Multidimensional Family Therapy (MDFT) for Young People in Treatment for Non‐opioid Drug Abuse: A Systematic Review

Abstract

BACKGROUND Youth drug abuse is a severe problem worldwide, and the use of cannabis, amphetamine, ecstasy and cocaine (referred to here as non-opioid drugs) is strongly associated with a range of health and social problems. This review focuses on drug abuse that is severe enough to warrant treatment. The population of interest is young people who are receiving MDFT specifically for non-opioid drug abuse. MDFT is a manual-based family therapy approach that focuses on individual characteristics of the young person, the parents, and other key individuals in the young person’s life, as well as on the relational patterns contributing to the drug abuse and other problem behaviors. A variety of therapeutic techniques are used to improve the young person and the family’s behaviors, attitudes, and functioning across the variety of domains. MDFT aims to reorient the young person and his/her family towards a more functional developmental trajectory based on key principles that include: 1) Individual biological, social, cognitive, personality, interpersonal, familial, developmental, and social ecological aspects can all contribute to the development, continuation, worsening and chronicity of drug problems; 2) The relationships with parent(s), siblings and other family members are fundamental domains of assessment and change; 3) Change is multifaceted, multi-determined and relates to the youths’ cognitive and psychosocial developmental stages; 4) Motivation is not assumed, but is malleable; and motivating the young person and his or her family members about treatment participation and change is a fundamental therapeutic task; 5) Multiple therapeutic alliances are required to create a foundation for change; and 6) Therapist responsibility and attitude is fundamental to success (Liddle, 2010). OBJECTIVES The main objectives of this review are to evaluate the current evidence on the effects of MDFT on drug abuse reduction for young people (aged 11-21 years) in treatment for non-opioid drug abuse, and if possible to examine moderators of drug abuse reduction effects, specifically analysing whether MDFT works better for particular types of participants. SEARCH STRATEGY\t An extensive search strategy was used to identify qualifying studies. Searches were run in October 2014. A wide range of electronic bibliographic databases were searched along with government and policy databanks, grey literature databases, citations in other reviews and the included primary studies, hand searching in relevant journals, and Internet searches using Google. We also maintained correspondence with researchers in the field of MDFT. No language or date restrictions were applied to the searches. SELECTION CRITERIA To be eligible for inclusion, studies must: •\thave involved a manual-based outpatient MDFT drug treatment for young people aged 11-21 years enrolled for non-opioid drug abuse; •\thave used experimental, quasi-experimental or non-randomized controlled designs; •\thave reported at least one of the following eligible outcome variables: abstinence, reduction of drug abuse, family functioning, education or vocational involvement, retention, risk behavior or any other adverse effect; •\tnot have focused exclusively on treating mental disorders; and •\thave had MDFT as the primary intervention. DATA COLLECTION AND ANALYSIS The literature search yielded a total of 6,519 references, of which 170 studies were deemed potentially relevant and retrieved for eligibility determination. Of these, 16 papers describing five unique studies were included in the final review. Meta-analysis was used to examine the effects of MDFT on drug usage (measured by both frequency and problem severity), on education and on treatment retention. It was not possible to perform a meta-analysis on family functioning, risk behavior or other adverse effects, nor was it possible to assess moderators of drug abuse reduction effects, or whether MDFT works better for particular types of participants. RESULTS Not all the studies provided data that enabled the calculation of comparable effect sizes on the different outcomes. Two studies had two comparison groups with different individuals, and we performed separate analyses including the different control groups where these two studies provided relevant outcome measures. The most conservative effects for the different outcomes are reported in the following. All outcomes are measured as decreases; hence a negative effect size favours MDFT. Meta-analysis of the five included studies showed a small effect (around 30 percent of a standard deviation for the different control combinations) of MDFT for reduction in youth drug abuse problem severity at 6 months post-intake (SMD=-0.30 (95% CI -0.53 to -0.07, p=0.01 compared to Cognitive Behavioral Therapy (CBT), peer group, treatment as usual (TAU), multifamily educational therapy (MEI) and Adolescent Community Reinforcement Approach (ACRA)). At 12 months post-intake meta-analysis of the five included studies showed a small effect (around 20 percent of a standard deviation for the different control combinations) of MDFT for reduction in youth drug abuse problem severity (SMD=-0.23 95% CI -0.39 to -0.06, p=0.007 compared to CBT, peer group, TAU, adolescent group therapy (AGT) and ACRA). Pooled results of the four studies providing data on drug abuse frequency reduction favoured MDFT. The effect of MDFT for youth drug abuse frequency reduction was small at 6 months post-intake (overall around 20 percent of a standard deviation for the different control combinations) (SMD = -0.24; 95% CI -0.43 to -0.06; p=0.01 compared to CBT, peer group, TAU and MET/CBT5). It was not statistically significant at 12 month follow-up compared to CBT, peer group, TAU and MET/CBT5/ACRA. Two studies reported on school grades as an outcome, providing data at 6 months post-intake only. Meta-analysis favored MDFT when the controls used in the analysis were peer group and MEI (SMD = -0.47; 95% CI -0.92, -0.01; p=0.05). It was not statistically significant when the comparisons used in the analysis were peer group and AGT. We extracted data on retention from all five included studies. Meta-analysis favoured MDFT for retention of participants for all the different control combinations (OR = 0.44; 95% CI 0.21 to 0.94; p=0.03 compared to CBT, peer group, TAU, AGT and MET/CBT5). Overall the results indicated that retention may be positively affected by structured MDFT treatment compared to less structured control conditions. AUTHORS’ CONCLUSIONS The available data support the hypothesis that, compared with certain other active treatments, MDFT reduces the severity of drug abuse among youth. The treatments MDFT was compared against in the included studies were Cognitive Behavioral Therapy (CBT), peer group, treatment as usual (TAU), adolescent group therapy (AGT)/multifamily educational therapy (MEI) and Motivational Enhancement Therapy/Cognitive Behavioral Therapy (MET/CBT5)/Adolescent Community reinforcement approach (ACRA). Furthermore, the available data support the hypothesis that there is a reduction in the frequency of drug abuse when treating young drug abusers with MDFT compared to CBT, peer group, TAU and MET/CBT5/ACRA at 6 months post-intake, but the effect is not statistically significant 12 months after intake. The number of studies providing data that allowed calculation of an effect size for drug abuse reduction was limited, however, and this should be considered when interpreting these results. The conclusions that can be drawn about MDFT as an effective treatment for young drug abusers compared to other treatments would be more convincing if more studies were available. The pooled effect sizes are small and confidence intervals are often close to zero. The statistically significance of the pooled results on severity of drug abuse among youth 6 months post-intake is sensitive to the removal of studies with methodological weaknesses. Overall, the results also indicate that retention may be positively affected by structured MDFT treatment compared to CBT, peer group, TAU, AGT/MEI and MET/CBT5/ ACRA which are all less-structured control conditions. However, the results must be interpreted with caution as two studies stand out from the others; here the effect sizes are large, confidence intervals are wide, and the estimated between study variation is relatively large. The main conclusion of this review is that there is insufficient firm evidence of the effectiveness of MDFT, especially with regard to moderators of drug abuse reduction effects, and whether MDFT works better for particular types of participants. While additional research is needed, the review does, however, offer support that MDFT treatment to young non-opioid drug abusers reduce their drug abuse somewhat more than CBT, peer group, TAU, AGT/MEI and MET/CBT5/ACRA.