MDFT vs. Residential Treatment RCT Outcomes JMATE 2012

JMATE 2012 Multidimensional Family Therapy: New Settings, New Studies, New Outcomes Howard A. Liddle, Gayle A. Dakof Department of Epidemiology & Public Health, and Center for Treatment Research on Adolescent Drug Abuse University of Miami Miller School of Medicine Miami, Florida Craig Henderson Department of Psychology Sam Houston State University, Huntsville Texas Am. J. Drug & Alcohol Abuse, 2009, 35, 220-2009 Certain malleable parent and youth characteristics predict engagement  Parent expectations about education, and severity of externalizing  Youth report of higher levels of family conflict Used as part of the content base that informs MDFT engagement strategies Differential strategies for youth and parent Evaluations of MDFT NIDA NOTES 2011 “MDFT treatment outcomes are among the best there are for adolescents. Not only does it work, but it joins the category of behavioral interventions whose effects seem to endure after treatment ends.” Lisa Onken, PhD, Chief of the Behavioral and Integrative Branch National Institute on Drug Abuse 2008 ”Multidimensional Family Therapy was the only probably efficacious treatment for drug-abusing ethnic minority youth.” (p. 206) The strong research base demonstrating the effects of MDFT in both indicated prevention and treatment settings has led it to be recognized as a best practice by the Office of Juvenile Justice and Delinquency Prevention, the National Institute on Drug Abuse (1999), the U.S. Department of Health and Human Services (2002), and SAMHSA (2005). “The strongest empirical support has been provided for Multidimensional Family Therapy (MDFT) and group administered Cognitive Behavioral Therapy (CBT). While MDFT and Multisystemic Therapy (MST) have similar treatment foci and theoretical underpinnings, MDFT has stronger empirical support, with replicated sustained results.” Perepletchikova, Krystal, & Kaufman, J. (2008) Is It Possible to Create an Effective, Outpatient Alternative to Residential Treatment? Howard A. Liddle, Gayle A. Dakof, Cindy Rowe, Craig Henderson, Paul Greenbaum, and Linda Alberga JMATE July 12, 2012 Center for Treatment Research on Adolescent Drug Abuse University of Miami Miller School of Medicine A challenge, a puzzle, a scandal… a mess!  Adolescent substance abuse, juvenile justice involvement of youth, high risk sexual activity,      school failure, family stresses and dysfunction Co-morbidity is the norm in clinically referred samples 5% of youth who need it get treatment When youth do get treatment they drop out with an alarming frequency  Kazdin’s 40-60%  Grella et al 2001 DATOS-A 23% complete 90 days, 77% drop out before 90 days Existing services are rarely evidence-based programs  Standard treatment yields worse outcomes than EBPs Family-based therapies among the most tested and transferred to community clinics  Still, family-based treatment is far from the norm  Knudsen (2010) JSAT adolescent specific services, few families  Chassin et al (Pathways to Desistance) – family involvement cases offer better outcomes, but less than 20% of the cases get any family involvement  Family involvement does not equal evidence based therapy Think of a sunset… Start to describe it… http://www.youtube.com/watch?v=tu-r27w6mgg Link to youtube video Context  Co-morbidity is the norm in adolescent substance abuse samples  One of the few rigorous evaluations of an outpatient treatment, multidimensional family therapy, tested as an alternative to the residential treatment of substance abusing and conduct disorder youths  Inquiring minds want to know  Alternative to residential treatment?  Can youths meeting ASAM criteria for intensive interventions that remove the youths from their home and communities be safely and effectively treated with a familybased outpatient alternative.  To our knowledge, this is the first randomized controlled trial of a family-based treatment evaluated as an outpatient alternative to residential drug abuse treatment for a substance abuse, co-morbid sample. Participants: Sample Characteristics  113 adolescents (84 males [75%] and 29 females [25%]) with an average age of 15.36 (SD = 1.07)  Ethnically diverse:  Hispanic (68%)  African American (15%)  white, non-Hispanic (12%)  American Indian (3%)  Haitian or Jamaican (2%)  Socioeconomic status with a median yearly family income of $18,777  Parents - 33% previous criminal involvement; 50% previous or current alcohol or drug use problems Sample Characteristics  81% involved in the juvenile justice system at intake, either on probation or pending a     court hearing and had an extensive history of school problems 66% having repeated at least one grade, and 16% having repeated two or more. Psychiatric evaluation conducted by a single board certified child and adolescent psychiatrist who was blind to participant’s treatment condition assignment. 