Cannabis Youth Treatment CYT Trials: 12 and 30 Month Main Findings

1
Cannabis Youth Treatment (CYT) Trials 12 and 30
Month Main Findings

• Michael Dennis, Ph.D.
• Chestnut Health Systems
• Bloomington, IL
• Part of the continuing education workshop, What
  Works? In Alcohol Other (AOD) Treatment for
  Adolescents, Marlborough, MA, April 21, 2005.
  Sponsored by Massachusetts Department of Public
  Health, Bureau of Substance Abuse Services
  AdCare Educational Institute, Inc. The content of
  this presentations are based on treatment
  research funded by the Center for Substance Abuse
  Treatment (CSAT), Substance Abuse and Mental
  Health Services Administration (SAMHSA) under
  contract 270-2003-00006 and several individual
  grants. The opinions are those of the author and
  do not reflect official positions of the
  consortium or government. Available on line at
  www.chestnut.org/LI/Posters or by contacting Joan
  Unsicker at 720 West Chestnut, Bloomington, IL
  61701, phone [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org

2
AcknowledgementThis presentation is based on
the work, input and contributions from several
other people including Nancy Angelovich, Tom
Babor, Laura (Bunch) Brantley, Joseph A.
Burleson, George Dent, Guy Diamond, James Fraser,
Michael French, Rod Funk, Mark Godley, Susan H.
Godley, Nancy Hamilton, James Herrell, David
Hodgkins, Ronald Kadden, Yifrah Kaminer, Tracy L.
Karvinen, Pamela Kelberg, Jodi (Johnson)
Leckrone, Howard Liddle, Barbara McDougal, Kerry
Anne McGeary, Robert Meyers, Suzie
Panichelli-Mindel, Lora Passetti, Nancy Petry, M.
Christopher Roebuck, Susan Sampl, Meleny Scudder,
Christy Scott, Melissa Siekmann, Jane Smith,
Zeena Tawfik, Frank Tims, Janet Titus, Jane
Ungemack, Joan Unsicker, Chuck Webb, James West,
Bill White, Michelle White, Caroline Hunter
Williams, the other CYT staff, and the families
who participated in this study. This presentation
was supported by funds and data from the Center
for Substance Abuse Treatment (CSATs) Persistent
Effects of Treatment Study (PETS, Contract No.
270-97-7011) and the Cannabis Youth Treatment
(CYT) Cooperative Agreement (Grant Nos. TI11317,
TI11320, TI11321, TI11323, and TI11324). The
opinions are those of the author and steering
committee and do not reflect official positions
of the government .
3
CYT
Cannabis Youth Treatment Randomized Field Trial
Coordinating Center Chestnut Health Systems,
Bloomington, IL, and Chicago, IL University
of Miami, Miami, FL University of Conn. Health
Center, Farmington, CT
Sites Univ. of Conn. Health Center, Farmington,
CT Operation PAR, St. Petersburg, FL Chestnut
Health Systems, Madison County, IL Childrens
Hosp. of Philadelphia, Phil. ,PA
Sponsored by Center for Substance Abuse
Treatment (CSAT), Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services
4
Marijuana

• Use is starting at younger ages
• Is at an historically high level among
  adolescents
• Potency increased 3-fold from 1980 to 1997
• Is three times more likely to lead to dependence
  among adolescents than adults
• Is associated with many health, mental and
  behavioral problems
• Is the leading substance mentioned in adolescent
  emergency room admissions and autopsies

5
Treatment

• Marijuana related admissions to adolescent
  substance abuse treatment increased by 115 from
  1992 to 1998
• Over 80 of adolescents entering treatment in
  1998 had a marijuana problem
• Over 80 are entering outpatient treatment
• Over 75 receive less than 90 days of treatment
  (median of 6 weeks)
• Evaluations of existing adolescent outpatient
  treatment suggest that last than 90 days of
  outpatient treatment is rarely effective for
  reducing marijuana use.

