Completed MDFT Studies

An Examination of the Efficacy of Family-Based Treatment for Adolescent Drug Abuse

H. Liddle & G. Dakof

NIDA, Grant #1 P50 DA11328-01

Aims
This clinical trial examined the efficacy of Multidimensional Family Therapy (MDFT) as compared to two, alternative treatments for adolescent substance abuse, Adolescent Group Therapy (AGT) and a Multifamily Education Intervention (MFEI).

Procedures
One hundred and eighty-two marijuana and alcohol-abusing adolescents were randomized to MDFT, AGT, or MFEI and followed for up to a year. Participants were primarily male, and came largely from low income, single parent households; approximately 50% were minorities. Youth were primarily polydrug users, coupling near daily use of marijuana and alcohol with weekly use of cocaine, hallucinogens, or amphetamines, and averaged 2.5 years of drug abuse.

Findings

  • MDFT was most effective in retaining youth in treatment, with 73% of MDFT youth completing treatment as compared to 65% of MFEI and 52% of AGT youth.
  • Youth who received MDFT showed the greatest reductions in drug use and maintained their improvements through the 12 month follow-up
  • Forty-five percent of adolescents in MDFT (versus 32% in AGT and 26% in MFEI) demonstrated clinically significant change in drug use, such that their drug use profiles at follow-up fell below intake eligibility criteria.
  • Only MDFT participants reported significant improvement in family competence and school functioning. 

Conclusions/Implications
Overall improvement was evident among youth in all 3 treatments, but the greatest and most consistent improvement was seen among those who received MDFT, suggesting that MDFT is a promising approach for ameliorating adolescent substance abuse and associated behavior problems. The pattern of results suggests than an important ingredient for the successful treatment of adolescent substance use is the simultaneous focus on the family and the individual youth (see also Dakof et al., 2001).

References
Dakof, G. A., Tejeda, M., & Liddle, H. A. (2001). Predictors of engagement in adolescent drug abuse treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1-8.

Liddle, H. A., Dakof, G. A., Parker, K., Diamond, G. S., Barrett, K., & Tejeda, M. (2001). Multidimensional family therapy for adolescent substance abuse: Results of a randomized clinical trial. American Journal of Drug and Alcohol Abuse, 27, 651-687.


An Examination of the Efficacy of Two Empirically Supported, State of the Art Treatments-MDFT vs. CBT

H. Liddle & G. Dakof

NIDA, Grant #1 P50 DA11328-01

Aims
This clinical trial examined the efficacy of Multidimensional Family Therapy (MDFT) versus individual, Cognitive Behavioral Therapy (CBT) in the treatment of adolescent substance abusers.

Procedures
Two hundred twenty-four adolescents referred to a community clinic for substance abuse treatment were randomly assigned to MDFT or CBT and followed for one-year post treatment discharge. The sample consisted primarily of male, African American drug using teens from low income families.  Most were referred from the juvenile justice system, with 78% meeting DSM criteria for substance dependence and 17% meeting criteria for substance abuse.  Extensive monitoring and adherence analyses were conducted to ensure that both treatments were delivered with high fidelity.

Findings

  • MDFT and CBT were both effective in decreasing substance related problems as well as marijuana and hard drug use from intake through a 12-month follow-up.
  • However, only MDFT produced sustained improvements after termination in that adolescents receiving MDFT showed a continued reduction in their substance related problems post discharge whereas youth receiving CBT showed a gradual increase following treatment termination.
  • MDFT was also more effective than CBT in reducing hard drug use.
  • Finally, an abstinence analysis indicated that youth receiving MDFT were more likely to abstain from drug use over the previous month at the 12 month follow-up.

Conclusions/Implications
Both treatments emerged as at least somewhat efficacious in decreasing substance abuse and associated problems. However, MDFT was more effective in maintaining gains through the one-year follow up period. The advantage to MDFT, then, concerns its ability, in comparison to CBT, to retain the effects of treatment beyond the treatment phase.