79% met criteria for cannabis dependence (4% for abuse), 16% for alcohol dependence (14% for abuse), 15% for polysubstance dependence, 13% for cocaine dependence (12% for abuse), and 1% for opioid dependence (1% for abuse). 90% had initiated substance use before the age of 15, and 39% reported substance use initiation before age 12. Sample Characteristics  Consistent with the study and program eligibility criteria, all youth also met criteria for a comorbid psychiatric disorder at intake:  78% had moderate to serious conduct disorder  21% ADHD  18% major depressive disorder  8% bipolar disorder  9% dysthymic disorder  Youth had an average of 3.83 (SD = 3.31) total psychiatric diagnoses, including substance use disorders.  Seventy-nine percent of adolescents had a previous substance abuse treatment episode (34% having two or more), with 71% having had a previous residential treatment episode (17% two or more).  The treatment groups did not differ significantly (p= > .05) on any of these variables at baseline or on any demographic characteristics. Therapists   Primary therapists in both conditions held a master’s degree in counseling, social work, family therapy or a related field, and had equivalent prior experience (M=2 yrs.). In both conditions, primary therapists worked on a multidisciplinary team, assisted by therapist assistants/case managers (MDFT) and milieu staff (residential), and having the same adolescent psychiatrist conduct an initial evaluation and regular appointments to monitor medications and compliance. Measures   Measures administered at all assessment points. Data capture rates were high for parents and youths, respectively:  intake 98/99%  2 month 97/99%  4 month 96/96%  12 month 95/96%  18 month 97/99%  48 month data being collected Outcome Measures- Substance Use  The Personal Experience Inventory (PEI; Winters & Henley, 1989) is a multi-scale self-report measure assessing substance use problem severity and psychosocial risk.  The Personal Involvement with Chemicals scale was used in the current study and is a 29-item scale focusing on the psychological and behavioral depth of substance use involvement and related consequences in the previous 30 days.  Items composing this scale address substance use to feel calm; substance use during the whole day, weekends, or school; and canceling plans to get high. Widely used in applied research settings (Weinberg, Rahdert, Colliver, & Glantz, 1998), the PEI demonstrates excellent reliability (alpha=.84 to .97) and validity (e.g., scales significantly related to diagnostic ratings) across diverse adolescent samples (Henly & Winters, 1989; Tarter, 1990; Winters, Latimer, Stinchfield, & Egan, 2004). Coefficient alpha for the current study was .95. Outcome Measures - Substance Use  Timeline Follow-Back Method (TLFB) measured youths’ substance consumption (Sobell & Sobell, 1992). The measure was adapted to measure adolescent drug use (Leccese & Waldron, 1994).  TLFB obtained 30-day retrospective reports of daily substance use by employing a calendar and other memory prompts to stimulate recall.  Youth report on specific substances used daily for the 30-day period just prior to the intake evaluation and each follow-up evaluation.  A 30-day period was selected given the potential for recall bias for longer periods of time (Vinson, Reidinger, & Wilcosky, 2003). Outcome Measures - Delinquent Behavior  National Youth Survey Self Report Delinquency Scale (SRD) is a well- validated instrument that has been used extensively with African American and Hispanic adolescents.  This measure was administered to youth at all measurement occasions. Part of the National Youth Survey (Huizinga & Elliot, 1983), the SRD assesses criminal behavior on five subscales: total delinquency, general theft, crimes against persons, index offenses, and drug sales.  The SRD is well validated with clinical samples and serious offenders (Henggeler, 1989). Outcome Measures - Mental Health Symptoms  The Youth Self-Report (YSR; Achenbach, 1991a) and Child Behavior Checklist (CBCL; Achenbach, 1991b) were used to assess adolescent and parent reports of youth internalizing and externalizing symptoms.  We used the internalizing scale to assess internal distress and the aggression and delinquency subscales to assess these specific externalizing symptoms.  