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Intervention Summary

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Family Support Network (FSN)

Family Support Network (FSN) is an outpatient substance abuse treatment program targeting youth ages 10-18 years. FSN includes a family component along with a 12-session, adolescent-focused cognitive behavioral therapy--called Motivational Enhancement Therapy/Cognitive Behavioral Therapy (MET/CBT12)--and case management. The family component attempts to engage adolescents and their parents in a joint commitment to the treatment and recovery process. It establishes a support system, encourages family communication, and teaches parents behavioral management skills with the ultimate goal of improving the quality of family interrelationships. The family component includes:

  • Six biweekly, multifamily education meetings addressing teen beliefs, adolescent development, adolescent drug use patterns, drugs and adolescents, the recovery process, and family management issues such as boundaries, parental discipline, and communication
  • Four monthly home visits to reinforce the family's commitment to treatment and help the adolescent and his or her family individualize the skills they learned

The MET/CBT12 component provides 2 individual sessions of MET that explore and resolve the youth's ambivalence about changing substance abuse behaviors and 10 group sessions of CBT that teach youth specific cognitive behavioral skills. These skills include refusing cannabis, problem solving, anger awareness and management, dealing with criticism, managing depression, coping with cravings, managing thoughts about marijuana, planning for emergencies, building a better social network, engaging in activities unrelated to drug use, and coping with relapse.

The case management component addresses barriers to treatment participation and can include weekly phone calls to discuss attendance, transportation, and child care, as well as mediating support among the adolescent, parents, and social institutions (e.g., school, social services, juvenile court system). Families with more complex needs, such as those related to housing, school, and employment, are provided more intensive case management services for 2 months, after which they receive standard case management.

The family component, MET/CBT12, and case management are administered concurrently using different providers trained in each specialty.

Descriptive Information

Areas of Interest Substance abuse treatment
Co-occurring disorders
Outcomes Review Date: July 2008
1: Abstinence from substance use
2: Recovery from substance use
3: Cost effectiveness
Outcome Categories Alcohol
Cost
Drugs
Treatment/recovery
Ages 13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Outpatient
Home
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History First implemented in 1998, FSN has been used in 40 sites in 3 States and has reached several thousand youth.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations FSN has been adapted for an outpatient program that treats recently victimized youth who have co-occurring mental and substance use disorders.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: July 2008

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Dennis, M. (2002, August). 30 month findings from the Cannabis Youth Treatment (CYT) randomized field experiment. Presented at the 110th annual conference of the American Psychological Association, Chicago, IL.

Dennis, M., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., et al. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27(3), 197-213.  Pub Med icon

Supplementary Materials

Dennis, M. L., Funk, R., Godley, S. H., Godley, M. D., & Waldron, H. (2004). Cross-validation of the alcohol and cannabis use measures in the Global Appraisal of Individual Needs (GAIN) and Timeline Followback (TLFB; Form 90) among adolescents in substance abuse treatment. Addiction, 99(Suppl. 2), 120-128.  Pub Med icon

Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F. M., et al. (2002). The Cannabis Youth Treatment (CYT) experiment: Rationale, study design, and analysis plans. Addiction, 97(Suppl. 1), 16-34.  Pub Med icon

Diamond, G. S., Liddle, H. A., Wintersteen, M. B., Dennis, M. L., Godley, S. H., & Tims, F. (2006). Early therapeutic alliance as a predictor of treatment outcome for adolescent cannabis users in outpatient treatment. American Journal on Addictions, 15(Suppl. 1), 26-33.  Pub Med icon

French, M. T., Roebuck, M. C., Dennis, M. L., Diamond, G., Godley, S. H., Tims, F., et al. (2002). The economic cost of outpatient marijuana treatment for adolescents: Findings from a multi-site field experiment. Addiction, 97(Suppl. 1), 84-97.  Pub Med icon

Garcia, B. C. (Moderator), Leveille, T., Hamilton, N., Tims, F., & Vargo, M. (2006, March). Implementation of the Family Support Network in an operating program: A replication. Presented at the Joint Meeting on Adolescent Treatment Effectiveness, Washington, DC.

Hamilton, N., & Tims, F. (2008). The Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) Grant Programs Final Report for Family Support Network (FSN) of Juvenile Outpatient Program (JOP), Grant Number T113190 (Rev. ed.).

