Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination

The effects of multisystemic therapy (MST) in treating violent and chronic juvenile offenders and their families in the absence of ongoing treatment fidelity checks were examined. Across 2 public sector mental health sites, 155 youths and their families were randomly assigned to MST versus usual juvenile justice services. Although MST improved adolescent symptomology at posttreatment and decreased incarceration by 47% at a 1.7-year follow-up, findings for decreased criminal activity were not as favorable as observed on other recent trials of MST. Analyses of parent, adolescent, and therapist reports of MST treatment adherence, however, indicated that outcomes were substantially better in cases where treatment adherence ratings were high. These results highlight the importance of maintaining treatment fidelity when disseminating complex family-based services to community settings.     

A randomized controlled trial of a peer support intervention targeting antiretroviral medication adherence and depressive symptomatology in HIV-positive men and women.

Objective: To determine the efficacy of a peer-led social support intervention involving support groups and telephone contacts compared with standard clinical care to enhance antiretroviral medication adherence. Design: Randomized controlled trial with follow-up. Participants were 136 HIV-positive indigent mainly African American and Puerto Rican men and women recruited from an outpatient clinic in the Bronx, New York. The 3-month intervention was delivered by other HIV-positive clinic patients trained in addressing barriers to adherence and sensitively providing appraisal, spiritual, emotional, and informational adherence-related social support. Main outcome measures: Medical chart-abstracted HIV-1 RNA viral load, antiretroviral adherence according to electronic drug monitoring and participant self-report, and social support and depressive symptomatology. All assessments conducted at baseline, 3 months, and 6 months. Results: Intent-to-treat and as-treated analyses indicated no between-conditions intervention effects on the primary outcome of HIV-1 RNA viral load or any of the secondary outcomes at immediate postintervention or follow-up. Post hoc analyses within the intervention condition indicated greater intervention exposure was associated with higher self-reported adherence, higher social support, and lower depressive symptomatology at follow-up, even after controlling for baseline adherence. Conclusion: Null findings, consistent with the limited literature on efficacious highly active antiretroviral therapy (HAART) adherence interventions, may be due to insufficient exposure to the intervention, its low intensity, or the nature of the sample-a heterogeneous HAART-experienced group of patients with high levels of substance use and multiple other competing stressors. Overall, findings highlight the need for more comprehensive and intensive efforts to battle nonadherence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A controlled smoking cessation trial for substance-dependent inpatients.

Smoking treatment for newly recovering drug and alcohol-dependent smokers in a residential rehabilitation program was examined. The randomly assigned conditions (n?=?50 each) were multicomponent smoking treatment (MST), MST plus generalization training of smoking cessation to drug and alcohol cessation (MST+G), or usual care (UC). Fifty participants who declined smoking treatment (treatment refusers) also were studied. Both treatment conditions achieved continuous smoking abstinence rates (MST: 12%. MST+G: 10%, at 12-month follow-up) that were significantly higher than in the UC condition (0%). The MST condition had a continuous drug and alcohol abstinence rate that was significantly higher than that of the MST+G condition (40% vs. 20% at 12-month follow-up) although neither differed significantly from that of the UC condition (33%). These results support the feasibility of smoking treatment for this population and provide information regarding appropriate treatment components. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Unique and common mechanisms of change across cognitive and dynamic psychotherapies.

The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multisystemic Treatment: A Meta-Analysis of Outcome Studies.

Multisystemic treatment (MST) is a family- and home-based therapeutic approach that has been found to be effective in treating antisocial youths and that has recently been applied to youths with serious emotional disturbances. In light of the increasing dissemination of MST, this review examines the effectiveness of MST by quantifying and summarizing the magnitude of effects (treatment outcomes) across all eligible MST outcome studies. Included in a meta-analysis were 7 primary outcome studies and 4 secondary studies involving a total of 708 participants. Results indicated that across different presenting problems and samples, the average effect of MST was d = .55; following treatment, youths and their families treated with MST were functioning better than 70% of youths and families treated alternatively. Results also showed that the average effect of MST was larger in studies involving graduate student therapists (i.e., efficacy studies; d = .81) than in studies with therapists from the community (i.e., effectiveness studies; d = .26). In addition, MST demonstrated larger effects on measures of family relations than on measures of individual adjustment or peer relations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An investigation of systemic conceptualizations of parent-child coalitions and symptom change.