The YSR, and the CBCL on which the YSR is based, are two of the best validated measures of child-behavioral functioning. Outcome Measures- Data Analytic Approach  MDFT and ATP treatments were compared on the following primary outcomes:  (1) substance use  (2) externalizing symptoms of aggression and delinquency  3) internalizing symptoms  (4) frequency of delinquent behaviors  Individual client change for the primary outcomes was analyzed using latent growth curve (LGC) modeling (Curran & Hussong, 2003).  Individual differences are captured in random variances for the growth parameters, providing estimates of individual variation around the average group intercept and slope estimates.  Consistent with our hypotheses, we modeled growth trajectories as a discontinuous change process (i.e., a piecewise model) using two distinct trajectories.  The first trajectory represented change during early treatment (intake through the 2 month follow-up) and the second trajectory represented change during followup (4 month to the 18 month follow-up).  Outcome Measures - Data Analytic Approach  In addition to self- and parent-report data, we also obtained official court records regarding youth arrests and charges, along with school outcomes using records obtained from the public school’s database for:  (a) grades  (b) absences  (c) suspensions Outcome Measures- Data Analytic Approach  LGC models controlled for adolescent age, gender, time in treatment, and initial severity of the     outcome variable by entering these variables as covariates and included all randomized participants in the analyses regardless of the number of therapy sessions they received (i.e., intent to treat analyses). Growth curve modeling was done using Mplus software (Version 5.1; Muthén & Muthén 1998– 2012). Robust maximum likelihood estimation was used to minimize bias due to nonnormal outcome variables (Satorra & Bentler, 1994). In addition, natural log transformation was used to improve the normality of frequency of delinquent activity and school suspensions. Missing data were handled using full information maximum likelihood (FIML) estimation under the missing at random (MAR) assumption (i.e., after conditioning on observed variables, any remaining missingness is completely at random; Graham, 2009; Little & Rubin, 1987). Outcome Measures - Data Analytic Approach  Due to the severity of substance abuse symptoms and delinquency, the number of psychiatric diagnoses, the number of        previous substance abuse treatment placements, and the extent to which participants were involved in the justice system at study entry, they were at high risk for being placed in a long-term juvenile justice or substance abuse treatment facility at some time during the study follow-up period. As noted by McCaffery et al. (2007), behavioral frequency data such as TLFB-assessed substance use and number of delinquent acts committed (e.g., NYS assessment results) are subject to selection and suppression effects when placement in a post-treatment controlled environment is not taken into account (i.e., the placement environment may artifiically reduce or eliminate the frequency of the outcome). Therefore, we treated TLFB and NYS outcomes differently than our other outcomes that were less susceptible to such biases. For these measures, a latent class pattern mixture analysis (LCPMM; Morgan-Lopez & Fals-Stewart, 2007) was conducted to control for potentially biased reports of substance use and delinquency. LCPMM is a variant of Growth Mixture Modeling (GMM) that can take into account participants’ different longitudinal patterns present in data such as therapy attendance (Morgan-Lopez & Fals-Stewart, 2007), missingness (Linehan et al., 2006), or controlled versus nonrestrictive post-treatment placements. GMM identifies subgroups or latent classes of individuals with similar growth trajectories; individuals within each latent class share the same average intercept and slope. Accounting for bias due to controlled environment placements, LCPMM extends GMM by taking into account the probability of placement at each month of the 18 month follow-up period. LCPMM forms latent classes of participants with similar placement probabilities and outcome trajectories, and treatment effects are examined within each latent class, allowing treatment comparisons to be made between clients with approximately equivalent placement patterns. Study Implementation  Missing data due to missed assessments at each follow-up assessment was  1% at the 2-month follow-up  4% at the 4-month follow-up  5% at the 12-month follow-up  2% at the 18-month follow-up.  