Mothers and their families were seen in their homes rather than offices of service providers, treatment sessions were increased from 60 minutes to 75 minutes, the duration of treatment was extended from 4 months to 6 months, the target number of treatment sessions was extended from 15 sessions to 20 sessions, and several intervention components were incorporated.
This modified FBT has demonstrated preliminary efficacy in controlled and uncontrolled case trials specific to coexisting child neglect and drug abuse in home-based settings Donohue, Romero et al. TAU was selected because it permitted the drawing of definitive conclusions by controlling extra-treatment variables associated with the passage of time e.
Family Behavior Therapy
As customarily performed in outcome research involving drug abuse Henggeler et al. There was no standard referral system, as caseworkers referred to various services according to their assessment of family needs and motivation, problem severity, availability of services, and relationship of caseworker with referral agencies. TAU services were consistent with referrals made by Child Protective Service agencies, including child placement e. Eleven providers participated in the study. Two treatment providers were scheduled to implement FBT components during each home-based session.
Prior to this study, the providers had no experience implementing FBT, and their professional experience varied i. FBT providers received approximately 16 hours of formal FBT training in workshop format utilizing behavioral role-playing prior to intervention implementation. Providers attended 90 to minutes of weekly group supervision throughout the study. Group supervision focused on reviewing family safety, treatment planning, and maintenance of intervention adherence. Strategies were employed to ensure the integrity of treatment Azrin, Donohue et al. Reliability and validity estimates of treatment integrity were derived from completed protocol checklists see Intervention Fidelity in the Results section.
Reliability and validity for the latter method was demonstrated in an effectiveness trial of Multisystemic Therapy involving community providers Sheidow et al. Participants were referred to treatment for coexisting child neglect and drug abuse. Higher scores are indicative of greater likelihood of child maltreatment potential, with scores above indicating significant potential for child maltreatment. Psychometric properties of the CAPI have been examined in more than articles during the past 20 years. Walker and Davies review 27 studies that have demonstrated the CAPI's cross-cultural validity, internal consistency of its subscale and total scale scores across sample groups and cultures, relatively high albeit varied sensitivity and specificity classification rates, differential validity, and treatment sensitivity.
The TLFB utilizes a calendar to evaluate daily patterns and frequency of drug use over a specified time period i. As in our previous controlled trials, the TLFB was administered to both study participants and their primary adult significant others separately. An 8-panel urinalysis toxicology screen marijuana, cocaine, amphetamines, barbiturates, opiates, benzodiazepines, methadone, phencyclidine incorporating conventional detection cut-offs was used to corroborate TLFB data.
To derive a reliable estimate of the number of days participants used marijuana and hard drugs, the substance use measure participant TLFB, significant other TLFB, urinalysis that indicated greatest substance use during the respective 4-month assessment period was utilized.
For instance, if a participant reported 3 days of marijuana use, the significant other reported 1 day of marijuana use, and urinalysis testing results indicated no marijuana use, 3 days of marijuana use was used to estimate the frequency of marijuana use. The TLFB has consistently demonstrated concurrent validity, predictive validity, inter-rater agreement, face validity, and treatment sensitivity Carey, ; Donohue et al.
Higher scores indicate greater risk of HIV transmission. The RAB has demonstrated construct validity in factor analyses, it's test-retest reliability has been shown to range from. Intent-to-treat data analysis was performed to determine the effects of treatment and neglect type on the dependent variables. A similar series of separate analyses was conducted to determine if outcomes were different between baseline and the month post-randomization assessments. It was further hypothesized that there would be significant 2-way interactions in all dependent measures showing greatest relative improvements in FBT mothers who were referred for child neglect not due to their child being exposed to illicit drugs, as compared with FBT mothers who were referred for child neglect due to their child being exposed to drugs and TAU participants, from baseline to 6-month post-randomization, and baseline to month post-randomization.
The method of determining protocol adherence has been utilized in our previous NIDA- and NIMH-funded clinical trials, and has been formally demonstrated to be a reliable and valid method Azrin et al. Protocol checklists include each of the critical steps required to implement each intervention and are used by therapists during treatment to guide the intervention. Protocol adherence of FBT providers was determined by computing the number of protocol instructions reported to have been implemented by providers, and dividing this number by the total number of prescribed protocol instructions.
The intra-class correlation coefficient was The average number of FBT sessions attended by mothers was Potential pre-treatment differences between experimental conditions were examined utilizing Chi-square analyses on baseline categorical demographic and outcome variables, and one-way ANOVAs on continuous demographic and outcome variables utilizing assigned experimental condition FBT, TAU as the independent variable. Table 1 presents demographic data. Means and standard deviations for the primary measures for FBT and TAU participants by referral status across time are presented in Table 2.
