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This retrospective non-experimental study examined the short-term (2-year) and longer-term (5-year and 8-year) sustainment of 137 programs in Europe and North America implementing a single evidence-based practice (EBP), Multidimensional Family Therapy (MDFT). MDFT implementation and sustainment is based on the Stages of Implementation (SIC) model outlined by Saldana and colleagues. The study had two primary objectives: (1) to examine short-term and longer-term sustainment rates of MDFT in Europe and North America, and (2) to explore potential factors that may be associated with sustainment of MDFT in particular, and the potential implications for behavioral health EBPs more generally. Results show that 90% of MDFT programs were sustained for at least 2 years, 87% of the programs sustained for at least 5 years, and 70% for at least 8 years. These findings compare favorably with the previous research on implementing and sustaining evidence-based practices. The findings support the growing consensus that not only start-up funding but also ongoing financing either through governments or third-party payors may be essential for longer-term sustainability of EBPs in both Europe and North America. This study also highlights the potential value of multi-site program networks. Future research directions are suggested, such as examination of the potential importance of the quality and nature of the EBP itself, adaptability to different organizations and clients, and providing high-quality structured and empowering training and quality assurance to sustain evidence-based behavioral health interventions. These programmatic and clinician-level factors are critical areas for further investigation into the sustainment of EBPs.

For some adolescent gamers, playing online games may become problematic, impairing functioning in personal, family, and other life domains. Parental and family factors are known to influence the odds that adolescents may develop problematic gaming (PG), negative parenting and conflictual family dynamics increasing the risk, whereas positive parenting and developmentally supportive family dynamics protecting against PG. This suggests that a treatment for adolescent PG should not only address the gaming behaviors and personal characteristics of the youth, but also the parental and family domains. An established research-supported treatment meeting these requirements is multidimensional family therapy (MDFT), which we adapted for use as adolescent PG treatment. We report here on one adaptation, applying in-session gaming. In-session demonstration of the "problem behavior" is feasible and informative in PG. In the opening stage of therapy, we use in-session gaming to establish an alliance between the therapist and the youth. By inviting them to play games, the therapist demonstrates that they are taken seriously, thus boosting treatment motivation. Later in treatment, gaming is introduced in family sessions, offering useful opportunities to intervene in family members' perspectives and interactional patterns revealed in vivo as the youth plays the game. These sessions can trigger strong emotions and reactions from the parents and youth and give rise to maladaptive transactions between the family members, thus offering ways to facilitate new discussions and experiences of each other. The insights gained from the game demonstration sessions aid the therapeutic process, more so than mere discussion about gaming.

Background and aims Social variables including parental and family factors may serve as risk factors for Internet Gaming Disorder (IGD) in adolescents. An IGD treatment programme should address these factors. We assessed two family therapies – multidimensional family therapy (MDFT) and family therapy as usual (FTAU) – on their impact on the prevalence of IGD and IGD symptoms. Methods Eligible for this randomised controlled trial comparing MDFT ( N = 12) with FTAU ( N = 30) were adolescents of 12–19 years old meeting at least 5 of the 9 DSM-5 IGD criteria and with at least one parent willing to participate in the study. The youths were recruited from the Centre Phenix-Mail, which offers outpatient adolescent addiction care in Geneva. Assessments occurred at baseline and 6 and 12 months. Results Both family therapies decreased the prevalence of IGD across the one-year period. Both therapies also lowered the number of IGD criteria met, with MDFT outperforming FTAU. There was no effect on the amount of time spent on gaming. At baseline, parents judged their child’s gaming problems to be important whereas the adolescents thought these problems were minimal. This discrepancy in judgment diminished across the study period as parents became milder in rating problem severity. MDFT better retained families in treatment than FTAU. Discussion and Conclusions Family therapy, especially MDFT, was effective in treating adolescent IGD. Improvements in family relationships may contribute to the treatment success. Our findings are promising but need to be replicated in larger study. Trial registration number ISRCTN 11142726.

Background and aims To remedy problematic Internet use (PIU) and problematic online gaming (POG) in adolescents, much is expected from efforts by parents to help youths to contain their screen use. Such parental mediation can include (a) refraining from acting, (b) co-viewing or co-gaming with the teen, (c) active mediation, and (d) restrictive mediation. We evaluated if parental mediation practices are linked to PIU and POG in adolescents. Methods For a systematic literature review, we searched for publications presenting survey data and relating parental mediation practices to levels of PIU and/or POG in adolescents. The review’s selection criteria were met by 18 PIU and 9 POG publications, reporting on 81.002 and 12.915 adolescents, respectively. We extracted data on gaming problems, mediation interventions, study design features, and sample characteristics. Results No type of parental mediation was consistently associated with lower or elevated problematic screen use rates in the adolescents. Refraining from parental mediation tended to aggravate screen use problems, whereas active mediation (talking to the teen) may mitigate such problems in PIU, but less clearly in POG. The link of restrictive mediation with problematic screen use varied from positive to negative, possibly depending on type of restriction. In both PIU and POG, family cohesion was related to lower rates of the problem behavior concerned and family conflict to higher rates. Discussion and conclusions Parental mediation practices may affect problematic screen use rates for better or worse. However, research of higher quality, including observations of parent-teen interactions, is needed to confirm the trends noted and advance the critical issue of the possible association between PIU, POG, and family interactions.

Background and aimsClinicians and researchers are increasingly interested in investigating excessive use of video gaming recently named Internet gaming disorder (IGD). As is the case with extensively researched adolescent problem behaviors such as substance use disorder, several studies associate IGD with the young person’s family environment and the parent–adolescent relationship in particular. Evidence-based treatments for a range of adolescent clinical problems including behavioral addictions demonstrate efficacy, the capacity for transdiagnostic adaptation, and lasting impact. However, less attention has been paid to developing and testing science-based interventions for IGD, and at present most tested interventions for IGD have been individual treatments (cognitive behavioral therapy).MethodsThis article presents the rationale for a systemic conceptualization of IGD and a therapeutic approach that targets multiple units or subsystems. The IGD treatment program is based on the science-supported multidimensional family therapy approach (MDFT). Following treatment development work, the MDFT approach has been adapted for IGD.ResultsThe article discusses recurring individual and family-based clinical themes and therapeutic responses in the MDFT-IGD clinical model, which tailors interventions for individuals and subsystems within the young person’s family.Discussion and conclusionsBasic science developmental research can inform conceptualization of IGD and a systemic logic model of intervention and change. This paper aims to expand treatment theorizing and intervention approaches for practitioners working with frequently life-altering behaviors of excessive Internet gaming. We operationalize this aim by addressing the question ofwhyandhowparents should be involved in youth IGD treatment.

