Rebecca H. Burke

Efficacy of Outpatient Aftercare for Adolescents With Alcohol Use Disorders : A Randomized Controlled Study

OBJECTIVE Relapse rates for treated adolescents with alcohol use disorders (AUDs) amount to approximately 60% at 3 to 6 months after treatment completion. This randomized controlled study tested the hypothesis that active aftercare may maintain treatment gains better than no active aftercare (NA). METHOD A total of 177 adolescents, 13 to 18 years of age, diagnosed with DSM-IV AUD, participated in nine weekly outpatient cognitive behavioral therapy group sessions. The 144 treatment completers were randomized into a 5-session in-person, brief telephone, or NA condition. Three alcohol use variables were the main outcome measures for 130 aftercare completers. RESULTS At the end of aftercare, the likelihood of relapse increased significantly compared with end of treatment outcomes. The likelihood of relapse for youths in NA, however, increased significantly more for youths in combined active aftercare (AA) conditions (p =.008). This effect was driven primarily by a significant sex x active aftercare interaction: girls showed no significant relapse under AA but relapsed significantly in NA. Youths enrolled in AA also showed significantly fewer drinking days (p =.044) and fewer heavy drinking days (p =.035) per month relative to NA. CONCLUSIONS In general, active aftercare interventions showed certain efficacy in slowing the expected posttreatment relapse process for alcohol use, with maintenance of treatment gains only for girls. Frequency of interventions, dose-response, duration of aftercare phase, and mediators of behavior change should be examined further to optimize aftercare for youths with AUD.

An Interactive Voice Response (IVR) System for Adolescents with Alcohol Use Disorders: A Pilot Study

In order to understand predictors of relapse among adolescents treated for alcohol use disorders (AUD), it is important to accurately assess the daily circumstances associated with use. This pilot study investigates the feasibility and acceptability of an interactive voice response (IVR) system in adolescents with AOSUD. Twenty-six adolescents 14 to 19 years old, with a mean age of 16.8, who were enrolled into an adolescent treatment program for AUD consented to make phone calls for 14 successive evenings to an IVR system and answer 14 questions pertaining to daily use of alcohol and other drugs. The subjects were compensated for their participation. A satisfaction questionnaire was administered at the end of the study. Participants completed 72% of scheduled recordings, with an average of 10.1 calls per subject. Most participants reported that they answered the questions honestly and accurately and were very much satisfied with the IVR system. The preliminary data presented here suggests that the use of IVR for the purpose of generating daily reports in youth is feasible and acceptable. The utilization of IVR systems should be explored to improve efficacy and attainment of generalizability to heterogeneous adolescent populations and lifestyles including for other psychiatric disorders.

Twelve-month follow-up of aftercare for adolescents with alcohol use disorders

Adolescents with alcohol use disorders (AUDs) previously completed a randomized controlled outpatient aftercare study (Y. Kaminer, J. A. Burleson, & R. H. Burke, 2008) in which they were randomly assigned to in-person, brief telephone, or no-active aftercare. Youth were assessed at end of aftercare and at 3-, 6-, and 12-month follow-up on frequency and quantity of alcohol use. It was predicted that active aftercare (in-person and brief telephone) would be superior to no-active aftercare in reducing alcohol use, as shown in the original study. No subject or therapy group attributes were significant moderators of outcome. Active aftercare in general maintained short-term favorable effects by reducing relapse in youth with AUD and should be considered as part of standard procedures in therapeutic interventions for all alcohol and other substance use. In-person and the brief telephone procedures did not differ in their effectiveness. Structured communications with AUD youth during and after treatment by use of electronic technology rather than in-person contact might therefore be more fully investigated.

Suicidal ideation among adolescents with alcohol use disorders during treatment and aftercare.