The effect of intervention and neglect type on child maltreatment potential was analyzed utilizing repeated measures analyses of variance ANOVAs. In determining the clinical meaningfulness of these results, CAPI Abuse scale scores were examined based on clinical cut-off scores that indicate risk for child maltreatment potential i.
As can be seen in Figure 1 , these results corroborate that FBT was particularly meaningful in mothers of non-drug exposed children. In reducing child maltreatment potential from baseline to 6-month post-randomization and from baseline to month post-randomization FBT demonstrated medium effects, whereas TAU demonstrated small effects. Mothers of drug exposed children in TAU demonstrated significant decreases in hard drug use, as compared with mothers of drug exposed children in FBT and mothers of non-drug exposed children in TAU.
Consistent with these results, Table 3 indicates that effect sizes for hard drug use were small to medium for both FBT and TAU from baseline to 6-month post-randomization, and from baseline to month post-randomization assessment. Examination of effect sizes in Table 3 shows that FBT and TAU participants demonstrated medium to large effect sizes from baseline to both 6- and month post-randomization. Similar intent to treat repeated measures analyses were conducted for secondary dependent measures RAB total scale, TLFB hours employed, days intoxicated from alcohol, days incarcerated, days child spent in DFS custody.
Means and standard deviations of these outcome measures are presented in Table 4. These results are consistent with the effect sizes indicated in Table 3. Participants in FBT evidenced a small to medium effect size from baseline to 6-month post-randomization, whereas TAU participants essentially demonstrated no effect during this time. There were no significant effects in time for baseline to 6- and month post-randomization in hours of employment.
No other significant interaction effects for hours employed were found. No other significant differences were found for alcohol intoxication. With the exception of baseline to 6-month post-randomization for TAU no effect , these results are consistent with small to medium effect sizes reported in Table 3. No other significant differences between experimental conditions were found. Examination of Table 3 shows no effect for FBT from baseline to 6- and month post-randomization, whereas there are medium effects specific to TAU during this same time period.
In understanding these effects it is important to consider that examination of means in Table 4 shows TAU participants increased their incarceration.
Family Behavior Therapy | National Institute on Drug Abuse (NIDA)
Thus, FBT to some extent may have assisted in preventing future incarceration. Thus, children were significantly more likely to spend more time in DFS custody from baseline to 6-month post-randomization. No other significant differences were found. Examination of Table 3 shows there was a small effect for both FBT and TAU from baseline to 6-month post-randomization, indicating the children of participants increased their time in DFS custody during this time. These effects were diminished from baseline to month post-randomization, particularly in FBT participants. The very few controlled treatment outcome studies that have been conducted in child neglect samples indicate in-situ delivered family-supported treatment programs are relatively efficacious, although results are not universally positive.
We are unaware of controlled trials that have demonstrated positive outcomes in parents who have been referred to treatment for concurrent child neglect and drug abuse. Therefore, the current randomized controlled trial is a methodological advancement in the treatment in coexisting child neglect and drug abuse.
It was hypothesized that FBT, relative to TAU, would result in improved outcomes from baseline to 6- and month post-randomization assessments, and that FBT would be particularly efficacious with mothers of non-drug exposed children relative to mothers of children exposed to drugs who report relatively less severe behavior problems.
Results indicated that within-subject improvements were found from baseline to 6- and month post-randomization for most measures and many of the hypothesized interaction effects were significant. Specific to the primary measures, FBT was more effective than TAU in reducing child maltreatment potential in mothers of non-drug exposed children from baseline to 6- and month post-randomization. For instance, more FBT mothers of non-drug exposed children were below the clinical cut-off score for child maltreatment potential at month post-randomization than all other mothers i.
FBT was also more efficacious than TAU in hard drug use in mothers of non-drug exposed children from baseline to both 6- and month post-randomization. However, from baseline to 6- and month post-randomization, TAU mothers of drug exposed children demonstrated a greater decrease in hard drug use than TAU mothers of non-drug exposed children and FBT mothers of drug exposed children. These differences, however, were not significantly discrepant. Mothers of non-drug exposed children also had relatively older children who were in the age range typically targeted in parent training child management programs for physical abuse Chaffin et al.
Moreover, the families of these mothers appeared to be more intact and less transient than mothers who had exposed their children to drugs, permitting FBT providers to encourage family support and facilitate family activities, home safety tours, and in vivo child management practice opportunities e. Therefore, in treating child maltreatment potential and hard drug use in mothers who have been indicated to neglect their children and abuse drugs, the results of this study suggest recommendations for treatment may need to be based on the type of child neglect evidenced.
The FBT intervention components examined in this study are probably more in line with mothers who are referred for non-drug exposed types of neglect e. However, in treating hard drug use and child maltreatment in mothers who have been found to expose their children to drugs and evidence relatively low risk for child maltreatment, TAU community services appear to be supported over FBT. FBT was also shown to be more effective than TAU from baseline to month post-randomization in the improvement of days employed. Improvements in secondary outcomes did not appear to be influenced by child neglect type, as hypothesized.