6
Purpose of CYT

• To learn more about the characteristics and needs
  of adolescent marijuana users presenting for
  outpatient treatment.
• To adapt evidence-based, manual-guided therapies
  for use in 1.5 to 3 month adolescent outpatient
  treatment programs in medical centers or
  community based settings.
• To field test the relative effectiveness, cost,
  cost-effectiveness, and benefit cost of five
  interventions targeted at marijuana use and
  associated problems in adolescents.
• To provide validated models of these
  interventions to the treatment field in order to
  address the pressing demands for expanded and
  more effective services.

7
Design

• Target Population Adolescents with marijuana
  disorders who are appropriate for 1 to 3 months
  of outpatient treatment.
• Inclusion Criteria 12 to 18 year olds with
  symptoms of cannabis abuse or dependence, past 90
  day use, and meeting ASAM criteria for outpatient
  treatment
• Data Sources self report, collateral reports,
  on-site and laboratory urine testing, therapist
  alliance and discharge reports, staff service
  logs, and cost analysis.
• Random Assignment to one of three treatments
  within site in two research arms and quarterly
  follow-up interview for 12 months
• Long Term Follow-up under a supplement from
  PETSA follow-up was extended to 30 months (42 for
  a subsample)

8
Two Trials or Study Arms
Trial 2
Trial 1
Incremental Arm
Alternative Arm
Randomly Assigns to
Randomly Assigns to
MET/CBT5
MET/CBT5
Motivational Enhancement Therapy/
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12
ACRA
Motivational Enhancement Therapy/
Adolescent Community
Reinforcement Approach(12 weeks)
Cognitive Behavioral Therapy (12 weeks)
MDFT
FSN
Family Support Network
Multidimensional Family Therapy
Plus MET/CBT12 (12 weeks)
(12 weeks)
Source Dennis et al, 2002
9
Contrast of the Treatment Structures
Individual Adolescent Sessions
CBT Group Sessions
Individual Parent Sessions
Family Sessions/Home Visits
Parent Education Sessions
Total Formal Sessions
Case management/ Other Contacts
Total Expected Contacts
Total Expected Hours
Total Expected Weeks
Source Diamond et al, 2002
10
Actual Treatment Received by Condition
ACRA and MDFT both rely on individual, family and
case management instead of group
FSN adds multi family group, family home visits
and more case management
And MDFT using more family therapy
MET/CBT12 adds 7 more sessions of group
With ACRA using more individual therapy
Source Dennis et al, under review
11
Interventions Also Differ in Content
100
90
80
70
60
50
40
30
20
10
0
Direct
Family
External
Total
(3-6,9-10,19,99)
(1,7-8,15)
(2,11-14,16-17)
(all)
MET/CBT5
FSNM
MET/CBT5
MDFT
MET/CBT12
ACRA
Source CYT data
12
Average Episode Cost (US) of Treatment
--------------------------------------------Econo
mic Cost------------------------------------------
--------- Director Estimate-----
4,000
3,322
3,500
3,000
2,500
Average Cost Per Client-Episode of Care
1,984
2,000
1,559
1,413
1,500
1,197
1,126
1,000
500
-
ACRA (12.8 weeks)
MET/CBT5 (6.8 weeks)
MET/CBT5 (6.5 weeks)
MET/CBT12 (13.4 weeks)
FSN (14.2 weeks w/family)
MDFT(13.2 weeks w/family)
Source French et al., 2002
13
Implementation of Evaluation

• Over 85 of eligible families agreed to
  participate
• Quarterly follow-up of 94 to 98 of the
  adolescents from 3- to 12-months (88 all five
  interviews)
• Long term follow-up completed on 90 at 30-months
  and 91 (of 116 subsample) at 42-months
• Collateral interviews were obtained at intake, 3-
  and 6-months on over 92-100 of the adolescents
  interviewed
• Urine test data were obtained at intake, 3, 6, 30
  and 42 months 90-100 of the adolescents who were
  not incarcerated or interviewed by phone (85 or
  more of all adolescents).
• Self report marijuana use largely in agreement
  with urine test at 30 months (13.8 false
  negative, kappa.63)
• 5 Treatment manuals drafted, field tested,
  revised, send out for field review, and finalized
  
