There can be no doubt that adolescent substance abuse is a public
health problem of considerable national importance (1, 2). The United
States achieves the dubious distinction of having the highest rate of
adolescent drug abuse among the industrialized nations of the world (3,
4). The immediate costs and developmental consequences of adolescent drug
problems on the youth, his or her family, and society are well documented:
school failure, delinquency, motor vehicle accidents, arrests and
incarceration, and increased risk for human immunodeficiency virus (HIV)
and other physical illnesses (5-7). Long-term consequences of drug misuse
include impaired psychological functioning, including mental health
problems, serious criminal involvement, marital problems and divorce, and
job instability (8). Moreover, the consequences of adolescent drug abuse
extend to the next generation (9). Longitudinal studies reveal that
substance-abusing parents show deficiencies in parenting and have children
with drug problems and/or behavioral difficulties as well (cf. 10-12).
Writing about at-risk youths, Dryfoos (13) claims the following:
A new class of "untouchables" is emerging in our inner cities, on the
social fringes of suburbia, and in some rural areas: young people who
are
functionally illiterate, disconnected from school, depressed, prone
to drug
abuse and early criminal activity, and eventually, parents of unplanned
and
unwanted babies. These are the children who are at high risk of never
becoming responsible adults. (p. 72)
INTERVENTION FOUNDATIONS: PSYCHOSOCIAL FACTORS AND DEVELOPMENTAL
PROCESSES ASSOCIATED WITH ADOLESCENT SUBSTANCE ABUSE
Considerable scientific progress has been made in understanding the
causes and correlates of adolescent drug problems. We know a great deal
about the ingredients, sequence, and interactions that predict initial and
increased drug involvement (14), and the clinical usefulness of this
expanded knowledge base has become increasingly apparent (15). Adolescent
substance abuse develops on several, sometimes intersecting, pathways (7),
hence its designation as a multidimensional and multidetermined phenomenon
(16) requiring interventions that address these multiple domains of
functioning (14, 17). The accumulation of empirically based knowledge
yields a new conceptualization of adolescent substance abuse that is more
complex than in previous historical periods (18). Drug problems are now
understood through the filter of one or several theoretical lenses. Social
cognitive factors; psychological functioning, personality, and
temperament; values and beliefs; family factors; peer relationships;
environmental influences such as school and neighborhood; and
sociocultural factors such as norms and media influences have empirical
links to the development and maintenance of adolescent drug abuse (7).
The clinical picture of adolescent drug abuse is as complex as its
etiology. Drug abuse can be conceived both as a stimulus that creates
problems in one or more developmentally important areas and as a response
to past or current life circumstances. Adolescent drug abuse co-occurs
with other clinical problems with alarming frequency. Conduct disorder,
depression, anxiety disorders, sexual acting out, and academic problems
co-occur with adolescent drug problems with significant regularity (19).
Family Factors
Family factors are influential in the genesis and exacerbation as well
as in the protection against adolescent drug abuse and behavioral problems
(20, 21). Parent and sibling substance abuse, parental attitudes that
minimize the dangers of drug use, poor relationships with parents, and
inadequate child-rearing practices are closely linked to adolescent drug
problems (22-24). Several studies have demonstrated the direct effect of
parental monitoring on levels of adolescent substance abuse (25). Parental
monitoring and changes in parenting practices prevent or delay drug
involvement and are related to a decrease in adolescent drug use even
after a pattern has been established (26, 27). One mechanism for this
influence process is the management role of parental monitoring vis-a-vis
the adolescent's peer environment (28). The extent and nature of parental
contact limits an adolescent's access to and opportunity for connection
with antisocial and drug-using peers and contexts not supervised by adults
(28, 29).
Additional aspects of how a positive parent-adolescent relationship
facilitates adaptive developmental outcomes are also becoming apparent. In
one of the largest studies to date on adolescent health, family
relationship variables such as feeling connected to and cared for by one's
parents, high parental expectations about school performance, and parents'
presence and interest in the adolescent's life all were strong predictors
of positive adolescent development (30). Findings from longitudinal
studies demonstrate that problems in family functioning commonly pre-date
the initiation of adolescent problem behaviors (31-34). Taken together,
these findings have established the family's critical role in facilitating
and maintaining developmental outcomes.
Individual Factors
Although family variables have demonstrated their centrality in the
causes and potential solutions for adolescent drug problems, other factors
also contribute to the development and maintenance of adolescent substance
abuse (35). Several longitudinal studies found personality variables, such
as shyness and aggressiveness, predict the development of adolescent drug
problems (36). For example, Shedler and Block (35) found a personality
syndrome marked in interpersonal alienation, poor impulse control, and
manifest emotional distress to characterize teens who were frequent drug
users. Other personality traits, such as high novelty seeking and low harm
avoidance (37), significantly predict early onset of substance use.
Impulsivity and poor emotion regulation in childhood and adolescence are
also correlates of adolescent drug use and abuse (38). An adolescent's
attitudes and beliefs, such as perceived harmfulness and perceptions about
the extensiveness of drug use by same age cohort, have also been found to
be related to the onset and continuation of adolescent substance use (14).
Peer Factors
Strong evidence exists for the direct and indirect influence of peer
relationships on the development and deepening of adolescent substance use
and abuse. Perhaps the most robust finding in this area concerns how
drug-using teenagers associate with teenagers who also use illicit
substances. Longitudinal research has demonstrated that peer affiliations
in adolescence are shaped by a dynamic social, family, and individual
process that includes social stratification, family functioning, and
individual behavioral predispositions (39). How peers influence the
adoption of drug-using attitudes and behaviors is complex. For example,
although rejection by nondeviant and nonantisocial age mates begins in
childhood (40), antisocial and drug-using adolescents are not without
friends. While these friendships tend to be less stable than those between
non-drug-using and nonantisocial peers, real friendships between
antisocial adolescents exist. One characteristic of these relationships is
a negative reciprocal coercion--a tendency to respond to negative
interchanges with an escalating negativity. This process is effective in
teaching new antisocial behaviors and solidifying existing antisocial
beliefs.
Peers are not only instrumental in the antisocial initiation process,
they also provide the context for the systematic escalation of problem
behaviors (41). Using behavioral coding research strategies, Dishion,
Patterson, and Griesler (42) studied the relational patterns of antisocial
boys. This study revealed that connection and positive affect between
adolescent boys is organized around rule-breaking topics (42). These
studies and others using fine-grained process analyses, including those in
the family interaction area (43-45), have particularized problem-producing
processes among teenagers, giving treatment developers rich and
empirically established knowledge to inform intervention design.
Interaction of More Than One Risk Factor
A breakthrough in our understanding of adolescent drug abuse occurred
when studies began to examine multiple factors in relation to each other,
as well as their sequential and dynamic interaction with each other
through time [an excellent example is the psychobiological, maturational
conceptual model by Tarter et al. (46)]. Recent advances have mapped a
process of multidirectional influence among various developmental
contexts, such as self, peer, and family (47). For instance, parenting
behaviors can be understood in terms of factors such as the psychological
functioning of the parent (17) or the different temperament
characteristics of the teenager. Carlo, Roesch, and Melby (48) found that
parents react differently and have different expectations of teens who
are, for example, aggressive or sociable. Moreover, parental responses and
expectations in combination with adolescent temperament led to different
behavioral outcomes for the teenager. In other work, as early theorists
suggested (49, 50), adolescent distress can derive from parental distress
and compound it, and parent distress can derive from adolescent distress
and compound it as well.
