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Study evaluating whether family therapy for adolescent behavior problems work in the real world.
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Aaron Hogue NIDA Grants R01DA019607, R01DA02
Family Therapy vs. Non-Family Treatment for Adolescent Behavior Problems in Usual Care
© CASAColumbia 2014
Aaron HogueSarah DauberMolly BobekCandace JohnsonEmily LichvarJon Morgenstern
Craig E. Henderson
Study Authors
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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)
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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?
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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?
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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?
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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
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Study Eligibility Criteria: Inclusion
Age 12-18 yearsPrimary caregiver willing to participate in treatment & research
Health insurance accepted by study sites
Willingness to engage in treatment
MH TRACKMet DSM-IV criteria for oppositional defiant disorder (ODD) or conduct disorder (CD)
SU TRACK1. 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
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Study Eligibility Criteria: Exclusion
Mental retardation or developmental disorder
Current psychotic features
Medical/psychiatric illness requiring hospitalization
Suicidal ideation
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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
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Screening
806 referred
433 screened
298 eligible
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298 eligible
205 baselined & randomized: 104 RFT; 101
TAU
193 completed at least one FU:
95 RFT; 98 TAU
Enrollment & Follow Up
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% 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
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% of sample
Study Track 63% MH37% SU
87%Oppositional Defiant DisorderConduct 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
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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)
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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)
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Evidence of Implementation Fidelity
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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)
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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
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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
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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
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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
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Apply the Templateand Your Layouts Could Look Great
Outcome Analyses
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Study Findings: Treatment Attendance
Client attended at least one session• RFT: 74%• TAU: 79%
Average number of sessions attendedRFT: 11.6 (SD=9.9)TAU: 13.3 (SD=10.2)
No differences between conditions
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Analytics Procedures Used to Test Clinical Outcomes
Latent growth curve modeling3-, 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)
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Clinical Outcomes: Externalizing Symptoms
Caregiver Report• Overall declines in
aggression, oppositionality, conduct problems
• No between-condition differences
Adolescent Report• Overall declines in
aggression, oppositionality, conduct problems
• RFT produced larger effects
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Clinical Outcomes: Internalizing Symptoms
Caregiver Report• Overall declines in
anxiety, depression, somatic problems
• No between-condition differences
Adolescent Report• Overall declines in
anxiety, depression, somatic problems
• RFT produced larger effects
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Clinical Outcomes: Delinquency
MH Track• Overall declines in
delinquency: proportion any act, total # acts
• No between-condition differences
SU Track• Overall declines in
delinquency: proportion any act, total # acts
• RFT larger effects for total # acts
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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
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Brief Conclusions
Both RFT and TAU promoted significant gains in multiple problem areas
RFT Outperformed TAU for5 out of 12 outcomes
Effect sizes for RFT (small to moderate)comparable to effects reported in meta-analyses of efficacy studies for manualized FTs
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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)
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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
© CASAColumbia 2014
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.)
© CASAColumbia 2014
© CASAColumbia 2014
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.