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Abstract: The effects of family therapy for adolescent substance use on parent substance use have not been explored. This study aimed to determine those effects for Brief Strategic Family Therapy (BSFT), as well as the relationship between parent substance abuse and adolescent substance use. Using data from the National Drug Abuse Treatment Clinical Trials Network protocol about the use of BSFT (CTN-0014), which involved 480 adolescents and parents randomized to BSFT or treatment as usual (TAU) across eight outpatient treatment programs, substance use for both parents and adolescents was assessed at baseline and 12 months post-randomization. Family functioning was assessed at baseline, 4, 8, and 12 months post-randomization. Parents in BSFT significantly decreased their alcohol use as measured by the ASI composite score from baseline to 12 months. Change in family functioning mediated the relationship between Treatment Condition and change in parent alcohol use. Children of parents who reported drug use at baseline had three times as many days of reported substance use at baseline compared with children of parents who did not use or only used alcohol. Adolescents in BSFT had a significantly lower trajectory of substance use than those in TAU if their parents used drugs at baseline. Conclusions: BSFT is effective in reducing alcohol use in parents, and also in reducing adolescents’ substance use in families where parents were using drugs at baseline. BSFT may also decrease alcohol use among parents by improving family functioning. These results have important clinical implications, providing evidence that BSFT could improve the alcohol use of parents and that BSFT may be particularly beneficial for adolescents of parents who were drug-using at baseline. Though BSFT was developed for adolescent drug abuse, these findings suggest future research is warranted on investigating the cost benefits of delivering BSFT to substance abusing families, as it is suggested that more than one member might obtain improvement in alcohol, drug, and other health outcomes. Related protocols: CTN-0014

Abstract:

This is the Results Article for CTN-0014-A-1.

Isomorphism, or parallel process, occurs in family therapy when patterns of therapist-client interaction replicate problematic interaction patterns within the family. This study investigated parallel demand-withdraw process in Brief Strategic Family Therapy (BSFT) for adolescent drug abuse, hypothesizing that therapist-demand/adolescent-withdraw interaction (TD/AW) cycles observed early in treatment would predict poor adolescent outcomes at follow-up for families who exhibited entrenched parent-demand/adolescent-withdraw interaction (PD/AW) before treatment began.

Participants were 91 families who received at least four sessions of BSFT in the National Drug Abuse Treatment Clinical Trials Network (CTN) study CTN-0014 (“Brief Strategic Family Therapy (BSFT) for Adolescent Drug Abusers”), a multisite clinical trial on adolescent drug abuse. Prior to receiving therapy, families completed videotaped family interaction tasks from which trained observers coded PD/AW. Another team of raters coded TD/AW during two early BSFT sessions. The main dependent variable was the number of drug-use days that adolescents reported in timeline follow-back interviews 7 to 12 months after family therapy began. Zero-inflated Poisson regression analyses supported the main hypothesis, showing that PD/AW and TD/AW interacted to predict adolescent drug use at follow-up. For adolescents in high PD/AW families, higher levels of TD/AW predicted significant increases in drug use at follow-up, whereas for low PD/AW families, TD/AW and follow-up drug use were unrelated.

Conclusions: Results suggest that attending to parallel demand–withdraw processes in parent–adolescent and therapist–adolescent dyads may be useful in family therapy for substance-using adolescents, as it appears that parallel demand-withdraw processes in family therapy for adolescent drug abuse can compromise treatment outcome. Findings highlight two key BSFT principles — remaining decentralized and placing more demand for change on parents than on adolescents — and suggest these principles are particularly important to observe with therapists work with families that exhibit PD/AW.

Related protocols: CTN-0014-A-1

Abstract:

Research shows that interventions for substance use disorders may be helpful in reducing internalizing disorders in adolescents. This paper examines the prevalence and reductions of anxiety and depression symptoms among youth receiving substance use treatment. Four hundred and eighty adolescents ages 12-17 who received treatment for substance abuse as part of the Brief Strategic Family Therapy (BSFT) effectiveness trial in the National Drug Abuse Treatment Clinical Trials Network (protocol CTN-0014) were screened for anxiety and depression using the Diagnostic Interview Schedule for Children-Predictive Scales (DISC-PS). Twelve-month post-randomization assessments were completed by 327 parents and 315 youth. Sixty-five percent of the sample was found to have probability of at least one anxiety disorder or depression diagnosis. Significant reductions of anxiety and depressive symptoms and significant reductions in probable anxiety and depression diagnoses were observed at follow-up. Few differences by treatment type and ethnic group were noticed.

