This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month followup. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed.Keywords treatment adherence; therapist competence; adolescent substance use; cognitive-behavioral therapy; multidimensional family therapy Rigorous fidelity monitoring and evaluation are required elements of efficacy research on manual-based behavioral interventions (Carroll, Kadden, Donovan, Zweben, & Rounsaville, 1994), and fidelity research is rapidly becoming a centerpiece of treatment dissemination as well. Some evidence has indicated that strong fidelity to empirically based interventions may be essential for producing treatment effects in real world settings. For example, Henggeler and colleagues (Henggeler, Melton, Brondino, Scherer, & Hanley, 1997;Henggeler, Pickrel, & Brondino, 1999) found that fidelity to multisystemic therapy for delinquent adolescents was poor when community therapists implemented the model without ongoing supervision from model experts; moreover, poor fidelity was linked to worse outcomes compared with results NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript from efficacy studies. Interestingly, Morgenstern, Morgan, McCrady, Keller, and Carroll (2001) showed that whereas community practitioners intensively trained in cognitivebehavioral therapy for adult substance abuse could reach fidelity and outcome benchmarks set by research therapists, control group practitioners with no additional training reached the same outcome benchmarks. As dissemination research continues to mature, it seems certain that fidelity issues will remain a priority for treatment developers, program administrators, and policymakers.Research on the link between fidelity and outcome i...

Callous-unemotional (CU) traits have been shown to delineate a unique subgroup of children with severe and persistent conduct problems that seem to have unique etiological origins. However, commonly used measures of CU traits in children may not adequately capture the full range of these characteristics in a developmentally appropriate manner. As a result, the 24-item Inventory of Callous-Unemotional Traits (ICU; self-, parent-, and teacher-report versions; Frick, 2004) was recently developed as a more extensive assessment of CU traits. However, studies to date have focused almost exclusively on the self-report version ICU in adolescents and have identified problems with the factor structure of the measure. The current study is the 1st to examine the factor structure of the parent-report version ICU in a sample of 250 boys (ages 6-12 years) exhibiting significant conduct problems. Initial analyses indicated that factor models reported for the parent-report version of the ICU demonstrated a relatively poor fit to the data. Item response theory techniques were used to develop a more psychometrically sound and efficient short form of the ICU consisting of 2 factors (i.e., Callous and Uncaring) using 12 of the original 24 items. The revised version scores demonstrated high internal consistency, good discrimination across the continuum of the CU construct, and adequate short-term test-retest reliability. The revised measure total score also exhibited evidence of convergent and discriminant validity, although the subscales exhibited some differential correlations with theoretically meaningful constructs. Avenues for future measure refinement and use with children are discussed.

Research has established the dangers of early onset substance use for young adolescents and its links to a host of developmental problems. Because critical developmental detours can begin or be exacerbated during early adolescence, specialized interventions that target known risk and protective factors in this period are needed. This controlled trial (n = 83) provided an experimental test comparing multidimensional family therapy (MDFT) and a peer group intervention with young teens. Participants were clinically referred, were of low income, and were mostly ethnic minority adolescents (average age = 13.73 years). Treatments were manual guided, lasted 4 months, and were delivered by community agency therapists. Adolescents and parents were assessed at intake, at 6-weeks post-intake, at discharge, and at 6 and 12 months following treatment intake. Latent growth curve modeling analyses demonstrated the superior effectiveness of MDFT over the 12-month follow-up in reducing substance use (effect size: substance use frequency, d = 0.77; substance use problems, d = 0.74), delinquency (d = 0.31), and internalized distress (d = 0.54), and in reducing risk in family, peer, and school domains (d = 0.27, 0.67, and 0.35, respectively) among young adolescents.

Both interventions are promising treatments. Consistent with previous controlled trials, MDFT is distinguished by the sustainability of treatment effects.

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