FamilyBased Interventions with Adolescent Substance Abusers

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Functional Family Therapy for Adolescent
Substance Use Disorders

Holly Barrett Waldron Oregon Research Institute
Funding National Institute on Drug Abuse
(R01DA09422 R01DA13350 R01DA13354) National
Institute on Alcohol Abuse and Alcoholism
(R01AA12183)
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Treatments for Adolescent Substance Use Disorders

• Vast majority of substance abusing youth receive
  outpatient treatment (SAMHSA, 1998)
• Outpatient treatments appear as effective as more
  intensive treatments (Winters et al., 1999)
• Randomized controlled trials have provided
  empirical support for specific treatment models

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Effect Sizes for Adolescent Substance Abuse
Treatments
Effect Size
Overall d 0.39 (Waldron Turner, 2008)
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Individual Cognitive Behavior Therapy
Well Established

• (Azrin et al., 2001 Dennis et al., 2004 Liddle
  et al., 2003 Hops et al., 2007 Waldron et al.,
  2001 2005 2007)

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Group Cognitive Behavior Therapy
Well Established

• (Dennis et al., 2004 Kaminer et al., 1998 2002
  Liddle et al., 2001 2004 Waldron et al., 2001
  2005)

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Family Therapy
BFT (Behavioral Family Therapy) Azrin et al.,
1994 2001 Krinsley Bry, 1995
FFT (Functional Family Therapy) Friedman, 1989
Hops et al., 2007 Waldron et al., 2001 2005
2007
MDFT (Multidimensional Family Therapy) Dennis et
al., 2004 Liddle et al., 2001 2003 2004
Well Established
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Family Therapy
Probably Efficacious

• MST (Multisystemic Family Therapy)
• Henggeler et al., 1991 1999 2002 2007

SSFT (Structural-Strategic Family Therapy)
Joanning et al., 1992 Lewis et al., 1994
Robbins et al., in press Santisteban et al.,
2003 Szapocznik et al., 1983 19861988
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Controlled Clinical Trials for Adolescent
Substance Use DisordersFunctional Family
TherapyIntegrative Behavioral and Family
TherapyGroup Cognitive Behavioral
TherapyIndividual Cognitive Behavioral Therapy
Team of Investigators Holly Barrett Waldron
Hyman Hops Charles W. Turner Manuel
Barrera Timothy J. Ozechowski Janet L.
Brody
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Randomized Trial for Marijuana Abuse (Study 1)
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Randomized Trial for Alcohol Abuse (Study 2)
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Two-Site Randomized Trial for Drug-Abusing
Hispanic and Anglo Youth (Study 3)
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Common Design Features of Three Randomized
Clinical Trials

• Combined samples (n range 89-260)
• 12-14 sessions of treatment
• Four assessments conducted at
• T1 (treatment intake), T2 (3-months), T3 (7-9
  months), and T4 (15-19 months)
• Measures
• Time-Line Follow-Back interview days of
  marijuana use
• Youth Self Report delinquency subscale
• Family Environment Scale cohesion, conflict, and
  organization subscales

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Adolescent Marijuana Use at Pre- and
Post-Treatment Follow-Up
Mean Percent Days of Use
(Waldron et al., 2001 2005)
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Proportion of Adolescents Abstinent or Using at
Minimal Levels (lt10 of days)
Proportion of Adolescents
(Waldron et al., 2001 2005)
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Adolescent Alcohol Use by Treatment Condition
Pre-Treatment to Follow-Up
Mean Percent Days of Use
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Summary of Substance Use Outcomes

• All treatments were associated with significant
  and clinically meaningful reductions in substance
  use
• Family-based treatments led to more immediate
  benefit maintenance of benefit over time
• Consistently better outcomes for family
  interventions across time and measures of use
• Support for efficacy of CBT group intervention at
  follow-up
• Support for CBT individual interventions for some
  youth

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yet, there is considerable individual
variability in outcomes
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What treatments work?For whom?Why?
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Four Marijuana Use Profiles for Baseline to
18-month Follow-Up
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Proportion of Youth with Each Change Trajectory

• Continuous Heavy Use 24.8
• Rapid Sustained Improvement 36.8
• Improvement Relapse 24.8
• Gradual Improvement 13.7

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Predictors of Change Trajectories

• Parent-Adolescent Conflict
• Delinquent behavior
• Depression
• School problems
• Deviant peers

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Non Family Tx Low BDI
Non Family Tx Hi BDI
Family Tx Hi BDI
Family Tx Low BDI
Note BDI gt 9 High BDI Heavy Marijuana Use
gt20 Days Use.
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Implications for Treatment

• Clear need for enhancement of empirically
  supported treatments to improve outcomes for
• Heavy users, polydrug users
• Co-morbid disorders
• Enhanced motivational strategies for youth and
  families
• Better relapse prevention components
• Booster treatment sessions aftercare
• Improved consolidation of treatment gains
• New ways to approach treatment research
• Evaluate adaptive, progressive interventions or
  stepped care (Compton Pringle, 2004 Sobell
  Sobell, 2000)
• Tailoring treatments to specific subgroups

