Substance abuse

Liddle and Dakof's (1995) comprehensive review of the status of family-based treatment for drug abuse concluded that this modality offered a "promising, but not definitive" approach to treating drug abuse among adolescents and adults. Less than a decade later, significant progress can be seen in the treatment of drug abuse problems using family-based approaches, particularly with adolescents. Family-based treatments are currently recognized as among the most effective approaches for adolescent drug abuse. Family-based treatment of adult drug abuse problems has also advanced in important ways with the recent systematic application and testing of engagement techniques and behavioral couples therapy approaches. The current review characterizes and discusses the developmental status of this subspecialty and outlines areas in which continued research attention is needed.     

EFFICACY OF FAMILY THERAPY FOR DRUG ABUSE: PROMISING BUT NOT DEFINITIVE

Drug abuse is an enormous public health problem with consequences not only for individuals using drugs but also for families, communities, and society. Moreover, research evidence and clinical experience agree that drug abuse is one of the more difficult problems to treat. Despite considerable research on the connection between family factors and drug use, and the existence of family therapy models for drug abuse, comparatively few controlled efficacy studies have been conducted. This article presents a critical review of controlled treatment outcome research in the area of family therapy for drug abuse in both adults and adolescents. A number of studies from different clinical research groups demonstrate that different versions of family intevention can engage and retain drug users and their families in treatment, significantly reduce drug use and other related problem behaviors, and enhace particular domains of prosocial functioning. Moreover, a smaller number of comparative efficacy studies have shown family therapy to be more effective than nonfamily therapies. Family therapy of adolescent drug abuse is more developed at present than family therapy of adult drug abuse. Although the results of the reviewed studies are promising, a blanket confirmation of family therapy's efficacy for drug abuse cannot be made at this time because of the relatively small number of studies and the noted methodological limitations of the studies published to date. Nonetheless, substantial progress in this clinical research area has occurred, and if research and funding support continue or can expand, significant breakthroughs in the treamtment of drug abuse with family-based treatments are possible.     

A family-based, developmental-ecological preventive intervention for high-risk adolescents

Family-based preventive intervention has emerged as a promising modality for preventing antisocial behavior problems in youth. This article introduces an intensive, family-based preventive intervention for high-risk adolescents: Multidimensional Family Prevention. Multidimensional Family Prevention combines the advantages of standard prevention models (curriculum based and protection focused) with those of psychosocial treatment models (assessment based and problem focused). The model's main features are described: theoretical foundations (risk and protection theory, developmental psychopathology, ecological theory), guidelines for constructing a multidomain prevention program (family and peer relationships, school and prosocial activities, drug use and health issues, cultural themes), and strategies for tailoring and implementing five flexible intervention modules (adolescent, parent, interactional, extended family, extrafamilial). Implemented in the family's home, the intervention works to create a resilient family environment that supports the basic adolescent developmental goals of renegotiated attachment bonds within the family and durable connections with prosocial institutions.     

Multidimensional Family Therapy: A Science‐Based Treatment System

MDFT is a family‐based intervention for adolescent substance abuse and associated mental health and behavioural problems (Liddle, 2010). Integrative in several ways, MDFT uses an ecological or contextual conceptual framework to understand the developmental tasks of teens and their families. Research‐derived knowledge about risk and protective factors, and proximal causes, correlates and contributors to adolescent drug and related problems inform clinical thinking and interventions with every case. A multisystems approach, MDFT assesses and intervenes in four areas: (1) the adolescent as an individual and a member of a family and peer network; (2) the parent(s), both as individual adults and in his or her role as mother; father or caregiver; (3) the family environment and family relationships, as manifested in day‐to‐day family transactional patterns; and (4) extrafamilial sources of influence such as peers, school and juvenile justice. Interventions are made within and coordinated across domains. Progress in one area or with one person has implications for and use in others. Individual meetings with parent(s) and teen set the stage for family sessions, and family meetings may offer content and new outcomes that need to be brought to extrafamily meetings with juvenile justice or school personnel. MDFT was developed and tested as a treatment system rather than a one‐size‐fits‐all approach. A treatment system offers different versions of a clinical model that vary according to factors such as clinical sample characteristics (older versus younger adolescents, juvenile justice involved versus no involvement in juvenile justice systems), and treatment parameters (type of clinical setting and treatment dose).     

