Multidimensional Family Research Articles

INCANT: a transnational randomized trial of Multidimensional Family Therapy versus treatment as usual for adolescents with cannabis use disorder

BackgroundIn 2003, the governments of Belgium, France, Germany, the Netherlands and Switzerland agreed that there was a need in Europe for a treatment programme for adolescents with cannabis use disorders and other behavioural problems. Based on an exhaustive literature review of evidence-based treatments and an international experts meeting, Multidimensional Family Therapy (MDFT) was selected for a pilot study first, which was successful, and then for a joint, transnational randomized controlled trial named INCANT (INternational CAnnabis Need for Treatment).Methods/designINCANT is a randomized controlled trial (RCT) with an open-label, parallel group design. This study compares MDFT with treatment as usual (TAU) at and across sites in Brussels, Berlin, Paris, The Hague and Geneva. Assessments are at baseline and at 3, 6, 9 and 12 months after randomization. A minimum of 450 cases in total is required; sites will recruit 60 cases each in Belgium and Switzerland, and a maximum of 120 each in France, Germany and the Netherlands.Eligible for INCANT are adolescents from 13 through 18 years of age with a cannabis use disorder (dependence or abuse), with at least one parent willing to take part in the treatment. Randomization is concealed to, and therefore beyond control by, the researcher/site requesting it. Randomization is stratified as to gender, age and level of cannabis consumption.Assessments focus on substance use; mental function; behavioural problems; and functioning regarding family, school, peers and leisure time.For outcome analyses, the study will use state of the art latent growth curve modelling techniques, including all randomized participants according to the intention-to-treat principle.INCANT has been approved by the appropriate ethical boards in Belgium, France, Germany, the Netherlands, Switzerland, and the University of Miami Miller School of Medicine. INCANT is funded by the (federal) Ministries of Health of Belgium, Germany, the Netherlands, Switzerland, and by MILDT: the Mission Interministerielle de Lutte Contra la Drogue et de Toximanie, France.DiscussionUntil recently, cannabis use disorders in adolescents were not viewed in Europe as requiring treatment, and the co-occurrence of such disorders with other mental and behavioural problems was underestimated. This has changed now.Initially, there was doubt that a RCT would be feasible in treatment sectors and countries with no experience in this type of study. INCANT has proven that such doubts are unjustified. Governments and treatment sites from the five participating countries agreed on a sound study protocol, and the INCANT trial is now underway as planned.Trial registrationISRCTN51014277

Multidimensional Family Therapy

Background: Multidimensional family therapy is the most researched family based intervention for adolescent substance abuse. Research and coverage: Funded continuously since 1985 in a series of controlled trials, process studies, economic analyses, and implementation studies, MDFT has achieved positive outcomes at post treatment and at various follow-up periods at one year and beyond when compared to a variety of active treatments, including cognitive behavior therapy, group counseling, multifamily groups, as well as in comparisons against services as usual. MDFT is a treatment system rather than a one size fits all model, having been adapted for testing and implementation in a variety of U.S. locations and in a multinational controlled trial in Europe over the past 5 years (Berlin, Paris, Brussels, The Hague, and Geneva). Studies have tested MDFT in juvenile justice settings such as drug courts, detention centers, residential treatment, as well as in outpatient treatment offered in drug and juvenile justice outpatient settings.

Supplemental Material for Effectiveness of Multidimensional Family Therapy With Higher Severity Substance-Abusing Adolescents: Report From Two Randomized Controlled Trials

Supplemental Material for Effectiveness of Multidimensional Family Therapy With Higher Severity Substance-Abusing Adolescents: Report From Two Randomized Controlled Trials

Le cannabis chez l’adolescent : prise en charge par les familles

Cannabis is the most frequently used illegal drug in France. In 2007, the average age for a first use was 15.1 years. Most teenagers will limit their use to a few experiences or controlled use. However, for those who do become dependent, the lapse between the first use and dependence is brief (approximately 18 months) with an average of 28 months compared to tobacco (3–5 years) and alcohol (5–9 years). In light of this brief delay, it is crucial to quickly recognize adolescents who have problem cannabis use and to educate parents to warning signs and to teach them how to efficiently discuss the subject with their teenager. Multidimensional Family Therapy, Cognitive and Behavioral Family Therapy and Brief Strategic Family Therapy have shown their efficacy in clinical trials. Improving family dynamics represents not only a motivational opportunity to help the adolescent to adhere to drug dependence treatment, but may also facilitate reintegration into a drug-free social environment and maintenance in a drug-free existence. Family interventions have been shown to be even more effective when community family assistance relations (social workers, educational counselors) are optimized. Family therapy should also be combined with personal empowerment and life planning interventions which enable the adolescent to increase his self-esteem through scholastic and professional achievement.

