Juvenile Justice Risk Factors and Functional Family Therapy Fidelity on Felony Recidivism.

Families (n = 5,884) received Functional Family Therapy (FFT) provided as part of court-ordered probation services by 11 community sites throughout Florida. Sites provided home-based FFT to families with male (72%) or female (28%) delinquent youth. Juvenile justice courts referred clients to these services in an effort to redirect them away from incarceration. Clients were Hispanic (18%), Black (41%), and White Non-Hispanic (36%), while therapists (female, 79%) were of Hispanic (28%), Black (20%), and White Non-Hispanic (50%) ethnic/racial origins. Analyses of clients' pretreatment recidivism risk and therapist's caseload of risky clients demonstrated that both individual and treatment site case-mix of client criminal risk levels were associated with higher adjudicated felony recidivism. Furthermore, clinical process indicators suggest that therapists with larger rather than smaller caseloads of high-risk clients provided treatment with greater fidelity. Results suggest that experience in working with challenging clients is critical for achieving fidelity with these cases.

Evaluating Supervision Models in Functional Family Therapy: Does Adding Observation Enhance Outcomes?

This study examined the effects of observation-based supervision Building Outcomes with Observation-Based Supervision of Therapy (BOOST therapists = 26, families = 105), versus supervision as usual (SAU therapists = 21, families = 59) on (a) youth externalizing behavior problems and (b) the moderating effects of changes in family functioning on youth externalizing behaviors for adolescents receiving Functional Family Therapy (FFT). Exploratory analyses examined the impact of supervision conditions on youth internalizing problems. In 8 community agencies, experienced FFT therapists (M = 1.4 years) received either BOOST or SAU supervision in a quasi-experimental design. Male (59%) or female (41%) adolescents were referred for the treatment of behavior problems (e.g., delinquency, substance use). Clients were Hispanic (62%), African American (19%), Non-Hispanic White (12%), or Other (7%) ethnic/racial origins. Therapists (female, 77%) were Hispanic 45%, African American (19%), White Non-Hispanic (30%), or other (4%) ethnic/racial backgrounds. Analyses controlled for the presence or absence of clinically elevated symptoms on outcome variables. Clinical outcomes were measured at baseline, 5 months, and 12 months after treatment initiation. Clients with externalizing behavior above clinical thresholds had significantly greater reductions in problem behaviors in the BOOST versus the SAU conditions. Clients below thresholds did not respond differentially to conditions. Supervisors in BOOST had more experience with the FFT model; as such, the observed results may be a result of supervisor experience. The BOOST supervision was associated with improved outcomes on problem behaviors that were above clinical thresholds. The findings demonstrate the importance of addressing client case mix in implementation studies in natural environments.

Este estudio examinó los efectos de la supervisión basada en la observación (terapeutas de BOOST = 26, familias = 105) frente a la supervisión habitual (terapeutas de SAU = 21, familias = 59) en (a) la externalización de problemas de conducta en los jóvenes y (b) los efectos moderadores de los cambios en el funcionamiento familiar sobre la externalización de conductas de los jóvenes en el caso de adolescentes que reciben terapia familiar funcional (FFT). Los análisis exploratorios analizaron el efecto de las condiciones de la supervisión en la internalización de problemas de los jóvenes. En 8 agencias comunitarias, terapeutas experimentados en FFT (M = 1,4 años) recibieron supervisión BOOST o SAU en un diseño cuasiexperimental. Se derivó a adolescentes masculinos (59%) o femeninos (41%) para el tratamiento de problemas conductuales (p. ej.: delincuencia, consumo de sustancias). Los pacientes eran hispanos (62%), afroamericanos (19%), blancos no hispanos (12%) o de otros orígenes étnicos o raciales (7%). Los terapeutas (femeninos, 77%) eran hispanos 45%, afroamericanos (19%), blancos no hispanos (30%) o de otros orígenes étnicos o raciales (4%). Los análisis tuvieron en cuenta la presencia o la ausencia de síntomas clínicamente elevados en los criterios de valoración. Se midieron las variables clínicas al inicio, a los 5 meses y 12 meses después del inicio del tratamiento. Resultados: Los pacientes con externalización del comportamiento por encima de los límites clínicos tuvieron reducciones considerablemente mayores de los comportamientos problemáticos en las condiciones de BOOST frente a las de SAU. Los pacientes por debajo de los límites no respondieron de forma diferencial a las condiciones. Los supervisores de BOOST tenían más experiencia con el modelo de FFT; por lo tanto, los resultados observados pueden ser el resultado de la experiencia de los supervisores. La supervisión BOOST estuvo asociada con mejores resultados en los comportamientos problemáticos que estaban por encima de los límites clínicos. Los resultados demuestran la importancia de abordar la variedad de casos de pacientes en la implementación de estudios en ambientes naturales.

