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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
J Fam Ther. Author manuscript; available in PMC 2010 November 22.
Published in final edited form as:
J Fam Ther. 2009 May 1; 31(2): 126–154.
doi:  10.1111/j.1467-6427.2009.00459.x
PMCID: PMC2989619
NIHMSID: NIHMS183547

Family-based treatment for adolescent substance abuse: controlled trials and new horizons in services research

Abstract

This article provides an overview of controlled trials research on treatment processes and outcomes in family-based approaches for adolescent substance abuse. Outcome research on engagement and retention in therapy, clinical impacts in multiple domains of adolescent and family functioning, and durability and moderators of treatment effects is reviewed. Treatment process research on therapeutic alliance, treatment fidelity and core family therapy techniques, and change in family processes is described. Several important research issues are presented for the next generation of family-based treatment studies focusing on delivery of evidence-based treatments in routine practice settings.

Family-based treatment (FBT) is the most thoroughly studied behavioural treatment modality for adolescent substance abuse (ASA) (Becker and Curry, 2008). The extensive empirical support for FBT has been described in comprehensive literature reviews (Deas and Thomas, 2001; Williams et al., 2000), meta-analyses of controlled outcome studies (Stanton and Shadish, 1997; Vaughn and Howard, 2004; Waldron and Turner, 2008), and quality of evidence analyses (Becker and Curry, 2008; Vaughn and Howard, 2004). In addition, basic research on developmental psychopathology has emphasized the central role played by family environments in the development of adolescent alcohol and drug problems (Repetti et al., 2002). As a result, clinical practice guidelines put forth by federal agencies (Center for Substance Abuse Treatment, 1999), national associations (American Academy of Child and Adolescent Psychiatry, 1997) and influential policy-making groups (Drug Strategies, 2003, 2005) all underscore the importance of involving caregivers and other family members in the treatment of adolescent drug users.

This article provides an overview of the extant research literature on treatment processes and outcomes in family-based approaches for ASA. First, we review outcome research on engagement and retention in therapy, clinical impacts in multiple domains of adolescent and family functioning, and durability and moderators of treatment effects. Second, we describe treatment process research on therapeutic alliance, treatment fidelity and core family therapy techniques, and change in family processes. Finally, we present several important research issues for the next generation of FBT studies focusing on delivery of evidence-based treatments in routine practice settings.

Treatment outcome research on family-based treatment for ASA

The first wave of controlled studies testing clinical outcomes and treatment engagement strategies in FBT for ASA were conducted during the 1980s (Friedman, 1989; Joanning et al., 1992; Lewis et al., 1990; Szapocznik et al., 1983, 1986, 1988). These studies exemplified cutting-edge research according to prevailing standards: well-defined treatment and comparison conditions, availability of documented treatment procedures or treatment manuals, ongoing clinical supervision of therapists implementing the treatments, and standardized assessments of drug use and related outcomes. Research during this period established family therapy as a safe, acceptable, viable and promising approach for adolescent drug problems (Liddle and Dakof, 1995). However, these studies were also limited by relatively small samples, shorter follow-up assessment windows, and limited data on treatment implementation and fidelity.

The scientific quality of family-based adolescent drug treatment research continues to progress (Becker and Curry, 2008) and has garnered considerable and broad-based federally funded research support (Rowe and Liddle, 2006). A host of randomized, well-controlled, long-term studies have been reported in the scientific literature. Table 1 presents a summary of controlled trials of behavioural treatments for adolescent substance use. Studies were included in the table if they met the following selection criteria: a family-based model was a credible study condition either as a standalone treatment or featured component of a multi-component model; there was at least one comparative treatment to which participants were randomly or near-randomly assigned; all study conditions were outpatient treatment models; the study sample was drawn from a clinical population for which ASA was a primary referral problem; drug use was a main outcome variable in the study; at least one follow-up assessment (i.e. beyond immediate post-treatment assessment) was included in analyses; the study was published in an English-language peer-reviewed journal. For projects that yielded more than one publication reporting follow-up results, the most recent publication is included. Reporting of follow-up assessment data was made a selection criterion in order to place emphasis on the durability of treatment effects. In addition, note that multi-family groups (Joanning et al., 1992; Liddle et al., 2001) were considered group-based psychoeducational models rather than family-based interventions per se.

TABLE 1
Summary of randomized controlled trials of family-based treatments for adolescent substance use that report follow-up outcome data

Findings from these and other FBT studies are discussed below as they pertain to treatment engagement, outcomes, and durability and moderators of outcomes. A host of manualized family therapy models has been tested over the past three decades, and family therapy is now considered an efficacious treatment approach for adolescent substance abuse (Austin et al., 2005; Waldron and Turner, 2008). Several reviews have rated family therapy as the treatment of choice for ASA (Stanton and Shadish, 1997; Williams et al., 2000). Waldron and Turner (2008) recently presented a meta-analytic synthesis of seventeen studies of outpatient treatments for ASA completed since 1998. Their review analysed forty-six different treatment conditions classified as individual cognitive-behavioral therapy (CBT), group CBT, family therapy or minimal treatment control. Of the three specific models that emerged as ‘well-established’ interventions (Chambless et al., 1996) – multidimensional family therapy (MDFT), functional family therapy (FFT) and group CBT – two were family-based treatments. Three additional family models – brief strategic family therapy (BSFT), behavioural family therapy (BFT) and multisystemic therapy (MST) – were classified as ‘probably efficacious’ and, given their ongoing research programmes, moving towards status as well-established treatments (Waldron and Turner, 2008). Another recent, comprehensive review of outpatient ASA treatments was completed by Becker and Curry (2008), who rated thirty-one randomized trials published since 1983 on fourteen indicators of methodological quality. Three approaches showed evidence of treatment superiority in the highest quality studies: ecological family therapy (including MDFT and MST), individual and group CBT, and brief motivational intervention. Finally, Vaughn and Howard (2004) combined meta-analysis and quality of evidence analysis to synthesize ASA treatment research, and determined that MDFT and group CBT generated the strongest empirical support, with MST and FFT also showing evidence of effectiveness.

Treatment engagement and retention

Families of clinically referred adolescents can be very difficult to engage in treatment (Armbruster and Kazdin, 1994), and a strong case has been made that clinical engagement of multi-problem families requires an intensive approach that involves youth, caregivers and extra-familial support systems (Cunningham and Henggeler, 1999; Prinz and Miller, 1996). Controlled studies of specialized engagement procedures developed for FBT models treating adolescent drug users (e.g. Donohue et al., 1998; Santisteban et al., 1996; Slesnick and Prestopnik, 2004; Szapocznik et al., 1988) find that well-articulated, intensive, family-based engagement strategies are superior to standard engagement practices (typically one initial phone contact to schedule a first session) in enrolling adolescents and families into outpatient counselling. In addition, retention rates (i.e. completion of a full course of prescribed treatment) in controlled trials of FBT have been uniformly high, typically from 70 per cent to 90 per cent (Liddle, 2004). However, although FBT has outperformed usual care and also some comparison treatments in retaining high-risk teens (Friedman, 1989; Henggeler et al., 1991, 1996; Stanton and Shadish, 1997), there tend to be fewer differences in retention rates when FBT is compared to other well-defined approaches with specialized engagement strategies of their own (e.g. Azrin et al., 1994; Liddle et al., in press b; Waldron et al., 2001).