When the levee breaks: treating adolescents and families in the aftermath of hurricane katrina

Hurricane Katrina brought to the surface serious questions about the capacity of the public health system to respond to community-wide disaster. The storm and its aftermath severed developmentally protective family and community ties; thus its consequences are expected to be particularly acute for vulnerable adolescents. Research confirms that teens are at risk for a range of negative outcomes under conditions of life stress and family disorganization. Specifically, the multiple interacting risk factors for substance abuse in adolescence may be compounded when families and communities have experienced a major trauma. Further, existing service structures and treatments for working with young disaster victims may not address their risk for co-occurring substance abuse and traumatic stress reactions because they tend to be individually or peer group focused, and fail to consider the multi-systemic aspects of disaster recovery. This article proposes an innovative family-based intervention for young disaster victims, based on an empirically supported model for adolescent substance abuse, Multidimensional Family Therapy (MDFT; Liddle, 2002). Outcomes and mechanisms of the model's effects are being investigated in a randomized clinical trial with clinically referred substance-abusing teens in a New Orleans area community impacted by Hurricane Katrina.     

The intergenerational transmission of health-risk behaviors: adolescent lifestyles and gender moderating effects.

The present longitudinal study of 330 adolescents used structural equation models to investigate whether (1) health-risk lifestyles exist among adults and adolescents, (2) parents' health-risk behaviors influence adolescents' health-risk behaviors, and (3) intergenerational transmission occurs by way of a health-risk lifestyle, by direct transmission of specific behaviors, or through both mechanisms. To address these questions, we estimated several models. The findings were generally supportive of the expectations. Results of single factor measurement models provided modest evidence for the existence of an underlying health-risk lifestyle factor among parents and adolescents. Results of structural equation models also demonstrated that parents' health-risk behaviors were transmitted to adolescents both at the lifestyle factor level and the unique component level. These associations prevailed even after controlling for family social status. However, parents' health-risk lifestyles mediated the effect of family social status on adolescents' lifestyles, net of the direct effect of family social status on adolescents' lifestyle. In these two-parent families, the effects of parents' health-risk lifestyles on adolescents seems to have gender symmetry. The findings of the separate models for boys and girls demonstrated that (1) fathers' health-risk lifestyle affected only boys' health-risk lifestyle, whereas (2) mother's health-risk lifestyle affected only girls' health-risk lifestyle. A similar gender moderating effect was not found for specific health-risk behaviors. Implications of these findings for future research and theoretical development are discussed.     

Empirically supported family-based treatments for conduct disorder and delinquency in adolescents

Several family-based treatments of conduct disorder and delinquency in adolescents have emerged as evidence-based and, in recent years, have been transported to more than 800 community practice settings. These models include multisystemic therapy, functional family therapy, multidimensional treatment foster care, and, to a lesser extent, brief strategic family therapy. In addition to summarizing the theoretical and clinical bases of these treatments, their results in efficacy and effectiveness trials are examined with particular emphasis on any demonstrated capacity to achieve favorable outcomes when implemented by real-world practitioners in community practice settings. Special attention is also devoted to research on purported mechanisms of change as well as the long-term sustainability of outcomes achieved by these treatment models. Importantly, we note that the developers of each of the models have developed quality assurance systems to support treatment fidelity and youth and family outcomes; and the developers have formed purveyor organizations to facilitate the large-scale transport of their respective treatments to community settings nationally and internationally.     