Two important theoretical assumptions of family therapy were examined: (a) Child behavior problems are associated with cross-generational coalitions, and (b) treatment of these coalitions using family therapy leads to decreases in individual symptomatology. Ss were 45 delinquent adolescents assigned to multisystemic therapy (MST) or individual therapy and 16 well-adjusted adolescents. Pretreatment and posttreatment assessments included measures of observed family relations and self-reported symptoms. Cross-generational coalitions were more evident in families of delinquents vs. families of well-adjusted adolescents. In addition, changes in adolescent and paternal symptoms in the MST group were linked with changes in marital relations. Implications for systemic conceptualizations of symptom maintenance and change are highlighted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Studies on the efficacy of child psychoanalysis.

This article summarizes 3 studies that evaluated the psychoanalytic psychotherapeutic treatment of diabetic children and adolescents with grossly abnormal blood glucose profiles necessitating repeated admissions to hospital. Study 1 used time series analysis to demonstrate that improvements in control were predicted by unconscious themes emerging in the analytic material. Study 2 compared the effect of psychotherapeutic treatment with that of minimal psychological intervention in 2 well-matched groups (n?=?11). Patients in the treatment group were offered psychoanalytic psychotherapy 3–4 times per week on the hospital ward. The intervention was highly effective in improving the diabetic control of the children, and this improvement was maintained at 1-yr follow-up. Study 3 used single-case experimental design to demonstrate the marked effect of psychotherapeutic help on growth in diabetic children with short stature. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Targeting of soybean-derived sterylglucoside liposomes to liver tumors in rat and mouse models

A cross-sectional multicentre study was conducted in 165 French diabetic children aged 7-13 y and their parents. A standardized scale (FACES III) was used to determine if family cohesion and adaptability (i) differed in diabetic children's families, as compared to other families; (ii) were related to an adherence measure; or (iii) were related to metabolic control. More diabetic families than comparison families fell into the categories of disengaged with low levels of cohesion, and rigid with low levels of adaptability. Scores of cohesion and adaptability were significantly and positively correlated with both children's and parents' adherence scores, but not with HbA1c levels. Children whose families were characterized as rigidly disengaged had a significantly greater number of hypoglycaemias and six times as many episodes of ketoacidosis than the other diabetic children. Not only in adolescents, but also in families of diabetic children, family-centred interventions are needed to improve compliance and to prevent acute metabolic complications.     

The effects of manual-based training on treatment fidelity and outcome: A review of the literature on adult individual psychotherapy.

The authors examine training issues related to the use of treatment manuals in psychotherapy outcome research. In particular, they examine methodological considerations such as the operationalization of manual-based training, trainer effects, therapist variables that mediate training, issues related to experimental design, and the choice and definition of appropriate dependent variables. The research literature indicates that manual-based training can produce technical adherence. Improvements in treatment competence were seen within, as opposed to across, cases. Researchers have been unable to draw strong links between treatment fidelity and patient outcomes. The review concludes that the limited focus on training studies in the manual-based treatment field compromises conclusions drawn from psychotherapy outcome research that relies on manuals to ensure a uniform delivery of the experimental variable. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multisystemic therapy: Bridging the gap between university- and community-based treatment.

This article proposes, within the context of discouraging findings from child psychotherapy literatures, 2 theory- and empirically based explanations for the emergent success of multisystemic therapy (MST) when implemented in community settings as well as for MST's favorable long-term effects on serious antisocial behavior in adolescents. First, MST may have demonstrated success in community settings because it explicitly bridges the gap between university-based psychotherapy studies and their community-based counterparts (J. R. Weisz & B. Weiss, 1993). Second, although MST is based on a social-ecological model of behavior, its favorable cross-setting and temporal outcomes may exemplify the successful use of several active behavioral generalization strategies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beyond brand names of psychotherapy: Identifying empirically supported change processes.