Tims, F. M., Dennis, M. L., Hamilton, N., Buchan, B. J., Diamond, G., Funk, R., et al. (2002). Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment. Addiction, 97(Suppl. 1), 46-57.  Pub Med icon

Outcomes

Outcome 1: Abstinence from substance use
Description of Measures Abstinence from substance use was measured using the Global Appraisal of Individual Needs (GAIN) and was defined as the total number of abstinent days over four 3-month follow-up periods (3, 6, 9, and 12 months after intake). Abstinence was also defined as the percentage of participants who reported, at 30 months after intake, that they had either no past-month symptoms (short-term remission) or no past-year symptoms (sustained remission) of any substance abuse or dependence. The GAIN is a standardized, semistructured interview with eight main sections (background, substance use, physical health, risk behaviors, mental health, environment, legal, and vocational) that is designed to support the diagnosis, placement, and outcome monitoring of patients and the economic analysis of an intervention.

Self-report data were confirmed by urinalysis at intake and at follow-up assessments 3, 6, and 30 months after intake.
Key Findings In two trials of a randomized controlled study, five manual-driven treatment interventions for adolescents with cannabis-related disorders were compared. Trial 1 compared the following interventions at two sites: 

  • FSN
  • Motivational Enhancement Therapy/Cognitive Behavior Therapy with 5 sessions (MET/CBT5)
  • MET/CBT with 12 sessions (MET/CBT12)
Trial 2 compared the following interventions at two sites:

  • Adolescent Community Reinforcement Approach (A-CRA)
  • MET/CBT5
  • Multidimensional Family Therapy (MDFT)
In both trials, assessments were conducted at intake and at 3-, 6-, 9-, and 12-month follow-ups. Trial 1 additionally included a 30-month follow-up as part of the Persistent Effects of Treatment Studies--Adolescents (PETS-A) study. Findings from these trials included: 

  • Days of total substance abstinence reported by all participants increased 24% (from 52 to 65 days) between intake and the 3-month follow-up, with no significant differences by intervention. Similar gains were seen at each of the subsequent follow-ups (6, 9, and 12 months after intake), regardless of intervention, site, or trial participation. Across both trials, total days reported abstinent from all substances over 12 months ranged from 251 to 269 days, with no significant differences by intervention.
  • At the 30-month follow-up, 60% of FSN participants reported no past-month substance abuse or dependence symptoms, compared with 51% for MET/CBT5 (trial 1) participants and 56% of MET/CBT12 participants, but this finding was not statistically significant.
  • At the 30-month follow-up, 33% of FSN participants reported no past-year substance abuse or dependence symptoms, compared with 23% of MET/CBT5 (trial 1) participants and 27% of MET/CBT12 participants, but this finding was not statistically significant.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)
Outcome 2: Recovery from substance use
Description of Measures Recovery from substance use was measured by the percentage of adolescents living in the community (as opposed to living in a correctional facility, inpatient treatment program, or other controlled environment) and reporting no past-month substance use, abuse, or dependence problems at follow-up interviews 3, 6, 9, 12, and 30 months after intake. For the 6% of adolescents who did not complete a 12-month follow-up, data from their last follow-up were used to determine their recovery status.
Key Findings In two trials of a randomized controlled study, five manual-driven treatment interventions for adolescents with cannabis-related disorders were compared. Trial 1 compared the following interventions at two sites: 

  • FSN
  • Motivational Enhancement Therapy/Cognitive Behavior Therapy with 5 sessions (MET/CBT5)
  • MET/CBT with 12 sessions (MET/CBT12)
Trial 2 compared the following interventions at two sites: 

  • Adolescent Community Reinforcement Approach (A-CRA)
  • MET/CBT5
  • Multidimensional Family Therapy (MDFT)
In both trials, assessments were conducted at intake and at 3-, 6-, 9-, and 12-month follow-ups. Trial 1 additionally included a 30-month follow-up as part of the Persistent Effects of Treatment Studies--Adolescents (PETS-A) study. Findings from these trials included: 

