Treatment techniques and outcomes in multidimensional family therapy for adolescent behavior problems.

The link between treatment techniques and long-term treatment outcome was examined in an empirically supported family-based treatment for adolescent drug abuse. Observational ratings of therapist interventions were used to predict outcomes at 6 and 12 months posttreatment for 63 families receiving multidimensional family therapy. Greater use of in-session family-focused techniques predicted reduction in internalizing symptoms and improvement in family cohesion. Greater use of family-focused techniques also predicted reduced externalizing symptoms and family conflict, but only when adolescent focus was also high. In addition, greater use of adolescent-focused techniques predicted improvement in family cohesion and family conflict. Results suggest that both individual and multiperson interventions can exert an influential role in family-based therapy for clinically referred adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Efficacy of brief strategic family therapy in modifying Hispanic adolescent behavior problems and substance use.

This study investigated the efficacy of brief strategic family therapy (BSFT) with Hispanic behavior problem and drug using youth, an underrepresented population in the family therapy research literature. One hundred twenty-six Hispanic families with a behavior problem adolescent were randomly assigned to 1 of 2 conditions: BSFT or group treatment control (GC). Results showed that, compared to GC cases, BSFT cases showed significantly greater pre- to post-intervention improvement in parent reports of adolescent conduct problems and delinquency, adolescent reports of marijuana use, and observer ratings and self reports of family functioning. These results extend prior findings on the efficacy of family interventions to a difficult to treat Hispanic adolescent sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist adherence in brief strategic family therapy for adolescent drug abusers.

Objective: 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 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 who received brief strategic family therapy within a multisite effectiveness study. Method: Participants were 480 adolescents (age 12–17) and their family members, who were randomized to the Brief Strategic Family Therapist treatment condition (J. Szapocznik, U. Hervis, & S. Schwartz, 2003) or treatment as usual. The adolescents were mostly male (377 vs. 103 female) and Hispanic (213), whereas 148 were White, and 110 were Black. Therapists were also randomly assigned to treatment condition within agencies. Results: 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. Conclusions: 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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist adherence/competence and treatment outcome: A meta-analytic review.

Objective: The authors conducted a meta-analytic review of adherence–outcome and competence–outcome findings, and examined plausible moderators of these relations. Method: A computerized search of the PsycINFO database was conducted. In addition, the reference sections of all obtained studies were examined for any additional relevant articles or review chapters. The literature search identified 36 studies that met the inclusion criteria. Results: R-type effect size estimates were derived from 32 adherence–outcome and 17 competence–outcome findings. Neither the mean weighted adherence–outcome (r = .02) nor competence–outcome (r = .07) effect size estimates were found to be significantly different from zero. Significant heterogeneity was observed across both the adherence–outcome and competence–outcome effect size estimates, suggesting that the individual studies were not all drawn from the same population. Moderator analyses revealed that larger competence–outcome effect size estimates were associated with studies that either targeted depression or did not control for the influence of the therapeutic alliance. Conclusions: One explanation for these results is that, among the treatment modalities represented in this review, therapist adherence and competence play little role in determining symptom change. However, given the significant heterogeneity observed across findings, mean effect sizes must be interpreted with caution. Factors that may account for the nonsignificant adherence–outcome and competence–outcome findings reported within many of the studies reviewed are addressed. Finally, the implication of these results and directions for future process research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of continuing care adherence on environmental risks, substance use, and substance-related problems following adolescent residential treatment.

The effectiveness of adolescent treatment to reduce substance use has been demonstrated by a number of different literature reviews, yet longer term outcome studies have suggested that continued alcohol and other drug use is common. Participation in continuing care services and reductions in environmental risk factors (e.g., peer substance use or alcohol or drug use in the home) have both been found to be associated with improved posttreatment substance use. The authors conducted Path analysis to examine the experimental direct effect of the Assertive Continuing Care Protocol (S. H. Godley, M. D. Godley, & M. L. Dennis, 2001) on general continuing care adherence following residential treatment and the protocol's indirect effect (via general continuing care adherence) on social and environmental risk factors, as well as subsequent substance use and substance-related problems. Supporting previous findings, the final model indicates that greater adherence to continuing care is associated with reductions in environmental risk, which in turn is associated with reduced adolescent substance use and substance-related problems 9 months after discharge from residential treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist strategies for building involvement in cognitive–behavioral therapy for adolescent depression.