Engagement in Mental Health Treatment Among Adolescents and Young Adults: A Systematic Review

The purpose of the present study is to review empirical evidence of the effects of interventions designed to improve engagement in mental health services among adolescents, young adults and their families. Investigators searched relevant databases, prior reviews, and conducted hand searches for intervention studies that met the following criteria: (1) examined engagement in mental health services; (2) included a comparison condition; and (3) focused on adolescents and/or young adults. Effect sizes for all reported outcomes were calculated. Thirteen studies met inclusion criteria. Conceptualizations of engagement and measurement approaches varied throughout studies. Approaches to improving engagement varied in effectiveness based on level of intervention. Individual level approaches improved attendance during the initial stage of treatment. While family level engagement interventions increased initial attendance rates, the impact did not extend to the ongoing use of services, whereas service delivery level interventions were more effective at improving ongoing engagement. The review illuminated that engagement interventions framed in an ecological model may be most effective at facilitating engagement. Implications for future research and practice are discussed.     

Risky alcohol use, peer and family relationships and legal involvement in adolescents with antisocial problems

The aim of the study was to examine risk and vulnerability factors contributing to problems with alcohol use in adolescence. Data relating to seven life areas (medical status, school status, social relationships, family background and relationships, psychological functioning, legal involvement, and alcohol use) was gathered using the ADAD (Adolescent Drug Abuse Diagnosis) interview. A total of 1163 Swedish adolescents (809 boys and 354 girls) between the ages of 12 and 20 years old were interviewed. All had antisocial problems and were detained at special youth homes. It was found that for those aged between 12 and 18 years, the general risk factors for alcohol use were leisure and peer problems, problems associated with family background and relationships, and criminal behavior. These results suggest that drug abuse treatment planning should focus on altering the predisposing factors that exist in these domains. It was also found that the ADAD problem areas seem to be most useful as prognostic indicators of treatment outcome for adolescents with antisocial problems who are under 18 years of age.     

Getting reluctant substance abusers to engage in treatment/self-help: a review of outcomes and clinical options

This review examines the results from 19 outcome studies, involving 1,501 cases, within 10 different clinical approaches to getting alcohol or drug abusers to engage in treatment or self-help. Each approach is summarized and its "success rate(s)" presented. Comparisons are made across various subcategories, such as alcohol vs. drug abusers, adolescents vs. adults, and experimental conditions vs. controls. A distinction is drawn between "Dual-Purpose" approaches, which combine engagement with counseling of the concerned person who originally sought help for the substance abuser, and "Engagement-Primary" approaches, which generally confine their efforts (through working with family members and others) to getting the substance abuser into treatment/self-help. "Best bet" clinical options are presented in terms of which particular approach appears to have the edge with which kind of substance abuser.     

Family histories and multiple transitions among homeless young adults: Pathways to homelessness

This study explored the early family histories of homeless young adults, the types and number of transitions they experienced, and their pathways to the street. Intensive qualitative interviews were audio taped and transcribed with 40 homeless young adults 19 to 21 years of age in the Midwest. Findings show that family backgrounds were generally characterized by substance use, child maltreatment, and witnessing violence, all of which provide social context for understanding why so many of these young people opted to leave home in search of an alternative living situation. The current findings also reveal that while some young adults ran away from home as adolescents, others were “pushed out” (i.e., told to leave), or removed by state agencies. Current study findings illustrate that young adults' trajectories are marked by multiple living arrangements such as home, foster care, detention facility, and drug rehabilitation. Overall, study results show that young adults' family histories place them on trajectories for early independence marked by multiple transitions and numerous living situations, culminating in lack of a permanent residence to call home.     

Affective disorders

Depression is a heterogeneous disorder with lifetime prevalence of "major depressive disorder" estimated to be 16.2%. Although the disorder is common and impairs functioning, it often goes untreated, with less than adequate response even when treated. We review research indicating the likely value of utilizing currently available, well-validated, couple- and family-based treatments with depressed individuals, and we provide empirically based treatment decision rules to guide effective application of marital and family interventions for depression in clinical practice. We suggest that traditional forms of couple-based intervention may be most appropriate for discordant, depressed couples, whereas nondiscordant, or mildly distressed, depressed couples may respond well to forms of intervention that have become available more recently and which focus on strengthening the dyad as a source of support. We also discuss parent training as an intervention for depression and describe briefly the directions for future research to enhance couple-based treatment for depression.     

