Does family therapy for adolescent behavior problems work in the real world

Aaron Hogue NIDA Grants R01DA019607, R01DA02

Family Therapy vs. Non-Family Treatment for Adolescent Behavior Problems in Usual Care

© CASAColumbia 2014

Aaron HogueSarah DauberMolly BobekCandace JohnsonEmily LichvarJon Morgenstern

Craig E. Henderson

Study Authors


Family Therapy is an Evidence-Based Approach (EBA) for Adolescent Behavior Problems

What Are Adolescent Behavior Problems?• Conduct problems and

delinquency

• Substance misuse and abuse

What is Family Therapy (FT)?• Intervene directly in

family relationships• Address key

extrafamilial systems (“ecological”)

Manualized FT is a Success Story• Win or drawn every

research comparison with other EBAs

• There are several brand names of manualized FT: • Brief Strategic Family

Therapy (BSFT), Functional Family Therapy (FFT), Multidimensional Family Therapy (MDFT), Multisystemic Therapy (MST)


What are some Barriers to Adopting Manualized Family Therapy?

Manualized Family Therapy is costly • Contract with model

purveyors• Need for extensive

training and fidelity monitoring procedures

• Need to renew contracts to sustain certification

Are EBAs superior to usual care for youth?• Mixed evidence when

therapists randomized• EBAs may be less

potent for complex cases

• Are EBAs already prevalent in usual care?


Is “Routine” FT effective for ABP?• Strong allegiance to FT in

youth services• Not yet tested as a

generic approach in usual care (UC)

• Can FT be a success without the contracts and intensive supervision by outside experts

Evidence based interventions• EST = “brand-name”

manualized model• EBP = generic, modular,

core version of EST• EBPs are not (yet) widely

tested in routine care

What is “Routine” Family Therapy?


Study Hypotheses

Is routine FT (RFT) superior to Treatment as usual (TAU) in promoting treatment attendance?

Will both RFT and TAU show positive outcomes: • Externalizing,

Internalizing symptoms

• Delinquency: proportion, # acts

• Substance use: proportion, # days

Will RFT be superior to TAU?


Participant Recruitment

Conducted aggressive community outreach• Did not use the

existing clinic referral streams (not enough clients)

Referral criteria• Caregiver willing to

participate in treatment

• Referral problems beyond scope of services at referral site

• Not currently in any other behavioral treatment


Study Eligibility Criteria: Inclusion

Age 12-18 yearsPrimary caregiver willing to participate in treatment & research

Health insurance accepted by study sites

Willingness to engage in treatment

MH TRACKMet DSM-IV criteria for oppositional defiant disorder (ODD) or conduct disorder (CD)

SU TRACK1. 1 day alcohol to

intoxication or illegal drug use in past month

2. Endorse 1 or more DSM symptoms of SUD

3. Met American Society of Addiction Medicine (ASAM) criteria for outpatient SU treatment


Study Eligibility Criteria: Exclusion

Mental retardation or developmental disorder

Current psychotic features

Medical/psychiatric illness requiring hospitalization

Suicidal ideation


Used Intensive Linking Procedures to Help Families Enroll in Treatment

Intensive family systems engagement

Counteract barriers to enrollment• Information• Logistics• Insurance

Continue through initial intake


Screening

806 referred

433 screened

298 eligible


298 eligible

205 baselined & randomized: 104 RFT; 101

TAU

193 completed at least one FU:

95 RFT; 98 TAU

Enrollment & Follow Up


% of sample

Female 48%15.4 (1.4)

Age (mean/SD)

Hispanic 59%

African American 21%

Multiracial 15%

Single parent household 66%

Caregiver graduated high school 71%

Caregiver employed full or part time 64%

Household income < $15K per year 44%

History of child welfare involvement 51%

Participant Demographics


% of sample

Study Track 63% MH37% SU

87%Oppositional Defiant DisorderConduct Disorder 52%Attention Deficit Hyperactivity Disorder 74%Mood Disorder or Dysthymia 42%Substance Use Disorder 28%Generalized Anxiety Disorder 17%Posttraumatic Stress Disorder 17%More than one disorder 78%

Track & Diagnosis


Study Sites and TherapistsRFT TAU

N Sites 1 5 clinics: Community MH, Hospital MH, Addictions

Treatment approaches featured

FT Diverse

N Therapists 15 17

Therapist age range 28-59 25-45

Gender Predominantly female

Predominantly female

Race/ethnicity Mostly Hispanic American

Mostly European American

Average years experience 3.1 (SD = 4.3) 3.2 (SD = 2.9)


Clinic Intake and Treatment Attendance Rates

Full Sample RFT TAU

Total N 205 104 101

Completed intake 61% 58% 64%

Attend 1 session 39% 41% 37%

Attend >3 sessions 30% 31% 30%

Sessions attended (avg) 12.4 (10.1) 11.6 (9.9) 13.3 (10.2)


Evidence of Implementation Fidelity


Pre-Study Therapist Self-Report: Proficiency in EBAs

Proficiency score: Average skill & allegiance

Therapist rated skill and allegiance to each

of the four EBAs: CBT, FT, MI, DC (drug

counseling)


Differences in Therapist Proficiency (RFT vs. TAU)