The extent that participant characteristics are associated with outcome disparities for behavioral treatments generally, and adolescent drug abuse treatments in particular, is arguably one of the most important, albeit difficult to answer questions in the psychotherapy field (Blake, Amaro, Schwartz, & Flinchbaugh, 2001). Limited knowledge about gender and ethnicity as moderators remains ubiquitous in treatment research. Sparse representation of minority individuals in RCTs and paucity of subgroup analyses based on ethnicity has been well-documented. For example, a recent review of NIMH-funded randomized clinical trials, revealed that only 10% and 5% reported moderation analyses for gender and ethnicity, respectively (Mak, Law, Alvidrez, & Perez-Stable, 2007). A major impediment for conducting these subgroup analyses has been small to moderate sample sizes (80% had less than 200 participants). Ethnic and gender subgroup sizes have been seldom more than 40 with consequently little power to test moderation (Mak et al., 2007). From this perspective, the state of the literature stands at odds with a growing emphasis on disseminating evidence-based treatments (EBT) on a wide-scale, and researchers have argued that results from existing RCTs cannot be generalized to individuals from ethnic minority backgrounds (Hall, 2001; Sue, Zane, Hall, & Berger, 2009). Correspondingly, there has been recognition that treatment needs, processes, and outcomes might differ across gender (American Psychological Association, 2007; Blake et al., 2001). Although girls and women generally have been adequately represented in RCTs, few researchers have investigated potential gender differences in treatment effects (Mak et al., 2007).

This randomized clinical trial (RCT) compared Multidimensional Family Therapy (MDFT) with residential treatment (RT) for adolescents with co-occurring substance use and mental health disorders on substance use, delinquency, and mental health symptoms. Using an intent-to-treat design, 113 adolescents who had been referred for residential treatment were randomly assigned to either RT or MDFT in the home/community. The sample was primarily male (75%) and Hispanic (68%) with an average age of 15.4 years. Seventy-one percent of youth had at least one previous residential treatment placement. Participants were assessed at baseline and at 2, 4, 12 and 18 months post-baseline. During the early phase of treatment (baseline to 2 months), youth in both treatments showed significant reductions in substance use [substance use problems (d = 1.10), frequency of use (d = 1.36)], delinquent behaviors (d = 0.18) and externalizing symptoms (d = 0.77), and youth receiving MDFT reported significantly greater reductions in internalizing symptoms than youth receiving RT (d = 0.42). In phase 2, from 2 to 18 months after baseline, youth in MDFT maintained their early treatment decreases in substance use problems (d = 0.51), frequency of use (d = 0.24), and delinquent behaviors (d = 0.42) more effectively than youth in RT. During this period, there were no significant treatment differences in maintenance of gains for externalizing and internalizing symptoms. Results suggest that Multidimensional Family Therapy is a promising alternative to residential treatment for youth with substance use and co-occurring disorders. The results, if supported through replication, are important because they challenge the prevailing assumption that adolescents who meet criteria for residential treatment cannot be adequately managed in a non-residential setting.

For over four decades family therapy research and family centered evidence-based therapies for justice-involved youths have played influential roles in changing policies and services for these young people and their families. But research always reveals challenges as well as advances. To be sure, demonstration that an evidence-based therapy yields better outcomes than comparison treatments or services as usual is an accomplishment. But the extraordinary complexity embedded in that assertion feels tiny relative to what we are now learning about the so-called transfer of evidence-based treatments to real world practice settings. Today's family therapy studies continue to assess outcome with diverse samples and presenting problems, but research and funding priorities also include studying particular treatments in nonresearch settings. Does an evidence-based intervention work as well in a community clinic, with clinic personnel? How much of a treatment has to change to be accepted and implemented in a community clinic? Perhaps it is the setting and existing procedures that have to change? And, in those cases, do accommodations to the context compromise outcomes? Thankfully, technology transfer notions gave way to more systemic, dynamic, and frankly, more family therapy-like conceptions of the needed process. Implementation science became the more sensible, as well as the theoretically and empirically stronger overarching framework within which the evidence-based family based therapies now operate. Using the example of Multidimensional Family Therapy, this article discusses treatment development, refinement, and implementation of that adapted approach in a particular clinical context-a sector of the juvenile justice system-juvenile detention. Language: en

Reliable therapist-report methods appear to be an essential component of quality assurance procedures to support adoption of evidence-based practices in usual care, but studies have found weak correspondence between therapist and observer ratings of treatment techniques. This study examined therapist reliability and accuracy in rating intervention target (i.e., session participants) and focus (i.e., session content) in a manual-guided, family-based preventive intervention implemented with 50 inner-city adolescents at risk for substance use. A total of 106 sessions selected from three phases of treatment were rated via post-session self-report by the participating therapist and also via videotape by nonparticipant coders. Both groups estimated the amount of session time devoted to model-prescribed treatment targets (adolescent, parent, conjoint) and foci (family, school, peer, prosocial, drugs). Therapists demonstrated excellent reliability with coders for treatment targets and moderate to high reliability for treatment foci across the sample and within each phase. Also, therapists did not consistently overestimate their degree of activity with targets or foci. Implications of study findings for fidelity assessment in routine settings are discussed.

This article summarizes the 30+-year evidence base of Multidimensional Family Therapy (MDFT), a comprehensive treatment for youth substance abuse and antisocial behaviors. Findings from four types of MDFT studies are discussed: hybrid efficacy/effectiveness randomized controlled trials, therapy process studies, cost analyses, and implementation trials. This research has evaluated various versions of MDFT. These studies have systematically tested adaptations of MDFT for diverse treatment settings in different care sectors (mental health, substance abuse, juvenile justice, and child welfare), as well as adaptations according to treatment delivery features and client impairment level, including adolescents presenting with multiple psychiatric diagnoses. Many published scientific reviews, including meta-analyses, national and international government publications, and evidence-based treatment registries, offer consistent conclusions about the clinical effectiveness of MDFT compared with standard services as well as active treatments. The diverse and continuing MDFT research, the favorable, multi-source independent evaluations, combined with the documented receptivity of youth, parents, community-based clinicians and administrators, and national and international MDFT training programs (U.S.-based organization is MDFT International, www.mdft.org; and Europe-based organization is www.mdft.nl) all support the potential for continued transfer of MDFT to real-world clinical settings.