Treatment outcomes in multiple domains of functioning

As evidenced in Table 1, FBT has demonstrated treatment effects across several domains of adolescent and family functioning. Significant effects for substance use were reported in all fourteen controlled studies. In seven of these studies FBT was found to have superior outcome effects for drug use compared to group CBT (Liddle et al., 2001, in press b; Waldron et al., 2001), individual CBT (Liddle et al., in press a; Waldron et al., 2001), psychoeducational approaches (Latimer et al., 2003; Liddle et al., 2001), drug court (Henggeler et al., 2006) and usual care (Henggeler et al., 2002).

Notably, FBT performed equally well in reducing behaviour problems that are associated with substance use such as delinquency, externalizing symptoms (e.g. aggressiveness, oppositionality), and internalizing symptoms (e.g. depression, anxiety). Again, FBT conditions in all fourteen studies in Table 1 showed a significant decrease in at least one behavioural problem other than drug use, and three studies reported that FBToutperformed alternative treatments in this area (Henggeler et al., 2002; Liddle et al., 2008, 2009). This is strong evidence that FBT models effectively treat co-occurring behavioural symptoms in substance-using teens (Whitmore and Riggs, 2006). In addition, in all eight studies that reported on family outcomes (e.g. parenting practices, family competence, parent–child interactions), FBT models achieved significant improvements at follow-up. FBTalso demonstrated gains in school performance (attendance, grade point average) in both studies reporting on this key developmental outcome (Friedman, 1989; Liddle et al., 2001). These findings highlight the pressing need for additional clinical and research focus on developmental outcomes beyond drug use and behavioural symptomatology (Liddle et al., 2000; Meyers et al., 1999).

Durability of treatment effects

The positive effects of family therapy on adolescent drug use extend beyond treatment termination. Every study listed in Table 1 reported significant treatment impacts at a follow-up assessment point, with nine of the fourteen reporting drug use effects at twelve months or more post-baseline. In the longest reported follow-up period, Henggeler et al. (2002) found that MST participants showed significantly higher rates of abstinence from marijuana than usual care participants at four years after treatment.

Moderators of treatment effects

Moderators of treatment effects refer to client, therapist and contextual factors that influence the impact of treatment on specific outcomes (Holmbeck, 1997). By and large, research on treatment moderators for youth psychotherapy models is scarce (Kazdin, 2001), and this is no less true for ASA interventions (Strada et al., 2006). However, FBT research has begun to make inroads in this priority area. Robbins et al. (2008) report that structural ecosystems therapy was more effective than control groups in reducing drug use in Hispanic American but not African American adolescents. Waldron and Turner (2008) suggest that FFT may be more efficacious than CBT for Hispanic American participants, and Rowe et al. (2004) report that substance-abusing youths with co-occurring externalizing and internalizing problems at intake initially responded to MDFT but subsequently returned to baseline levels of drug use at one-year follow-up. Findings such as these underscore the value added by moderator research to understanding which treatments work for which families and illuminating how FBT should be tailored for specific subtypes of ASA clients (Ozechowski and Liddle, 2000).

One area of moderator research in which FBT models have excelled is treatment of ethnic minority populations. Of the fourteen studies listed in Table 1, nine recruited samples were at least 50 per cent minority. Hispanic American youth have been a focus of treatment development and outcome research for BSFT (Robbins et al., 2008; Szapocznik et al., 1986; see also Santisteban et al., 2003) and FFT (Waldron et al., 2001), while African American youths are a focus for MDFT (Liddle et al., 2001, in press a, in press b) and MST (Henggeler et al., 2002, 2006). In their comprehensive review of evidence-based treatments for ethnic minority youths, Huey and Polo (2008) designate MDFTas the only probably efficacious treatment for drug-abusing minority youths, and MST as possibly efficacious. They also cite BSFT and MST as two of only three probably efficacious treatments for minority youths with conduct problems. In addition to inclusion of ethnic minorities in clinical research samples, advocates for culturally sensitive treatment (e.g. Hall, 2001; Strada et al., 2006) stress the need for greater articulation of culture-specific accommodations in treatment implementation. Here also, FBT models have made noteworthy progress (e.g. Jackson-Gilfort et al., 2001; Szapocznik et al., 1978).

Process research on family-based treatment for ASA

Treatment process and process-outcome studies play an integral role in FBT treatment development (Diamond and Diamond, 2001), and they have provided essential information about how FBT interventions activate mechanisms of behaviour change (Hogue et al., 1996). Table 2 contains a summary of process outcome studies on FBT for ASA that were conducted on clients participating in controlled trials. Studies were included in Table 2 if they met the following criteria: at least one study condition was a credible FBT model; the study reported analyses on the association between treatment process variables and clinical outcomes; the parent study from which the study sample originated was a controlled trial listed in Table 1, to ensure the methodological rigour of the research context and generalizability of findings to clinical populations; and the study was published in a peer-reviewed journal. Of the eight studies listed in Table 2, four focused on therapeutic alliance with the adolescent and/or caregiver, three on treatment fidelity and techniques, and one on parent/family change during treatment. Findings from these and other FBT process and process outcome studies are discussed below.

TABLE 2
Summary of process-outcome studies derived from controlled trials of family-based treatments for adolescent substance use

Therapeutic alliance

Therapeutic alliance has proven to be a transtheoretical process component associated with treatment outcome across a diverse range of treatment models and clinical subgroups in both adult (Martin et al., 2000) and youth populations (Shirk and Karver, 2003). Most alliance research on adolescent substance users has involved FBT models; much of this work has focused on alliance effects early in treatment. Diamond and colleagues (1999) found that improvements in adolescent alliance over the first three sessions of MDFT were linked to specific alliance-building therapy techniques. Robbins and colleagues (2006) reported that both adolescent alliance and parent alliance in MDFT declined significantly between sessions one and two for dropout cases (attended fewer than eight sessions) but not treatment completers. Flicker and colleagues (2008) found that Hispanic families who dropped out early from FFT had greater discrepancies in parent versus adolescent alliance in the first session than families who completed treatment; this finding was not replicated with European American families.

A few studies involving the MDFT model have linked therapeutic alliance to treatment outcome. Tetzlaff and colleagues (2005) found that client ratings of adolescent alliance predicted reduced drug use across five manualized treatment conditions, including MDFT; alliance effects occurred at six months post-intake but not at longer follow-up. Shelef and colleagues (2005) reported that observer ratings of adolescent alliance in MDFT predicted reductions in substance use and psychological symptoms at up to three-months’ follow-up, but only for cases with high parent alliance. Hogue and colleagues (2006b) found that stronger parent alliances in early MDFT sessions predicted declines in adolescent drug use and externalizing symptoms at six-month follow-up; moreover, adolescents with weak early alliances that subsequently improved by mid-treatment showed greater reductions in externalizing than adolescents whose alliances declined. As a group, these engagement and outcome studies support theoretical assumptions that strong therapeutic alliances with both adolescents and caregivers are key to successful family-based treatment with ASA clients (Liddle, 1995).

