Pilot Trial of Online Measurement Training and Feedback in Family Therapy for Adolescent Behavior Problems

OBJECTIVE

Pragmatic procedures for sustaining high-fidelity delivery of evidence-based interventions are needed to support implementation in usual care. This study tested an online therapist training system, featuring observational coder training and self-report fidelity feedback, to promote self-report acumen and routine use of family therapy (FT) techniques for adolescent behavior problems.

METHOD

Therapists (N = 84) from nine substance use and mental health treatment sites reported on 185 adolescent clients. Therapists submitted baseline data on FT technique use with clients, completed a workshop introducing the 32-week training system, and were randomly assigned by site to Core Training versus Core Training + Consultation. Core Training included a therapist coder training course (didactic instruction and mock session coding exercises in 13 FT techniques) and fidelity feedback procedures depicting therapist-report data on FT use. Consultation convened therapists and supervisors for one-hour monthly sessions with an external FT expert. During the 32 weeks of training, therapists submitted self-report data on FT use along with companion session audiotapes subsequently coded by observational raters.

RESULTS

Therapist self-report reliability and accuracy both increased substantially during training. Observers reported no increase over time in FT use; therapists self-reported a decrease in FT use, likely an artifact of their improved self-report accuracy. Consultation did not enhance therapist self-report acumen or increase FT use.

CONCLUSIONS

Online training methods that improve therapist-report reliability and accuracy for FT use may confer important advantages for treatment planning and fidelity monitoring. More intensive and/or different training interventions appear needed to increase routine FT delivery.

Training Community Therapists in Core Elements of CBT and Family Therapy for Adolescent Externalizing Problems

OBJECTIVE

This pilot study tested pragmatic methods for training therapists in core techniques of two evidence-based interventions (EBIs) for adolescent externalizing problems: cognitive-behavioral therapy (CBT) or family therapy (FT). Training methods were designed to help therapists accurately self-monitor their use of EBIs and increase delivery of EBIs with current clients. The study compared coder training only versus coder training plus fidelity-focused consultation.

METHOD

Therapists (N = 42) from seven behavioral health clinics reported on 65 youth clients; four clinics elected to train in CBT and three in FT. Therapists were randomized to either coder training only, consisting of a 25-week observational coder training course (didactic instruction and mock session coding exercises in core EBI techniques); or coder training plus fidelity-focused consultation, consisting of direct-to-therapist fidelity measurement feedback along with fidelity-focused expert consultation. During the 25 weeks of training, therapists submitted self-report data on EBI use along with companion session audiotapes subsequently coded by observational raters.

RESULTS

Compared to coder training only, coder training plus fidelity-focused consultation produced superior effects in therapist ability to judge the extensiveness of EBI techniques in online coding sessions, as well as therapist ability to self-rate use of EBI techniques with their own cases. In both conditions, therapists who trained in CBT showed a significant, though modest, increase in real-world delivery of core CBT techniques; this did not occur for FT.

CONCLUSIONS

Pragmatic training and consultation methods show promise as viable and effective options for enhancing EBI fidelity monitoring and, for CBT, increasing EBI delivery.

Caregiver Engagement in Outpatient Treatment for Adolescents in Community Settings: Construct and Predictive Validity of Family Therapy Techniques

Caregiver engagement and participation in community-based outpatient treatment services for adolescents is generally poor, which is problematic given the integral role of caregivers prescribed by evidence-based treatments across orientations. The current study explores the psychometric and predictive properties of a set of caregiver engagement techniques distilled from family therapy, used by community clinicians in routine care. It highlights relational engagement interventions and adds to growing work distilling core elements of family therapy. The study examined caregiver engagement techniques observed in 320 recorded sessions and outcome data from 152 cases treated by 45 therapists participating in one of three randomized trials investigating delivery of family therapy for adolescent behavior problems in community settings. Construct and predictive validity of caregiver engagement coding items were analyzed to understand the degree to which they cohered as a single factor and predicted outcomes in predictable ways. Results demonstrated item reliability and construct validity of a Caregiver Engagement Techniques factor. Greater use of these techniques was associated with decreased adolescent substance use. Unexpected results suggested greater use of techniques was associated with worsening internalizing symptoms and family cohesion per youth-report only. Post-hoc analyses revealed additional complexities in the association between engagement techniques and outcomes. Caregiver engagement practices tested in the current study represent a unified treatment factor that may contribute to positive therapeutic outcomes for adolescents in some clinical domains. Further research is needed to understand predictive effects.

Longitudinal relations between physical activity and alcohol consumption among young adults

OBJECTIVE

Recent research has revealed positive associations between alcohol use and physical activity. However, findings from these studies have been inconsistent, and longitudinal designs have been underutilized. Therefore, the present study examined longitudinal associations between physical activity and alcohol use in a sample of young adults.

METHOD

This study is a secondary analysis of 383 college students (57% female) who reported their drinking behaviors at 3-month assessments over an approximately 2-year period. Self-reported physical activity was examined for the first 9 months, and drinking was assessed over 21 months.

RESULTS

Analyses revealed that increases in the intensity of physical activity over the first 9 months predicted increases in drinking over the same time period; however, predictions over the subsequent year were nonsignificant. Conversely, increases in alcohol use over the first 9 months were associated with concurrent increases in duration of physical activity.

CONCLUSIONS

Results extend previous cross-sectional research findings by indicating that positive associations between physical activity and alcohol use also are found longitudinally. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Examination of college student health behaviors and self-reported executive functions

Objective: Emerging adulthood is characterized by maturation of executive functions (EF) and changes in health behaviors (HB). Interestingly, EF are bi-directionally related to many specific HB; yet how EF performs in relation to overall patterns of HB engagement is unclear. Groupings of HB and the relationship between these HB groupings and EF were examined.

PARTICIPANTS

Full-time college students were recruited from three large Mid- and Southwest universities (N = 1,387).

METHODS

Online self-report questionnaires assessing demographics, HB, and EF were completed.

RESULTS

Latent class analysis of HB revealed three classes: (1) High Substance Use, (2) Moderately Healthy, (3) Healthy. In general, the Healthy class had significantly greater EF compared to no significant differences between the other two classes.

CONCLUSIONS

Collective engagement in HB is associated with EF. Interventions targeting both HB and EF simultaneously may be most efficacious.

Subjective and Behavioral Impulsivity Differentially Moderate Within- and Between-Person Associations Between Physical Activity and Alcohol Consumption

OBJECTIVE

Evidence indicates a counterintuitive positive relationship between physical activity and alcohol consumption, suggesting that people who engage in more physical activity consume more alcohol. Impulsivity, which has a well-documented role in alcohol use disorders, has been shown to moderate the between-person physical activity-drinking association among emerging adults. However, only a handful of studies have explored within-person associations of physical activity and drinking and potential moderators of this relationship. The current study evaluated the effects of both subjective and behavioral impulsivity on the within- and between-person association between physical activity and alcohol consumption among college students.