This study tested a family-based human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention approach integrated within an empirically supported treatment for drug-involved young offenders, Multidimensional Family Therapy (MDFT). A randomized, controlled, two-site community-based trial was conducted with 154 youth and their parents. Drug-involved adolescents were recruited in detention, randomly assigned to either MDFT or Enhanced Services as Usual (ESAU), and assessed at intake, 3, 6, 9, 18, 24, 36, and 42-month follow-ups. Youth in both conditions received structured HIV/STI prevention in detention and those in MDFT also received family-based HIV/STI prevention as part of ongoing treatment following detention release. Youth in both conditions and sites significantly reduced rates of unprotected sex acts and STI incidence from intake to 9 months. They remained below baseline levels of STI incidence (10%) over the 42-month follow-up period. At Site A, adolescents who were sexually active at intake and received MDFT showed greater reduction in overall frequency of sexual acts and number of unprotected sexual acts than youth in ESAU between intake and 9-month follow-ups. These intervention differences were evident through the 42-month follow-up. Intervention effects were not found for STI incidence or unprotected sex acts at Site B. Intensive group-based and family intervention in detention and following release may reduce sexual risk among substance-involved young offenders, and a family-based approach may enhance effects among those at highest risk. Site differences in intervention effects, study limitations, clinical implications, and future research directions are discussed.

Adolescent drug and alcohol abuse remains a serious health problem. Family-based treatments are recognized as among the most effective interventions for youth with drug and alcohol problems. This chapter presents the state of the science of the family-based adolescent substance abuse treatment field, summarizing the advances, methodological features, and outcomes of 36 randomized controlled trials, representing 18 distinct models of family-based therapies for youth substance abuse. The chapter reviews developments and gaps in this specialty, including theory issues, treatment development, research, and services for referred youths. The chapter also discusses the unknowns of the field, including the topic of treatment mechanisms and moderators, and deliberates on the complicated topic of implementing evidence-based therapies in usual care settings.

Background: Multidimensional family therapy is the most researched family based intervention for adolescent substance abuse. Research and coverage: Funded continuously since 1985 in a series of controlled trials, process studies, economic analyses, and implementation studies, MDFT has achieved positive outcomes at post treatment and at various follow-up periods at one year and beyond when compared to a variety of active treatments, including cognitive behavior therapy, group counseling, multifamily groups, as well as in comparisons against services as usual. MDFT is a treatment system rather than a one size fits all model, having been adapted for testing and implementation in a variety of U.S. locations and in a multinational controlled trial in Europe over the past 5 years (Berlin, Paris, Brussels, The Hague, and Geneva). Studies have tested MDFT in juvenile justice settings such as drug courts, detention centers, residential treatment, as well as in outpatient treatment offered in drug and juvenile just...

Objective: We used growth mixture modeling to examine heterogeneity in treatment response in a secondary analysis of 2 randomized controlled trials testing multidimensional family therapy (MDFT), an established evidence-based therapy for adolescent drug abuse and delinquency. Method: The first study compared 2 evidence-based adolescent substance abuse treatments: individually focused cognitive–behavioral therapy and MDFT in a sample of 224 urban, low-income, ethnic minority youths (average age 15 years, 81% male, 72% African American). The second compared a cross-systems version of MDFT (MDFT—detention to community) with enhanced services as usual for 154 youths, also primarily urban and ethnic minority (average age 15 years, 83% male, 61% African American, 22% Latino), who were incarcerated in detention facilities. Results: In both studies, the analyses supported the distinctiveness of 2 classes of substance use severity, characterized primarily by adolescents with higher and lower initial severity; the higher severity class also had greater psychiatric comorbidity. In each study, the 2 treatments showed similar effects in the classes with lower severity/frequency of substance use and fewer comorbid diagnoses. Further, in both studies, MDFT was more effective for the classes with greater overall substance use severity and frequency and more comorbid diagnoses. Conclusions: Results indicate that for youths with more severe drug use and greater psychiatric comorbidity, MDFT produced superior treatment outcomes.

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

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.

Drug and juvenile justice involved youths show remarkably high rates of human immunodeficiency virus (HIV)/sexually transmitted disease (STD) risk behaviors. However, existing interventions aimed at reducing adolescent HIV risk behavior have rarely targeted these vulnerable young adolescents, and many approaches focus on individual-level change without attention to family or contextual influences. We describe a new, family-based HIV/ STD prevention model that embeds HIV/STD focused multifamily groups within an adolescent drug abuse and delinquency evidence-based treatment, Multidimensional Family Therapy (MDFT). The approach has been evaluated in a multisite randomized clinical trial with juvenile justice involved youths in the National Institute on Drug Abuse Criminal Justice Drug Abuse Treatment Studies (www.cjdats.org). Preliminary baseline to 6-month outcomes are promising. We describe research on family risk and protective factors for adolescent problem behaviors, and offer a rationale for family-based approaches to reduce HIV/STD risk in this population. We describe the development and implementation of the Multidimensional Family Therapy HIV/STD risk-reduction intervention (MDFT-HIV/ STD) in terms of using multifamily groups and their integration in standard MDFT and also offers a clinical vignette. The potential significance of this empirically based intervention development work is high; MDFT-HIV/STD is the first model to address largely unmet HIV/STD prevention and sexual health needs of substance abusing juvenile offenders within the context of a family-oriented evidence-based intervention.