• Descriptive, outcome and economic analyses
  completed

Source Dennis et al, 2002, under review
14
Adolescent Cannabis Users in CYT were as or More
Severe Than Those in TEDS
Source Tims et al, 2002
15
Demographic Characteristics
Source Tims et al, 2002
16
Institutional Involvement
Source Tims et al, 2002
17
Patterns of Substance Use

100
73
80
71
60
40
17
20
9
0
Weekly Alcohol
Weekly
Weekly
Significant Time
Tobacco Use
Cannabis Use
Use
in Controlled
Environment
Source Tims et al, 2002
18
Multiple Problems are the NORM
Self-Reported in Past Year
Source Dennis et al, under review
19
Co-occurring Problems are Higher for those
Self-Reporting Past Year Dependence
Source Tims et al., 2002

p
20
CYT Increased Days Abstinent and Percent in
Recovery (no use or problems while in community)
Source Dennis et al., 2004
21
Similarity of Clinical Outcomes by Conditions
Source Dennis et al., 2004
22
Moderate to large differences in
Cost-Effectiveness by Condition
Source Dennis et al., 2004
23
Evaluating the Effects of Treatment
Month
Z-Score
Source Dennis et al, under review, forthcoming
24
Change in Substance Frequency Scale in CYT Trial
1 Incremental Arm
Months from Intake
Source Dennis et al, forthcoming
25
Change in Number of Substance Problems in CYT
Trial 1 Incremental Arm
Months from Intake
Source Dennis et al, forthcoming
26
Change in Substance Frequency Scale inCYT Trial
2 Alternative Arm
Months from Intake
Source Dennis et al, forthcoming
27
Change in Number of Substance Problems inCYT
Trial 2 Alternative Arm
Months from Intake
Source Dennis et al, forthcoming
28
Percent in Past Month Recovery (no use or
problems while living in the community)
Source Dennis et al, forthcoming
29
Cumulative Recovery Pattern at 30 months(The
Majority Vacillate in and out of Recovery)
Source Dennis et al, forthcoming
30
Adolescents different in their Relapse
trajectories
Source Godley, et al, 2004
31
Environmental Factors are also the Major
Predictors of Relapse
AOD use in the home, homelessness, family
problems, fighting, victimization, self help
group participation, structure activities
Peer AOD use, fighting, illegal activity,
treatment, recovery, vocational activity
Model Fit CFI.97 to .99 RMSEA.04 to .06
Source Godley et al (2005)
32
Cost Per Person in Recovery at 12 and 30 Months
After Intake by CYT Condition

Trial 1 (n299)
Trial 2 (n297)
Cost Per Person in Recovery (CPPR)
30,000
25,000
20,000
15,000
10,000
5,000
0
MET/ CBT5
MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
3,958
7,377
15,116
6,611
4,460
11,775
CPPR at 12 months
Pmonths Pmonths
Source Dennis et al., under review forthcoming
33
Reduction in Average Cost to Society in CYT
Trial 1 Incremental Arm
Source French et al, 2004 forthcoming
34
Reduction in Average Cost to Society in CYT
Trial 2 Alternative Arm
Source French et al, 2004 forthcoming
35
Average Cost to Society Varied More by Site than
Condition
6,000
5,000
4,000
3,000
2,000
1,000
0
0
3
6
9
12
15
18
21
24
27
30
Months from Intake
Source French et al, 2004 forthcoming
36
Reprise of Clinical Outcomes

• Co-occurring problems were the norm and varied
  with substance use severity.
• In Trial 1, FSN and MET/CBT5 were relatively more
  effective than MET/CBT12 in reducing substance
  abuse/dependence problems (treatment effect)
  With FSN doing better at holding its gains out to
  30 months
• In Trial 2, ACRA and MDFT were more effective
  than MET/CBT5 in reducing substance
  abuse/dependence problems (treatment effect) and
  short term stability on substance use With ACRA
  and MDFT doing better at holding their gains out
  to 30 months.
• These were not easily explained simply by dosage
  or level of family therapy and there was no
  evidence of iatrogenic effects of group therapy.
• While more effective than many earlier outpatient
  treatments, 2/3rds of the CYT adolescents were
  still having problems 12 months latter, 4/5ths
  were still having problems 30 months latter.