METHOD

Undergraduate students (N = 250) between ages 18 and 25 years were asked to report their daily physical activity and drinking over 21 days. Physical activity was also recorded objectively through Pacer, a smartphone app. Subjective impulsivity was assessed using the UPPS-P Impulsive Behavior Scale, and behavioral impulsivity was evaluated using the Balloon Analogue Risk Task.

RESULTS

Within- and between-subject physical activity-drinking associations were differentially moderated by behavioral impulsivity and self-reported impulsivity. For instance, behavioral impulsivity moderated the within-person association between drinking and self-reported vigorous physical activity, whereas negative urgency moderated the between-person association between drinking and objective physical activity.

CONCLUSIONS

Impulsivity, whether measured subjectively or behaviorally, significantly moderates the physical activity-alcohol consumption association. Importantly, this effect operates differently when predicting variation in behavior within individuals as compared with predicting differences in behavior between individuals.

Family involvement in treatment and recovery for substance use disorders among transition-age youth: Research bedrocks and opportunities

This article presents a narrative review and conceptual framework for research on family involvement across the continuum of substance use disorder (SUD) services for transition-age youth (ages 15-26). Though families are powerful resources for enhancing treatment and recovery success among youth with SUDs, they are not routinely included in clinical practice. This article summarizes youth SUD prevalence and service utilization rates and presents developmental and empirical rationale for increasing family involvement in services. It then describes key research issues on family involvement across the SUD services continuum: Problem Identification, Treatment Engagement, Active Treatment, Recovery Support. Within each phase, it highlights bedrock research findings and suggests promising opportunities for advancing the scientific knowledge base on family involvement. The main goals are to endorse family-oriented practices for immediate adoption in routine care and identify areas of research innovation that could significantly enhance the quality of youth SUD services.

Core Elements of Family Therapy for Adolescent Behavioral Health Problems: Validity Generalization in Community Settings

OBJECTIVE

The core elements of family therapy for adolescent mental health and substance use problems, originally distilled from high-fidelity sessions conducted by expert clinicians, were tested for validity generalization when delivered by community therapists in routine settings.

METHOD

The study sampled recorded sessions from 161 cases participating in one of three treatment pools: implementation trial of Functional Family Therapy (98 sessions/50 cases/22 therapists), adaptation trial of Multisystemic Therapy (115 sessions/59 cases/2 therapists), and naturalistic trial of non-manualized family therapy in usual care (107 sessions/52 cases/21 therapists). Adolescents were identified as 60% male and 40% female with an average age of 15.4 years; 49% were Latinx, 27% White Non-Latinx, 15% African American, 3% another race/ethnicity, 6% race/ethnicity unknown. Session recordings (n = 320) were randomly selected for each case and coded for 21 discrete family therapy techniques. Archived data of one-year clinical outcomes were gathered.

RESULTS

Confirmatory factor analyses replicated the factor structure from the original distillation study, retaining all four clinically coherent treatment modules comprised of all 21 techniques: Interactional Change (ICC = .77, Cronbach's α = .81); Relational Reframe (ICC = .75, α = .81); Adolescent Engagement (ICC = .72, α = .78); Relational Emphasis (ICC = .76, α = .80). Exploratory analyses found that greater use of core techniques predicted symptom improvements in one treatment pool.

CONCLUSIONS

Core techniques of family therapy distilled from manualized treatments for adolescent behavioral health problems showed strong evidence of validity generalization, and initial evidence of links to client outcomes, in community settings.

Identifying the Contributions of Maternal Factors and Early Childhood Externalizing Behavior on Adolescent Delinquency

We examined whether childhood externalizing group subtypes were uniquely related to maternal depression and victimization and whether these subtypes differentially predicted adolescent delinquency. Data were drawn from the Longitudinal Study on Child Abuse and Neglect (LONGSCAN) consortium (N = 1091; 51.3% female, 52.2% African American). Latent class analysis indicated three groups at age 4 (titled "well-adjusted," "hyperactive/oppositional," and "aggressive/rule-breaking"). Caregiver victimization and depression significantly predicted group membership such that aggressive/rule-breaking group had higher levels of maternal depression and victimization although the well-adjusted group had higher levels of maternal victimization relative to the hyperactive/oppositional group. Further, membership in higher externalizing groups at age four is associated with greater risk of adolescent delinquency at age 16. These findings underscore the need to address maternal risk factors in the treatment of childhood disruptive behavior and provide evidence of the continuity of disruptive behaviors from early childhood to adolescence.

Online Training of Community Therapists in Observational Coding of Family Therapy Techniques: Reliability and Accuracy

A foundational strategy to promote implementation of evidence-based interventions (EBIs) is providing EBI training to therapists. This study tested an online training system in which therapists practiced observational coding of mock video vignettes demonstrating family therapy techniques for adolescent behavior problems. The study compared therapists ratings to gold-standard scores to measure therapist reliability (consistency across vignettes) and accuracy (approximation to gold scores); tested whether reliability and accuracy improved during training; and tested therapist-level predictors of overall accuracy and change in accuracy over time. Participants were 48 therapists working in nine community behavioral health clinics. The 32-exercise training course provided online instruction (about 15 min/week) in 13 core family therapy techniques representing three modules: Family Engagement, Relational Orientation, Interactional Change. Therapist reliability in rating technique presence (i.e., technique recognition) remained moderate across training; reliability in rating extensiveness of technique delivery (i.e., technique judgment) improved sharply over time, from poor to good. Whereas therapists on average overestimated extensiveness for almost every technique, their tendency to give low-accuracy scores decreased. Therapist accuracy improved significantly over time only for Interactional Change techniques. Baseline digital literacy and submission of self-report checklists on use of the techniques in their own sessions predicted coding accuracy. Training therapists to be more reliable and accurate coders of EBI techniques can potentially yield benefits in increased EBI self-report acumen and EBI use in daily practice. However, training effects may need to improve from those reported here to avail meaningful impact on EBI implementation.Trial Registration: The parent clinical trial is registered at www.ClinicalTrials.gov , ID: NCT03342872 (registration date: 11.10.17).

Conceptual framework for telehealth strategies to increase family involvement in treatment and recovery for youth opioid use disorder

With opioid use at crisis levels, it is imperative to support youth ages with opioid use disorders (OUD) in taking medication and accessing behavioral services over long periods. This article presents a conceptual framework for telehealth strategies that can be adopted to increase family involvement across a four-stage continuum of youth OUD treatment and recovery: Treatment Preparation, Treatment Initiation, Treatment Stabilization, OUD Recovery. It first identifies provider-delivered tele-interventions that can enhance OUD services in each of the four stages, including family outreach, family engagement, family-focused intervention, and family-focused recovery maintenance. It then introduces several types of direct-to-family tele-supports that can be used to supplement provider-delivered interventions. These include both synchronous tele-supports (remote interactions that occur in real time) such as helplines, peer-to-peer coaching, and online support groups; and asynchronous tele-supports (communications that occur without participants being simultaneously present) such as automated text messaging, self-directed internet-based courses, and digital web support.

