Vol:.(1234567890)

Community Mental Health Journal (2021) 57:1094–1110
https://doi.org/10.1007/s10597-020-00735-z

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O R I G I N A L PA P E R

Randomized Controlled Trial of an Integrated Family‑Based Treatment
for Adolescents Presenting to Community Mental Health Centers

Ashli J. Sheidow1 · Kristyn Zajac2 · Jason E. Chapman1 · Michael R. McCart1 · Tess K. Drazdowski1

Received: 14 May 2020 / Accepted: 23 October 2020 / Published online: 29 October 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Most adolescents presenting to community mental health centers have one or more comorbidities (internalizing, externalizing,
and substance use problems). We evaluated an integrated family-based outpatient treatment for adolescents (OPT-A) that can
be delivered in a community mental health center by a single therapist. A sample of 134 youth/families were randomized to
receive OPT-A or usual services, delivered at the same public sector mental health center. Repeated, multi-informant assess-
ments occurred through 18-months post-baseline. At baseline, the sample displayed low internalizing symptoms, moderate
substance use, and high externalizing problems. Compared to usual services, OPT-A had effects on abstinence rates, retention,
motivation, parent involvement, and satisfaction, but not on internalizing or externalizing problems. While OPT-A achieved
some key improvements for youth who present to community mental health centers, and families were satisfied with treat-
ment, continued work is necessary to examine treatments for comorbidity while balancing treatment feasibility and complex
strategies to boost treatment effectiveness.

Keywords Comorbidity · Adolescent substance use · Adolescent mental health · Community-based treatment · Family
therapy

The majority of adolescents presenting for outpatient treat-
ment at public sector community mental health centers have
comorbid symptoms such as internalizing, externalizing, and
substance use problems, but there is a striking paucity of

experimental treatment research on integrated psychosocial
treatments for these teens (Hogue et al. 2018; Hulvershorn
et  al. 2015). In general, multicomponent treatments that
have been found to effectively target each of these present-
ing problems (e.g., cognitive behavioral therapy [CBT],
behavioral family-based treatment, motivational enhance-
ment) tend to be most effective for treating substance use
and comorbid disorders simultaneously (Brewer et al. 2017).
However, research in this area is still limited by very few
well-powered randomized controlled trials; and, of these,
most are very limited (e.g., substance use and depres-
sion only), are sequential or parallel treatment rather than
integrated (i.e., requires attendance at two or more sepa-
rate treatments), and are not representative of the range of
adolescents seen in public sector community mental health
centers.

Over 4 million U.S. adolescents use illicit drugs each
year, and over 1 million are in need of treatment for sub-
stance use (SAMHSA 2018). Tens of thousands of U.S.
youth receive some form of addiction treatment services
each year, the vast majority of which occur in outpatient
community-based clinics (SAMHSA 2018). An estimated
60% of teens with substance use problems have a comorbid

Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s1059 7-020-00735 -z) contains
supplementary material, which is available to authorized users.

* Kristyn Zajac
[email protected]

Ashli J. Sheidow
[email protected]

Jason E. Chapman
[email protected]

Michael R. McCart
[email protected]

Tess K. Drazdowski
[email protected]

1 Oregon Social Learning Center, 10 Shelton McMurphey
Blvd., Eugene, OR 97401, USA

2 University of Connecticut School of Medicine, 263
Farmington Avenue, Farmington, CT 06030, USA

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mental health diagnosis, with comorbid externalizing dis-
orders being the most common (up to 50%; Armstrong and
Costello 2002; Couwenbergh et  al. 2006). Internalizing
disorders (i.e., mood or anxiety) are also prevalent (up to
30%; Armstrong and Costello 2002). Approximately half
of adolescents presenting for outpatient treatment for either
substance use or internalizing disorders exhibit both (e.g.,
Stephens et al. 2014; Turner et al. 2004). A number of mod-
els have been proposed as explanations for this comorbid-
ity among youth (e.g., the self-medication model, common
factor model, bi-directional model), but no definitive model
has been accepted by the field (Kaminer and Winters 2020).
Regardless of the underlying reasons for the link between
disorders, it is well established that youth with comorbid
substance use and mental health problems present with more
familial, school, and legal problems than adolescents with
substance use problems alone (Grella et al. 2001). It is not
surprising that clinicians in public sector community mental
health centers are tasked with treating complicated youth
presentations.