The presence of missing data did not differ by treatment condition ([(2 (1, N = 113) = 1.83, p = .18). Fidelity  We conducted a rigorous treatment fidelity evaluation of both treatments based on adherence procedures developed in previous MDFT trials (Hogue et al., 1998, 2004) and methods adapted from evaluation research in residential care settings (Holland, 1986) to specify and measure the components and therapeutic processes of the residential treatment (Faw et al., 2005).  In order to demonstrate that therapists adhered to the basic parameters of the treatments (i.e., session frequency and duration, domains targeted), therapists in MDFT completed therapeutic contact logs for every contact with clients.  Residential treatment program daily logs were completed by all ATP staff members who provided services to the adolescent during a routine program day, including basic living services (e.g., meals, school, hygiene), therapeutic services (e.g., therapy sessions, milieu groups, psychological and psychiatric consultations), and recreational services.  Daily logs were routinely completed at the ATP prior to this study; that is, they were not introduced as a feature of the randomized clinical trial. ATP staff members logged the amount of time spent in each contact, the general goal of the contact, the identity of the staff member involved, and any pertinent notes or clinical observations gathered in the contact. Fidelity  Evaluation of treatment contacts revealed that both interventions were delivered in accordance to     their prescribed treatment parameters. In the residential program, on average, adolescents completed 61% of the weekly prescribed amount of treatment services, 47% of the prescribed amount of time in functional activities, 63% of the weekly prescribed productive activities, 60% of the prescribed number of re-entry activities, and 15% of the prescribed number of hours of interpersonal/recreational activities (Faw et al., 2005). Adolescents rated the therapeutic milieu as being highly therapeutic (Faw et al., 2005). MDFT cases averaged 3.28 hours per week (SD = 1.74) of family and individual sessions, as prescribed in MDFT for this level of intervention. Consistent with MDFT parameters, on average (median) participants received the following amount to treatment in each of the four types of MDFT sessions:  (1) adolescent alone (24.7 hours)  (2) parent(s) alone (8.4 hours)  (3) parents and adolescent together (37.8 hours)  (4) extrafamilial contact with or without youth and family members (11.5 hours) Fidelity  Observational ratings of therapy sessions were also used to document adherence to both treatments and       differentiate the interventions delivered in individual and family sessions. Videotapes of individual and family sessions were selected for rating using the Therapist Behavior Rating Scale (TBRS), an observational adherence coding system used in previous MDFT studies (Hogue et al., 1996, 1998). A total of 31 (27%) MDFT and residential cases were randomly selected for adherence ratings. For each of these cases, one session from the middle stage of therapy was randomly selected to be rated with the TBRS. The raters were two female doctoral-level clinical researchers trained extensively by TBRS developers. They rated the therapy sessions on the extensiveness with which the therapists adhered to core MDFT and drug treatment interventions. Raters demonstrated good interrater reliability (ICC(1,2)=.86) using a subset of 5 MDFT sessions coded by both raters before coding study tapes. Fidelity  Equivalence testing procedures (Tryon, 2001) were used to compare the mean MDFT adherence score     obtained in the current study to the mean MDFT adherence score reported in a previous MDFT fidelity study establishing the validity of the TBRS (Hogue, Liddle, Dauber, & Samuolis, 2004). Following FalsStewart and Birchler’s (2002) procedures, we used an equivalence interval (EI) of +/- 10% around the mean MDFT adherence score obtained by Hogue et al. (2004; i.e., the reference group mean). The reference group mean was 31.09 (SD=8.37) and the EI was +/-3.10. A 90% confidence interval (CI) was calculated around the mean MDFT adherence score obtained in the current study (i.e., the test group mean). The obtained test group mean was 31.18 (SD=8.06), making the 90% CI 28.06 to 34.30. Though the 90% CI for the test group mean fell slightly outside of the pre-established EI around the reference group mean, it was because therapists in the current study obtained higher scores on the TBRS than the reference group. Thus we concluded that the therapists delivered MDFT with high fidelity. 2005  Logic model containing two main components was measured.  