Youth OUD treatment during and after COVID: Increasing family involvement across the services continuum

Telehealth innovations in substance use treatment necessitated by the COVID-19 pandemic present a generational opportunity to increase family involvement in medication for opioid use disorders (MOUD) among youth. This commentary describes a conceptual framework for engaging and retaining youth and families across four stages of MOUD services: Preparation, Initiation, Stabilization, Remission & Recovery. Case vignettes illustrate provider-delivered and direct-to-family tele-interventions for augmenting family involvement in each MOUD stage: Family Outreach, Family Engagement, Family Training, Family Recovery Maintenance.

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COVID-19 has necessitated that substance use treatment services rely on tele-interventions.

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Youth and their families are difficult to engage and retain in medication for opioid use disorder (MOUD).

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Tele-interventions can increase family involvement across the youth MOUD services continuum.

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Case vignettes illustrate provider-delivered and direct-to-family tele-intervention strategies.

Daily physical activity and alcohol use among young adults

Evidence suggests that physical activity and alcohol use are positively related among young adults. Two studies have examined daily relations, and results have shown conflicting findings. We examined relations between physical activity and alcohol use at both within- and between-individual levels and investigated moderators of the relation at both levels. 269 college students wore accelerometers to collect physical activity data over a 2-week period. At the end of each day, they indicated whether or not they drank alcohol. Multilevel logistic regression indicated neither within- nor between-subject relations were statistically significant. Positive affect, negative affect, and drinking motives moderated these relations at the between-subject level. Contrary to previous research, we did not observe a relation between physical activity and alcohol use at the daily level. Unique features of the current study suggest next steps for future research examining the perplexing PA-alcohol relation in this population.

Randomized Trial of Academic Training and Medication Decision-Making for Adolescents with ADHD in Usual Care

Objective: This study tested two family-based interventions designed for delivery in usual care: Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA), containing motivational interventions, homework management and schoolwork organization training, and family-school partnership building; and Medication Integration Protocol (MIP), containing ADHD psychoeducation, medication decision-making, and integrated medication management.Method: This study used a cluster randomized design to test CASH-AA + MIP versus CASH-AA Only for adolescents with ADHD in five sites. Therapists (N = 49) were site clinicians randomized to condition. Clients (N = 145) included 72% males; 42% White Non-Hispanic, 37% Hispanic American, 15% African American, and 6% more than one race; average age was 14.8 years. Fidelity data confirmed protocol adherence and between-condition differentiation.Results: One-year improvements were observed across conditions in several outcomes. Overall, CASH-AA + MIP produced greater declines in adolescent-report inattentive symptoms and delinquent acts. Similarly, among non-substance users, CASH-AA + MIP clients attended more treatment sessions. In contrast, among substance users, CASH-AA Only clients showed greater declines in caregiver-report hyperactive symptoms and externalizing.Conclusions: This study provides initial experimental support for family-based ADHD medication decision-making when coupled with academic training in usual care. The treatment protocols, CASH-AA and MIP, showed positive effects in addressing not only ADHD symptoms but also common co-occurring problems, and youth with substance use problems benefitted along with non-using peers.

Measurement training and feedback system for implementation of evidence-based treatment for adolescent externalizing problems: protocol for a randomized trial of pragmatic clinician training

BACKGROUND

Innovations in clinical training and support that enhance fidelity to evidence-based treatment (EBT) for adolescent behavior problems are sorely needed. This study will develop an online training system to address this gap: Measurement Training and Feedback System for Implementation (MTFS-I). Using procedures intended to be practical and sustainable, MTFS-I is designed to increase two aspects of therapist behavior that are fundamental to boosting EBT fidelity: therapist self-monitoring of EBT delivery, and therapist utilization of core techniques of EBTs in treatment sessions. This version of MTFS-I focuses on two empirically supported treatment approaches for adolescent conduct and substance use problems: family therapy and cognitive behavioral therapy (CBT).

METHODS/DESIGN

MTFS-I expands on conventional measurement feedback systems for client outcomes by adding training in observational coding to promote EBT self-monitoring and focusing on implementation of EBT treatment techniques. It has two primary components. (1) The training component, delivered weekly in two connected parts, involves self-monitored learning modules containing brief clinical descriptions of core EBT techniques and mock session coding exercises based on 5-8 min video segments that illustrate delivery of core techniques. (2) The feedback component summarizes aggregated therapist-reported data on EBT techniques used with their active caseloads. MTFS-I is hosted online and requires approximately 20 min per week to complete for each treatment approach. This randomized trial will first collect data on existing delivery of family therapy and CBT techniques for youth in outpatient behavioral health sites (Baseline phase). It will then randomize site clinicians to two study conditions (Implementation phase): Training Only versus Training + Feedback + Consultation. Therapists will choose whether to train in family therapy, CBT, or both. Study aims will compare clinician performance across study phase and between study conditions on MTFS-I uptake, reliability and accuracy in EBT self-monitoring, and utilization of EBT techniques in treatment sessions (based on observer coding of audiotapes).

DISCUSSION

Study contributions to implementation science and considerations of MTFS-I sustainability are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03722654. Registered on 29 October 2018.

Randomized clinical trial of exercise for nontreatment seeking adults with alcohol use disorder

The vast majority of individuals with alcohol use disorder (AUD) do not seek professional help despite its significant consequences upon the individual and society. Current interventions for nontreatment seeking individuals with AUD (e.g., screening, brief intervention, and referral to treatment [SBIRT]) have limited efficacy and alternative nonstigmatizing approaches are needed. This randomized clinical trial examined the utility of exercise as an intervention for sedentary nontreatment seeking adults with AUD. Participants (N = 66) were randomized to receive (a) a 4-month YMCA gym membership only (MO) or (b) a 4-month YMCA gym membership plus a 16-week integrated motivational intervention for exercise consisting of motivational interviewing and contingency management (MI + CM). Participants in both study conditions significantly increased their exercise behavior compared to baseline, and the MI + CM participants exercised significantly more often and an overall larger volume of exercise than the MO participants (ds > 2.0). Significant reductions in drinking and alcohol-related consequences were noted over time but did not differ significantly by study condition and were not related to changes in exercise. Future interventions using exercise as an intervention for AUD may want to frame this type of intervention as "wellness," directly link the 2 behaviors, and compare this intervention to SBIRT. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Measurement Training and Feedback System for Implementation of family-based services for adolescent substance use: protocol for a cluster randomized trial of two implementation strategies

BACKGROUND

This article describes a study protocol for testing the Measurement Training and Feedback System for Implementation (MTFS-I) and comparing two implementation strategies for MTFS-I delivery. MTFS-I is a web-based treatment quality improvement system designed to increase the delivery of evidence-based interventions for behavioral health problems in routine care settings. This version of MTFS-I focuses on family-based services (FBS) for adolescent substance use. FBS, comprising both family participation in treatment and family therapy technique use, have achieved the strongest evidence base for adolescent substance use and are a prime candidate for upgrading treatment quality in outpatient care. For FBS to fulfill their potential for widespread dissemination, FBS implementation must be bolstered by effective quality procedures that support sustainable delivery in usual care.