References
Liddle, H. A., Dakof, G. A., Turner, R. W., Henderson, C. E., & Greenbaum, P. (2004). Treating adolescent drug abuse: A comparison of Cognitive Behavioral Therapy and Multidimensional Family Therapy.  Manuscript submitted for publication.

Liddle, H. A. (2002b). Advances in family-based therapy for adolescent substance abuse: Findings from the Multidimensional Family Therapy research program. In L. S. Harris (Ed.), Problems of drug dependence 2001: Proceedings from the 63rd annual scientific meeting (NIDA Research Monograph No. 182, NIH Publication No. 02-5097; pp. 113-115). Bethesda, MD: National Institute on Drug Abuse.

Alternative to Residential Treatment

H. Liddle, G. Dakof, & C. Rowe

NIDA, Grant #1 P50 DA11328-01

Aims
This ongoing study is among the first controlled trials to compare residential drug treatment for adolescent substance abusers with an outpatient treatment alternative -- an intensive version of MDFT designed to approximate the treatment intensity of residential treatment.

Procedures
One hundred thirteen youth meeting criteria for residential treatment were randomized to receive an intensive outpatient version of MDFT or residential treatment. Participants had a long history of school failure, legal problems, and previous treatment All youth were diagnosed with a comorbid psychiatric disorder.  Most were male and Hispanic.  The families of these adolescents also have had serious difficulties including alcohol and drug abuse problems, legal problems, and mental health problems.

  • Preliminary Findings
    MDFT was more successful than residential treatment in engaging and retaining youth and their families in treatment.
  • Ninety-five percent of adolescents receiving MDFT completed 90 days of treatment as compared to 58% of teens in residential treatment.
  • Eighty-eight percent completed 180 days as compared to 24% of teens in residential treatment.
  • Both conditions significantly reduced marijuana use and externalizing problems from treatment intake to discharge.
  • Following discharge, MDFT youths continue to show reductions in marijuana use and externalizing problems, whereas adolescents receiving residential treatment show increased marijuana use and externalizing problems.
  • MDFT costs much less per week of treatment than residential treatment ($384 vs. $1068)

Conclusions/Implications
These results are promising in demonstrating that an outpatient alternative to residential treatment can feasibly be implemented with very low treatment attrition.  Although both MDFT and residential treatment are effective in producing improvement during treatment, in the year following treatment entry MDFT has thus far produced superior results.  Given the lower costs of MDFT, these findings suggest that MDFT may also be more cost beneficial than residential care.

References
Dakof, G. A., Rowe, C. L., Henderson, C. E., & Liddle, H. A. (2003, March). Engaging and retaining drug abusing youth in home-based Multidimensional Family Therapy. Poster presented at the NIMH/NIDA/NIAAA Conference, "Beyond the Clinic Walls: Expanding Mental Health, Drug and Alcohol Services Research outside the Specialty Care System." Washington, D.C.  

Liddle, H. A., Dakof, G. A., & Henderson, C. E. (2002). Controlled trial of a family-based alternative to residential drug treatment for co-morbid adolescent substance abusers: Preliminary findings. Poster presented at the 2002 CPDD Annual Conference. Quebec, Canada.

Transporting Family Therapy to Adolescent Day Treatment

NIDA, Grant # R01 DA13089-01

H. Liddle, G. Dakof, & C. Rowe

Aims
Despite tremendous advances in the past two decades in developing and establishing an empirical base for family-based substance abuse interventions for adolescents, these treatments remain inaccessible to and underutilized by most clinicians in community settings. The current study examined whether MDFT could be adapted and transported into an existing adolescent day treatment program.

