Developing and Testing FamilyBased Treatment for Adolescent Substance Abuse

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Developing and Testing Family-Based Treatment for
Adolescent Substance Abuse and Related
Problems Research Emphases and Themes Howard A.
Liddle, Ed.D. Professor, Departments of
Epidemiology Public Health, and
Psychology Director, Center for Treatment
Research on Adolescent Drug Abuse University of
Miami School of Medicine
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Presentation Outline

• The specialty of adolescent substance abuse
• Clinical research program
• Features and findings
• Clinical approach
• Characteristics and implementation issues
• Transportation, adaptation, testing of
  research-supported family-based treatment

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Advances in Adolescent Drug Abuse

• Specialty status
• New knowledge about etiology
• New knowledge about consequences
• New conceptual frameworks
• New treatments and accompanying
  science that has tested these treatments
• New levels of public concern,
  research activity and support

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Core Goals of theResearch Program

• Commitment to highest quality science and service
• Construct a treatment approach that is clinically
  and cost effective, flexible, clearly
  articulated, and presented systematically
• Disseminate the treatment approach
• Transport and test the treatment approach

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Characteristics and Background of the Research
Program

• Research support from NIDA, CSAT, CSAP since 1985
• 20M - 2 center grants, clinical trials,
  treatment development, process studies,
  dissemination/technology transfer studies
• NIDA (Effective Drug Abuse Treatments)
• CSAT (Adol TIPS, ATM, CYT)
• CSAP (Strengthening Families Best Practices
  Program)
• OJJDP (Promising Empirically Supported Treatments)

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Features and Themes of the MDFT Research Program
(1)

• Knowledge about development and dysfunction
• Therapeutic ingredients and processes
• Therapist competence and development
• Efficacy Rigorous treatment evaluation
• Effectiveness Rigorous treatment evaluation in
  regular clinical settings

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Research Program (2)

• Transporting and disseminating
• Refining and adapting
• Defining and testing different versions
• Continued exploration of key components and
  processes

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Reviews of Family-Based Treatments

• Behavioral problems/Delinquency
• Alexander et al (1996) Garfield Bergin (4th)
• Friedlander (1998) Family therapy (Nichols /
  Schwartz)
• Lebow Gurman (1995) Ann. Rev. Psychol
• Substance Abuse
• Liddle Dakof (1995, 1996) (NIDA Monograph 156,
  October JMFT 1996)
• Ozechowski Liddle (2000) Child Family
  Psychology Review
• Stanton Shadish (Sept-1997) Psychol. Bull.
• Waldron (1997) Advances in Clinical Child
  Psychology

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Outcomes of Treatment

• MDFT, Group, Multi-Family Educational Clinical
  Trial (NIDA)
• MDFT - Individual CBT Clinical Trial (NIDA)
• MDFP Prevention (CSAP)
• MDFT-I Treatment Development (NIDA)
• CYT Multisite Clinical Trial (CSAT)
• Alternative to Residential Treatment Clinical
  Trial (NIDA)
• Early Adolescent Clinical Trial (CSAT)
• Transporting MDFT to PHP (NIDA)
• Girls - Gender Sensitive Treatment
• Drug Court
• Adaptation and transportation studies

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MDFT, Group and Multifamily Educational Drug Use
at Pre-Tx, Post-Tx, 6 Month 12 Month Follow-Up
Liddle , Dakof et al. Am J Drug Alcohol Abuse
(2001)
Pre-Tx Post-Tx 6 month 12 month
Drug Use
MDFT
Group
MFET
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Decreases in Marijuana UseAJDAA 16 sessions
CYT 12 sessions

Post Tx 12 Mo.
Follow-Up AJDAA -54 -48 CYT (IL,
Phila.) -20 -42
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Changes in Family DysfunctionRatings of
Videotapes
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Prosocial Domain Passing Grade Point Average

Post-Tx 1 Year Follow-Up MDFT
25 60 Multi-Family 33
41 Group 43 60
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Cost Comparison MDFT vs. NTIES Data in CYT
Multi-Site Study

Mean Weekly Outpatient Cost MDFT
164 NTIES 365
NTIES - Outpatient Adolescent Treatment Program
Directors sample Dennis, M.L., et al. (in
press). The Cannabis Youth Treatment (CYT)
experiment A multi-site study of five approaches
to outpatient treatment for adolescents.
Addiction. French, M., et al. (in press). Cost
estimates of adolescent drug treatment in the CYT
field experiment. Addiction.
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CBT - MDFT for Adolescent Drug Abuse

• 224 adolescents, 12-17 (15.4), 75 juv justice
  involved, 80 male, 72 African American, 12,000
  family income, 70 began marij lt 15, 58 close
  family member with history of criminal justice
  involvement, 78 two or gt diagnoses, school
  failure, community characteristics
• Multi-method, multi-person assessments
• Two treatments CBT (adol) and MDFT, up to 26
  sessions, 1x wk, some extra-session activity

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Differential Response According to n
Sessions DRUG USE (4 TO 16 SESSIONS) Marijuana
(TLFB) MDFT - CBT (Significant univariate time x
treatment condition effect (F(2, 20)4.87, p
0.039, eta squared .20)
16.07 (22.36)
13.69 (15.39)
12.2 (16.3)
5.08 (6.17)
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NUMBER OF COMORBID DISORDERSRowe, Liddle, Dakof,
Tejeda, 2001
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Patterns of Comorbidity Rowe, Liddle, Dakof
Tejeda, 2001
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Change in Marijuana Use
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Changes in Personal Experiences with Drugs
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Changes in Externalizing Symptoms (Parent Report)
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Changes in Externalizing Symptoms (Adolescent
Report)
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Changes in Internalizing Symptoms (Adolescent
Report)
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MDFT (intensive version) vs. Residential Tx Study