METHODS/DESIGN

Adapted from measurement feedback systems for client outcomes, MTFS-I contains three synergistic components: (a) weekly reporter training modules to instruct therapists in reliable post-session self-reporting on FBS utilization; (b) weekly mock session videos of FBS interventions (5-8 min) for supportive training in, and practice coding of, high-quality FBS; and (c) monthly feedback reports to therapists and supervisors displaying aggregated data on therapist-reported FBS use. MTFS-I is hosted online and requires approximately 20 min per week to complete. The study will experimentally compare two well-established implementation strategies designed to foster ongoing MTFS-I usage: Core Training, consisting of two 3-h training sessions focused on FBS site mapping, selecting FBS improvement goals, and sustaining MTFS-I, followed by routine remote technical assistance; and Core + Facilitation, which boosts Core Training sessions with collaborative phone-based clinical consultation and on-site facilitation meetings for 1 year to promote FBS goal achievement. The study design is a cluster randomized trial testing Core Training versus Core + Facilitation in ten substance use treatment clinics. Study aims will compare conditions on MTFS-I uptake, FBS delivery (based on therapist-report and observational data), and 1-year client outcomes.

DISCUSSION

Study contributions to implementation science and considerations of MTFS-I sustainability are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03342872 . Registered 10 November 2017.

Core Elements of Family Therapy for Adolescent Behavior Problems: Empirical Distillation of Three Manualized Treatments

Family therapy has the strongest evidence base for treating adolescent conduct and substance use problems, yet there remain substantial barriers to widespread delivery of this approach in community settings. This study aimed to promote the feasibility of implementing family-based interventions in usual care by empirically distilling the core practice elements of three manualized treatments. The study sampled 302 high-fidelity treatment sessions from 196 cases enrolled in 1 of 3 manualized family therapy models: multidimensional family therapy (102 sessions/56 cases), brief strategic family therapy (100 sessions/94 cases), or functional family therapy (100 sessions/46 cases). Adolescents were 57% male; 41% were African American, 31% White non-Hispanic, 9% Hispanic American, 6% another race/ethnicity, and 13% unknown. The observational fidelity measures of all three models were used to code all 302 sessions. Fidelity ratings were analyzed to derive model-shared treatment techniques via exploratory factor analyses on half the sample; the derived factors were then validated via confirmatory factor analyses supplemented by Bayesian structural equation modeling on the remaining half. Factor analyses distilled 4 clinically coherent practice elements with strong internal consistency: Interactional Change (6 treatment techniques; Cronbach's α = .93), Relational Reframe (7 techniques; α = .79), Adolescent Engagement (4 techniques; α = .68), and Relational Emphasis (4 techniques; α = .67). The 4 empirically derived factors represent the core elements of 3 manualized family therapy models for adolescent behavior problems, setting the foundation of a more sustainable option for delivering evidence-based family interventions in routine practice settings. Public Health Significance: Increasing implementation of high-fidelity family-based interventions would improve the quality of treatment services for adolescent conduct and substance use problems.

Family therapy techniques and one-year clinical outcomes among adolescents in usual care for behavior problems

OBJECTIVE

This study tested whether use of family therapy (FT) techniques predicted long-term clinical outcomes in usual care for adolescents enrolled in either family-based or non-family-based treatment for conduct and substance use problems.

METHOD

Participants included 70 adolescents (53% female; mean age 15.4 years) from diverse backgrounds (64% Hispanic, 16% African American, 11% multiracial) assessed at baseline and 3-, 6-, and 12-month follow-up. Utilization of FT techniques was assessed for 802 therapy sessions via a therapist-report tool that collected postsession data on delivery of core treatment techniques of the FT approach.

RESULTS

Latent growth curve modeling was used to examine individual change over 12-month follow-up. FT technique scores, averaged across treatment sessions, were included as a predictor in latent growth models, controlling for adolescent age, sex, and ethnicity. More extensive use of core FT techniques predicted significant decreases in adolescent-reported delinquency and externalizing behavior and marginal decreases in substance use and parent-reported externalizing for cases in both family and nonfamily treatment.

CONCLUSIONS

Greater use of FT techniques in routine care was associated with better long-term adolescent outcomes, regardless of whether clients attended services featuring family therapy or an alternative treatment approach. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evidence Base on Outpatient Behavioral Treatments for Adolescent Substance Use, 2014-2017: Outcomes, Treatment Delivery, and Promising Horizons

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 Hogue, Henderson, Ozechowski, and Robbins (2014). It first summarizes the Hogue et al. findings along with those from recent literature reviews and meta-analytic studies of ASU treatments. It then presents study design and methods criteria used to select 11 comparative studies subjected to Journal of Clinical Child and Adolescent Psychology level of support evaluation. These 11 studies are detailed in terms of their sample characteristics, methodological quality, and substance use outcomes. Cumulative level of support designations are then made for each identified treatment approach. These cumulative designations are virtually identical to those of the previous review: ecological family-based treatment, individual cognitive-behavioral therapy, and group cognitive-behavioral therapy remain well-established; behavioral family-based treatment and motivational interviewing remain probably efficacious; drug counseling remains possibly efficacious; and an updated total of 5 multicomponent treatments combining more than 1 approach (3 of which include contingency management) are deemed well-established or probably efficacious. Treatment delivery issues associated with evidence-based approaches are then reviewed, focusing on client engagement, fidelity and mediator, and predictor and moderator effects. Finally, to help accelerate innovation in ASU treatment science and practice, the article outlines promising horizons in improving youth identification and access, specifying and implementing pragmatic treatment in community settings, and leveraging emerging lessons from implementation science.

Cross-Cultural Differences in the Experience of Grandparent-Grandchild Relationships and Related Psychosocial Outcomes

This study examined grandchildren’s perceptions of the quality of their relationship with their grandmothers and how these perceptions relate to psychosocial outcomes. Eighty-two youth from Mexico and 99 youth from the United States aged between 13 and 16 participated. Results suggested that both cultures benefit in unique ways from positive relationship with their grandmothers. Yet, there were also differences in the relational experience of grandmother–grandchild relationships across cultures. Specifically, grandchildren in the U.S. sample reported higher relationship quality, relational competency, and self-efficacy than the grandchildren in the Mexico sample. Within the U.S. sample, relationship quality was associated with grandchildren’s relational competence, while in the Mexico sample, relationship quality was associated with self-efficacy. Limitations of the present study include restricted generalizability to other age groups and to grandfathers and that only one element of the grandparent–grandchild dyad was sampled. Longitudinal research will improve our understanding of the causal dynamics of grandparent–grandchild relationships.

