Hispanic Perspectives on Recovery High Schools: If We Build Them, Will They Come?

Abstract

Recovery High Schools (RHSs) have been among the continuum of care for adolescents experiencing addiction since 1979 (Moberg & Finch, 2008). Outcome studies for RHSs are limited, and even less is known about RHS engagement of Hispanics. RHS students are overwhelmingly middle-class non-Hispanic White students with prior formal treatment (Moberg & Finch, 2008). Hispanic youth are more likely to live in discordant low-income ethnic enclaves, placing them at high risk for addictive disorders (Torres, Kaplan, & Valdez, 2011). The individualized approach of RHSs could make them a culturally relevant continuing care intervention. This paper reviews the literature to explore the use of RHSs by Hispanics.

Since 1979, Recovery High Schools—specifically designed for students recovering from substance use disorders—have provided a continuum of care for adolescents with addictions (Moberg and Finch, 2007). Recovery High Schools offer a full range of academic services within a structured environment that encourages, promotes, and facilitates recovery. To date, Moberg, Finch, and Krupp (2014) provide the most complete description of the program models used in Recovery High Schools. With funding from the National Institute on Drug Abuse, Finch and colleagues are currently examining the effectiveness of Recovery High Schools and their impact of behavioral, academic, and substance use outcomes compared to students who attend regular high schools post-treatment. While data on whether Recovery High Schools indeed lead to superior outcomes is still emerging, we know far less about the use of Recovery High Schools by Hispanic youth.

Students who attend Recovery High Schools are overwhelmingly White; upper middle class; more likely to come from two-parent homes; and more likely to have had prior formal treatment for substance use disorders (Moberg and Finch, 2007). Hispanic youth, on the other hand, are more likely to live in ethnic-dense communities characterized by social strife, including single parent homes, high rates of poverty, community violence, and substance-using environments, which places them at higher risk for substance use disorders (Torres, Peña, Westhoff, & Zayas, 2008; Torres, Kaplan, & Valdez, 2011). Moreover, intervention options for Hispanic youth are few, and when they exist they are either unaffordable or not culturally relevant.

As we continue to learn about the effectiveness of Recovery High Schools, some important empirical questions remain about Recovery High Schools and Hispanics. For instance, what do Hispanic families know about Recovery High Schools, and how did they learn it? How do Hispanic families view Recovery High Schools? How do they engage with Recovery High Schools? Do Hispanic families find Recovery High Schools acceptable and culturally relevant? And of course, are outcomes for Hispanic students who enroll in Recovery High Schools comparable to those of non-Hispanic students?

To date, the scarce numbers of Hispanics enrolled in Recovery High Schools have made it impossible to answer these questions. The opening of Recovery High Schools in areas with large concentrations of Hispanics, from Houston, TX which is almost 50% Hispanic to Laredo, TX which is along the Texas-Mexico border and is 96% Hispanic, offers us an unprecedented opportunity to explore some of these questions. This paper presents an overview of the literature as a first step to summarize our understanding of the utilization of intervention services by Hispanic youth; discuss some of the salient issues we need to explore with regard to Hispanics and Recovery High Schools; and present a trajectory for the balance of the current research study and future studies.

Background

Many intervention approaches have been developed over the last few decades to address adolescent substance use disorders. A search of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices using the delimiters “substance abuse treatment” and “co-occurring disorders” for areas of interest; “13 to 17 (Adolescent)” for age; and limiting the search to interventions evaluated in studies with 50% or more of the selected groups; yields 27 interventions. Add the delimiter “Hispanic or Latino” for races and ethnicities, and the list drops to 3 interventions: Brief Strategic Family Therapy, Functional Family Therapy for Adolescent Alcohol and Drug Abuse, and Phoenix House Academy. Add “school” as the setting, and the list drops to zero. Clearly, there is a dearth of treatment and intervention options for Hispanic youth with substance use disorders (Szapocznik, Lopez, Prado, Schwartz, and Pantin, 2006).

