Guy Diamond

Attachment-Based Family Therapy for Depressed Adolescents: A Treatment Development Study

OBJECTIVE To design a treatment manual and adherence measure for attachment-based family therapy (ABFT) for adolescent depression and to collect pilot data on the treatments efficacy. METHOD Over a period of 2 years, 32 adolescents meeting criteria for major depressive disorder (MDD) were randomly assigned to 12 weeks of ABFT or a 6-week, minimal-contact, waitlist control group. The sample was 78% female and 69% African American; 69% were from low-income, inner-city communities. RESULTS At post-treatment, 81% of the patients treated with ABFT no longer met criteria for MDD, in contrast with 47% of patients in the waitlist group. Mixed factorial analyses of variance revealed that, compared with the waitlist group, patients treated with ABFT showed a significantly greater reduction in both depressive and anxiety symptoms and family conflict. Of the 15 treated cases assessed at the follow-up, 13 patients (87%) continued to not meet criteria for MDD 6 months after treatment ended. CONCLUSIONS ABFT appears to be a promising treatment and worthy of further development.

Attachment-Based Family Therapy for Depressed Adolescents: Programmatic Treatment Development

Few effective psychosocial treatment models for depressed adolescents have been developed, let alone ones that use the developmentally potent context of the family as the focus of intervention. Attachment-based family therapy (ABFT) is a brief, manualized treatment model tailored to the specific needs of depressed adolescents and their families. Attachment theory serves as the main theoretical framework to guide the process of repairing relational ruptures and rebuilding trustworthy relationships. Empirically supported risk factors for depression are the primary problem states that therapists target with specific treatment strategies or tasks. Parent problem states include criticism/hostility, personal distress, parenting skills, and disengagement. Adolescent problem states include motivation, negative self-concept, poor affect regulation, and disengagement. Intervention tasks include relational reframing, building alliances with the adolescent and with the parent, addressing attachment failures, and building competency. A small, randomized clinical trial provides initial support for the model. Several process research studies, using both qualitative and quantitative methods, have helped refine the clinical guidelines for each treatment task. ABFT is a promising new treatment for depressed adolescents and more research on it is warranted.

Do Gender and Racial Differences Between Patient and Therapist Affect Therapeutic Alliance and Treatment Retention in Adolescents

Parents, referral sources, and even therapists wonder whether the gender and racial match between therapists and patients contributes to poorer alliances and treatment dropout. Six hundred adolescent substance abusers andtheir therapists from a large randomized clinical trial were grouped according to matches and mismatches on both gender and race, and alliance ratings were collected from both patients and therapists. Results revealed that gender-matched dyads reported higher alliances and were more likely to complete treatment. Racial matching predicted greater retention but not patient-rated alliance. However, therapists in mismatched dyads rated significantly lower alliances. Results suggest that. although multicultural training remains critical, training emphasis should also be placed on understanding how gender and racial differences affect therapeutic processes.

Current Status of Family-Based Outcome and Process Research

OBJECTIVE To review family-based treatment research. A growing body of research and several meta-analytic reviews demonstrate that family-based treatments are effective for a variety of child and adolescent disorders. In addition, an emerging tradition of family-based process research has begun to identify important ingredients of effective family psychotherapy. This article reviews these advances and their implications for future research. METHOD Selected studies on the treatment of schizophrenia, depression, anxiety, eating disorders, attention deficit, conduct disorder, and substance abuse are reviewed, as well as several process research and meta-analytic studies. RESULTS Family-based therapies have been shown to be effective for treating schizophrenia, conduct disorder, and substance abuse. Some data support their effectiveness in the treatment of eating disorders. Few studies have targeted internalizing disorders. A process research tradition is emerging, but it is in need of methodological advances. Meta-analytic studies suggest that family-based therapies are as effective as other models. CONCLUSIONS More well-designed studies with diverse populations are needed to assess accurately the effectiveness of this increasingly popular treatment approach.

Reassessing Psychotherapy Research

Six critical assessments of substantive results, research methods, theoretical and metatheoretical models, and other aspects of the psychotherapy research tradition, and suggestions for alternative investigative strategies at all levels of research from the choice of constructs and designs to interp

Feasibility and Effects of a Web-Based Adolescent Psychiatric Assessment Administered by Clinical Staff in the Pediatric Emergency Department

