Protocol for a Systematic Review: Recovery Schools for Improving Well-Being among Students in Recovery from Substance Use Disorders: A Systematic Review

Youth Substance Use Disorders

Substance use disorders (SUDs) among youth are a major public health problem. In the United States, for example, the incidence of SUDs increases steadily after age 12 and peaks among youth ages 18-23 (White, Evans, Ali, Abrahams, & King, 2009). Although not every youth who experiments with alcohol or illicit drugs is diagnosed with a SUD, approximately 7-9% of 12-24 year olds in the United States were admitted for public SUD treatment in 2013 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). The true prevalence of SUDs among youth in the United States is likely higher than 7-9%, however, given that many youth receive treatment in private or in non-specialty settings (Laudet, Harris, Kimball, Winters, & Moberg, 2014), and other youth may never receive treatment for their substance use problems (SAMHSA, 2015). Data available on substance use patterns and treatment availability in other nations also suggests that there are significant numbers of youth worldwide in need of some form of substance use treatment and/or aftercare, although this research is primarily limited to developed nations. For example, in Australia, adolescents aged 10-19 years old comprised approximately 12% of all treatment admissions from 2012-2013 (Australian Institute of Health and Welfare, Canberra, 2014). Similarly, the European Council estimated that across surveyed countries, youth constituted anywhere from 16% (Italy) to 65% (Czech Republic) of the overall substance use treatment population (Council of Europe, Pompidou Group, 2006). And, in 2011, approximately 28,000 adolescents were newly admitted to outpatient treatment across Europe (European Monitoring Centre for Drugs and Drug Addiction, 2013).

Substance use problems can have numerous detrimental consequences on the academic, social, and general well-being of youth. This might include negative effects on school or work performance, legal problems, and substance use tolerance and progression (American Psychiatric Association [APA], 2013). Prior research has documented the multiple negative effects from prolonged and heavy substance use, including diminished memory and cognitive abilities, reduced grades, a decreased likelihood of finishing high school or attending post-secondary education, problems attaining or keeping employment, higher rates of more acute and chronic health conditions than those without a history of use, poverty, and family and social problems (Brown & Tapert, 2004; Homel, Thompson, & Leadbeater, 2014; Larm, Hodgins, Larsson, Samuelson, & Tengström, 2008; Leslie et al., 2016; Lisdahl, Wright, Kirchner-Medina, Maple, & Shollen, 2014; Menasco & Blair, 2014; Newcomb & Bentler, 1988; Patrick, Schulenberg, & O'Malley, 2016; Silins et al., 2014; Squeglia, Jacobus, & Tapert, 2009; Thoma et al., 2011). Given the numerous negative effects associated with heavy substance use among youth, it is important to understand what programs and interventions might be effective in assisting youth with SUDs.

Youth Development, Problematic Substance Use, and Substance Use Disorders

The period of adolescence “is characterized by more biological, psychological, and social role changes than any other stage of life except infancy” (Holmbeck, Devine, Wasserman, Schellinger, & Tuminello, 2012, p. 431). These changes begin in adolescence and continue into emerging adulthood and involve pubertal and cognitive development, and identity, relationship, and achievement transitions (Shulenberg & Maggs, 2001). Generally, the period of adolescence lasts from ages 10-19, although the World Health Organization's term “young people” includes individuals between 10-24 years of age (World Health Organization, 2016).

Adolescent neurodevelopment has been described as a biologically critical period of heightened vulnerability to experimentation and habitual use of substances (Chambers, Taylor, & Potenza, 2003). For example, due to neurodevelopmental processes, adolescents are more prone to impulsive behaviors, risk taking, and drug and reward seeking compared to adults, all behaviors that are linked to substance use (Chambers et al., 2003; Simon & Moghaddam, 2014). Indeed, animal studies of neural processing have demonstrated that adolescent and adult brains respond differently to rewards, with activity in adolescents’ brain regions of learning and habit formation potentially predisposing them to form problematic substance use habits (Sturman & Modhaddam, 2012). This area of research has also demonstrated that adolescents consume larger quantities of alcohol than adults, a behavior that continues into adulthood, suggesting that drinking habits begun early in life, i.e., during adolescence, may worsen relative to habits begun during adulthood and extend for longer periods of time (Serlin & Torregrossa, 2015).

