In this section we describe some of the major research efforts designed to create new and more effective prevention and treatment interventions. These interventions are culturally informed and can be used by providers around the country to improve the lives of the youngsters and families they serve.
CIFFTA Prevention and Treatment Research
Interventions for disadvantaged and underserved youth and families.
Many adolescents, and especially minority adolescents, experience powerful stressors and exhibit problem behaviors that place them at risk for deteriorating physical and mental health. Social and environmental determinants poorly performing schools, families with poor parenting and/or high conflict, perceived discrimination, alcohol use, depression/suicide ideation, and illicit and prescription drug abuse.
In treating this vulnerable population, family interventions have proven to be highly efficacious because their powerful effects on parenting and family relationships can have a life-long influence on a child’s development. Our program of treatment and research has focused on addressing several treatment challenges including:
- A shortage of interventions that are culturally informed and able to impact the unique and often hidden risk processes of minority adolescents.
- Too many treatments often help only about half of the adolescents that attend treatment. This success rate is unacceptable.
- Evidence based manualized treatments that often use a “one-size-fits-all” approach that does not meet the unique needs of individual children and families.
- A shortage of innovative prevention/treatment interventions that are more attractive, cost-effective, efficient, and sustainable.
- A shortage of effective methods of early identification of child and family problems and the effective mobilization of the family to seek early intervention.
Funded by a series of NIH grants to Dr. Daniel Santisteban, our program has developed and rigorously evaluated an enhanced family counseling intervention (Culturally Informed and Flexible Family-Based Treatment for Adolescents: CIFFTA) for minority adolescents and families. CIFFTA is designed to help both adolescents who are already abusing drugs (as a treatment approach) and those younger adolescents who are not currently using but are at risk for serious problems like drug use and STIs/HIV (as a prevention and early intervention approach). One of CIFFTA’s most innovative aspects is that it is a flexible/adaptive treatment that tailors the components to the unique clinical (e.g., depression) and cultural (e.g., immigration and acculturation stressors) characteristics of the adolescent and family, and does so in a systematic fashion that can be replicated. This tailoring/adaptive aspect of the treatment makes it much more patient centered and relevant to her/his specific needs and preferences. CIFFTA provides adolescents with the skills and knowledge needed to react more effectively in the face of stressors while also stimulating the protective and healing processes in minority parents so that they can be more effective in guiding their children even in stressful and unfriendly environments. One of the primary ways to reduce the impact of difficult environments for high risk youth is through effective parenting
Recently we developed and tested a technology assisted version of CIFFTA that can:
- make interventions more attractive and engaging by using multimedia presentations of psycho-educational material
- eliminate practical barriers to office-based treatments such as travel and child care
- aid in the promotion of healthy habits such as good eating and exercise
- reduce the resources (e.g., staff time and space) needed to deliver the intervention
- standardize the delivery of the intervention to increase fidelity to the original design
- help to keep clients working on behavior change during the week (between therapy sessions) so that change gains more momentum.
It is clear to us that innovative uses of technology can support and enhance the work of both SBIRT/MI interventions and CIFFTA interventions.
Evidence of Efficacy:
CIFFTA has been shown to be efficacious in changing important risk factors for future drug use. An indicated prevention/early intervention study with a computer assisted CIFFTA intervention was effective at reducing adolescent (ages 12-15) conduct problems and peer-based delinquency, while also showing strong treatment effects on family functioning such as family cohesion. A similar study showed that the CIFFTA family treatment was more effective at retaining kids and families in services than a more traditional individual child treatment. CIFFTA has also shown great promise in working with older adolescents (14-17) who have existing serious drug problems. In a study focused on adolescents with more severe drug use profiles, CIFFTA was able to significantly reduce drug use and improve family functioning such as positive parenting and parental involvement.
See sites.education.miami.edu/CIFFTA/ for more information on this treatment and it research.
I-BAFT Treatment Research
Improve services for adolescents reporting severe self-harm, impulsivity, drug use symptoms.
A group of adolescents who are in need of specialized services are those reporting both substance use disorders and severe co-occurring psychiatric disorders or personality disorders. Such adolescents can be identified due to self-harm behavior (e.g., cutting and suicide-related behavior), due to severe drug use, or due to other self-destructive behaviors. Many adolescents in the juvenile justice system show this profile and entry into the juvenile justice system may be triggered by an offense not formally linked to a mental or substance use disorder. Many adolescents with this profile are never treated in a comprehensive way because they can be bounced around from a treatment mainly focused on psychiatric symptoms to one focused mainly on addiction. One body of research that has consistently focused on adolescents with severe symptom clusters is found in the literature on adolescent Borderline Personality Disorders. Marsha Linehan’s DBT therapy is one of the few that has been truly effective with BPD adults. In a recent study of adolescents, borderline personality disorder symptoms predicted lower social functioning, worse academic and occupational attainment, greater general impairment, and increased use of health care services even 20 years later. Adolescents with borderline personality disorder were 13 times more likely than youth without borderline personality disorder to maintain the symptoms and receive a borderline personality disorder diagnosis two years later. These studies have shown that it is possible to identify adolescents displaying a profile of co-occurring substance use, impulsivity, and self-harm behaviors that often require multiple residential/inpatient hospitalizations and that symptoms endure over time if not properly treated. The handful of available randomized trials with adolescents with borderline personality disorder have reported mixed results.