The prevalence of substance use among adolescents requires an expansion of specific care options for these youth (Sussman, Skara, & Ames, 2008). Among the continuum of care options for adolescents are recovery schools that offer academic programs, supportive after-school opportunities, individual and group counseling, within a sober/drug-free environment that support recovery (Moberg & Finch, 2007). Once an adolescent exits inpatient treatment, the likelihood of relapse may be higher if they return to the same school environment of initial enrollment attended. Moreover, many families forego traditional (e.g., inpatient) treatment for their adolescent with a substance use disorder and the adolescent enrolls into a Recovery High School.

Developmentally, adolescents are transitioning from childhood to adulthood, presenting unique challenges that require intervention options that are tailored specifically to a brief history of use that may influence life-long efforts towards recovery. In one particular study by Ciesla, Valle & Spear (2008), severity of cannabis use was determined to be a significant predictor of success of recovery efforts among adolescents. Moreover, recovery efforts that facilitate participation in support groups and motivate school attendance were determined to significantly reduce relapse (Ciesla, Valle, & Spear, 2008). Such efforts would seem to provide viable options for all youth, but despite their rates of substance use, Hispanic adolescents are not representative of the youth who are engaged in such treatment and post-treatment options. While SAMHSA (2015) has for two decades maintained that there is “no wrong door” into treatment, for Hispanic youth, there is often no door at all into treatment.

Method

Five databases (PsychINFO, ERIC, Medline, Google Scholar, and Psychological & Behavioral Sciences Collection) were searched using the following keywords: Hispanic* OR Latino/a* AND substance use* OR abuse OR treatment OR intervention OR recovery). These databases were selected for their coverage of the social sciences and health related literature. The university social science reference librarian was consulted to ensure the search strategy was appropriate and exhaustive. Materials published between 2001 and 2015 were included for review, with 2001 representing the release of the most comprehensive publication solely devoted to Latino health since the original 1994 edition (Aguirre-Molina, Molina, & Zambrana, 2002).

The Current Review

Nationally, Hispanic youth are disproportionately impacted by substance use disorders (SAMHSA, 2015). The 2013 Youth Risk Behavior Surveillance Survey (YRBSS) ranks Hispanic adolescents at the top across multiple categories of alcohol and substance use risk behaviors (Kahn et al., 2014). Hispanic adolescents’ current alcohol use (37.5%) exceeded the national average (34.9%) as well as the averages of their non-Hispanic White (36.3%) and Black (29.6%) peers (Centers for Disease Control and Prevention [CDC], 2014). Further, the 2014 YRBSS results indicated that Hispanic youth’s current marijuana use (27.6%) exceeded the national average (23.4%) and ranked among the top in comparison to their White (20.4%) and Black (28.9%) counterparts. Additionally, results showed high rates of illicit drug debut by Hispanic youth that exceed those of their same aged peers, indicating initiation of heroin (3.4%); hallucinogens (8.4%) and a startling rate of cocaine initiation (9.5%) that was almost twice that of the national average of 5.5% (Kahn et al., 2014). Rates of substance use and alcohol consumption characterize some of the most significant factors contributing to health disparities between Hispanic adolescents and non-Hispanic White adolescents (Prado, Szapocznik, Maldonado-Molina, Schwartz, & Pantin, 2008).

Hispanics, substance use and interventions

While these national statistics indicate elevated use of illegal substances and increased risks for alcohol and substance dependence among Hispanic youth, the limited research available underscores the need for greater understanding of this problem. Yet, estimating the needs of these Hispanic youth is extremely challenging, as this group is very heterogeneous, continues to grow rapidly, and the demographics within this group are quickly changing; as such, it is a moving target. Torres et al. (2008) suggested that of particular importance to the United States is the circulatory migration pattern of immigrants from Mexico, as well as countries in Central America, particularly the Northern Triangle (i.e., El Salvador, Honduras, and Guatemala) and those in the Caribbean Basin (e.g., Cuba, Dominican Republic, and Puerto Rico). These are among the largest Hispanic subgroups in the U.S., and factors such as geographic proximity, relative low cost of travel, and large families in both countries (the U.S. and the country of origin) ensure a continuous flow in both directions.