Research has established the dangers of early onset substance use for young adolescents and its links to a host of developmental problems. Because critical developmental detours can begin or be exacerbated during early adolescence, specialized interventions that target known risk and protective factors in this period are needed. This controlled trial (n = 83) provided an experimental test comparing multidimensional family therapy (MDFT) and a peer group intervention with young teens. Participants were clinically referred, were of low income, and were mostly ethnic minority adolescents (average age = 13.73 years). Treatments were manual guided, lasted 4 months, and were delivered by community agency therapists. Adolescents and parents were assessed at intake, at 6-weeks post-intake, at discharge, and at 6 and 12 months following treatment intake. Latent growth curve modeling analyses demonstrated the superior effectiveness of MDFT over the 12-month follow-up in reducing substance use (effect size: substance use frequency, d = 0.77; substance use problems, d = 0.74), delinquency (d = 0.31), and internalized distress (d = 0.54), and in reducing risk in family, peer, and school domains (d = 0.27, 0.67, and 0.35, respectively) among young adolescents.

Aim To examine the efficacy of two adolescent drug abuse treatments: individual cognitive behavioral therapy (CBT) andmultidimensionalfamilytherapy(MDFT).Design A2(treatmentcondition)x4(time)repeated-measuresintent- to-treat randomized design. Data were gathered at baseline, termination, 6 and 12 months post-termination. Analyses used latent growth curve modeling. Setting Community-based drug abuse clinic in the northeastern United States. Participants A total of 224 youth, primarily male (81%), African American (72%), from low-income single-parent homes (58%) with an average age of 15 years were recruited into the study. All youth were drug users, with 75% meeting DSM-IV criteria for cannabis dependence and 13% meeting criteria for abuse. Measurements Five outcomes were measured: (i) substance use problem severity; (ii) 30-day frequency of cannabis use; (iii) 30-day frequency of alcohol use; (iv) 30-day frequency of other drug use; and (v) 30-day abstinence. Findings Both treatments produced significant decreases in cannabis consumption and slightly significant reductions in alcohol use, but there were no treatment differences in reducing frequency of cannabis and alcohol use. Significant treatment effects were found favoring MDFT on substance use problem severity, other drug use and minimal use (zero or one occasion of use) of all substances, and these effects continued to 12 months following treatment termination. Conclusion Both interven- tions are promising treatments. Consistent with previous controlled trials, MDFT is distinguished by the sustainability of treatment effects.

SUMMARY Multidimensional Family Therapy (MDFT) has been empirically supported in a series of randomized clinical trials over 20 years. These studies have demonstrated the potency of MDFT in achieving outcomes across functional areas of the teen's life, including reductions in alcohol-other drug use, behavioral problems, emotional symptoms, negative peer associations, school failure, and deficits within the family. This article describes our approach to refining and testing MDFT with teens who abuse alcohol. Drawing from the research base on risk and protective factors for teen alcohol abuse and relapse patterns, a strong case can be made for using a family-based approach for adolescent alcohol problems. MDFT shows promising preliminary results with teens who have alcohol and marijuana use disorders. Specific change targets within this empirically supported family-based intervention for adolescent alcohol problems are outlined.

The objective of this article is to examine the effectiveness of 2 theoretically different treatments delivered in juvenile drug court—family therapy represented by multidimensional family therapy (MDFT) and group-based treatment represented by adolescent group therapy (AGT)—on offending and substance use. Intent-to-treat sample included 112 youth enrolled in juvenile drug court (primarily male [88%], and Hispanic [59%] or African American [35%]), average age 16.1 years, randomly assigned to either family therapy (n 55) or group therapy (n 57). Participants were assessed at baseline and 6, 12, 18 and 24 months following baseline. During the drug court phase, youth in both treatments showed significant reduction in delinquency (average d .51), externalizing symptoms (average d 2.32), rearrests (average d 1.22), and substance use (average d 4.42). During the 24-month follow-up, family therapy evidenced greater maintenance of treatment gains than group-based treatment for externalizing symptoms (d 0.39), commission of serious crimes (d .38), and felony arrests (d .96). There was no significant difference between the treatments with respect to substance use or misdemeanor arrests. The results suggest that family therapy enhances juvenile drug court outcomes beyond what can be achieved with a nonfamily based treatment, especially with respect to what is arguably the primary objective of juvenile drug courts: reducing criminal behavior and rearrests. More research is needed on the effectiveness of juvenile drug courts generally and on whether treatment type and family involvement influence outcomes. Trial Registry Name: Clinical Trials.gov, Identified NCT01668303.

We investigated direct and shared effects of family functioning and self-concept on the severity of adolescent externalizing problems in a sample of 224 clinically referred adolescents. Structural equation modeling (SEM) revealed strong, direct relationships between problem behaviors and both family functioning and self-concept. Using R. M. Baron and D. A. Kenny's (1986) and G. N. Holmbeck's (1997) criteria for testing mediation in SEM, family functioning partially mediated the relationship between self-concept and problem behaviors. A moderation model, testing the relationship between externalizing problems and the interaction between family functioning and self-concept, did not yield a significant effect. Our findings indicate that self-concept and family functioning exert direct and shared effects on externalizing problems and suggest that interventions for clinically referred adolescents should target both the individual adolescent and his/her family.

The relation between family functioning and school success was examined in 211 at risk, African American, inner city adolescents attending middle school (grades 6-8). Interviews with adolescents and caregivers yielded data on family cohesion, parental monitoring, and school engagement; school records provided data on grade point average. Results showed that both family cohesion and parental monitoring predicted school engagement, but neither family characteristic predicted GPA. Important gender differences also emerged. For boys only, the relation between family cohesion and school engagement was stronger when parental monitoring was high. For girls only, the effects of cohesion and monitoring on school engagement were additive: girls with both high family cohesion and high parental monitoring were most likely to be engaged in school. These findings extend the research base on family protective factors for antisocial behavior in young adolescents. Implications for future examination of family process characteristics in high-risk adolescents are discussed.

The authors examined the relations between adolescent-therapist and mother-therapist therapeutic alliances and dropout in multidimensional family therapy for adolescents who abuse drugs. The authors rated videotapes of family therapy sessions using observational methods to identify therapist-adolescent and therapist-mother alliances in the first 2 therapy sessions. Differences in adolescent and mother alliances in families that dropped out of therapy and families that completed therapy were compared. Results indicate that both adolescent and mother alliances with the therapist discriminated between dropout and completer families. Although no differences were observed between the 2 groups in Session 1, adolescents and mothers in the dropout group demonstrated statistically significantly lower alliance scores in Session 2 than adolescents and parents in the completer group. These findings are consistent with other research that has established a relationship between therapeutic alliance and treatment response.