Treatment fidelity and techniques

To date three FBT studies have examined links between treatment implementation and clinical outcomes in ASA samples. Huey and colleagues (2000) showed that adherence to fundamental principles of MST predicted improved family relations and decreased affiliation with delinquent peers; in addition, changes in these two outcomes mediated the relation between treatment adherence and reduced delinquent behaviour in the target adolescent. Hogue and colleagues (2006a) found that greater use of core family- and adolescent-focused treatment techniques in MDFT were associated with greater reductions in adolescent internalizing and externalizing symptoms, as well as improvements in family cohesion and conflict, up to one year after treatment. And again for MDFTas well as for individual CBT, Hogue and colleagues (2008) showed that stronger treatment adherence predicted greater decline in externalizing symptoms (linear adherence effect), whereas intermediate levels of adherence predicted the largest declines in internalizing behaviour, with high and low adherence predicting smaller improvements (curvilinear adherence effect). Interestingly, no outcome effects were found for observer-rated therapist competence. Overall, these findings indicate that the implementation of core FBT interventions promotes positive outcomes in both adolescent and family functioning.

Parent and family change

FBT models have also demonstrated the ability to enact behavioural changes in parenting and family interactions that are directly in keeping with theory of change principles for systemic interventions (Liddle, 1999). Schmidt and colleagues (1996) found significant improvement in the quality of in-session parenting behaviours observed between the first three sessions versus the last three sessions of treatment in twenty out of twenty-nine MDFT cases, and these parenting improvements were linked to post-treatment reductions in drug use. Diamond and Liddle (1996, 1999) identified particular MDFT interventions targeting problematic parent–adolescent interactions (e.g. actively blocking, diverting or working through negative emotions; amplifying feelings of sadness, regret and loss; prompting parent–adolescent conversation on important topics) that were associated with successful resolution of family impasses observed in treatment sessions. Other noteworthy advances in process research on parent and family change have been made for families of conduct-disordered youth participating in behavioural parent training (e.g. Patterson and Forgatch, 1985), MST (e.g. Henggeler et al., 1986; Mann et al., 1990) and FFT (e.g. Robbins et al., 1996, 2000).

The next stage for research is practice: delivering family-based treatment for ASA in routine service settings

Rigorous treatment process and outcome research has demonstrated that high-fidelity family-based treatment is an efficacious approach for adolescent substance abuse and related behaviour problems. The next challenge facing FBT developers, researchers and practitioners is translating success in controlled research settings to success in everyday practice. Efforts are currently underway to determine the best methods for delivering empirically supported FBT models in a variety of routine care settings (Liddle et al., 2002; National Institute on Drug Abuse Clinical Trials Network, 2008) and to create clinical and policy guidelines that promote family therapy as a first-line treatment option for drug-using adolescents (Drug Strategies, 2003). Below we present promising avenues for advancing clinical science in three important dimensions of FBT service delivery: treatment fidelity, client heterogeneity, and implementation in multiple service contexts.

Delivering high-fidelity treatment

Can empirically supported FBT models be delivered with fidelity in standard practice settings? Initial attempts to transport FBT models into usual care have yielded encouraging results. Henggeler and colleagues (1997, 1999) found in two MST transportability studies that community therapists delivering MST produced outcomes comparable to research therapists when supervision by model experts ensured strong fidelity; however, fidelity and outcomes both suffered when expert supervision was withdrawn. In addition, Liddle and colleagues (2002, 2006) demonstrated that intensive training and supervision in MDFTcould change provider practices and programme environment characteristics within a hospital-based day treatment programme, promote solid fidelity to MDFT based on observational adherence measures, and maintain improved adolescent outcomes after training.

A research methodology that offers great utility for growing the knowledge base on FBT implementation in usual care is benchmarking analysis. Benchmarking studies typically compare the performance of community-based providers to accepted gold standards (i.e. benchmarks) in critical areas such as retention, implementation and outcomes (Hunsley and Lee, 2007). Benchmarks can be derived from many sources, including local or nationwide performance standards (e.g. Weersing, 2005), national warehouse databases (Mellor-Clark et al., 2006; Mullin et al., 2006), or treatment efficacy trials in the form of single landmark studies (Gaston et al., 2006) or a group of studies aggregated via quantitative review (Chorpita et al., 2002) or meta-analyses (Minami et al., 2007).

Benchmarking research to date has focused primarily on client outcomes for adult disorders (e.g. Barkham et al., 1996; McEvoy and Nathan, 2007; Merrill et al., 2003; Wade et al., 1998) and depressed youth (Weersing and Weisz, 2002). By and large, these studies have found that empirically supported treatments exported to community sites using manual-guided training achieved outcomes similar to those produced in controlled trials, although effects in community sites may be less durable over time. By examining how FBT implementation and outcome in routine care compare to standards achieved in controlled research, benchmarking analyses can play a pivotal role in discovering whether FBT models are feasible, potent and durable when delivered in front-line settings (Weisz et al., 2006).

Serving a multi-problem, heterogeneous population

Can FBT models serve the diverse clinical needs of adolescent drug users and their families? Among the most consistent findings to emerge from basic and applied research on ASA is the complexity, heterogeneity and multiplicity of problems associated with this disorder (Rowe and Liddle, 2006). Contemporary assessment and treatment efforts are therefore organized around a constellation of problems that typically co-occur with ASA: psychiatric symptoms, school problems, delinquency and high-risk sexual behaviour (Dennis et al., 2003). Unfortunately, most adolescent substance users in community programmes do not receive comprehensive interventions to address their multiple needs (Etheridge et al., 2001; Jaycox et al., 2003), and there is a well-documented mismatch between the services offered and the service needs of these clients (Grella et al., 2001). In the absence of appropriate care, ASA youth with co-occurring disorders are at especially high risk to drop out of treatment (Kaminer et al., 1992; Wise et al., 2001) and have poor long-term outcomes (Crowley et al., 1998; Whitmore and Riggs, 2006).

Two innovative approaches to serving clients with multiple behavioural problems warrant further research for treating ASA: combined treatments and core elements approaches. Combined treatments refer to integrated behavioural and pharmacological interventions for co-occurring substance use and mental health disorders (Mattson and Litten, 2005). In the case of adolescent substance users, combined treatment refers to integrating a pharmacological intervention to treat a co-occurring mental health disorder for which effective medications exist, such as attention-deficit hyperactivity disorder, anxiety and depression (Bukstein and Cornelius, 2006; Libby and Riggs, 2005). Although resources exist for treating ‘dual-disorder’ adult clients (e.g. Mueser et al., 2003), there remains a dearth of empirical research on combined treatments for comorbid disorders in adolescents to guide clinical interventions and decision-making. The few existing studies of combined interventions for comorbid ASA populations suggest that treatment of one disorder may not be successful unless there is active treatment of the other (Whitmore and Riggs, 2006). For example, Riggs et al. (2004) found that pharmacotherapy for attention-deficit hyperactivity disorder (ADHD) in teens with comorbid ADHD and ASA was successful in reducing ADHD symptoms but had no impact on SUD problems. In contrast, the same research group (Riggs et al., 2007) subsequently found in a combined treatment study for co-occurring ASA and major depressive disorder (MDD) that the behavioural intervention for ASA, individual CBT, also had clinical impacts on MDD symptoms in the absence of MDD medication. Of note is the fact that CBT is an evidenced-based treatment for both substance use (Waldron and Kaminer, 2004; Waldron and Turner, 2008) and depression (Chu and Harrison, 2007; David-Ferdon and Kaslow, 2008) in adolescents, which may account for the cross-over effects. It remains to be seen whether ASA clients with a co-occurring mental health disorder can benefit from integrated treatments combining FBTwith evidence-based medications for that disorder.