In addition to neurodevelopmental findings, research has demonstrated that adolescents develop expectancies about potential benefits or risks of substance use (Shulenberg & Maggs, 2001), which vary depending on their social networks and settings and affect when and how they decide to use substances. The social context is especially important as adolescents undergo relationship changes with parents by seeking to differentiate themselves as autonomous individuals and youth create relationships with peers that become more influential. Youth also tend to overestimate the prevalence of drinking in their social environment, with college students viewing drinking as highly normative; youth may also experience increased sociability and report better bonding with peers as a result of drinking (Shulenberg & Maggs, 2001). Social influence has also been consistently identified to be especially important in relapse situations among recovering adolescents (Ramo, Prince, Roesch, & Brown, 2012).

In addition, specific changes related to this developmental period have been identified as risk factors for more problematic substance use (e.g., early maturation, affiliation with deviant peers, and conflicts with parents; Weisz & Hawley, 2002). Adolescent development processes as well as the presence of these additional factors are both risk factors for problematic use, setting this population apart from adults and thus, treatments and aftercare supports should take developmental issues into account (Deas, Riggs, Langenbucher, Goldman, & Brown, 2000; Weisz & Hawley, 2002). In support of this contention, addiction literature has documented different relapse precipitants for adolescents than for adults, with adolescents more likely to relapse under social pressure and also exhibiting greater complexity in relapse patterns (Ramo & Brown, 2008). Adolescents often use multiple substances and may use a broader array of substances than adults (Deas et al., 2000).

Although not all experimentation with substances leads to problematic use, problematic use can transition to a substance use disorder (SUD), i.e., “a maladaptive pattern of substance use leading to clinically significant impairment or distress” (American Psychiatric Association, 1994). Substance abuse and dependence were originally diagnosed separately with substance abuse considered an early phase and dependence the more severe manifestation; however, the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) modified the definition of an SUD to combine abuse and dependence into one category with different levels (American Psychiatric Association, 2013). An SUD is manifested in multiple ways, including substance use that repeatedly impacts school or work performance or contributes to legal problems. Individuals with an SUD demonstrate an increasing need for more of the substance to achieve the same effect (i.e., tolerance) and taking the substance for longer or in larger doses and experience unsuccessful attempts to quit using the substance. Thus, recovery from an SUD is a process involving many factors, the hallmark of which is reduction or complete abstinence of use. Recovery also refers to overall healthy functioning and has been defined as “voluntarily sustained control over substance use, which maximises health and wellbeing and participation in the rights, roles and responsibilities of society” (UK Drug Policy Commission, 2012).

Approaches for Addressing Youth in Recovery from Substance Use Disorders

Given the biological, psychological, and social developmental changes in adolescence, it is important to attend to distinct developmental issues of adolescence when focusing on adolescents in recovery (Weisz & Hawley, 2002). Thus, for youth diagnosed with an SUD there are a variety of adolescent-specific treatment options available, which fall within a spectrum of varying intensity from early intervention, such as screening, brief intervention, and referral to treatment (SBIRT: Bien, Miller, & Tonigan, 1993; Madras et al., 2009) to intensive inpatient treatment (American Society of Addiction Medicine [ASAM], 2013). However, SUDs are often experienced as chronic conditions; thus, multiple treatment episodes and ongoing recovery supports after treatment are often necessary to assist with the recovery process (Brown, D'Amico, McCarthy, & Tapert, 2001; Ramo, Prince, Roesch, & Brown, 2012; White et al., 2004). Indeed, research has demonstrated that youth seeking SUD treatment do not always engage in or successfully complete that treatment (Kaminer, Burleson, Burke, & Litt, 2014; Pugatch, Knight, McGuiness, Sherritt, & Levy, 2014; Winters, Stinchfield, Latimer, & Lee, 2007). Lack of engagement in treatment is due to a variety of factors including denial about the extent of the problem, motivation, emotional reasons, life stressors, financial or insurance barriers, peer influence and social norms, and access and availability of substances combined with triggers to use (Gonzales, Anglin, Beattie, Ong, & Glik, 2012; Wisdom, Cavaleri, Gogel, & Nacht, 2011), and has been linked to community factors such as median family income (Jones, Heflinger, & Saunders, 2007). Among youth who successfully complete substance use treatment programs, 45-70% return to substance use within months of treatment discharge (Anderson et al., 2007; Brown, et al., 2001; Ramo et al., 2012; White et al., 2004).