  • Across interventions and sites in both trials, the percentage of adolescents reporting being in recovery increased from an average of 3% at intake to an average of 24% at the 3-month follow-up, where it remained across the 6-, 9-, and 12-month follow-ups.
  • The percentage of participants who reported being in recovery at the 12-month follow-up showed small differences by intervention assignment, but after controlling for site and recovery status in the month prior to intake, the differences were not significant. Twenty-two percent of FSN participants reported that they were in recovery at the 12-month follow-up, compared with 28% of MET/CBT5 (trial 1) participants, 17% of MET/CBT12 participants, 34% of A-CRA participants, 23% of MET/CBT5 (trial 2) participants, and 19% of MDFT participants.
  • At the 30-month follow-up, 20% of FSN participants reported being in recovery during the previous month, compared with 25% of MET/CBT5 (trial 1) participants and 26% of MET/CBT12 participants, but this finding was not statistically significant.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)
Outcome 3: Cost effectiveness
Description of Measures Cost effectiveness was measured by the average daily cost of an adolescent achieving abstinence from substance use and the cost of an adolescent being in recovery 12 months after intake. Abstinence from substance use was measured using the GAIN and was defined as the total number of abstinent days during the 12-month period following intake. Recovery was defined as living in the community (as opposed to living in a correctional facility, inpatient treatment program, or other controlled environment) and reporting no past-month substance use, abuse, or dependence problems at the 12-month follow-up. Cost estimates were based on data collected using the Drug Abuse Treatment Cost Analysis Program (DATCAP), which measures both the accounting and opportunity costs of a substance abuse treatment program based on standard economic principles. DATCAP was supplemented with service contact logs completed by therapists and case managers.
Key Findings In two trials of a randomized controlled study, five manual-driven treatment interventions for adolescents with cannabis-related disorders were compared. Trial 1 compared the following interventions at two sites: 

  • FSN
  • Motivational Enhancement Therapy/Cognitive Behavior Therapy with 5 sessions (MET/CBT5)
  • MET/CBT with 12 sessions (MET/CBT12)
Trial 2 compared the following interventions at two sites: 

  • Adolescent Community Reinforcement Approach (A-CRA)
  • MET/CBT5
  • Multidimensional Family Therapy (MDFT)
In both trials, assessments were conducted at intake and at 3-, 6-, 9-, and 12-month follow-ups. Findings from these trials included: 

  • In trial 1, the average cost per day of abstinence over the 12 months of follow-up was $8.79 and varied significantly by intervention assignment, with FSN costing $15.13 per participant, significantly more than either MET/CBT5 or MET/CBT12 ($4.91 and $6.15, respectively, p < .05). This cost difference was associated with a large effect size (Cohen's f = 0.48). The higher cost per day of abstinence for an FSN participant compared with either an MET/CBT5 or MET/CBT12 participant was consistent across both sites, with site 1 costs being $17.04 versus $5.75 and $7.67, respectively (p < .05), and site 2 costs being $13.80 versus $4.17 and $5.00, respectively (p < .05). These cost differences by site were associated with large effect sizes (Cohen's f = 0.40 for site 1 and Cohen's f = 0.63 for site 2).
  • In trial 1, the average cost per participant in recovery at the 12-month follow-up was $8,846 and varied significantly by intervention assignment, with FSN costing $15,116 per participant, significantly more than either MET/CBT5 or MET/CBT12 ($3,958 and $7,377, respectively, p < .05). This cost difference was associated with a large effect size (Cohen's f = 0.72). The higher cost per day of recovery for an FSN participant compared with either an MET/CBT5 or MET/CBT12 participant was consistent across both sites, with site 1 costs being $18,284 versus $3,495 and $9,257, respectively (p < .05), and site 2 costs being $12,899 versus $4,369 and $5,914, respectively (p < .05). These cost differences by site were associated with large effect sizes (Cohen's f = 0.67 for site 1 and Cohen's f = 0.81 for site 2).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent) 83% Male
17% Female
61% White
30% Black or African American
5% Race/ethnicity unspecified
4% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Abstinence from substance use 4.0 3.8 3.9 3.9 3.1 3.8 3.7
2: Recovery from substance use 3.9 3.8 3.9 3.9 3.1 3.6 3.7
3: Cost effectiveness 3.5 3.3 3.9 3.5 3.0 3.7 3.5

Study Strengths

The self-report measure for abstinence, the GAIN, has robust psychometric properties and was supplemented by collateral reports, urinalysis, and treatment records at baseline and at the 3-, 6-, and 30-month follow-ups. The study had strong intervention and assessment fidelity and achieved a complete dataset through excellent follow-up rates at 12 and 30 months after intake. The analysis thoroughly addressed the limited data loss.