Multidimensional Family Therapy Reduces Self-Reported Criminality Among Adolescents With a Cannabis Use Disorder

Multidimensional family therapy (MDFT) is an established treatment program for youth displaying multiproblem behavior. We examined whether MDFT decreased criminal offending among cannabis abusing adolescents, as compared with individual psychotherapy (IP). In a Western European randomized controlled trial comparing MDFT with IP, a sample of 169 adolescents with a cannabis disorder completed self-reports on criminal offending. Half indicated they had committed one or more criminal offenses in the 90 days before the baseline assessment. Follow-up assessments were at 6 and 12 months after randomization. The proportion of adolescents reporting nondelinquency increased during the study period, most so in the MDFT condition. In addition, MDFT lowered the number of violent offenses more than IP. This difference was not seen for property crimes. In cannabis abusing adolescents, MDFT is an effective treatment to prevent and reduce criminal offending. MDFT outperforms IP for violent crimes.

Frequency, Nature, and Correlates of Hate Crime Victimization Experiences in an Urban Sample of Lesbian, Gay, and Bisexual Community Members

The present study examines two central research questions. First, we sought to add to current knowledge on the frequency and types of hate crime experiences in an urban sample. Also, drawing on existing frameworks for sexual minority specific (SMS) stress, we examined internalized SMS stress (defined by internalized homophobia and acceptance concerns regarding one's minority status) as a mediator of the association between hate crime victimization (i.e., objective or social SMS stress) and mental health symptoms (i.e., symptoms of depression, anxiety, and general stress). Participants were 336 self-identified lesbian, gay, and bisexual (LGB) community members who elected to participate in research at a community health agency in an urban southwestern United States jurisdiction. Results suggested (a) approximately one third of the sample reported lifetime hate crime victimization, with the most common types characterized by interpersonal, as opposed to property, crimes; (b) approximately half of participants reported their most recent victimization to law enforcement; and (c) internalized SMS stress mediated the relation between hate crime victimization and overall mental health symptoms. Findings are discussed with respect to implications of the unique nature of hate crimes in an urban setting, as well as theoretical and practical implications of SMS stress findings.

Distilling the Core Elements of Family Therapy for Adolescent Substance Use: Conceptual and Empirical Solutions

This article describes several barriers to widespread dissemination of manualized family-based treatments for adolescent substance use (ASU). We then offer a highly promising solution for adopting and sustaining family therapy in usual care: distilling the core practice elements of empirically validated family therapy models for ASU. We present a conceptual distillation of family therapy for ASU grounded in existing observational fidelity measures for three manualized models, a process that yielded four core elements: Family Engagement, Relational Reframing, Family Behavior Change, and Family Restructuring. We then introduce an innovative empirical method for distilling core elements that can serve as a template for rigorous distillation of other treatment approaches. Finally, we discuss how core elements can enhance family therapy services within the diverse workforce of usual care for ASU.

Multidimensional Predictors of Treatment Outcome in Usual Care for Adolescent Conduct Problems and Substance Use

This study investigated baseline client characteristics that predicted long-term treatment outcomes among adolescents referred from school and community sources and enrolled in usual care for conduct and substance use problems. Predictor effects for multiple demographic (age, sex, race/ethnicity), clinical (baseline symptom severity, comorbidity, family discord), and developmental psychopathology (behavioral dysregulation, depression, peer delinquency) characteristics were examined. Participants were 205 adolescents (52 % male; mean age 15.7 years) from diverse backgrounds (59 % Hispanic American, 21 % African American, 15 % multiracial, 6 % other) residing in a large inner-city area. As expected, characteristics from all three predictor categories were related to various aspects of change in externalizing problems, delinquent acts, and substance use at one-year follow-up. The strongest predictive effect was found for baseline symptom severity: Youth with greater severity showed greater clinical gains. Higher levels of co-occurring developmental psychopathology characteristics likewise predicted better outcomes. Exploratory analyses showed that change over time in developmental psychopathology characteristics (peer delinquency, depression) was related to change in delinquent acts and substance use. Implications for serving multiproblem adolescents and tailoring treatment plans in routine care are discussed.

Exercise as an Adjunctive Treatment for Substance Use Disorders: Rationale and Intervention Description

Substance use disorders (SUDs) are maladaptive patterns of substance use that are associated with psychiatric comorbidity, unhealthy lifestyle choices, and high rates of relapse. Exercise is associated with a wide range of acute and long-term benefits for both mental and physical health and is presently being investigated as a promising adjunctive treatment for SUD. Despite positive effects of regular physical activity on treatment outcomes and risk factors for relapse, low adherence and high attrition rates limit the benefits derived from exercise interventions. Lack of motivation is one of many perceived barriers to initiating exercise that contributes to poor adherence to interventions. In the present article, we describe the protocol for a novel, integrated exercise intervention that combines motivational interviewing (MI), a client-centered approach designed to enhance intrinsic motivation and resolve ambivalence toward change, and contingency management (CM), a behavioral treatment that provides monetary incentives for the completion of target behaviors. The protocol seeks to address the challenges surrounding initiation and maintenance of an exercise program at a level consistent with public health guidelines, particularly for sedentary patients. We conclude with considerations for the implementation of the intervention in SUD specific clinics.

Sedentary college student drinkers can start exercising and reduce drinking after intervention

Heavy drinking by college students is exceedingly harmful to the individuals and to the overall college environment. Current interventions to reduce drinking and negative consequences are infrequently utilized. This randomized clinical trial examined an alternative approach that sought to increase exercise behavior, a substance free activity, in sedentary heavy drinking college students. Participants (N = 70) were randomized to an 8-week exercise intervention: (a) motivational interviewing plus weekly exercise contracting (MI + EC) or (b) motivational interviewing and weekly contingency management for exercise (MI + CM). Follow-up evaluations occurred at posttreatment (2 months) and 6 months post baseline. Participants in both interventions significantly increased exercise frequency initially, and the MI + CM participants exercised significantly more than the MI + EC intervention participants during the intervention period (d = 1.70). Exercise behavior decreased during the follow-up period in both groups. Significant reductions in drinking behaviors and consequences were noted over time, but were not related to changes in exercise or the interventions (ds ≤ 0.01). This study underscores the complex nature of promoting 1 specific health behavior change with the goal of changing another. (PsycINFO Database Record

Therapeutic alliance and treatment outcome in the outpatient treatment of urban adolescents: The role of callous-unemotional traits

