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      Valerie Connell was a 16-year-old girl who was referred to an inpatient residential treatment program for adolescents with substance use disorders. Val was ordered to participate in treatment by the juvenile court after she was arrested for opioid possession and distribution.

      Val grew up in a western suburb of Chicago. Her father was a musician with a history of alcohol and marijuana use problems. He left Val and her mother when Val was 5 years old. Although he continued to live in the Chicago area, he had only occasional contact with Val. Val had mixed feelings about her father. On one hand, she was attracted to his glamorous lifestyle: performing, traveling, and socializing. On the other hand, she resented his decision to abandon his family when she was so young and harbored anger toward him because of the many times he disappointed her over the years. “If your own dad doesn’t care about you, no one will,” said Val. “I saw myself as pretty worthless—like no one will ever really love me.”

      Val’s mother also had a history of alcohol use. She became pregnant with Val when she was 17, a single parent by the time she was 22, and a recovering alcoholic by the time she was 26. Mrs. Connell attends Alcoholics Anonymous meetings to maintain her sobriety and supports herself and Val by working two jobs. Long hours limit her ability to be involved in Val’s school or extracurricular activities. Although she says, “Val means the world to me—the one thing I live for,” she admits that stress at work and concerns about her ability to pay the bills “sometimes cause me to lose my temper with her.”

      Val exhibited problems with hyperactivity and oppositional behavior as a preschooler. “She was a handful,” recalled her mother. “She’d always be on the go, she never wanted to be quiet and listen to me. If I would tell her to do something, she’d ignore me, yell, or scream.” Val’s disruptive behavior persisted into elementary school. Her pediatrician prescribed stimulant medication to manage her hyperactive-impulsive behavior, but it had little effect on her defiance and tantrums. By the time Val was in the third grade, she was behind her classmates in reading and math and had gained a reputation as a troublemaker.

      Val’s substance use began with her transition to middle school. She was referred to a special education program for children with behavior problems and learning disabilities. She quickly made friends with several girls who introduced her to smoking (age 12) and marijuana (age 13). Although she tried alcohol at approximately the same age, she did not like its taste and limited its use to parties and social gatherings. By the time Val was 14 years old, she was using marijuana several times per week and drinking five to six sweet alcoholic drinks at parties on the weekends. She found it easy to hide her substance use from her mother.

      Val transitioned to an alternative high school during her freshman year. “All of the kids there used drugs,” Val recalled. Her 17-year-old boyfriend introduced her to prescription pain medication. Val’s favorite combination was OxyContin in the morning followed by Roxicodone periodically throughout the school day. She quickly became known as the “Oxy and Roxy” girl. “I’d sleep during class, slur my speech, didn’t care about anything,” she recalled. “The teachers didn’t say anything to me because I didn’t cause trouble, so I kept on going.” Val obtained $10 pills from her boyfriend and sold them to classmates for $25, pocketing the profits to support her own drug use.

      “I first used heroin with my boyfriend—a different boyfriend—during my sophomore year,” Val reported. “I was afraid of needles so I snorted it. The feeling was excellent, like all the pain in my life was taken away. I could relax, stay still, and not worry about school or family. Snorting worked much faster than taking pills and the effects of heroin were much better.” Within 6 months, Val was