Disclosures. Learning Objectives. Treating Adolescent Substance Abuse with Behavioral Family Therapies: Two Evidence- Based Examples

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1 Treating Adolescent Substance Abuse with Behavioral Family Therapies: Two Evidence- Based Examples Melisa D. Rowland, M.D. Associate Professor Family Services Research Center Department of Psychiatry & Behavioral Sciences Medical University of South Carolina Charleston, SC Disclosures Source Consultant Advisory Board AACAP Annie E. Casey Stock of Equity >$10,000 Speakers Bureau Research Support X Honorarium for this talk or meeting X Expenses Related to This talk or meeting X Other Honorarium National Institute on Drug Abuse X Multi Systematic Therapy Services Inc. X Learning Objectives At the conclusion of this presentation, participants should: Understand the empirical bases for using behavioral family therapies to address adolescent substance abuse; Be familiar with research supporting the use of Multisystemic Therapy (MST) and Family Behavior Therapy (FBT) to treat adolescent substance abuse; and Be generally familiar with the MST and FBT models and their respective clinical approaches to treating adolescent substance abuse. 9/16/00 1

2 The Two Evidence-Based Interventions: Multisystemic Therapy (MST) & Family Behavior Therapy (FBT) Overview Research supporting family-based treatment strategies The MST model: MST Outcomes MST Clinical Foundations MST Case example The FBT model: FBT Outcomes FBT Clinical Foundations Research on Determinants of Adolescent Substance Use Disorders Individual Factors other antisocial behaviors low self-esteem low social conformity psychiatric symptomatology positive expectancies genetic loading Family factors ineffective management/discipline low warmth high conflict parental drug use parental mental health problems 1 National Institutes of Health. (2006). State-of-the-science conference statement: Preventing violence and other health-risking, social behaviors in adolescents, October Journal of Abnormal Child Psychology, 34, Sheidow, A. J., & Henggeler, S. W. (in press). Multisystemic Therapy with Substance Using Adolescents: A Synthesis of the Research. In N. Jainchill (Ed.), Understanding and Treating Adolescent Substance Use Disorders. Kingston, NJ: Civic Research Institute. 9/16/00 2

3 Research on Determinants of Adolescent Substance Use Disorders II Peers Association with substance using peers Association with prosocial peers School IQ, achievement, commitment to achieve Neighborhood Disorganized High crime 1 National Institutes of Health. (2006). State-of-the-science conference statement: Preventing violence and other health-risking, social behaviors in adolescents, October Journal of Abnormal Child Psychology, 34, Sheidow, A. J., & Henggeler, S. W. (in press). Multisystemic Therapy with Substance Using Adolescents: A Synthesis of the Research. In N. Jainchill (Ed.), Understanding and Treating Adolescent Substance Use Disorders. Kingston, NJ: Civic Research Institute. Causal Models of Delinquency & Drug Use Condensed Longitudinal Model Family Low Parental Monitoring Low Affection Delinquent High Conflict Peers School + Low School Involvement Poor Academic Performance + Prior Delinquent Behavior Delinquent Behavior Elliott, D. S. (1994). Youth Violence: An Overview. Boulder, CO: University of Colorado, Center for the Study and Prevention of Violence, Institute of Behavioral Science. + + Clear Evidence Determinants of adolescent substance use are: Complex Multi-determined Occur in Ecological Contexts 9/16/00 3