The Role of Stress,Family Coping,Ethnic Identity,and Mother-Daughter Relationships on Substance Use Among Gang-Affiliated Hispanic Females

ABSTRACT

Hispanic adolescent females are the largest group of minority adolescents in the nation and appear to be at great risk for substance use. This research is based on data generated from a cross-sectional study of 150 Mexican American gang-affiliated adolescent females to predict substance-use recurrence. Findings reveal that positive family relationships, and in particular, mother-daughter relationships are protective factors for alcohol- and tobacco-use recurrence. Furthermore, the ability of the immediate family to cope with difficulties, stress, and conflicts were significant in averting illicit drug recurrence. This research provides evidence of the role of the family as a protective factor among these adolescents, despite their gang affiliation and street orientation. Discussed is how these findings contribute to formulating effective intervention, prevention, and treatment responses aimed at this “beyond risk” population.     

Coping with Family Conflict and Economic Strain: The Adolescent Perspective

This study tested two models of family economic problems and adolescent psychological adjustment. Using adolescents’ survey data and information regarding school lunch program enrollment, the associations among family SES, perceived economic strain, family conflict, and coping responses were examined in a sample of 364 adolescents from rural New England. Two theoretical models were tested using structural equation modeling — one tested coping as a mediator of the stress – psychopathology relation and the other tested coping as a moderator. Results revealed that family economic hardship was related to aggression and anxiety/depression primarily through two proximal stressors: perceived economic strain and conflict among family members. Family conflict partially mediated the relation between economic strain and adolescent adjustment, and coping further mediated the relation between family conflict and adjustment. These analyses identified two types of coping that were associated with fewer anxiety/depression and aggression problems in the face of these stressors — primary and secondary control coping. Although primary and secondary control coping were associated with fewer adjustment problems, youth who were experiencing higher amounts of stress tended to use less of these potentially helpful coping strategies and used more of the potentially detrimental disengagement coping. The models did not differ according to the age or gender of the adolescents, nor whether they lived with two parents or fewer. No support was found for coping as a moderator of stress. Implications of these findings and suggestions for future research involving coping with economic stressors are reviewed.     

Sociodemographic and maternal behaviors in younger and older pregnant adolescents

Sociodemographic and maternal behaviors were examined in a group of 295 (59%) younger adolescents 10–17 years of age, and compared to a group of older adolescents over 18 (n=203, 41%). Younger adolescents were more likely to be single, of minority group status, family dependent, and poor users of contraceptives. Older adolescents had higher rates of substance abuse, treated psychiatric problems, and abortion histories. Both groups reported parental drinking problems, parental divorce, and poverty. Health indicators did not show differences between groups, although older adolescents had higher than national average low birth weight babies. The age of first pregnancy was markedly lower for the younger than older teen. These findings support the need for prevention strategies in treatment programs.     

Predictors of substance use and family therapy outcome among physically and sexually abused runaway adolescents

There is a dearth of research that examines the impact of family systems therapy on problems among sexually and/or physically abused youth. Given this void, differential outcome and predictors of substance use change were evaluated for abused, as compared with nonabused, runaway adolescents who were randomly assigned to family therapy or treatment as usual. Abused adolescents reported lower family cohesion at baseline, although both abused and nonabused adolescents showed similar substance use reductions. Utilizing hierarchical linear modeling, we found that substance use changed with change in cohesion over time. These findings link change in family functioning to change in adolescent substance use, supporting fiamily systems theory. Findings suggest that a potent target of intervention involves focus on increasing positive communication interactions.     

Violence Exposure and Drug Use in Central American Youth: Family Cohesion and Parental Monitoring as Protective Factors

Associations between witnessing serious violence and drug use, and the protective influences of family cohesion and parental monitoring, were investigated among 9,840 adolescents (50.5% female, M age=15.29 years, SD=1.76) living in Panama and Costa Rica. After accounting for demographics and parental and sibling substance use, witnessing serious violence was associated with greater drunkenness, tobacco use, number of illicit drugs used, and problems with drugs and alcohol. In every analysis, exposure to violence was associated with more drug use, while family cohesion and parental monitoring attenuated risk. Further, family cohesion and parental monitoring exerted a protective‐stabilizing effect on number of illicit drugs used and on problems with drugs and alcohol. There were few interactions with age. Implications for prevention are discussed.     