37
Reprise of Economic Outcomes

• There were considerable differences in the cost
  of providing each of the interventions.
• MET/CBT-5, -12 and ACRA were the most cost
  effective at 12 months, though the stability of
  the MET/CBT findings were mixed at 30 months.
• Reductions in Average Quarterly Cost to Society
  offset the cost of treatment within 12 months in
  trial 1 and with 30 months in trial 2.
• At 12 months the MET/CBT5 intervention clearly
  had the highest rate of return.
• By 30 months MET/CBT12, ACRA and MDFT were doing
  better and FSN was doing as well as MET/CBT in
  terms of costs to society.
• Results of clinical outcomes, cost-effectiveness,
  and benefit cost were different suggesting the
  importance of multiple perspectives

38
Effective Adolescent Treatment (EAT) Replication
of MET/CBT 5

• Large scale replication of the CYT MET/CBT
  intervention in early intervention, school,
  detention and outpatient settings
• Data from 22 of 36 grants Bradley, Brown,
  Clayton,Curry, Davis, Dillon, Dodge, Kressler,
  Kincaid, Levine, Levy, Locario, Mason, Moore,
  Rajaee-Moore, Paull, Payton, Rezende, Taylor,
  Tims, Turner, Vincent
• 857 Intake cases and 521 3 Month Follow-up from
  22 sites (71 of those due, 82 of those out of
  window)
• Outcome data matched to people with both intake
  and follow-up
• Early, but already larger that CYT (n202 from 4
  sites)

39
General Treatment Process Measures
Better than CYT on initiation
100
90
80
70
60
50
40
30
20
10
0
Initiated (within 14
Engaged
Retained
Continuing Care
High Satisfaction
(4 session, 6 weeks)
(90 days in index admission)
(post 90 days)
(TxSI13.5)
days)
CYT
EAT
Source CYT Final Data Set and EAT 8/04 data set
40
Consistent MET/CBT5 Content Across Sites
Virtually Identical Implementation in CYT
UCHC (n48)
PAR (n54)
CHS (n42)
CHOP (n58)

Total MET/CBT5 (n202)
Source CYT data
41
Treatment Content Matches CYT (S7g)
100
90
80
70
60
50
40
30
20
10
0
Direct
Family
External
Total
(3-6,9-10,19,99)
(1,7-8,15)
(2,11-14,16-17)
(all)
CYT (n199)
EAT (n201)
Source CYT Final Data Set and EAT 8/04 data set
42
Top 10 Reasons Adolescents Gave to Quit
10. 52 AOD cause health problems for others
9. 53 don't want to embarrass your family
8. 55 concerned about health problems
7. 56 to improve my memory
6. 57 to feel in control of your life
5. 57 to keep close people from being upset
4. 59 to think more clearly
3. 60 to save money you would have spend on AOD
2. 63 to prove you are not addicted
1. 73 to show you can quit
These reasons provide hooks for MET and
counseling in general
Source EAT 8/04 data set
43
Not everyone has the same reasons

• 7 of 10 the same in CYT (included above)
• 10 of 10 for 15 to 17, male, white adolescents
• 8 of 10 for other ages
• Under 15 more likely to say known others with
  health problems (55) or to have more energy
  (55)
• 18 to 20 more likely to say known others with
  health problems (61) or legal problems (58)
• 7 of 10 for females, who were more likely than
  males to say
• because AOD is less "cool" (55 vs. 23)
• so that hair and clothes won't smell (54 vs.
  40)
• To receive special gift if you quit (51 vs. 10)
• to avoid leave social functions to use (49 vs.
  28)