Procedures
The study employed a 4-phase interrupted time series design. During a 12-month Baseline/ Pre-Exposure phase (Phase I), multiple aspects of the existing day treatment program were simply observed and assessed. This was followed by a 6-month Training/Exposure phase (Phase II) during which the day treatment program staff and administrators were intensively trained in the MDFT model. The next 12-month Implementation phase (Phase III) involved regular supervision and evaluation of the delivery of the treatment and patient outcomes. In the final 12-month Durability/ Practice phase (Phase IV), regular supervision by the MDFT team was withdrawn although assessments continued.

Preliminary Findings:
Therapists showed a dramatic change in practice patterns from pre- to post-MDFT training, i.e., Baseline to Implementation, including:

  • A 36% increase in the number of individual sessions held
  • A 150% increase in family therapy sessions held
  • A 390% increase in contacts with juvenile justice personnel
  • A 1,400% increase in contacts with school personnel.

Adolescents also showed improved outcomes, with a 50% reduction if drug use during the Implementation phase as compared to a 25% reduction under usual conditions, during the Baseline phase.

Day treatment staff reported that the program was more organized and that they were clearer about program expectations during Implementation.

Changes in therapists’ practice patterns were significantly correlated with reductions in adolescents’ self-reported marijuana use.

From Implementation to Durability, gains in practice patterns remained relatively stable or increased (i.e., the number of individual sessions held and contacts with school personnel)

Implications/Conclusions
This study showed that MDFT could be successfully adapted and transported into community drug treatment settings, and that this dissemination effort had a positive impact on therapist practice patterns, the organizational climate of the treatment program, and client outcomes.  In addition, we see initial evidence indicating that changes in therapist practice patterns were maintained following the withdrawal of supervision and monitoring.

References
Liddle H. A., Rowe, C. L., Quille, T. J., Dakof, G. A., Mills, D. S., Sakran, E., & Biaggi, H. (2002).   Transporting a research-based adolescent drug treatment into practice. Journal of Substance Abuse Treatment, 22(4), 231-243.

Early Intervention for Adolescent Substance Abuse

CSAT, Grant # KD1 TI11871-01

H. Liddle, G. Dakof, C. Rowe, & C. Henderson

Aims
This ongoing study was the first to examine the potential of MDFT to serve as an early intervention approach for young adolescents who were referred to a community treatment center for problems related to substance use.

Procedures
Eighty adolescents (average age of 14) were randomly assigned to MDFT or a theory-driven, manual-guided peer group therapy.  The sample was primarily male, minority, and low income.

Findings

  • MDFT was more effective than peer group therapy in retaining youth for the 12-week duration of treatment (97% vs. 27%).
  • MDFT was more effective than peer group therapy in reducing teens’ substance use over the course of the relatively short term treatment.
  • MDFT was also able to alter developmental trajectories in four targeted risk domains: individual, family, peer, and school.
  • There also was a trend favoring MDFT in terms of reducing delinquent behavior.

Conclusions/Implications
This study provides further support for MDFT not only as a treatment model for youth with established substance abuse and related problems, but also as an appropriate and promising intervention for samples at high risk of worsening substance abuse and delinquency (CSAP 2003).

References
Dakof, G. A., Rowe, C. L., Henderson, C. E., & Liddle, H. A. (2003, March). Engaging and retaining drug abusing youth in home-based Multidimensional Family Therapy. Poster presented at the NIMH/NIDA/NIAAA Conference, "Beyond the Clinic Walls: Expanding Mental Health, Drug and Alcohol Services Research outside the Specialty Care System." Washington, D.C.

Liddle, H. A., Rowe, C. L., Dakof, G. A., Ungaro, R. A., & Henderson, C. E. (2004). Early intervention for adolescent substance abuse: Pretreatment to posttreatment outcomes of a randomized controlled trial comparing Multidimensional Family Therapy and peer group treatment. Journal of Psychoactive Drugs, 36, 49-63.

