Craig E. Henderson

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.

Treating adolescent drug abuse: a randomized trial comparing multidimensional family therapy and cognitive behavior therapy.

AIM To examine the efficacy of two adolescent drug abuse treatments: individual cognitive behavioral therapy (CBT) and multidimensional family therapy (MDFT). DESIGN A 2 (treatment condition) x 4 (time) repeated-measures intent-to-treat randomized design. Data were gathered at baseline, termination, 6 and 12 months post-termination. Analyses used latent growth curve modeling. SETTING Community-based drug abuse clinic in the northeastern United States. PARTICIPANTS A total of 224 youth, primarily male (81%), African American (72%), from low-income single-parent homes (58%) with an average age of 15 years were recruited into the study. All youth were drug users, with 75% meeting DSM-IV criteria for cannabis dependence and 13% meeting criteria for abuse. MEASUREMENTS Five outcomes were measured: (i) substance use problem severity; (ii) 30-day frequency of cannabis use; (iii) 30-day frequency of alcohol use; (iv) 30-day frequency of other drug use; and (v) 30-day abstinence. FINDINGS Both treatments produced significant decreases in cannabis consumption and slightly significant reductions in alcohol use, but there were no treatment differences in reducing frequency of cannabis and alcohol use. Significant treatment effects were found favoring MDFT on substance use problem severity, other drug use and minimal use (zero or one occasion of use) of all substances, and these effects continued to 12 months following treatment termination. CONCLUSION Both interventions are promising treatments. Consistent with previous controlled trials, MDFT is distinguished by the sustainability of treatment effects.

Impact of psychiatric comorbidity on treatment of adolescent drug abusers

Comorbidity of substance abuse disorders (SUD) and psychiatric disorders is one of the most important areas of investigation in contemporary drug abuse treatment research. This study examined the impact of psychiatric comorbidity on the treatment of 182 adolescent drug abusers in a randomized clinical trial comparing family and individual cognitive-behavioral therapy. Three distinct groups of adolescent substance abusers were compared: (1) Exclusive Substance Abusers (SUD only); (2) Externalizers (SUD + externalizing disorder); and (3) Mixed Substance Abusers (SUD + externalizing and internalizing disorder). The purpose of this study was to determine whether adolescents in these comorbid groups differed in clinical presentation and treatment response. More severe comorbidity was associated with greater family dysfunction and being female and younger at intake. An examination of substance use trajectories over time indicated that the Mixed group initially responded to treatment but returned to intake levels of substance use by 1 year post-discharge.

Early Intervention for Adolescent Substance Abuse: Pretreatment to Posttreatment Outcomes of a Randomized Clinical Trial Comparing Multidimensional Family Therapy and Peer Group Treatment

Abstract This randomized clinical trial evaluated a family-based therapy (Multidimensional Family Therapy, MDFT; Liddle 2002a) and a peer group therapy with 80 urban, low-income. and ethnically diverse young adolescents (11 to 15 years) referred for substance abuse and behavioral problems. Both treatments were outpatient, relatively brief, manual-guided, equal in intervention dose, and delivered by community drug treatment therapists. Adolescents and their parents were assessed at intake to treatment, randomly assigned to either MDFT or group therapy, and reassessed at six weeks after intake and at discharge. Results indicated that the family-based treatment (MDFT. an intervention that targets teen and parent functioning within and across multiple systems on a variety of risk and protective factors) was significantly more effective than peer group therapy in reducing risk and promoting protective processes in the individual, family, peer, and school domains. as well as in reducing substance use over the course of treatment. These results. which add to the body of previous findings about the clinical and cost effectiveness of MDFT, suppon the clinical effectiveness and dissemination potential of this family-based, multisystem and developmentally-oriented intervention.

Multidimensional Family Therapy for Young Adolescent Substance Abuse: Twelve-Month Outcomes of a Randomized Controlled Trial

Research has established the dangers of early onset substance use for young adolescents and its links to a host of developmental problems. Because critical developmental detours can begin or be exacerbated during early adolescence, specialized interventions that target known risk and protective factors in this period are needed. This controlled trial (n = 83) provided an experimental test comparing multidimensional family therapy (MDFT) and a peer group intervention with young teens. Participants were clinically referred, were of low income, and were mostly ethnic minority adolescents (average age = 13.73 years). Treatments were manual guided, lasted 4 months, and were delivered by community agency therapists. Adolescents and parents were assessed at intake, at 6-weeks post-intake, at discharge, and at 6 and 12 months following treatment intake. Latent growth curve modeling analyses demonstrated the superior effectiveness of MDFT over the 12-month follow-up in reducing substance use (effect size: substance use frequency, d = 0.77; substance use problems, d = 0.74), delinquency (d = 0.31), and internalized distress (d = 0.54), and in reducing risk in family, peer, and school domains (d = 0.27, 0.67, and 0.35, respectively) among young adolescents.