Conclusions: This article makes a novel contribution to the literature by showing that community-based drug abuse treatments may help reduce the prevalence of anxiety and depression symptoms and probability of diagnoses among adolescents. Adolescents with comorbid substance use and mental health problems constitute a unique clinical population at a very high risk for comorbid problems into adulthood to the extent that it has become one of the most pressing issues in developing and testing effective interventions for drug abuse. Results of this study suggest there were significant reductions in symptoms after treatment, even when controlling for other services that these adolescents might have received for these problems, a discovery with important clinical implications.

Related protocols: CTN-0014

Abstract:

Parent substance use has significant effects on adolescent substance use. Dysfunctional family structure and inadequate parenting practices, resulting from parent substance use, are strongly associated with adolescent substance use. This poster reports on an ancillary investigation of CTN-0014 that sought to determine the effects of Brief Strategic Family Therapy (BSFT) on parent substance use; to determine the impact of parent substance use on adolescent substance use; and to examine the mediating effects of family functioning on the relationship between parent substance use and adolescent substance use. Generalized estimated equations revealed that parents in BSFT significantly decreased their alcohol score from baseline to 12 months at a rate of 0.74. Wilcoxon analyses revealed that children of parents who reported substance use at baseline had twice as many days of reported drug use at baseline compared with children of parents who did not use or only used alcohol. Mixed model longitudinal analyses showed that adolescents in BSFT had a significantly lower trajectory of substance use than those in TAU if their parents used substances at baseline. Mediation analyses indicated a statistically significant effect, evidence that change in family functioning significantly predicts parent alcohol use.

Conclusions: BSFT appears to be effective in reducing alcohol use in parents, and in reducing an adolescent’s substance use if their parents were also using at baseline.

Related protocols: CTN-0014

Abstract:

This one-day conference was designed to benefit front-line clinical staff delivering addiction treatments in Texas. Speakers presented on a wide variety of topics, focusing primarily on the scientific basis for selected pharmacological and behavioral evidence-based practices, providing concrete examples, experiential learning experiences, and practical implementation guidance.

View conference agenda.

Presentations:

Exercise for the Treatment of Addiction, Madhukar H. Trivedi, M.D.

Motivational Interviewing: Implementing an Evidence-Based Practice, Mary M. Velasquez, PhD.

Conducting Research in a Community-Based Setting: Challenges and Rewards, A. Rebecca Crowell, MEd, LPC, LCDC; Douglas Denton, MA, LCDC, LCCA

Addictions Pharmacotherapy, Thomas Kosten, MD

CTN-0030 POATS Blending Review, Jennifer Sharpe Potter, PhD, MPH

Evidence-Based Treatments for Traumatic Stress and Addictions, Denise Hien, PhD

HIV Blending Product, Richard Spence, PhD

Research into Practice – Motivational Incentives, Michael Levy, PhD

Brief Strategic Family Therapy, Joan Muir, PhD

Abstract:

Growing recognition of the negative impact of anxiety disorders in the lives of youth has made their identification an important clinical task. Multiple perspective assessment (e.g., parents, children) is generally considered a preferred method in the assessment of anxiety disorder symptoms, although it has been generally thought that disagreement between parent and youth ratings of the child’s emotions is common. This study examined parent and child reports of the child’s anxiety disorder symptoms using the Diagnostic Interview Schedule for Children-Predictive Scales (DISC-PS) in a clinic-referred sample of substance using adolescents participating in the National Drug Abuse Treatment Clinical Trials Network protocol CTN-0014 (“Brief Strategic Family Therapy for Adolescent Drug Abusers”). Parents and adolescents (N=480) who were referred for substance abuse treatment were screened for anxiety disorder symptoms using the DISC-PS at pretreatment. Results suggest similar (low) levels of agreement between the parent report and child report versions as found with other anxiety symptom and anxiety disorder measures.