Concerns about the feasibility of transporting research-based treatments into routine care have led clinical researchers in both mental health (Chorpita et al., 2007; Garland et al., 2008) and substance use (Carroll and Rounsaville, 2006) to call for consideration of a core elements approach to dissemination that focuses on essential treatment elements that are common across therapy manuals for similar populations. The best-known example is described by Chorpita and colleagues (Chorpita et al., 2005, 2007), who call their core elements approach the ‘distillation and matching model’. In the distillation phase, the numerous treatment techniques prescribed by multiple independent manuals for a specific disorder are boiled down to a smaller number of overlapping practice elements considered to be core active ingredients of each manual. Then in the matching phase, clinicians decide which set of distilled practice elements to use for a presenting case based on client factors and other considerations highlighted in the research literature for the relevant disorder. It follows that for ASA clients, core elements FBT would be a primary treatment of choice. The overall goal of the core elements approach is to shift the emphasis of dissemination away from a focus on discrete therapy models and towards a focus on basic curative elements of research-supported approaches. The benefits of this shift may be profound (Daleiden et al., 2006; Garland et al., 2008): unify and simplify the task of transporting evidence-based approaches into routine care with fidelity; retain the importance of provider judgement about duration, intensity and other parameters of implementing evidence-based practices; provide evidence-based options for client groups with diagnostic complexity and/or for whom no treatment manuals currently exist; and create continuity across the process of adapting and replicating discrete manuals. However, while intriguing as an alternative or complementary dissemination strategy for FBT and other empirically based treatments, the core elements approach is a recent innovation with unknown endpoint value pending controlled implementation and testing in real world conditions.

Implementation in various service delivery contexts

Can FBT models meet the clinical needs presented by ASA clients in various service sectors? Adolescent substance users are prevalent in multiple systems of care–substance abuse treatment, juvenile justice, mental health programmes, child welfare and the schools – and each sector presents unique treatment service contexts (Center for Substance Abuse Treatment, 1999; Institute of Medicine, 2006). FBT models that can be flexibly delivered while maintaining adherence to the fundamental treatment principles and techniques that make them effective will have great appeal to various stakeholders and greater viability within and across systems. One strategy for addressing the fit of research-developed treatments within various sectors of care is developing treatment systems that can be flexibly adapted for implementation in diverse clinical contexts. MDFT is an example of a family-based model that has evolved into a treatment system via iterative treatment development research (Liddle, 1999; Liddle and Hogue, 2001). MDFT has been adapted and tested as an indicated preventive intervention for high-risk youth (Hogue et al., 2002, 2005), an early treatment intervention for substance-using teens (Liddle et al., 2004, in press b), an outpatient treatment model for adolescent drug abusers with co-occurring psychological problems (Liddle et al., 2001, in press b), an adjunctive family intervention integrated within a hospital-based day-treatment programme (Liddle et al., 2002, 2006), and an intensive home-based intervention with case management for adolescents in the juvenile justice system who exhibit comorbid substance use and conduct disorders (Liddle and Dakof, 2002). Observational fidelity assessment and controlled outcome research support the integrity and effectiveness of each ‘version’ of the MDFT system.

A promising method for conducting policy-relevant research on implementing FBT in diverse applied settings is the practical clinical trial. Practical clinical trials (PCTs; March et al., 2005; Tunis et al., 2003) are designed to directly inform clinical practice by asking research questions that are clinically relevant, highly generalizable to routine practice, and of substantial public health importance. PCTs have a number of essential features. They should be controlled trials, optimally with random assignment; be conducted under conditions that mirror clinical practice; include samples large enough to detect small to moderate effects and support analysis of client subgroups; and use simple, clinically meaningful outcome measures (March et al., 2005). PCTs differ from large-scale effectiveness trials primarily in their limited use of elaborate quality assurance and research management strategies, such as rigorous provider training and monitoring procedures that are very difficult to sustain outside a research context. Another important design feature readily leveraged by PCTs is strong academic–government agency partnership (Morgenstern et al., in press). Government is often the sole funder of services and a primary stakeholder in accountability and quality of those services; gaining stakeholder buy-in to a study design increases the likelihood that study findings will be adopted at a systems level after research is completed (Morgenstern et al., under review; Zerhouni, 2003).

Conclusion

Three additional issues warrant attention from clinical researchers working on family-based approaches for ASA. First, assessment designs should extend beyond substance use patterns, psychiatric problems and behavioural coping skills to routinely include indicators of positive youth development that provide a fuller picture of developmental functioning and adult role-taking (Weisz and Hawley, 2002). These broader indicators should be chosen for their salience to development success in the context of adolescence and early adulthood (Steinberg, 2002), and they should also map well on to targeted therapeutic changes (Gladis et al., 1999). Involvement in pro-social activities, school and academic outcomes, employment readiness, quality of close relationships, and self-management patterns are a few good candidates for ASA youth (see Williams et al., 2002).

Second, FBT research should renew its early intentions to examine processes of family change during the course of treatment (Pinsof, 1989). On the one hand, FBT process research has increased appreciably in size and rigour since Friedlander and colleagues (1994) reported that family therapy process studies were few in number, small in sample size and mostly descriptive in nature. On the other hand, the bulk of recent FBT process studies have focused on therapy change processes; that is, therapeutic interventions hypothesized to be the active ingredients of a given treatment (Doss, 2004). Too few FBT studies (with notable exceptions, e.g. Diamond and Liddle, 1999; Patterson and Forgatch, 1985; Robbins et al., 2000) have measured client change processes; that is, client behaviours or experiences that occur as a direct result of therapy change processes and are expected to precipitate treatment gains (Doss, 2004). Without accounting for this second dimension of the therapeutic process, investigators cannot adequately capture the conceptual centrepiece of FBT theories of change: dynamic, bidirectional processes of therapist–family interactions that give rise to enduring systemic change (Pinsof, 1989). Reliable technology exists for measuring family processes in treatment (e.g. Gardner, 2000; Margolin et al., 1998), leaving the onus on clinical researchers to design studies of family change that promote the development of more effective FBT principles and techniques for ASA and other clinical populations.

Finally, the research area now known as implementation science offers a world of exciting new challenges and opportunities. Indeed, given the lack of widespread use of family-based therapies in regular clinical practice settings, this research area has more urgency than it might have if such dissemination were widespread. Certainly the dissemination of family-based therapies is vastly superior to what it was only a few years ago, given the institutionalization of these therapies in national and international registries of best (or evidence-based) practices (e.g. NREPP). While these developments represent clear advances, national and international family therapy associations can play a significant role in the widespread dissemination of family-based therapies and bridging the divide between research and clinical practice.

