Recovery High Schools may be a Key Component of Youth Recovery Support Services

Peer group associations are an important part of an adolescent’s identity that can be difficult to shift without significant support and positive reinforcement for change. Youth with substance use disorder (SUD) struggle to access sober peer supports and associated substance free activities even at school (1). After treatment youth with SUD commonly relapse in the context of interactions with substance using peers (2). Since adolescents spend substantial time with peers at school there has been increasing attention devoted to the impact of the school environment on youth with SUD.

The number of recovery high schools, educational settings that promote, support, and reinforce abstinence, have been growing over the past thirty years as an alternative educational setting for youth with SUD (3). Despite this growth there has been limited research on the effectiveness of recovery high schools. In this issue of the American Journal of Drug and Alcohol Abuse, Finch et al. provide outcome data on the longitudinal effectiveness of recovery high schools for youth who have been treated for SUD using a novel quasi-experimental approach (4). The investigators found that youth treated for a SUD who attended a recovery high school were four times more likely to report complete abstinence from all substances at six-month follow-up compared to youth with SUD who did not attend a recovery high school following treatment. Furthermore, youth who attended a recovery high school reported substantially fewer days on which they used marijuana and had less school absenteeism compared to peers who did not attend a recovery high school. Findings have relevance for clinicians, families, educators, and policy makers who are working to support youth with SUD.

The work of Finch and colleagues makes a significant contribution to the literature by evaluating the effectiveness of recovery high schools on substance use and academic outcomes. To date, this has been difficult to evaluate since it is not feasible or ethical to randomize students to recovery and non-recovery high schools. To help overcome some of the challenges of non-equivalence among intact groups in quasi-experimental designs, the authors used an innovative approach of propensity scores to identify a sample of controls that were similar on baseline characteristics to youths who chose to attend a recovery high school (4). Although the size of the control group was limited—of the recruited controls, 37% did not have similar enough propensity scores to be included in the analytic sample—this strategy helped to provide a meaningful comparison group.

As policy makers and educators consider recovery high school development, one challenge has been sustainability. Recovery high schools have low rates of enrollment and high student turnover (5). The sample recruited by Finch and colleagues in this issue reflects this challenge (4). The authors struggled to recruit adolescents entering recovery high schools from treatment facilities since most adolescents chose to attend non-recovery high schools. Furthermore, 38% of the sample of adolescents who initially attended a recovery high school for one month were no longer attending at six-month follow-up. Increased research is needed to investigate adolescent and family knowledge and perceptions regarding recovery high schools as well as barriers to attendance, engagement, and retention. Additionally, differences in enrollment requirements for recovery high school admittance, response to substance use while enrolled, and academic programming have been described (3, 5) but not compared to evaluate recovery high school program components that increase student retention and improve outcomes.

It is currently unclear which adolescents, in particular, may be best suited to benefit from the support a recovery high school can provide. Future research should examine moderators of the effects of participation in recovery high schools. These resources may be particularly helpful, for example, for youths with higher SUD severity, higher social network support for continued substance use, or severe impulsivity. Such knowledge could help increase the specificity of referral recommendations. Another consideration for this developing field of research is the cost-effectiveness of recovery high schools versus non-recovery high schools to the education, treatment, and legal systems. Currently, most recovery high schools are funded by per pupil enrollment (5). Since recovery high schools are part of the continuum of care for adolescents with SUD, it may be cost-effective for health care insurers and the criminal justice system to also support recovery high schools.

As the field of research on adolescent SUD continues to move forward, increased research on the feasibility and effectiveness of school and community-based interventions that build recovery conducive and supportive environments is critical. Among those who do receive treatment, the amount of time an adolescent spends with a clinician is minimal relative to the time they spend at school and in the community with peers or with family. With convincing data, Finch and colleagues demonstrate that school and community-based interventions may be an important approach to support youth struggling with substance use.