Other researchers emphasized the impact of acculturation levels and nativity, stating that levels of substance use are positively correlated with acculturation and acculturation stress (Gil & Vega, 2001). With regard to nativity, U.S.-born Hispanics have higher rates of substance use than foreign-born Hispanics. With regards to acculturation, among foreign-born Hispanics rates increase with length of time in the U.S., and among U.S.-born Hispanics, rates increase with generation (that is, third generation Hispanics have higher rates than second generation Hispanics, who in turn have higher rates than first or immigrant generation Hispanics). Adjustment, or the lack thereof, is implicated in the development of substance use behaviors among Hispanics, with acculturation stress as a strong predictor (Gil, Wagner, & Tubman, 2004). Whereas acculturation experiences among Hispanic groups is extensively being studied, and the relationship between acculturation and drug use is also being determined, best practices for recovery services remain scant.

Insight into treatment provided by Vega and Lopez (2001) suggested that there is a circular, self-defeating cycle, whereas fewer Hispanics finish school-partly because of substance use issues—which results in fewer Hispanics being available to become service providers, which then results in fewer providers who are culturally competent and could help prevent the cycle from continuing. This scarcity translates to a gap in in the necessary services that improve academic and treatment outcomes for Hispanic youth. Programs that boost high school completion rates and stimulate careers in the human services through apprenticeship and internship experiences are vital to the engagement of these youth (Vega & Lopez, 2001). They further stated that emphasis should be placed on attracting bilingual educators and practitioners to help facilitate the recruitment of Latino youth in becoming the future helping professionals (Vega & Lopez, 2001). These recommendations were the outcomes of their analyses of epidemiologic studies, needs assessments and studies that evaluated availability and utilization of quality services.

More recently, Alegría et al. (2006) linked low retention rates, as well as the absence of appropriate services, as major challenges of delivering treatment services to Hispanic drug users; resulting in a disproportionate cluster of negative consequences among the Hispanic population. Further, additional research that focused on clustering of drug involvement revealed high levels of substance use behavior among a large sample of school-aged Hispanic adolescent youth from Central America (Costa Rica, El Salvador, Guatemala, Honduras, and Nicaragua), Panama and the Caribbean nation of the Dominican Republic (Dormitzer et al., 2004). Dormitzer and colleagues focused on clustering of drug involvement among school-attending youth in this 2004 study to determine estimates for initiation and use of various substances. Results indicated that males were more likely than females to use all substances and overall rates of interests were as follows: alcohol (52%), tobacco (29%), inhalants (5%), marijuana (4%), and other illegal drug use (5%). This seminal work revealed experiences of Hispanic adolescents in countries of origin (Panama, Central America, and the Dominican Republic) and presents the first estimates of drug involvement of youth who attend school in these seven countries. This suggests that the problem is not uniquely a U.S. problem—although substance use rates by Hispanic youth in the U.S. are far higher than those in Latin America (Torres et al, 2008). Exposure to drugs or drug using behaviors prior to immigrating is a risk factor for developing substance use disorders after immigrating, in the context of acculturative stress.

Another study, by Aguilar-Gaxiola et al. (2006) reviewed fifteen years of research on the epidemiology and status of illicit drug use, utilization of services and the relationship between HIV and drug use in Latin America. They noted that some of the variability in the results of the research across Latin American nations is due to the variations in methodological approaches. The authors stated that there is a need to create an international level collaboration for research. Even with internationally standardized research methods, such a partnership would seem over-reaching, given the various cultural implications. Researchers have found that among Hispanic groups, cultural values continue to emerge as a strong indicator of successful engagement and intervention (Castro et al., 2006). In fact, Castro et al. (2006) examined almost three decades of literature on substance abuse prevention and intervention with Hispanic populations (1974 – 2003) and found that adapting prevalent theories to the reality and context of Hispanic groups was necessary. Further, the researchers suggested that among the culturally-focused adaptations would be theories relevant to Hispanics and the inclusion of cultural variables in subsequent studies (Castro et al., 2006).

Engaging Hispanics in treatment is paramount to reducing the negative outcomes of substance use. In a 2008 study, characteristics of inclusion were explored by Amodeo, Chassler, Oettinger, Labiosa, & Lundgren. They explored whether client characteristics related to retention were associated with the completion of treatment among a sample of 164 Latino substance users who were admitted into a residential program that was characterized as culturally competent. The researchers determined that those clients who were most likely to prematurely terminate treatment had self-reported co-occurring psychiatric diagnoses. This study contributes findings beyond prior studies by considering the broader implications of the universal challenges involved in treating individuals with co-occurring disorders. The results also indicated that Hispanic substance users have a more difficult time remaining in residential treatment.