Effectiveness of multidimensional family therapy with higher severity substance-abusing adolescents: report from two randomized controlled trials.

OBJECTIVE We used growth mixture modeling to examine heterogeneity in treatment response in a secondary analysis of 2 randomized controlled trials testing multidimensional family therapy (MDFT), an established evidence-based therapy for adolescent drug abuse and delinquency. METHOD The first study compared 2 evidence-based adolescent substance abuse treatments: individually focused cognitive-behavioral therapy and MDFT in a sample of 224 urban, low-income, ethnic minority youths (average age = 15 years, 81% male, 72% African American). The second compared a cross-systems version of MDFT (MDFT-detention to community) with enhanced services as usual for 154 youths, also primarily urban and ethnic minority (average age = 15 years, 83% male, 61% African American, 22% Latino), who were incarcerated in detention facilities. RESULTS In both studies, the analyses supported the distinctiveness of 2 classes of substance use severity, characterized primarily by adolescents with higher and lower initial severity; the higher severity class also had greater psychiatric comorbidity. In each study, the 2 treatments showed similar effects in the classes with lower severity/frequency of substance use and fewer comorbid diagnoses. Further, in both studies, MDFT was more effective for the classes with greater overall substance use severity and frequency and more comorbid diagnoses. CONCLUSIONS Results indicate that for youths with more severe drug use and greater psychiatric comorbidity, MDFT produced superior treatment outcomes.

Changing Provider Practices, Program Environment, and Improving Outcomes by Transporting Multidimensional Family Therapy to an Adolescent Drug Treatment Setting

Effective interventions for drug abusing adolescents are underutilized. Using an interrupted time series design, this study tested a multicomponent, multi-level technology transfer intervention developed to train clinical staff within an existing day treatment program to implement multidimensional family therapy (MDFT), an evidence-based adolescent substance abuse treatment. The sample included 10 program staff and 104 clients. MDFT was incorporated into the program and changes were noted in the program environment, therapist behavior, and in most (e.g., drug abstinence, and out of home placements) but not all (e.g., drug use frequency) client outcomes. These changes remained after MDFT supervision was withdrawn.

Implementation Outcomes of Multidimensional Family Therapy-Detention to Community: A Reintegration Program for Drug-Using Juvenile Detainees:

Responding to urgent calls for effective interventions to address young offenders’ multiple and interconnected problems, a new variant of an existing empirically-validated intervention for drug-using adolescents, Multidimensional Family Therapy (MDFT)—Detention to Community (DTC) was tested in a two-site controlled trial. This article (a) outlines the rationale and protocol basics of the MDFT-DTC intervention, a program for substance-using juvenile offenders that links justice and substance abuse treatment systems to facilitate adolescents’ postdetention community reintegration; (b) presents implementation outcomes, including fidelity, treatment engagement and retention rates, amount of services received, treatment satisfaction, and substance abuse—juvenile justice system collaboration outcomes; and (c) details the implementation and sustainability challenges in a cross-system (substance abuse treatment and juvenile justice) adolescent intervention. Findings support the effectiveness of the MDFT-DTC intervention, and the need to develop a full implementation model in which transfer and dissemination issues could be explored more fully, and tested experimentally.

Refining the Parent-Reported Inventory of Callous-Unemotional Traits in Boys With Conduct Problems

Callous-unemotional (CU) traits have been shown to delineate a unique subgroup of children with severe and persistent conduct problems that seem to have unique etiological origins. However, commonly used measures of CU traits in children may not adequately capture the full range of these characteristics in a developmentally appropriate manner. As a result, the 24-item Inventory of Callous-Unemotional Traits (ICU; self-, parent-, and teacher-report versions; Frick, 2004) was recently developed as a more extensive assessment of CU traits. However, studies to date have focused almost exclusively on the self-report version ICU in adolescents and have identified problems with the factor structure of the measure. The current study is the 1st to examine the factor structure of the parent-report version ICU in a sample of 250 boys (ages 6-12 years) exhibiting significant conduct problems. Initial analyses indicated that factor models reported for the parent-report version of the ICU demonstrated a relatively poor fit to the data. Item response theory techniques were used to develop a more psychometrically sound and efficient short form of the ICU consisting of 2 factors (i.e., Callous and Uncaring) using 12 of the original 24 items. The revised version scores demonstrated high internal consistency, good discrimination across the continuum of the CU construct, and adequate short-term test-retest reliability. The revised measure total score also exhibited evidence of convergent and discriminant validity, although the subscales exhibited some differential correlations with theoretically meaningful constructs. Avenues for future measure refinement and use with children are discussed.

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.