44
Not everyone has the same reasons (continued)

• 6 or more of 10 for other races
• African Americans more likely to say because AOD
  use may shorten your life (65) and to have more
  energy (62)
• Asians more likely to say to have more energy
  (60), so you can get more things done (60), and
  so your hair and clothes will not smell (60)
• Hispanics more likely to say to have more energy
  (60), because AOD use may shorten your life
  (57) and because you will be praised by people
  close to you (57)
• Native Americans more likely to say to have more
  energy (100), so you can get more things done
  (100), because you noticed AOD use was hurting
  your health (100), you will like yourself better
  if you quit (90), because of legal problems
  (90), so your hair and clothes will not smell
  (90)

Hence the need for personalized feedback
45
Comparison of In-Treatment Outcomes
Substance Frequency Scale (SFS)
Substance Problem Scale (SPS)
1
0.5
0
Z-Score from CYT MET/CBT5 baseline
-0.5
-1
Lower severity at intake, Similar reductions at 3
months
-1.5
Intake
3 M
Intake
3 M
CYT (n202)
EAT (n409)
Source CYT Final Data Set and EAT 8/04 data set
46
Comparison of In-Treatment Outcomes (continued)
100
90
80
70
60
50
40
40
29
27
30
20
10
3
0
Intake 3 Month
Intake 3 Month
CYT (n202)
EAT (n407)
Source CYT Final Data Set and EAT 8/04 data set
47
Impact and Next Steps

• Papers published on design, validation,
  characteristics, matching, clinical contrast,
  treatment manuals, therapist reactions, cost, 12
  month outcomes, cost-effectiveness, benefit cost
• Papers with main clinical and cost-effectiveness
  findings at 30 month findings being submitted
  this year.
• Interventions being replicated as part of over
  four dozen studies currently or about to go into
  the field
• 30 to 40,000 copies of each of the 5 manuals
  distributed to policy makers, providers,
  individual clinicians and training programs

Source Dennis et al, 2002, in press
48
Implications

• The CYT interventions provide replicable models
  of brief (1.5 to 3 month) treatments that can be
  used to help the field maintain quality while
  expanding capacity.
• While a good start, the CYT interventions were
  still not an adequate dose of treatment for the
  majority of adolescents.
• The majority of adolescents continued to
  vacillate in and out of recovery after discharge
  from CYT.
• More work needs to be done on providing a
  continuum of care, longer term engagement and on
  going recovery management.

49
Contact Information

• Michael L. Dennis, Ph.D., CYT Coordinating Center
  PI
• Lighthouse Institute, Chestnut Health Systems
• 720 West Chestnut, Bloomington, IL 61701
• Phone [phone], Fax [phone]
• E-Mail Mdennis_at_Chestnut.Org
• Manuals and Additional Information are Available
  at
• CYT www.chestnut.org/li/cyt/findings or
• www.chestnut.org/li/bookstore or
• www.chestnut.org/li/apss/csat/protocols
• NCADI www.health.org/govpubs