There is considerable debate about which empirical research methods best advance clinical outcomes in psychotherapy. The prevailing tendency has been to test treatment packages using randomized, controlled clinical trials. Recently, focus has shifted to considering how studying the process of change in naturalistic treatments can be a useful complement to controlled trials. Clinicians self-identifying as psychodynamic treated 17 panic disorder patients in naturalistic psychotherapy for an average of 21 sessions. Patients achieved statistically significant reductions in symptoms across all domains. Rates of remission and clinically significant change as well as effect sizes were commensurate with those of empirically supported therapies for panic disorder. Treatment gains were maintained at 6-month follow-up. Intensive analysis of the process of the treatments revealed that integrative elements characterized the treatments: Adherence to cognitive-behavioral process was most characteristic, adherence to interpersonal and psychodynamic process, however, was most predictive of positive outcome. Specific process predictors of outcome were identified using the Psychotherapy Process Q-Set. These findings demonstrate how process research can be used to empirically validate change processes in naturalistic treatments as opposed to treatment packages in controlled trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Vitamin E modifies neither fructosamine nor HbA1c levels in poorly controlled diabetes

OBJECTIVE: To examine the effects of vitamin E on total serum protein glycation (fructosamine), hemoglobin glycation (HbA1c), and serum levels of glucose, total cholesterol, triglycerides, LDL-C, HDL-C, apolipoprotein A1 and apolipoprotein B. MATERIAL AND METHODS: Sixty poorly controlled diabetic patients were randomly assigned to receive either 1200 mg/day of vitamin E or identical placebo capsules during a two month period following a double blind cross-over design with a four week wash-out period between regimens. RESULTS: Seven patients were excluded from the study because of reasons not related to the medication. In the remaining 53 patients, the levels of serum glucose, fructosamine, HbA1c, total cholesterol, HDL-C, LDL-C, Apo A1 and Apo B did not vary significantly with vitamin E as compared with placebo. CONCLUSIONS: No significant effects of vitamin E on any of the parameters evaluated were observed in poorly controlled diabetic patients.     

The impact of perceived interpersonal functioning on treatment for adolescent depression: IPT-A versus treatment as usual in school-based health clinics.

Objective: Aspects of depressed adolescents’ perceived interpersonal functioning were examined as moderators of response to treatment among adolescents treated with interpersonal psychotherapy for depressed adolescents (IPT-A; Mufson, Dorta, Moreau, & Weissman, 2004) or treatment as usual (TAU) in school-based health clinics. Method: Sixty-three adolescents (12–18 years of age) participated in a clinical trial examining the effectiveness of IPT-A (Mufson, Dorta, Wickramaratne, et al., 2004). The sample was 84.1% female and 15.9% male (mean age = 14.67 years). Adolescents were 74.6% Latino, 14.3% African American, 1.6% Asian American, and 9.5% other. They came primarily from low-income families. Adolescents were randomly assigned to receive IPT-A or TAU delivered by school-based mental health clinicians. Assessments, completed at baseline and at Weeks 4, 8, and 12 (or at early termination), included the Hamilton Rating Scale for Depression (Hamilton, 1967), the Conflict Behavior Questionnaire (Robin & Foster, 1989), and the Social Adjustment Scale–Self-Report (Weissman & Bothwell, 1976). Results: Multilevel modeling indicated that treatment condition interacted with adolescents’ baseline reports of conflict with their mothers and social dysfunction with friends to predict the trajectory of adolescents’ depressive symptoms over the course of treatment, controlling for baseline levels of depression. The benefits of IPT-A over TAU were particularly strong for the adolescents who reported high levels of conflict with their mothers and social dysfunction with friends. Conclusions: Replication with larger samples would suggest that IPT-A may be particularly helpful for depressed adolescents who are reporting high levels of conflict with their mothers or interpersonal difficulties with friends. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diabetic ketoacidosis associated with cocaine use

