed medications was observed, participants reported a genuine sense of trust in facilitators and desire to participate in group therapy. The overall assessment of the program’s effectiveness is positive and can provide some inspiration for future interventions.

Cicchetti, D., & Handley, E. D. (2019). Child maltreatment and the development of substance use and disorder. Neurobiology of Stress, 10, 100144. https://doi.org/10.1016/j.ynstr.2018.100144

Keywords: developmental psychopathology, trauma, behavioral pathways, allostatic load, SUD

Cicchetti and Handley (2019) describe how childhood maltreatment disrupts behavioral development, leading to either externalizing (aggression, disinhibition) or internalizing (anxiety, depression) trajectories that can culminate in substance use. Their developmental model positions behavior change as a process of interrupting negative cascades through early intervention. The article emphasizes that effective interventions must target emotional regulation and executive functioning to redirect maladaptive behaviors. This aligns with group CBT, DBT, and multisystemic therapy models. The paper supports behaviorally informed strategies that intervene in the emotional and relational consequences of trauma. Outcomes of these interventions include reduced emotional dysregulation and substance-related risk-taking behaviors.

Danielson, C. K., McCart, M. R., Walsh, K., de Arellano, M. A., White, D., & Resnick, H. S. (2012). Reducing substance use risk and mental health problems among sexually assaulted adolescents: A pilot randomized controlled trial. Journal of Family Psychology, 26(4), 628–635. https://doi.org/10.1037/a0028862

Keywords: RRFT, sexual trauma, behavior regulation, family therapy, PTSD

Danielson et al. (2012) assess the Risk Reduction through Family Therapy (RRFT) model, an integrated behavioral intervention for sexually assaulted adolescents at risk for substance use. The therapy addresses emotional regulation, avoidance behaviors, and family dynamics across seven modules. RRFT achieves behavior change by replacing trauma-avoidant coping with active, relational, and skill-based strategies. Compared to treatment-as-usual, RRFT participants reported reduced PTSD symptoms, substance use, and family conflict. This model aligns with the behavior change goals of your intervention by providing evidence that trauma-informed, skills-based family therapy reduces maladaptive behaviors. Outcomes include sustained reductions in emotional symptoms and substance use over six months.

Department of Health and Human Services. (1999). Substance Abuse and Mental Health Services Administration: Notices: Center for Mental Health Services; Center for Substance Abuse Treatment; Fiscal Year 1999 funding opportunity [FR Doc # 99-14228]. 64 Fed. Reg. 30350-30352.

Keywords: wraparound services, homelessness, co-occurring disorders, behavioral health, family preservation

This federal funding initiative promotes behavior change through wraparound service models for homeless families with SUD and mental illness. Although dated, the initiative emphasizes structured intervention phases, with a focus on housing stability, mental health support, and substance use reduction. Behavioral outcomes are achieved through comprehensive support rather than punitive compliance. This framework supports your intervention’s emphasis on trauma-informed, multi-system behavioral change in vulnerable populations. Expected outcomes include greater housing stability, family reunification, and reduced reliance on maladaptive behaviors like substance use.

Dvir, Y., Ford, J. D., Hill, M., & Frazier, J. A. (2014). Childhood Maltreatment, Emotional Dysregulation, and Psychiatric Comorbidities. Harvard Review of Psychiatry, 22(3), 149–161. https://doi.org/10.1097/HRP.0000000000000014

Keywords: affect regulation, trauma, stress, childhood maltreatment, mood disorders

This article explores how interpersonal trauma and stress contribute to difficulties in affect regulation. To clarify the developmental impact of childhood maltreatment on emotional dysregulation and related psychiatric outcomes, it provides an overview of emotional regulation and its neurobiological foundations. Additionally, the article examines empirical evidence linking childhood trauma to emotional dysregulation and the emergence of psychiatric comorbidities across the lifespan.

Fairbairn, Catharine E., Daniel A. Briley, Dahyeon Kang, R. Chris Fraley, Benjamin L. Hankin, and Talia Ariss. “A Meta-Analysis of Longitudinal Associations between Substance Use and Interpersonal Attachment Security.” Psychological Bulletin 144, no. 5 (2018): 532–55. https://doi.org/10.1037/bul0000141.