Perhaps the greatest risk of relapse for youth in recovery is during the late adolescent and emerging adulthood years (Anderson, Ramo, Cummins, & Brown, 2010); thus, youth with an SUD require developmentally appropriate, sustained, and multi-pronged intervention and follow-up support (Gonzales et al., 2012). To this end, research has demonstrated the importance of structured continuing care supports after treatment for youth in recovery from substance use. These continuing care supports can include, for instance, a dedicated case manager, home visits, meetings with caregivers, or other environmental supports for the youth and their family (Godley, Godley, Dennis, Funk, Passetti, & Petry, 2014; Stanger, Ryan, Scherer, Norton, & Budney, 2015; Tanner-Smith, Wilson, & Lipsey, 2013). Indeed, youth who engage in recovery supports posttreatment have the greatest likelihood of abstinence from substance use (Brown et al., 2001; Hennessy & Fisher, 2015). Engagement in substance-free peer environments is one recovery support system that shows particular promise, and has been linked to reduced substance use and increased psychosocial functioning among youth (Anderson, Ramo, Schulte, Cummins, & Brown, 2008; Nelson, Henderson, & Lackey, 2015; Terrion, 2012).

The Importance of Schools in the Recovery Process

Success and engagement at school and in postsecondary education are critical to healthy youth development. For youth in recovery from SUDs, school attendance, engagement, and achievement build human capital by motivating personal growth, creating new opportunities and social networks, and increasing life satisfaction and meaning (Keane, 2011; Terrion, 2012; 2014). Upon discharge from formal substance use treatment settings, schools become one of the most important social environments in the lives of youth with SUDs. Healthy school peer environments can enable youth to replace substance use behaviors and norms with healthy activities and prosocial, sober peers.

Unfortunately, however, some of the most significant risk factors for substance use are embedded within school environments, including perceived peer use, association with substance-using peers, alcohol or drug availability, and academic challenges (Derzon, 2007; Mason, Mennis, Linker, Bares, & Zaharakis, 2014; Svensson, 2000; Wambeam, Canen, Linkenbach, & Otto, 2014). Indeed, in a nationwide survey of high school students in the United States, approximately 26% of respondents were offered, sold, or given an illicit drug on school property (CDC, 2011). This trend is especially problematic for youth in recovery from SUDs: for example, in a study of recovering youth, almost all adolescents who returned to their old school after treatment reported being offered drugs on their first day back in high school (Spear & Skala, 1995). College students suffer similar environmental risks, particularly given the high rates of, and social norms that approve of alcohol consumption on campus. For example, a study of seven universities in Great Britain demonstrated that approximately 70% of enrolled students reported heavy drinking at least once during the previous two weeks. Across five New Zealand universities, 37% of student respondents reported at least one binge drinking episode during the previous week and approximately 68% scored in the hazardous drinking range on the Alcohol Use Disorders Identification Test consumption scale (Kypri, Paschall, Langley, Baxter, Cashell-Smith, & Bourdeau, 2009). In the United States, 35-39% of college students reported binge drinking (i.e., five or more drinks in one sitting) at least once in the past month (Monitoring the Future, 2013; SAMHSA, 2013) and research has documented a rapid escalation in alcohol consumption during the first two years of college in the United States (Shulenberg & Maggs, 2001). Indeed, approximately one-half of substance use treatment admissions for college students in the United States were for alcohol use (Center for Behavioral Health Statistics and Quality, 2012). In addition, a recent review highlighted that approximately 20% of college students in the United States use drugs on a monthly basis and that 5% reported daily use (Dennhardt & Murphy, 2013). One study of recovering college students found that the majority of students were addicted to multiple substances while only a few students were solely addicted to alcohol (Cleveland, Harris, Baker, Herbert, & Dean, 2007). Given the prevalence of binge drinking and substance use among this population as well as the social acceptability of alcohol consumption during the college years, it is no surprise that the college environment has been described as “abstinence hostile” for youth in recovery (Cleveland et al., 2007).

Recovery Schools as Interventions to Improve Students’ Well-Being

Given the many social and environmental challenges faced by youth in recovery from substance use, recovery-specific institutional supports are increasingly being linked to educational settings. The two primary types of education-based continuing care supports for youth in recovery are recovery high schools (RHS) and collegiate recovery communities or programs (CRC): both settings will be referred to under the broad umbrella term of “recovery schools” for this review. Federal offices in the United States have recently recognized these two educational programs as viable supports for youth after they complete formal substance use treatment programs (National Institute on Drug Abuse [NIDA], 2014; Office on National Drug Control and Policy [ONDCP], 2014).