4 MST: Mechanisms for Change MST treatment effects on antisocial behavior & substance abuse, mediated by: Family cohesion Family monitoring Affiliation with deviant peers Huey, Henggeler, Brondino, & Pickrel (2000). Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and improving family and peer functioning. Journal of Consulting and Clinical Psychology, 68, MST: Multisystemic Therapy MST Substance Abuse Outcomes Cited as evidence-based practice by: National Institute on Drug Abuse NREPP SAMHSA s National Registry of Evidencebased Programs and Practices Center for Substance Abuse Treatment Center for Substance Abuse Prevention Early MST Substance Use Outcomes Two Randomized Trials with Serious Juvenile Offenders. In comparison with control youths, MST achieved greater: Henggeler, Melton, & Smith (1992) 1 Pre-post reductions in self-reported alcohol and marijuana use Borduin et al. (1995) 2 Reductions in substance-related arrests at 4-year follow-up (4% for MST vs. 16% for individual therapy) Schaeffer & Borduin (2005) 3 greater reductions in substance-related arrests at 14-year follow-up (64% decrease) 1 Henggeler, S.W., Melton, G.B., & Smith, L.A. (1992). Family preservation using Multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology, 60, Borduin, C.M., Mann, B.J., Cone, L.T., Henggeler, S.W., Fucci, B.R., Blaske, D.M., & Williams, R.A. (1995). Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 63, Schaeffer, C.M., & Borduin, C.M. (2005). Long-term follow-up to a randomized clinical trial of multisystemic therapy with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology, 73 (3), /16/00 4

5 Randomized Trial 118 Substance Abusing/Dependent Offenders MST vs. Community Treatment (Henggeler et al., 1999) 1 Substance Use Greater post-treatment reductions for MST Favorable Treatment Effects at 4-Year Follow-Up 2 - violent criminal behavior (.15 versus.57 arrests per year) - higher rates of marijuana abstinence (55% versus 28% [based on urine screens]) 1 Henggeler, S.W., Pickrel, S.G., & Brondino, M.J. (1999). Multisystemic treatment of substance abusing and dependent delinquents: Outcomes, treatment fidelity, and transportability. Mental Health Services Research. 1, Henggeler, S.W., Clingempeel, W.G., Brondino, M.J., Pickrel, S.G. (2002). Four-year follow-up of Multisystemic therapy with substance-abusing and substance-dependent juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry, 41 (7), Developing More Specific Treatment for Substance Abuse Within MST Integrating Contingency Management (CM) Techniques A community reinforcement plus vouchers approach: Treating cocaine addiction, Budney & Higgins, 1998 First used with caregivers of MST youths in treatment Then modified for youths Caregivers involved with all aspects of treatment Budney, A. J., & Higgins, S. T. (1998). A community reinforcement plus vouchers approach: Treating cocaine addiction. Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Juvenile Drug Court Study 161 juvenile offenders meeting DSM-IV criteria for substance abuse or dependence Randomized to: Family court and treatment as usual (TAU) Drug court and TAU Drug court and MST Drug court and MST with contingency management 12 month follow-up outcomes Henggeler, S.W., Halliday-Boykins, C.A., Cunningham, P.B., Randall, J., Shapiro, S.B., Chapman, J.E., (2005). Juvenile drug court: enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology, 34(4), /16/00 5

6 Juvenile Drug Court Study Form-90 Standardized Score Composites Family Court Drug Court Drug Court + MST/CM Pretreatment 4 Months 12 Months Assessment Time Point Henggeler, S.W., Halliday-Boykins, C.A., Cunningham, P.B., Randall, J., Shapiro, S.B., Chapman, J.E., (2005). Juvenile drug court: enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology, 34(4), Juvenile Drug Court Study Percent Postive Cannabis Urine Drug Screens Drug Court Drug Court + MST/CM Pretreatment - 4 Months 4 Months - 12 Months Henggeler, S.W., Halliday-Boykins, C.A., Cunningham, P.B., Randall, J., Shapiro, S.B., Chapman, J.E., (2005). Juvenile drug court: enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology, 34(4), What is MST? Master s level home-based therapists Trained in empirically-based treatments Working with all contexts within which the youth is embedded to effect improvement in functioning Supervised by doctoral level clinicians Closely monitored with an extensive quality assurance/improvement protocol 9/16/00 6