Understanding the major factors that contribute to substance use and subsequent addiction are relevant to the development of treatment interventions, as Hispanic youth are at increased risk for substance use disorders due to a host of individual, community, and societal factors (Torres et al., 2008). The short-term and long-term consequences of substance use behaviors during adolescence, as well as the evaluation of the efficacy of prevention and intervention efforts are all important concerns both in the United States and abroad (Torres et al., 2008). Research has indicated that improved access and increased utilization of qualified and comprehensive mental health services is needed (Vega & Lopez, 2001). Further, scholars emphasized the need for additional research and bilingual mental health practitioners to serve Latino groups (Vega & Lopez, 2001). The evolution of such treatment and recovery efforts for youth is being evidenced and best practices are emerging. Among the most effective programs are school-based services.

de Miranda and Williams (2011) reviewed the history of adolescent recovery efforts and reported an increase in the number of academic institutions that provide supportive secondary and higher education and recovery services. More specifically, the authors demonstrate how recovery high schools and colleges have devoted efforts to providing safe environments with specialized and supportive recovery services (de Miranda & Williams, 2011). Despite this overall trend, there is a scarcity of literature on culturally competent, evidence-based treatment options for Hispanic youth, and especially in school settings. Increased knowledge of the differences and similarities between Hispanic subgroups, and between Hispanics and non-Hispanics, could facilitate improved assessment and identification of the co-occurring conditions that are precipitated by their mental health concerns and risky substance use behaviors. This increased knowledge can also result in more culturally appropriate intervention models for Hispanic youth experiencing substance misuse or addiction.

Responding to the call for diversity

As previously stated, students who attend Recovery High Schools are overwhelmingly White; upper middle class; more likely to come from two-parent homes; and more likely to have had prior formal treatment for substance use disorders (Moberg and Finch, 2007). Hispanic youth, on the other hand, are more likely to live in ethnic-dense communities characterized by social discord, including single parent homes, high rates of poverty, community violence, and substance-using environments (Torres, Peña, Westhoff, & Zayas, 2008; Torres, Kaplan, & Valdez, 2011). These factors all place Hispanic youth at greater risk for substance use disorders, with fewer treatment options in existence. Further compounding the few available treatment options, existent barriers to treatment include unaffordability—despite advances made under the Affordable Care Act, Hispanics remain the single largest uninsured group in the country—and services that are culturally inappropriate.

Recovery High School efforts in Texas

In the latter part of 2014, Houston was added as a data collection site on the NIDA-funded study examining the effectiveness of Recovery High Schools as Continuing Care (5R01DA029785-04). Houston was added because of the presence of two well-established Recovery High Schools, Archway Academy and Three Oaks Academy, as well as an existing network of adolescent treatment and recovery programs. Given Houston’s status as the fourth largest city in the U.S., and it being a distinctive Hispanic city, Houston also held the promise of helping increase the understanding surrounding recovery services available to Hispanic youth living in the Houston area. Houston presents a unique opportunity to explore the utilization of recovery services among diverse groups because the city is a national and international hub. Houston encompasses the major thoroughfare of the I-10 corridor, and is a southeastern city five hours from the Texas-Mexico border. Conservatively, Houston has about a 43.8% Hispanic or Latino population (United States Census Bureau, 2015). Programs in Austin, Dallas, and Laredo were also explored, visited, and recruited as partners. Laredo in particular offers an unprecedented opportunity, with the opening of a new Recovery High School in a city 97% Hispanic and their willingness to be part of our study.

Hispanic youth services along the Texas and Mexico border

The City of Laredo, located in Webb County, Texas along the border with Mexico (across the Rio Grande River from Nuevo Laredo, Mexico) is 97% Hispanic. The almost 6,000 youth enrolled in the six Laredo Independent School District (LISD) high schools are almost 100% Hispanic. About 60 of these students attend the district’s Non-Traditional (Recovery) High School. Another 40 attend an Alternative High School, and for many of these youth, substance use is part of the challenges they experience. The LISD also has three Traditional High Schools and an Early College High School. Occasionally, students from these schools are also identified as having challenges related to substance use. Connecting with this key population that would not be accessed elsewhere and is vital to explore and understand their use of Recovery High Schools as part of their continuum of care. This partnership can increase the overall understanding of the experiences of these Hispanic youth and potentially add some vital instruments to the protocols, culturally tailored for Hispanic youth and their parents.