In a related vein, Mounts and Steinberg (51) present an ecological
analysis of the interaction of peer and parent influence on adolescent
school functioning and drug use. These researchers found that, if an
adolescent had parents who were less authoritative, the impact of having a
drug-using friend was stronger than with teens whose parents offered more
optimal parenting. Another example of the complex etiological picture that
emerges when we consider multiple risk factors in dynamic relation to each
other is found in the longitudinal research of Brook and colleagues (52).
Family relationship factors and peer relationships were found to be direct
mediators of neighborhood and school effects in the progression of
adolescent drug problems. Adversarial parent-adolescent relationships are
connected to and precede a teen's association with deviant peers (53-55).
Moreover, the passage of time interacts with and predicts increases in
illicit drug involvement as well. The cumulative effect of stressful life
experiences over time can lead to a pronounced escalation of drug use in
adolescence (56).
In sum, given the fact that an adolescent's association with deviant
peers elicits drug use tendencies (57) and the well-documented importance
of family relationship and antisocial peer connections in the development
and exacerbation of deviance, interventions that can change these multiple
and interacting processes are important to develop and test. Research
strongly recommends the level of comprehensive (16, 58), developmentally
sensitive (59) treatments that not only ameliorate symptoms, but also
facilitate protective and prosocial processes, and that these new
therapies be tested according to contemporary, state-of-the-science
criteria (60).
Selection of the Three Treatments
Perhaps nothing is more important in the design of a randomized
clinical trial than the decision concerning which treatments will be
compared (61). The treatment conditions of a controlled trial should
represent commonly used interventions and test the theoretical
underpinnings of a treatment (62). A controlled trial should also reflect
the stage of knowledge development in a field. Above we outlined the
causes and correlates of adolescent drug abuse. This knowledge base,
particularly as it pertains to the contributions made by families and
peers in adolescent health and psychopathology, has informed the selection
of the treatments for the present study. We examined the efficacy of
multidimensional family therapy (MDFT) (63, 64) in reducing adolescent
drug use and associated problems such as delinquent behaviors, school
failure, and maladaptive family functioning by comparing it to two
alternative treatments: adolescent group therapy (AGT) (65) and
multifamily educational intervention (MEI) (66). The two comparison
treatments, group and multifamily educational therapy, were selected
because of the theory-based contrasts they could provide. Briefly, MDFT
and MEI are both family-based interventions that aim to change, among
other things, parenting behaviors and family interactions. However, MDFT
works with one family at a time, and MEI works with several families at
once. MDFT derives from more of a family therapy or psychotherapy
tradition than does MEI, which is both more structured and more
psychoeducationally focused than MDFT. MDFT and AGT, although using vastly
different treatment formats (MDFT uses family and AGT uses adolescent peer
group), both focus on the individual adolescent (e.g., psychosocial
developmental issues [including self-efficacy and social skills]) to a
considerable degree. Finally, both MEI and AGT utilize peer group support
delivered mainly through a semistructured therapeutic group format in
which peer influence is the putative primary change mechanism.
As the most comprehensive treatment in the study, MDFT targeted more of
the known determinants of adolescent substance abuse and other problem
behaviors (see Refs. 67, 68) than either of the comparison treatments.
Although there is considerable discussion on the importance of
comprehensiveness in treating adolescent drug problems, there have been
few empirical tests of this particular factor in accounting for efficacy
(69). We hypothesized that youths who received MDFT would show
significantly greater reduction in drug use, antisocial and delinquent
behaviors, and negative family functioning at termination than youths who
received either of the other two treatments. Moreover, we hypothesized,
again on the basis of the targeting of multiple developmental systems by
MDFT (15), empirically established determinants of dysfunction, and
facilitating protective processes (27, 43), that symptom reduction and
prosocial improvement would be maintained in MDFT subjects at the two
follow-up periods, 6 and 12 months following termination.
In this study, we were interested in testing the effectiveness of drug
abuse treatments that might be stand-alone alternatives to those based on
a chemical dependency philosophy and approach. This interest was not
guided by an ideological bias against chemical dependency or
12-step-focused models, but rather in the scientific quest to test the
influence and limits of treatments that were developed from psychotherapy
rather than drug counseling traditions. A previous comparison of this
nature (psychotherapy and drug counseling treatments) was carried out with
adult cocaine-abusing patients (70).
METHOD
Participants
Eligible participants were adolescents between 13 and 18 years old,
with no history of mental retardation or organic dysfunction, who did not
require inpatient detoxification, and who were using any illegal substance
other than alcohol at least three times per week. Alcohol use could be
greater or less than three times per week. Youths and their families were
referred from the juvenile justice system and secondarily through schools
and health and mental health agencies. To be eligible for the present
study, youths could not be involved in any other form of
psychotherapy-oriented drug treatment or any Alcoholics Anonymous (AA) or
Narcotics Anonymous (NA) treatment at the time of referral. The mean age
of the adolescents was 15.9 years (SD = 1.4), and 80% were male. There
were 51% white, non-Hispanic; 18% African-American; 15% Hispanic; 6%
Asian; and 10% other. Thirty-one percent came from two-parent households,
48% from single-parent households, and 21% from stepfamilies. Youths had
an average of 1.29 siblings. The median yearly family income from all
sources was approximately $25,000. Of the adolescents, 51% were polydrug
users, while 49% were strictly marijuana and alcohol users. Adolescents
had been using drugs for an average of 2.5 years. Reflecting delinquent
behaviors in addition to drug abuse problems, 61% were on juvenile
probation at intake.
Treatment Conditions
Youths were randomly assigned to one of three treatments: MDFT, MEI, or
AGT. Treatment dosage and duration were equalized across the three
intervention groups. Each of the three treatments consisted of a minimum
of 14 and a maximum of 16 weekly sessions, which occurred over a period of
5 to 6 months in a clinic setting.
Multidimensional Family Therapy
MDFT is an outpatient, family-based treatment for adolescent substance
abuse (71). It was influenced by the strong tradition of family therapy
models in the substance abuse field (21, 72, 73). Different versions of
the treatment have been developed and tested in treatment outcome studies
(74). Treatment development goals (e.g., testing the model under different
treatment delivery parameters, such as treatment dose or intensity),
adolescent sample characteristics (e.g., age, comorbid status, gender),
and a variety of scientific questions (e.g., transporting the approach to
regular clinical settings) are among the factors that have led to the
development of different versions and tests of MDFT (75). Treatment
process studies of MDFT have helped to define outcome related within
therapy content themes, family interactional patterns, therapist-family
member interactions, and therapist techniques (27, 43, 76-78).
Developmental psychology and developmental psychopathology have also
significantly influenced the MDFT treatment. MDFT interventions are based
on research-derived knowledge about adolescent and family development and
adolescent drug abuse and problem behavior formation (67, 68). Assessment
and intervention are fully informed by contemporary research on the causes
and correlates of adolescent substance abuse. At the same time, the
established protective factors that can combat the influence of risk- and
dysfunction-producing processes are also used to guide interventions.
Another influence is family systems theory generally and the family
therapies of Minuchin (79) and Haley (80) in particular.