Conclusions: This study adds to the existing research on the assessment of anxiety disorder symptoms in both clinically and theoretically important ways. Findings provide data on multi-informant agreement and highlight issues in the use of the DISC-PS to identify anxiety problems in youth.

Related protocols: CTN-0014

Abstract:

This is the primary outcomes article for CTN-0014.

This study was designed to determine the effectiveness of brief strategic family therapy (BSFT, an evidence-based family therapy) compared to treatment as usual (TAU) as provided in community-based adolescent outpatient drug abuse programs. In protocol CTN-0014, BSFT was compared to TAU with a multiethnic sample of adolescents (213 Hispanic, 148 White, and 110 Black) referred for drug abuse treatment at eight community treatment agencies nationwide. Randomization encompassed both adolescents’ families (n=480) and the agency therapists (n=49) who provided either TAU or BSFT services. The primary outcome was adolescent drug use, assessed monthly via adolescent self-report and urinalysis for up to 1 year post-randomization. Secondary outcomes included treatment engagement (2 or more sessions), retention (8 or more sessions), and participants’ reports of family functioning 4, 8, and 12 months following randomization. No overall differences between conditions were observed in the trajectories of self-reports of adolescent drug use. However, the median number of days of self-reported drug use was significantly higher in TAU than in BSFT at the final observation point. BSFT was significantly more effective than TAU in engaging and retaining family members in treatment and in improving parent reports of family functioning.

Conclusions: The current findings provide support for the impact of the BSFT intervention on engagement, retention, and parent-reported family functioning with adolescents from diverse racial/ethnic groups. However, the weak effects on drug use outcomes, combined with the difficulties in establishing optimal implementation of the BSFT model, raise concerns about how to most successfully transport the BSFT model into community settings. These challenges, as well as recommendations for further research, are discussed.

Related protocols: CTN-0014

Abstract:

Therapist adherence has been shown to predict clinical outcomes in family therapy. In prior studies, adherence has been represented broadly by core principles and a consistent family (vs. individual) focus. To date, these studies have not captured the range of clinical skills that are represented in complex family-based approaches or examined how variations in these skills predict different clinically relevant outcomes over the course of treatment. In this ancillary study, the authors examined the reliability and validity of an observational adherence measure and the relationship between adherence and outcome in a sample of drug-using adolescents receiving Brief Strategic Family Therapy as part of protocol CTN-0014, “Brief Strategic Family Therapy (BSFT) for Adolescent Drug Abusers.” Results supported the proposed factor structure of the adherence measure, providing evidence that it is possible to capture and discriminate between distinct dimensions of family therapy.

Analyses demonstrated that the mean levels of the factors varied over time in theoretically and clinically relevant ways and that therapist adherence was associated with engagement and retention in treatment, improvements in family functioning, and reductions in adolescent drug use. Clinical implications and future research directions are discussed, including the relevance of these findings on training therapists and studies focusing on mechanisms of action in family therapy. Although this measure was developed specifically for the BSFT intervention, it is possible that the domains identified may be present in other empirically based family interventions and, as such, future studies may consider validating the use of this or similar measures with other clinical models and populations. The results of this study provide a necessary first step by validating a measure that can be used to capture the complexity of family therapy, and can be used to understand mechanisms of change in family therapy with drug-using youth.

Related protocols: CTN-0014

Abstract:

This article describes the development and implementation of a trial of Brief Strategic Family Therapy (BSFT) in eight community substance abuse treatment programs in the National Drug Abuse Treatment Clinical Trials Network (CTN). BSFT is an evidence-based drug intervention for adolescents that addresses family relationships associated with adolescent drug use. It has been shown to be efficacious in reducing adolescent drug use and conduct problems and in improving family functioning overall.

The CTN protocol, protocol CTN-0014, compared BSFT to adolescent outpatient treatment as usual. Researchers and treatment programs collaborated closely to identify and overcome challenges, many of them related to achieving results that were both scientifically rigorous and applicable to the widest possible variety of adolescent substance abuse treatment programs. To meet these challenges, the collaborative team drew on lessons and practices from efficacy, effectiveness, and implementation research. The strategies described in this paper are particularly relevant for furthering implementation research focused on family-based treatments of adolescents.