A Conceptual Model and Clinical Framework for Integrating Mindfulness into Family Therapy with Adolescents.

Individual and group-based psychotherapeutic interventions increasingly incorporate mindfulness-based principles and practices. These practices include a versatile set of skills such as labeling and attending to present-moment experiences, acting with awareness, and avoiding automatic reactivity. A primary motivation for integrating mindfulness into these therapies is compelling evidence that it enhances emotion regulation. Research also demonstrates that family relationships have a profound influence on emotion regulation capacities, which are central to family functioning and prosocial behavior more broadly. Despite this evidence, no framework exists to describe how mindfulness might integrate into family therapy. This paper describes the benefits of mindfulness-based interventions, highlighting how and why informal mindfulness practices might enhance emotion regulation when integrated with family therapy. We provide a clinical framework for integrating mindfulness into family therapy, particularly as it applies to families with adolescents. A brief case example details sample methods showing how incorporating mindfulness practices into family therapy may enhance treatment outcomes. A range of assessment modalities from biological to behavioral demonstrates the breadth with which the benefits of a family-based mindfulness intervention might be evaluated.

Depression Change Profiles in Adolescents Treated for Comorbid Depression/Substance Abuse and Profile Membership Predictors.

Using data from a randomized trial in which adolescents with depressive and substance use disorders (SUD) received treatments for both disorders in either a sequenced or coordinated manner, we (a) determine the number and nature of depression response profiles through 1-year posttreatment and (b) examine whether 8 previously identified factors predict profile membership. There were 170 adolescents (M age = 16.4 years; 22% female; 28% Hispanic, 61% Non-Hispanic White) with comorbid depressive disorder/SUD randomized to one of three sequences of receiving the Adolescent Coping With Depression Course and Functional Family Therapy for SUD (depression treatment followed by SUD treatment; SUD treatment followed by depression treatment; coordinated treatment). Depression was assessed at 7 points from baseline to 1-year follow-up. A 4-class solution fit the data best, with groups labeled Mildly Depressed Responders (57.1%), Depressed Responders (18.8%), Depressed Non-Responders (12.9%), and Depressed with Recurrence (11.2%). The 4 change profiles differed on indices of all but 1 predictor (age); most differences were driven by lower scores among Mildly Depressed Responders. Profile membership was most strongly predicted by depression severity, cognitive distortions, hopelessness, and global functioning. The strongest predictor of Nonresponse was low family cohesion, whereas Recurrence was associated with hopelessness, suicide attempts, and starting treatment near the end of the school year. Most depressed adolescents experienced a positive response that was maintained. Understanding the most common profiles of depression change during and following treatment and the variables that predict change can help improve treatment outcomes and advance tailoring efforts.

A randomized study of a method for optimizing adolescent assent to biomedical research.

PURPOSE: Voluntary consent/assent with adolescents invited to participate in research raises challenging problems. No studies to date have attempted to manipulate autonomy in relation to assent/consent processes. This study evaluated the effects of an autonomy-enhanced individualized assent/consent procedure embedded within a randomized pediatric asthma clinical trial. METHODS: Families were randomly assigned to remain together or separated during a consent/assent process; the latter we characterize as an autonomy-enhanced assent/consent procedure. We hypothesized that separating adolescents from their parents would improve adolescent assent by increasing knowledge and appreciation of the clinical trial and willingness to participate. RESULTS: Sixty-four adolescent-parent dyads completed procedures. The together versus separate randomization made no difference in adolescent or parent willingness to participate. However, significant differences were found in both parent and adolescent knowledge of the asthma clinical trial based on the assent/consent procedure and adolescent age. The separate assent/consent procedure improved knowledge of study risks and benefits for older adolescents and their parents but not for the younger youth or their parents. Regardless of the assent/consent process, younger adolescents had lower comprehension of information associated with the study medication and research risks and benefits, but not study procedures or their research rights and privileges. CONCLUSIONS: The use of an autonomy-enhanced assent/consent procedure for adolescents may improve their and their parent's informed assent/consent without impacting research participation decisions. Traditional assent/consent procedures may result in a "diffusion of responsibility" effect between parents and older adolescents, specifically in attending to key information associated with study risks and benefits.

Summary of comparison between FFT-CW® and Usual Care sample from Administration for Children's Services.