Callous-unemotional (CU) traits designate a unique subset of youth with externalizing psychopathology who have a severe pattern of aggressive behavior and tend to have worse outcomes in treatment. However, little research has addressed how CU traits relate to different components of psychotherapy, such as the therapeutic alliance. The current study examined the role of CU traits in predicting therapeutic alliance in 59 adolescents (M age = 15.3, 51% female, 64% Hispanic American, 15% African American) who were part of a larger randomized naturalistic trial of outpatient behavioral psychotherapy. Multilevel regression analysis further investigated the role of therapeutic alliance in predicting treatment outcome (as measured by self-reported delinquency) and the moderating role of CU traits. Results suggested that regardless of the severity of their externalizing problems, youth with higher levels of CU traits reported more positive ratings of therapeutic alliance. In addition, a positive therapeutic alliance predicted reductions in delinquent behavior, and this association was even stronger for youth higher in CU traits. Our results suggest that CU traits are related to improvement in the formation of the therapeutic alliance among youth with externalizing psychopathology, perhaps because these youth lack many of the social and emotional deficits that other youth with conduct problems possess. Adolescents high in CU traits should not be viewed as untreatable. Indeed, the therapeutic alliance may be an important mechanism for affecting meaningful change in these adolescents' lives. (PsycINFO Database Record

Reliability of therapist self-report on treatment targets and focus in family-based intervention

Reliable therapist-report methods appear to be an essential component of quality assurance procedures to support adoption of evidence-based practices in usual care, but studies have found weak correspondence between therapist and observer ratings of treatment techniques. This study examined therapist reliability and accuracy in rating intervention target (i.e., session participants) and focus (i.e., session content) in a manual-guided, family-based preventive intervention implemented with 50 inner-city adolescents at risk for substance use. A total of 106 sessions selected from three phases of treatment were rated via post-session self-report by the participating therapist and also via videotape by nonparticipant coders. Both groups estimated the amount of session time devoted to model-prescribed treatment targets (adolescent, parent, conjoint) and foci (family, school, peer, prosocial, drugs). Therapists demonstrated excellent reliability with coders for treatment targets and moderate to high reliability for treatment foci across the sample and within each phase. Also, therapists did not consistently overestimate their degree of activity with targets or foci. Implications of study findings for fidelity assessment in routine settings are discussed.

Temporal Variations in the Experience of Custodial Grandparenting: A Short-Term Longitudinal Study

To explore the experience of custodial grandparenting over time, 54 of 78 grandparents in a previous study of custodial grandparenting were reassessed during a 6-month time frame. Results suggested that grandparent group differences were maintained over time in terms of role strain, satisfaction with the relationship with the grandchild, perceptions of the grandchild, and life disruption, which favored traditional over both groups of custodial grandparents. Those persons raising problem grandchildren continued to be the most negatively affected by the resumption of the parent role. Findings also suggested that there were temporal shifts for all grandparents in the extent to which their relationships with their grandchildren were characterized by mutual respect, fairness, trust, and affection. Despite such changes, however, the overwhelming pattern over time for the grandparents in this study was one of stability. The implications of these data for research and public policy regarding grandparents raising their grandchildren are discussed.

Family-Based HIV and Sexually Transmitted Infection Risk Reduction for Drug-Involved Young Offenders: 42-Month Outcomes

This study tested a family-based human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention approach integrated within an empirically supported treatment for drug-involved young offenders, Multidimensional Family Therapy (MDFT). A randomized, controlled, two-site community-based trial was conducted with 154 youth and their parents. Drug-involved adolescents were recruited in detention, randomly assigned to either MDFT or Enhanced Services as Usual (ESAU), and assessed at intake, 3, 6, 9, 18, 24, 36, and 42-month follow-ups. Youth in both conditions received structured HIV/STI prevention in detention and those in MDFT also received family-based HIV/STI prevention as part of ongoing treatment following detention release. Youth in both conditions and sites significantly reduced rates of unprotected sex acts and STI incidence from intake to 9 months. They remained below baseline levels of STI incidence (10%) over the 42-month follow-up period. At Site A, adolescents who were sexually active at intake and received MDFT showed greater reduction in overall frequency of sexual acts and number of unprotected sexual acts than youth in ESAU between intake and 9-month follow-ups. These intervention differences were evident through the 42-month follow-up. Intervention effects were not found for STI incidence or unprotected sex acts at Site B. Intensive group-based and family intervention in detention and following release may reduce sexual risk among substance-involved young offenders, and a family-based approach may enhance effects among those at highest risk. Site differences in intervention effects, study limitations, clinical implications, and future research directions are discussed.

An independent replication of the Adolescent-Community Reinforcement Approach with justice-involved youth

BACKGROUND AND OBJECTIVES

Substance use disorders among youth remain a serious public health problem. Although research has overwhelmingly supported the use of evidenced-based interventions, one of the primary limitations of the current evidence base is that for the vast majority of treatments, the developers of the treatments are also the ones conducting research on them, raising the possibility of allegiance bias.

METHODS

The present study was an independently conducted randomized controlled trial (n = 126) comparing an evidenced-based treatment for adolescent substance use, Adolescent-Community Reinforcement Approach (A-CRA), and assertive continuing care (ACC), to services as usual (SAU) provided by a juvenile probation department. Latent growth curve modeling was used to compare the treatments on change in substance use assessed by the Global Appraisal of Individual Needs (GAIN) at baseline and 3, 6, and 12 months following treatment entry.

RESULTS

All youth evidenced a substantial reduction in substance use frequency and substance-related problems following treatment; however, youth treated with A-CRA/ACC evidenced a substantially greater decrease in substance-related problems.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Results are consistent with studies conducted by A-CRA/ACC model developers supporting the effectiveness of the clinical approach and, because the outcomes resulted from an independent replication, are encouraging for the transportation potential of A-CRA/ACC.

Gender and ethnicity as moderators: Integrative data analysis of multidimensional family therapy randomized clinical trials

This study examined gender and ethnicity as moderators of Multidimensional Family Therapy (MDFT) effectiveness for adolescent drug abuse and illustrated the utility of integrative data analysis (IDA; Bauer & Hussong, 2009) for assessing moderation. By pooling participant data from 5 independent MDFT randomized clinical trials (RCTs), IDA increased power to test moderation. Participants were 646 adolescents receiving treatment for drug use, aged 11 to 17 years (M = 15.31, SD = 1.30), with 19% female (n = 126), 14% (n = 92) European American, 35% (n = 225) Hispanic, and 51% (n = 329) African American. Participants were randomized to MDFT or active comparison treatments, which varied by study. Drug use involvement (i.e., frequency and consequences) was measured at study entry, 6-, and 12-months by a 4-indicator latent variable. Growth curve change parameters from multiple calibration samples were regressed on treatment effects overall and by moderator subgroups. MDFT reduced drug use involvement (p < .05) for all participant groups. Pooled comparison groups reduced drug use involvement only for females and Hispanics (ps < .05). MDFT was more effective than comparisons for males, African Americans, and European Americans (ps <.05; Cohen's d = 1.17, 1.95, and 1.75, respectively). For females and Hispanics, there were no significant differences between MDFT and pooled comparison treatments, Cohen's d = 0.63 and 0.19, respectively. MDFT is an effective treatment for drug use among adolescents of both genders and varied ethnicity with males, African American, and European American non-Hispanic adolescents benefitting most from MDFT.