Also along the Texas and Mexico border, is a community-based, nonprofit social services organization, Serving Children and Adults in Need, Inc. (SCAN). SCAN has a 32-year history of providing a variety of comprehensive, culturally-grounded services to a population that is almost 95% Hispanic and which resides in this Southwest Texas community bordering Mexico. SCAN programs provide diverse prevention, intervention, and treatment services for children, adolescents, adults, and families. SCAN has more than 30 programs providing services in 14 different counties along the Texas-Mexico border.

Pouring the foundation

Scientific research pertaining to adolescent substance use and addiction is most authentically and fully evaluated within a public health, namely preventive framework (Yzaguirre, 2001). The ultimate goal of substance abuse research is to contribute to the knowledge base; increase understanding; advance treatment services, and most importantly enable society to more effectively reduce and prevent abuse of harmful substances and drugs. The list of options for many American adolescents may be of potential use when they are experiencing substance abuse or related problems; yet, the effectiveness of these services for Hispanic youth in the Houston area and nationally is still undetermined. The services may be well suited and comprehensive enough to incorporate the needed diversity and supple enough to embrace almost all of the cultural differences Hispanics possess. Yet, until our Hispanic youth enter these facilities and enroll in these recovery schools in higher numbers, answers to the questions of best practices remain unanswered. Conversely, there is a need to take advantage of organic opportunities like the one provided by the Laredo Independent School District’s Recovery High School so we can learn more about the place these schools can play in Hispanic communities before we advocate for their broad dissemination. Mixed-methods (quantitative and qualitative) approaches can help us better understand the academic, behavioral, and substance use outcomes of Hispanic youth enrolled in Recovery High Schools and can help us shed light on the phenomenology of Recovery High Schools in Hispanic communities, that is, the experience of Recovery High Schools by Hispanic youth and families.

Conclusion

The prevalence of alcohol and drug use within our Hispanic communities has heightened our awareness of the need for substance use research and sensible, evidence-informed drug abuse policies. We know historically that substance use research and funding is inevitably shaped by prevailing assumptions and values. This may seem altogether appropriate, as drug research is primarily funded by the public through taxation, and those in power are influenced by societal opinions. Nevertheless, Hispanic youth are at potential risk of not being heard or served through our treatment facilities, despite their growing rates of substance use, because they are not represented in our treatment facilities. Yet, if we build it, will they come?

RHSs involve the family in treatment; however, the adolescent defines family. Hispanics are largely family-centered and research by Vega and colleagues suggests they do well in family-based treatment (e.g., Brief Strategic Family Therapy) (2007). Further, Hispanics are a heterogeneous group, and RHSs lend themselves to be tailored to specific groups of students. Such customization within RHSs allows work to combat and reduce stigma, which is one of the key barriers to treatment for Hispanics. The LISD and SCAN programs provide resources to gain relevant knowledge as well as a framework for assessing priority treatment services for Hispanic youth. These facilities have been built, but will they come?

In this spirit of true scientific evaluation and reflection, it is important to highlight that the ultimate goal of this contribution, as a component of the larger and ongoing study, is to affect social policy for the purposes of reducing the adverse health and social consequences associated with substance use and abuse. This includes the reduction of the staggering social costs associated with substance abuse treatment. This paper reviews the current literature of utilization of RHSs as a continuum of care among Hispanic communities as a means of preventing abuse and to advance our knowledge regarding the causes and best preventive methods.

The value of the investment in substance abuse and addiction research is measured by the number of lives saved and the success of each young person who lives recovery daily, attends secondary and higher education, enters the workforce, and experiences the joy of happiness and well-being. This paper provides an overview of the literature and begins the conversation of how Recovery High Schools can play an important role in unveiling the stories and the experiences of Hispanic adolescents who suffer and influence their families’ experiences because of substance use and addiction. Answering the question, “If we build it, will they come?” is a critical first step to provide intervention alternatives to the largest minority group in the U.S.