Drug Abuse by Adolescents: General Considerations

1. Ximena Sanchez-Samper, MD* 2. John R. Knight, MD* 1. *Center for Adolescent Substance Abuse Research, Children's Hospital Boston, Boston, Mass After completing this article, readers should be able to: 1. Discuss current trends in adolescent substance use and the specific substances used most commonly among 8th, 10th, and 12th graders. 2. Identify risk and protective factors, including genetic and environmental correlates, for the initiation of substance use in adolescents. 3. Discuss the most common concomitant mental health disorders and how they can affect the course of diagnosis and treatment for substance abuse. 4. Delineate the variety of treatment options available. 5. Describe the role of the pediatrician in educating patients and families on substance abuse prevention; performing screening and initial assessments; and providing support, brief counseling, or referrals for in-depth treatment. Adolescence is a time of physical, emotional, and psychological maturation as well as a period of searching for independence and experimentation. One area of experimentation associated with adolescence is substance use. (1) Although many adolescents experiment with drugs and alcohol from time to time without enduring problems, those who develop the disorders of substance abuse and dependence make substance use a major public health concern. The Monitoring the Future Study (MTFS) is a nationwide survey measuring smoking, drinking, and illicit drug use among nearly 50,000 8th, 10th, and 12th graders in more than 400 secondary schools in the United States each year. (2)(3) According to the 2006 overview of findings from the MTFS, approximately one fifth (21%) of today's 8th graders, more than one third (36%) of 10th graders, and nearly half (48%) of all 12th graders reported using an illicit drug at least once during their lifetimes. Despite a minimum legal age requirement to purchase alcohol, 6% of 8th graders, 19% of the 10th graders, and 30% of the 12th graders self-reported drunkenness during the month prior to being interviewed. (2)(3) Among the problems experienced by adolescents who use alcohol and drugs are …

Multidimensional Family Therapy HIV/STD Risk‐Reduction Intervention: An Integrative Family‐Based Model for Drug‐Involved Juvenile Offenders

Drug and juvenile justice involved youths show remarkably high rates of human immunodeficiency virus (HIV)/sexually transmitted disease (STD) risk behaviors. However, existing interventions aimed at reducing adolescent HIV risk behavior have rarely targeted these vulnerable young adolescents, and many approaches focus on individual-level change without attention to family or contextual influences. We describe a new, family-based HIV/ STD prevention model that embeds HIV/STD focused multifamily groups within an adolescent drug abuse and delinquency evidence-based treatment, Multidimensional Family Therapy (MDFT). The approach has been evaluated in a multisite randomized clinical trial with juvenile justice involved youths in the National Institute on Drug Abuse Criminal Justice Drug Abuse Treatment Studies (www.cjdats.org). Preliminary baseline to 6-month outcomes are promising. We describe research on family risk and protective factors for adolescent problem behaviors, and offer a rationale for family-based approaches to reduce HIV/STD risk in this population. We describe the development and implementation of the Multidimensional Family Therapy HIV/STD risk-reduction intervention (MDFT-HIV/ STD) in terms of using multifamily groups and their integration in standard MDFT and also offers a clinical vignette. The potential significance of this empirically based intervention development work is high; MDFT-HIV/STD is the first model to address largely unmet HIV/STD prevention and sexual health needs of substance abusing juvenile offenders within the context of a family-oriented evidence-based intervention.

Multidimensional family therapy for young adolescent substance abuse: Twelve-month outcomes of a randomized controlled trial.

