Family and Adolescent Motivational Incentives for Leveraging Youth

Research has provided support for the efficacy of cognitive-behavioral and family
interventions for adolescent substance use disorders (SUD), HIV-risk behaviors, and related
problems. Despite support for these interventions, substantial heterogeneity in treatment
outcomes and high relapse rates have been consistently found across studies. Such variability
highlights the need for innovative strategies to broaden the impact and strengthen the
durability of effects of adolescent substance abuse treatments. Over the past two decades,
research has demonstrated the positive effects of contingency management (CM) methods on
reductions in substance use and other problem behaviors such as HIV-risk, primarily with
adults. CM has been shown to improve outcomes when combined with evidence-based practices and
research is emerging to suggest that such integrations may also be effective for adolescent
substance abusers. The proposed Stage II efficacy trial examines the integration of CM with
two empirically-supported interventions: group MET/CBT and FFT. By comparing two intervention
modalities (group vs. family, the study provides a unique opportunity to examine the
robustness of the effects of CM across established adolescent treatments, and to compare
change mechanisms that may account for treatment outcomes. In the proposed research,
substance abusing adolescents (n = 160) will be randomly assigned either to FFT or group
MET/CBT. Random assignment will also be used to determine whether or not youth will receive a
CM condition that provides incentives for abstinence (i.e., clean urine screens) and
treatment participation. Thus, participants will receive one of four intervention conditions,
two with an integrated CM intervention (MET/CBT-CM, FFT-CM) and two without CM (MET/CBT,
FFT). The study will employ a 2 (Incentives: CM, nonCM) x 2 (Modality: MET/CBT, FFT) x 5
(Time: Baseline, 2-, 4-, 8-, and 12-months post-randomization) factorial design. The primary
aim of the study is to examine the efficacy of an integrated CM intervention for the two
evidence-based treatments for adolescents, MET/CBT and FFT, compared to these treatments
without CM on drug abuse abstinence (a) during treatment (i.e., speed of effects) and (b) at
post-treatment follow-up assessments (i.e., durability of effects). A second aim of the study
is to evaluate the effects of CM on hypothesized mediators of the intervention effects in the
MET/CBT and the FFT conditions. The investigators anticipate that the CM conditions, compared
to the nonCM conditions, are more likely to accelerate the adolescent's motivation (1) to
achieve abstinence, to attend and participate in treatment, and to complete homework
assignments. Exploratory analyses will examine differences between modalities (MET/CBT vs
FFT) on the presumed mediators. The investigators expect that MET/CBT will produce greater
improvements in adolescents' drug avoidance self-efficacy and FFT will produce greater
improvements in family relationships. The investigators will also examine the effects of the
interventions on HIV-risk behaviors and expect that CM will demonstrate the largest
reductions in HIV-risk behaviors compared to the nonCM conditions.

The study addresses the question of whether adding a Contingency Management (CM) approach, in
which adolescents are provided with a monetary incentive for providing clean urine, enhances
the efficacy of two research-proven interventions for adolescent substance use. Specifically,
the investigators compare if Functional Family Therapy (FFT) and Motivational
Enhancement/Cognitive Behavioral Therapy (MET/CBT) combined with CM are better than either
intervention alone. The investigators also explore the extent to which the addition of CM
increases the speed with which adolescents achieve abstinence as well as the durability of
these effects over time. The inclusion of two distinct forms of therapy also permits the
investigation of how the interventions achieve their effects on adolescent drug use (e.g.,
improvements in family functioning in FFT vs. improvements in drug avoidance and
self-efficacy skills in MET/CBT).

Specific Aim 1: To evaluate the efficacy of CM versus nonCM conditions delivered in the
context of either group (MET/CBT) or family (FFT) treatments for substance abusing
adolescents. The investigators will use two substance use dependent variables. The first
variable assesses the presence or absence of illegal substances in urine samples collected
weekly beginning at baseline and continuing during the 12-14 weeks of scheduled treatment.
Urine samples will be collected at all post-randomization assessments. Although most of the
adolescents are polydrug users, marijuana is the primary drug of abuse. The investigators
anticipate that once weekly urine screens will be able to detect recent marijuana use. The
Time Line Follow-back (TLFB) will be used to provide weekly estimates of drug use abstinence
for a period from 3 months before to 12 months after randomization. Specifically, the
investigators predict that the CM versus the nonCM conditions will produce a significant main
effect increase in the number of weeks of drug use abstinence during the treatment phase
(i.e., months 1-4; Hypothesis 1a) and during the post treatment period (i.e., 4-12 months;
Hypothesis 1b).

Specific Aim 2: To evaluate the efficacy of CM versus nonCM on secondary behavioral outcomes.
Specifically, The investigators predict that CM versus the nonCM conditions will be
associated with significantly lower levels of sexually risky behaviors (Hypothesis 2a) and
conduct problems (Hypothesis 2b) over time.

Specific Aim 3: To evaluate the effects of CM on hypothesized mediators of the MET/CBT and
the FFT intervention effects. The investigators anticipate that the CM conditions are more
likely than the nonCM conditions to accelerate the adolescent's motivation (1) to achieve
abstinence, (2) to attend and participate in treatment, (3) to complete homework assignments.
The SOCRATES scale will assess their motivation to achieve abstinence. Specifically, the
investigators predict that youth receiving the CM versus nonCM will show higher rates of
motivation for change at the 2-month assessment (Hypothesis 3a) and higher rates of treatment
attendance and homework compliance (as measured by weekly therapist reports) over the course
of treatment (Hypothesis 3b).

Exploratory Aims: The investigators will conduct exploratory analyses to examine if the
number of continuous weeks of abstinence during treatment, adolescent's motivation to achieve
abstinence, attendance, and homework compliance will mediate abstinence following treatment.
Additional analyses will examine differences between modalities (MET/CBT vs FFT) on the
presumed mediators: MET/CBT will produce greater improvements in adolescent's drug avoidance
self-efficacy and FFT will produce greater improvements in family relationships (as measured
by the FES). Improvements in drug avoidance self-efficacy and family relationships will
mediate improvements in MET/CBT and FFT, respectively. The investigators will also explore
potential differences within modality to determine if adding CM enhances the effects of each
modalities impact on the presumed mediators of outcome. The results of these analyses will
help determine if there is sufficient merit to warrant additional research into mechanisms of
action within each modality. Finally, the investigators will conduct an informal
cost-effectiveness analysis to derive preliminary estimates of the relative costs of each
treatment modality, particularly with respect to treatment engagement/attendance and youth
outplacement to restricted settings.

Inclusion Criteria:

- 13 to 17 years of age

- Meets DSM-IV diagnostic criteria for substance abuse or dependence

- Living at home with the participating parent

- Sufficient residential stability to permit probable contact at follow- up(e.g., not
homeless at time of intake)

Exclusion Criteria:

- Evidence of psychotic or organic state of sufficient severity to interfere with the
understanding of study instruments and procedures

- Deemed dangerous to self or others at intake

- Services other than outpatient treatment are required for the youth (e.g., inpatient,
detoxification)

- Marijuana use is reported as being less than 13% of the previous 90 days