This evaluation compared the efficiency and effectiveness of Functional Family Therapy-Child Welfare (FFT-CW®, n=1625) to Usual Care (UC: n=2250) in reducing child maltreatment. FFT-CW® is a continuum of care model based on the family's risk status. In a child welfare setting, families received either UC or FFT-CW® in a quasi-experimental, stepped wedge design across all five boroughs of New York City. The families were matched using stratified propensity scoring on their pre-service risk status and followed for 16 months. The ethnically diverse sample included African American (36%), Asian (4%); Hispanic (49%), and Non-Hispanic White (6%) or Other (6%) participants. Referral reasons included abuse or neglect (57.4%), child service needs (56.9%) or child health and safety concerns (42.8%). Clinical process variables included staff fidelity, service duration, and number of contacts. Positive outcomes included whether all clinical goals were met and negative outcomes included transfers, outplacement, recurring allegations and service participation within 16 months of the case open date. Families receiving FFT-CW® completed treatment more quickly than UC and they were significantly more likely to meet all of the planned service goals. Higher treatment fidelity was associated with more favorable outcomes. Fewer FFT-CW® families were transferred to another program at closing, and they had fewer recurring allegations. FFT-CW® had fewer out-of-home placements in families with higher levels of risk factors. The FFT-CW® program was more efficient in completing service, and more effective than UC in meeting treatment goals while also avoiding adverse outcomes.

Evolution of Functional Family Therapy as an Evidence-Based Practice for Adolescents with Disruptive Behavior Problems.

This article summarizes the evolution of functional family therapy (FFT) based upon four decades of clinical practice and scientific scrutiny through research evidence. FFT research has evolved from an initial focus upon clinical process research, which examined sequential exchanges between therapists and family members. A key element of this research has been an examination of the way in which clinicians acquire, consolidate, and maintain the skills needed to implement FFT effectively with youth and families. Many randomized efficacy and effectiveness studies have evaluated the impact of FFT across diverse clinical populations. Subsequent research investigated factors that influence the effectiveness of implementation across more than 300 clinical settings in which more than 2,500 trained clinicians have provided service to nearly 400,000 families. Another important set of investigations concerned the cost-effectiveness of the interventions.

Sequenced versus coordinated treatment for adolescents with comorbid depressive and substance use disorders.

OBJECTIVE: We evaluated 3 methods of integrating interventions for depression (Adolescent Coping With Depression Course; CWD) and substance use disorders (Functional Family Therapy; FFT), examining (a) treatment sequence effects on substance use and depression outcomes and (b) whether the presence of major depressive disorder (MDD) moderated effects. METHOD: Participants were 170 adolescents (ages 13-18; 22% female; 61% non-Hispanic White) with comorbid depressive disorder (54% MDD, 18% dysthymia) and substance use disorders who were randomized to (a) FFT followed by CWD (FFT/CWD), (b) CWD followed by FFT (CWD/FFT), or (c) coordinated FFT and CWD (CT). Acute treatment (24 treatment sessions provided over 20 weeks) and 6- and 12-month follow-up effects are presented for substance use (percentage of days of substance use; Timeline Followback) and depression (Children's Depression Rating Scale-Revised). RESULTS: FFT/CWD achieved better substance use outcomes than CT at posttreatment, and 6- and 12-month follow-ups; substance use effects for CWD/FFT were intermediate. For participants with baseline MDD, the CWD/FFT sequence resulted in lower substance use than either FFT/CWD or CT. Depressive symptoms decreased significantly in all 3 treatment sequences with no evidence of differential effectiveness during or following treatment. Attendance was lower for the second of both sequenced interventions. A large proportion of the sample received treatment outside the study, which predicted better outcomes in the follow-up. CONCLUSIONS: Depression reductions occurred early in all 3 treatment sequences. Of the examined treatment sequences, FFT/CWD appeared most efficacious for substance use reductions but addressing depression early in treatment may improve substance use outcomes in the presence of MDD.

Predicting adolescent asthma research participation decisions from a structural equations model of protocol factors.

PURPOSE: To examine similarities and differences in the process that parents and adolescents use to make decisions concerning participation in an asthma clinical trial. We hypothesized that a single conceptual model, tested through structural equations modeling, could explain adolescent assent and parent consent for adolescent research participation. METHODS: One hundred nine adolescents enrolled with at least one parent and received an asthma evaluation from a pediatric asthma specialist and then evaluated a hypothetical asthma research protocol. Family members independently evaluated the protocol and made research participation decisions. RESULTS: Perceived risk, benefit, and compensation were direct predictors of participation decisions for parents and adolescents. Adolescents perceived direct study benefit from the relationship with the physician, however parents did not. Parent decisions were most strongly associated with perceived risk, and parents associated discomfort with risk more strongly than did adolescents. Protocol procedures contributed to perceptions of benefit and discomfort for parents and adolescents. CONCLUSIONS: Parent and adolescent research participation decisions are influenced by protocol variables in similar ways, although there are differences that account for disagreements within families. Findings may help investigators develop protocols that appeal to parents and adolescents and highlight issues of particular importance to address during the process of informed consent.