BACKGROUND: Multiple risk factors for diabetic ketoacidosis (DKA) have been described, including omission of insulin therapy and clinical conditions known to increase counterregulatory hormones. Recently, substance abuse has been identified in patients with DKA. We observed many cases of DKA in cocaine users, although the association between cocaine use and DKA has not been well described in the medical literature. METHODS: We performed a retrospective case-control study of admissions for DKA in cocaine users and non-user controls in an urban teaching hospital from January 1, 1985, to December 31, 1994. RESULTS: We identified 720 adult admissions for DKA. Twenty-seven cocaine users accounted for 102 admissions (14% of all DKA admissions). The users were compared with 85 nonuser controls who had 154 DKA admissions. Cocaine users had more admissions for DKA (mean, 3.78 vs 1.81; P = .03). Cocaine users were less likely than controls to have an intercurrent illness identified as a precipitating factor for DKA (14.7% vs 33.1%; P<.001) and were more likely to have missed taking insulin prior to admission (45.1% vs 24.7%; P<.001). Although cocaine users had higher serum glucose levels on admission (32.9 mmol/L [593.4 mg/dL] vs 29.5 mmol/L [531.1 mg/dL]; P =.03), no differences in intensity of illness or treatment outcome were detected. CONCLUSIONS: In this preliminary study, cocaine use was found in a significant number of adults admitted with DKA and was associated with more frequent omission of insulin therapy and the absence of precipitating systemic illness. Either because of its association with insulin therapy omission or its effects on counterregulatory hormones, cocaine use should be considered a risk factor for DKA, particularly in patients with multiple admissions.     

Videoconferencing-based family counseling for rural teenagers with epilepsy: Phase 1 findings.

Objective: Assess the effects of videoconferencing-based counseling on the psychosocial functioning of rural teenagers with epilepsy. Setting: University and rural communities. Participants: Twenty-two teenagers with epilepsy and their parents. Interventions: Six sessions of home-based video counseling, home-based speakerphone counseling, or office-based counseling. Main Outcome Measures: Problem severity and frequency, Social Skills Rating System, modified Working Alliance Inventory, and treatment adherence. Results: Teenagers and parents reported significant reductions in both problem severity and frequency across all 3 conditions from pre- to post-6th session to the 6-month follow-up. Parents reported significant increases in prosocial behaviors from pre- to post-6th session to follow-up. In contrast, both parents and teachers reported no change in problem behaviors over time. No differences in adherence were found across the 3 modalities. Overall therapeutic alliance was high but varied as a function of family member and treatment. Conclusions: Mode of delivery did not influence initial treatment outcomes or adherence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment preferences affect the therapeutic alliance: Implications for randomized controlled trials.

The influence of treatment preferences on the development of the therapeutic alliance was investigated. Seventy-five patients were followed while participating in a randomized controlled trial comparing supportive-expressive psychotherapy with sertraline or pill placebo in the treatment of major depressive disorder. Therapeutic alliance was assessed before treatment and at the 3rd, 5th, and 9th weeks of treatment. Among patients initially preferring psychotherapy, those receiving psychotherapy experienced increases in their alliance over time, whereas those receiving active medication or placebo experienced decreases. Among patients preferring pharmacotherapy, there were no differences in alliance development whether they received psychotherapy, active medication, or placebo. These relations were observed even when controlling for symptom severity. Thus, the congruence of patients' treatment preference and the treatment that they ultimately received influenced the development of the therapeutic alliance. Because alliance is a robust predictor of outcome, treatment preferences may need to be carefully considered in randomized controlled trial settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical supervision in treatment transport: Effects on adherence and outcomes.

This nonexperimental study used mixed-effects regression models to examine relations among supervisor adherence to a clinical supervision protocol, therapist adherence, and changes in the behavior and functioning of youths with serious antisocial behavior treated with an empirically supported treatment (i.e., multisystemic therapy [MST]) 1 year posttreatment. Participants were 1,979 youths and families treated by 429 clinicians across 45 provider organizations in North America. Four dimensions of clinical supervision were examined. Mixed-effects regression model results showed that one dimension, supervisor focus on adherence to treatment principles, predicted greater therapist adherence. Two supervision dimensions, Adherence to the Structure and Process of Supervision and focus on Clinician Development, predicted changes in youth behavior. Conditions required to test hypothesized mediation by therapist adherence of supervisor adherence effects on youth outcomes were not met. However, direct effects of supervisor and therapist adherence were observed in models including both of these variables. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety.