MDFT is a family-based, developmental-ecological, multiple systems
approach (81). It is a comprehensive and multicomponent, stage-oriented
therapy. Treatment addresses the individual characteristics of the
adolescent (e.g., cognitive mediators such as perceptions of the
harmfulness of drugs; emotion regulation processes [drug use as coping or
as a manifestation of distress]), the parent(s) (e.g., parenting
practices, parental stress), and other relevant family members (e.g.,
presence of drug using adults); as well as the interactional patterns
(e.g., emotional disconnection) (82) that link to the development and
continuation of drug use and related problem behaviors.
In the present study, MDFT consisted of 16 total sessions delivered on
a weekly basis in an office-based setting over an average of 5 months.
Individual and family sessions were used throughout, frequently on the
same treatment occasion. Individual sessions with the parent and/or
adolescent might have preceded a family session on any particular day or
evening. Engagement and establishing a foundation for treatment were major
emphases in the first treatment phase (1 month). Establishing multiple
therapeutic alliances with the adolescent, parent(s), other family
members, and even extrafamilial sources of actual or potential influence
was vital in this stage as well (76). Using knowledge of normative and
atypical development, including the generic themes of family life with
teenagers, the therapist explored and crafted content themes that were
personally meaningful to each family member (67, 83). This process helped
the parents and teenager to articulate an agenda and objectives that made
the treatment personally relevant for each of them (77). Individualized
treatment objectives were defined through a negotiation and integration of
these personal agendas with the generic goals of the treatment program.
Examples of generic goals would be the improved functioning of the
teenager in the form of stopping or decreasing drug use and movement from
a drug-using lifestyle to one characterized by prosocial activities and
development-enhancing activities and relationships.
Since MDFT is a therapy of multiple subsystems, a comprehensive,
multisystemic assessment is a critical component of the first phase of
treatment. Each area of the adolescent's life is assessed. The multiple
reports of the adolescent, family members, relatives/extended kin, and
important adults involved with the teenager, including school personnel or
friends of the family, paint a portrait of the teenager's current life
circumstances, as well as the therapy-relevant pieces of his or her
history. By the end of treatment's first 3 to 4 weeks, the therapist has
established relationships with those persons most relevant to the
adolescent. Within three key intervention domains--the adolescent, parent,
and parent-adolescent interaction--the attempt is made to accomplish
particular tasks (e.g., relationship formation, agenda establishment,
definition of and motivation to attempt treatment, renewal of parent's
connection to the adolescent or the teenager to the parent) as
prerequisites to and foundations for the more demanding and stressful
directive behavioral change strategies (42, 84).
The approach builds social competence, prosocial behaviors, antidrug
use attitudes and behaviors, a nondeviant peer network, and more
developmentally facilitative family relationships. To accomplish these
goals, the clinician seeks direct access to the youth's functioning in
multiple domains (e.g., access to the youth's emotional life and thinking
processes, access to interactions with the youth's parents, access to the
youth's parents directly). The approach works aggressively to win the
cooperation of family members (e.g., Ref. 76), who are enlisted in strong
efforts to reorganize the youth's daily environment.
The middle phase of treatment lasts about 2 months, and it addresses,
in a problem-solving way and in a manner that promotes new areas of
functioning, the clinical themes and individualized objectives outlined in
the first month. The treatment format involves individual and family
sessions. Change is facilitated with the adolescent and other family
members at intrapersonal and interpersonal levels, and change in each of
these realms is understood in the context of change in the other. During
individual sessions, the therapist and adolescent work on important
developmental tasks such as decision making and mastery. Encouraging
important aspects of development, the therapist helps the adolescent
acquire new communication skills to express thoughts, feelings, and
experiences. Problem-solving skills that address life stressors are also
taught in an individualized way. Discussions and problem solving
concerning job skills and vocational training or GED (general equivalency
diploma) facilitation are also frequent areas of work during this
treatment phase.
Certain parenting styles and belief systems as they pertain to children
have been shown to be related to adolescent drug abuse, and as such, they
are prime intervention targets. Therapists help parents to examine their
current relationship with their teenager since the quality and tone of
this relationship influence an adult's parenting styles. Parents learn to
distinguish influence from control, and they learn to accept that not
everything can or needs to be changed to have a developmentally
appropriate influence on their child. Compared to the opening phase of
treatment, this phase involves more directive change attempts of family
interactional patterns through the clinical method called enactment (79).
Positive and deleterious aspects of family relationships are expressed
through behavioral interactional patterns or repetitions that are linked
to the development and continuation of dysfunction. Enactment, as a
technique, gives an in vivo picture of existing family relationships and a
technique to shape new kinds of family interactions (81).
Therapists coach parents on new ways of reaching out to their teenagers
(e.g., expressing their concerns about their teen's development, taking a
stand against deviant peers and against drug use). Therapists help
adolescents address the issues that stand between them and their parents.
Sometimes, these are present-focused issues such as conflict over
autonomy, but frequently they involve historically powerful family
disagreements or crises (77). Therapist techniques in this phase are
action oriented rather than reflective. The therapist prompts new
transactional alternatives within the family as well as between the
adolescent and his or her social world. Drug taking is defined in
lifestyle terms, and thus it is the complex of drug taking and the youth's
connection to the antisocial peer network that we seek to help the
adolescent reject and replace with a prosocial lifestyle.
The third phase lasts the final month and involves the transitioning
away from a weekly therapy-involved and focused lifestyle to one that
bridges the new ideas, skills, and behaviors begun in treatment to
real-world environments. Generalization and maintenance of change are
emphasized during this phase, with special focus on articulating for
future use and reference the new ways of thinking, responding, and
interacting.
Multifamily Educational Intervention
The MEI treatment blended features of psychoeducational and multifamily
interventions. Multifamily groups have a strong history in family therapy.
Variations of this approach have been found effective with diverse
clinical problems such as chronic disease and alcoholism (73).
Psychoeducational interventions also have a noteworthy track record with
patients with major mental illness and with their families (85).
The multifamily educational intervention (66) consisted of groups of
three to four families. This treatment was guided by theoretical
principles from family systems and social support theory generally and
from psychoeducational approaches to family intervention in particular.
The intervention format consisted of focused and structured,
content-specific group discussions, didactic presentations that included
handouts, skill-building exercises, individual family problem solving
within a group meeting of several families, and homework assignments.
Intervention content consisted of learning alternative forms of stress
reduction, family and individual risk and protective factors, improving
family organization rules and limit setting, and improving family
communication and problem-solving abilities.
The multifamily groups attempted to facilitate a supportive interfamily
group process. Families were encouraged to help each other and to use
themselves as examples for mutual problem solving. There was a consistent
message of family and personal empowerment in all of the activities. The
peer influence of the group was as useful with adults as with adolescents.
As part of the group social support process, families were encouraged to
bring food to share and to celebrate goals met and changes made during the
course of the program. The group also functioned as an extended family for
single parents or for families that were isolated in the community.
Each 90-minute session was structured in three parts: (a) didactic
presentation (informal and conversational vs. formal lecture) by the
leader, (b) topic-focused intrafamily and/or interfamily group discussion,
and (c) skill-building exercises. Families received workbooks with content
summaries of the session foci and activities. Homework assignments
encouraged the practicing of new skills. The MEI therapist's role was one
of educator and facilitator of inter- and intrafamily communication
processes. Leader presentations focused on the program topic of the week.