Conceptualizing the role of research literacy in advancing societal health.

'Research literacy' is proposed as a key concept for advancing societal health. To examine whether improvements in research literacy would affect knowledge of and ethical participation in research, parents of young children received a brief educational intervention designed to enhance their understanding of child research. Results demonstrated that the intervention improved research-related knowledge and increased parents' comfort with their research participation decisions. Moreover, enhanced understanding of child volition increased parents' willingness to enrol their children in research. The proposed research literacy model identifies methods to enhance population knowledge and appreciation of research, strengthening links between scientific advancement and health.

Adolescent health-risk sexual behaviors: effects of a drug abuse intervention.

Adolescents who abuse substances are more likely to engage in health-risking sexual behavior (HRSB) and are at particularly high risk for HIV/AIDS. Thus, substance abuse treatment presents a prime opportunity to target HIV-risk behaviors. The present study evaluated a one-session HIV-risk intervention embedded in a controlled clinical trial for drug-abusing adolescents. The trial was conducted in New Mexico and Oregon with Hispanic and Anglo adolescents. Youths were randomly assigned to individual cognitive behavior therapy (CBT) or to an integrated behavioral and family therapy (IBFT) condition, involving individual and family sessions. The HIV-specific intervention was not associated with change. IBFT and CBT were both efficacious in reducing HIV-risk behaviors from intake to the 18-month follow-up for high-risk adolescents. For low-risk adolescents, CBT (versus IBFT) was more efficacious in suppressing HRSB. These data suggest that drug abuse treatments can have both preventative and intervention effects for adolescents, depending on their relative HIV-risk.

The effectiveness of functional family therapy for youth with behavioral problems in a community practice setting.

The study examined the effectiveness of Functional Family Therapy (FFT), as compared to probation services, in a community juvenile justice setting 12 months posttreatment. The study also provides specific insight into the interactive effects of therapist model specific adherence and measures of youth risk and protective factors on behavioral outcomes for a diverse group of adolescents. The findings suggest that FFT was effective in reducing youth behavioral problems, although only when the therapists adhered to the treatment model. High-adherent therapists delivering FFT had a statistically significant reduction of (35%) in felony, a (30%) violent crime, and a marginally significant reduction (21%) in misdemeanor recidivisms, as compared to the control condition. The results represent a significant reduction in serious crimes 1 year after treatment, when delivered by a model adherent therapist. The low-adherent therapists were significantly higher than the control group in recidivism rates. There was an interaction effect between youth risk level and therapist adherence demonstrating that the most difficult families (those with high peer and family risk) had a higher likelihood of successful outcomes when their therapist demonstrated model-specific adherence. These results are discussed within the context of the need and importance of measuring and accounting for model specific adherence in the evaluation of community-based replications of evidence-based family therapy models like FFT.

Adolescent and parent alliances with therapists in Brief Strategic Family Therapy with drug-using Hispanic adolescents.

This study examined the relationship between alliance and retention in family therapy. Alliance was examined at the individual (parent, adolescent) and family level (within-family differences) for families that either dropped out or completed family therapy. Participants were 31 Hispanic adolescents and their family members who received brief strategic family therapy for the treatment of adolescent drug use. Videotapes of first sessions were rated to identify parent and adolescent alliances with the therapist. Results demonstrated that Completer cases had significantly higher levels of alliance across all family members than Dropout cases, and Dropout cases had significantly higher unbalanced alliances than Completer cases. Clinical implications are discussed.

Ethnic matching and treatment outcome with Hispanic and Anglo substance-abusing adolescents in family therapy.

This study examined treatment outcomes of 86 highly acculturated Hispanic and Anglo substance-abusing adolescents in functional family therapy, testing the hypothesis that ethnic matching of therapist and client is related to better treatment outcomes for clients. Adolescents reported on their substance use pre- and posttreatment on a timeline follow-back interview. Ethnically matched Hispanic adolescents demonstrated greater decreases in their substance use compared with Hispanic adolescents with Anglo therapists. Ethnic match status was not related to treatment outcome for Anglo clients. Thus, the matching hypothesis was supported for Hispanic clients only. The results underscore the importance of greater ethnic diversity among therapists and better cultural competency training for Anglo therapists. More research is needed on individual differences in the effects of ethnic matching.

