In 2020, 4.5% of adolescents aged 12–17 in the United States (1.1 million people) had a substance use disorder (SUD) (National Institute on Drug Abuse, 2020). This is hugely concerning for practitioners, researchers, and parents for several reasons. First, adolescent substance use is concerning because of the effects on the developing brain. For example, literature indicates that the prefrontal cortex (what some call the "CEO of the brain") has not fully developed by adolescence, making this age group more prone to risky decision making such as drug and alcohol use (Winters & Arria, 2011). In turn, heavy drug and alcohol use can have substantial adverse effects on brain development, brain functioning, and neuropsychological performance (Brown & Tapert, 2004). In part because of concerns about the impact of substances on the developing brain, the National Institutes of Health initiated the Adolescent Brain Cognitive Development (ABCD) study, which will track youth brain development over ten years (Karcher & Barch, 2021). Additionally, about one in five fatal car crashes (14% for females, 20% for males) in 2019 among drivers aged 15–20 involved alcohol use (Centers for Disease Control, 2019). Accidents are a leading cause of death for ages 15–24, especially those involving motor vehicles.
Although there are several negative consequences associated with substance use and SUD among adolescents, we know very little about the recovery processes for adolescents. The aims of this study are to: 1) learn how adolescents in and out of recovery conceptualize the term "recovery”, 2) work toward a definition of adolescent recovery that includes those perceptions, and 3) help identify treatment components and aid in policy development for adolescent recovery-oriented systems of care.
Defining Adult Recovery
There is substantial existing definitional research around the construct of adult recovery, which sets the stage for further research on adult recovery-oriented systems of care (Kelly et al., 2018; White, 2008). However, there is no single agreed-upon definition of recovery in research or in the substance use community, and therefore the number of people “in recovery” is unknown (Laudet, 2007).
The classic definition of recovery that aligns with Narcotics Anonymous’s (NA) school of thought asserts that “abstinence from mind and mood-altering substances” is the foundation of recovery; but abstinence itself does not equal recovery (mid-late recovery also involves addressing past errors, making amends, and participating in one's life) (Narcotics Anonymous, 2016). However, in one study measuring public perceptions of recovery, only 22% of people said that their loved one in recovery was free from addiction and no longer using drugs/alcohol. These results suggest that while the mainstream definition of recovery includes abstaining from substances, many people identify as being in recovery without abstaining from substances (Laudet, 2007).
More contemporary harm reduction-inclusive definitions of recovery differ in that abstinence is not an essential foundation for recovery. For example, the Recovery Research Institute's "addictionairy" defines recovery from a substance use disorder as, "a process of improved physical, psychological, and social wellbeing and health after having suffered from a substance-related condition" (Recovery Research Institute, 2021). This definition leaves room for reduced use (or safer use practices) instead of total cessation so long as the person has improved overall wellbeing. Harm reduction definitions of recovery often include the option of abstinence, but abstinence is not required for one to identify being "in recovery."
In addition to reducing or cessation of substance use, several studies have also pointed to social support as a cornerstone of recovery (Best & Laudet, 2010; Kelly et al, 2018). Others claim that spirituality is an essential component of recovery, particularly within the 12-step approach (Leukefeld, 2015). Social support and spirituality are only two of the many factors of recovery that some cite as being essential, outside of reduction or cessation of use. Best and Laudet (2010) suggest that the strength of someone's "recovery capital" influences the degree to which someone can recover and improve their overall wellbeing. Evidence from the above studies suggest that there is more to being in recovery than the reduction or cessation of substance use.
Although there is not total agreement on language and definitions, there has been substantial research on adult substance use and recovery, which has provided a wealth of knowledge for researchers and providers alike. With this knowledge, communities and stakeholders can develop and implement recovery-oriented systems of care (ROSC) for adults. ROSC's are macro-level networks of professional, social, and familial support to cultivate long-term recovery. According to the Substance Use and Mental Health Service Administration’s ROSC resource guide, ROSC's involve prevention (e.g., early screening), intervention (e.g., outreach and early intervention), treatment (e.g., a menu of treatment options, recovery support services), and post-treatment (e.g., continuing care). In addition, there are regional meetings to assist states in planning and implementing ROSC's, and these systems of care have made a significant difference in the lives of those impacted by substance use (Substance Abuse and Mental Health Services Administration, 2010).
Defining Adolescent Recovery
While having a definition of recovery is a crucial foundation for developing recovery-oriented systems of care, there appears to be little work on defining recovery for adolescents. Finch (2020) states, "None of the major efforts to conceptualize recovery have specified age or developmental concerns, which creates the impression that either the definitions were intended for adults, or the drafters considered adolescent recovery to be indistinguishable from adult recovery. In most instances, youth recovery simply has not been addressed in the definitional literature". Gonzales-Castaneda and Kaminer (2016) echo these sentiments and caution using the term “recovery” for youth under 12.
Using an AA-based definition of recovery may be challenging to apply to adolescents, partly because adolescents have less exposure to self-help/mutual-help support groups. Highlighting this, one study of adolescents and young adults post-SUD treatment found that less than a quarter (21%) of its participants had attended any self-help groups/meetings (Baumer et al., 2018). In addition, very few studies have actually asked adolescents about their conceptualization of the term "recovery." Gonzales and colleagues (2012) asked youth in treatment about their conceptualization of recovery and found that adolescents are less inclined to think in terms of lifelong abstinence. In addition, recovery capital studies with adolescents show that peer groups are essential components of adolescent recovery supports, but not necessarily those obtained from 12-step fellowships (Nash et al., 2019). Finally, Smith and colleagues (under review) recently found that about 3.9% of youth in a large statewide sample reported they were in recovery (n = 69,959). While this study did not shed light on how youth defined recovery, it found that youth in recovery were less likely to report past year and past month abstinence relative to a control group of youth who used substances but had not resolved a substance use problem. Thus, additional research on adolescents' definitions of the term recovery is desperately needed.
Having better definitions of recovery could help support the development of the recovery school movement. The Association of Recovery Schools has created and supported Recovery High Schools, which are high schools specifically designed to educate and support high school students who are in recovery from substance use disorders (Association of Recovery Schools, 2021). These high schools have successfully improved both substance use and academic outcomes at 6-month and 12-month follow-ups (Hennessy, et al., 2018). Understanding youth definitions of recovery could help bolster the need for recovery schools and help with planning decisions such as tailoring services toward complete or partial abstinence.
Recovery Identity
Kelly et al. (2018) differentiate the acquisition of a recovery identity, where people consider themselves "in recovery," from other processes that look relatively similar to existing definitions of recovery. For example, less than 50% of individuals in this national study who resolved a significant substance use problem identified as "in recovery"; however, most technically achieved recovery even if the more conservative definition of recovery (i.e., complete abstinence and a changed lifestyle) was used (White, 2007). Kelly and colleagues (2018) reported that most of those who fell into this category had not been through formal substance use treatment or mutual help-support groups. Some thought that since they did not have much difficulty abstaining, the "recovery" label did not apply. The authors suggested adding additional language to the discourse around substance use improvements to make help it more approachable to those individuals, including phrases such as "problem resolution" (Kelly et al., 2018). This distinction may particularly be of interest for adolescent recovery identity due to the low participation in 12-step meetings and other factors that may make the "recovery" term less relatable.
Summary/Hypotheses
Much of what we know and understand about recovery comes from adult research. However, having a definition of adolescent recovery, including understanding adolescents' perceptions of recovery, is vital to creating systems of care designed for adolescents. For that reason, this paper will look at youth perceptions on the definition of recovery.