Many economic evaluations have been conducted for adult substance abuse treatments, but only a few have been conducted for adolescent-specific treatments. This is the first article to present rigorous methodological guidelines for estimating the economic costs and benefits of adolescent substance abuse treatments while also addressing the potential challenges associated with such research activities. A representative case study of two adolescent substance abuse treatment programs (one residential and one outpatient) is presented to show some of the initial steps of a comprehensive economic evaluation (e.g., cost analyses, selection of treatment outcome measures, and valuation of outcome measures via monetary conversion factors). Cost data were collected and analyzed using the Drug Abuse Treatment Cost Analysis Program. Monetary conversion factors were obtained and presented for a variety of treatment outcomes. The methodological guidelines, discussion of analytic challenges, and recommendations set forth in this article provide a foundation for future economic studies on adolescent substance abuse treatments.

The authors applied contemporary methods from the evaluation literature to measure implementation in a residential treatment program for adolescent substance abuse. A 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. In addition, variability in implementation was measured using statistical process control (SPC) procedures. Adolescents completed, on average, 50% of the weekly prescribed services. The milieu of the program was rated by the adolescents as highly therapeutic. Moreover, preliminary psychometrics suggest therapeutic milieu can be measured reliably in adolescents. These two main variables were implemented with consistency across adolescents. These findings are discussed along with implications for evaluation work in similar fields.

This study examined fidelity in multidimensional family prevention (MDFP), a family-based prevention counseling model for adolescents at high risk for substance abuse and related behavior problems, in comparison to two empirically based treatments for adolescent drug abuse: multidimensional family therapy (MDFT) and cognitive-behavioral therapy (CBT). Randomly selected videotapes of 109 MDFP sessions, 57 MDFT sessions, and 31 CBT sessions were observationally rated along two key dimensions of implementation: intervention parameters and intervention techniques. Overall, MDFP was similar to MDFT and different from CBT in a manner congruent with its theoretical principles of interactional, systemic intervention. However, deficiencies in parental monitoring and developmental knowledge interventions point the way for continued model development. The utility of fidelity process research for conveying intervention technology along the prevention-treatment continuum of mental health services is discussed. © 2005 Wiley Periodicals, Inc. J Comm Psychol 33: 191–211, 2005.

This study piloted a 14-item, observer-rated therapeutic alliance scale with adolescents enrolled in family-based substance abuse prevention counseling. The Adolescent Therapeutic Alliance Scale (ATAS) was drawn from 2 main sources: (a) items from the Vanderbilt Therapeutic Alliance Scale–Revised based on developmental considerations and (b) Bordin's (1979) theory of the alliance as consisting of bond, tasks, and goals. Independent observers rated the therapist–adolescent alliance for 51 at-risk, African American adolescents (aged 11–14 years). Factor analysis suggested the ATAS measures one construct (eigenvalue=8.6, accounting for 61.3% of total scale variance). Item loadings ranged from .40 to .90. Convergent validity with both therapist- and observer-rated engagement was also high. Internal consistency reliability (α=.90) and intraclass correlation (ICC1,2=.74) were acceptable. A trend emerged for ATAS ratings to predict improvement in adolescent investment in school. Recommendations are made for futu...

This study was designed to establish and validate a multi- dimensional empirically based typology of clinically referred adolescent substance abusers. A total of 141 adolescent substance abusers, most of whom were male, African-American, and juvenile justice involved, comprised the study sample. Youth and their parents completed compre- hensive assessments at intake to treatment, discharge, and at 6 months and 12 months post-discharge from treatment. Adolescents were classi- fied based on individual and family risk factors, associated problems, and severity of substance use. Variables included in the 2-stage cluster analysis included adolescents' substance use, psychiatric disorders, and legal involvement; peer substance use; family substance abuse; parental psychopathology; and family conflict. Three groups emerged: Juvenile

Objective To characterize the developmental status of the family-based adolescent alcohol and drug treatment specialty by identifying and discussing research and clinical advances. Method Selective and interpretative literature review and analysis. Study selection Controlled trials and mechanisms of change studies of family-based treatments for adolescent alcohol and drug misuse. Results Clinical innovations of family-based treatments include development of detailed therapy, training/supervision, and adherence manuals. Different family-based treatments have been tested with success in controlled trials and process studies. Different versions of the same approach might vary on parameters such as treatment dose, setting, and client characteristics. Research advances include findings that engagement and retention rates for family-based treatments are superior to standard treatment engagement/retention methods. Also, in clinical trials in which they are compared with alternative interventions, in the majority of studies, family-based treatments produce superior and stable outcomes with significant decreases on target symptoms of alcohol and drug use, and related problems such as delinquency, school and family problems, and affiliation with substance abusing peers. Mechanisms of change studies support the theory basis of family-based treatments. For instance, improvements in family interaction patterns coincide with decreases in core target alcohol and drug misuse symptoms. Conclusions Once in the shadows of the adult substance abuse field, the adolescent substance abuse specialty has become a unique, clinically creative, and empirically-based area. Research and clinical advances of family-based treatments have implications for non-family-based interventions in the adolescent substance misuse treatment specialty.

This article presents the main outcome findings from two inter-related randomized trials conducted at four sites to evaluate the effectiveness and cost-effectiveness of five short-term outpatient interventions for adolescents with cannabis use disorders. Trial 1 compared five sessions of Motivational Enhancement Therapy plus Cognitive Behavioral Therapy (MET/CBT) with a 12-session regimen of MET and CBT (MET/CBT12) and another that included family education and therapy components (Family Support Network [FSN]). Trial II compared the five-session MET/CBT with the Adolescent Community Reinforcement Approach (ACRA) and Multidimensional Family Therapy (MDFT). The 600 cannabis users were predominately white males, aged 15-16. All five CYT interventions demonstrated significant pre-post treatment during the 12 months after random assignment to a treatment intervention in the two main outcomes: days of abstinence and the percent of adolescents in recovery (no use or abuse/dependence problems and living in the community). Overall, the clinical outcomes were very similar across sites and conditions; however, after controlling for initial severity, the most cost-effective interventions were MET/CBT5 and MET/CBT12 in Trial 1 and ACRA and MET/CBT5 in Trial 2. It is possible that the similar results occurred because outcomes were driven more by general factors beyond the treatment approaches tested in this study; or because of shared, general helping factors across therapies that help these teens attend to and decrease their connection to cannabis and alcohol.