Keywords: substance use, insecure attachment, relationships

Metanalysis examining attachment security, substance use, and substance-related problems. Targeting longitudinal studies of attachment and substance use, this study examined 665 effect sizes drawn from 34 samples (total N = 56,721) spanning time frames ranging from 1 month to 20 years (M = 3.8 years). Analysis showed that early attachment patterns were a significantly stronger predictor of later substance use than the reverse relationship. In addition, several factors were found to influence the strength of the attachment-substance use connection. These results suggest that insecure attachment may serve as a risk factor for developing substance use issues and highlight the importance of exploring the role of close relationship quality in understanding vulnerability to substance use disorders.

Gabrielli, J., Jackson, Y., Huffhines, L., & Stone, K. (2017). Maltreatment, coping, and substance use in youth in foster care: Examination of moderation models. Child Maltreatment, 23(2), 175–185. https://doi.org/10.1177/1077559517741681

Keywords: coping styles, behavioral risk, maltreatment, asocial coping, substance use

Gabrielli et al. (2017) explore how coping behaviors moderate the relationship between trauma and substance use in foster youth. Notably, asocial coping (self-reliance, withdrawal) can act as a protective behavior in high-risk contexts, while prosocial coping is inversely related to substance use. The study suggests that behavior change interventions should recognize the adaptive functions of certain behaviors, even if they diverge from normative expectations. Programs must tailor strategies to individual coping repertoires and foster environments where adaptive behaviors are possible. Behavior change is framed not as conformity to norms but as transformation of high-risk coping patterns. Outcomes support nuanced, individualized interventions for behavior modification.

Harden, B. J. (2004). Safety and Stability for Foster Children: a Developmental Perspective. The Future of Children, 14(1), 30. https://doi.org/10.2307/1602753

Keywords: foster breakdown, child welfare, development, adolescence

This article investigates the factors contributing to "foster breakdown" and examines how this experience is retrospectively perceived by individuals who underwent it during their youth. Using semi-structured interviews, the study engaged 14 Israeli participants aged 16 to 30 who experienced the disruption of their foster placements at different points during adolescence. Although many participants initially described the breakdown as abrupt and unforeseen, further analysis revealed it to be the outcome of a gradual and complex deterioration. This process was influenced by multiple elements, including systemic issues within the child welfare framework, dynamics within the foster family, and developmental challenges characteristic of adolescence. The interplay of these factors ultimately resulted in the early termination of foster care placements.

Heindel, C. (2011). Group therapy with adolescent girls in foster care: a treatment manual for clinicians at the Rutgers Foster Care Counseling Project. https://doi.org/10.7282/t3f76bzh

Keywords: group therapy, adolescents, females, foster care, clinical guide

This doctoral dissertation addresses the need for adequate interventions for female adolescents suffering from mental health problems as a result of emotional, physical, and sexual abuse incurred while in foster care. The dissertation specifically acknowledges contextual factors such as traumatic separation from family, friends, and homes as well as the dysfunctional nature of many placement settings. This guide is designed to equip clinicians with foundational knowledge of group therapy, adolescent development, and the unique needs of youth in foster care. It offers a clear framework and practical strategies for leading therapeutic groups tailored to this population. The manual includes essential planning considerations for launching a group, provides key forms and handouts, and explores the various stages of group development along with common obstacles. Additionally, it features recommended activities specifically crafted to support both the therapeutic goals of foster youth and the broader developmental needs of adolescents.

Kelly, J. F., Myers, M. G., & Brown, S. A. (2005). The Effects of Age Composition of 12-Step Groups on Adolescent 12-Step Participation and Substance Use Outcome. Journal of Child & Adolescent Substance Abuse, 15(1), 63–72. https://doi.org/10.1300/j029v15n01_05

Keywords: This article examined the effectiveness of tried and true 12-step models of treatment for substance use disorders amongst teens (a cohort less studied in relation to these 12 step programs). A group of adolescents (N = 74; average age = 15.9 years; 62% female) were enrolled during inpatient treatment and assessed again at 3 and 6 months post-treatment. Results indicated that having peers of a similar age was associated with higher attendance rates and greater perceived value of attending meetings. There were also modest links to increased engagement in step-work and reduced substance use. These initial findings suggest that guiding young people toward meetings with peers close to their own age may enhance participation in 12-step programs and support better recovery outcomes.