References

  • American Academy of Child and Adolescent Psychiatry (AACAP) Practice parameters for the assessment and treatment of children and adolescents with substance use disorders. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36:140–156. [PubMed]
  • Armbruster P, Kazdin A. Attrition in child psychotherapy. In: Ollendick TH, Prinz RJ, editors. Advances in Clinical Child Psychology. Vol. 16. New York: Plenum Press; 1994. pp. 81–108.
  • Austin AM, Macgowan MJ, Wagner EF. Effective family-based interventions for adolescents with substance use problems: a systematic review. Research on Social Work Practice. 2005;15:67–83.
  • Azrin NH, Donohue B, Besalel VA, Kogan ES, Acierno R. Youth drug abuse treatment: a controlled outcome study. Journal of Child and Adolescent Substance Abuse. 1994;3:1–16.
  • Azrin NH, Donohue B, Teicher GA, Crum T, Howell J, DeCato LA. A controlled evaluation and description of individual-cognitive problem solving and family-behavior therapies in dually-diagnosed conduct-disordered and substance-dependent youth. Journal of Child and Adolescent Substance Abuse. 2001;11:1–43.
  • Barkham M, Rees A, Shapiro DA, Stiles WB, Agnew RM, Halstead J. Outcomes of time-limited psychotherapy in applied settings: replicating the second Sheffield Psychotherapy Project. Journal of Consulting and Clinical Psychology. 1996;64:1079–1085. [PubMed]
  • Becker SJ, Curry JF. Outpatient interventions for adolescent substance abuse: a quality of evidence review. Journal of Consulting and Clinical Psychology. 2008;76:531–543. [PubMed]
  • Bukstein OG, Cornelius J. Psychopharmacology of adolescents with substance use disorders: using diagnostic-specific treatments. In: Liddle HA, Rowe CL, editors. Adolescent Substance Abuse: Research and Clinical Advances. Cambridge: Cambridge University Press; 2006. pp. 241–263.
  • Carroll KM, Rounsaville BJ. Behavioral therapies: the glass would be half full if only we had a glass. In: Miller WR, Carroll KM, editors. Rethinking Substance Abuse: What the Science Shows and What We Should Do About It. New York: Guilford Press; 2006.
  • Center for Substance Abuse Treatment (CSAT) Treatment of Adolescents with Substance Use Disorders. Washington, DC: US Government Printing Office; 1999. Treatment Improvement Protocol (TIP) Series, No. 32. DHHS publication No. (SMA) 01–3494.
  • Chambless DL, Sanderson WC, Shoham V, Bennett Johnson S, Pope KS, Crits-Christoph P. An update on empirically validated therapies. The Clinical Psychologist. 1996;49:5–18.
  • Chorpita BF, Becker KD, Daleiden EL. Understanding the common elements of evidence-based practice: misconceptions and clinical examples. Journal of the American Academy of Child and Adolescent Psychiatry. 2007;46:647–652. [PubMed]
  • Chorpita BF, Daleiden EL, Weisz JR. Identifying and selecting the common elements of evidence based interventions: a distillation and matching model. Mental Health Services Research. 2005;7:5–20. [PubMed]
  • Chorpita BF, Yim LM, Donkervoet JC, Arensdorf A, Amundsen MJ, McGee C. Toward large-scale implementation of empirically-supported treatments for children: a review and observations by the Hawaii Empirical Basis to Services Taskforce. Clinical Psychology Science and Practice. 2002;9:165–190.
  • Chu BC, Harrison TL. Disorder-specific effects of CBT for anxious and depressed youth: a meta-analysis of candidate mediators of change. Clinical Child and Family Psychology Review. 2007;10:352–372. [PubMed]
  • Crowley TJ, Mikulich SK, MacDonald M, Young SE, Zerbe GO. Substance-dependent, conduct-disordered adolescent males: severity of diagnosis predicts 2-year outcome. Drug and Alcohol Dependence. 1998;49:225–237. [PubMed]
  • Cunningham PB, Henggeler SW. Engaging multi-problem families in treatment: lessons learned throughout the development of multisystemic therapy. Family Process. 1999;38:265–286. [PubMed]
  • Daleiden EL, Chorpita BF, Donkervoet C, Arensdorf AM, Brogan M. Getting better at getting them better: health outcomes and evidence-based practice within the system of care. Journal of the American Academy of Child and Adolescent Psychiatry. 2006;45:749–756. [PubMed]
  • David-Ferdon C, Kaslow NJ. Evidence-based psychosocial treatments for child and adolescent depression. Journal of Clinical Child and Adolescent Psychology. 2008;37:62–104. [PubMed]
  • Deas D, Thomas SE. An overview of controlled studies of adolescent substance abuse treatment. American Journal on Addictions. 2001;10:178–189. [PubMed]
  • Dennis M, Dawud-Noursi S, Muck RD, McDermeit M. The need for developing and evaluating adolescent treatment models. In: Stevens SJ, Morral AR, editors. Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study. New York: Haworth; 2003. pp. 3–34.
  • Dennis M, Godley SH, Diamond G, Tims FM, Babor T, Donaldson J. The Cannabis Youth Treatment (CYT) Study: main findings from two randomized trials. Journal of Substance Abuse Treatment. 2004;27:197–213. [PubMed]
  • Diamond GS, Diamond GM. Studying a matrix of change mechanisms. An agenda for family-based process research. In: Liddle HA, Santisteban DA, Levant RF, Bray JH, editors. Family Psychology: Science-based Interventions. Washington, DC: American Psychological Association; 2001. pp. 41–66.
  • Diamond GS, Liddle HA. Resolving a therapeutic impasse between parents and adolescents in Multidimensional Family Therapy. Journal of Consulting and Clinical Psychology. 1996;64:481–488. [PubMed]
  • Diamond GS, Liddle HA. Transforming negative parent-adolescent interactions: from impasse to dialogue. Family Process. 1999;38:5–26. [PubMed]
  • Diamond GM, Liddle HA, Hogue A, Dakof GA. Alliance building interventions with adolescents in family therapy: a process study. Psychotherapy: Theory, Research, Practice, and Training. 1999;36:355–368.
  • Diamond GS, Liddle HA, Wintersteen MB, Dennis ML, Godley SH, Tims F. Early therapeutic alliance as a predictor of treatment outcome for adolescent cannabis users in outpatient treatment. The American Journal on Addictions. 2006;15:26–33. [PubMed]
  • Donohue B, Azrin N, Lawson H, Friedlander J, Teicher G, Rindsberg J. Improving initial session attendance of substance abusing and conduct disordered adolescents: a controlled study. Journal of Child and Adolescent Substance Abuse. 1998;8:1–13.
  • Doss BD. Changing the way we study change in psychotherapy. Clinical Psychology: Science and Practice. 2004;11:368–386.
  • Drug Strategies. Treating Teens: A Guide to Adolescent Drug Programs. Washington, DC: Drug Strategies; 2003.
  • Drug Strategies. Bridging the Gap: A Guide to Drug Treatment in the Juvenile Justice System. Washington, DC: Drug Strategies; 2005.
  • Etheridge RM, Smith JC, Rounds-Bryant JL, Hubbard RL. Drug abuse treatment and comprehensive services for adolescents. Journal of Adolescent Research. 2001;16:563–589.
  • Flicker SM, Turner CW, Waldron HB, Brody JL, Ozechowski TJ. Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances. Journal of Family Psychology. 2008;22:167–170. [PubMed]
  • Friedlander ML, Wildman JW, Heatherington L, Skowron EA. What we do and don’t know about the process of family therapy. Journal of Family Psychology. 1994;8:390–416.