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Therapist-Client Ethnic Matching and Family
Therapy Outcome
Source Flicker, Waldron, Turner, Brody, Hops,
2008 Journal of Family Psychology
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Research on Mental Health Services for Hispanic
Clients

• At higher risk for mental illness (related to
  poverty, discrimination) compared to individuals
  in the dominant culture Underutilize mental
  health services
• Higher premature drop out rates
• Higher likelihood of inappropriate or ineffective
  services
• Benefit less from services than clients from the
  majority culture Referred to substance abuse
  treatment at higher rates than Anglo youth
• Experience higher rates of unsatisfactory
  releases from treatment
• (Shillington Clapp, 2003 Sue, 1977 Sue et al.,
  1991 Vera et al., 1998)

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Rationale for Research on Ethnic Matching of
Therapists and Clients

• Better communication in primary language and
  understanding of clients cultural background
  (Flaskerud, 1986).
• Better therapeutic alliance due to common
  experience of therapist and client (Sue, 1988)
• Less frequent miscommunication and misdiagnosis
  (Sue, 1988 Sue Sundberg, 1996)
• Therapeutic goals similarly conceptualized by the
  client and therapist
• Similarity positively influences liking,
  persuasion, and credibility, processes important
  to treatment success (Simons et al., 1970)
• Better identification of the impact of cultural
  issues on problem
• Preference of clients for working with
  culturally-similar therapist (Atkinson Lowe,
  1995)

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Sample

• 89 substance-abusing adolescents in FFT
• 84 male 13-19 years
• 1/2 Anglo, 1/2 New Mexican Hispanic
• 80 in Class 2 3 of Hollingshead Scale
• 40 2-parent, 30 1-parent, 25 blended
• 72 in legal system 1/3 treatment mandate
• Mean sessions completed 89

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Adolescent Marijuana Use by Ethnicity and Ethnic
Match
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Major Findings - Ethnicity

• No significant differences between Anglos and
  Hispanics on treatment engagement or outcome
• Hispanic adolescents had significantly lower
  treatment alliances in 1st session
• Perhaps Hispanic adolescents have different time
  course of alliance

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Ethnicity Findings

• No significant differences between Anglos and
  Hispanics on FFT treatment engagement or outcome
• Hispanic adolescents significantly lower
  treatment alliances in 1st session

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Ethnic Match Findings

• No significant differences between ethnically
  matched Anglos and Hispanics on engagement or
  outcome
• Ethnic match not related to attendance or
  treatment satisfaction
• Non-matched Anglos had most balanced alliance
• Ethnically matched Hispanics had greater
  decreases in drug use

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Therapist Ethnicity Effects

• Hispanic therapists had more balanced alliances
  with families than Anglo therapists
• Hispanic therapists achieved better substance use
  outcomes with youth than Anglo therapists

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Discussion

• Ethnic match findings, despite highly
  acculturated Hispanic sample
• Relationship between ethnic match and treatment
  outcome unrelated to acculturation level
• Therapeutic alliance unrelated to relationship
  between ethnic match and change in drug use

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Implications

• Evidence that FFT is as or more effective with
  New Mexican Hispanic families
• Ethnic match more important for Hispanic families
  than for Anglo families
• Findings highlight the need for
• ethnic diversity among therapists
• better cross-cultural competence training

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New FFT Investigations
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FFT Aftercare An Evaluation of Three Approaches
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Sequential Multiple Assignment Randomization
Trial (SMART)

• Approach used to build and refine adaptive
  treatments using empirical research and clinical
  judgment
• Randomization identifies optimal strategies at
  key decision points

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Our SMART Trial

• Two definitions of early treatment response
  (abstinence or minimal use)
• Two stepped adaptive interventions (MET/CBT or
  FFT)

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Adaptive/Progressive Treatment
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Adaptive-Progressive Adolescent Substance Abuse
Treatment
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Effective Sequencing of Evidence-based Treatments
for Co-Morbid Depression and Substance Use
Disorders
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FFT and Methamphetamine
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Family-based Methamphetamine Treatment for
Adolescents
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Integrative FFT and CBT Treatment for Adolescents
Methamphetamine Abuse

• Motivational Enhancement
• Goal-setting
• Feedback
• Strategies
• Group and individual CBT for drug use and coping
  skills training
• Concrete visual and written material
• Repetition to compensate for cognitive deficits
• Time scheduling (24 hrs-7 days/week)
• Functional Family Therapy

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Conclusions

• FFT is an efficacious treatment for adolescent
  drug abuse
• FFT can integrate behavior change techniques that
  target a host of other problem behaviors
• FFT can be implemented across many diverse
  settings
• More research is needed