The topics reflected research on adaptive family and individual
developmental processes during the adolescent life cycle stage. The nine
topics were
1. Understanding the family as a social system and the family life
cycle
2. Enhancing individual and family strengths
3. Negotiating rules, privileges, and developing effective discipline
4. Promoting household cooperation
5. Understanding emotions in the context of the family
6. Improving problem solving skills
7. Improving communication skills
8. Managing stress
9. Understanding adolescent substance abuse and adolescent development
Family and group discussion focused on learning about the week's topic
and on reviewing the results of homework assignments. According to the
focus and goals of the unit, discussions sometimes involved adolescents
and siblings only, with parents present but only listening. On other
occasions, only parents were involved. Some discussions involved only one
family, while others involved talk among several families. Skill-building
exercises were handled in much the same way as the group discussions.
Skills included learning a model of problem solving, the application of
natural and logical consequences, devising ways to divide household
responsibilities, learning to use "I messages" or make
self-representational statements, and using constructive ways to express
feelings.
In addition to the multifamily groups, individual crisis sessions were
available to families on request of the family or the therapist in the
case of emergencies. These sessions were limited to two sessions per
family in the 16-week period.
Adolescent Group Therapy
Although group treatment for teenagers has not always been effective
(86), and at least one study reports iatrogenic results from a group
intervention for drug-involved youths, evidence for the effectiveness of
group therapy has been found for a variety of adolescent problems (87). In
this study, the group therapy approach was an adaptation of Beck's (88,
89) group therapy model. This intervention is based on phases of group
development, with different therapeutic tasks and goals assigned to each
phase (also see Refs. 90 and 91 for a discussion of the phases of group
therapy with adolescents). The emphasis was on developing individual
social skills such as communication, self-control, self-acceptance, and
problem solving, as well as building social support among group members.
Didactic presentations, group discussions, and group skill-building
exercises were initiated in a decidedly noncoercive manner to establish
participation and trust. Groups of between six and eight adolescents were
led by two therapists for 90 minutes.
Treatment began with two individual family sessions to enlist
cooperation, outline the goals and format of the treatment, and discuss
group rules and procedures. In these family sessions, the therapist tried
to enlist and facilitate parental support of and cooperation in the
treatment. Parents were requested to facilitate actively the adolescent's
attendance at the weekly group sessions. Making verbal reminders,
providing bus or train fare, or driving the teen to group were the most
frequent areas identified by parents as ways they could support the teen's
participation in treatment. The therapists also had an individual meeting
with each teenager to gather personal history information, provide an
introduction to the group therapy process, and initiate the motivation
enhancement procedures believed to be critical to group attendance. An
individual needs assessment was conducted from which the adolescent set
personal goals, and the therapist-adolescent alliance was begun.
Phase 2 of the AGT model had four structured adolescent group therapy
sessions that began with member introductions and discussions of
confidentiality and limit setting. Structured activities facilitated
self-disclosure. Past and current problem areas and
strengths/accomplishments were shared. Phase 2 also included communication
skill-building exercises. When the process was successful, trust among the
adolescents and a group identity had been established by the end of this
phase.
Phase 3 was the skill-building phase. The goal of the structured
activities and homework assignments was to develop the adolescents' social
skills. The content included developing drug refusal, conflict resolution,
and anger management skills; communication and problem solving with peers,
parents, and other adults; clarification and communication in the
affective realm (e.g., anger, assertiveness); and developing prosocial
interests and behaviors. Group support processes (e.g., support for a
drug-free lifestyle), a fundamental hypothesized mechanism of change, were
facilitated in every session, and members received homework assignments to
practice their skills. Reviewing homework assignment results was an
important part of Phase 3 sessions.
Phase 4 emphasized generalization and maintenance of new skills. Skill
behaviors were refined; continued practice of these skills was encouraged;
members assessed their progress; and relapse prevention and termination
issues were discussed.
Therapists
Therapists were nested within each treatment condition--they were
trained and conducted therapy in the modality in which they had the most
expertise and allegiance (92). All therapists had similar levels of
previous experience and educational backgrounds prior to working on this
study. Study therapists were recruited through local professional
organizations and several community clinics. We selected therapists who
were working in community agencies to add to the generalizability of the
study to those practice settings (92). Project therapists worked part time
on the research project and continued to work in their community clinic
positions throughout the study.
The therapists who delivered the treatment were divided evenly between
men and women, and 80% were white, non-Hispanic. There were 80% with
master's degrees, and 20% had doctoral degrees. They had an average of 7
years of experience working with teenagers, 3 years of experience with
adolescent substance abusers, and 6 years working within the therapeutic
modality they delivered in the present study (family therapy, multifamily
therapy, or adolescent group therapy). Each therapist worked with an
average of four cases. Multivariate analyses of variance (MANOVAs)
revealed no significant differences as a function of therapist or of
therapist-by-treatment condition. Hence, there was no therapist-effect
variable included in the evaluation of treatment effects (92).
Treatment Integrity
To ensure that the study results reflect the effects of the three
distinct, manual-guided treatments, all study treatments need a high
degree of internal model consistency (93). To maintain treatment
integrity, each treatment developed a treatment manual and model-specific
training videotapes. The treatment manual was used in the training phase
and throughout treatment.
Supervisors were experts in the particular modality and were principal
developers of the models tested in the study. Close supervision is a well
established aspect of any efficacy study (94, 95), and empirical support
exists for the relationship between adherence to a well-defined treatment
model and clinical outcomes (96). All therapy sessions were videotaped for
supervision and treatment adherence purposes. Supervision methods included
case review, videotape review, and live supervision. Supervision time
averaged 1 hour per week for each therapist throughout the study. Although
no rating scale was used to monitor treatment adherence to the respective
manuals, the close supervision, which included the videotapes of therapy
sessions, prevented drift from the manuals. This process allowed
supervisors to correct deviations from the treatment protocols on a weekly
basis.
Research Procedures
Families who were referred to the study were contacted by telephone and
screened for initial eligibility. They were informed that a 1.5-hour
research assessment would be conducted prior to treatment, immediately
after termination, and again at 6 and 12 months following termination. It
was emphasized that participation was voluntary, and that subjects had the
right to discontinue participation in the research at any time. Research
assistants received 20 hours of initial training and additional ongoing
supervision to standardize data collection procedures and minimize
circumstances that might threaten the validity of the data (e.g.,
client/family resistance, reading problems). The research assistant
explained the general procedures and purpose of the assessment and
obtained written consent prior to the first assessment session.
Outcome Measures
Attrition
Attrition was measured as client-initiated termination after the first
session and before session 14 or refusing to return for the posttreatment
assessment battery.
Drug Use
Multiple sources of information--a standard in substance abuse
treatment research (97)--adolescent self-report, collateral report (parent
report), and urinalysis data were gathered for each adolescent. Using a
structured interview guide that asked about the youth's frequency of drug
use over the prior 30 days, assessors separately interviewed youth and
parents. Information gathered from the interviews and urinalyses reports
were independently reviewed by three experienced clinician-raters (two
master's level and one doctoral level individuals). These raters, blind to
treatment condition and assessment phase (intake, termination, follow-up),
reviewed each adolescent' s dossier of information about (a) type of
drug(s) used, (b) frequency of use, and (c) number and combination of
different drugs used as determined by the three data sources of adolescent
self-report, parent report, and urinalysis results.