This study examined predictive relations between 9 therapist behaviors and client involvement in manual-guided, cognitive–behavioral therapy for adolescent depression. Analyses included 42 adolescents who met criteria for a depressive disorder (major depressive disorder, dysthymic disorder, or adjustment disorder with depressed mood) and who were treated in school-based clinics. Therapist behaviors hypothesized to promote client involvement were coded from Session 1 audiotapes; client involvement was coded from Session 2. Unlike prior research, the current study examined associations between behaviors and involvement while controlling for initial client resistance to isolate the therapist contribution to involvement. Results show that 3 therapist behaviors from Session 1 (attending to teen’s experience, exploring teen’s motivation, and less structure) predicted greater client involvement in Session 2, controlling for initial resistance. Only exploring motivation and less structure uniquely predicted Session 2 involvement when the 3 behaviors were examined simultaneously. Session 1 therapist behaviors predicted significant variance in involvement at Sessions 2, 4, and 8. Client initial presentation as resistant was associated with more exploring motivation and praising, but initial resistance did not explain associations between therapist behaviors and involvement. Implications for implementing evidence-based treatments are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effectiveness of functional family therapy for youth with behavioral problems in a community practice setting.

The study examined the effectiveness of Functional Family Therapy (FFT), as compared to probation services, in a community juvenile justice setting 12 months posttreatment. The study also provides specific insight into the interactive effects of therapist model specific adherence and measures of youth risk and protective factors on behavioral outcomes for a diverse group of adolescents. The findings suggest that FFT was effective in reducing youth behavioral problems, although only when the therapists adhered to the treatment model. High-adherent therapists delivering FFT had a statistically significant reduction of (35%) in felony, a (30%) violent crime, and a marginally significant reduction (21%) in misdemeanor recidivisms, as compared to the control condition. The results represent a significant reduction in serious crimes 1 year after treatment, when delivered by a model adherent therapist. The low-adherent therapists were significantly higher than the control group in recidivism rates. There was an interaction effect between youth risk level and therapist adherence demonstrating that the most difficult families (those with high peer and family risk) had a higher likelihood of successful outcomes when their therapist demonstrated model-specific adherence. These results are discussed within the context of the need and importance of measuring and accounting for model specific adherence in the evaluation of community-based replications of evidence-based family therapy models like FFT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An adaptive approach to family intervention: Linking engagement in family-centered intervention to reductions in adolescent problem behavior.

This study used Complier Average Causal Effect analysis (CACE; see G. Imbens & D. Rubin, 1997) to examine the impact of an adaptive approach to family intervention in the public schools on rates of substance use and antisocial behavior among students ages 11-17. Students were randomly assigned to a family-centered intervention (N = 998) in 6th grade and offered a multilevel intervention that included (a) a universal classroom-based intervention, (b) the Family Check-Up (selected; T. J. Dishion & K. Kavanagh, 2003), and (c) family management treatment (indicated). All services were voluntary, and approximately 25% of the families engaged in the selected and indicated levels. Participation in the Family Check-Up was predicted by 6th-grade teacher ratings of risk, youth reports of family conflict, and the absence of biological fathers from the youths' primary home. Relative to randomized matched controls, adolescents whose parents engaged in the Family Check-Up exhibited less growth in alcohol, tobacco, and marijuana use and problem behavior during ages 11 through 17, along with decreased risk for substance use diagnoses and police records of arrests by age 18. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trajectories of family management practices and early adolescent behavioral outcomes.

Stage–environment fit theory was used to examine the reciprocal lagged relations between family management practices and early adolescent problem behavior during the middle school years. In addition, the potential moderating roles of family structure and of gender were explored. Hierarchical linear modeling was used to describe patterns of growth in family management practices and adolescents' behavioral outcomes and to detect predictors of interindividual differences in initial status and rate of change. The sample comprised approximately 1,000 adolescents between ages 11 years and 15 years. The results indicated that adolescents' antisocial behaviors and substance use increased and their positive behavioral engagement decreased over time. As adolescent age increased, parental knowledge of their adolescent's activities decreased, as did parental rule making and support. The level and rate of change in family management and adolescent behavioral outcomes varied by family structure and by gender. Reciprocal longitudinal associations between parenting practices and adolescent problem behavior were found. Specifically, parenting practices predicted subsequent adolescent behavior, and adolescent behavior predicted subsequent parenting practices. In addition, parental warmth moderated the effects of parental knowledge and rule making on adolescent antisocial behavior and substance use over time. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Ethnic matching and treatment outcome with Hispanic and Anglo substance-abusing adolescents in family therapy.

