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

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

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

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

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

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

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

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

0

2

4

6

8

10

12

Pre-TxPost-Tx6 month12 month

MDFT vs. Peer Group and Multifamily Education: Substance Use Outcomes

Dru

g U

se

MDFT

Group MFET

Liddle , Dakof et al. Am J Drug & Alcohol Abuse (2001)

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

0102030405060708090

100

MDFTGroup

00.20.40.60.8

11.21.41.61.8

MDFTGroup

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 transformedMore MDFT participants report abstaining from drug use at intake

Percentage Arrested During

12 Month Follow-Up

23%

44%

0%

10%

20%

30%

40%

50%

Percentage Placed on Probation During 12 Month

Follow-Up

10%

30%

0%

10%

20%

30%

40%

50%

*

*p<.05

MDFT Group

*

*

0

0.5

1

1.5

2

2.5

3

3.5

4

Intake 6 Months 12 Months

MDFTGroup

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

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

Change in Cannabis Use Frequency

2

4

6

8

10

12

14

Intake Discharge 6 Months 12 Months

Tim

es

use

d c

annabis

last

30 d

ays

MDFT

CBT

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)

Proportion of Adolescents Abstaining from Cannabis Use

7

42

42

64

4

3945 44

0

10

20

30

40

50

60

70

MDFT CBT

Intake Discharge 6 Months 12 Months

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

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

Inta

ke

3 m

ths

6 m

ths

9 m

ths

12 m

ths

15 m

ths

18 m

ths

21 m

ths

24 m

ths

27 m

ths

30 m

ths

CYT Study: Average Episode Cost of Drug Treatment

Dennis et al., in press, Journal of Substance Abuse Treatment

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

MDFT (13.2weeks

w/ family)

NTIES (6.7weeks)

NTIES(13.1

weeks)

FSN (14.2weeks)

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

Change in Drug Use Frequency

0

5

10

15

20

25

30

Intake Discharge

MDFTResidential

0123456789

10

MDFTATP

Change in School Absences

During follow-up, residential youth increase school absences, whereas MDFT participants decrease absences

Change in School Suspensions

Proportion of youth suspended decreases in MDFT, but increases among residential treatment youth

0%

10%

20%

30%

40%

50%

60%

70%

80%

Intake 3 Mnth 6 Mnth 9 Mnth 12 Mnth

MDFTATP

Relative Costs of MDFT and Residential Treatment

MDFT (Intensive

Outpatient)

Residential Treatment

Weekly Costof TreatmentPer Patient

$384. $1,068.

Zavala, French, et al. (in press), Journal of Substance Abuse Treatment

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

MDFT and CBT Average Change in Hard Drug Use Intake to 12 Month

Follow-Up

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Intake Discharge 6 Months 12 Months

Tim

es

use

d H

ard

Dru

gs

in L

ast

30

Days

MDFT

CBT

(4-6 Months Post

Baseline)

(Post Discharge)

MDFT youth decrease hard drug use, whereas CBT youth increase

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