Therapist self-report of evidence-based practices in usual care for adolescent behavior problems: factor and construct validity

This study introduces a therapist-report measure of evidence-based practices for adolescent conduct and substance use problems. The Inventory of Therapy Techniques-Adolescent Behavior Problems (ITT-ABP) is a post-session measure of 27 techniques representing four approaches: cognitive-behavioral therapy (CBT), family therapy (FT), motivational interviewing (MI), and drug counseling (DC). A total of 822 protocols were collected from 32 therapists treating 71 adolescents in six usual care sites. Factor analyses identified three clinically coherent scales with strong internal consistency across the full sample: FT (8 items; α = .79), MI/CBT (8 items; α = .87), and DC (9 items, α = .90). The scales discriminated between therapists working in a family-oriented site versus other sites and showed moderate convergent validity with therapist reports of allegiance and skill in each approach. The ITT-ABP holds promise as a cost-efficient quality assurance tool for supporting high-fidelity delivery of evidence-based practices in usual care.

Codevelopment of psychopathic features and alcohol use during emerging adulthood: Disaggregating between- and within-person change

The current study examined whether there is a bidirectional association between changes in alcohol use and psychopathic features during the transition into emerging adulthood. The nature of this association was investigated among a large sample of serious male adolescent offenders (N = 1,170) across 7 annual assessments (ages ∼17-23), with a focus on disaggregating between- and within-person change. Findings indicated that there was significant variability between participants in their rate of change of psychopathic features and alcohol use throughout this period of development. Both, between- and within-person increases in alcohol use tended to parallel increases in psychopathic features during the transition into emerging adulthood. In addition, evidence indicated that during years when adolescents consumed more alcohol than normal, they experienced higher than usual levels of self-reported psychopathic features at the subsequent assessment. The relevance of these findings for public policy and their potential to inform treatments and interventions are discussed.

Does change in alliance impact alcohol treatment outcomes?

BACKGROUND

Although both researchers and practitioners widely recognize therapeutic alliance's importance in general psychotherapy, studies specific to alcohol use treatments have produced mixed results and generally do not investigate if and how alliance changes over course of treatment.

METHODS

Using parallel process latent growth curve modeling, the authors examined if increase in alliance was associated with reduced drinking behaviors and a statistical mediator in the relationship between treatment modality and outcome. The authors used data from Project MATCH (J Stud Alcohol. 1997;58:7-29; Addiction. 1997;92:1671-1698), which investigated client-treatment matching effects for alcohol treatment among outpatient (n = 952) and aftercare (n = 774) participants randomized to cognitive behavioral treatment (CBT), 12-step facilitation (TSF), or motivational enhancement therapy (MET).

RESULTS

Results indicate therapist-rated alliance increased significantly for CBT and TSF participants, but not MET. Participants across modalities in both samples evidenced the largest decrease in drinking behaviors from baseline to midtreatment and a slight deterioration in treatment gains from midtreatment to 15 months posttreatment. Alliance did not mediate the relationship between treatment modality and outcome, but increase in alliance was significantly related to decrease in drinking frequency.

CONCLUSIONS

These findings provide further justification for researchers to specifically design studies to examine change in alliance as a mechanism of change in alcohol treatments.

A randomized clinical trial of family therapy in juvenile drug court

The objective of this article is to examine the effectiveness of 2 theoretically different treatments delivered in juvenile drug court--family therapy represented by multidimensional family therapy (MDFT) and group-based treatment represented by adolescent group therapy (AGT)--on offending and substance use. Intent-to-treat sample included 112 youth enrolled in juvenile drug court (primarily male [88%], and Hispanic [59%] or African American [35%]), average age 16.1 years, randomly assigned to either family therapy (n = 55) or group therapy (n = 57). Participants were assessed at baseline and 6, 12, 18 and 24 months following baseline. During the drug court phase, youth in both treatments showed significant reduction in delinquency (average d = .51), externalizing symptoms (average d = 2.32), rearrests (average d = 1.22), and substance use (average d = 4.42). During the 24-month follow-up, family therapy evidenced greater maintenance of treatment gains than group-based treatment for externalizing symptoms (d = 0.39), commission of serious crimes (d = .38), and felony arrests (d = .96). There was no significant difference between the treatments with respect to substance use or misdemeanor arrests. The results suggest that family therapy enhances juvenile drug court outcomes beyond what can be achieved with a nonfamily based treatment, especially with respect to what is arguably the primary objective of juvenile drug courts: reducing criminal behavior and rearrests. More research is needed on the effectiveness of juvenile drug courts generally and on whether treatment type and family involvement influence outcomes.

TRIAL REGISTRY NAME

Clinical Trials.gov, Identified NCT01668303.

Validity of therapist self-report ratings of fidelity to evidence-based practices for adolescent behavior problems: correspondence between therapists and observers

Developing therapist-report fidelity tools to support quality delivery of evidence-based practices in usual care is a top priority for implementation science. This study tested the reliability and accuracy of two groups of community therapists who reported on their use of family therapy (FT) and motivational interviewing/cognitive-behavioral therapy (MI/CBT) interventions during routine treatment of inner-city adolescents with conduct and substance use problems. Study cases (n = 45) were randomized into two conditions: (a) Routine Family Therapy (RFT), consisting of a single site that featured family therapy as its standard of care for behavioral treatment; or (b) Treatment As Usual (TAU), consisting of five sites that featured non-family approaches. Therapists and trained observational raters provided FT and MI/CBT adherence ratings on 157 sessions (104 RFT, 53 TAU). Overall therapist reliability was adequate for averaged FT ratings (ICC = .66) but almost non-existent for MI/CBT (ICC = .06); moreover, both RFT and TAU therapists were more reliable in reporting on FT than on MI/CBT. Both groups of therapists overestimated the extent to which they implemented FT and MI/CBT interventions. Results offer support for the feasibility of using existing therapist-report methods to anchor quality assurance procedures for FT interventions in real-world settings, though not for MI/CBT.

Exercise and Alcohol Consumption: What We Know, What We Need to Know, and Why it is Important

Exercise provides a wealth of benefits to brain and body, and is regarded as a protective factor against disease. Protective factors tend to cluster together - that is, people who engage in one healthy behavior, such as exercise, also engage in other healthy behaviors, such as maintaining a nutritious diet and getting sufficient sleep. In contrast to exercise, alcohol consumption is not typically regarded as a health-promoting behavior, although moderate intake has been associated with a lower risk of cardiovascular disease. Surprisingly, several large, population-based studies have shown a positive association between physical activity and alcohol intake. The present review focuses on what is known about this relationship, including potential neural bases as well as moderating factors, and discusses important directions for further study, such as a more thorough characterization of people who both drink and exercise. We focus on ramifications for intervening with people who have alcohol use disorders, as exercise has been assessed as both a treatment and preventive measure, with mixed results. We believe that, in order for such interventions to be effective, clinical trials must distinguish treatment-seeking populations from non-treatment-seeking ones, as well as ensure that the use of exercise as a tool to decrease alcohol consumption is made explicit. We posit that a better understanding of the relationship between physical activity and alcohol intake will maximize intervention efforts by informing the design of clinical trials and research-driven prevention strategies, as well as enable individuals to make educated decisions about their health behaviors.