The objectives of this study are to assess the magnitude and course of suicidal ideation during outpatient treatment and aftercare for adolescents with alcohol use disorders (AUD). One hundred seventy-seven adolescents meeting eligibility criteria, including no past 30-day suicidal behavior, participated in 9 weeks of outpatient cognitive-behavioral group therapy. Treatment completers were randomized into: (1) No-Active, (2) In-Person, or (3) Telephone aftercare conditions for a period of 12 weeks. No specific intervention for suicidal behavior was provided during the study. The Suicide Ideation Questionnaire (SIQ-JR, Reynolds, 1988) was administered at baseline, end of treatment, and end of aftercare. The results are as follows, a higher baseline suicidal ideation was associated with higher retention at the end of treatment and through aftercare. The In-Person Aftercare condition showed a significant decrease in suicidal ideation, relative to the No-Active Aftercare condition. There was a trend for similarly reduced severity of suicidal ideation in the Telephone Aftercare condition. In conclusion, the type of aftercare and resulting decrease in AUD may play a role in the reduction in suicidal ideation. The mechanism of change by which suicidal ideation is reduced in adolescents in treatment for AUD needs to be further explored.

Trauma and PTSD - Among Youths in Outpatient Treatment for Alcohol Use Disorders

This article examines the relationships among trauma histories and diagnoses of partial or full posttraumatic stress disorder (PTSD) among 106 youths in outpatient treatment for alcohol use disorders (AUD). Subjects were 13 to 18 years old and were recruited from treatment facilities, schools, and juvenile corrections programs. Chi-square (χ2) tests and one-way analyses of variance examined prevalence estimates of exposure to traumatic stressors, PTSD status, and related characteristics. Pearson’s correlation coefficients, K-Cluster procedure, and logistic regression examined correlates of PTSD status. Almost 90% reported a trauma history, and 13% met criteria for a PTSD diagnosis. Logistic regression analyses indicated that sexual abuse history, comorbid psychiatric symptom severity, and suicide ideation were associated with PTSD. These findings underscore the importance of addressing trauma with youths in AUD treatment.

Can Assessment Reactivity Predict Treatment Outcome among Adolescents with Alcohol and Other Substance Use Disorders

The objectives of this paper are two-fold: to examine first, if the change from positive to negative alcohol and any other substance use status from baseline assessment to the onset of the first session (i.e., pre-treatment phase) occurs in adolescents, that is, Assessment Reactivity (AR); second, whether AR predicts treatment outcome. Participants were 177 adolescents with alcohol and other substance use disorders (AOSUD) in a 9-weekly group sessions of cognitive behavioral therapy. Drug urinalysis results at baseline assessment, first and last session and self-report for alcohol use were used as outcome measures. Participants showed a highly significant shift to non-use of both alcohol and of other substances from intake assessment to first session and from first to last session. Alcohol and substance use at first session predicted use at last session. This is the first study in youth asserting Assessment Reactivity as a valid construct during the pretreatment phase. AR should be considered in any analysis targeting treatment outcomes.

The efficacy of contingency management for adolescent cannabis use disorder: a controlled study.

BACKGROUND This study was performed to investigate the efficacy of a voucher-based reinforcement therapy (VBRT) rewarding drug-free urine for adolescents with cannabis use disorder. METHODS A controlled 10-week study where 59 adolescents aged 14-18 years were assigned by cohorts into groups of either an integrated cognitive-behavioral therapy (CBT) and VBRT or CBT with attendance-based reward program. Substance use was monitored by twice-weekly urinalysis. Other measures were collected at pre- and posttreatment and at 3-month follow-up. RESULTS There was no significant difference in the linear change between conditions for cannabis use either from Sessions 1 to 10 or between end-of-treatment to 3-month follow-up. Also, self-efficacy and coping response did not show improvement during treatment. CONCLUSIONS In this study, the addition of contingency management (CM) to CBT in youth was not found to be more efficacious than similar compensation rewarding attendance only. Continued examination of the efficacy of CM and its interaction with the associated mechanisms of behavior change of CBT in youth is necessary. Examination of the effect of the magnitude of the reward as well as considering the emotional and cognitive developmental differences from adults is warranted.

Stability of Comorbid Psychiatric Diagnosis among Youths in Treatment and Aftercare for Alcohol Use Disorders.