Program structure (adherence to the intended framework of service delivery) was measured using data from daily activity logs completed by program staff.  Treatment process, conceptualized as therapeutic milieu, was measured using an adapted version of a scale used to measure implementation in therapeutic communities.  Milieu rated by the adolescents as highly therapeutic.  Preliminary psychometrics suggest therapeutic milieu can be measured reliably in adolescents.  These two main variables were implemented with consistency across adolescents. Results Treatment Retention  The acceptability and feasibility of outpatient MDFT with this severely impaired, referred for residential population was explored by comparing treatment retention rates in the two conditions.  Further, it was important to consider early treatment retention due to the differing restrictiveness of the two treatments.  Outpatient MDFT 6.5 months / Residential treatment 3.7 months  Youth receiving MDFT remained in treatment longer than youth receiving residential treatment (average length of stay 6.5 [SD = 2.0] vs. 3.7 [SD = 3.0] months; t (111) = 5.81, p < .001).  In addition, youth in MDFT were more likely to be retained in treatment for three months than those receiving residential treatment [χ2 (1, N = 113) = 22.50, p < .001, OR = 11.5). Intake to 2 Months Following Intake Substance Use Problem Severity Aggression Delinquency Internalizing Symptoms Substance Use: Baseline to 2 months  Both treatments show significant declines in substance use  From intake to 2 month follow up, all youth showed a significant decline in substance use problem severity as measured by the PEI (Mean Slope = -12.39, standard error [SE] = 1.13, pseudo z = -10.69, p < .001).  Contrary to our hypothesis – no difference between outpatient MDFT and residential treatment.  There was not a significant treatment difference during this initial treatment phase despite our hypothesis that the residential treatment would improve more (treatment coefficient for slope = -3.88, SE = 2.56, pseudo z = -1.52), as both treatments showed large decreases in substance use. Delinquency & Aggression Symptoms: Baseline to 2 months  Youth in both treatments show significant declines  As with substance use problem severity, youth in both treatments showed declines in delinquency and aggression symptoms during the first two months of treatment according to both parent and youth reports (Parent Report Delinquency: Mean Slope = -9.26, SE = 1.37, pseudo z = -6.76, p < .001; Youth Report Delinquency: Mean Slope = -5.94, SE = 0.81, pseudo z = -7.37, p < .001; Parent Report Aggression: Mean Slope = -3.15, SE = 0.86, pseudo z= -3.67, p < .001; Youth Report Aggression: Mean Slope = -0.99, SE = 0.14, pseudo z= -6.89, p < .001). Delinquency & Aggression Symptoms: Baseline to 2 months  Parent report - Parents of residential treatment youths report a more rapid decrease than MDFT parents  With respect to treatment differences, in this early phase of treatment parents of youth receiving residential treatment reported a more rapid decrease in both delinquency and aggressive symptoms in their teen than did parents of teen who received MDFT (Parent Report Delinquency: treatment coefficient for slope = -11.78, SE= 2.43, pseudo z = -4.93, p < .001, 95% CI = -16.64 to 6.92; Parent Report Aggression: treatment coefficient for slope = -6.04, SE = 1.55, pseudo z = -3.89, p < .001, 95% CI = -9.14 to -2.94).  Youth report – No treatment differences according to youth self report (Youth Report Delinquency: treatment coefficient for slope = -1.38, SE = 1.52, pseudo z = -0.90, ns; Youth Report Aggression: treatment coefficient for slope = 1.92, SE = 1.02, pseudo z = 1.88, ns ) with both groups reporting a similar decrease in delinquency symptoms. Internalizing Symptoms: Baseline to 2 months  Both treatment groups decrease internalizing symptoms  Youth in both treatments reported significant decreases in internalizing symptoms during early treatment (Mean Slope = -1.36, SE = 0.50, pseudo z= -2.71, p < .01).  But parent rated internalizing symptoms did not concur  However, parent-rated symptoms did not decrease (Mean Slope = -0.46, SE = 0.65, pseudo z = -0.71, ns).  Comparing the treatments – MDFT youth show significantly greater decreases in internalizing symptoms  Youth receiving MDFT reported greater decreases than youth receiving ATP (slope coefficient on treatment = 2.60, SE = 0.92, pseudo z = 2.81, p < .01, 95% CI = 0.76 to 4.44).  