OBJECTIVES To determine the adoption rate of the Web-based Behavioral Health Screening-Emergency Department (BHS-ED) system during routine clinical practice in a pediatric ED, and to assess this systems effect on identification and assessment of psychiatric problems. DESIGN Descriptive design to evaluate the feasibility of a clinical innovation. SETTING The ED of an urban tertiary care childrens hospital. PARTICIPANTS Adolescents from 14 to 18 years of age, without acute or critical injuries or illness, presenting with nonpsychiatric symptoms. INTERVENTION The ED clinical staff initiated the use of the BHS-ED system, which identifies and assesses adolescents for depression, suicidal ideation, posttraumatic stress, substance use, and exposure to violence. Treating clinicians reviewed results and followed routine care practices thereafter. MAIN OUTCOME MEASURES Adoption rate of the BHS-ED system by nursing staff, identification rates of occult psychiatric problems, and social worker or psychiatrist assessment. Data were collected for 19 months before implementation of the BHS-ED system and for 9 months during implementation. RESULTS Of 3979 eligible patients, 1327 (33.4%) were asked by clinical staff to get screened using the BHS-ED; of these 1327 patients, 857 (64.6%) completed the screening and 470 (35.4%) refused. During implementation, identification of adolescents with psychiatric problems increased significantly (4.2% vs 2.5%; odds ratio [OR], 1.70; 95% confidence interval [CI], 1.38-2.10), as did ED assessments by a social worker or psychiatrist (2.5% vs 1.7%; OR, 1.47; 95% CI, 1.13-1.90). Of the 857 patients who were screened with the BHS-ED, 90 (10.5%) were identified as having psychiatric problems (OR, 4.58; 95% CI, 3.53-5.94), and 71 (8.3%) were assessed (OR, 5.12; 95% CI, 3.80-6.88). CONCLUSIONS In a busy pediatric ED, computerized, self-administered adolescent behavioral health screening can be incorporated into routine clinical practice. This can lead to small but significant increases in the identification of unrecognized psychiatric problems.

Development, Validation, and Utility of Internet-Based, Behavioral Health Screen for Adolescents

OBJECTIVES: The goals were to develop and to validate the Internet-based, Behavioral Health Screen (BHS) for adolescents and young adults in primary care. METHODS: Items assessing risk behaviors and psychiatric symptoms were built into a Internet-based platform with broad functionality. Practicality and acceptability were examined with 24 patients. For psychometric validation, 415 adolescents completed the BHS and well-established rating scales. Participants recruited from primary care waiting rooms were 12 to 21 years of age (mean: 15.8 years); 66.5% were female and 77.5% black. RESULTS: The BHS screens in 13 domains by using 54 required items and 39 follow-up items. The administration time was 8 to 15 minutes (mean: 12.4 minutes). The scales are unidimensional, are internally consistent (Cronbachs α = 0.75–0.87), and discriminate among adolescents with a range of diagnostic syndromes. Sensitivity and specificity were high, with overall accuracy ranging from 78% to 85%. Patients with scores above scale cutoff values for depression, suicide risk, anxiety, and posttraumatic stress disorder symptoms were ≥4 times more likely to endorse other risk behaviors or stressors. CONCLUSIONS: The BHS addresses practical and clinical barriers to behavioral health screening in primary care. It is a brief but comprehensive, self-report, biopsychosocial assessment. The psychiatric scales are valid and predictive of risk behaviors, which facilitates exclusion of false-positive results, as well as assessment and triage.

The therapist–parent alliance in family‐based therapy for adolescents

This article describes procedures for developing a therapeutic alliance with a parent within the context of family therapy for adolescents. After an overview of the general clinical model, specific themes and interventions are described that provide a map to facilitate this process. Following Bordins (1979) model, alliance is conceptualized in three parts: bonds, goals, and tasks. The bond phase consists of the therapist showing empathy and understanding toward the parent and the parent developing empathy toward their own life struggles. The goal phase consists of defining parent-child relationship building as a primary focus of treatment. The task phase consists of preparing parents to better communicate with their adolescent. These phases can occur sequentially within a single session with a parent alone. The alliance building session sets the foundation for parent-adolescent conflict resolution leading to reattachment in future sessions.

Psychiatric syndromes in adolescents with marijuana abuse and dependency in outpatient treatment

ABSTRACT Objective: The purpose of the current study to assist in understanding the prevalence and clinical correlates of psychiatric distress in adolescents seeking outpatient services for marijuana abuse or dependency. Methods: In a multi-site randomized clinical trial, 600 adolescents and their parents were assessed at intake using the Global Appraisals of Individual Needs. DSM-IV criteria were used to diagnose marijuana use disorders, and a symptom check list was used to measure symptoms on five syndromes: conduct disorder, ADHD, depression, anxiety, and disorders of traumatic distress. Results: Patients endorsed acute levels of conduct disorder (74%), ADHD (77%), depression (37.7%), anxiety (28.8%), and traumatic distress (13.8%), and 72% endorsed acute levels on two or more syndromes. Adolescents with a diagnosis of dependency and females evidenced the greatest severity of mental health distress, and minimal differences were found between racial groups. Patients with acute levels of both internalizing and externalizing syndromes reported problems with substance use, criminal activities, trauma experience, and family environments. Conclusion: Co-occurring psychiatric distress is the norm for adolescents seeking outpatient services for marijuana disorders. Better integration of substance use and mental health services would likely improve the quality of care for these troubled youth.

Sexual Trauma History Does not Moderate Treatment Outcome in Attachment-Based Family Therapy (ABFT) for Adolescents With Suicide Ideation

Despite the well-documented association between history of sexual trauma (HSA) and suicide ideation, HSA is largely overlooked in suicide treatment studies. Existing studies showed that patients with a HSA have a weaker treatment response. In this randomized clinical trial for suicide ideation, HSA did not moderate treatment outcome for Attachment-Based Family Therapy (ABFT). Adolescents responded better to ABFT than a control condition, regardless of HSA status. At baseline, adolescents with HSA were also more likely to report past suicide attempts than those without HSA, indicating that they are a particularly important subgroup to consider when developing and evaluating interventions that target suicide ideation. Findings suggest that ABFT is a robust intervention for suicide ideation regardless of HSA.