1. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. Percentage Arrested During 12 Month Follow-Up Percentage Placed on Probation During 12 Month Follow-Up * * p<.05 MDFTGroup * *

14. 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

15. 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

16. 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)

17. Proportion of Adolescents Abstaining from Cannabis Use

18. 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

19. 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

20. CYT Study: Average Episode Cost of Drug Treatment Dennis et al., in press, Journal of Substance Abuse Treatment

21. 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

22. Change in Drug Use Frequency

23. Change in School Absences During follow-up, residential youth increase school absences, whereas MDFT participants decrease absences

24. Change in School Suspensions Proportion of youth suspended decreases in MDFT, but increases among residential treatment youth

25. 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

26. 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

27. 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

28. 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