Along these lines, intervention implementation for some of the secondary measures i. Although the reduction of HIV risk behaviors in FBT, compared to TAU, was relatively short-lived, the integration of an HIV prevention program within family-based treatment is an important first step in treatment research involving this highly susceptible population. While our focus was specifically on behaviors that place mothers at risk for HIV, future studies are needed to determine whether there are corresponding decreases in HIV seroconversion associated with integrated HIV prevention implementation in this population, including concomitant decreases in other infectious diseases.
Employment is a critical factor in community re-integration among persons suffering from substance disorders, and assisting women in this population to meet financial obligations is necessary to ensure adequate housing and nutrition of their children.
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Therefore, FBT providers spent considerable time teaching mothers in this condition to develop career interests, prepare resumes, solicit job interviews, develop job interview and financial management skills, and retain employment. Mothers and their significant others were generally very motivated to participate in these activities, and we believe there may be long-term beneficial effects in training mothers in this population to gain and retain employment, such as financial independence from federal and state resources and abusive intimate partners.
The current trial suggests FBT may be beneficial in mothers who have been referred by CPS for child neglect and drug abuse, particularly in mothers of children referred for non-drug exposed child neglect types that are likely to evidence high risk potential for future child maltreatment. However, it is important to emphasize that TAU mothers showed improvements on a number of treatment outcome measures, and that mothers of drug exposed children with less risk for future child maltreatment victimization demonstrated greater reductions in hard drug use and child maltreatment potential when compared with FBT mothers who were referred due to having exposed their children to drugs.
Although it is difficult to determine the change agents in TAU, these results should be anticipated given that both specific and non-specific treatment factors play an important role in treatment effectiveness, and these factors positively influence intervention programs typically provided in TAU e. Future studies are needed to identify and integrate TAU community services, including the development of psychometrically validated measures of TAU implementation, to better understand the merits of TAU conditions.
Given that this was the first clinical trial to concurrently address substance abuse and child neglect, despite its extremely high comorbidity, there are a number of issues that are worthy of consideration when conducting family-based treatment in this population. First, it was originally proposed to exclude mothers from the study if they did not have an adult significant other living in the home and willing to participate in their treatment.
This criterion is hypothesized to assist in providing opportunities to implement prescribed family supported interventions, including home practice of parenting techniques and drug relapse prevention strategies, with adult significant others who are likely to monitor children in the homes of participating mothers. However, in our pilot trials for this study we discovered that many of the referred women did not have supportive significant others who were stable, positive influences permanently living in their homes.
Many of the available significant others transitioned in and out of the mother's residence. This change probably resulted in the inclusion of mothers with a higher proportion of troublesome or superficial relationships. For example, some mothers were financially and emotionally dependent on significant others who were abusive to them or abused substances. Therefore, many of the FBT sessions were focused on assisting mothers in achieving employment or learning self-protection strategies, which took therapy session time away from other target problem areas, but improved sustainable employment and personal independence.
Therefore, methods of engaging appropriate significant others within the context of family-based treatment for concurrent child neglect and substance abuse is warranted. Consistent with the U. Department of Health and Human Services, Administration on Children, Youth and Families guidelines for family preservation, it was originally proposed that the neglected child would need to be living in the residence of the mother to qualify for the study.
However, as Table 4 indicates, a high percentage of neglected children were removed from the homes of their mothers throughout the study, which often decreased motivation of mothers to participate in treatment, and decreased opportunities to apply or practice parenting skills learned in FBT with their children.
Therefore, this study inclusion criterion was modified prior to this study to permit mothers to be enrolled in the study if it was the intention of CPS to work with the Court to return the child to the mother after appropriate services were established. Despite assurances from CPS caseworkers, and often inconsistent with the progress of mothers in therapy, children were often not returned into the homes of their mothers in a timely manner, and sometimes were not returned. Of course, this decreased motivation of the mothers to actively participate in treatment and made it difficult to practice behavioral parenting strategies in vivo with their children, which as indicated previously is important in the treatment of child neglect Hurley et al.
Along this vein, an examination of child protection cases in the County for which this study was conducted revealed that homelessness, methamphetamine use, and lack of resources regularly prompted placement of children into CPS custody, with many cases showing drug use as the exclusive reason for separation Pelton, Moreover, many of the separated children experienced instability in their living arrangements and emotional problems.
However, many of the emergency outcomes e. Lastly, time spent in crisis management competed with the implementation of prescribed treatments aimed at addressing underlying issues perpetuating child neglect and drug abuse. It is important to emphasize that FBT does not include prescribed intervention components designed to assist caseworkers in managing positive consequences for successful treatment participation and outcomes.
