Recovery schools for improving behavioral and academic outcomes among students in recovery from substance use disorders

BACKGROUND 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, Achara‐Abrahams, & King, 2009). Although not every youth who experiments with alcohol or illicit drugs is diagnosed with an 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). Recovery from an SUD involves reduction or complete abstinence of use, defined broadly 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, 2008). However, SUDs are often experienced as chronic conditions; among youth who successfully complete substance use treatment, approximately 45–70% return to substance use within months of treatment discharge (Anderson, Ramo, Schulte, Cummins, & Brown, 2007; Brown, D’Amico, McCarthy, & Tapert, 2001; Ramo, Prince, Roesch, & Brown, 2012; White et al., 2004). Thus, multiple treatment episodes and ongoing recovery supports after treatment are often necessary to assist with the recovery process (Brown et al., 2001; Ramo et al., 2012; White et al., 2004). 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. Conversely, many school environments may be risky for youth in recovery from SUDs due to perceived substance use among peers, availability of drugs or alcohol, and substance‐approving norms on campus (Centers for Disease Control [CDC], 2011; Spear & Skala, 1995; Wambeam, Canen, Linkenbach, & Otto, 2014). 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, defined under the umbrella term of “recovery schools” for this review, are recovery high schools (RHSs) and collegiate recovery communities (CRCs). RHSs are secondary schools that provide standard high school education and award secondary school diplomas, but also include therapeutic programming aimed at promoting recovery (e.g., group check‐ins, community service, counseling sessions). CRCs also provide recovery oriented support services (e.g., self‐help groups, counseling sessions, sober dorms) for students, but are embedded within larger college or university settings. The primary aims of RHSs and CRCs are to promote abstinence and prevent relapse among students, and thus ultimately improve students' academic success. OBJECTIVES This review summarized and synthesized the available research evidence on the effects of recovery schools for improving academic success and behavioural outcomes among high school and college students who are in recovery from substance use. The specific research questions that guided the review are as follows: 1. What effect does recovery school attendance (versus attending a non‐recovery or traditional school setting) have on academic outcomes for students in recovery from substance use? Specifically (by program type): a. For recovery high schools: what are the effects on measures of academic achievement, high school completion, and college enrolment? b. For collegiate recovery communities: what are the effects on measures of academic achievement and college completion? 2. What effect does recovery school attendance have on substance use outcomes for students in recovery from substance use? Specifically, what are the effects on alcohol, marijuana, cocaine, or other substance use? 3. Do the effects of recovery schools on students' outcomes vary according to the race/ethnicity, gender, or socioeconomic status of the students? 4. Do the effects of recovery schools on students' outcomes vary according to existing mental health comorbidity status or juvenile justice involvement of the students? SEARCH METHODS We aimed to identify all published and unpublished literature on recovery schools by using a comprehensive and systematic literature search. We searched multiple electronic databases, research registers, grey literature sources, and reference lists from prior reviews; and contacted experts in the field. SELECTION CRITERIA Studies were included in the review if they met the following criteria: Types of studies: Randomized controlled trial (RCT), quasi‐randomized controlled trial (QRCT), or controlled quasi‐experimental design (QED). Types of participants: Students in recovery from substance use who were enrolled part‐time or full‐time in secondary (high school) or postsecondary (college or university) educational institutions. Types of interventions: Recovery schools broadly defined as educational institutions, or programs at educational institutions, developed specifically for students in recovery and that address recovery needs in addition to academic development. Types of comparisons: Traditional educational programs or services that did not explicitly have a substance use recovery focus. Types of outcome measures: The review focused on primary outcomes in the following two domains: academic performance (e.g., achievement test scores, grade‐point average, high school completion, school attendance, college enrolment, college completion) and substance use (alcohol, marijuana, cocaine, heroin, stimulant, mixed drug use, or other illicit drug use). Studies that met all other eligibility criteria were considered eligible for the narrative review portion of this review even if they did not report outcomes in one of the primary outcome domains. Other criteria: Studies must have been reported between 1978 and 2016. The search was not restricted by geography, language, publication status, or any other study characteristic. DATA COLLECTION AND ANALYSIS Two reviewers independently screened all titles and abstracts of records identified in the systematic search. Records that were clearly ineligible or irrelevant were excluded at the title/abstract phase; all other records were retrieved in full‐text and screened for eligibility by two independent reviewers. Any discrepancies in eligibility assessments were discussed and resolved via consensus. Studies that met the inclusion criteria were coded by two independent reviewers using a structured data extraction form; any disagreements in coding were resolved via discussion and consensus. If members of the review team had conducted any of the primary studies eligible for the review, external and independent data collectors extracted data from those studies. Risk of bias was assessed using the ROBINS‐I tool for non‐randomized study designs (Sterne, Higgins, & Reeves, 2016). Inverse variance weighted random effects meta‐analyses were planned to synthesize effect sizes across studies, as well as heterogeneity analysis, subgroup analysis, sensitivity analysis, and publication bias analysis. However, these synthesis methods were not used given that only one study met the inclusion criteria for the review. Instead, effect sizes (and their corresponding 95% confidence intervals) were reported for all eligible outcomes reported in the study. RESULTS Only one study met criteria for inclusion in the review. This study used a QED to examine the effects of RHSs on high school students' academic and substance use outcomes. No eligible studies examining CRCs were identified in the search. The results from the one eligible RHS study indicated that after adjusting for pretest values, students in the RHS condition reported levels of grade point averages (= 0.26, 95% CI [‐0.04, 0.56]), truancy (= 0.01, 95% CI [‐0.29, 0.31]), and alcohol use (= 0.23, 95% CI [‐0.07, 0.53]) similar to participants in the comparison condition. However, students in the RHS condition reported improvements in absenteeism (= 0.56, 95% CI [0.25, 0.87]), abstinence from alcohol/drugs (OR = 4.36, 95% CI [1.19, 15.98]), marijuana use (= 0.51, 95% CI [0.20, 0.82]), and other drug use (= 0.45, 95% CI [0.14, 0.76]). Overall, there was a serious risk of bias in the one included study. The study had a serious risk of bias due to confounding, low risk of bias due to selection of participants into the study, moderate risk of bias due to classification of interventions, inconclusive risk of bias due to deviations from intended interventions, inconclusive risk of bias due to missing data, moderate risk of bias in measurement of outcomes, and low risk of bias in selection of reported results. AUTHORS’ CONCLUSIONS There is insufficient evidence regarding the effectiveness of RHSs and CRCs for improving academic and substance use outcomes among students in recovery from SUDs. Only one identified study examined the effectiveness of RHSs. Although the study reported some beneficial effects, the results must be interpreted with caution given the study's potential risk of bias due to confounding and limited external validity. No identified studies examined the effectiveness of CRCs across the outcomes of interest in this review, so it is unclear what effects these programs may have on students' academic and behavioral outcomes. The paucity of evidence on the effectiveness of recovery schools, as documented in this review, thus suggest the need for caution in the widespread adoption of recovery schools for students in recovery from SUDs. Given the lack of empirical support for these recovery schools, additional rigorous evaluation studies are needed to replicate the findings from the one study included in the review. Furthermore, additional research examining the costs of recovery schools may be needed, to help school administrators determine the potential cost‐benefits associated with recovery schools.