Sample characteristics - Adolescents, average age
16, referred for residential Tx, dual diagnosis,
and previous outpatient Tx failure, most juvenile
justice involved MDFT treatment features -
Intensive involvement, case management, multiple
components, extensive involvement in multiple
social systems
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Treatment Engagement Retention MDFT vs.
Residential Tx Study

Initial engage Length Tx MDFT
94 186 days Residential 67 90
days
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Graph 1 Changes in Marijuana Use Up to 12 Months
Post Tx MDFT and Residential Tx Decrease
Marijuana Use at Termination Marijuana of MDFT
Teens Continues to Decrease 12 Months Post
Tx Residential Tx Increases Past Baseline
Levels
MDFT Multidimensional Family Therapy ATP
Adolescent Treatment Program (Residential Tx)
Graph 2 Changes in Parent Report of Adol
Externalizing Behaviors MDFT Parents Continue to
Report Fewer Problems 12 Months Post
Tx Residential Tx Parents, Report Improvements
at Termination. But then Report Worsening
Behaviors Over 12 Months Post Tx
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Summary of Treatment Outcomes

• Substance use reductions
• Individual psychological functioning -
  internalizing and externalizing symptoms
• School and job functioning
• Parenting practices and psychological functioning
• Family environment - family interaction
• No or fewer arrests
• Decreased involvement with antisocial, drug using
  peers

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Treatment Mechanisms

• Modules
• In-session impasse
• Alliance with adolescent
• Parenting practices
• Cultural themes
• Stages of treatment/stages of change

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Treatment Mechanisms (cont.)

• Treatment parameters
• Predictors of dropout and retention
• ATI
• Drug counseling (AA/NA, Spirituality, use of drug
  tests)
• Life skills - school and jobs
• HIV-AIDS risk reduction

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Change in Parenting and Change in Adolescent
Drug Use
Schmidt, Liddle Dakof, J. Family Psychology,
1996
60 Tandem change 20 Adolescent only change 10
Parent only change 10 Neither parent or
adolescent change
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Treatment Development Framework

• Conceptualization of the clinical phenomena
• Research on processes related to dysfunction
• Conceptualization of treatment
• Specification of treatment process
• Tests of treatment process
• Tests of treatment outcome
• Tests of boundary conditions, moderators, and
  mediators

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Outcome
Treatment Parameters
Process
Multiple Dimensions of MDFT
Family Therapy
Development
Psychotherapy
Problem Behaviors
Ecology
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Adolescent development
Community connection
School / academic
Treatment Foci
Family relations
Job/vocational
Cultural identity
Peer network
Drug use / drug taking contexts
Liddle, H. (2001). Multidimensional Family
Therapy for Adolescent Substance Abuse. CSAT CYT
Manual Series.
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Key Features and Processes

• Facilitation of development
• Working the four corners
• Therapeutic alliances concrete alternatives
• Adolescent connection - school, work, family
• Parent functioning stress, parental subsystem
  conflict, parenting practices
• Changing family environment
• Therapist attitude and behavior

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Theoretical Conceptual Features

• Development
• Ecology
• Culture
• Risk and protective factors
• Mapping varieties of change
• Multivariate thinking
• Integrative orientation

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Clinical Features

• Treatment protocol capable of being adapted and
  tested in different forms
• To date - outpatient and intensive outpatient
  variations
• Masters level therapists
• Initial training and ongoing supervision
• Use knowledge about known causes and correlates
  to assess and target dysfunction

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Clinical Features (cont.)

• Use knowledge about known buffers and protectors
  to assess and target strengths
• Principle-driven
• Flexible adaptation
• Multiple, simultaneous targets and activities in
  several realms of functioning
• Sequenced, multi-level, multi-person change
• Organization, planning and orchestration

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Intervention Targets

• Parent Self and parenting
• Adolescent Self, son/daughter, peer system
• Parent-adolescent relationship
• Family member-social context interactions

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Clinician Characteristics

• Systems thinking - seeing the case through a
  complex lens
• Skill in family therapy facilitates development
• Knowledge of social systems and systems of care
• Comparable relationship and intervention skill
  with parent, adolescent, and extrafamilial
• Navigation ability -- The Loop
  functioning-dysfunction-change processes-intervent
  ions-read feedback-track outcomes-recalibrate
• Practical, outcome orientation
• Motivation - Wanting to work in this way
• Do what it takes attitude

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Practice Guidelines 1

• Complex conceptualization
• Think in terms of interaction and synergy
  among various social systems
• Dangers in too narrow or too broad a
  conceptualization
• Clinical phenomenon is multidimensional and
  involves multiple systems
• These systems vary in nature, process, role
  and function, access, malleability, and change
  difficulty

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Practice Guidelines 2

• Standardization and flexibility
• Treatment stages
• Stages within stages
• Core treatment components
• Core treatment processes

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Practice Guidelines 3

• Integration of drug and psychotherapy foci
• Integration of treatment and casework
• Integration of different service delivery
  orientations - clinic, home, community,
  school, court
• Flexibility of dose
• Focus on the research derived determinants
• Facilitate growth of the known protectors
  and buffers

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Practice Guidelines 4

• Need to acquire knowledge and skill in
  several areas- drugs, jj, schools, families,
  individuals, peer networks, residential care
• Orchestration and organization skills
• Mobilizing individual and social context
  forces to sustain gains

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Center for Treatment Research on Adolescent Drug
Abuse University of Miami School of
Medicine hliddle_at_med.miami.edu gdakof_at_med.miami.e
du afrank_at_med.miami.edu