Recovery High Schools. The RHS model addresses academic advancement and recovery maintenance among adolescents that have completed treatment for a SUD and are still seeking to complete their high school education (Finch & Frieden, 2014). First instituted in 1979, RHSs are now located in multiple cities across the United States and are typically small, with school size on average around 30-40 students (Ruben, 2002; White & Finch, 2006). According to the Association of Recovery Schools (ARS), a national United States-based non-profit organization that supports the creation, improvement, and maintenance of RHSs, there are currently 36 recovery high schools in operation in the United States (ARS, 2016), although there have been as many as 84 operating over the past 30 years (Finch, Karakos, & Hennessy, 2016). Depending on the location and policies of the educational system in which it is embedded, an RHS may be free of charge for students or provide scholarships for tuition (Finch et al., 2016). Although the ARS has recently developed accreditation standards and begun to review RHSs under these standards, RHSs are implemented using a variety of models and share a set of common characteristics (Moberg, Finch, & Krupp, 2014). The RHS's primary purpose is to educate youth in recovery from substance use or co-occurring disorders (ARS, 2013). Thus, RHSs have two primary foci: (1) an educational focus, which includes meeting state requirements for awarding a secondary school diploma; (2) a recovery focus that ensures that all students enrolled at the school are in recovery for substance use or co-occurring disorders and that they work toward maintaining recovery while enrolled. Finally, RHSs should be available to any student who is in recovery and who would meet state or district eligibility for attendance.

Academics are a primary focus in RHSs, however, the schools also incorporate recovery-specific elements into the day, such as a daily group check-in, community service, and individual counseling sessions. Schools employ administrative and teaching staff, but vary in their employment of counseling staff. For example, some schools have dedicated counselors located daily at the school, while others employ mental health staff to visit the school on a regular basis for individual meetings with students (Finch, Moberg, & Krupp, 2014). Most schools have admission criteria that require some SUD treatment and/or minimum length of sobriety and a desire to remain abstinent; however, if a school is part of the public school system, they are unable to mandate previous treatment for enrolling students and instead rely on interviews with youth to determine their interest in maintaining sobriety and contributing to the sober culture (Finch & Wegman, 2012). In addition, RHSs encourage parent involvement in their students’ learning experience through the creation of parent support groups (Finch et al., 2014) and some schools mandate this practice via regular parent-teacher meetings. These criteria, along with structured and supervised learning, foster a recovery-supportive culture where students and staff attend to academic development and recovery maintenance. Thus, the characteristics that distinguish RHSs from traditional high schools include attention to maintenance of a positive, sober peer culture and explicit therapeutic support (Tanner-Smith et al., 2014). Because peer substance use is highly predictive of one's own substance use (Lewis & Mobley, 2010), the RHS sober peer environment is especially important to the RHS model.

Descriptive research has demonstrated that students in RHSs do feel supported by peers in the RHS setting (Karakos, 2014), and that RHSs may be effective in promoting the health and well-being of students. For example, one evaluation of three recovery high schools in Massachusetts found that the majority of students remained enrolled in the school for the year during the study and maintained A or B grades while also remaining abstinent or only enduring 1-2 relapse episodes during this year (Kochanek, 2008). Interviews with youth also demonstrated psychosocial benefits to remaining in the RHS. Another descriptive pre-post study of 17 RHSs found that students enrolled in these schools had reduced substance use and improved mental health functioning at follow-up (Moberg & Finch, 2007).

Collegiate Recovery Communities or Programs. As a result of the substance use environment on college campuses, CRCs have been instituted with college/university support or via grassroots student organizations on at least 75 college campuses to provide college students with recovery supports and a social environment that encourages abstinence (Bugbee, Caldeira, Soong, Vincent, & Arria, 2016; Harris, Kimball, Casiraghi, & Maison, 2014). Recent data suggests that as many as 600 students are members of CRCs in the United States every academic year (Laudet et al., 2014). Given that students are typically members of CRCs for a relatively short amount of time (i.e., their duration in college), there is a likely possibility that many college enrolled youth in recovery spend time in these communities; thus, the number of unique student members is likely much higher than 600.

Similar to RHSs, CRCs are typically small communities and range in size from 5-80 students (Cleveland et al., 2007). The CRC model focuses heavily on providing environmental sober supports and settings and incorporates recovery-related supports such as seminars, 12-Step meetings and counseling, recreational activities and social events, life-skills training, educational supports and peer and family support, as well as linkages to community supports and services (Bugbee et al., 2016; Harris, Baker, Kimball, & Shumway, 2008; Laudet et al., 2014). Some CRCs also require that members sign a behavioral and sobriety contract that may be implemented and enforced by a peer governance system (Bugbee et al., 2016). Similar to RHSs, some CRCs also have admission criteria for their community programs. For example, one CRC at a large public university requires that members have been in recovery for one year, continue to pursue their education, and are willing to attend at least one on-campus 12-Step meeting each week (Cleveland et al., 2007). Other CRCs may require that student members have previously received treatment for addiction.

