The integrative family-based model described above is being empirically tested in the St. Charles Parish community with youth clinically referred for substance abuse and related problems. The study is a randomized clinical trial in which MDFT is being compared against a high-quality group drug abuse treatment with traditional CBT trauma interventions. A range of outcomes are being examined with each teen and family over the year following treatment, including substance abuse and behavioral problems among the adolescents, trauma symptoms and other emotional problems among both teens and parents, and parenting and family strengths and risk factors. Although a main focus of the research is determining the comparative effects of MDFT versus group treatment for young disaster victims, the study will also examine other key questions, such as how the intervention works and for whom.
The study screens and recruits all clinically referred teens from St. Charles Parish who were living in FEMA disaster areas at the time of the storm and meet basic eligibility criteria. They must be between 13 and 17 years of age, have a family member willing to participate in research assessments and treatment (if randomized to MDFT), have a substance abuse problem requiring clinical intervention, and report mild to moderate trauma symptoms. Eligible youth whose families consent to participate in the study are randomized to either MDFT or the group-based treatment. The two treatment conditions are delivered by two sets of therapists from the same clinical agency (although housed at different sites to minimize contagion of the interventions), in order to maximize generalizability to real-world treatment settings. Both treatments last approximately 4 months and have equivalent dosage (approximately two sessions per week). Treatment fidelity measures used in several previous randomized clinical trials of MDFT (see Hogue et al., 1998
) will be employed to ensure that the treatments are delivered as specified and are sufficiently distinct. Teens and parents each complete a comprehensive battery of well-validated measures to assess a range of processes and outcomes at intake to treatment and at 2, 4, 6, and 12 months following intake. In addition to main questions about the relative effectiveness of the integrative MDFT model in comparison to group treatment over the year following intake, additional research questions will be explored.
Developing effective interventions for adolescents following disasters requires a thorough understanding of the mediators of youths’ outcomes, or the factors that account for the treatments’ effects. Previous research suggests that youths’ reactions to community-wide disasters such as Hurricane Katrina are explained by a multidimensional stress-and-coping model that includes characteristics of the stressor (e.g., exposure), the child (e.g., pretrauma functioning), the postdisaster environment (e.g., family functioning), and the child’s ability to cope (La Greca, Silverman, Vernberg, & Prinstein, 1996
). Compromised coping appears to mediate the impact of stress on a range of negative outcomes (e.g., Capaldi & Patterson, 1991
), including increased substance use over adolescence (Hoffman, Cerbone, & Su, 2000
). Although children’s coping has been validated as an important process across a range of developmental outcomes, there is no existing research on the extent to which family-based treatment approaches improve youths’ coping skills. Thus an important aim of the current study will be to examine whether MDFT more significantly improves teens’ coping skills, and whether changes in teens’ coping are linked to reduced drug use and trauma symptoms. This study is the first to examine youths’ coping as a mediator of substance abuse and trauma outcomes in family-based treatment.
A related question is whether improvements in parents’ coping (hypothesized to improve more in MDFT) are linked to increased use of positive coping skills among teens. Parents may be the most important single influence in helping youth cope better and reduce their emotional symptoms and substance use. Research shows that parents are the most important source of support for children in the posttrauma period (La Greca et al., 1996
). Parents’ own PTSD reactions are an important predictor of the severity of PTSD among children following disasters. Family disruption following traumatic events may be more predictive of children’s adjustment than their experiences during the event itself (McFarlane, 1987
). Research also demonstrates that families buffer youth from the effects of life stress. For instance, the impact of life stress on externalizing problems is buffered by low levels of family conflict (Holmes, Yu, & Frentz, 1999
). Thus family-based interventions work with families to reduce risk factors for poor outcomes, such as parenting stress and family conflict, and promote protective processes, such as parental monitoring and positive parent–child relationships, that improve teens’ coping. Targeting these core processes in treatment may help adolescents recover from trauma and substance abuse following extreme life stress. The current study will examine the extent to which improved parent coping predicts healthier coping and less drug use among teens.
In addition to examining the effects of family-based treatment and its potential mediators, examining moderators of outcome is essential to understanding the “boundary conditions” of the treatment with specific populations (Kazdin, 1994
). Level of hurricane-related stress and life disruption/loss may moderate the effects of treatment. For instance, stressful life events in the 6 months following Hurricane Andrew were more predictive of teens’ PTSD than exposure to the disaster itself (Garrison et al., 1995
). Thus for adolescents with greater life stress, loss, and trauma symptoms in the aftermath of Katrina, comprehensive, family-based treatment may be critical for reducing substance abuse and emotional distress.
The study explores unresolved questions in the disaster research specialty, in family-based interventions, and in the examination of the drug abuse/trauma nexus. Potential for new knowledge is high, yet the challenges are considerable. Postdisaster situations pose obstacles in almost every aspect of research, from staffing to recruitment to follow-up of participants. Some of the most obvious and daunting challenges lie in the timing of the research, given that the power to test postdisaster interventions fades over time yet there are few shortcuts to setting up the research (e.g., obtaining funding, IRB approval, conducting trainings, finalizing assessment instruments, setting up the database procedures). However, the current intervention was not designed to be delivered directly after the disaster, but rather to target and address the problems that unfold over the long term following trauma. Other challenges had to do with the high rate of displacement in New Orleans and its environs and lack of resources, compounding normal start-up difficulties (e.g., space for the project was scarce, funding was cut, services to set up phones and internet access were agonizingly slow).
In other ways, the context has been ideal for the development and testing of the integrative family-based approach. The community is tremendously receptive to and appreciative of help. Community leaders have worked closely with the clinical and research teams to assist in the process so that the youth and families can receive the help they need. Tremendous work lies ahead to repair the damage left in Katrina’s wake. It will continue to require a massive effort on all fronts. Entire communities are rebuilding together, and families are reclaiming their lives and their homes. As for the children of Katrina, all will not be lost.