Research has established the dangers of early onset substance use for young adolescents and its links to a host of developmental problems. Because critical developmental detours can begin or be exacerbated during early adolescence, specialized interventions that target known risk and protective factors in this period are needed. This controlled trial (n = 83) provided an experimental test comparing multidimensional family therapy (MDFT) and a peer group intervention with young teens. Participants were clinically referred, were of low income, and were mostly ethnic minority adolescents (average age = 13.73 years). Treatments were manual guided, lasted 4 months, and were delivered by community agency therapists. Adolescents and parents were assessed at intake, at 6-weeks post-intake, at discharge, and at 6 and 12 months following treatment intake. Latent growth curve modeling analyses demonstrated the superior effectiveness of MDFT over the 12-month follow-up in reducing substance use (effect size: substance use frequency, d = 0.77; substance use problems, d = 0.74), delinquency (d = 0.31), and internalized distress (d = 0.54), and in reducing risk in family, peer, and school domains (d = 0.27, 0.67, and 0.35, respectively) among young adolescents.

Parenting Practices as Mediators of Treatment Effects in an Early-Intervention Trial of Multidimensional Family Therapy

Background: Contemporary intervention models use research about the determinants of adolescent problems and their course of symptom development to design targeted interventions. Because developmental detours begin frequently during early-mid adolescence, specialized interventions that target known risk and protective factors in this period are needed. Methods: This study (n = 83) examined parenting practices as mediators of treatment effects in an early-intervention trial comparing Multidimensional Family Therapy (MDFT), and a peer group intervention. Participants were clinically referred, low-income, predominantly ethnic minority adolescents (average age 14). Assessments were conducted at intake, and six weeks after intake, discharge, and at 6 and 12 months following intake. Results: Previous studies demonstrated that MDFT was more effective than active treatments as well as services as usual in decreasing substance use and improving abstinence rates. The current study demonstrated that MDFT improves parental monitoring—a fundamental treatment target—to a greater extent than group therapy, and these improvements occur during the period of active intervention, satisfying state-of-the-science criteria for assessing mediation in randomized clinical trials. Conclusions and Scientific Significance: Findings indicate that change in MDFT occurs through improvements in parenting practices. These results set the foundation for examining family factors as mediators in other samples.

Practitioner review: adolescent alcohol use disorders: assessment and treatment issues.

Alcohol use disorders in adolescents are associated with significant morbidity and mortality. Over the past decade, there has been a burgeoning of research on adolescent alcohol use disorders. A summary of the alcohol assessment tools is provided, and randomized studies reviewed and synthesized to provide an overview of state of the art knowledge of treatment of adolescent alcohol use disorders. Animal models of addiction are also briefly reviewed, and the value of translational research approaches, using findings from basic studies to guide the design of clinical investigations, is also highlighted. Comorbidity is the rule, not the exception in adolescent alcohol use disorders. Comprehensive assessment of psychiatric and other substance use disorders, trauma experiences, and suicidality is indicated in this population to optimize selection of appropriate clinical interventions. In terms of available investigated treatments for adolescents with alcohol use disorders, Multidimensional Family Therapy and group administered Cognitive Behavioral Therapies have received the most empirical support to date. There is a paucity of research on pharmacological interventions in this patient population, and no firm treatment recommendations can be made in this area. Given the high rate of relapse after treatment, evaluation of combined psychosocial and pharmacological interventions, and the development of novel intervention strategies are indicated.

Transformation of the California Mental Health System: Stakeholder-Driven Planning as a Transformational Activity

This study describes strategies developed by California counties to transform their mental health systems under the 2004 Mental Health Services Act (MHSA). This voter initiative places a 1% tax on annual incomes over $1 million; tax monies are earmarked to transform county-operated mental health services into systems that are oriented more toward recovery. MHSA implementation itself can be considered "transformational" by balancing greater standardization of mental health service delivery in the state with a locally driven planning process. A qualitative content analysis of the three-year plans submitted by 12 counties to receive funds under MHSA was conducted to identify common themes, as well as innovative approaches. These 12 (out of 58) counties were chosen to represent both small and large counties, as well as geographic diversity, and they represent 62.3% of the state population. This analysis showed that the state guidelines and local planning process generated consistency across counties in establishing full-service partnerships with a "whatever it takes" approach to providing goal-directed services and supports to consumers and their families. There was, however, little convergence around the specific strategies to achieve this vision, reflecting both the local planning process and a relative lack of clear policy and guidance on evidence-based practices. There are many obstacles to the successful implementation of these ambitious plans. However, the state-guided, but stakeholder-driven, transformation in California appears to generate innovative approaches to recovery-oriented services, involve consumers and family members in service planning and delivery, and build community partnerships that create new opportunities for consumers to meet their recovery goals.