CRCs differ from RHSs, however, in that although they offer educational supports, they do not usually offer separate academic classes for students in recovery. They primarily provide recovery support services including offering group meetings and individual counseling services, providing dedicated space for students in recovery to meet, organizing sober events and community service activities, and educating the broader community in an effort to reduce stigma around addiction (Association of Recovery in Higher Education [ARHE], 2015; Cleveland et al., 2007; Harris et al., 2014; Perron et al., 2011). They also may offer scholarships toward university fees and provide substance-free, supervised dormitories (Cleveland et al., 2007; Harris et al., 2014), although presence of a sober dormitory does not in itself constitute a CRC (Bugbee et al., 2016).

The primary aim of the CRC is to improve abstinence rates and prevent relapse so that students can remain enrolled and succeed at secondary education (Harris et al., 2014): indeed, preliminary descriptive research demonstrates evidence of this success (Cleveland et al., 2007). For example, the relapse rate among CRC members across one academic semester was only 4.4%. In addition, the majority of CRC members in this study had solid academic records while enrolled at the university and many maintained working part/full time jobs. And, in a nationwide survey of students enrolled in 29 different CRCs, approximately only 5% of students who considered themselves in recovery from addiction had used a substance in the past month (Laudet, Harris, Kimball, Winters, & Moberg, 2016).

Theory of Change

RHSs and CRCs seek to build upon the social connectedness contained within the educational environment (Finch & Frieden, 2014). The recovery school model draws heavily on the notion of social capital, or the social support, connections, and access to resources available through social networks, as one of the strongest factors influencing educational and recovery outcomes (Coleman, 1988; Granfield & Cloud, 2004; Meier, 1999). Connectedness between youth, family, peers, school, and community generates social capital and can potentially translate into academic achievement for youth (Meier, 1999).

RHSs support the recovery and academic achievement of students by fostering connectedness and social capital in a setting that addresses issues related to addiction and recovery with dedicated attention to healthy adolescent growth and development. They provide a safe environment for youth in recovery to practice the skills learned in treatment, use structured activities so that youth learn how to engage with their own emotional state and physiological responses they previously avoided through substance use, and use the sober community to model positive behaviors of peers and mentors (Finch & Frieden, 2014). The primary elements through which this underlying theory of change is operationalized are: build a richer base of peer and family connection, social support, and accountability; minimize contact with negative peers to increase school engagement and reduce relapse risk; provide students the opportunity to meet peers in recovery and to incorporate skills learned in treatment; quickly respond to problematic behaviors or symptoms of a co-occurring disorder due to the small school environment and specialized school staff; promote contact with positive peers and adults outside school by requiring participation in support groups after school; and support graduation from high school by providing an accredited curriculum taught by licensed teachers (Tanner-Smith et al., 2014).

Similar to RHSs, CRCs also support students’ academic goals through fostering a positive, sober peer environment that provides companionship as well as emotional and recovery social support (Harris et al., 2014). Youth in recovery who choose to enroll in postsecondary education have additional tasks that can challenge their recovery. For example, unlike youth attending high school, youth in college are tasked with finding their own network of social support and developing healthy peer relationships, moving away from home and learning to live outside of their caregiver's supervision, and setting and attaining educational and career goals (Harris et al., 2008). For youth in recovery, these tasks must be undertaken with the added pressure of finding a sober peer environment that supports abstinence, a difficult task in an abstinence-hostile environment. Thus, through their available programming and dedicated on-campus recovery support, CRCs seek to create an internal community of recovery support, advocate for sobriety among the larger community, and support students as they transition to young adulthood. CRCs are vital environmental supports for youth in recovery wishing to attend postsecondary education: indeed, in a recent survey of students in 29 CRCs across the United States, one-third of respondents stated they would not have chosen to attend higher education without a campus recovery support system (Laudet et al., 2016).

