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Reducing adolescent cannabis abuse and co-occurring problems through family-based intervention Howard Liddle, Ed.D., Cynthia Rowe, Ph.D., Gayle Dakof, Ph.D., & Craig Henderson, Ph.D. Center for Treatment Research on Adolescent Drug Abuse University of Miami Miller School of Medicine Presented at the College on Problems of Drug Dependence Annual Convention; Orlando, FL; June 22, 2005
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Adolescent Cannabis Abuse Serious public health issue Linked to a range of other problems Increasing need for drug treatment Treatment need far surpasses available services for youth Research-supported models exist but are not practiced in community settings where they’re needed
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Risk and Protective Factors Multiple interacting risk factors for adolescent cannabis abuse: Family conflict/ poor communication Parenting skills deficits Negative peer relationships School failure and disconnection Behavior problems Emotional reactivity
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Development of Cannabis Abuse Cannabis experimentation is developmentally normative for teens Cannabis abuse/dependence is predicted by early childhood risk Cannabis abuse compromises emotional/social/cognitive development Early cannabis abuse linked to long- term deficits across domains
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Families and Drug Abuse Family factors are strong predictors of adolescent cannabis abuse Parenting skills deficits Poor communication Parental substance abuse/psychopathology Conflict/disconnection in family Families are a primary context for development in adolescence, but there are others (schools, peers) Effective interventions go beyond a uni- dimensional theory of change
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Integrative family-based drug treatment Addresses multiple risk factors Multisystemic assessment & intervention Flexibility in different service settings Well specified, adaptable protocols Now recognized as a “Best Practice” (NIDA, USDHHS, Drug Strategies, CSAT) Multidimensional Family Therapy
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MDFT Core Processes Facilitation of development Working the four corners: adolescent, parent, family, and extrafamilial interventions Building adolescents’ connection to school, work, family, and prosocial outlets/friends Improving parents’ functioning: decreasing stress; addressing parenting practices Changing family environment Targeting multiple domains of functioning in addition to reducing drug use
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Study 1: MDFT vs. Group and Multifamily Education 182 adolescents randomized to MDFT, adolescent group therapy, or multifamily educational intervention Sample Characteristics 13 - 18 years old (M=16); mostly male (80%) 51% White/non-Hispanic, 18% African American, 15% Hispanic, 6% Asian Average annual family income = $25,000 48% from single parent homes 61% involved with juvenile justice at intake
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Pre-Tx Post-Tx 6 month 12 month MDFT vs. Peer Group and Multifamily Education: Substance Use Outcomes Drug Use MDFTGroup MFET Liddle, Dakof et al. Am J Drug & Alcohol Abuse (2001)
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Study 2: MDFT with Young Adolescent Cannabis Abusers 83 young adolescents randomized to MDFT or adolescent peer group treatment Sample Characteristics 11 - 15 years old (M=13.7) Primarily male (73%) and minority youth (42% Hispanic; 38% African American) Average annual family income = $19,000 53% from single parent homes 47% substance dependent; 16% substance abusing Referred from juvenile justice (45%)/ schools (41%) First treatment episode for 98% of adolescents
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CH Change in Cannabis Use Trend for more MDFT participants to abstain from drug use Of those using drugs, MDFT participants decrease more rapidly. Continuous data log transformed More MDFT participants report abstaining from drug use at intake
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Percentage Arrested During 12 Month Follow-Up Percentage Placed on Probation During 12 Month Follow-Up * * p<.05 MDFTGroup * *
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Change in Self-Reported Mental Health Symptoms MDFT participants decrease GMDI more rapidly. GMDI only assessed at Intake and 6 and 12 month follow-ups; consequently, data were analyzed using conventional latent growth curve modeling
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Study 3: MDFT vs. Individual Cognitive Behavioral Therapy (CBT) 224 adolescents randomized to MDFT or individual Cognitive Behavioral Therapy (CBT) Sample Characteristics Between 13 and 17 years (M=15.4) Primarily male (81%) and African American (72%) Family income = $13,000; 58% with single parents 88% substance dependent; 15% substance abusing 60% had an externalizing disorder/ 28% int. disorder Referred from juvenile justice (48%)/ social services (36%) 73% involved in the juvenile justice system at intake
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Change in Cannabis Use Frequency Cannabis use after the 6- month follow- up leveled off for CBT youth MDFT youth continue to improve after the 6-month follow-up (4-6 Months Post Baseline) (Post Discharge)
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Proportion of Adolescents Abstaining from Cannabis Use
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Study 4: Cannabis Youth Treatment Study MDFT one of 5 CYT treatments; tested at two sites (one urban and one rural) 12 – 18 year olds with marijuana use disorders Primarily male (83%) and White/non-Hispanic (61%); 30% African American 50% from single parent homes 46% cannabis dependent; 40% cannabis abusing 71% reported weekly or more use of any drug 61% had an externalizing disorder/ 33% int. disorder 62% involved with juvenile justice at intake
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CYT Study: Change in Cannabis Use 43% reduction from Intake to 6-Month Follow-Up 41% reduction from Intake to 12-Month Follow-Up Reductions at 12 Month Follow-Up maintained through 30 months 0 0.04 0.08 0.12 0.16 0.2 Intake 3 mths6 mths9 mths 12 mths15 mths18 mths21 mths24 mths27 mths30 mths
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CYT Study: Average Episode Cost of Drug Treatment Dennis et al., in press, Journal of Substance Abuse Treatment
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Study 5: Intensive MDFT as an Alternative to Residential Treatment 113 adolescents randomized to residential treatment or intensive in-home MDFT 13 - 17 year olds referred for residential treatment Primarily male (75%) and Hispanic (69%) Family income = $18,800 43% from single parent homes 90% substance dependent; 25% substance abusing Average of 3.6 DSM-IV diagnoses (78% CD) Heavily juvenile justice involved (81%) Extensive family problems: 54% familial substance abuse; 58% familial CJ involvement
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Change in Drug Use Frequency
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Change in School Absences During follow-up, residential youth increase school absences, whereas MDFT participants decrease absences
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Change in School Suspensions Proportion of youth suspended decreases in MDFT, but increases among residential treatment youth
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Relative Costs of MDFT and Residential Treatment MDFT (Intensive Outpatient) Residential Treatment Weekly Cost of Treatment Per Patient $384.$1,068. Zavala, French, et al. (in press), Journal of Substance Abuse Treatment
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Impact of MDFT on Alcohol and Polysubstance Use Many youth in MDFT trials have had a substance use disorder other than alcohol or cannabis at intake 50% (Liddle et al., 2001) 32% (Liddle, 2002b) 38% (Liddle & Dakof, 2002) MDFT is more effective than comparison treatments in reducing more severe forms of ‘other’ drug use (most frequently amphetamine, barbiturates, and cocaine) and alcohol use
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MDFT and CBT Average Change in Hard Drug Use Intake to 12 Month Follow-Up (4-6 Months Post Baseline) (Post Discharge) MDFT youth decrease hard drug use, whereas CBT youth increase
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Summary and Conclusions Adolescent cannabis abuse is a serious clinical problem for many teens Those at greatest vulnerability for chronic cannabis abuse are those with multiple problems early in life, particularly family dysfunction Comprehensive interventions are needed to target the multiple systems that maintain symptoms MDFT is effective with a range of adolescent cannabis abusers MDFT impacts cannabis use as well as delinquency, school problems, and mental health symptoms The model’s flexibility and relative economic costs and benefits increase its implementation potential
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