Comorbidity of substance abuse disorders (SUD) and psychiatric disorders is one of the most important areas of investigation in contemporary drug abuse treatment research. This study examined the impact of psychiatric comorbidity on the treatment of 182 adolescent drug abusers in a randomized clinical trial comparing family and individual cognitive-behavioral therapy. Three distinct groups of adolescent substance abusers were compared: (1) Exclusive Substance Abusers (SUD only); (2) Externalizers (SUD + externalizing disorder); and (3) Mixed Substance Abusers (SUD + externalizing and internalizing disorder). The purpose of this study was to determine whether adolescents in these comorbid groups differed in clinical presentation and treatment response. More severe comorbidity was associated with greater family dysfunction and being female and younger at intake. An examination of substance use trajectories over time indicated that the Mixed group initially responded to treatment but returned to intake levels of substance use by 1 year post-discharge.

Psychotherapy process research plays an integral role in the development of empirically based treatments. Treatment development refers to systematic efforts to test, critique, and revise the theoretical underpinnings and technical ingredients of intervention models in connection with an accumulating research base (Kazdin, 1994; Rounsaville, Carroll, & Onken, 2001). Treatment development relies on process research that can elucidate the mechanisms of change responsible for observed outcome effects: How does a treatment work and what features are essential for its success? (Kazdin, 1999). Process research is also poised to make a substantial contribution to treatment dissemination efforts. The imposing gap between efficacy research (testing therapies under highly controlled conditions to maximize internal validity) and effectiveness research (testing therapies under standard practice conditions to maximize external and ecological validity) has prompted demand for research on transporting treatment models from the lab to the clinic (Nathan, Stuart, & Dolan, 2000; Weisz, Donenberg, Han, & Weiss, 1995). One key to successful transportation will be identifying the specific aspects of efficacious models that are linked with good outcomes—knowing what, exactly, should be transported (Kazdin, 2001). This is particularly true for multicomponent, flexibly delivered models whose clinical look may vary from case to case as therapists attempt to meet the unique needs of each client (Gaston & Gagnon, 1996). The current study investigated specific therapy processes for two empirically supported outpatient treatments for adolescent substance abuse: cognitive–behavioral therapy and family therapy. National surveys and household probability studies conducted within the past decade reveal that adolescent drug use remains a prevalent and serious problem (Department of Health and Human Services, 2000; Gfroerer, 1995; Johnston, O’Malley, & Bachman, 1995; Kilpatrick et al., 2000). To date, family therapy has generated the largest evidence base in the treatment of adolescent drug use and cooccurring symptoms (Stanton & Shadish, 1997; Williams, Chang, & ACARG, 2000). Rigorous empirical studies have shown that family-based therapy can produce engagement and retention of drug users and their families in treatment (Henggeler et al., 1991); reduction or elimination of drug use (Liddle et al., 2001; Waldron, Slesnick, Brody, Turner, & Peterson, 2001); decreased involvement in delinquent activities (Henggeler, Melton, Smith, Schoenwald, & Hanley, 1993); improvement in multiple domains of psychosocial functioning such as school grades, school attendance, and family functioning (Liddle et al., 2000); and increased quality of parenting behavior (Mann, Borduin, Henggeler, & Blaske, 1990; Schmidt, Liddle, & Dakof, 1996). There is also evidence that therapeutic gains maintain at long-term follow-up (Liddle et al., 2001) and that family-based approaches are cost-effective in comparison to treatment as usual (Schoenwald, Ward, Henggeler, Pickrel, & Patel, 1996). A second highly regarded treatment approach for adolescent drug abuse is cognitive–behavioral therapy (Bukstein, 1995; Weinberg, Rahdert, Colliver, & Glantz, 1998). Cognitive–behavioral approaches have demonstrated efficacy in reducing adolescent substance abuse (Waldron et al., 2001; Winters, Latimer, & Stinchfield, 1999) and comorbid psychiatric problems (Kaminer, Blitz, Burleson, & Sussman, 1998). Cognitive–behavioral approaches are also widely practiced with adolescent drug users (Bukstein, 1995), making them a critical target for further empirical validation. This study investigated two manualized treatments for adolescent substance use: individual cognitive–behavioral therapy (CBT) and multidimensional family therapy (MDFT). These models were previously tested in a randomized controlled trial with inner-city, primarily ethnic minority adolescent drug abusers (Liddle & Hogue, 2001). Results of that study indicated that both treatments were effective in reducing marijuana use, externalizing symptoms, and internalizing symptoms at posttreatment and up to 1 year later, with MDFT showing some superiority in producing gains more rapidly and maintaining posttreatment gains at follow-up. The main goals of the current study were to identify differences between CBT and MDFT in the use of specific therapy techniques and to link these process elements to outcomes found in the parent randomized trial. Specific therapy techniques are the technical aspects of a treatment model that derive directly from its fundamental theory- and practice-based principles (Elkin, Pilkonis, Docherty, & Sotsky, 1988). Advances in the technology of psychotherapy process research, including specification of clinically meaningful process variables and use of dimensional scales to measure therapist behavior (Greenberg, 1986; Schaffer, 1982; Sechrest, 1994), have spurred efforts to identify specific techniques that predict treatment outcome. A recent meta-analysis found that the effects of specific therapy components exceeded those of non-specific and facilitative factors, particularly for clients with more severe problems (Stevens, Hynan, & Allen, 2000). Nevertheless, the therapeutic potency of specific techniques (Messer & Wampold, 2002; Wampold et al., 1997), and the theoretical and methodological feasibility of discovering process–outcome correlations involving discrete technique variables (Stiles & Shapiro, 1994), are still in question. This study examined the degree to which individual-focused and family-focused techniques within CBT and MDFT promote change in core behavioral symptoms related to adolescent substance abuse. Both approaches provide for some degree of therapist flexibility in targeting both individual and family functioning in order to achieve treatment goals. CBT focuses on changing the behaviors and cognitions of individual adolescents and works predominantly with teens alone in session. However, CBT therapists are trained to discuss salient issues pertaining to the youth’s relationships with parents and family members and, also, to meet periodically with care-givers. In the same vein, whereas MDFT targets family interactions directly and works predominantly with caregivers and other family participants in session, MDFT therapists also routinely hold individual sessions and work on the personal attitudes and behaviors of teens. There are two primary study hypotheses: Greater use of adolescent-focused intervention techniques will predict improvement in CBT, whereas greater use of family-focused techniques will predict improvement in MDFT. Adolescent outcomes in drug use, externalizing symptoms, and internalizing symptoms were measured at pre- and posttreatment. Therapy techniques were measured using observational scales from a psychotherapy process instrument developed in a previous study on this sample (Hogue et al., 1998). The current study extended the Hogue et al. 1998 study by adding new items to the observational scales, conducting new exploratory factor analyses of the expanded scale, increasing the number of participants, and conducting process–outcome analyses.