Although RHSs and CRCs operate along a similar theory of change in relation to sober peer support and community, they have different operating models and structures based on how they seek to intervene with youth and due to their placement in particular educational systems. For example, RHSs operate as both the formal school and recovery support system and there may be less of a clearer distinction between the classroom as an academic versus recovery space. As part of the educational system, RHSs are also able to award their students secondary diplomas when they graduate. Alternatively, CRCs are operated on a college campus but are primarily separate from academic classroom spaces, offering additional supports outside of the academic structure. Youth in CRCs may choose to discontinue their participation in the CRC activities but still remain enrolled at the college, while youth at RHSs need to remain sober for continued enrollment at the school. Relapse situations in RHSs are typically treated on a case-by-case basis, but if the youth continues to use substances without indicating motivation to change, they are eventually referred to another school setting to preserve the sober environment of the RHS. Given the close proximity of students and teachers and small school size of RHSs, there is also closer monitoring of youth behavior at the RHS, compared to CRCs, which are housed on larger campuses.

Factors That Affect Youth Experience of Recovery Schools

Multiple, interacting factors may affect whether participants enroll in or join a recovery school and once participating, will determine how the recovery school setting affects subsequent substance use and other behavioral outcomes. Most often studied are individual-level factors such as demographic and socioeconomic characteristics.

Gender and age have distinguished different pathways of youth recovery involvement and outcomes (Stevens, Estrada, Murphy, McKnight, & Tims, 2004; Wellman, Contreras, Dugas, O'Loughlin, & O'Loughlin, 2014). For example, male college students have higher annual prevalence rates of use of marijuana and most other drugs than female college students (Dennhardt & Murphy, 2013). There are also differences between males and females on mental health comorbidity and level of juvenile justice involvement (Stevens et al., 2004), which may interact with level of substance use and/or level of care received for that use (Oser, Karakos, & Hennessy, 2016). Mental health, specifically diagnoses of mental illness comorbidities, has also been studied in this population and found important to outcomes (Hersh, Curry, & Yaminer, 2014; Yu, Buka, Fitzmaurice, & McCormick, 2006). For example, one review of comorbid depression and adolescent treatment outcomes indicated mixed results depending on study characteristics and concluded that there is not a simple way to categorize the relationship between depression and substance use outcomes (Hersh et al., 2014).

Finally, evidence suggests that tangible resources affect recovery, possibly through either restricting or enhancing access to supportive social networks and other established recovery supports (Granfield & Cloud, 1999; Pesetski, 2015; Terrion, 2012); thus, measures of socioeconomic status are important indicators of potential inequity among this population.

Why it is Important to do the Review

To our knowledge, no reviews of CRCs exist in the literature. Further, there is only one systematic review to date that has included findings from RHSs (Fisher, 2014). That systematic review identified a range of adolescent-specific continuing care supports, however, and did not solely focus on RHSs. In addition, although four studies of RHSs were identified in the review, the author had limited resources with which to conduct the review and a meta-analysis was not attempted. Since that review was completed, we are aware of at least three additional primary studies that would be potentially eligible for a review of RHSs, as well as multiple studies of CRCs that have never been reviewed or synthesized.

Other reviews on adolescent treatment and recovery have compared the effectiveness of different adolescent outpatient treatments (Tanner-Smith et al., 2013; Waldron & Turner, 2008), reviewed adolescent participation in 12-Step programs (Kelly & Myers, 2007; Sussman, 2010) and the role of social support in collegiate recovery programs (Smock, Baker, Harris, & D'Sauza, 2011), and explored the relationship between 12-Step attendance and adolescent substance use outcomes posttreatment (Hennessy & Fisher, 2015). Although these reviews have highlighted the importance of treatment and support programs for youth with SUDs, they have not focused explicitly on examining the potential effectiveness of recovery schools. Thus, there is a need to understand the effects of education-based interventions in light of our understanding of other youth recovery supports especially given the recent enthusiasm for their implementation (NIDA, 2014; ONDCP, 2014; White, 2009) and recovery school funding mechanisms in some U.S. states (Finch et al., 2016).

Finally, based on resources located from U.S.-based national networks and recent documents outlining the recovery school movement (ARHE, 2016; Laudet et al., 2014; White & Finch, 2006), we anticipate that the majority of the programs will be located in the United States. We are aware of at least one potential recovery school program in China (Lin, Lu, & Wu, 2017). However, we are not aware of other attempts to locate recovery school program literature on an international scale. An extensive systematic search would enable knowledge around whether, and if so, where such programs are in operation worldwide. Substance use disorders among youth are problematic in every nation, and many countries have instituted treatment and recovery resources specific to adolescents and young adults. Thus, this review could highlight gaps in recovery supports and potential solutions for addressing youth recovery moving forward.

Criteria for including and excluding studies