Parents reports on decreases in internalizing symptoms  There were no treatment differences according to parents’ reports (slope coefficient on treatment = -2.15, SE = 1.21, pseudo z = -1.78, ns). Anxiety/Depressive Symptoms and Withdrawl: Baseline to 2 months  Youth in both treatments reported significant decreases in both anxiety/depressive symptoms and withdrawal during early treatment (Anxiety/Depression: Mean Slope = -1.40, SE = 0.50, pseudo z= -2.81, p < .01; Withdrawal: Mean Slope = -1.67, SE = 0.50, pseudo z= -3.37, p < . 01).  Parents reported decreases in withdrawal (Mean Slope = -1.54, SE = 0.76, pseudo z= -2.02, p < .05) but not anxiety/depressive symptoms (Mean Slope = -0.23, SE = 0.53, pseudo z= -0.44, ns). Results- Anxiety/Depressive Symptoms and Withdrawl: Baseline to 2 months  MDFT youth report significantly greater decreases in anxiety – depressive symptoms and withdrawl  Comparing the treatments, youth receiving MDFT reported greater decreases than youth receiving residential treatment in anxiety/depressive symptoms and withdrawal (Anxiety/Depression: slope coefficient on treatment = 2.00, SE = 0.95, pseudo z= 2.09, p < .05, 95% CI = 0.10 to 3.90; Withdrawal: slope coefficient on treatment = 1.09, SE = 0.17, pseudo z= 6.32, p < .001, 95% CI = 0.75 to 1.43).  No treatment differences according to parents self report  There were no treatment differences in either outcome according to parents’ reports (Anxiety/Depression: slope coefficient on treatment = -1.03, SE = 1.05, pseudo z = -0.98, ns; Withdrawal: slope coefficient on treatment = -2.21, SE = 1.50, pseudo z= -1.48, ns). Outcomes at 18 Months Following Intake Longer-term outcomes to determine the sustainability of changes following early treatment (approximately 2 months after intake) through 18 months after intake. Substance Use at 18 Months  From 2 to 18 months substance use problem severity remained relatively low in comparison to intake status and stable (Mean Slope = 0.12, SE = 0.11, pseudo z = 1.17, ns).  MDFT youths maintain previous decreases. Residential youths increase substance use problem severity  When comparing the treatments, youth receiving MDFT maintained their early treatment gains; while youth receiving residential treatment reported increased substance use problem severity over time (slope coefficient for treatment = 0.72, SE = 0.22, pseudo z = 3.28, p < .01, 95% CI = 0.28 to 1.16; see Figure 1).  Note: Although youth who received residential treatment showed increased substance use problems in comparison to youth who received MDFT, this increase did not reach baseline levels. Drug Use Problem Severity Delinquency-Related Symptoms and Aggression at 18 months  Parents of MDFT youths report continued decreases at 18 months  Comparing the treatments, parents of youth receiving MDFT, in comparison to parent reports from youth who received residential treatment, indicate a continuing decrease in symptoms of delinquency and aggression over the follow-up period (Parent Report Delinquency: treatment coefficient for slope = 1.22, SE = 0.39, pseudo z = 3.11, p < .01, 95% CI = 0.44 to 2.00; Parent Report Aggression: slope coefficient for treatment = 0.89, SE = 0.22, pseudo z = 4.02, p < .001, 95% CI = 0.44 to 1.32) (see Figure 2).  Youths in MDFT vs. residential report more decreases in aggressive behaviors at 18 months  Youth in MDFT report more pronounced decreases over time in aggression than youth from residential treatment (Youth Report Aggression: slope coefficient for treatment = 0.07, SE = 0.03, pseudo z = 2.10, p < .05, 95% CI = 0.01 to 0.13). There were no differences, however, in youth reports of delinquency (Youth Report Delinquency: treatment coefficient for slope = 0.10, SE = 0.17, pseudo z = 0.56, ns) with youth in both treatments reporting a general maintenance of decreased delinquency symptoms. Delinquent Behavior Internalizing Symptoms at 18 Months  Between 2 and 18 months, parents reported a decrease in their teen’s internalizing symptoms (Mean Slope = -0.32, SE = 0.08, pseudo z = -3.97, p < .001).  Youth reports indicated these symptoms remain reduced – data show a trend toward significant decreases (Mean Slope = -0.12, SE = 0.06, pseudo z= -1.85, p < .10).  There were no treatment differences according to both parents (slope coefficient for treatment = -0.18, SE = 0.14, pseudo z = -1.25, ns) and youth (slope coefficient for treatment = 0.05, SE= 0.16, pseudo z = 0.31, ns). Anxiety/Depressive Symptoms and Withdrawal at 18 Months  Between 2 and 18 months, anxiety/depressive symptoms and withdrawal remained stable according to youth reports (Anxiety/Depression: Mean Slope = -0.09, SE = 0.07, pseudo z= -1.28, ns; Withdrawal: Mean Slope = -0.06, SE = 0.08, pseudo z= -0.76, ns).  