  • Friedman AS. Family therapy vs. parent groups: effects on adolescent drug abusers. The American Journal of Family Therapy. 1989;17:335–347.
  • Gardner F. Methodological issues in the direct observation of parent–child interaction: do observational findings reflect the natural behavior of participants? Clinical Child and Family Psychology Review. 2000;3:185–198. [PubMed]
  • Garland AF, Hawley KM, Brookman-Frazee LI, Hurlburt M. Identifying common elements of the evidence-based problems for children’s psychosocial treatments disruptive behavior. Journal of the American Academy of Child and Adolescent Psychiatry. 2008;47:505–514. [PubMed]
  • Gaston JE, Abbott MJ, Rapee RM, Neary SA. Do empirically supported treatments generalize to private practice? A benchmark study of a cognitive-behavioral group treatment program for social phobia. British Journal of Clinical Psychology. 2006;45:33–48. [PubMed]
  • Gladis MM, Gosch EA, Dishuk NM, Crits-Christoph P. Quality of life: expanding the scope of clinical significance. Journal of Consulting and Clinical Psychology. 1999;67:320–331. [PubMed]
  • Grella CE, Hser YI, Joshi V, Rounds-Bryant J. Drug treatment outcomes for adolescents with comorbid mental and substance use disorders. Journal of Nervous and Mental Diseases. 2001;189:384–392. [PubMed]
  • Hall NGC. Psychotherapy research with ethnic minorities: empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology. 2001;69:502–510. [PubMed]
  • Henggeler SW, Pickrel SG, Brondino MJ. Multisystemic treatment of substance-abusing and-dependent delinquents: outcomes, treatment fidelity, and transportability. Mental Health Services Research. 1999;1:171. [PubMed]
  • Henggeler SW, Clingempeel WG, Brondino MJ, Pickrel SG. Four-year follow-up of multisystemic therapy with substance-abusing and substance-dependent juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry. 2002;41:868–874. [PubMed]
  • Henggeler SW, Pickrel SG, Brondino MJ, Crouch JL. Eliminating (almost) treatment dropout of substance abusing or dependent delinquents through home-based multisystemic therapy. American Journal of Psychiatry. 1996;153:427–428. [PubMed]
  • Henggeler SW, Brondino MJ, Melton GB, Scherer DG, Hanley JH. Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology. 1997;65:821–833. [PubMed]
  • Henggeler SW, Borduin CM, Melton GB, Mann BJ, Smith LA, Hall JA. Effects of multisystemic therapy on drug use and abuse in serious juvenile offenders: a progress report from two outcome studies. Family Dynamics of Addiction Quarterly. 1991;1:40–51.
  • Henggeler SW, Halliday-Boykins CA, Cunningham PB, Randall J, Shapiro SB, Chapman JE. Juvenile drug court: enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology. 2006;74:42–54. [PubMed]
  • Henggeler SW, Rodick JD, Borduin CM, Hanson CL, Watson SM, Urey JR. Multisystemic treatment of juvenile offenders: effects on adolescent behavior and family interaction. Developmental Psychology. 1986;22:132–141.
  • Hogue A, Liddle HA, Rowe C. Treatment adherence process research in family therapy: a rationale and some practical guidelines. Psychotherapy: Theory, Research, Practice, and Training. 1996;33:332–345.
  • Hogue A, Dauber S, Samuolis J, Liddle HA. Treatment techniques and outcomes in multidimensional family therapy for adolescent behavior problems. Journal of Family Psychology. 2006a;20:535–543. [PMC free article] [PubMed]
  • Hogue A, Liddle HA, Becker D, Johnson-Leckrone J. Family-based prevention counseling for high-risk young adolescents: immediate outcomes. Journal of Community Psychology. 2002;30:1–22.
  • Hogue A, Liddle HA, Singer A, Leckrone J. Intervention fidelity in family-based prevention counseling for adolescent problem behaviors. Journal of Community Psychology. 2005;33:191–211.
  • Hogue A, Dauber S, Faw L, Cecero JJ, Liddle HA. Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems. Journal of Consulting and Clinical Psychology. 2006b;74:121–129. [PMC free article] [PubMed]
  • Hogue A, Henderson CE, Dauber S, Barajas PC, Fried A, Liddle HA. Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems. Journal of Consulting and Clinical Psychology. 2008;76:544–555. [PMC free article] [PubMed]
  • Holmbeck GN. Toward terminological, conceptual, and statistical clarity in the study of mediators and moderators: examples from the child-clinical and pediatric psychology literatures. Journal of Consulting and Clinical Psychology. 1997;65:599–610. [PubMed]
  • Huey SJ, Polo AJ. Evidence-based psychosocial treatments for ethnic minority youth. Journal of Clinical Child and Adolescent Psychology. 2008;37:262–301. [PMC free article] [PubMed]
  • Huey SJ, Henggeler SW, Brondino MJ, Pickrel SG. Mechanisms of change in multisystemic therapy: reducing delinquent behavior through therapist adherence and improved family and peer functioning. Journal of Consulting and Clinical Psychology. 2000;68:451–467. [PubMed]
  • Hunsley J, Lee CM. Research-informed benchmarks for psychological treatments: efficacy studies, effectiveness studies, and beyond. Professional Psychology: Research and Practice. 2007;38:21–33.
  • Institute of Medicine. Improving the Quality of Healthcare for Mental and Substance-use Conditions. Washington, DC: National Academy Press; 2006.
  • Jackson-Gilfort A, Liddle HA, Tejeda MJ, Dakof GA. Facilitating engagement of African American male adolescents in family therapy: a cultural themes process study. Journal of Black Psychology. 2001;27:321–340.
  • Jaycox LH, Morral AR, Juvonen J. Mental health and medical problems and service use among adolescent substance abusers. Journal of the American Academy of Child and Adolescent Psychiatry. 2003;42:701–709. [PubMed]
  • Joanning H, Quinn W, Thomas F, Mullen R. Treating adolescent drug abuse: a comparison of family systems therapy, group therapy, and family drug education. Journal of Marital and Family Therapy. 1992;18:345–356.
  • Kaminer Y, Tarter RE, Bukstein OG, Kabene M. Comparison between treatment completers and noncompleters among dually diagnosed substance-abusing adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 1992;31:1046–1049. [PubMed]
  • Kazdin AE. Bridging the enormous gaps of theory with therapy research and practice. Journal of Clinical Child Psychology. 2001;30:59–66. [PubMed]
  • Latimer WW, Winters KC, D’Zurilla T, Nichols M. Integrated family and cognitive-behavioral therapy for adolescent substance abusers: a stage I efficacy study. Drug and Alcohol Dependence. 2003;71:303–317. [PubMed]
  • Lewis RA, Piercy FP, Sprenkle DH, Trepper TS. Family-based interventions for helping drug-abusing adolescents. Journal of Adolescent Research. 1990;5:82–95.
  • Libby AM, Riggs PD. Integrated substance use and mental health treatment for adolescents: aligning organizational and financial incentives. Journal of Child and Adolescent Psychopharmacology. 2005;15:824–832. [PubMed]
  • Liddle HA. Empirical values and the culture of family therapy. Journal of Marital and Family Therapy. 1991;17:327–348.
  • Liddle HA. Conceptual and clinical dimensions of a multidimensional, multisystems engagement strategy in family-based adolescent treatment. Psychotherapy: Theory, Research, Practice, and Training. 1995;32:39–58.