The raters then rated the severity of drug use on a Guttman-type scale
designed to reflect both existing knowledge about adolescent drug-using
patterns (98) and specific drug-using patterns in the current sample. The
raters examined the evidence presented in each dossier and then classified
drug use consumption on a 15-point scale; a rating of 1 indicated no drugs
used, and each subsequent scale point indicated gradually increasing
seriousness of drug use, ending at 15, which indicated daily marijuana use
and more than twice per week use of other substances, excluding alcohol.
See Table 1 for a complete listing of the drug use classification scheme.
Interrater reliability was assessed using the intraclass correlation
coefficient (ICC) for random judges (99). The ICC was .92, indicating
excellent agreement among raters.
The measure of drug consumption used in this study evidenced concurrent
criterion-related validity by its correlations with criteria that are
known to be associated negatively with drug use among adolescents, namely,
perceived harmfulness of drugs and perceptions of friend disapproval of
drug use as assessed by measures employed in the Drugs and American High
School Students surveys (100). At intake, drug use was negatively
correlated with youth perceptions of both the harmfulness of drugs (-.30),
and their friends' disapproval of drug use (-.44).
Problem Behaviors
Problem behaviors were measured by the Acting Out Behaviors (AOB) Scale
(101) derived from the Devereux Adolescent Behavior Rating Scale (102),
which was administered to the adolescent's primary parent. The AOB Scale
identifies the extent of poor anger control, interpersonal problems,
impulsivity, mood swings, and antisocial, aggressive, and sexual acting
out behaviors. The AOB Scale has been found to be internally consistent
with an average coefficient alpha of .87 (101). Cronbach's coefficient
alpha in the current study was .93, indicating excellent internal
consistency. External and concurrent validity have also been demonstrated
(103).
School Performance
School
performance was assessed by the adolescent's grade point average (GPA).
School records were gathered for the semester immediately before
treatment, immediately after treatment, and during the follow-up period
between 6 and 12 months following treatment. One concern in conducting
analyses was that a raw GPA score does not account for many differences
associated with improvement. That is, the range restriction of GPA
potentially confounds important change. Specifically, there are important
meanings attached to and consequences of improving the GPA one point or
more among youths who are failing at intake. For example, earning a grade
of 2.0 or above indicates that, at a minimum, the youth had to attend
classes, pay attention, and pass tests. Moreover, a 2.0 average allows the
student to enter college preparatory courses and access extramural
activities such as sports. To reflect these meanings best, analyses were
conducted on transformed GPAs. The transformation was a simple inverse
logarithm (base 10) of GPA to overcome the range restriction of the
variable. This transformation was conducted to account for the important
qualitative differences observed between a GPA below 2.0 and GPAs above
2.0. However, data were transformed back to customary GPAs for
presentation (cf. 104).
Family Functioning
Family functioning was measured by a rating scale that assesses the
degree of health and dysfunction of behavioral family transactions, the
Global Health Pathology Scale of the Beavers Interactional Competence
Scales. This scale has demonstrated adequate reliability and validity in
previous studies (e.g., 105, 106). The Global Health Pathology Scale is
rated from 1 (optimal functioning) to 10 (severely dysfunctional) and is
based on general systems theory, clinical work with families, and research
investigating family relationship qualities that correlate with family
health or dysfunction (107). The global scale characterizes the overall
level of family competence/health by focusing on features of family
structure, communication, and expression. Detailed descriptions of each of
the 10 anchor points are provided in the scale's manual (107). Research
assistant raters trained by the developers of the scale rated videotaped
family interaction. Raters viewed 20 minutes of videotaped family
interaction in which families responded to three standardized family
interaction tasks (108). The format asked the families to (a) plan a menu
for dinner, (b) discuss what they like and dislike about each other, and
(c) talk together about a family argument or fight. Raters made their
ratings after viewing the entire segment. Interrater reliability was
assessed using the ICC for random judges (99). The ICC was .85, indicating
excellent agreement among raters.
RESULTS
Preliminary Analyses
First, we examined whether subjects assigned to each of the three
treatment groups differed at intake on measures of adolescent
symptomatology and demographic characteristics. ANOVAs and chi-square
tests revealed no significant differences among the three treatments at
intake on adolescent age, gender, ethnicity, juvenile justice/probation
status, family structure, family income, mother's education, and nature
and extent of adolescent symptomatology. However, youths assigned to MEI
had significantly higher family competence than youths assigned to MDFT (p
= .03) as measured by the Beavers Interactional Competence Scales. In
addition, we ran these same analyses on youths who completed treatment and
obtained the same pattern of results. Also, no differences were found on
intake status characteristics (i.e., demographic and outcome variables)
between those adolescents who completed treatment and those who dropped
out prior to the posttreatment phase.
Attrition
There were 182 cases assigned to treatment, with 30 (16%) classified as
treatment refusers since they failed to attend even one therapy session.
Of the remaining 152 cases, 47 were assigned to MDFT, 52 to MEI, and 53 to
AGT. There were 30% who did not complete MDFT (n = 14), 35% (n = 18)
dropped from MEI, and 47% (n = 25) dropped from AGT. The overall
chi-square analysis revealed a small effect, [chi](2) = 5.06, p = .08, V =
0.03. No significant difference was found between the two family-based
treatments (MDFT and MEI): [chi square](1) = 0.71, p = .40. However, a
significant difference in attrition was found between MDFT and the AGT,
[chi square](1) = 4.79, p = .03, V = 0.06.
Treatment Effectiveness
Intake to Termination
Repeated measures ANOVAs were used to evaluate intake-to-termination
changes. Separate ANOVAs were conducted for the drug use scale, AOB Scale,
GPA, and Beavers Family Competence Global Scale. The means and standard
deviations for the measures at intake and termination are presented in
Table 2. Significant ANOVAs for the effect of time were found on the
measure of drug use, F(1, 92) = 53.15, p = .0001, [[eta].sup.2] = 0.36;
and acting out behaviors, F(1, 92) = 12.55, p = .0006, [[eta].sup.2] =
0.12; but not for family competence, F(1, 70) = 0.33, p = .56 or GPA, F(1,
72) = 3.73, p = .076.
Differential effects due to treatment condition are shown by the Time x
Condition interactions. The ANOVA for the measures of drug use, F(2, 92) =
6.61, p = .002, [[eta].sup.2] = 0.12, and family competence, F = (2, 70) =
4.48, p = .01, [[eta].sup.2] = 0.11, showed a significant interaction. The
interaction between treatment and time was not significant for either
acting out behaviors, F(2, 92) = 1.16, p = .32, or GPA, F(2, 72) = 1.83, p
= .17. With respect to drug use and family functioning, examination of the
means shows that adolescents receiving MDFT, on average, showed the most
improvement from intake to termination.
Intake, Termination, and Follow-Up
Table 3 presents the repeated measures ANOVA with type of treatment as
the single between-subjects factor and time as the within-subjects factor.