7 Home-Based Model of Service Delivery Low therapist caseloads (4-6 families) 24 hour/7 day availability of therapist 60 to 100 hours of direct therapist-family contact over 4-5 months Focuses on families as the solution Therapists work in teams with significant clinical and organizational support MST Quality Assurance System Organizational Context Manualized Manualized Supervisor Therapist Youth/ Family Supervisory Adherence Measure Therapist Adherence Measure Manualized Manualized MST Consultants/ MST Institute Internet communication Person to Person communication The Clinical Process of MST Case Example Joanne 9/16/00 7

8 MST: A Case Example Joanne -16 year old white female referred to Department of Juvenile Justice for runaway/burglary - under influence ETOH runaway x 3 this year polysubstance abuse Attention Deficit Disorder (ADD) Past psychiatric history psychiatric hospital 3 years prior, OD pills 2nd suicide attempt 1 year, ER h/o antidepressants and stimulants Joanne ETOH Sx Prp Grandparents? Father SF ADHD Florida d. x 5 years 25 Anxiety -Paxil Mom 35 Dave - boyfriend 18 Liza 16 Joanne Ecological Models Community Neighborhood School Peers Family Child 9/16/00 8

9 Desired Outcomes of Key Participants Mom - Joanne to go to school, be safe, be happy, off probation Joanne - to get out of 9th grade, get along with mom, get a job Liza - Joanne to get off probation Dave - Joanne to stop stressing mom out, mom to get help for nerves, Joanne to behave and go to school Overarching Goals Joanne will refrain from drug use as evidenced by random weekly urine drug screen Joanne will attend and actively participate in school/vocational placement Joanne will follow mom s rules as evidenced by no run away, family member reports Joanne will refrain from self-injurious behaviors such as unprotected sex, threatening to harm self or others Key Behaviors ETOH/ Drug Use Sexual Behavior Running/ Illegal 9/16/00 9

10 Initial Conceptualization Permissive Parenting Anxiety ETOH/ Drug Use Deviant Peers Sexual Behavior Running/ Illegal Poor School Performance M s anxiety disorder Guilt Permissive Parenting M was poorly parented Broader Conceptualization M s knowledge Anxiety No prosocial Hard to change Deviant Peers M s skills ETOH/ Drug Use Older than classmates Sexual Behavior Running/ Illegal School not invested A.D.D. Anxiety School Performance Repeated Failure Interventions - Caregiver Engage, assess fit, set joint goals Knowledge - parenting Skills - *help apply Facilitate treatment of Mother s anxiety disorder Cognitive Behavioral Therapy (CBT) of Mother s role reversal Mother taught to do self management plan with Joanne around drugs & sex Mother administer and consequate urine drug screen/breath 9/16/00 10

11 Interventions - Youth Engage, assess fit, set joint goals Functional analysis of drugs, sex, running triggers, thoughts, feelings, consequences Self management plan (with Mother assisting) Urine drug screen/breathalyzer Medications for anxiety and ADD Medical evaluation/treatment - STD risks CBT for anxiety symptoms Interventions - Peers Parental monitoring Mother to know peers Mother to call peers parents Mother to provide consequences Time, access, negative peers and sister Time with appropriate peers Change school, part-time job Interventions - Family Parental monitoring of sibling interaction Limit sister s involvement, rules for sister Boyfriend s support of Mother s parenting Family rules, structure, communication Mother s social support Interventions - School Work with school/youth/caregiver to set appropriate attainable goals Mother s involvement in Joanne s education Change to GED program 9/16/00 11