Related protocols: CTN-0014

Abstract:

Behavioral intervention research has lagged behind biomedical research in developing principles for defining, categorizing, identifying, reporting, and monitoring adverse events and unanticipated problems. In this article, a set of principles for defining adverse events are presented, along with how they were applied in the National Drug Abuse Treatment Clinical Trials Network multi-site family therapy study for substance-using adolescents, protocol CTN-0014, the Brief Strategic Family Therapy (BSFT) for Adolescent Drug Abusers study. This study tested how BSFT compares to treatment as usual (TAU) for the treatment of drug-abusing adolescents. During protocol development, experts in the BSFT intervention, medical safety officers, ethicists, and senior investigators defined the procedures for identifying, tracking, and reporting adverse events for drug using adolescents as well as their family members. During this process, the team identified five key guiding principles: that the adverse events should be validated and plausible and that monitoring systems should assess relatedness, be systematic, and be a shared responsibility. Non-serious adverse events included arrest, school suspension and drop-out, runaway, kicked out of home, and violence. Serious adverse events included physical or sexual abuse, suicidal behavior, homicidal behavior, hospitalization (drug-related or psychiatric only), and death. More than 50% of the adolescent population experienced an adverse event during the trial. Family members experienced fewer (4.5%). The most common event for the adolescent group was arrest, followed by school suspension/drop-out. For the family member group, the most common event was violence, followed by arrest. There was a significant difference in the presence of adverse events in family members that were randomized to BSFT (6.1%) when compared to TAU (2.8%). One probable explanation for this is that there were more opportunities to identify adverse events for family members assigned to BSFT because family members attended therapy sessions.

The safety plan of the BSFT study has important implications for future studies with drug using adolescents and family-based interventions, though as these principles were developed specific to the issues and challenges faced in this single protocol, the application of the principles in designing procedures for defining and tracking adverse events in research on other behavioral interventions or clinical populations may be limited. Safety data in the BSFT trial support the principles that founded the BSFT safety plan, and illustrate the importance of safety monitoring in behavioral intervention research.

Related protocols: CTN-0014

Abstract:

Treatment fidelity (or integrity), defined as the extent to which a therapist faithfully implements manualized intervention procedures, is an increasingly important area in psychotherapy research. While most interest centers on associations between fidelity and outcome, recent studies of therapeutic “responsiveness” suggest that client characteristics such as problem severity or case difficulty might help to explain how competently a therapist applies a given manualized intervention. This poster reports on a study investigating this possibility in the Brief Strategic Family Therapy (BSFT) protocol, CTN-0014.

Results found that the fidelity with which community therapists implemented BSFT was responsive to case difficulty, with youth problem severity predicting compromised fidelity more than the quality of family interaction. In particular, youth with relatively severe externalizing problems appeared to pull specific kinds of off-model therapist behavior, and this may imply directions for training (or inoculating) family therapists who work with this difficult population. Another implication is that research using treatment fidelity ratings as a proxy independent variable should account for possible responsiveness effects related to case difficulty.

Related protocols: CTN-0014-A-1

Abstract:

Cultural differences in normative family functioning have long interested family theorists and therapists. Of particular interest is the possibility that the adaptive significance of structural family systems patterns such as enmeshment, parent-child role reversal, and cross-generation coalitions varies by culture. For example, parent-child coalitions may be less associated with child problems in Hispanic cultural groups that place more emphasis on extended kinship ties than does the dominant nuclear-family culture, or role reversal may be more problematic in cultures that emphasize respect for authority and tradition along with intergenerational bonds. The present study examined data from CTN-0014 (“Brief Strategic Family Therapy for Adolescent Drug Abusers”) to look at ethnic differences in structural family systems patterns during a family interaction task across samples of Hispanic, African American, and White families with a substance-using adolescent. Then, the cultural-variant hypothesis was testing through an examination of ethnicity as a possible moderator of associations between observed structural family systems dynamics and adolescent substance use severity. Results provide tentative support for a cultural variant perspective on structural family relations, at least regarding substance-using Hispanic adolescents. Such a perspective may provide meaningful implications for therapy with families from different cultural backgrounds.