Furthermore, youth with comorbid disorders are at par-
ticular risk for negative outcomes. For example, Copeland
et al. (2007) found that youth with anxiety and substance
use were 11 times more likely to engage in severe or vio-
lent offending, and youth with depression and substance
use were nearly 15 times more likely compared to youth
without psychiatric and behavioral problems. Youth with
internalizing and externalizing symptoms are also consist-
ently found to be at increased risk for initiating substance
use earlier (e.g., Molina et al. 2018), increased amount and
severity of substance use (e.g., Warden et al. 2012), future
substance-related disorders (Groenman et  al. 2017), and
relapse and negative clinical outcomes (e.g., Godley et al.
2014a, b; Tomlinson et al. 2004) compared to youth without
comorbid problems. Even more problematic, Evans et al.
(2007) showed an interactive impact of multiple comorbid
disorders rather than simple additive effects. Together, these
findings highlight the need for special attention to maximiz-
ing treatment outcomes for youth with comorbid disorders,
especially at community-based clinics where the vast major-
ity of these youth are treated (SAMHSA 2018).

Pilot research conducted specifically on treatments target-
ing substance and comorbid problems among adolescents
are few in number, with most being uncontrolled and demon-
strating modest results and no follow-up experimental trials
(e.g., Curry et al. 2003; Goldstein et al. 2014; Hides et al.
2010; Kaminer et al. 1998). As noted, well-powered experi-
mental studies have typically not examined psychosocial
treatments for the range of adolescent clients seen in public
sector community mental health centers, although a few have
specifically targeted comorbid substance use and depression.
For instance, Rohde et al. (2014) evaluated sequencing of
a family-based treatment for substance use and group CBT

for depression, finding substance use improved most in the
group receiving substance use treatment first and depres-
sion improved to a similar degree in all groups. Importantly,
however, the two treatments were delivered independently
by separate therapists, rather than as an integrated model.
Such sequential models are poorly suited for community-
based clinics that often lacking the resources and staffing
to provide multiple specialized therapists for each youth.
Riggs et al. (2007) large-scale fluoxetine trial for conduct
disordered youth with comorbid substance use and depres-
sion provided further support for outpatient CBT. CBT for
substance use was provided in both pharmacotherapy con-
ditions, albeit in an academic clinic rather than a commu-
nity clinic setting, with equivalent gains across conditions
in substance use and one depression measure. A recently
published trial of an integrated family-based intervention
delivered in child advocacy centers focused on subthreshold
substance use and trauma-related problems in youth, with
more improvement in days of substance use for the treatment
group compared to usual services, but no group differences
for trauma-related symptoms (Danielson et al. 2020).

Experimental research on outpatient treatments for
adolescent substance use alone is more extensive than the
comorbid treatment literature. Reviews support several
models (e.g., Hogue et al. 2018), with family-based mod-
els consistently found to be superior (Tanner-Smith et al.
2013). Within family-based approaches, inclusion of CBT
and behavioral strategies, rather than a sole focus on family
relationships and communication, is routine (e.g., Donohue
and Azrin 2001; Henggeler et al. 2011; Liddle et al. 2001).
In fact, CBT and behavioral strategies have primarily proven
successful within family-based approaches, with parents
used to support CBT skills and implement behavior modi-
fication at home (Hogue et al. 2018). This is not surprising
given the key role of family in etiology and maintenance of
substance use (Rowe 2012). Further, Hogue et al.’s (2014)
review concluded substance use clients with comorbid dis-
orders benefited more from family treatment than other
approaches.