An economic evaluation of five outpatient adolescent treatment approaches (12 total site-by-conditions) was conducted. The economic cost of each of the 12 site-specific treatment conditions was determined by the Drug Abuse Treatment Cost Analysis Program (DATCAP). Economic benefits of treatment were estimated by first monetizing a series of treatment outcomes and then analyzing the magnitude of these monetized outcomes from baseline through the 12-month follow-up. The average economic costs ranged from $90 to $313 per week and from $839 to $3,279 per episode. Relative to the quarter before intake, the average quarterly cost to society for the next 12 months (including treatment costs) significantly declined in 4 of the 12 site-by-treatment conditions, remained unchanged in 6 conditions, and increased in 2 treatment conditions (both in the same site). These results suggest that some types of substance-abuse intervention for adolescents can reduce social costs immediately after treatment.

Aims This paper provides a description of the rationale, study design, treatments and assessment procedures used in the Cannabis Youth Treatment (CYT) experiment. Design CYT was designed to (a) test the relative effectiveness, cost and benefit–cost of five promising treatment interventions under field conditions and (b) provide evidence based manual-guided models of these interventions to the treatment field. Setting The study involved two community-based treatment programs and two major medical centers. Participants Participants were 600 adolescents recruited from the regular intake who were between the ages of 12 and 18, had used marijuana in the past 90 days, and met one or more criteria of dependence or abuse. Interventions Participants were randomly assigned to one of five interventions: Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT), Family Support Network (FSN), Adolescent Community Reinforcement Approach (ACRA), or Multidimensional Family Therapy (MDFT). Measurements Self-report data were collected at intake, 3, 6, 9 and 12 months post discharge using the Global Appraisal of Individual Needs (GAIN), as well as several supplemental self-reports, collateral reports, urine testing, and service logs. Findings This paper reports on the study's implementation including the psychometric properties of the measures (alphas over 0.8), validity of self-report (kappa over 0.6), high rates of treatment completion (81% completed two or more months), and high rates of follow-up (over 94% per wave). Conclusions The feasibility of implementing the CYT manual-guided treatment and quality assurance model in community-based adolescent treatment programs is discussed.

The five manual-guided treatment models tested in the Cannabis Youth Treatment study funded by the Center for Substance Abuse Treatment are described. The five models include (a) a 6-week intervention consisting of two sessions of individual motivational enhancement therapy plus three sessions of group cognitive behavioral therapy (MET/CBT5); (b) a 12-week intervention consisting of two sessions of motivational enhancement therapy plus 10 sessions of group cognitive behavioral therapy treatment (MET/CBT12); (c) a 12-week intervention consisting of MET/CBT12 plus the family support network (FSN), a multi-component intervention that includes parent education, family therapy and case management; (d) a 12-week intervention based on the adolescent community reinforcement approach (ACRA), an individual behavioral treatment approach designed to help adolescents and their parents reshape their environment and learn new skills; and (e) multi-dimensional family therapy (MDFT), a multi-faceted, developmentally and contextually oriented family-based model targeting individual, family and social systems. For each model, we describe the treatment background and/or its empirical support, its theoretical underpinnings, its goals and proposed treatment mechanism and the structure and content of each treatment. Procedures used for maintaining treatment fidelity and monitoring quality assurance are also described. These interventions represent the first readily available, manual-guided interventions to be evaluated in a large randomized field study for this population. Consequently, these manuals have the potential to advance treatment and research for adolescents with substance use disorders.

The divide separating research and clinical work is narrowing. New therapies have been informed by research from specialties such as developmental psychology and developmental psychopathology. In this article, we attempt to illustrate the usefulness of research on attachment relations for family-based therapy with adolescents. We examine the clinical utility of adolescent attachment research within the context of multidimensional family therapy, an empirically supported treatment model that has incorporated developmental research, including basic research on attachment, in its assessment and intervention framework.

Family-based prevention programs have shown promise in preventing drug use and antisocial behavior in high-risk youth. Multidimensional family prevention (MDFP) is an intensive, family-based counseling program in which a family-specific prevention agenda is crafted with each family. This collaborative, individualized approach to intervention requires a high degree of engagement on the part of families. The main challenges of engagement are discussed, and the main features of an engagement strategy are described: capturing the interest of the family and assessing risk and protective factors within the specific ecological context of the family in order to create a working agenda for preventive intervention.

Adolescent substance abusers demonstrate numerous emotional and behavioral difficulties in conjunction with drug problems. In this study, 236 clinically referred substance abusing adolescents were grouped on level of self-reported and parent-reported internalizing and externalizing symptoms and compared on important variables. Three groups emerged: Externalizers, Exclusive Substance Abusers, and Mixed (adolescents with both internalizing and externalizing symptoms). Exclusive Substance Abusers showed a general pattern of more positive functioning than adolescents in the other groups. This study reveals that clinically referred adolescent substance abusers can be meaningfully distinguished on levels of externalizing and internalizing problems, and that family characteristics differentiate these groups.