In contrast with the early treatment results, which showed no change, parents reported decreases in both anxiety/depressive symptoms and withdrawal (Anxiety/Depression: Mean Slope = -0.31, SE = 0.07, pseudo z= -4.17, p < .001; Withdrawal: Mean Slope = -0.27, SE = 0.10, pseudo z= -2.72, p < .01).  There were no treatment differences according to youth or parent reports in either outcome (Parent Report Anxiety/Depression: slope coefficient on treatment = -0.02, SE = 0.15, pseudo z= -0.16, ns; Parent Report Withdrawal: slope coefficient on treatment = 0.13, SE = 0.20, pseudo z= 0.63, ns; Youth Report Anxiety/Depression: slope coefficient on treatment = -0.22, SE = 0.16, pseudo z = -1.41, ns; Withdrawal: slope coefficient on treatment = -0.03, SE = 0.16, pseudo z= -0.19, ns).] Latent Class Pattern Mixture Modeling: Drug Use and Delinquent Activity  Results of the LCPMM indicated that three latent classes provided the best      representation of the heterogeneity in placement patterns. The first class (Early Placement) represented 18% of participants who showed high probabilities of being placed in a controlled environment toward the beginning of the follow up period (defined between 3 – 9 months from intake). By the end of the follow up period, defined as between 10 – 18 months from intake, these individuals tended to be discharged from their placements and living at home. Members of the second class (Late Placement; 11%) were also institutionalized at a high rate, but the placement tended to occur later in follow-up. Earlier in the follow-up period—during months 3 to 9—these individuals showed moderate probabilities of being placed in a controlled environment. The third class consisted of 72% of the sample (Minimal Placement) who showed fairly low probabilities of being institutionalized throughout the follow-up period. Minimal Placement Class  Drug use frequency outcome at 2 months  Thirty-day drug use frequency among youth in the Minimal Placement class decreased similarly across treatments during the first two months of treatment (slope coefficient for treatment = 1.01, SE = 2.34, pseudo z= -4.18, p < .001)  Drug use frequency outcome at 18 months  This pattern changed in the follow up period where youth who received residential treatment showed a greater increase in drug use in comparison to MDFT youth (b = 0.41, SE = 0.20, pseudo z= 1.96, p < .05, 95% CI = 0.00 to 0.81)  Treatment effects for the Minimal Placement class were significant for frequency of delinquent behaviors.  Delinquent behavior outcomes at 2 months  During early treatment, residential treatment youths showed a trend toward decreasing their delinquent behavior more rapidly than those who received MDFT (slope coefficient for treatment = -0.23, SE = 0.14, pseudo z= -1.67, p = .10).  Delinquent behavior outcomes at 18 months  However, during the follow-up period, residential treatment youths increased their delinquent activity, while MDFT youths remained stable and maintained their treatment gains (slope coefficient for treatment = 0.04, SE = 0.02, pseudo z = 2.43, p < .05). Three study hypotheses were tested  The first hypothesis addressed the feasibility of a family based outpatient alternative to residential treatment.  A majority of youth in both residential and MDFT remained in treatment for 90-days or longer.  Youth in MDFT, however, remained in treatment almost 3 months longer than did youth in residential treatments. Comment  A fundamental question in this study concerned the feasibility of an outpatient alternative     treatment for youth who had been deemed in need of residential treatment. Strong documentation exists supporting the challenges of treating adolescents with the characteristics of the current sample across treatment modalities and levels of care (Wong et al 2002). Although there is no national standard for the prescribed length of stay in residential treatment programs, and in fact, there is significant variability on what should constitute an adequate or preferred amount of treatment dose, some standards have been used with adolescent samples. In national studies DATOS-A study (Grella et al 2001), and the SAMHSA CSAT Adolescent Treatment Study (Dennis, 2007), the preferred treatment length was 90 days (also see Gottfredson et al). In the DATOS-A study 58% of the adolescents referred for residential treatment remained in the residential programs for 3 months. Comment  In the present study, the residential treatment program met this benchmark, retaining 54% of the      adolescents at 3 months. One of the most consistent findings in the adolescent substance abuse treatment outcome literature pertains to program completion and time in treatment. MDFT participants – average length of 195 days vs. 111 days for residential treatment MDFT in