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

Aaron Hogue
NIDA Grants R01DA019607, R01DA02
Family Therapy vs. Non-Family Treatment
for Adolescent Behavior Problems
in Usual Care
© CASAColumbia 2014

Aaron Hogue
Sarah Dauber
Molly Bobek
Candace Johnson
Emily Lichvar
Jon Morgenstern
Craig E. Henderson
Study Authors

Family Therapy is an
Evidence-Based Approach
(EBA) for Adolescent
Behavior Problems
What Are Adolescent
Behavior Problems?
• Conduct problems and
delinquency
• Substance misuse and
abuse
What is Family
Therapy (FT)?
• Intervene directly in
family relationships
• Address key
extrafamilial systems
(“ecological”)
Manualized FT is a
Success Story
• Win or drawn every
research comparison
with other EBAs
• There are several
brand names of
manualized FT:
• Brief Strategic Family
Therapy (BSFT), Functional
Family Therapy (FFT),
Multidimensional Family
Therapy (MDFT),
Multisystemic Therapy (MST)

What are some Barriers to
Adopting Manualized
Family Therapy?
Manualized Family
Therapy is costly
• Contract with model
purveyors
• Need for extensive
training and fidelity
monitoring procedures
• Need to renew
contracts to sustain
certification
Are EBAs superior to
usual care for youth?
• Mixed evidence when
therapists randomized
• EBAs may be less
potent for complex
cases
• Are EBAs already
prevalent in usual
care?

Is “Routine” FT
effective for ABP?
• Strong allegiance to FT in
youth services
• Not yet tested as a
generic approach in usual
care (UC)
• Can FT be a success
without the contracts and
intensive supervision by
outside experts
Evidence based
interventions
• EST = “brand-name”
manualized model
• EBP = generic, modular,
core version of EST
• EBPs are not (yet) widely
tested in routine care
What is “Routine”
Family Therapy?

Study Hypotheses
Is routine FT (RFT)
superior to Treatment
as usual (TAU) in
promoting treatment
attendance?
Will both RFT and
TAU show positive
outcomes:
• Externalizing,
Internalizing
symptoms
• Delinquency:
proportion, # acts
• Substance use:
proportion, # days
Will RFT be superior
to TAU?

Participant Recruitment
Conducted
aggressive
community outreach
• Did not use the
existing clinic referral
streams (not enough
clients)
Referral criteria
• Caregiver willing to
participate in
treatment
• Referral problems
beyond scope of
services at referral site
• Not currently in any
other behavioral
treatment

Study Eligibility Criteria:
Inclusion
Age 12-18 years
Primary caregiver
willing to participate
in treatment &
research
Health insurance
accepted by study
sites
Willingness
to engage in
treatment
MH TRACK
Met DSM-IV criteria
for oppositional
defiant disorder
(ODD) or conduct
disorder (CD)
SU TRACK
1. 1 day alcohol to
intoxication or illegal
drug use in past month
2. Endorse 1 or more DSM
symptoms of SUD
3. Met American Society of
Addiction Medicine
(ASAM) criteria for
outpatient SU treatment

Study Eligibility Criteria:
Exclusion
Mental retardation
or developmental
disorder
Current psychotic
features
Medical/
psychiatric illness
requiring
hospitalization
Suicidal
ideation

Used Intensive Linking
Procedures to Help Families
Enroll in Treatment
Intensive family
systems engagement
Counteract barriers to
enrollment
• Information
• Logistics
• Insurance
Continue through
initial intake

Screening
806
referred
433
screened
298
eligible

298
eligible
205
baselined &
randomized:
104 RFT;
101 TAU
193
completed at
least one FU:
95 RFT;
98 TAU
Enrollment & Follow Up

% of sample
Female 48%
15.4 (1.4)Age (mean/SD)
Hispanic 59%
African American 21%
Multiracial 15%
Single parent household 66%
Caregiver graduated high school 71%
Caregiver employed full or part time 64%
Household income < $15K per year 44%
History of child welfare involvement 51%
Participant Demographics

% of sample
Study Track 63% MH
37% SU
87%Oppositional Defiant Disorder
Conduct Disorder 52%
Attention Deficit Hyperactivity Disorder 74%
Mood Disorder or Dysthymia 42%
Substance Use Disorder 28%
Generalized Anxiety Disorder 17%
Posttraumatic Stress Disorder 17%
More than one disorder 78%
Track & Diagnosis

Study Sites and Therapists
RFT TAU
N Sites 1 5 clinics: Community MH,
Hospital MH, Addictions
Treatment approaches
featured
FT Diverse
N Therapists 15 17
Therapist age range 28-59 25-45
Gender Predominantly
female
Predominantly
female
Race/ethnicity Mostly Hispanic
American
Mostly European
American
Average years experience 3.1 (SD = 4.3) 3.2 (SD = 2.9)

Clinic Intake and Treatment
Attendance Rates
Full Sample RFT TAU
Total N 205 104 101
Completed intake 61% 58% 64%
Attend 1 session 39% 41% 37%
Attend >3 sessions 30% 31% 30%
Sessions attended (avg) 12.4 (10.1) 11.6 (9.9) 13.3 (10.2)

Evidence of
Implementation
Fidelity

Pre-Study Therapist Self-
Report: Proficiency in EBAs
Proficiency score:
Average skill & allegiance
Therapist rated skill
and allegiance to each
of the four EBAs:
CBT, FT, MI, DC (drug
counseling)