This study examined treatment outcomes of 86 highly acculturated Hispanic and Anglo substance-abusing adolescents in functional family therapy, testing the hypothesis that ethnic matching of therapist and client is related to better treatment outcomes for clients. Adolescents reported on their substance use pre- and posttreatment on a timeline follow-back interview. Ethnically matched Hispanic adolescents demonstrated greater decreases in their substance use compared with Hispanic adolescents with Anglo therapists. Ethnic match status was not related to treatment outcome for Anglo clients. Thus, the matching hypothesis was supported for Hispanic clients only. The results underscore the importance of greater ethnic diversity among therapists and better cultural competency training for Anglo therapists. More research is needed on individual differences in the effects of ethnic matching. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment outcomes for adolescent substance abuse at 4- and 7-month assessments.

This randomized clinical trial evaluated individual cognitive-behavioral therapy (CBT), family therapy, combined individual and family therapy, and a group intervention for 114 substance-abusing adolescents. Outcomes were percentage of days marijuana was used and percentage of youths achieving minimal use. Each intervention demonstrated some efficacy, although differences occurred for outcome measured, speed of change, and maintenance of change. From pretreatment to 4 months, significantly fewer days of use were found for the family therapy alone and the combined interventions. Significantly more youths had achieved minimal use levels in the family and combined conditions and in CBT. From pretreatment to 7 months, reductions in percentage of days of use were significant for the combined and group interventions, and changes in minimal use levels were significant for the family, combined, and group interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Training and dissemination of cognitive behavior therapy for depression in adults: A preliminary examination of therapist competence and client outcomes.

Objective: In this study, the authors examined the feasibility and effectiveness of training community therapists to deliver cognitive behavior therapy (CBT) for depression. Method: Participants were therapists (n = 12) and clients (n = 116; mean age = 41 years, 63% women) presenting for treatment of depression at a not-for-profit and designated community mental health center for St. Joseph County, Indiana. The training model included a 2-day workshop followed by 1 year of phone consultations. CBT competence ratings from the Cognitive Therapy Scale were obtained prior to training and at 6 and 12 months posttraining. Two different groups of clients, a treatment-as-usual (TAU) group (n = 74) and a CBT group (n = 42), were compared with respect to decrease in symptoms of depression (assessed with the Beck Depression Inventory) and anxiety (assessed with the Beck Anxiety Inventory). Results: Therapists showed significant increases in total scores from pretraining to 6 months posttraining, increases that were maintained at 12 months. The increase in the total score reflected gains on items that specifically measure CBT skills and structure. Although both TAU and CBT resulted in a significant decrease in depressive symptoms, the CBT clients showed significantly greater change than the TAU clients, F(2, 113) = 53.40, p     

Assessing intervention competence and its relation to therapy outcome: A selected review derived from the outcome literature.

The assessment of intervention competence possesses an obvious relevance for practitioners and clinical scientists alike. It is often assessed as part of the evaluation of treatment integrity in clinical research in general, and in randomized clinical trials (RCTs) in particular. The authors first attempt to add clarity to the concept and better differentiate intervention competence from closely related constructs. Next, the authors review and evaluate the main measures of therapist competence used in RCTs, relying on this conceptual foundation to provide suggestions for future measures. The empirical literature on the relation between therapist competence and clinical outcome is then reviewed. The relation, while positive, is weaker than expected, and factors having a potential bearing on this are discussed. The authors then recommend that new measures be created and that the assessment of limited-domain competence be supplemented by explorations of global competence. Due to the potential ramifications for the field, the authors also recommend that caution be exercised in the task of operationally defining competence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Coparenting, family process, and family structure: Implications for preschoolers' externalizing behavior problems.

This study examined how aspects of triadic-level family interaction relate to preschoolers' externalizing behavior problems. The quality of coparenting, family affective processes, and family structure was assessed at 3 years, and mothers, fathers, and teachers reported on children's externalizing behavior problems at 4 years. High levels of supportive coparenting and more adaptive family structures were associated with fewer externalizing behavior problems, whereas high levels of undermining coparenting and negative affect and less adaptive family structures were associated with more externalizing behavior problems. Moreover, the quality of family affectivity and family structure interacted with coparenting and appeared to influence its effects on the family. This study highlights the importance of focusing on triadic, family-level variables for understanding children's behavior problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change.