Kim, H. K., Pears, K. C., Leve, L. D., Chamberlain, P. C., & Smith, D. K. (2013). Intervention effects on health-risking sexual behavior among girls in foster care: The role of placement disruption and tobacco and marijuana use. Journal of Child & Adolescent Substance Abuse, 22(5), 370–387. https://doi.org/10.1080/1067828X.2013.788880

Keywords: placement disruption, adolescent girls, substance mediation, MSS intervention, risk behavior

This longitudinal study finds that reductions in substance use mediate the effect of the Middle School Success (MSS) program on sexual risk behavior in girls in foster care. The intervention achieves behavior change by reducing placement disruptions, improving self-regulation, and altering peer networks. By targeting early adolescence, MSS capitalizes on a developmental window where behavior is still malleable. The study illustrates that behavioral interventions aimed at one domain (e.g., substance use) can produce ripple effects across others (e.g., sexual risk). Outcomes include long-term reductions in tobacco/marijuana use and fewer instances of high-risk sexual behavior.

Kim, H. K., Buchanan, R., & Price, J. M. (2017). Pathways to preventing substance use among youth in foster care. Prevention Science, 18(5), 567–576. https://doi.org/10.1007/s11121-017-0800-6

Keywords: prevention, peer influence, caregiver relationship, behavioral mediation, foster care

Kim et al. (2017) evaluate the KEEP SAFE program, which promotes behavior change by strengthening caregiver-youth relationships and reducing deviant peer associations. These relational improvements mediate reductions in substance use, illustrating that emotional bonds and supervision play key roles in modifying behavior. The intervention focuses on positive reinforcement, communication skills, and behavioral coaching, particularly effective in foster care settings. This pathway supports behavior change by targeting upstream relational dynamics rather than individual pathology. Outcomes include fewer peer-risk behaviors and lower reported substance use over an 18-month period.

Kobulsky, J. M. (2017). Gender differences in pathways from physical and sexual abuse to early substance use. Children and Youth Services Review, 83, 25–32. https://doi.org/10.1016/j.childyouth.2017.10.027

Keywords: gender differences, trauma, externalizing behavior, early substance use, foster care

Kobulsky (2017) focuses on early substance use as a maladaptive behavioral response to physical and sexual abuse among youth involved in child protective services. The study finds that physical abuse severity, particularly among girls, leads to externalizing behaviors, which in turn predict early substance use. The behavior change pathway identified is trauma → externalizing behavior → substance use, suggesting that interventions should focus on behavioral regulation strategies for girls with abuse histories. Sexual abuse, however, was not directly linked to early substance use, underscoring the complexity of trauma responses. This study supports behavior-focused interventions like group CBT, especially when targeted to gendered patterns of behavioral dysregulation. The outcomes emphasize the need for trauma-informed approaches to alter behavioral trajectories early in adolescence.

Pilowsky, D. J., & Wu, L.-T. (2006). Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents involved with foster care. Journal of Adolescent Health, 38(4), 351–358. https://doi.org/10.1016/j.jadohealth.2005.06.014

Keywords: foster care, adolescents, SUD, psychiatric symptoms

This study investigates adolescents aged 12–17 years using data from the 2000 National Household on Drug Abuse survey (n = 19,430, including 464 adolescents with history of foster care placement). Psychiatric symptoms and substance use disorders were ascertained through direct interviewing of adolescents. Logistic regression analyses were used to estimate the odds of past-year psychiatric symptoms and substance use disorders among adolescents involved with foster care, as compared to those without a lifetime history of foster care placement (comparison group).

Radenhausen, Megan, Jacqueline Unkrich, Sarah J. Beal, Shauna Acquavita, and Mary V. Greiner. “Young People in Foster Care and Substance Use.” Seminars in Pediatric Neurology 50 (July 2024): 101136. https://doi.org/10.1016/j.spen.2024.101136.