Tests of the sphericity assumption have been questioned by a number of
authors (e.g., 109). Hence, we followed Keppel's (110) suggestion to
assume a violation of the sphericity assumption. Standard guidelines
concerning violation of the sphericity assumption to adjust the degree of
freedom of the F test by the Huynh-Felt epsilon if epsilon is greater than
0.75 and to use the more stringent Greenhouse-Geisser adjustment if
epsilon is less than 0.75 were followed (111). With respect to all four
analyses presented below (drug use, acting out behaviors, GPA, family
competence), epsilon was greater than 0.75; thus, a univariate approach
with the Huynh-Feldt correction to the F test was used to minimize the
type I error rate (112).
Changes in drug use and acting out behaviors across time from intake to
termination to the follow-up periods for all subjects were significant (p
< .001). As a group, all participants showed decreased drug use and
acting out behaviors over time. No main effects (treatment condition or
time) were observed for GPA and family competence.
The interaction of Time x Treatment was significant for adolescent drug
use, F(6, 240) = 2.68, p = .01, [[eta].sup.2] = 0.05; GPA, F(2, 64) =
3.17, p = .05, [[eta].sup.2] = 0.09; and family competence, F(6, 117) =
3.66, p = .002, [[eta].sup.2] = 0.16, with youths who received MDFT
showing the most improvement. The interaction of Time x Treatment was not
significant for acting out behaviors [F(6, 261) = 1.15, p = .32].
Clinical Significance
Treatment research has been criticized for its overly narrow focus on
reporting only tests of difference--statistically significant group mean
or average differences between compared treatment conditions. Contemporary
recommendations underscore the need to include clinical significance
indicators in controlled trials (113, 114). Two features of the present
study can be discussed in this regard: inclusion of (a) prosocial and
competence measures (as complementary pieces of the multidimensional
picture of change we hope to render) and (b) an estimator of clinical
significance.
For this study, we judged a meaningful indicator of clinical
significance to be reduction in the youths' drug use below the
preestablished eligibility criteria for entry into the study. Youths were
accepted into the study by virtue of their drug use. The drug use
eligibility level was marijuana use at least three times per week over the
last 30 days or single use of hard drugs (alcohol use could be present,
but was not the primary study entry criterion). Hence, an indicator of
clinical significance would be that, at termination or follow-up, the
youth no longer met the symptomatic criteria that prompted their referral
for drug treatment. Another marker of clinically meaningful change
concerns the important prosocial domain of school competence, a robust
predictor of adolescent problems generally and adolescent drug abuse in
particular (14, 115). For GPA, we defined criteria for clinical
significance in this domain to be passing grades--at least a 2.0 GPA.
At termination, 42% of the youths who received MDFT, in comparison to
25% in AGT and 32% in MEI, reported clinically significant reduction in
drug use. At the 1-year follow-up, 45% in MDFT, 32% in AGT, and 26% in MEI
demonstrated clinically significant change in that their drug use was
below initial treatment entry criteria. With respect to GPA, at intake
only 25% of the youths assigned to MDFT had GPAs of 2.0 (C average) or
better; 43% of AGT youths and 36% of MEI youths had GPAs of 2.00 or
better. One year after treatment, 76% of the youths in the MDFT treatment
condition had a C average or better, while 60% of AGT and 40% of MEI
youths had a C average or better. While the three groups did not differ
significantly with respect to the percentage of youths having a C average
or better at intake [[chi square](2) = 1.47, p = .48], the groups did
differ significantly at the 1-year follow up [[chi square](2) = 5.99, p =
.05].
DISCUSSION
Comparative intervention effects were evaluated on four adolescent
outcome indicators in a clinical sample of youths referred for drug abuse
treatment. Two measures of symptomatic impairment and improvement measured
drug use and problem behaviors. Two other measures assessed empirically
established protective factors: school performance and family competence.
These are aspects of prosocial functioning and development that mitigate
an adolescent's deepening involvement in antisocial and drug-using
lifestyles. The four assessment domains provide a multidimensional view of
treatment outcomes.
The general pattern of results indicates an overall improvement among
youths in each of the three manual-guided treatments. Parents of youths in
each treatment reported similarly on their adolescents' acting out
behaviors, indicating significant improvement over time in problem
behaviors. However, differential outcomes among the three treatments also
were found. Results concerning adolescent drug use, GPA, and family
functioning bring the differences between the three treatments into
relief, rendering a portrait in which those receiving MDFT showed the most
improvement, followed by those receiving AGT and then MEI.
At the end of treatment, participants in MDFT showed a sharp reduction
in drug use, and these treatment gains were maintained during the 6- and
12-month follow-up periods. Thus, MDFT produced a rapid (16 once-a-week
treatment sessions over a period of 5 to 6 months)and dramatic reduction
in drug use. Importantly, youths not only showed a reduction in drug use,
but also demonstrated improved prosocial functioning, evidenced by
improved academic achievement and family functioning. From intake to
follow-up, youths who received MDFT showed considerable improvement in
school performance. These youths went from below average grades to passing
grades in just over 1 year. Whereas particular educational and
psychosocial interventions have been shown to improve academic achievement
of at-risk elementary and secondary school students (e.g., 116, 117), as
far as we know, there have been only two other treatment studies that
demonstrated improved educational performance in a clinical sample of
secondary school students evidencing academic failure, moderate to heavy
drug use, and behavior problems (118, 119). These findings run counter to
the pessimism many educators have expressed about the likelihood of
improving the academic performance of failing high school students who use
drugs or evidence behavior problems (120).
As hypothesized, the MDFT treatment also produced significant
improvement in family functioning. This is important since the
adolescent's family environment (specifically family support, parenting
practices, and the parent-adolescent relationship) is an empirically
established predictor not only of adolescent drug problems, but also of
adolescent drug treatment success (121). From intake to follow-up periods,
the observable transactional patterns of MDFT parents and adolescents
became more functional and developmentally facilitative according to
behavioral ratings of videotaped family interactions. MDFT families moved
from the behaviorally incompetent to the competent range, while AGT cases
showed no change, and MEI families deteriorated on the family functioning
scales. These findings are consistent with findings from an earlier MDFT
study on the parenting behaviors of parents of clinically referred
drug-using teens. In that study, we demonstrated that MDFT changed
targeted parenting practices, and that these changes in parenting were
correlated with reductions in the adolescent's drug abuse and problem
behaviors (27). Taken together, the findings of the present study, along
with those of the aforementioned process study, support a core premise
about a potential mechanism of change in MDFT, namely, that model-specific
changes in the family environment are associated with reductions in
adolescent drug taking.
Although some studies that tested group approaches with drug-using
teens had mixed (122) and, in one case, iatrogenic results (123),
adolescent group therapy in the current study showed a certain potential
that should not be overlooked. Although results indicate that MDFT was
superior to AGT in retaining youths in treatment and in improving family
and school performance outcomes, youths who completed AGT showed a gradual
decline in drug use from intake to follow-up. One year after treatment,
AGT teens' drug use was as low as for those who participated in MDFT. It
appears that there is a sleeper effect with the AGT subjects by which the
impact of therapy is not immediate, but rather shows itself at some time
later. A finding of this nature is not uncommon in the drug treatment
literature (see Refs. 124, 125). Perhaps there is a latent positive
response to the skills learned during group therapy intervention.
Immediately after treatment, adolescents may have been unable or unwilling
to utilize these skills for individual, interpersonal, or other contextual
reasons.