Experimental research specific to treatments for adolescent
internalizing and externalizing problems individually is more
extensive as well, compared to research for substance use and
comorbid disorders. Adolescent treatments for internalizing
disorders have been the most extensively studied, with reviews
consistently concluding that psychosocial interventions are
robustly beneficial (David-Ferdon and Kaslow 2008; Higa-
McMillan et al. 2016). These reviews provide strong sum-
maries of the literature, identifying various behavioral and
CBT approaches as evidence-based and some approaches that
include a parent component as probably efficacious. Reviews
have highlighted that adolescent treatments for externalizing
problems have been primarily tested in justice-involved popu-
lations, which are more difficult to treat, and treatment effects

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are modest compared to treatments for internalizing behaviors
(Bakker et al. 2017; McCart and Sheidow 2016). Neverthe-
less, similar psychosocial approaches (i.e., CBT, behavioral,
family-based) appear to be promising for adolescents with
externalizing problems. Importantly, effects of psychosocial
interventions are generally not as substantial when evaluated
in real-world settings where dually diagnosed youth are not
excluded (Weersing et al. 2006; Weersing and Weisz 2002).

Since there are few evidence-based adolescent treatments
that could be deployed in public sector community mental
health settings, particularly one that can address a range of
comorbid problems, it is no wonder adolescent treatment
programs are cited as being unprepared to serve such cases
(Hawkins 2009). Thus, we endeavored to develop an effec-
tive integrated model specifically for outpatient providers at
public sector community mental health centers that could be
used to treat a range of comorbid problems in adolescents,
including internalizing, externalizing, and substance use. We
incorporated prior findings establishing CBT and behavioral
techniques as central to treating specific problems and used
a family-based approach. Although family-based approaches
have some logistical challenges (e.g., they tend to be more
complex, parents and adolescents sometimes have competing
goals, some parents are difficult to engage), overwhelming evi-
dence supports the efficacy of such approaches in achieving
and maintaining change, particularly for complex youth pres-
entations (McCart and Sheidow 2016). We used an integrated
instead of a sequential approach (e.g., Rohde et al. 2014).
Integrated approaches are consistently recommended for
outpatient treatment development, especially for adolescents
with comorbid disorders (e.g., Aviram et al. 2001; McCart and
Sheidow 2016), but little research on such treatments exists.

We conducted a randomized controlled trial comparing
an experimental treatment (OutPatient Treatment for Adoles-
cents; OPT-A) to treatment as usual (TAU) through 18-months
post-referral. To ensure high external validity (e.g., community
referral streams, “real world” clients), we conducted the trial
in a public sector community mental health center rather than
a university clinic, with therapists who were employed by the
mental health center delivering the intervention. We hypoth-
esized that OPT-A would produce greater improvement in pri-
mary outcomes (substance use, internalizing, externalizing)
than TAU at both short- and long-term follow-up, as well as
better functional outcomes (parenting, school enrollment) and
therapy process (working alliance, satisfaction, motivation).

Method

Participants

Recruitment

Adolescents were recruited from a public sector community
mental health center. Inclusion criteria were: (a) seeking out-
patient treatment; (b) 10–17 years of age; (c) residing with
a parent/adult caregiver; and (d) per clinic staff, determined
to require treatment for current comorbid substance use and
internalizing (mood or anxiety) disorders. We emphasized
these comorbid disorders because most adolescents in com-
munity mental health centers present with externalizing
problems, and this was an effort to recruit a broader sample
that is typically understudied and more difficult to identify
in community mental health settings. Exclusion criteria
were minimal to maintain a “real-world” sample: pervasive
developmental disorder, psychotic disorder, or severe/pro-
found intellectual disability. To maximize the study’s exter-
nal validity and mirror customary admittance practices for
community mental health centers, the clinic’s assessment
of treatment need was used for inclusion criteria (d). Of
152 youth assessed by the research team and determined to
be eligible, 18 families declined and 134 were randomized
(88% recruitment rate; Fig. 1).

Demographics

Participants were 11.9–17.9 years of age (M = 16.0, SD 1.1)
and representative of the community: 76.4% White, 15.7%
African American, 5.7% more than one race, 2.1% not
reported; 2.1% were Hispanic. Over half were male (62.1%).
A slight majority resided in single-parent homes (52.9%),
and 67.2% of the youth’s mothers were the primary parent.
Families were economically diverse (income: 19% < $10 k,
18% $10  k–$20  k, 33% $20  k–$40  k, 30% > $40  k; 50%
received government assistance). Parents generally worked
full time (49.3%), although some worked part-time (5.2%),
were homemakers or students (12.7%), retired (7.5%), or
unemployed (25.3%). Parental education was: 16.3% < HS
diploma, 26.7% HS graduate, 34.1% some college, 20.0%
college graduate or more. There were no between-group dif-
ferences in demographics.