The Transmission of Psychopathology From Parents to Offspring: Development and Treatment in Context* In their research report, Loukas et al. report that parental alcoholism is prognostic of childhood behavior problems, both directly, through genetic and modeling effects, and indirectly, through parental distress and physical problems. They hypothesized that the heightened rate of behavior problems in young children of alcoholics could be traced to the combination of negative interactions with the alcoholic parent (e.g., abuse, neglect) and the generalized stress involved in living with an alcoholic (e.g., chaotic and unpredictable family climate). Loukas et al. point out that the negativity in alcoholic families is likely to be exacerbated by heightened levels of parental distress and by a lack of closeness and "quality time" between parents and children. As a result, children may somehow "act out" their parents' distress in addition to acting out the dysfunction inherent in an alcoholic family. Loukas et al. found that alcoholic fathers with comorbid antisocial personality disorder tended to have sons with the most severe conduct problems, replicating an earlier finding obtained by the same research group (Puttler, Zucker, Fitzgerald, & Bingham, 1998). They argue that this finding may be due to the personal and family antecedents and correlates of antisocial personality disorder, particularly a history of psychiatric problems and childhood conduct disorder, heightened family stress, less "quality time" spent between parents and children, and a chaotic family environment. These factors have all been empirically found to contribute to the genesis of child behavior problems: Negative psychiatric histories and conduct problems have been shown to be transmitted familially (Merikangas & Avenevoli, 2000; Taylor & Carey, 1998). Family stress is a significant predictor of conduct problems in childhood (Kagan & Schlossberg, 1989; Keiley, Bates, Dodge, & Pettit, 2000). The amount of time parents and children spend together (Griffin, Botvin, Scheier, Diaz, & Miller, 2000) and the quality of parent-child communication (Harnish, Dodge, Valente, & Conduct Problems Prevention Research Group, 1995) are protective factors against child behavior problems. Finally, a chaotic family environment is often implicated in the onset of conduct problems (Patterson, 1982; Patterson, Bank, & Stoolmiller, 1990; Weiss, Dodge, Bates, & Pettit, 1992). The risk for problem behaviors is further exacerbated when these risk factors act in combination with one another (beater-Deckard, Dodge, Bates, & Pettit, 1998), especially when risk factors from different contexts act in concert with one another (Dishion, Capaldi, & Yoerger, 1999). The findings reported by Loukas et al. are highly consistent with the extant literature on parental substance abuse, family dysfunction, and childhood conduct problems. The associations among parental substance abuse, family chaos, and childhood conduct disorder have been reported in the literatures on parenting, drug abuse, behavior problems, and psychiatric disorders (e.g., Bukstein, 1995, 1997; Conduct Problems Prevention Research Group, 2000; Dishion et al., 1999; Loeber, Green, Lahey, Frick, & McBurnett, 2000; Pettit, Bates, & Dodge, 1997; Taylor & Carey, 1998). The purpose of this companion paper is to trace some of the antecedents, causes, and treatment implications of the findings of Loukas et al. As treatment- and prevention-oriented researchers, we are particularly interested in the developmental psychopathology of childhood behavior problems, because understanding the etiology and developmental course of any disorder is key to preventing or treating it (cf. Cicchetti, 1984, 1993; Liddle & Hogue, 2000). Moreover, as we will discuss further, childhood conduct disorder occupies a pivotal position in the developmental sequence of behavior problems. …

This study suggests that systematic discussion of culturally salient content in therapy sessions can positively influence engagement (i.e., therapy participation and therapeutic alliance) with clinically referred African American adolescent males. In a sample of 18 African American adolescent males participating in 187 videotaped psychotherapy sessions, the in-session discussion of research derived, developmentally and culturally related content themes (anger/rage, alienation, respect, and journey from boyhood to manhood) were found to be positively associated with therapist-adolescent alliance and adolescent engagement. Discussions that focused on issues of trust and mistrust were found to negatively predict ratings of therapist-adolescent relationship, and discussions of racial identity/racial socialization were found to have no association with adolescent engagement. These findings provide clues about (a) how culturally responsive treatments can be developed, and (b) in this era of manualized therapies, the possibility of enhancing therapeutic outcomes by tailoring treatment protocols at specific levels of content focus and detail.

Family prevention counseling, which features customized prevention planning for individual families, is a promising approach for preventive intervention with adolescents at high risk for substance abuse and conduct disorder. A randomized study (N = 124) tested the post-intervention efficacy of an indicated, family-based prevention model with a sample of inner-city African-American youths (ages 11–14). Key risk and protective factors associated with the development of drug use and antisocial behavior were targeted in four domains: self-competence, family functioning, school involvement, and peer associations. Compared to controls, participants in family prevention counseling showed gains in global self-worth, family cohesion, and bonding to school, and a decrease in peer antisocial behavior. The potential utility of family prevention counseling within a unified prevention framework is discussed. © 2002 John Wiley & Sons, Inc.

Tremendous advances have been made in our understanding of the intrapersonal, interpersonal, familial, and contextual characteristics and processes that contribute to adaptive as well as maladaptive developmental outcomes with high-risk and clinically referred adolescents. This empirical knowledge base offers clinically rich opportunities for systematic treatment development. An important step in this process is distinguishing which research findings in basic science areas such as developmental psychology and developmental psychopathology might have clinical relevance. Toward this goal, we review relevant but selective research in areas that are central to clinical work with adolescents (parent-adolescent relationship, biological aspects, and affect and cognition), and we offer examples of how basic research in these areas can inform treatment.

Family-based therapy is one of the most thoroughly studied treatments for adolescent drug abuse. Considerable empirical support exists for the efficacy of family-based therapy in curtailing adolescent drug use and cooccurring behavior problems. This article extends knowledge of the effects of family-based therapy for adolescent drug abuse by reviewing 16 controlled trials and 4 therapy process studies from a treatment development perspective. We articulate "knowns and unknowns" regarding the outcomes of treatment as well as the components, processes, mechanisms, moderators, and boundaries of effective family-based therapy for adolescent drug abuse. The review highlights areas of progress and future research needs within the specialty of family-based therapy for adolescent drug abuse.

This article describes procedures for developing a therapeutic alliance with a parent within the context of family therapy for adolescents. After an overview of the general clinical model, specific themes and interventions are described that provide a map to facilitate this process. Following Bordin's (1979) model, alliance is conceptualized in three parts: bonds, goals, and tasks. The bond phase consists of the therapist showing empathy and understanding toward the parent and the parent developing empathy toward their own life struggles. The goal phase consists of defining parent–child relationship building as a primary focus of treatment. The task phase consists of preparing parents to better communicate with their adolescent. These phases can occur sequentially within a single session with a parent alone. The alliance building session sets the foundation for parent–adolescent conflict resolution leading to reattachment in future sessions. © 2000 John Wiley & Sons, Inc. J Clin Psychol/In Session 56: 1037–1050, 2000.