Aaron Hogue

Treatment Adherence, Competence, and Outcome in Individual and Family Therapy for Adolescent Behavior Problems

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed.

Homophily of internalized distress in adolescent peer groups

This study examined various homophilic mechanisms by which adolescents affect, and are affected by, levels of internalized distress within their immediate peer groups. The sample included approximately 6,000 14- to 18-year-olds who were assessed twice over a 1-year period. Results showed that adolescents tend to associate with peers who report similar levels of internalized distress and that internalizers are no less successful than others at establishing friendships. Moreover, homophily of internalizing symptoms develops from 3 distinct sources : (a) Adolescents tend to choose friends who possess similar levels of internalized distress (selection effect) ; (b) in male, but not female, peer groups, individual distress levels grow increasingly similar to peer levels over time (socialization effect) ; and (c) peer group distress levels vary according to the distress of individual members (contagion effect).

Early Therapeutic Alliance and Treatment Outcome in Individual and Family Therapy for Adolescent Behavior Problems

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations.

Treatment adherence process research in family therapy: A rationale and some practical guidelines.

Treatment adherence research has recently established a permanent niche in psychotherapy outcome research as a means for testing whether interventions have been implemented as intended. Advanced-level adherence methods allow investigators to move beyond treatment integrity questions regarding model fidelity and toward treatment process questions regarding therapeutic technique and intervention dosage. Though still in the developmental stage, treatment adherence process procedures appear to be congruent with the methods, goals, and theoretical framework that characterize contemporary psychotherapy process research. Because adherence process research is

Treatment Adherence and Differentiation in Individual Versus Family Therapy for Adolescent Substance Abuse.

Treatment adherence and differentiation in dynamic cognitive-behavioral therapy and multidimensional family therapy for adolescent substance abuse were evaluated with a treatment adherence process measure. Full-length videotapes of 90 treatment sessions (36 clients) were reviewed by nonparticipant raters. Adherence scales for each treatment generated through factor analysis of observational ratings demonstrated sound interrater reliability and internal consistency. Therapists in each condition used techniques unique to their own model and avoided those unique to the competing model. Individual therapists emphasized behavioral and substance-use interventions, whereas family therapists focused on interactional and affective interventions. Challenges in conducting adherence research that compares individual and family treatments are addressed. as are implications of these results for advancing treatment development for adolescent drug users.

Treatment Techniques and Outcomes in Multidimensional Family Therapy for Adolescent Behavior Problems

The link between treatment techniques and long-term treatment outcome was examined in an empirically supported family-based treatment for adolescent drug abuse. Observational ratings of therapist interventions were used to predict outcomes at 6 and 12 months posttreatment for 63 families receiving multidimensional family therapy. Greater use of in-session family-focused techniques predicted reduction in internalizing symptoms and improvement in family cohesion. Greater use of family-focused techniques also predicted reduced externalizing symptoms and family conflict, but only when adolescent focus was also high. In addition, greater use of adolescent-focused techniques predicted improvement in family cohesion and family conflict. Results suggest that both individual and multiperson interventions can exert an influential role in family-based therapy for clinically referred adolescents.

Evidence Base on Outpatient Behavioral Treatments for Adolescent Substance Use: Updates and Recommendations 2007–2013

This article updates the evidence base on outpatient behavioral treatments for adolescent substance use (ASU) since publication of the previous review completed for this journal by Waldron and Turner (2008). It first summarizes the Waldron and Turner findings as well as those from more recent literature reviews and meta-analytic studies of ASU treatment. It then presents study design and methods criteria used to select 19 comparative studies subjected to Journal of Clinical Child & Adolescent Psychology level of support evaluation. These 19 studies are grouped by study category (efficacy or effectiveness) and described for sample characteristics, methodological quality, and substance use outcomes. Cumulative level of support designations are then made for each identified treatment approach: ecological family-based treatment, group cognitive-behavioral therapy, and individual cognitive-behavioral therapy are deemed Well Established; behavioral family-based treatment and motivational interviewing are deemed Probably Efficacious; drug counseling is deemed Possibly Efficacious; and four integrated treatment models combining more than one approach are deemed Well Established or Probably Efficacious. The remainder of the article (a) articulates fidelity, mediator, and moderator effects reported for evidence-based approaches since 2008 and (b) recommends four enhancements to the prevailing business model of ASU outpatient services to accelerate penetration of evidence-based approaches into the underserved consumer base: pursue partnerships with influential governmental systems, utilize web-based technology to extend reach and control costs, adapt effective methods for linking services across sectors of care, and promote uptake and sustainability by emphasizing return on investment.

An Afrocentric Approach to Group Social Skills Training with Inner-City African American Adolescents.