  • Liddle HA. Theory development in a family-based therapy for adolescent drug abuse. Journal of Clinical Child Psychology. 1999;28:521–532. [PubMed]
  • Liddle HA. Family-based therapies for adolescent alcohol and drug use: research contributions and future research needs. Addiction. 2004;99:76–92. [PubMed]
  • Liddle HA, Dakof GA. Efficacy of family therapy for drug abuse: promising but not definitive. Journal of Marital and Family Therapy. 1995;21:511–544.
  • Liddle HA, Dakof GA. A randomized controlled trial of intensive outpatient, family based therapy vs. residential drug treatment for co-morbid adolescent drug abusers. Drug and Alcohol Dependence. 2002;66(#385):S2–S202. S103.
  • Liddle HA, Hogue A. Multidimensional family therapy for adolescent substance abuse. In: Wagner EF, Waldron HB, editors. Innovations in Adolescent Substance Abuse Interventions. Amsterdam, Netherlands: Pergamon/Elsevier Science; 2001. pp. 229–261.
  • Liddle HA, Rowe CL, Quille TJ. Transporting a research-based adolescent drug treatment into practice. Journal of Substance Abuse Treatment. 2002;22:1–13. [PubMed]
  • Liddle HA, Dakof GA, Parker K, Diamond GS, Barrett K, Tejeda M. Multidimensional family therapy for adolescent drug abuse: results of a randomized clinical trial. American Journal of Drug and Alcohol Abuse. 2001;27:651–688. [PubMed]
  • Liddle HA, Dakof GA, Turner RM, Henderson CE, Greenbaum PE. Treating adolescent drug abuse: a randomized trial comparing multidimensional family therapy and cognitive behavior therapy. Addiction. 2008;103:1660–1670. [PubMed]
  • Liddle HA, Rowe CL, Dakof GA, Henderson C, Greenbaum P. Multidimensional family therapy for young adolescent substance abusers: twelve month outcomes of a randomized controlled trial. Journal of Consulting and Clinical Psychology. 2009;77:12–25. [PubMed]
  • Liddle HA, Rowe CL, Dakof GA, Ungaro RA, Henderson C. Early intervention for adolescent substance abuse: pretreatment to posttreatment outcomes of a randomized controlled trial comparing multidimensional family therapy and peer group treatment. Journal of Psychoactive Drugs. 2004;36:49–63. [PubMed]
  • Liddle HA, Rowe CL, Diamond GM, Sessa FM, Schmidt S, Ettinger D. Toward a developmental family therapy: the clinical utility of research on adolescence. Journal of Marital and Family Therapy. 2000;4:485–500. [PubMed]
  • Liddle HA, Rowe CL, Gonzalez A, Henderson CE, Dakof GA, Greenbaum PE. Changing provider practices, program environment, and improving outcomes by transporting multidimensional family therapy to an adolescent drug treatment setting. The American Journal on Addictions. 2006;15:102–112. [PubMed]
  • Mann BJ, Borduin CM, Henggeler SW, Blaske DM. An investigation of systemic conceptualizations of parent-child coalitions and symptom change. Journal of Consulting and Clinical Psychology. 1990;58:336–344. [PubMed]
  • March JS, Silva SG, Compton S, Shapiro MA, Califf R. The case for practical clinical trials in psychiatry. American Journal of Psychiatry. 2005;162:836–846. [PubMed]
  • Margolin G, Oliver PH, Gordis EB, O’Hearn HG, Medina AM, Ghosh CM, Morland L. The nuts and bolts of behavioral observation of marital and family interaction. Clinical Child and Family Psychology Review. 1998;1:195–213. [PubMed]
  • Martin DJ, Garske FP, Davis MK. Relationship of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology. 2000;68:438–450. [PubMed]
  • Mattson ME, Litten RZ. Combining treatments for alcoholism: why and how? Journal of Studies on Alcohol. 2005;15:8–16. [PubMed]
  • McEvoy PM, Nathan P. Effectiveness of cognitive behavior therapy for diagnostically heterogeneous groups: a benchmarking study. Journal of Consulting and Clinical Psychology. 2007;75:344–350. [PubMed]
  • Mellor-Clark J, Barkham M, Mothersole G, McInnes B, Evans R. Reflections on benchmarking NHS primary psychological therapies and counseling. Counseling and Psychotherapy Research. 2006;6:81–87.
  • Merrill KA, Tolbert VE, Wade WA. Effectiveness of cognitive therapy for depression in a community mental health center: a benchmarking study. Journal of Consulting and Clinical Psychology. 2003;71:404–409. [PubMed]
  • Meyers K, Hagan TA, Zanis D, Webb A, Frantz J, Ring-Kurtz S. Critical issues in adolescent substance use assessment. Drug and Alcohol Dependence. 1999;55:235–246. [PubMed]
  • Minami T, Wampold BE, Serlin RC, Kircher JC, Brown GS. Benchmarks for psychotherapy efficacy in adult major depression. Journal of Consulting and Clinical Psychology. 2007;75:232–243. [PubMed]
  • Morgenstern J, Hogue A, Dauber S, Dasaro C, McKay JR. A practical clinical trial of coordinated care management to treat substance use disorders among public assistance beneficiaries. Journal of Consulting and Clinical Psychology. in press. [PMC free article] [PubMed]
  • Mueser K, Noordsy D, Drake RE, Fox L. Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford Press; 2003.
  • Mullin T, Barkham M, Mothersole G, Bewick BM, Kinder A. Recovery and improvement benchmarks for counseling and the psychological therapies in routine primary care. Counseling and Psychotherapy Research. 2006;6:68–80.
  • National Institute on Drug Abuse Clinical Trials Network. Brief Strategic Family Therapy (BSFT) for Adolescent Drug Abusers (CTN 0014) Principal Investigator: J. Szapocznik; 2008.
  • Ozechowski TJ, Liddle HA. Family-based therapy for adolescent drug abuse: knowns and unknowns. Clinical Child and Family Psychology Review. 2000;3:269–298. [PubMed]
  • Patterson GR, Forgatch MS. Therapist behavior as a determinant for client noncompliance: a paradox for the behavior modifier. Journal of Consulting and Clinical Psychology. 1985;53:846–851. [PubMed]
  • Pinsof WM. A conceptual framework and methodological criteria for family therapy process research. Journal of Consulting and Clinical Psychology. 1989;57:53–59. [PubMed]
  • Prinz RJ, Miller GE. Parental engagement interventions for children at risk for conduct disorder. In: Peters RD, McMahon RJ, editors. Preventing Disorders, Substance Abuse, and Delinquency. Thousand Oaks, CA: Sage; 1996.
  • Repetti RL, Taylor SE, Seeman T. Risky families: family social environments and the mental and physical health of offspring. Psychological Bulletin. 2002;128:330–366. [PubMed]
  • Riggs PD, Hall SK, Mikulich-Gilbertson SK, Lohman M, Kayser A. A randomized controlled trial of pemoline for attention-deficit/hyper-activity disorder in substance-abusing adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 2004;43:420–429. [PubMed]
  • Riggs PD, Mikulich-Gilbertson SK, Davies RD, Lohman M, Klein C, Stover SK. A randomized controlled trial of fluoxetine and cognitive behavioral therapy in adolescents with major depression, behavior problems, and substance use disorders. Archives of Pediatrics and Adolescent Medicine. 2007;161:1026–1034. [PubMed]
  • Robbins MS, Alexander JF, Turner CW. Disrupting defensive family interactions in family therapy with delinquent adolescents. Journal of Family Psychology. 2000;14:688–701. [PubMed]
  • Robbins MS, Alexander JF, Newell RM, Turner CW. The immediate effect of reframing on client attitude in family therapy. Journal of Family Psychology. 1996;10:28–34.