Procedures

Once clinic staff referred youth, researchers arranged an in-
person meeting at a time and place convenient for the family
to obtain parental consent, adolescent assent, and confiden-
tial baseline assessments. Average length of time between

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clinic referral and study consent was 12 days. Full interviews
were at 3-, 6-, 12-, and 18-months post-baseline; at 1- and
2-months, select instruments (see below) were administered.
Families received $60 for baseline, $40 for each subsequent
full assessment, and $60 total for monthly phone calls to
maintain contact information and collect brief data at 1- and
2-months post-baseline.

Urn randomization was used to balance: (1) sex; (2)
age (10.0–12.9; 13.0–15.9; 16.0–17.9); (3) internalizing

severity (Revised Children’s Anxiety and Depression Scale
[RCADS] borderline clinical threshold T-score < 65 vs
65+); and (4) substance use “severity” (urine screen posi-
tive for < 3 different drugs vs 3+). Age was stratified due
to the expectation that most would fall in the oldest cat-
egory and fewest in the youngest category. An investigator
conducted randomization to keep interviewers blind. IRBs
at the Medical University of South Carolina and the state
Department of Mental Health approved procedures.

Fig. 1 CONSORT participant flow diagram. *The n for specific
measures differed due to adolescents being in detention, residential
treatment settings, etc. Also, some parents were occasionally unavail-

able for assessments even if their youth were available. Intent-to-treat
analyses were utilized

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Assessments

Clinical Outcomes

Data were from baseline and 3-, 6-, 12-, and 18-months
post-baseline. Substance use was assessed using lab-based
7-panel urine toxicology screens (marijuana, cocaine, ben-
zodiazepine, amphetamine, methamphetamine, opiate,
synthetic marijuana). Interviewers took steps to prevent
tampering (see Henggeler et  al. 2011), and adulterants
were lab-tested. Substance use was considered present if
any results were positive. Results were excluded if parents
reported youth medication that would result in a positive
screen.

Internalizing symptoms were measured using the 47-item
youth-reported RCADS (Chorpita et al. 2000), an adapta-
tion of the Spence Children’s Anxiety Scale (SCAS; Spence
1998) developed to closely correspond to DSM-IV anxiety
disorders and major depression. The measure is composed
of 7 subscales (separation anxiety disorder, social phobia,
generalized anxiety disorder, obsessive compulsive disorder,
panic disorder, total anxiety, major depressive disorder) and
a Total scale. Total scale T-scores were used in the current
analyses (Cronbach’s alpha = 0.94). Previous studies have
reported adequate internal consistency, test–retest stability
(Chorpita et al. 2000), and favorable convergent, discrimi-
nant, and factorial validity for both anxiety and depressive
disorders (Chorpita et  al. 2005). The RCADS measures
internalizing symptoms similarly to well established youth
measures of depression and anxiety (de Ross et al. 2002).

Externalizing problems were measured by the par-
ent Child Behavior Checklist (CBCL; Achenbach 1991)
T-scores (Cronbach’s alpha = 0.93). The CBCL has good
inter-rater reliability, test–retest reliability, criterion-related
validity, and convergent and discriminant validity.

Functional Outcomes

School enrollment was reported by parents at 6-month inter-
vals. This variable was coded “1” if youth were enrolled or
had completed their education and “0” if the youth dropped
out or was expelled or in placement. Parent and youth ratings
of parenting were collected at baseline and at 3-, 6-, 12-,
and 18-months post-baseline. The 42-item Alabama Parent-
ing Questionnaire (APQ; Shelton et al. 1996; Zlomke et al.
2014) assesses: Corporal Punishment, Inconsistent Disci-
pline, Poor Monitoring/Supervision, Positive Involvement,
Positive Practices/Reinforcement (Cronbach’s alpha = 0.72
for parent, 0.74 for youth). Two 4-item subscales were added
to capture additional parenting practices specific to adoles-
cents. A rules/expectations subscale assessed enforcement
of household rules and behavioral expectations. An Indirect
Supervision subscale, similar to the Oregon Social Learning

Center Monitoring scale (Brown et  al. 1991), measured
supervision at parties/friends’ houses and parents’ knowl-
edge of the youth’s whereabouts.