RFT TAU t p d

N therapists 10 16

FT Proficiency 3.7 (.88) 2.7 (.80) 2.8 .01 1.13

MI Proficiency 2.5 (1.0) 2.5 (1.0) -.08 .94 .03

CBT Proficiency 2.6 (.77) 3.2 (.71) -2.1 .05 .86

DC Proficiency 2.0 (.94) 2.1 (1.2) -.14 .89 .06


Therapists Self-Report of Use of EBAs During Treatment of Study Cases: Inventory of Therapy Techniques (ITT)

Therapist-report: Measure fidelity to EBAs for ABP using 5-point “extensiveness” scale

Item Origins: Derived from validated observational fidelity scales of ESTs

27 Individual Techniques from 4 Approaches:CBT, FT, MI, DC


DC MI/CBT FT

RFT 1.18(.28)

2.31(.72)

2.68(.70)

TAU 1.40(.84)

2.45(.95)

2.04(.72)

B (SE); pseudo-z

NS NS .53 (.19);2.73*

TAU: CMHCs(2 clinics)

1.03 (.09) 2.22(.92)

1.92(.68)

TAU: Child Psychiatry(2 clinics)

1.19 (.17) 2.40(.73)

1.90(.61)

Differences Between RFT vs. TAU in Therapist Report of Using EBAs


Differences Between RFT vs. TAU in Observer Report of Using EBAs

MI/CBT FT F-test;Effect size

RFT (n = 104) 1.6(.40)

2.0(.45)

p = .001;partial η2 = .33

TAU (n = 53) 1.6(.32)

1.4(.36)

p = .06;partial η2 = .07

N = 157


Apply the Templateand Your Layouts Could Look Great

Outcome Analyses


Study Findings: Treatment Attendance

Client attended at least one session• RFT: 74%• TAU: 79%

Average number of sessions attendedRFT: 11.6 (SD=9.9)TAU: 13.3 (SD=10.2)

No differences between conditions


Analytics Procedures Used to Test Clinical Outcomes

Latent growth curve modeling3-, 6-, 12-mo FU(nested data)

Delinquency and Substance Use(non-normal data)

• 2-part models: Categorical (any vs. none)

• Continuous (if occurred)

Externalizing and Internalizing: quadratic growth functions

Covariates, Study Track (MH vs. SU)


Clinical Outcomes: Externalizing Symptoms

Caregiver Report• Overall declines in

aggression, oppositionality, conduct problems

• No between-condition differences

Adolescent Report• Overall declines in

aggression, oppositionality, conduct problems

• RFT produced larger effects


Clinical Outcomes: Internalizing Symptoms

Caregiver Report• Overall declines in

anxiety, depression, somatic problems


Adolescent Report• Overall declines in

anxiety, depression, somatic problems

• RFT produced larger effects


Clinical Outcomes: Delinquency

MH Track• Overall declines in

delinquency: proportion any act, total # acts


SU Track• Overall declines in

delinquency: proportion any act, total # acts

• RFT larger effects for total # acts


Clinical Outcomes: Substance Use

Full Sample• No overall declines in

substance use

SU Track• No overall declines in

substance use

• Significant effects for RFT: proportion any use, # days use


Brief Conclusions

Both RFT and TAU promoted significant gains in multiple problem areas

RFT Outperformed TAU for5 out of 12 outcomes

Effect sizes for RFT (small to moderate)comparable to effects reported in meta-analyses of efficacy studies for manualized FTs


Study Limitations

Only 1 RFT Site (However: No measureable cost or organizational advantages for the RFT site)

Sample NOT referral as usual

Could not analyze site effects

Modest attendance rates: (However: Study rates were comparable to routine services)


Study Implications

Routine FT can be delivered with fidelity and effectiveness in usual care

What are important differences in fidelity procedures within usual care vs. outside contracts

FT is widely endorsed in youth services, but isn’t commonly practiced? With fidelity?

Need more research on EBAs used in routine care


This research was funded by the National Institute on Drug Abuse(R01 DA019607 and R01 DA023945; PI: Aaron Hogue, Ph.D.; Co-I: Sarah Dauber, Ph.D.)



Related References

Hogue, A., Dauber, S., Lichvar, E., Bobek, M., & Henderson, C. E. (in press). Validity of therapist self-report ratings of fidelity to evidence-based practices for adolescent behavior problems: Correspondence between therapists and observers. Administration and Policy in Mental Health and Mental Health Services Research.

Hogue, A., Dauber, S., & Henderson, C. E. (2014). Therapist self-report of evidence-based practices in usual care for adolescent behavior problems: Factor and construct validity. Administration and Policy in Mental Health and Mental Health Services Research, 41, 126-139.

Hogue, A., & Dauber, S. (2013). Assessing fidelity to evidence-based practices in usual care: The example of family therapy for adolescent behavior problems. Evaluation and Program Planning, 37, 21-30. Hogue, A., & Dauber, S. (2013). Diagnostic profiles among urban adolescents with unmet treatment needs: Comorbidity and perceived need for treatment. Journal of Emotional and Behavioral Disorders, 21, 18-32. Dauber, S., & Hogue, A. (2011). Profiles of systems involvement in a sample of high-risk urban adolescents with unmet treatment needs. Children and Youth Services Review, 33, 2018-2026.

Date post:	23-Feb-2017
Category:	Health & Medicine
Upload:	the-national-center-on-addiction-and-substance-abuse
View:	815 times
Download:	2 times

Does family therapy for adolescent behavior problems work in the real world

Health & Medicine