At the same time, the findings for AGT need to be understood in the
context of the high dropout rate for this intervention. Treatment dropout
is a severe problem, and its consequences are disastrous for treatment
providers and researchers. Winters (126) found that treatment completers
are 2 to 3 times more likely to have significant substance abuse
reductions than noncompleters. Of the teens assigned to AGT, 48% failed to
complete the treatment. This compares to a dropout rate of 30% for MDFT
and 34% for MEI. Retaining adolescents in outpatient drug treatment
remains a challenge for the field. Kaminer and coworkers (127), although
obtaining relatively positive results in their group therapy model, had
difficulty retaining drug-using teens in group treatment. Almost half of
the adolescents in group therapy dropped out prematurely.
Additional aspects of the findings are apparent if we consider the
differential foci and content of the three treatments. Both the MDFT and
AGT, but not MEI, spent considerable treatment time working individually
with the adolescent. MDFT focuses on developmental aspects of the self of
the adolescent, as well as the teen vis-a-vis the family and, indirectly,
the peer context. Adolescent group therapy focuses on the self of the
adolescent directly in a peer context. Both treatments, however, aim to
facilitate the adolescent's competent voicing of his or her concerns and
acquisition of developmentally appropriate life skills--including
communication, negotiation, perspective taking, and problem solving. MDFT
builds on these competencies in individual adolescent and parent sessions
and in family sessions. Obtained changes in each of these subsystems are
brought to bear, leveraged in a sense, in the other contexts in which
change is being worked (18). The group therapy approach achieved these
foci in peer group sessions, in which peer feedback and interaction
prompted acquisition of these skills and behaviors. Although MEI addresses
all of these focal areas, perhaps it falls short of the other two
treatments because of its structured, educational format and its focus on
a sequenced content in the context of several families meeting together.
It could be that this format does not provide sufficient individual time
for the adolescent or for the issues particular to each family to be
developed and tailored to each individual teen and family.
Given the pattern of results, it seems reasonable to suggest that an
important ingredient for the successful treatment of adolescent drug abuse
is the simultaneous focus on the family and the individual youth in an
individualized, case-tailored manner. The psychoeducationally oriented MEI
intervention focused on adolescent-parent communication and improving
parenting skills, and it showed limited success in comparison to the other
two treatments. Although the inclusion of family members, particularly
parents, in adolescent drug abuse treatment is commonly accepted [indeed,
it is seen as instrumental in some practice guidelines such as the CSAT
TIPS (128) and AACAP Practice Guidelines (129)], these results suggest
that only family-based interventions with particular features will be
maximally effective with treatment of adolescent drug abuse. AGT, with its
focus on peer support and adolescent skill building, showed a certain,
albeit slow-acting, success in decreasing the teen's drug involvement.
However, the group treatment did not change the adolescent's family
environment, nor did the teens in this treatment improve their school
performance as impressively as did the adolescents in the MDFT treatment.
It is MDFT, with its multiple targets of the adolescent's and parent's
individual functioning, and individualized attention to parenting
practices, family relationships, and the adolescent's extrafamilial
environment that showed the overall best results.
Developmental or Historical Context of the Findings
Additional perspective about the findings of the current study is
gained if we place these results in the developmental context of the
adolescent drug treatment specialty. Early-stage studies evaluating
outpatient adolescent substance abuse treatment yielded mixed results. For
example, in a state drug treatment outcome study, adolescents with serious
drug problems increased their drug use following treatment (130). The DARP
(131) and TOPS (132) studies showed reductions in behaviors associated
with drug use, such as criminal activity the year after treatment, but
drug outcomes were disappointing. Adolescents continued to use marijuana
and alcohol after treatment and at the 1-year follow-up point (133). The
adolescent drug treatment specialty is vastly different today. We now have
adolescent-specific therapies [the Rush study (130) reported on
adult-oriented treatments to which teenagers were assigned], that are
manual guided, can be taught to community therapists, and can be
implemented in community agency settings.
Metanalyses (134, 135) and comprehensive reviews (136-138) have
concluded that certain empirically tested family-based therapy models
appear to yield the best outcome results in terms of substance use
reduction at termination and follow-up. But, for new treatments to be
maximally useful in practice and influential at a policy level, they must
not only significantly reduce dysfunction, but also increase positive and
adaptive functioning. Ideally, this complex of change--the decrease of
target symptomatology and the facilitation of prosocial behaviors and
protective factors--should show stability or even growth if possible after
treatment ends. In the current study, the MDFT approach achieved superior
overall outcomes relative to the comparison treatments since it not only
created significant adolescent drug reductions, but also had an impact on
other critical domains of individual and family system functioning. Given
what we know about the important protective and adaptive developmental
functions served by positive family relations and a teenager's success in
school, the changes achieved by MDFT in these domains must be considered
significant.
Another important aspect of the MDFT findings pertains to the
durability of the obtained changes. Given previous research demonstrating
that between 50% and 71% of all teens relapse to consistent marijuana and
alcohol abuse within 90 days after ending treatment (139, 140), in this
light, the findings in this study about the stability of changes brought
about by the MDFT treatment are noteworthy as well. In addition, Bry and
Krinsley (141), among others, have written about the possibility of
including booster, posttreatment interventions to shore up the obtained
changes in adolescent family-based treatment. The current study design did
not include booster sessions or contacts of any kind for any of the three
tested treatments. The measured changes in the MDFT cases--the positive
outcomes in important symptom and prosocial domains--were of a treatment
that was delivered consistently and coherently in one package, within a
5-6-month, outpatient therapy regimen.
Limitations
Although the results are very encouraging, the study has certain
limitations. First, the results are limited by the absence of data on
comorbid conditions and a DSM substance abuse or dependence diagnosis.
Although the intake data (amount and types of drugs used, 2.5-year history
of use, legal problems due to juvenile justice system involvement, and
other demographic characteristics) indicate that this is a relatively
seriously impaired sample, the absence of clear diagnostic criteria limits
generalizability of results.
Next, the sample is heterogeneous in terms of ethnicity and gender.
While this improves generalizability of the results to clinical
populations of referred adolescents, the subgroups that could be
constituted by ethnicity and gender are too small to examine the outcomes
by these important variables adequately.
CONCLUSION
When evaluated in the context of research design and procedures
considered necessary in contemporary controlled trials, the study
evidences many strengths (142). Subjects were clinically referred
adolescents, and they were representative of cases clinicians see in
community settings. Full randomization was achieved. The measurement
strategy conforms with contemporary standards; we used multiple measures
from different respondents to assess different theory-related and
empirically derived domains of interest, including measures of target
symptom measures and prosocial functioning. Community therapists,
representative of clinicians in clinical settings, were used. The
treatments were delivered in community clinical settings rather than in a
research clinic or lab. Each treatment was manual guided, and each of the
three therapies tested in the study (family-based therapy, group therapy
for teenagers, and multifamily psychoeducationally oriented groups)
represents frequently used interventions for adolescent drug abuse. No
weak treatments or attention conditions were used. The tested treatments
represented strong versions of their respective modality and clinical
tradition. Treatment manuals guided each intervention, and weekly
supervision of the clinicians in each treatment monitored adherence and
shaped clinician behavior on model-specific parameters.