OBJECTIVES To examine the stability of comorbid psychiatric diagnoses among a sample of 50 adolescents in cognitive-behaviorally-based treatment for alcohol and other substance use disorders (AOSUD). METHODS A standardized psychiatric interview was administered at baseline and 12 month later to obtain current comorbid psychiatric disorders. Chi square and Wilconxon sign tests coefficients were used to examine changes in threshold status by type of disorder. Pearsons coefficients were used to identify correlates with improvements in threshold status, include the need for alcohol treatment and alcohol consumption at follow-up. RESULTS Diagnostic status changes considerably over time. Prevalence rates for comorbid disorders overall declined. Only declines in mood and externalizing disorders achieved statistical significance. Improvements were positively correlated with mental health service utilization and negatively correlated with the need for alcohol treatment and consumption at 12 months. CONCLUSIONS Further investigation on the stability and change in diagnostic status of AOSUD.

Goal commitment predicts treatment outcome for adolescents with alcohol use disorder

OBJECTIVE Commitment to change is an innovative potential mediator and mechanism of behavior change (MOBC) that has not been examined in adolescents with substance use disorders (SUD). The Adolescent Substance Abuse Goal Commitment (ASAGC) questionnaire is a reliable and valid 2-scale measure developed to assess the adolescents commitment to either abstinence or harm reduction (HR) that includes consumption reduction as a stated treatment goal. The objective of this study was to examine the ASAGCs ability to predict alcohol use treatment outcome. METHOD During sessions three and nine of a 10-week treatment program, therapists completed the ASAGC for 170 adolescents 13-18years of age with alcohol use disorder (AUD). Drinking behaviors were assessed during and after a continued-care phase until 12-month from study onset. RESULTS Analysis of Variance results indicated that adolescents who reported no alcohol use had significantly higher scores on the commitment to abstinence scale than adolescents who reported alcohol use. None of the ANOVA models were significant for commitment to HR. When treatment outcome was examined, commitment to abstinence consistently predicted number of drinking days, number of heavy drinking days, and the maximum number of drinks post-treatment. In contrast, commitment to HR did not predict any of the drinking outcomes. These results suggest that the more adolescents were committed to abstinence during treatment, the less they used and abused alcohol after treatment completion. CONCLUSIONS In addition to the ASAGCs ability to differentiate between commitment to abstinence and commitment to HR, study findings demonstrate that goal commitment consistently predicts AUD treatment outcome.

Adolescents with cannabis use disorders: Adaptive treatment for poor responders ☆ ☆☆ ☆☆☆

OBJECTIVE Treatment response as measured by both retention and abstinence attainment rates for adolescents with cannabis use disorders (CUD) has been unsatisfactory. This study tested the hypothesis that adaptive treatment (AT) will improve outcomes for poor responders (PR) to evidence-based practice interventions. METHOD A total of 161 adolescents, 13-18years of age, diagnosed with DSM-IV CUD, enrolled in this outpatient, randomized, AT study. Following a 7-session weekly motivational enhancement and cognitive behavioral therapy intervention (MET/CBT-7) only poor responders (defined as failing to achieve abstinence at week seven for any reason) were randomized into a 10-week AT phase of either an individualized enhanced CBT or an Adolescent Community Reinforcement Approach (ACRA) intervention. Good responders (GR) enrolled only in follow-up assessments starting at the completion of the AT phase (week 17). RESULTS Eighty adolescents (50%) met the criterion for poor response to treatment. Thirty seven percent of poor responders completed the AT phase and 27% of them achieved abstinence. There was no significant difference in retention and abstinence rates between the AT conditions. Although the majority of GR relapsed by week 17, they significantly differed from PR both for drug use (71% vs. 91%, respectively; p<0.05) and reporting to scheduled assessment on that week (78% vs. 54%, respectively; p<0.01). CONCLUSION Continuity of care to achieve abstinence among poor responders remains a therapeutic necessity and a research challenge. Examining innovative AT designed interventions including potential integrative approaches should be further studied in order to improve treatment outcomes.