50
CYT References

• Babor, T. F., Webb, C. P. M., Burleson, J. A.,
  Kaminer, Y. (2002). Subtypes for classifying
  adolescents with marijuana use disorders
  Construct validity and clinical implications.
  Addiction, 97(Suppl. 1), S58-S69.
• Buchan, B. J., Dennis, M. L., Tims, F. M.,
  Diamond, G. S. (2002). Cannabis use Consistency
  and validity of self report, on-site urine
  testing, and laboratory testing. Addiction,
  97(Suppl. 1), S98-S108.
• Dennis, M.L., (2002). Treatment Research on
  Adolescents Drug and Alcohol Abuse Despite
  Progress, Many Challenges Remain. Connections,
  May, 1-2,7, and Data from the OAS 1999 National
  Household Survey on Drug Abuse
• Dennis, M. L., Babor, T., Roebuck, M. C.,
  Donaldson, J. (2002). Changing the focus The case
  for recognizing and treating marijuana use
  disorders. Addiction, 97 (Suppl. 1), S4-S15.
• Dennis, M.L., Dawud-Noursi, S., Muck, R.,
  McDermeit, M. (2003). The need for developing
  and evaluating adolescent treatment models. In
  S.J. Stevens A.R. Morral (Eds.), Adolescent
  substance abuse treatment in the United States
  Exemplary Models from a National Evaluation Study
  (pp. 3-34). Binghamton, NY Haworth Press and
  1998 NHSDA.
• Dennis, M. L., Funk, R., Godley, S. H., Godley,
  M. D., Waldron, H. (2004). Cross validation of
  the alcohol and cannabis use measures in the
  Global Appraisal of Individual Needs (GAIN) and
  Timeline Followback (TLFB Form 90) among
  adolescents in substance abuse treatment.
  Addiction, 99(Suppl. 2), 125-133.
• Dennis, M. L., Godley, S. H., Diamond, G., Tims,
  F. M., Babor, T., Donaldson, J., Liddle, H.,
  Titus, J. C., Kaminer, Y., Webb, C., Hamilton,
  N., Funk, R. (2004). The Cannabis Youth
  Treatment (CYT) Study Main Findings from Two
  Randomized Trials. Journal of Substance Abuse
  Treatment, in press
• Dennis, M. L., Godley, S. and Titus, J. (1999).
  Co-occurring psychiatric problems among
  adolescents Variations by treatment, level of
  care and gender. TIE Communiqué (pp. 5-8 and 16).
  Rockville, MD Substance Abuse and Mental Health
  Services Administration, Center for Substance
  Abuse Treatment.
• Dennis, M. L. and McGeary, K. A. (1999).
  Adolescent alcohol and marijuana treatment Kids
  need it now. TIE Communiqué (pp. 10-12).
  Rockville, MD Substance Abuse and Mental Health
  Services Administration, Center for Substance
  Abuse Treatment.
• Dennis, M. L., Titus, J. C., Diamond, G.,
  Donaldson, J., Godley, S. H., Tims, F., Webb, C.,
  Kaminer, Y., Babor, T., Roebeck, M. C., Godley,
  M. D., Hamilton, N., Liddle, H., Scott, C., CYT
  Steering Committee. (2002). The Cannabis Youth
  Treatment (CYT) experiment Rationale, study
  design, and analysis plans. Addiction, 97,
  16-34..
• Dennis, M. L., Titus, J. C., White, M., Unsicker,
  J., Hodgkins, D. (2003). Global Appraisal of
  Individual Needs (GAIN) Administration guide for
  the GAIN and related measures. (Version 5 ed.).
  Bloomington, IL Chestnut Health Systems. Retrieve
  from http//www.chestnut.org/li/gain
• Dennis, M.L., White, M.K. (2003). The
  effectiveness of adolescent substance abuse
  treatment a brief summary of studies through
  2001, (prepared for Drug Strategies adolescent
  treatment handbook). Bloomington, IL Chestnut
  Health Systems. On line Available at
  http//www.drugstrategies.org
• Dennis, M. L. and White, M. K. (2004).
  Predicting residential placement, relapse, and
  recidivism among adolescents with the GAIN.
  Poster presentation for SAMHSA's Center for
  Substance Abuse Treatment (CSAT) Adolescent
  Treatment Grantee Meeting Feb 24 Baltimore,
  MD. 2004 Feb.
• Diamond, G., Leckrone, J., Dennis, M. L. (In
  press). The Cannabis Youth Treatment study
  Clinical and empirical developments. In R.
  Roffman, R. Stephens, (Eds.) Cannabis
  dependence Its nature, consequences, and
  treatment . Cambridge, UK Cambridge University
  Press.