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.

The efficacy of structural ecosystems therapy with drug-abusing/dependent African American and Hispanic American adolescents.

Many family therapies for adolescent drug use include ecological interventions. The purpose of this randomized clinical trial was to establish whether ecological interventions contribute to the impact of family therapy above and beyond the contributions of family process-only interventions. A family-based ecological approach, structural ecosystems therapy (SET), was compared with family process-only condition (FAM) and community services control (CS). One hundred ninety substance-abusing or dependent African American and Hispanic adolescents were randomized to SET, FAM, or CS. Follow-up assessments were conducted at 3, 6, 12, and 18 months postrandomization. SET was significantly more efficacious than FAM and CS in reducing adolescent drug use. However, these improvements were limited to Hispanic adolescents. The study demonstrates the importance of investigating changes in adolescent drug use as a result of treatment condition across more than 1 racial/ethnic group.

Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances.

In this study, the authors examined the role of balance between adolescent-therapist and parent-therapist alliances in the retention of functional family therapy clients. Therapeutic alliances of mothers, fathers, and adolescents were assessed from videotapes of the 1st treatment session for 43 Hispanic and 43 Anglo families. Hispanic families who dropped out before completing the requisite number of sessions were found to have greater imbalance in alliance (parent-adolescent) than those who did complete therapy. However, this finding was not replicated with Anglo families. Results are interpreted in terms of previous research on family-level balanced alliance effects.

Cost-effectiveness analysis of four interventions for adolescents with a substance use disorder.

Alcohol, tobacco, and illicit drug use among adolescents in the United States continues to be a serious public health challenge. A variety of outpatient treatments for adolescent substance use disorders have been developed and evaluated. Although no specific treatment modality is effective in all settings, a number of promising adolescent interventions have emerged. As policy makers try to prioritize which programs to fund with limited public resources, the need for systematic economic evaluations of these programs is critical. The present study attempted a cost-effectiveness analysis of four interventions, including family-based, individual, and group cognitive behavioral approaches, for adolescents with a substance use disorder. The results indicated that treatment costs varied substantially across the four interventions. Moreover, family therapy showed significantly better substance use outcome compared to group treatment at the 4-month assessment, but group treatment was similar to the other interventions for substance use outcome at the 7-month assessment and for delinquency outcome at both the 4- and 7-month assessments. These findings over a relatively short follow-up period suggest that the least expensive intervention (group) was the most cost-effective. However, this study encountered numerous data and methodological challenges in trying to supplement a completed clinical trial with an economic evaluation. These challenges are explained and recommendations are proposed to guide future economic evaluations in this area.

Mixed-effects logistic regression for estimating transitional probabilities in sequentially coded observational data.

This article demonstrates the use of mixed-effects logistic regression (MLR) for conducting sequential analyses of binary observational data. MLR is a special case of the mixed-effects logit modeling framework, which may be applied to multicategorical observational data. The MLR approach is motivated in part by G. A. Dagne, G. W. Howe, C. H. Brown, & B. O. Muthén (2002) advances in general linear mixed models for sequential analyses of observational data in the form of contingency table frequency counts. The advantage of the MLR approach is that it circumvents obstacles in the estimation of random sampling error encountered using Dagne and colleagues' approach. This article demonstrates the MLR model in an analysis of observed sequences of communication in a sample of young adult same-sex peer dyads. The results obtained using MLR are compared with those of a parallel analysis using Dagne and colleagues' linear mixed model for binary observational data in the form of log odds ratios. Similarities and differences between the results of the 2 approaches are discussed. Implications for the use of linear mixed models versus mixed-effects logit models for sequential analyses are considered.

Engaging resistant adolescents in drug abuse treatment.

In the first phase of a two-part treatment development study, families with a treatment-resistant drug-abusing adolescent (n = 42) were offered 12 sessions of Community Reinforcement and Family Training (CRAFT). This parent-focused intervention was designed to help parents facilitate their adolescents' entry into treatment, to support adolescents' subsequent behavior change, and to improve parent and family functioning. In the second phase, successfully engaged adolescents (n = 30) were offered 12 sessions of a multicomponent individual cognitive-behavioral therapy (CBT) targeting substance use and related problem behaviors. For parents and adolescents, measures were collected on pretreatment and posttreatment, with an additional follow-up assessment for parents at 3 months after treatment. Parents on CRAFT intervention experienced a significant reduction in negative symptoms, and 71% of parents were successful in engaging their resistant youths in treatment. The CBT intervention for engaged youths was associated with a statistically significant, but not clinically significant, reduction in marijuana use.