Therapy Process

Except for motivation, the therapy process variables were
measured at 1-, 2-, and 3-months post-baseline. Parent sat-
isfaction with treatment was assessed with an abbreviated
consumer satisfaction questionnaire (CSQ; Attkisson and
Greenfield 2004). Three items account for > 85% of variance
and represent general satisfaction, willingness to recommend
the service, and willingness to seek the same services again
if needed (Larsen et al. 1979). Previous studies reported
high internal consistency (Attkisson and Greenfield 2004).
Cronbach’s alpha in the current sample was 0.88. Parental
involvement in treatment was measured using three items
from the Vanderbilt Satisfaction Scale (VSS; Brannan et al.
1996), which assesses the parent’s understanding of and
involvement in treatment, as well as satisfaction with level
of involvement. Cronbach’s alpha for the current sample
was 0.92. Working alliance was measured using parent- and
youth-reports on the 12-item Working Alliance Inventory
(WAI; Horvath and Greenberg 1989), which measures emo-
tional bond and agreement on therapeutic goals and tasks. It
has adequate psychometric properties (Martin et al. 2000),
and both youth and parent reports predict treatment out-
come (Gaudiano and Miller 2006; Hawley and Weisz 2005;
Kazdin and Whitley 2006). Cronbach’s alpha for the current
sample was 0.87 for parent and 0.84 for adolescent versions.
Due to similarities between the goals and tasks subscales,
these were averaged (Agreement on Goals & Tasks), while
Emotional Bond was analyzed separately.

Treatment motivation was assessed at baseline and at
1-, 2-, and 3-months post-baseline, using a 4-item, 4-point
Client Motivation scale informed by other youth treatment
studies (Friedman et al. 1995). High scores indicated more
motivation to change and more faith in treatment. Motiva-
tion to continue treatment was assessed at follow-ups. A few
items focused exclusively on substance use. All parents rated
“how willing are you to help your child cut down on use?”
at the highest level; thus, this item was dropped. For the
youth version, this item was analyzed separately as Motiva-
tion to Cut Down. Two items (“how willing are you/is your
child to receive outpatient services?” and “how confident
are you that outpatient treatment will help you/your child?”)
were averaged for each informant as Treatment Motivation/
Confidence.

Conditions

The two conditions were OPT-A and treatment as usual
(TAU). Both conditions were provided by master’s level

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clinicians employed in the same Child, Adolescent, and
Family Services (CAFS) program of a public sector commu-
nity mental health center. This county mental health center
(i.e., each county in the state has a community mental health
center) is operated by a state Department of Mental Health.
All TAU and OPT-A treatment was paid by Medicaid, pri-
vate insurance, or state funding. Two therapists only deliv-
ered OPT-A, and TAU cases were assigned to therapists not
trained in OPT-A. Therapists agreed to maintain separation
of the conditions, and OPT-A therapists refrained from dis-
cussing cases or OPT-A with colleagues; further, the nature
of OPT-A (i.e., extensive training and monitoring required;
see below) makes likelihood of contamination low.

OPT‑A

The treatment manual is available from the authors. Briefly,
OPT-A is a novel approach to clinic-based treatment that
draws on the Multisystemic Therapy (MST; Henggeler et al.
2009) framework for problem conceptualization and treat-
ment planning (e.g., systemic conceptualization, provider
accountability for overcoming barriers, iterative hypothesis
testing). This framework allows comprehensive conceptual-
ization and treatment of multiple problems simultaneously
rather than sequentially and guides therapists to integrate
specific strategies from evidence-based interventions (e.g.,
CBT, behavior modification, parenting and communication
skills) based on presenting problems of each youth. The
OPT-A supervisor leads treatment planning using the MST
principles and analytical process (see Henggeler et al. 2009),
resulting in individualized regimens such that an identical
set of interventions is not delivered to each case. Treatment
length is criterion-based and dependent on goals being met.
OPT-A sessions occur roughly weekly and average length
was 9.7 months (SD 4.5).