this study and in other trials engages and retains adolescents and their families at comparatively higher rate Another point related to the meaning of the retention outcomes can be noted. In the DATOS-A study, the residential sample youths who had criminal involvement, of the kind evidenced in the current study sample, demonstrated significantly worse retention and higher rates of substance abuse post discharge (Galaif et al 2002). Current study - multiple diagnoses youths who were referred for residential treatment and largely juvenile justice involved (81%) were able to engage in the family-based outpatient alternative and improve on several important dimensions, including substance abuse, unlike the adolescents in the Galaif et al (2002) study. Comment  A second hypothesis predicted that in the early phase of treatment, residential treatment youths,     because of the greater intensity of the treatment and the restrictive environment, would show greater reduction in substance use, externalizing symptoms, delinquent behaviors, and internalized distress compared to the outpatient alternative youths receiving MDFT. The results did not support this hypothesis. First, it should be recognized that for both treatments the greatest decline on all variables was from intake to 2 months. Youth in residential treatment did not report better outcomes than youth in MDFT on any of the domains examined: substance use, aggression, delinquency, and internalizing symptoms. In fact, youth in MDFT reported significantly greater reduction in internalizing symptoms than residential youth during the first 2 months of treatment. Comment  The third hypothesis was based on existing evidence for long-term effects of MDFT in previous trials and its family-focus, targeting known characteristics and processes related to substance use and antisocial behavior.  We hypothesized that the pattern of improvements would reverse later in treatment and over the follow-up period, per other residential treatment evaluations, the gains made in early treatment (2 months) would not be maintained by residential treatment participant but would be maintained by MDFT youth at the 18-month follow up assessment.  The results appear to support this hypothesis with one exception, that is, internalizing disorders, where even though MDFT reported greater symptom reduction than residential youth during the first two months of treatment, ultimately there were no treatment differences during the 2 – 18 month period.  However, with respect to drug use, and symptoms of conduct disorder, namely delinquency and aggression, both youth and parent reports on all variables measured are consistent: youth randomized to the outpatient family-based treatment showed greater symptom reduction than youth randomized to residential treatment from 2 to 18 months following intake into treatment.  Limitations: only one site administered the residential treatment and another the outpatient alternative.  Because multisite trials indicate that outcomes can vary significantly according the treatment site (Helgerson et al 2005), and despite the RT site’s representative in terms of program features, and the intensive program fidelity analysis, the use of a single residential treatment setting is factor that limits the study’s generalizability.  Comparatively few numbers of non-hispanic whites and girls included in the sample  Strengths include strong methods, including full randomization, intent to treat design, multi- source outcomes, multiple measures of key outcomes with standardized and objective indicators, assessors blind to client’s treatment, and solid data capture rates. The study tested two well defined, theory driven, and well-defined treatments (Epstein (2004; Curry, 1991) and adherence checking indicated that treatments were delivered as planned. Is It Possible to Create an Effective, Outpatient Alternative to Residential Treatment? Summary and Conclusion Parents and youth referred for residential treatment could be retained in an outpatient, family based treatment. Youth in both treatments achieved considerable gains over the first, early phase of each treatment. However, only MDFT youths maintained or enhanced these gains through the 18 month follow up, while the youths receiving residential treatment did not maintain their in-treatment gains. 48 month results are forthcoming In this study outpatient MDFT demonstrated clinically significant and stable effectiveness as an alternative for multiply diagnosed youths referred for residential treatment Summing up A trainer’s experience. “...that’s just the best”. http://www.youtube.com/watch?v=dSp_XW2K6gI&sns=em