Our research team sought to develop a treatment that would combine one of the most effective interventions for adolescent substance abuse (i.e., family therapy) with components of one of the most effective interventions for Borderline Personality Disorder (i.e., DBT skills). The newly developed intervention sought to address both problems simultaneously through individual and family focused work (Integrative BPD-oriented Adolescent Family Therapy; I-BAFT). After developing the innovative intervention we were funded by NIH to conduct a randomized trial to investigate the efficacy of the I-BAFT intervention for adolescents with borderline personality disorder and substance abuse.
Integrative borderline personality disorder-oriented Adolescent Family Therapy (I-BAFT).
I-BAFT is a manualized treatment that adapted individual interventions and skills training modules from Dialectic Behavior Therapy (DBT; Linehan, 1993) and family interventions from Structural Family Therapy (Minuchin & Fishman, 1981). I-BAFT targets factors that directly contribute to adolescent drug abuse and other self-harm behaviors such as emotion dysregulation and impulsivity, failure to establish life goals and ineffective life skills, unstable family attachment, and maladaptive family interactions (Santisteban, Muir, Mena, & Mitrani, 2003). I-BAFT delivered weekly family therapy, individual therapy, and skills building interventions in a two session per week format over a seven-month period. One family session and either a skills training or an individual session with the adolescent were scheduled weekly.
Both the I-BAFT and the Drug Counseling had a clinically significant impact on borderline personality disorder behaviors 12 months after baseline. We documented that adolescents with depression had significantly more severe profiles of borderline personality disorder and of substance use. These youth with co-occurring depression were the only group to show significant reductions in substance use, but only if they received the I-BAFT intervention. Study data also documented the high dosage of intensive residential treatment needed by this population even when receiving a relatively effective outpatient treatment.
Graduate students conducting innovative research as part of the CEW RC mission.
(Doctoral Candidate: Ph.D. Counseling Psychology Program)
Marc has completed his coursework and internship and is working on completing his dissertation. His work with the CIFFTA (Culturally Informed and Flexible Family Based Treatment for Adolescents) team has included contributions to three multi-year randomized controlled clinical trials of the CIFFTA intervention. As a graduate research assistant, he took part in many aspects of study operations, including quality assurance, data analysis, data collection, IRB compliance, and work as a study therapist. He has also been involved with publications, most recently as a co-author on the main outcome paper of the CIFFTA Prevention study (submitted manuscript). This study is also the source of data for his dissertation, which focuses on how bi-dimensional acculturation and acculturative stress impact treatment response among Hispanic study participants. The purpose of this research is to further understanding of mechanisms of treatment action, and to provide evidence for differential effects of culturally tailored intervention. Along with the rest of the CIFFTA team, his hope is that this work will improve treatment efficacy and help reduce Hispanic health disparities.
Raha Forooz Sabet
(Graduate Student: Ph.D. in Counseling Psychology and Graduate Assistant for the CEW RC)
Raha is a fourth year Counseling Psychology doctoral student. Her research interests broadly fall into the categories of immigration, health disparities, and well-being. She is currently working on a qualitative study that is focused on the plight and triumph of undocumented and unaccompanied Latino immigrant youth as well as training implications for those interested in working with this population. She is also working on a manuscript that focuses on the experiences of Latina women diagnosed with breast cancer twice. Recently, she completed the data analysis phase of another qualitative investigation that sought to assess the university’s readiness to serve the needs of student veterans. Finally, she is working on the Practice Improvement Network project, which is a two-year collaboration that embraces and implements several aspects of the Community-Based Participatory Research model. As a part of this collaboration, she continues to gain experience and expertise in community-based work and specifically learning about how communities work together to improve services. Through this project she is exposed to the most effective evidence-based treatments and on effective ways to collaborate with community stakeholders to identify, select, and implement these interventions.
(Graduate Student: Ph.D. Counseling Psychology Program)
Evan is in his third year graduate studies. His research is done as part of the CIFFTA team and focuses on understanding key aspects of the therapeutic process as well as understanding social influences of adolescent substance use and behavior problems. A recent project he completed led to the validation of a measure of motivation to be used Hispanic/Latino adolescents. The results of the paper showed support for the use of the measure with Hispanic/Latino adolescents and identified dimensions of motivation that are relevant to treatment processes. An ongoing research project is a follow-up study that is examining motivational change processes and identifying how the unique components of CIFFTA have an impact on adolescents’ treatment experiences. Additionally, he has ongoing research examining the impacts that psychosocial stressors have on clinical presentation and their impact on treatment trajectories with stressors that are specific to Hispanic/Latino adolescents, such as discrimination-related experiences, and with general stressors, such as experiencing traumatic events. For the 2016-2017 academic year he was awarded a Mitchell Fellowship grant that will support research on traumatic events and their impact on adolescents.