Randomized Trial of Family Therapy Versus Nonfamily Treatment for Adolescent Behavior Problems in Usual Care

A major focus of implementation science is discovering whether evidence-based approaches can be delivered with fidelity and potency in routine practice. This randomized trial compared usual care family therapy (UC-FT), implemented without a treatment manual or extramural support as the standard-of-care approach in a community clinic, to nonfamily treatment (UC-Other) for adolescent conduct and substance use disorders. The study recruited 205 adolescents (M age = 15.7 years; 52% male; 59% Hispanic American, 21% African American) from a community referral network, enrolling 63% for primary mental health problems and 37% for primary substance use problems. Clients were randomly assigned to either the UC-FT site or one of five UC-Other sites. Implementation data confirmed that UC-FT showed adherence to the family therapy approach and differentiation from UC-Other. Follow-ups were completed at 3, 6, and 12 months postbaseline. There was no between-group difference in treatment attendance. Both conditions demonstrated improvements in externalizing, internalizing, and delinquency symptoms. However, UC-FT produced greater reductions in youth-reported externalizing and internalizing among the whole sample, in delinquency among substance-using youth, and in alcohol and drug use among substance-using youth. The degree to which UC-FT outperformed UC-Other was consistent with effect sizes from controlled trials of manualized family therapy models. Nonmanualized family therapy can be effective for adolescent behavior problems within diverse populations in usual care, and it may be superior to nonfamily alternatives.

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.

Multidimensional family therapy decreases the rate of externalising behavioural disorder symptoms in cannabis abusing adolescents: outcomes of the INCANT trial

BACKGROUND

US-based trials have shown that Multidimensional Family Therapy (MDFT) not only reduces substance abuse among adolescents, but also decreases mental and behavioural disorder symptoms, most notably externalising symptoms. In the INCANT trial, MDFT decreased the rate of cannabis dependence among Western European youth. We now focus on other INCANT outcomes, i.e., lessening of co-morbidity symptoms and improvement of family functioning.

METHODS

INCANT was a randomised controlled trial comparing MDFT with individual therapy (IP) at and across sites in Berlin, Brussels, Geneva, The Hague, and Paris. We recruited 450 boys and girls aged 13 up to 18 years with a cannabis use disorder, and their parent(s), and followed them for 12 months. Mental and behavioural characteristics (classified as 'externalising' or 'internalising') and family conflict and cohesion were assessed.

RESULTS

From intake through 12 months, MDFT and IP groups improved on all outcome measures. Models including treatment, site, and referral source showed that MDFT outperformed IP in reducing externalising symptoms.Adolescents were either self-referred to treatment (mostly on the initiative from people close to the teen) or referred under some measure of coercion by an external authority. These two groups reacted equally well to treatment.

CONCLUSIONS

Both MDFT and IP reduced the rate of externalising and internalising symptoms and improved family functioning among adolescents with a cannabis use disorder. MDFT outperformed IP in decreasing the rate of externalising symptoms. Contrary to common beliefs among therapists in parts of Western Europe, the 'coerced' adolescents did at least as well in treatment as the self-referred adolescents.MDFT shows promise as a treatment for both substance use disorders and externalising symptoms.

TRIAL REGISTRATION ISRNCT

ISRCTN51014277.

Multidimensional family therapy lowers the rate of cannabis dependence in adolescents: a randomised controlled trial in Western European outpatient settings

BACKGROUND

Noticing a lack of evidence-based programmes for treating adolescents heavily using cannabis in Europe, government representatives from Belgium, France, Germany, The Netherlands, and Switzerland decided to have U.S.-developed multidimensional family therapy (MDFT) tested in their countries in a trans-national trial, called the International Need for Cannabis Treatment (INCANT) study.

METHODS

INCANT was a 2 (treatment condition)×5 (time) repeated measures intent-to-treat randomised effectiveness trial comparing MDFT to Individual Psychotherapy (IP). Data were gathered at baseline and 3, 6, 9 and 12 months thereafter. Study participants were recruited at outpatient secondary level addiction, youth, and forensic care clinics in Brussels, Berlin, Paris, The Hague, and Geneva. Participants were adolescents from 13 through 18 years of age with a recent cannabis use disorder. 85% were boys; 40% were of foreign descent. One-third had been arrested for a criminal offence in the past 3 months. Three primary outcomes were assessed: (1) treatment retention, (2) prevalence of cannabis use disorder and (3) 90-day frequency of cannabis consumption.

RESULTS

Positive outcomes were found in both the MDFT and IP conditions. MDFT outperformed IP on the measures of treatment retention (p<0.001) and prevalence of cannabis dependence (p=0.015). MDFT reduced the number of cannabis consumption days more than IP in a subgroup of adolescents reporting more frequent cannabis use (p=0.002).

CONCLUSIONS

Cannabis use disorder was responsive to treatment. MDFT exceeded IP in decreasing the prevalence of cannabis dependence. MDFT is applicable in Western European outpatient settings, and may show moderately greater benefits than IP in youth with more severe substance use.

Neurotrophic factors in development and plasticity of spinal neurons

Factors affecting neuronal growth may be considered to fall into two major categories: those required for neuronal survival during development or following a lesion, and those which enhance growth or regeneration of axonal or dendritic processes. We briefly review here some recent studies on the former in spinal cord development and plasticity as an introduction to other papers in the session on Factors controlling Neural Growth, and then present in more detail work on factors affecting motoneuron development in vitro. The neurotrophins are a closely-related family of basic neurotrophic factors including nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) and neurotrophins -3, -4 and -5 that enhance neuronal survival by binding to surface receptors whose major components are the trk tyrosine kinases and p75NGF-R. Only the latter has been studied in the context of spinal cord neuroplasticity: its levels on motoneurons are up-regulated following central or peripheral trauma, although its function there remains unknown. Much evidence exists for the existence of 'motoneuron growth factors' involved in regulation of survival and development of spinal motoneurons. Following a critical comparison of techniques for their purification, we review results obtained in vitro and in vivo using known growth factors such as ciliary neurotrophic factor (CNTF), basic fibroblast growth factor (bFGF) and transforming growth factor (TGF/β1). Although none of them satisfies all the criteria for the embryonic 'motoneuron growth factor', CNTF is of potential interest for reducing motoneuron loss in pathological situations.