51
CYT References - continued

• Diamond, G., Panichelli-Mindel, S. M., Shera, D.,
  Dennis, M. L., Tims, F., Ungemack, J. (in
  press). Psychiatric syndromes in adolescents
  seeking outpatient treatment for marijuana with
  abuse and dependency in outpatient treatment.
  Journal of Child and Adolescent Substance Abuse.
• French, M.T., Roebuck, M.C., Dennis, M.L.,
  Diamond, G., Godley, S.H., Tims, F., Webb, C.,
  Herrell, J.M. (2002). The economic cost of
  outpatient marijuana treatment for adolescents
  Findings from a multisite experiment. Addiction,
  97, S84-S97.
• French, M. T., Roebuck, M. C., Dennis, M. L.,
  Diamond, G., Godley, S. H., Liddle, H. A., and
  Tims, F. M. (2003). Outpatient marijuana
  treatment for adolescents Economic evaluation of
  a multisite field experiment. Evaluation
  Review,27(4)421-459.
• Funk, R. R., McDermeit, M., Godley, S. H.,
  Adams, L. (2003). Maltreatment issues by level of
  adolescent substance abuse treatment The extent
  of the problem at intake and relationship to
  early outcomes. Journal of Child Maltreatment, 8,
  36-45.
• Godley, S. H., Dennis, M. L., Godley, M. D.,
  Funk, R. R. (2004). Thirty-month relapse
  trajectory cluster groups among adolescents
  discharged from outpatient treatment. Addiction,
  99(Suppl. 2), 129-139.
• Godley, S. H., Jones, N., Funk, R., Ives, M., and
  Passetti, L. L. (2004). Comparing Outcomes of
  Best-Practice and Research-Based Outpatient
  Treatment Protocols for Adolescents. Journal of
  Psychoactive Drugs, 36, 35-48.
• Godley, M. D., Kahn, J. H., Dennis, M. L.,
  Godley, S. H., Funk, R. R. (2005). The
  stability and impact of environmental factors on
  substance use and problems after adolescent
  outpatient treatment for cannabis use or
  dependence. Psychology of Addictive Behaviors,
  19(1), 62-70.
• Shelef, K., Diamond, G.M., Diamond, G.S.,
  Liddle, H.H (under review). Adolescent and
  Parent Alliance and Treatment Outcome in
  Multidimensional Family Therapy
• Tetzlaff, B. T., Kahn, J. H., Godley, S. H.,
  Godley, M. D., Diamond, G., Funk, R. R. (in
  press). Working alliance, treatment satisfaction,
  and relapse among adolescents participating in
  outpatient treatment for substance use.
  Psychology of Addictive Behaviors.
• Tims, F. M., Dennis, M. L., Hamilton, N., Buchan,
  B. J., Diamond, G. S., Funk, R., Brantley, L.
  B. (2002). Characteristics and problems of 600
  adolescent cannabis abusers in outpatient
  treatment . Addiction, 97, 46-57.
• Titus, J. C., Dennis, M. L. (in press).
  Cannabis Youth Treatment (CYT) Overview and
  summary of preliminary findings. H. A. Liddle,
  C. L. Rowe, (Eds.) Treating adolescent substance
  abuse State of the science. Cambridge, UK
  Cambridge University Press.
• Titus, J. C., Dennis, M. L., Lennox, R., Scott,
  C. K. (under review). Development and validation
  of brief versions of the GAIN's internal mental
  distress and behavior complexity scales.
• Wintersteen, M. B., Mensinger, J. L., Diamond,
  G. S. (in press). Do gender and racial
  differences between patient and therapist affect
  therapeutic alliance and treatment retention in
  adolescents? Clinical Psychology Science and
  Practice.
• White, M. K., Funk, R., White, W., Dennis, M.
  (2003). Predicting violent behavior in adolescent
  cannabis users The GAIN-CVI. Offender Substance
  Abuse Report, 3(5), 67-69.
• White, M. K., White, W. L., Dennis, M. L.
  (2004). Emerging models of effective adolescent
  substance abuse treatment. Counselor, 5(2),
  24-28.