Related protocols: CTN-0014-A-1

Abstract:

Although deficits in adolescent self-regulation (ASR) correlate with a variety of youth problems, including adolescent substance abuse, research has focused more on trait-like aspects of ASR than on the social contexts in which it occurs. Structural family systems theory suggests that the immediate context of family interaction may be especially relevant to an adolescent’s ability to self-regulate in specific social situations. Of particular interest is the structural systems hypothesis that compromised ASR reflects specific anomalies of the generation boundary between parents and children (e.g., role reversal, disengagement, cross-generation triangles). Using data from protocol CTN-0014, “Brief Strategic Family Therapy (BSFT) for Adolescent Drug Abusers,” the researchers aimed to correlate observer ratings of self-regulation by adolescent substance users with independent ratings of structural family systems patterns during video-recorded family interaction tasks. A secondary aim was to compare ASR observed during actual family interaction to trait measures of ASR based on adolescent and parent reports.

Results showed that adolescents regulate themselves best when their family functions well as a group. Self-regulation of attention, emotion, and behavior by substance-using adolescents during family interaction assessment tasks correlated with specific relationship patterns relevant to structural family systems theory, though not always in ways the theory predicted. Dispositional (trait) assumptions predominant in the literature may distract attention from current, contextual influences on adolescent self-regulation.

Related protocols: CTN-0014-A-1

Abstract:

Demand-withdraw interaction, a problematic pattern in which one person demands a change from another who resists or withdraws, occurs in both marital and parent-child dyads. In the treatment domain, intriguing evidence of a parallel demand-withdraw process comes from a study of couple therapy for alcohol men, where a wife-demand/husband-withdraw pattern predicted poor response to a high-demand therapeutic intervention. This study, an ancillary investigation of data from protocol CTN-0014, “Brief Strategic Family Therapy (BSFT) for Adolescent Drug Abusers,” extends this parallel-process idea to family therapy for adolescent drug users. Researchers hypothesized that adolescents entrenched in parent-demand/adolescent-withdraw (PD/AW) interaction before treatment began would show poorer substance use outcomes if they engaged in parallel therapist-demand/adolescent-withdraw interaction during family therapy. Results suggest that attending to these parallel demand-withdraw processes (parent/adolescent and therapist/adolescent) may be useful in clinical work with families of substance-using adolescents. In particular, an inadvertent replication of ineffective parent behavior within the therapeutic system may undermine the prospect of positive youth outcomes. Case conceptualization and treatment planning for families exhibiting high levels of PD/AW interaction may benefit from consideration of how the therapist can best maintain balanced alliances and avoid a high-demand stance toward the target adolescent.

Related protocols: CTN-0014-A-1

Abstract:

This presentation begins with an update on the CTN-0014 platform study, “Mediators and Moderators of BSFT for Adolescent Drug Use.” Previous research on BSFT, a family therapy based on structural family systems theory, has focused mainly on outcomes, with little attention to how the treatment actually works or for whom it might be the most beneficial. Using protocol CTN-0014 as a platform, the authors tested hypotheses about mediators and moderators of BSFT. The study found within-treatment associations between BSFT fidelity and outcome, with minority participants accounting for most of these associations. Associations between BSFT fidelity and observed family change also varied by ethnicity, with significant correlations appearing for minority families, but not whites. Unfortunately, the study also found that the modal quality of BSFT was considerably less than ideal — most of the cases reviewed by the investigators featured BSFT that was considered less than adequate. As fidelity is at the heart of good psychosocial intervention trials, good treatment effectiveness research, and replicable dissemination, the fact that establishing and maintaining high fidelity was very difficult in this trial warrants further examination.

The presentation ends with reflections on future directions for the CTN, including ways to elevate the study of mechanisms, focus on moderators at both the case and organizational level, study therapist development to maximize fidelity, and have centrally organized but independently conducted trials across sites.

Related protocols: CTN-0014, CTN-0014-A-1