Multicomponent Family-Based Intervention for Adolescent Drug Abuse

NIDA, Grant # R01 DA09424

H. Liddle

This project, a Stage I NIDA-funded treatment development study, revised our empirically -established family-based treatment, Multidimensional Family Therapy (MDFT). The study identified individual and family processes related to success and non-success in the treatment of adolescent drug abuse. Through intensive analyses of archival videotape data, three areas were investigated: (a) therapeutic alliance of the therapist and adolescent, (b) in-treatment changes in parenting practices that are related to adolescent development generally, and adolescent drug use, in particular, and (c) culturally-related responses to treatment for adolescent drug abuse. The study also specified a module to alter the ecology of the treatment delivery system by having the intervention be primarily a home-based treatment and offering case management services. An enhanced, comprehensive, integrative, multicomponent intervention for adolescent drug abusers was created and tested in a small scale pilot study. 

Therapy Development for Female Adolescent Drug Abuse

NIDA, Grant # R03 DA 11107

G. Dakof 

This Stage 1 NIDA-funded treatment development study was intended to increase the effectiveness of drug abuse treatment for adolescent women. It identified clinically relevant concomitants of adolescent drug abuse in females and males in order to identify critical factors of success and failure in the treatment of substance abuse in adolescent women, and to establish a foundation for the development of a gender-sensitive family therapy. In Study 1, with 90 males and 90 females, archived data was used to gain an understanding of the differences between male and female adolescent substance abusers, predicting that young women referred for treatment will evidence more severe family dysfunction and higher rates of depression than the males in our study. Study 2 identified predictors of success for females as compared with males, using a case analysis methodology. 

Treatment Adherence in Adolescent Drug Abuse Treatment

NIDA, 1R01 DA14571

A. Hogue

A process-based adherence evaluation confirmed that MDFT can be implemented with a high degree of treatment integrity (Hogue et al., 1998). This study compared intervention techniques exhibited by MDFT therapists to those exhibited by cognitive-behavioral therapists during a randomized efficacy trial for treating adolescent substance abuse. Nonparticipant coders observed videotapes of randomly selected sessions from the MDFT and cognitive-behavioral conditions using an adherence evaluation instrument designed to identify therapeutic techniques and facilitative interventions associated with the two treatment models. Results demonstrated that MDFT therapists reliably utilized the core systemic interventions prescribed by the model: shaping parenting skills, preparing for and coaching multiparticipant interactions in session, and targeting multiple family members for change.  Moreover, MDFT therapists focused significantly on establishing a supportive therapeutic environment, encouraging discussion and expression of affect, engaging clients in setting a collaborative treatment agenda, and exploring themes related to normative adolescent development.  This study illustrates how process-oriented adherence evaluation can contribute to treatment development and therapist training for well-specified therapy models. 

Comorbidity and Adolescent Drug Treatment

NIDA, Grant # 1 R03 DA 13657-01

C. Rowe

This NIDA-funded study investigates the variations in response to treatment based on the type and severity of adolescent substance abusers?comorbid psychiatric problems. 183 adolescents with a substance use disorder who participated in a randomized clinical trial comparing family therapy and individual cognitive-behavioral therapy will comprise the study sample. The participants in this study are largely low-income, minority youth with high rates of comorbid disorders. Adolescents and their parents were interviewed at intake to treatment, at the end of treatment, and at 6 and 12 month follow up to determine the level of their substance use and psychiatric symptoms, as well as family problems including parental psychopathology. The purpose of the study is to determine whether the presence of psychiatric comorbidity is related to changes in the rate of recovery for adolescents in treatment for drug abuse. The study has three aims: 1) To examine whether specific psychiatric diagnoses are related to changes in adolescent drug use trajectories from intake to the end of treatment and up to 6 month and 12 month follow up; 2) To examine whether severity of psychiatric comorbidity moderates changes in drug use and psychiatric symptom trajectories for adolescent substance abusers; and 3) To examine whether change in parental psychopathology is related to change in adolescent substance abuse and psychiatric comorbidity, and whether treatment modality moderates this relationship.