This study compared the effectiveness for inner-city African American youth (N = 64) of two social skills training (SST) curricula focusing on problem solving, anger management, and conflict resolution. One curriculum was Afrocentric, incorporating discussion of Black history and cultural experiences and emphasizing an Afrocentric value system; the other was culturally relevant but not Afrocentric. It was hypothesized that social skills acquisition would be better facilitated by Afrocentric curricula and that exposure to Afrocentric values would enhance the benefits of SST for Black youth. Neither hypothesis was confirmed; both curricula yielded similar decreases in trait anger and increases in assertiveness and self-control. However, results support the effectiveness of Afrocentric SST as a preventive intervention and the need for further study. INTRODUCTION Violence-encompassing a variety of intentional or unintentional acts of harm such as stabbings, shootings, rapes, assaults, physical abuse, and homicide-is a critical social problem confronting American society. Since the early 1990s, violent crime rates in the United States have been the highest seen in decades, with the latest upswing in violence largely accounted for by youth under age 18 (Guerra, Huesmann, Tolan, Van Acker, & Eron, 1995). This trend disproportionately affects African American and other racial/ ethnic minority youth, who populate the urban neighborhoods in which much of this violence is concentrated, and who experience more violence than youth living in nonurban areas (Cooley, Turner, & Beidel, 1995). As Bell and Jenkins (1991) maintain, exposure to violence has become commonplace for inner-city African American adolescents. For example, in a study conducted in predominantly Black central Baltimore (Maryland), Garbarino, Durbow, and Pardo (1991) note that 24% of their adolescent sample (N= 168) indicated having witnessed a murder, while 72% maintained that they knew someone who had been shot. The homicide rate for African American adolescents is reportedly six to nine times higher than that for White adolescents (Cotten, Resnick, Brown, & Martin, 1994; Durant, Cadenhead, Pendergrast, & Slavens, 1994). Between 1978 and 1988, homicide was the leading cause of death for African American male and female youth, and often these crimes were perpetrated by other African American youth (Hammond & Yung, 1993). Family disruption, poverty, unemployment, and racism are environmental risk factors that contribute to violence in urban communities (McLoyd,1990). Complex urban environmental stressors such as family and community violence, victimization, and poverty contribute to feelings of low self-worth, anger, hopelessness, and aggression among the youth who live in these communities (Oliver, 1989). These constant stressors can prevent the development and use of socially acceptable ways to mediate violence. As a result, urban youth are placed at high risk of neither developing nor maintaining healthy social interaction skills, which Reed (1994) defines as (a) the ability to organize cognitions and behaviors toward an action that is culturally and socially acceptable, and (b) the ability to assess, modify, and maximize or reach particular goals. With regard to violence prevention and intervention particularly, these skills involve problem solving, conflict resolution, and anger management (Bulkeley & Cramer, 1990). Social skills training (SST) is a popular and effective means of prevention and intervention with adolescent populations (Reed, 1994; Waksman, 1985). It is frequently used as a preventive intervention to remediate problematic social behaviors while encouraging positive social interactions (Gresham & Elliott, 1990). Most SST programs involve formal teaching of the problem-solving and interpersonal skills required for surviving, living with others, and succeeding in a complex society. As such, they provide a broad base of prosocial skills training that includes awareness building, and development of situationspecific skills that foster interpersonal competency. …

LINKING SESSION FOCUS TO TREATMENT OUTCOME IN EVIDENCE-BASED TREATMENTS FOR ADOLESCENT SUBSTANCE ABUSE

The relation between specific therapy techniques and treatment outcome was examined for 2 empirically supported treatments for adolescent substance abuse: individual cognitive-behavioral therapy and multidimensional family therapy. Participants were 51 inner-city, substance-abusing adolescents receiving outpatient psychotherapy within a larger randomized trial. One session per case was evaluated using a 17-item observational measure of model-specific techniques and therapeutic foci. Exploratory factor analysis identified 2 subscales, Adolescent Focus and Family Focus, with strong interrater reliability and internal consistency. Process-outcome analyses revealed that family focus, but not adolescent focus, predicted posttreatment improvement in drug use, externalizing symptoms, and internalizing symptoms within both study conditions. Implications for the implementation and dissemination of individual-based and family-based approaches for adolescent drug use are discussed.

Typologies of Alcohol Use in White and African American Adolescent Girls

This study examined typologies of alcohol use among 2,948 White and African American adolescent girls using data from the National Longitudinal Study of Adolescent Health. Self-report data were collected on frequency and quantity of alcohol use, negative consequences, and high-risk drinking behaviors, as well as co-occurring internalizing and externalizing problems. Latent class analysis revealed a four-group typology for White girls and a three-group typology for African American girls. Problematic drinkers reported having more internalizing and externalizing problems in both racial groups. The studys limitations and implications are discussed.