Objective: The study examined the relative efficacy of online (NET) versus clinic (CLIN) delivery of cognitive behavior therapy (CBT) in the treatment of anxiety disorders in adolescents. Method: Participants included 115 clinically anxious adolescents aged 12 to 18 years and their parent(s). Adolescents were randomly assigned to NET, CLIN, or wait list control (WLC) conditions. The treatment groups received equivalent CBT content. Clinical diagnostic interviews and questionnaire assessments were completed 12 weeks after baseline and at 6- and 12-month follow-ups. Results: Assessment at 12 weeks post-baseline showed significantly greater reductions in anxiety diagnoses and anxiety symptoms for both NET and CLIN conditions compared with the WLC. These improvements were maintained or further enhanced for both conditions, with minimal differences between them, at 6- and 12-month follow-ups. Seventy-eight percent of adolescents in the NET group (completer sample) no longer met criteria for the principal anxiety diagnosis at 12-month follow-up compared with 80.6% in the CLIN group. Ratings of treatment credibility from both parents and adolescents were high for NET and equivalent to CLIN. Satisfaction ratings by adolescents were equivalent for NET and CLIN conditions, whereas parents indicated slightly higher satisfaction ratings for the CLIN format. Conclusions: Online delivery of CBT, with minimal therapist support, is equally efficacious as clinic-based, face-to-face therapy in the treatment of anxiety disorders among adolescents. This approach offers a credible alternative to clinic-based therapy, with benefits of reduced therapist time and greater accessibility for families who have difficulty accessing clinic-based CBT. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Randomized controlled trial of motivational enhancement therapy with nontreatment-seeking adolescent cannabis users: A further test of the teen marijuana check-up.

Cannabis use adversely affects adolescents and interventions that are attractive to adolescents are needed. This trial compared the effects of a brief motivational intervention for cannabis use with a brief educational feedback control and a no-assessment control. Participants were randomized into one of three treatment conditions: Motivational Enhancement Therapy (MET), Educational Feedback Control (EFC), or Delayed Feedback Control (DFC). Those who were assigned to MET and EFC were administered a computerized baseline assessment immediately following randomization and completed assessments at the 3- and 12-month follow-up periods. Participants in the DFC condition were not assessed until the 3-month follow-up. Following the completion of treatment sessions, all participants were offered up to four optional individual treatment sessions aimed at cessation of cannabis use. The research was conducted in high schools in Seattle, Washington. The participant s included 310 self-referred adolescents who smoked cannabis regularly. The main outcome measures included days of cannabis use, associated negative consequences, and engagement in additional treatment. At the 3-month follow-up, participants in both the MET and EFC conditions reported significantly fewer days of cannabis use and negative consequences compared to those in the DFC. The frequency of cannabis use was less in MET relative to EFC at 3 months, but it did not translate to differences in negative consequences. Reductions in use and problems were sustained at 12 months, but there were no differences between MET and EFC interventions. Engagement in additional treatment was minimal and did not differ by condition. Brief interventions can attract adolescent cannabis users and have positive impacts on them, but the mechanisms of the effects are yet to be identified. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Benefit finding, affective reactions to diabetes stress, and diabetes management among early adolescents.

Objective: To examine whether benefit finding was associated with better adjustment among adolescents with diabetes by buffering negative affective reactions to diabetes stress and by promoting positive affective reactions. Design: Early adolescents aged 10–14 with Type 1 diabetes (n = 252) described recent diabetes stressors, affective reactions, and perceived coping effectiveness. They also completed measures of benefit finding, depressive symptoms, and adherence. Metabolic control (i.e., HbA1c) was obtained from medical records. Main Outcome Measures: The main outcome measures were perceived coping effectiveness, depressive symptoms, adherence, and HbA1c. Results: Benefit finding was associated with lower depressive symptoms, higher perceived coping effectiveness and better adherence, and with higher positive as well as negative affective reactions to diabetes stress. Benefit finding interacted with negative affective reactions to predict depressive symptoms and HbA1c. Negative affective reactions to stress were associated with poorer adjustment among those with low benefit finding, but were unrelated or more weakly related to poor adjustment among those with high benefit finding. Positive affective reactions did not mediate associations between benefit finding and any outcome. Conclusions: Consistent with a stress-buffering process, benefit finding may be a resource that buffers the disruptive aspects of negative affective reactions to stress for adolescents' diabetes management. (PsycINFO Database Record (c) 2011 APA, all rights reserved)