Each session included multiple intervention steps based
on prioritized needs. OPT-A includes traditional CBT tech-
niques (e.g., mood and thought monitoring, identifying
and modifying cognitive distortions, relaxation techniques,
collaborative session agenda setting, use of homework to
reinforce in-session learning; Beck 1995; Friedberg and
McClure 2002) tailored to each youth’s presenting problems.
In OPT-A, these are usually taught both to adolescents and
parents to encourage parents to practice CBT skills with
adolescents between sessions and, ultimately, improve gen-
eralizability. OPT-A also provides families with extensive
behavior modification targeting substance use and exter-
nalizing behaviors (e.g., individualized token-economy
behavior plans including well-defined rules, rewards, and
consequences). For substance use, adolescents submit urine
drug screens in session, and parents are trained to administer
frequent random screens to sustain monitoring and rewards,
similar to procedures described by Henggeler et al. (2011).

Most families receive family communication and parenting
training. Therapists have access to modest funds (< $100/
adolescent) to purchase initial rewards for behavior plans.
Families can choose to continue medication for ADHD
and/or mental health symptoms, and OPT-A therapists are
trained and supervised to coordinate medication monitoring
with the prescribing physician (e.g., 45% were prescribed
medication at the 6-month assessment). A comprehensive
treatment engagement protocol is implemented, based on the
work of McKay (2000) on service provision for outpatient
clinics. Therapists leverage technology (e.g., some sessions
conducted by phone, treatment materials sent via email), and
extensive homework protocols are implemented.

OPT-A was conducted by two master’s level clinicians
employed by the CAFS program. These therapists expressed
interest in serving as study therapists and were chosen by
their clinic director. Therapists were trained and supervised
in OPT-A by the investigators. Each therapist carried case-
loads of up to 12 active clients, and only treated clients
receiving OPT-A as part of this study. They received 65 h
of initial training on OPT-A, followed by intensive supervi-
sion on 2 pilot cases prior to treating study cases. Half-day
booster trainings were provided quarterly. Individual weekly
supervision occurred using web-conferencing. Adherence
was ensured using a system similar to MST’s intensive
quality assurance procedures (Henggeler et al. 2009; Smith-
Boydston et al. 2014), except that supervision was individual
rather than group. Highly structured session notes (focused
on specific session tasks/agendas, intervention outcomes,
and the MST methods for conceptualization, tracking, and
planning) were reviewed by supervisors in advance of super-
vision. Supervisors also reviewed session audiotapes and
materials (e.g., homework, behavior plans, functional analy-
ses). Because OPT-A was in Stage II of development, it was
premature to develop a parent- or client-reported adherence
instrument, typically used at the point when treatment devel-
opers are no longer directly supervising treatment. Instead,
the ongoing MST methods for achieving adherence (i.e.,
weekly review of session notes, tapes, and materials fol-
lowed by supervision and intensive training by developers)
were utilized throughout the trial. No concerns arose regard-
ing OPT-A being delivered as intended.

To confirm adherence, observational coding was com-
pleted on each youth’s taped sessions (744 session tapes
were collected and coded). We used the Therapy Proce-
dures Checklist (TPC; Kolko et al. 2009; Weersing et al.
2002), an assessment that includes 62 items representing the
most common techniques used by community-based thera-
pists in treating youth. TPC subscales represent Behavio-
ral, Cognitive, Psychodynamic, and Family Therapy tech-
niques. Results from this observational coding indicated
that nearly all (97.3%) families received parent manage-
ment and other behavioral techniques and most received

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family therapy (83.3%) and cognitive (73.0%) techniques.
Few (27.6%) received what would be considered psychody-
namic techniques. When looking at the percent of sessions
in which techniques occurred (averaged within category),
the most frequently occurring techniques were family ther-
apy (M = 48.8%), behavioral (M = 36.9%), and cognitive
(M = 34.3%), while psychodynamic techniques were infre-
quent (M = 6.1%). Thus, observational coding, in addition
to the intensive oversight methods used in this Stage II trial,
provided assurance of therapist adherence to the primary
techniques of …

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