Prevalence of Problem Gambling Among Adolescents: A Comparison Across Modes of Access,Gambling Activities,and Levels of Severity

The high availability and accessibility of online gambling have recently caused public concern regarding the potential increase of gambling-related problems among young people. Nonetheless, few studies among adults and none among adolescents have explored specific characteristics of gamblers as a function of gambling venues to date. This study sought to analyze the prevalence of gambling among a sample of adolescents in the last year, as well as sociodemographic and gambling-related characteristics as possible predictors of at-risk and problem gambling. The sample comprised 1313 adolescents aged 14–18 years. Participants were asked to respond to several questions regarding their gambling behavior. Chi square and ANOVA tests were performed in order to explore differences between groups, and a set of multinomial regressions established significant severity predictors. The prevalence of at-risk and problem gambling was 4 and 1.2 %, respectively. Regression analyses showed that having a relative with gambling problems predicted at-risk gambling. Both living with only one parent or not living with parents at all, and the prevalence of Electronic Gambling Machines in the last year were associated with problem gambling. Mixed-mode gambling was a predictor of both at-risk and problem gambling. Our findings extend previous research on gambling among adolescents by exploring gambling behavior according to different modes of access. Although the prevalence of exclusive online gambling among the total sample was low, these results support the need to consider specific subgroups of gamblers and their concrete related features when conducting both indicated prevention and treatment protocols for adolescents.     

Young adolescents, tobacco advertising, and smoking

BACKGROUND: In adolescents aged 12-14, we measured attitudes to tobacco advertising. Our purpose is to understand the relation of these attitudes to tobacco use and identify the groups most influenced by the advertising. METHODS: Survey of adolescents on Gran Canaria Island, Spain, about aspects of family, school, peers, tobacco consumption, and tobacco advertising. The subjects of the double-stratified cluster sample were 1910 students at the same grade level in 33 schools; 86.6% were 13 or 14 years old, and 51.2% were boys. We generated measures for attitudes to tobacco advertising from replies to seven questions with ordinal scales by an analysis of categorical principal components. To relate attitude to tobacco advertising and the profiles of these adolescents, we used multiple regression and logistic regression models. RESULTS: Attitudes to tobacco advertising are related to some home and school factors, but most significantly to tobacco and alcohol consumption, to amount of time at home without adults, and to peer influence. CONCLUSIONS: It is possible to draw up profiles of the students most vulnerable to tobacco advertising, and to cluster them in two groups, the "vitalists" and the "credulous." The effect of cigarette ads is different between these groups. This study can help to orientate smoking prevention.     

School Violence and Adolescent Mental Health in South Africa: Implications for School Health Programs

This study examines the perceptions of high-school adolescents about gang violence in a periurban community near Cape Town and the implications for school health in South Africa. Using the qualitative focus group discussion (FGD) guide, data were collected from 60 high-school adolescents, between 10 and 20 years of age. Trained moderators conducted nine FGDs with small groups of six to eight students. The constant comparative ethnographic method was used to analyze the data. Results indicate that gang violence is very common among high-school adolescents living on the Cape Flat. Gangs, perceived by many as part of the rite of passage among adolescents, are a major threat to the public health, mental well-being, general welfare, happiness, and development of high-school populations on the Cape Flat. Gang activity interlock with many other social problems, including drug and alcohol abuse, school unrest and violence, and the increasing prevalence of sexually transmitted diseases, especially HIV and AIDS. These findings suggest an urgent need for concerted efforts to develop mechanism to protect school pupils from gangs and develop healthier social alternatives to gang-related activites. Ties among government, school, parents, and community education and participation are urgently necessary to implement a school-based approach to adolescent health promotion.