Purpose The challenge of providing services to “hard to reach” populations is well documented. Arguably one of the hardest to reach populations today is minority inner city adolescents, who are exposed to risk behaviors at early ages and who, therefore, are forced to make important decisions, before they have either the cognitive or emotional maturity to understand the implications of these decisions. Substance abuse is one of the behavioral domains where this problem is most obvious. Data show that while older inner-city minority adolescents (high school age) are no more likely to use drugs and alcohol than their middle class counterparts, young inner-city minority adolescents (elementary and middle school age) are three times more likely to use drugs and alcohol than their middle class counterparts. Moreover, once they have begun using substances and have been caught, the challenge of getting these at-risk adolescents into treatment and keeping them in treatment is substantial. Part of the problem is that adolescent substance abuse treatment programs have largely been designed for and validated with older adolescents who are not living on the edge of survival (both economically and physically). The larger purpose of this study is to provide substance abuse treatment geared toward young inner-city minority adolescents and to evaluate the processes and outcomes. The specific purpose of this paper is to consider factors associated with keeping these adolescents in treatment.

Method Through SAMHSA/CSAT funding, we have developed the Strengthening Neighborhood Investment Program (SNIP) for marginalized inner city minority youths in impoverished neighborhoods in the Mobile, Alabama metropolitan statistical area. SNIP is an evidence-based treatment modality that incorporates cognitive behavioral therapy (CBT) and motivational interviewing (MI). To date, more than 150 youths have been enrolled in SNIP, but with varying success–both in terms of retention in treatment and in terms of treatment outcomes. In this paper, we discuss the challenges of enrolling adolescents in SNIP and making CBT and MI relevant to them. We also explore, using longitudinal data, the factors that predict their retention in treatment. We end by considering how these factors relate to the tenets of CBT and MI, and suggest areas where these models should be revised if they are to be more effective with this population.

Results The relevance of client characteristics such as age, feelings of self worth and hopelessness, experience with traumatic stress and other co-occurring disorders, involvement (length and magnitude) in other risk behaviors, and parental monitoring are reported.

Implications Context is an important factor in the determination of evidence-based treatment. Substance abuse treatment programs that work well for older adolescents who are not living in risky environments need modification to work with younger adolescents living in inner city neighborhoods. Before appropriate modifications can be made, the contextual factors that play a role in effectiveness must be identified and related to treatment components. This study suggests that such client factors as developmental status, environment, and alienation must be better acknowledged in designing substance abuse treatment programs for hard to reach populations.