Objective: The efficacy of cognitive therapy (CT) for depression has been well established. Measures of the adequacy of therapists' delivery of treatment are critical to facilitating therapist training and treatment dissemination. While some studies have shown an association between CT competence and outcome, researchers have yet to address whether competence ratings predict subsequent outcomes. Method: In a sample of 60 moderately to severely depressed outpatients from a clinical trial, we examined competence ratings (using the Cognitive Therapy Scale) as a predictor of subsequent symptom change. Results: Competence ratings predicted session-to-session symptom change early in treatment. In analyses focused on prediction of symptom change following 4 early sessions through the end of 16 weeks of treatment, competence was shown to be a significant predictor of evaluator-rated end-of-treatment depressive symptom severity and was predictive of self-reported symptom severity at the level of a nonsignificant trend. To investigate whether competence is more important to clients with specific complicating features, we examined 4 patient characteristics as potential moderators of the competence-outcome relation. Competence was more highly related to subsequent outcome for patients with higher anxiety, an earlier age of onset, and (at a trend level) patients with a chronic form of depression (chronic depression or dysthymia) than for those patients without these characteristics. Competence ratings were not more predictive of subsequent outcomes among patients who met (vs. those who did not meet) criteria for a personality disorder (i.e., among personality disorders represented in the clinical trial). Conclusions: These findings provide support for the potential utility of CT competence ratings in applied settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A behavior genetic investigation of adolescent motherhood and offspring mental health problems.

The present study examines the relations between adolescent motherhood and children's behavior, substance use, and internalizing problems in a sample of 1,368 children of 712 female twins from Australia. Adolescent motherhood remained significantly associated with all mental health problems, even when using a quasiexperimental design capable of controlling for genetic and environmental confounds. However, the relation between adolescent motherhood and offspring behavior problems and substance use was partially confounded by family background variables that influence both generations. The results are consistent with a causal relation between adolescent motherhood and offspring mental health problems, and they highlight the usefulness of behavior genetic designs when examining putative environmental risks for the development of psychopathology. The generalizability of these results to the United States, which has a higher adolescent birth rate, is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances.

In this study, the authors examined the role of balance between adolescent-therapist and parent-therapist alliances in the retention of functional family therapy clients. Therapeutic alliances of mothers, fathers, and adolescents were assessed from videotapes of the 1st treatment session for 43 Hispanic and 43 Anglo families. Hispanic families who dropped out before completing the requisite number of sessions were found to have greater imbalance in alliance (parent-adolescent) than those who did complete therapy. However, this finding was not replicated with Anglo families. Results are interpreted in terms of previous research on family-level balanced alliance effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities.

This randomized clinical trial compared the relative efficacy of individual (child) cognitive-behavioral therapy (ICBT), family cognitive-behavioral therapy (FCBT), and a family-based education/support/ attention (FESA) active control for treating anxiety disordered youth ages 7-14 years (M = 10.27). Youth (N = 161; 44% female; 85% Caucasian, 9% African American, 3% Hispanic, 3% other/mixed) with a principal diagnosis of separation anxiety disorder, social phobia, or generalized anxiety disorder and their parents participated. Outcome analyses were conducted using hierarchical linear models on the intent-to-treat sample at posttreatment and 1-year follow-up using diagnostic severity, child self-reports, parent reports, and teacher reports. Chi-square analyses were also conducted on diagnostic status at post and 1-year follow-up. Children evidenced treatment gains in all conditions, although FCBT and ICBT were superior to FESA in reducing the presence and principality of the principal anxiety disorder, and ICBT outperformed FCBT and FESA on teacher reports of child anxiety. Treatment gains, when found, were maintained at 1-year follow-up. FCBT outperformed ICBT when both parents had an anxiety disorder. Implications for treatment and suggestions for research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist behavior as a predictor of black and white caregiver responsiveness in multisystemic therapy.

This study examined whether (a) therapist behaviors thought to enhance family treatment predicted caregiver in-session responses, and (b) caregiver race, racial match between caregiver and therapist, and family financial hardship moderated the relationships between therapist and caregiver behavior. Observers coded caregiver and therapist behavior during one session of multisystemic therapy for substance abusing adolescents. Therapist teaching, focusing on strengths, making reinforcing statements, problem solving, and dealing with practical family needs predicted caregiver engagement and/or positive response, regardless of race, racial match, or financial hardship. Caregiver race, financial hardship, and therapist–caregiver racial match occasionally moderated the relationship between other therapist and caregiver behaviors. Findings suggest both commonalities and differences in how therapist behavior may function to engage caregivers in family treatment, depending on diversity-related factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)