Transformation of the California Mental Health System: Stakeholder-Driven Planning as a Transformational Activity

Transformation of the California Mental Health System: Stakeholder-Driven Planning as a Transformational Activity

Treating adolescent drug abuse: a randomized trial comparing multidimensional family therapy and cognitive behavior therapy

To examine the efficacy of two adolescent drug abuse treatments: individual cognitive behavioral therapy (CBT) and multidimensional family therapy (MDFT). A 2 (treatment condition) x 4 (time) repeated-measures intent-to-treat randomized design. Data were gathered at baseline, termination, 6 and 12 months post-termination. Analyses used latent growth curve modeling. Community-based drug abuse clinic in the northeastern United States. A total of 224 youth, primarily male (81%), African American (72%), from low-income single-parent homes (58%) with an average age of 15 years were recruited into the study. All youth were drug users, with 75% meeting DSM-IV criteria for cannabis dependence and 13% meeting criteria for abuse. Five outcomes were measured: (i) substance use problem severity; (ii) 30-day frequency of cannabis use; (iii) 30-day frequency of alcohol use; (iv) 30-day frequency of other drug use; and (v) 30-day abstinence. Both treatments produced significant decreases in cannabis consumption and slightly significant reductions in alcohol use, but there were no treatment differences in reducing frequency of cannabis and alcohol use. Significant treatment effects were found favoring MDFT on substance use problem severity, other drug use and minimal use (zero or one occasion of use) of all substances, and these effects continued to 12 months following treatment termination. Both interventions are promising treatments. Consistent with previous controlled trials, MDFT is distinguished by the sustainability of treatment effects.

THE EFFECTS OF ETHNICITY, FAMILIES AND CULTURE ON ENTREPRENEURIAL EXPERIENCE: AN EXTENSION OF SUSTAINABLE FAMILY BUSINESS THEORY

Entrepreneurs have been traditionally epitomized as rugged individuals garnering creative forces of innovation and technology. Applying this traditional, limited, and narrow view of entrepreneurship to ethnic firm creation and growth is to ignore or discount core cultural values of the ethnic contexts in which these firms operate. It is no longer possible to depend solely on human capital theory and household characteristic descriptions to understand the complex and interdependent relationships between the ethnic-owning family, its firm, and the community context in which the firm operates. This paper addresses the complex dynamic of ethnic firms with three purposes: (a) to provide a cultural context for the three ethnic groups composing the National Minority Business Owner Study; (b) to extend the Sustainable Family Business Theory, a dynamic, behaviorally-based, multi-dimensional family firm theory, by clarifying how it accommodates ethnic firm complexities within their cultural context, and (c) to derive implications for research, education and consulting with worldwide applications.

Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems.

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed.

When the Levee Breaks: Treating Adolescents and Families in the Aftermath of Hurricane Katrina

Hurricane Katrina brought to the surface serious questions about the capacity of the public health system to respond to community-wide disaster. The storm and its aftermath severed developmentally protective family and community ties; thus its consequences are expected to be particularly acute for vulnerable adolescents. Research confirms that teens are at risk for a range of negative outcomes under conditions of life stress and family disorganization. Specifically, the multiple interacting risk factors for substance abuse in adolescence may be compounded when families and communities have experienced a major trauma. Further, existing service structures and treatments for working with young disaster victims may not address their risk for co-occurring substance abuse and traumatic stress reactions because they tend to be individually or peer group focused, and fail to consider the multi-systemic aspects of disaster recovery. This article proposes an innovative family-based intervention for young disaster victims, based on an empirically supported model for adolescent substance abuse, Multidimensional Family Therapy (MDFT; Liddle, 2002). Outcomes and mechanisms of the model's effects are being investigated in a randomized clinical trial with clinically referred substance-abusing teens in a New Orleans area community impacted by Hurricane Katrina.