For instance, in this study, team meetings between participants, caseworkers, FBT providers and others were attempted to assist treatment planning. However, case management follow through was sometimes missing, limited or inconsistent. Some caseworkers closed their cases with CPS immediately after the referral to FBT or made non-contingent recommendations to separate children from the homes of their mothers. In these situations, motivation of mothers to complete treatment was compromised and parenting practice opportunities at home were limited.
Overall, this study represents a significant advancement in child welfare treatment, both in terms of its methodology and scope of practice implications. It is the first controlled outcome study to incorporate psychometrically validated clinical interviews, self-report measures, and biological testing to assist in formally examining and diagnosing substance use disorders in child maltreatment, and adheres to rigorous experimental methods e.
Specific to practice implications, the results of this study suggest family-based behavioral treatments are justified for use in this very difficult to treat population. However, as in most studies, there were limitations in the methodology of this study, including the lack of outcome measures specific to the direct assessment of behaviors, home conditions, attitudes, and underlying belief systems of participants.
Along these lines, the psychometric development of innovative outcome measures are desperately needed in child neglect and drug abuse, including the development of measures to assess quality in the relationship between perpetrators of child neglect and their significant others, role-play performance that is specific to preventing dangerous and inappropriate scenarios, and measures of service utilization in TAU conditions. In this regard, we are currently attempting to validate a measure aimed at detecting home hazards through behavioral observation occurring during home tours.
It should be mentioned that the average number of sessions attended by participants in the Family Behavior Therapy condition was 15, whereas they were scheduled to receive up to 20 sessions. For young people, this is often done through a wraparound process. Because people with mental and substance use disorders often have more physical health problems than the general population, assistance in coordinating care across behavioral and physical health care providers can be a valuable support.
One important outcome for people with serious mental illnesses is employment, and supported employment services can be an important link to a job that not only supports independence, but also provides important social interaction.
People may face barriers like lack of transportation or child care, so the ability to provide some flexible supports can be the difference between wellness and failure to receive treatment. Another important set of services is recovery supports. In combination with treatment, recovery support services can enable individuals to build a life that supports recovery as they work to control symptoms though traditional treatments or peer-support groups.
Individual and group counseling, medication treatments, and supportive services are evidence-based treatments that can be offered by providers individually or jointly. Depending on the type of service, some or all of these can be offered in a variety of settings. SAMHSA also seeks to support the most effective treatment methods possible through its programs, this includes support of evidence-based programs and treatments. Evidence-based programs are programs that have been shown to have positive outcomes through high quality research.
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NREPP provides descriptive information and expert ratings for evidence-based programs submitted by researchers and intervention developers across the nation. NREPP assists states and communities in identifying and selecting evidence-based programs that may meet their particular requirements through its library of rated programs. People with a mental disorder are more likely to experience a substance use disorder and people with a substance use disorder are more likely to have a mental disorder when compared with the general population.
SAMHSA supports an integrated treatment approach to treating co-occurring mental and substance use disorders. Integrated treatment requires collaboration across disciplines. Integrated treatment planning addresses both mental health and substance abuse, each in the context of the other disorder. Integrated treatment or treatment that addresses mental and substance use conditions at the same time is associated with lower costs and better outcomes such as:. Culture is often thought of in terms of race or ethnicity, but culture also refers to other characteristics such as age, gender, geographical location, or sexual orientation and gender identity.
Behavioral health care practitioners can bring about positive change by understanding the cultural context of their clients and by being willing and prepared to work within that context. This means incorporating community-based values, traditions, and customs into work plans and project evaluations.
Implementing strategies to improve and ensure cultural and linguistic competency in behavioral health care systems by using the CLAS standards is a powerful way to address disparities and ensure all populations have equal access to services and supports. Recovery Month Recovery Month promotes the societal benefits of prevention, treatment, and recovery for mental and substance use disorders.
A Controlled Evaluation of Family Behavior Therapy in Concurrent Child Neglect and Drug Abuse
Behavioral Health Treatments and Services Learn how health care professionals address common mental illnesses and substance use disorders and how SAMHSA helps people access treatments and services. Treatments and Supportive Services Individual paths to recovery differ, and packages of treatments and supportive services for mental and substance use disorders should be tailored to fit individual needs.
Treatments and supportive services are provided in a variety of locations, including: Skills training and exercises that teach conflict management and how to build healthy relationships. Standardized methods for managing problems that coexist with substance abuse, such as unemployment, depression, and incarceration. With an accompanying CD-ROM containing worksheets, handouts, and other practical materials, this hands-on behavioral approach to therapy equips all mental health professionals with effective strategies to help adult substance abusers and their families through the recovery process.
His research focuses on the neuropsychological correlates of mental illness, including substance use disorders and evidence-based interventions for these disorders. Request permission to reuse content from this site. Added to Your Shopping Cart.