12 FBT: Family Behavior Therapy FBT Substance Abuse Outcomes Cited as evidence-based practice by: National Institute on Drug Abuse NREPP SAMHSA s National Registry of Evidencebased Programs and Practices Support for FBT Combined Samples - Adult & Adolescent Drug Abusers Study 1: Azrin, McMahon et al. (1994) 1 82 subjects, random assignment: FBT vs. non-directive treatment Non-directive: 20% drug free at 12 months FBT: 65% drug free at 12 months, school/employment, parental satisfaction, mood, ETOH, institutional days Study 2: Azrin, Acierno et al. (1996) 2 74 subjects, FOLLOW-UP STUDY: FBT vs. non-directive treatment Non-directive: no decrease at 6 months FBT: 73% drug free at 6 months, school/employment, ETOH 1 Azrin. N. H., McMahon, P. T., Donohue, B., Besalel, V. A., Lapinski, K. J., & Kogan, E. S. (1994). Behavior therapy for drug abuse: A controlled treatment outcome study. Behavior Research and Therapy, 32, Azrin, N. H., Acierno, R., Kogan, E. S., Donohue, B., Besalel, V. A., & McMahon, P. T. (1996). Follow-up results of supportive versus behavioral therapy for illicit drug use. Behavior Research and Therapy, 34, Support for FBT Adolescent Drug Abusers Study 3: Azrin, Donohue et al. (1994) 1 26 youth drug users, random assignment: FBT vs. Supportive treatment Supportive: 9% drug free at 6 months FBT: 73% drug free at 6 months, school/employment, youth-care giver relationship satisfaction, depression, ETOH, conduct disorder Study 4: Azrin, Donohue et al. (2001) 2 56 youth dual Conduct Disorder & Substance Abuse, random assign.: FBT vs. Indiv. Prob. Solv. 6 months BOTH GROUPS significant: drug use, youth-care giver relationship satisfaction, conduct disorder, mood 1 Azrin, N. H., Donohue, B., Besalel, V. A., Kogan, E. S., & Acierno, R. (1994). Youth drug abuse treatment: A controlled Outcome study. Journal of Child & Adolescent Substance Abuse, 3, Azrin, N. H., Donohue, B., Teichner, G. A., Crum, T., Howell, J., & DeCato, L. A. (2001). A controlled evaluation and description of individual-cognitive problem solving and family-behavior therapies in dually diagnosed conduct-disordered and substancedependent youth. Journal of Child & Adolescent Substance Abuse, 11, /16/00 12

13 Family Behavior Therapy (FBT) Conceptualizes drug use - strong inherent primary reinforcer, enhanced by: Modeling, encouragement, and/or guidance by others Physiological and situational prompts for drug use Low reinforcement for non-drug associated activity Remoteness/uncertainty of negative consequences of drug use Family plays central role in recovery views strong, positive parent-youth relationship as central to treatment Family Behavior Therapy Treatment Goals: Enhance parenting skills & relationship Enhance motivation Enhance social relationships & family reinforcement of prosocial behaviors Enhance self-control strategies Facilitate appropriate consequences for drug use or rewards for abstinence Comparison: MST & FBT MST Social-Ecological & Behavioral Home-based model 4-5 months, 2-3x/week Contingency management Focus on caregiver to effect changes with youth and youth s ecology Quality assurance and fidelity tightly monitored FBT Behavioral & Social- Ecological Office-based model 6-12 months, weekly Contingency management Focus on affective and instrumental parenting Quality assurance and fidelity tightly monitored 9/16/00 13

14 Summary Research on the causes and correlates of adolescent substance abuse support the use of ecologically-friendly, family-based, behavioral treatment approaches Substantial data support the use of MST and FBT, as empirically-grounded, evidence-based approaches to adolescent substance use disorders Other Evidence-Based Family Therapies BSFT Brief Strategic Family Therapy FFT Functional Family Therapy MDFT Multidimensional Family Therapy Waldron, H. B., & Turner (in press). Psychological treatments for adolescent substance abuse: A review and meta analyses. Journal of Clinical Child and Adolescent Psychology. Acknowledgements National Institute of Mental Health National Institute on Drug Abuse Annie E. Casey Foundation 9/16/00 14

15 Thank You Please click continue to proceed to the next section or click the main menu button above to return to the main menu. Continue 9/16/00 15