Evidence-Based Psychosocial Treatments for Adolescent Substance Abuse

This review synthesized findings from 17 studies since 1998 regarding evaluation of outpatient treatments for adolescent substance abuse. These studies represented systematic design advances in adolescent clinical trial science. The research examined 46 different intervention conditions with a total sample of 2,307 adolescents. The sample included 7 individual cognitive behavior therapy (CBT) replications (n = 367), 13 group CBT replications (n = 771), 17 family therapy replications (n = 850) and 9 minimal treatment control conditions (n = 319). The total sample was composed of approximately 75% males, and the ethnic/racial distribution was approximately 45% White, 25% Hispanic, 25% African American, and 5% other groups. Meta-analysis was used to evaluate within-group effect sizes as well as differences between active treatment conditions and the minimal treatment control conditions. Methodological rigor of studies was classified using Nathan and Gorman (2002) criteria, and treatments were classified using criteria for well-established and probably efficacious interventions based on Chambless et al. (1996). Three treatment approaches, multidimensional family therapy, functional family therapy, and group CBT emerged as well-established models for substance abuse treatment. However, a number of other models are probably efficacious, and none of the treatment approaches appeared to be clearly superior to any others in terms of treatment effectiveness for adolescent substance abuse.

Multidimensional Family Therapy for Adolescent Alcohol Abusers

SUMMARY Multidimensional Family Therapy (MDFT) has been empirically supported in a series of randomized clinical trials over 20 years. These studies have demonstrated the potency of MDFT in achieving outcomes across functional areas of the teen's life, including reductions in alcohol-other drug use, behavioral problems, emotional symptoms, negative peer associations, school failure, and deficits within the family. This article describes our approach to refining and testing MDFT with teens who abuse alcohol. Drawing from the research base on risk and protective factors for teen alcohol abuse and relapse patterns, a strong case can be made for using a family-based approach for adolescent alcohol problems. MDFT shows promising preliminary results with teens who have alcohol and marijuana use disorders. Specific change targets within this empirically supported family-based intervention for adolescent alcohol problems are outlined.

Assessing fidelity in individual and family therapy for adolescent substance abuse

This study introduces an observational measure of fidelity in evidence-based practices for adolescent substance abuse treatment. The Therapist Behavior Rating Scale—Competence (TBRS-C) measures adherence and competence in individual cognitive–behavioral therapy and multidimensional family therapy for adolescent substance abuse. The TBRS-C assesses fidelity to the core therapeutic goals of each approach and also contains global ratings of therapist competence. Study participants were 136 clinically referred adolescents and their families observed in 437 treatment sessions. The TBRS-C demonstrated strong interrater reliability for goal-specific ratings of treatment adherence, and modest reliability for goal-specific and global ratings of therapist competence, evidence of construct validity, and discriminant validity with an observational measure of therapeutic alliance. The utility of the TBRS-C for evaluating treatment fidelity in field settings is discussed.

A comparison of spatial discretization schemes for differential solution methods of the radiative transfer equation

A comparison of discretization schemes required to evaluate the radiation intensity at the cell faces of a control volume in differential solution methods of the radiative transfer equation is presented. Several schemes developed using the normalized variable diagram and the total variation diminishing formalisms are compared along with essentially non-oscillatory schemes and genuinely multidimensional schemes. The calculations were carried out using the discrete ordinates method, but the analysis is equally valid for the finite-volume method. It is shown that the S schemes of the genuinely multidimensional family perform quite well, particularly in problems with discontinuous radiation intensity fields. However, they are time consuming, and so they do not always become more attractive regarding the trade-off between accuracy and computational requirements, in comparison with other high-order schemes that, although being less accurate, are also more economical.

Family Response to Adolescence, Youth and Alcohol

SUMMARY This review highlights three aspects of adolescent alcohol use and misuse that have ramifications for families: (a) adolescent disinhibition, (b) substance-specific parenting factors, and (c) non-substance-specific parenting factors. Although there are a great number of adolescent treatment models currently utilized across the country, this review focuses on three integrated family-based treatment models with proven efficacy: (a) Multisystemic Therapy (MST; Henggeler, Schoenwald, Borduin, Rawland, & Cunningham, 1998), (b) Brief Strategic Family Therapy (BSFT; Szapocznik, Hervis, & Schwartz, 2003), and (c) Multidimensional Family Therapy (MDFT; Liddle, 2004; Center for Substance Abuse Treatment [CSAT], 2004). These family-based therapies focus on accurately assessing multiple influences and targeting effective intervention strategies designed to support changes throughout a number of systems that affect and serve to reinforce or support the adolescent's problem behaviors.