Differences in Therapist
Proficiency (RFT vs. TAU)
RFT TAU t p d
N therapists 10 16
FT Proficiency 3.7 (.88) 2.7 (.80) 2.8 .01 1.13
MI Proficiency 2.5 (1.0) 2.5 (1.0) -.08 .94 .03
CBT Proficiency 2.6 (.77) 3.2 (.71) -2.1 .05 .86
DC Proficiency 2.0 (.94) 2.1 (1.2) -.14 .89 .06

Therapists Self-Report of Use
of EBAs During Treatment of
Study Cases: Inventory of
Therapy Techniques (ITT)
Therapist-report:
Measure fidelity to EBAs
for ABP using 5-point
“extensiveness” scale
Item Origins:
Derived from validated
observational fidelity
scales of ESTs
27 Individual
Techniques from 4
Approaches:
CBT, FT, MI, DC

DC MI/CBT FT
RFT 1.18
(.28)
2.31
(.72)
2.68
(.70)
TAU 1.40
(.84)
2.45
(.95)
2.04
(.72)
B (SE);
pseudo-z
NS NS .53 (.19);
2.73*
TAU: CMHCs
(2 clinics)
1.03 (.09) 2.22
(.92)
1.92
(.68)
TAU: Child Psychiatry
(2 clinics)
1.19 (.17) 2.40
(.73)
1.90
(.61)
Differences Between RFT
vs. TAU in Therapist Report
of Using EBAs

Differences Between RFT
vs. TAU in Observer Report
of Using EBAs
MI/CBT FT F-test;
Effect size
RFT (n = 104) 1.6
(.40)
2.0
(.45)
p = .001;
partial η2 = .33
TAU (n = 53) 1.6
(.32)
1.4
(.36)
p = .06;
partial η2 = .07
N = 157

Apply the Template
and Your Layouts Could
Look Great
Outcome
Analyses

Study Findings:
Treatment Attendance
Client attended at
least one session
• RFT: 74%
• TAU: 79%
Average number of
sessions attended
RFT: 11.6 (SD=9.9)
TAU: 13.3 (SD=10.2)
No differences
between conditions

Analytics Procedures Used
to Test Clinical Outcomes
Latent growth
curve modeling
3-, 6-, 12-mo FU
(nested data)
Delinquency and
Substance Use
(non-normal data)
• 2-part models:
Categorical
(any vs. none)
• Continuous (if
occurred)
Externalizing and
Internalizing:
quadratic growth
functions
Covariates,
Study Track
(MH vs. SU)

Clinical Outcomes:
Externalizing Symptoms
Caregiver Report
• Overall declines in
aggression,
oppositionality,
conduct problems
• No between-condition
differences
Adolescent Report
aggression,
oppositionality,
conduct problems
• RFT produced larger
effects

Clinical Outcomes:
Internalizing Symptoms
Caregiver Report
anxiety, depression,
somatic problems
• No between-
condition differences
Adolescent Report
anxiety, depression,
somatic problems
• RFT produced larger
effects

Clinical Outcomes:
Delinquency
MH Track
delinquency:
proportion any act,
total # acts
• No between-
condition differences
SU Track
delinquency:
proportion any act,
total # acts
• RFT larger effects for
total # acts

Clinical Outcomes:
Substance Use
Full Sample
• No overall declines in
substance use
SU Track
• No overall declines in
substance use
• Significant effects for
RFT: proportion any
use, # days use

Brief Conclusions
Both RFT and TAU
promoted significant gains
in multiple problem areas
RFT Outperformed
TAU for
5 out of 12 outcomes
Effect sizes for RFT
(small to moderate)
comparable to effects
reported in meta-analyses
of efficacy studies for
manualized FTs

Study Limitations
Only 1 RFT Site
(However: No
measureable cost
or organizational
advantages for
the RFT site)
Sample NOT
referral as usual
Could not
analyze site
effects
Modest
attendance rates:
(However: Study
rates were
comparable to
routine services)

Study Implications
Routine FT can be
delivered with
fidelity and
effectiveness
in usual care
What are important
differences in
fidelity procedures
within usual care
vs. outside
contracts
FT is widely
endorsed in youth
services, but isn’t
commonly
practiced?
With fidelity?
Need more
research on
EBAs used in
routine care

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

Related References
Hogue, A., Dauber, S., Lichvar, E., Bobek, M., & Henderson, C. E. (in press). Validity of therapist self-report
ratings of fidelity to evidence-based practices for adolescent behavior problems: Correspondence between
therapists and observers. Administration and Policy in Mental Health and Mental Health Services Research.
Hogue, A., Dauber, S., & Henderson, C. E. (2014). Therapist self-report of evidence-based practices in usual
care for adolescent behavior problems: Factor and construct validity. Administration and Policy in Mental Health
and Mental Health Services Research, 41, 126-139.
Hogue, A., & Dauber, S. (2013). Assessing fidelity to evidence-based practices in usual care: The example of
family therapy for adolescent behavior problems. Evaluation and Program Planning, 37, 21-30.
Hogue, A., & Dauber, S. (2013). Diagnostic profiles among urban adolescents with unmet treatment needs:
Comorbidity and perceived need for treatment. Journal of Emotional and Behavioral Disorders, 21, 18-32.
Dauber, S., & Hogue, A. (2011). Profiles of systems involvement in a sample of high-risk urban adolescents
with unmet treatment needs. Children and Youth Services Review, 33, 2018-2026.

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

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (12)

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

Similar to Does family therapy for adolescent behavior problems work in the real world (20)

Recently uploaded

Recently uploaded (20)

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