Keywords: foster care, youth, substance use, treatment options

This review article examines the prevalence of substance use among adolescents in foster care and the interventions commonly used to address substance use in this context. The authors write that rates of substance use amongst youth in foster care have been reported at rates as high as 49%. Early prevention and treatment efforts are critical in reducing substance use and the development of substance use disorders (SUD). Strategies such as universal screening, brief interventions, and targeted treatment can help mitigate these risks. Common brief interventions for adolescents include motivational interviewing and contingency management. Among the most widely supported outpatient treatments are cognitive behavioral therapy, family-based therapy, and integrated approaches combining multiple methods. For youth who require more intensive support, residential treatment may be appropriate when outpatient care proves insufficient. However, research on the effectiveness of ongoing or continuing care to help adolescents sustain recovery remains limited.

Substance Abuse and Mental Health Services Administration. (2021). Treatment considerations for youth and young adults with serious emotional disturbances and serious mental illnesses and co-occurring substance use (Publication No. PEP20-06-02-001). National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration. https://library.samhsa.gov/sites/default/files/pep20-06-02-001.pdf

Keywords: co-occurring disorders, integrated care, behavior change, CBT, MDFT

SAMHSA (2021) outlines behavior change as a key treatment goal for youth with co-occurring SUD and mental health disorders. The brief promotes CBT and MDFT (Multidimensional Family Therapy) as central interventions, each targeting different behavioral drivers—CBT for emotional regulation and cognitive restructuring, MDFT for family and relational behavior change. The report advocates for integrated systems of care that reduce barriers to consistency and engagement. These models provide a foundation for your intervention by affirming the importance of addressing behavioral and relational patterns simultaneously. Expected outcomes include decreased symptoms of depression and anxiety, and lower rates of substance use and relapse.

Underwood, L. A., Stewart, S. E., & Castellanos, A. M. (2007). Effective practices for sexually traumatized girls: Implications for counseling and education. International Journal of Behavioral Consultation and Therapy, 3(3), 403–419.

Keywords: trauma therapy, adolescent girls, group therapy, DBT, identity repair

Underwood et al. (2007) describe multiple behavioral interventions for sexually traumatized girls, with a focus on group therapy, DBT, and narrative therapy. These approaches emphasize behavior change through trust-building, emotional literacy, and identity reconstruction. Group therapy is especially effective in fostering self-esteem and reducing isolation-driven coping behaviors like substance use. The paper aligns with Danielson et al. (2012) and Gabrielli et al. (2017) in supporting interventions that rebuild relational trust and offer structured emotional outlets. Outcomes include improved affect regulation, decreased self-harm behaviors, and greater participation in therapeutic relationships.

Valdez, C. E., Bailey, B. E., Santuzzi, A. M., & Lilly, M. M. (2014). Trajectories of Depressive Symptoms in Foster Youth Transitioning Into Adulthood: The Roles of Emotion Dysregulation and PTSD. Child Maltreatment, 19(3–4), 209–218. https://doi.org/10.1177/1077559514551945

Keywords: foster care, youth, trauma, PTSD, emotional dysregulation, maltreatment

This article considers the link between adversity commonly experienced by foster youth during key developmental periods and the resulting impact on emotional functioning. Particular focus is given to PTSD and emotion dysregulation. It then explores in detail the trajectory of depressive symptoms in foster youth from age 17 to 19 using a piecewise linear growth model, examining the effects of PTSD and emotion dysregulation on youth’s depressive symptoms over time. Foster care youth, in particular, have high rates of trauma exposure and are often removed from their family-of-origin home for reasons of abuse and/or neglect. In fact, trauma exposure rates for foster youth approach 90% (Stein et al., 2001), and a sizable proportion (21%) have reported maltreatment while in foster care (Pecora et al., 2003). A recent meta-analysis found high rates of physical abuse (6–48%), sexual abuse (4–35%), emotional abuse (8–77%), and neglect (18–78%), as well as other compromising experiences such as having an unavailable caregiver (21–30%) and parental substance abuse (14–30%; Oswald, Heil, & Goldbeck, 2010).