In conclusion, this study contributes to the growing body of work on
the treatment of adolescent substance abuse (143). This literature
indicates that certain family-based treatments can engage and retain
youths and their families in treatment and reduce drug consumption more
effectively than non-family-based treatments (135, 136). The family-based
therapy tested in this study stands out in its success in not only
reducing drug abuse and related serious functional impairments, but also
promoting prosocial behavior, school performance, and family functioning,
all in a relatively brief period of time (4-5 months). And, these
treatment effects were stable; indeed, in some cases, they accelerated
over the 1-year posttreatment follow-up period.
Table 1. Adolescent Drug Use Scale
1 = No drug use
2 = Alcohol or marijuana; a single drug used not more
than 1 time/month
3 = Alcohol or marijuana used 2-3 times/month
4 = Marijuana used 3-4 times/month
5 = Marijuana used 5-6 times/month
6 = Marijuana used 1-2 times/week
7 = Marijuana used 3-4 times/week
8 = Marijuana used 5-6 times/week
9 = Marijuana used daily or more
10 = Marijuana used daily or more, plus single other drug
used less than once/month
11 = Marijuana used daily or more, plus single other drug
used 1 time/month
12 = Marijuana used daily or more, plus other drug(s)
used between 2 and 3 times/month
13 = Marijuana used daily or more, plus other drug(s)
used between 4 and 6 times/month
14 = Marijuana used daily or more, plus other drug(s)
used between 1 and 2 times/week
15 = Marijuana used daily or more, plus other drug(s)
used more than 2 times/week
Note. Points 4-15 may include consumption of alcohol. Usually, youth
consumed marijuana in combination with alcohol. Points 1-15 notation
of "other drug" includes any and all drugs with the exception of
alcohol.
Table 2. Analysis of Variance (ANOVA) Results, Group Means, and
Standard Deviations on Outcome Variables for the Three Treatments
from Intake to Termination
ANOVA Results
Mean (SD) Time
Intake Termination F p
Drug use (a) 53.15 .0001
MDFT 9.85 (3.77) 4.54 (3.10)
AGT 8.90 (2.82) 7.28 (3.30)
MEI 10.29 (3.18) 7.76 (5.10)
Acting out (b) 12.55 .0006
MDFT 81.67 (22.46) 71.48 (17.46)
AGT 72.93 (26.78) 69.53 (26.46)
MEI 83.62 (23.74) 77.73 (22.64)
Grade point 3.73 .076
average (c)
MDFT 1.27 (.93) 1.91 (1.15)
AGT 1.54 (.79) 1.52 (1.36)
MEI 1.61 (1.07) 1.52 (1.07)
Global family 0.33 .56
competence (d)
MDFT 6.15 (1.27) 5.07 (1.31)
AGT 5.39 (1.78) 5.61 (1.69)
MEI 4.65 (1.36) 5.10 (1.99)
ANOVA Results
Time Condition x Time
[[eta].sup.2] F p [[eta].sup.2]
Drug use (a) 0.36 6.61 .002 0.12
MDFT
AGT
MEI
Acting out (b) 0.12 1.16 .32 --
MDFT
AGT
MEI
Grade point -- 1.83 .17 --
average (c)
MDFT
AGT
MEI
Global family -- 4.48 .01 0.11
competence (d)
MDFT
AGT
MEI
MDFT, multidimensional family therapy; AGT, adolescent group therapy;
MEI, multifamily educational intervention.
(a) Planned comparisons at termination revealed MDFT to be
significantly different from AGT and MEI (t = -3.33, p = .002;
t = -3.11, p = .003); no differences between AGT and MEI
(t = -43, p = .67).
(b) Comparisons were nonsignificant at termination.
Table 3. Analysis of Variance (ANOVA) Results, Group Means, Standard
Deviations on Outcome Variables for the Three Treatments from Intake
to 12-Month Follow-Up
Mean (SD)
6-month
Intake Termination Follow-up
Drug use (a)
MDFT 9.89 (3.79) 4.79 (3.20) 5.04 (3.77)
AGT 8.83 (2.76) 7.33 (3.41) 6.21 (3.66)
MEI 10.03 (3.45) 7.26 (5.05) 6.87 (3.79)
Acting out (b)
MDFT 83.34 (20.62) 71.87 (17.59) 67.22 (17.15)
AGT 75.80 (26.61) 72.68 (26.02) 66.36 (21.11)
MEI 83.42 (24.09) 77.45 (22.93) 75.51 (24.29)
Grade point
average (c)
MDFT 1.77 (1.80) 2.56 (2.59)
AGT 1.85 (1.78) 2.44 (2.63)
MEI 1.98 (2.20) 2.05 (1.89)
Global family
competence
(b)
MDFT 6.15 (1.33) 5.18 (1.32) 4.70 (1.32)
AGT 6.00 (1.27) 5.67 (1.94) 6.78 (1.94)
MEI 4.31 (1.36) 4.77 (1.84) 5.23 (1.75)
Mean (SD) ANOVA Results
Time
12-Month [[eta].
Follow-Up F p sup.2]
Drug use (a) 31.45 .000
MDFT 4.25 (2.98)
AGT 5.08 (3.71)
MEI 7.26 (3.97)
Acting out (b) 12.55 .001
MDFT 63.56 (20.14)
AGT 61.80 (16.92)
MEI 71.57 (23.44)
Grade point 2.95 .09
average (c)
MDFT 2.62 (2.47)
AGT 2.26 (2.09)
MEI 1.925 (1.78)
Global family 0.70 .56
competence
(b)
MDFT 4.70 (2.00)
AGT 5.83 (1.71)
MEI 5.35 (2.14)
ANOVA Results
Condition x Time
F p [[eta].sup.2]
Drug use (a) 2.68 .01 0.05
MDFT
AGT
MEI
Acting out (b) 1.15 .32 --
MDFT
AGT
MEI
Grade point 3.17 .05 0.09
average (c)
MDFT
AGT
MEI
Global family 3.66 .002 0.16
competence
(b)
MDFT
AGT
MEI
MDFT, multidimensional family therapy; AGT, adolescent group therapy;
MEI, multifamily educational intervention.
(a) Planned comparisons at 12 months revealed MDFT to be significantly
different than MEI (t = -3.59, p = .0006) and AGT to be significantly
different from MEI (t = -2.36, p = .02).
(b) Comparisons were nonsignificant at 12 months.
(c) Post hoc tests at 12 months also revealed MDFT to be marginally
significantly different from MEI (t = 1.80, p = .08).
ACKNOWLEDGMENT
Preparation of this article was supported by grants from the National
Institute on Drug Abuse (P50-DA07697 and R01 DA3714). We thank Shelley
Hurwitz, Karin LaPann, Ruth Palmer, and Fran Sessa for comments on an
earlier draft.
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Howard A. Liddle, (1), * Gayle A. Dakof, (1) Kenneth Parker, (2) Guy S.
Diamond, (3) Kimberly Barrett, (4) and Manuel Tejeda (1)
(1) Center for Treatment Research on Adolescent Drug Abuse, Department
of Epidemiology and Public Health, University of Miami School of Medicine,
1400 NW Tenth Avenue, 11th Floor, Miami, Florida 33136 (2) Families First,
Stockton, California (3) Children's Hospital of Philadelphia/University of
Pennsylvania, Philadelphia, Pennsylvania (4) University of Washington,
Seattle, Washington
* Corresponding author. E-mail:
hliddle@med.miami.edu