  • Robbins MS, Liddle HA, Turner CW, Dakof GA, Alexander JF, Kogan SM. Adolescent and parent therapeutic alliances as predictors of dropout in multidimensional family therapy. Journal of Family Psychology. 2006;20:108–116. [PubMed]
  • Robbins MS, Szapocznik J, Dillon FR, Turner CW, Mitrani VB, Feaster DJ. The efficacy of structural ecosystems therapy with drug-abusing/dependent African American and Hispanic American adolescents. Journal of Family Psychology. 2008;22:51–61. [PubMed]
  • Rowe CL, Liddle HA. Treating adolescent substance abuse: state of the science. In: Liddle HA, Rowe CL, editors. Adolescent Substance Abuse: Research and Clinical Advances. Cambridge, MA: Cambridge University Press; 2006.
  • Rowe CL, Liddle HA, Greenbaum PE, Henderson C. Impact of psychiatric comorbidity on treatment outcomes of adolescent drug abusers. Journal of Substance Abuse Treatment. 2004;26:1–12. [PubMed]
  • Santisteban DA, Coatsworth JD, Perez-Vidal A, Kurtines WM, Schwartz SJ, LaPerriere A. Efficacy of brief strategic family therapy in modifying Hispanic adolescent behavior problems and substance use. Journal of Family Psychology. 2003;17:121–133. [PMC free article] [PubMed]
  • Santisteban DA, Szapocznik J, Perez-Vidal A, Kurtines WM, Murray EJ, LaPerriere A. Efficacy of intervention for engaging youth and families into treatment and some variables that may contribute to differential effectiveness. Journal of Family Psychology. 1996;10:35–44.
  • Schmidt SE, Liddle HA, Dakof GA. Changes in parenting practices and adolescent drug abuse during multidimensional family therapy. Journal of Family Psychology. 1996;10:12–27.
  • Schoenwald SK, Henggeler SW, Brondino MJ, Rowland MD. Multisystemic therapy: monitoring treatment fidelity. Family Process. 2000;39:83–103. [PubMed]
  • Shelef K, Diamond GM, Diamond GS, Liddle HA. Adolescent and parent alliance and treatment outcome in multidimensional family therapy. Journal of Consulting and Clinical Psychology. 2005;73:689–698. [PubMed]
  • Shirk SR, Karver M. Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta-analytic review. Journal of Consulting and Clinical Psychology. 2003;71:452–464. [PubMed]
  • Slesnick N, Prestopnik JL. Office- versus home-based family therapy for runaway, alcohol-abusing adolescents: examination of factors associated with treatment attendance. Alcoholism Treatment Quarterly. 2004;22:3–19. [PMC free article] [PubMed]
  • Slesnick N, Prestopnik JL. Ecologically based family therapy outcome with substance abusing runaway adolescents. Journal of Adolescence. 2005;28:277–298. [PMC free article] [PubMed]
  • Smith DC, Hall JA, Williams JK, An H, Gotman N. Comparative efficacy of family and group treatment for adolescent substance abuse. The American Journal on Addictions. 2006;15:131–136. [PubMed]
  • Stanton MD, Shadish WR. Outcome, attrition, and family-couples treatment for drug abuse: a meta-analysis and review of the controlled, comparative studies. Psychological Bulletin. 1997;122:170–191. [PubMed]
  • Steinberg L. Clinical adolescent psychology: what it is, and what it should be. Journal of Consulting and Clinical Psychology. 2002;70:124–128. [PubMed]
  • Strada MJ, Donohue B, Lefforge NL. Examination of ethnicity in controlled treatment outcome studies involving adolescent substance abusers: a comprehensive literature review. Psychology of Addictive Behaviors. 2006;20:11–27. [PubMed]
  • Szapocznik J, Scopetta MA, King OE. Theory and practice in matching treatment to the special characteristics and problems of Cuban immigrants. Journal of Community Psychology. 1978;6:112–122. [PubMed]
  • Szapocznik J, Kurtines WM, Foote FH, Perez-Vidal A, Hervis O. Conjoint versus one-person family therapy: some evidence for the effectiveness of conducting family therapy through one person. Journal of Consulting and Clinical Psychology. 1983;51:889–899. [PubMed]
  • Szapocznik J, Kurtines WM, Foote F, Perez-Vidal A, Hervis O. Conjoint versus one-person family therapy: further evidence for the effectiveness of conducting family therapy through one person with drug-abusing adolescents. Journal of Consulting and Clinical Psychology. 1986;54:395–397. [PubMed]
  • Szapocznik J, Perez-Vidal A, Brickman AL, Foote FH, Santisteban D, Hervis O. Engaging adolescent drug abusers and their families in treatment: a strategic structural systems approach. Journal of Consulting and Clinical Psychology. 1988;56:552–557. [PubMed]
  • Tetzlaff BT, Kahn JH, Godley SH, Godley MD, Diamond GS, Funk RR. Working alliance, treatment satisfaction, and patterns of posttreatment use among adolescent substance users. Psychology of Addictive Behaviors. 2005;19:199–207. [PubMed]
  • Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. Journal of the American Medical Association. 2003;290:1624–1632. [PubMed]
  • Vaughn MG, Howard MO. Adolescent substance abuse treatment: a synthesis of controlled evaluations. Research on Social Work Practice. 2004;14:325–335.
  • Wade WA, Treat TA, Stuart GL. Transporting an empirically supported treatment for panic disorder to a service clinic setting: a benchmarking strategy. Journal of Consulting and Clinical Psychology. 1998;66:231–239. [PubMed]
  • Waldron HB, Kaminer Y. On the learning curve: the emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse. Addiction. 2004;2:93–105. [PMC free article] [PubMed]
  • Waldron HB, Turner CW. Evidence-based psychosocial treatments for adolescent substance abuse. Journal of Clinical Child and Adolescent Psychology. 2008;37:238–261. [PubMed]
  • Waldron HB, Slesnick N, Brody JL, Turner CW, Peterson TR. Treatment outcomes for adolescent substance abuse at 4- and 7-month assessments. Journal of Consulting and Clinical Psychology. 2001;69:802–813. [PubMed]
  • Weersing VR. Benchmarking the effectiveness of psychotherapy: program evaluation as a component of evidence-based practice. Journal of the American Academy of Child and Adolescent Psychiatry. 2005;44:1058–1062. [PubMed]
  • Weersing VR, Weisz JR. Community clinic treatment of depressed youth: benchmarking usual care against CBT clinical trials. Journal of Consulting and Clinical Psychology. 2002;70:299–310. [PubMed]
  • Weisz JR, Hawley KM. Developmental factors in the treatment of adolescents. Journal of Consulting and Clinical Psychology. 2002;70:21–43. [PubMed]
  • Weisz JR, Jensen-Doss A, Hawley KM. Evidence-based youth psychotherapies versus usual clinical care: a meta-analysis of direct comparisons. American Psychologist. 2006;61:671–689. [PubMed]
  • Whitmore EA, Riggs PD. Developmentally informed diagnostic and treatment considerations in comorbid conditions. In: Liddle HA, Rowe CL, editors. Adolescent Substance Abuse: Research and Clinical Advances. Cambridge: Cambridge University Press; 2006. pp. 264–283.
  • Williams PG, Holmbeck GN, Greenley RN. Adolescent health psychology. Journal of Consulting and Clinical Psychology. 2002;70:828–842. [PubMed]
  • Williams RJ, Chang SY. A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clinical Psychology: Science and Practice. 2000;7:138–166.
  • Wise BK, Cuffe SP, Fischer T. Dual diagnosis and successful participation of adolescents in substance abuse treatment. Journal of Substance Abuse Treatment. 2001;21:161–165. [PubMed]
  • Zerhouni E. Medicine: the NIH roadmap. Science. 2003;302:63–72. [PubMed]