Study Weaknesses

The absence of any type of control group makes it difficult to interpret the effect of the intervention. Cost outcome measures were restricted to a narrowly defined assessment over less than 4 months and did not take into consideration the differential costs of expert judgments, professional personnel, or region-specific cost of living expenses.

Readiness for Dissemination
Review Date: July 2008

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Certification overview

Coleman, M., & Hamilton, N. (2008). MET/CBT clinical supervisors training. Largo, FL: Operation PAR.

Coleman, M., Welsh, T., & Hamilton, N. (2008). Motivational interviewing, motivational enhancement therapy, cognitive behavioral therapy (MET/CBT) training. Largo, FL: Operation PAR.

Cost sheet for training

Definition of completion

Hamilton, N. (2008). MET/CBT post training and coaching evaluation questions: CEO version. Largo, FL: Operation PAR.

Hamilton, N. (2008). MET/CBT post training and coaching evaluation questions: Counselor/therapist version. Largo, FL: Operation PAR.

Hamilton, N. (2008). MET/CBT post training and coaching evaluation questions: Supervisor version. Largo, FL: Operation PAR.

Hamilton, N. (2008). Motivational interviewing: Effective communication to achieve goals [PowerPoint slides]. Largo, FL: Operation PAR.

Hamilton, N. (2008). Family Support Network [PowerPoint slides]. Largo, FL: Operation PAR.

Hamilton, N. (2008). Goals of cognitive behavioral therapy: Restructuring thoughts, perceptions, & beliefs [PowerPoint slides]. Largo, FL: Operation PAR.

Hamilton, N. (2008). Motivational enhancement therapy & cognitive behavioral therapy: A brief introduction [PowerPoint slides]. Largo, FL: Operation PAR.

Hamilton, N. (2008). Motivational enhancement therapy: Facilitating change [PowerPoint slides]. Largo, FL: Operation PAR.

Hamilton, N. (2008). Sample training contract. Largo, FL: Operation PAR.

Hamilton, N. L., Brantley, L. B., Tims, F. M., Angelovich, N., & McDougall, B. (2001). Cannabis Youth Treatment (CYT) Series: Volume 3. Family Support Network for adolescent cannabis users [DHHS Pub. No. SMA 05-4103]. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.

Supervisor Ratings of Therapist Skillfulness. (1999).

Therapist/Counselor Competency Model

Therapist Skillfulness Rating Scale Definitions

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.3 3.8 3.5 3.5

Dissemination Strengths

The program manual is highly detailed and includes tips, goals, and instructions for each component of the intervention. Initial, booster, and organizational supervisor training support the implementation of this intervention, with additional coaching also available. Organizational supervisors are trained to use videotapes or audiotapes to evaluate adherence to the model and improve clinical quality. A certification process is also available to support quality assurance.

Dissemination Weaknesses

Some implementation materials appear to be in draft form. It is unclear how organizational readiness is assessed. Some training slides are wordy and redundant. The overall training content addressing individual intervention components may be difficult to grasp in the short training time allotted. The overall plan for quality assurance is unclear.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Program manual Free Yes
On- or off-site training $2,000 per day for 20 participants, plus travel expenses Yes
Certification sessions $350 each within 3 months of training; $400 each 3 months or more after training Yes
Package of 10 certification sessions $2,000 within 3 months of training No
Clinical supervision $200 per hour or $2,250 for 15 hours over 4 months No
Agency certification $1,500 per site No
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Hamilton, N., & Tims, F. (2008). The Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) Grant Programs Final Report for Family Support Network (FSN) of Juvenile Outpatient Program (JOP), Grant Number T113190 (Rev. ed.).

Contact Information

To learn more about implementation, contact:
Jackie Griffin, M.S.
(727) 545-7564 ext 268
jgriffin@operpar.org

To learn more about research, contact:
Mark Vargo, Ph.D.
(727) 538-7245 ext 204
mvargo@operpar.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.