Program Profile: Risk Reduction through Family Therapy (RRFT) for Adolescents

The goal of this exposure-based, integrative intervention was to reduce substance use and mental health problems in adolescents who have experienced trauma. The program is rated Promising. The program had a statistically significant impact on depressive and internalizing symptoms, family cohesion, and family conflict. There were mixed results for PTSD symptoms and substance use. There was no statistically significant impact on externalizing symptoms.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

Program Goals

Risk Reduction through Family Therapy (RRFT) for Adolescents is an exposure-based, integrative intervention targeted at adolescents who experienced interpersonal violence (child sexual abuse, physical abuse, physical assault, threat with a weapon, and/or witnessing violence) and other types of traumatic events (traumatic grief, disasters, accidents involving injury) [Hahn et al. 2020]. The program’s goals are to reduce symptoms of posttraumatic stress disorder (PTSD) and depression, substance use, high-risk sexual behavior, sexual revictimization, and other health risk behaviors often experienced by trauma-exposed adolescents.

Program Theory

The therapeutic nature of RRFT and the focus on family and the social systems of the youth was guided by ecological theory, which proposes that an adolescent’s behavior is influenced by multiple social and environmental contexts, including the family, peer network, school, and community (Bronfenbrenner 1979). Further, the two-factor theory (Mowrer 1960), which suggests that gradual exposure techniques can extinguish distress symptoms that have become paired with trauma cues, and negative reinforcement theory (Baker et al. 2004), which suggests that reductions in substance use parallel reductions in PTSD avoidance and/or hyperarousal, guided the program components that addressed PTSD, substance use, and their overlap.

Program Components

RRFT was an adaptation and integration of cognitive–behavioral interventions that addressed PTSD symptoms (e.g., trauma-focused cognitive behavioral therapy [TF-CBT]), substance use problems (e.g., multisystemic therapy and contingency management), and sexual health and child sexual abuse (e.g., TF-CBT). The program was tailored to address each youth’s individualized risk and protective factors and was organized across seven treatment components:1) psychoeducation, 2) coping, 3) family communication, 4) substance abuse, 5) PTSD, 6) healthy dating and sexual decision making, and 7) revictimization risk reduction.

Each clinician completed a 3-day intensive training and had been previously trained in TF-CBT. RRFT was administered through weekly individual, 40- to 90-minute sessions with adolescents. When applicable, brief caregiver and family sessions were administered in addition to occasional telephone or text check-ins between sessions. During therapy sessions, clinicians targeted self-regulation deficits to decrease trauma-related substance use problems. Additionally, to address PTSD symptoms and decrease distress symptoms paired with trauma cues, or reminders of traumatic experiences, clinicians used gradual exposure techniques during therapy through the development of detailed written and/or oral narratives composed by the youth. Over time, repeatedly recalling the traumatic event in the absence of feared aversive consequences (e.g., abuse, shame) was meant to reduce the fear response paired with trauma cues. Cognitive–behavioral therapy was also incorporated into the exposure-based trauma narrative work. Therapists helped adolescents identify and replace inaccurate and/or unhelpful beliefs that they developed in relation to the traumatic events (e.g., “The abuse was my fault”). Youth were given the opportunity to share their trauma narratives with family members.

The duration of the program varied for each youth. The order of treatment components, as well as the amount of time spent on each component, was determined by the specific needs of each youth and their family. Weekly timeline follow-back (TLFB) assessments, random urine drug screens, PTSD symptom assessments, and ongoing assessment updates to the risk and protective factors for PTSD symptoms and substance use problems were conducted to assess treatment progress.

Study

Research Design/Sample

Danielson and colleagues (2012) conducted a randomized controlled trial evaluating the effectiveness of Risk Reduction through Family Therapy on a sample of 30 treatment-seeking adolescents and their caregivers who had been recruited from an urban clinic specializing in trauma treatment. Youth eligible for participation were age 12–17, had experienced at least one lifetime childhood sexual assault that the youth could recollect, and did not have severe learning disabilities.

Eighty-eight percent of the participants were female. Of the sample, 46 percent were Black, 37 percent were white, 4 percent were Native American, 8 percent were biracial, and 4 percent were Hispanic. The age of participants ranged from 13 to 17 years old, and their age at first/only childhood sexual assault experience ranged from 4 to 15 years. Roughly 67 percent reported having experienced additional traumatic events (other than childhood sexual assault), and the average time since the most recent assault was 3.7 years.

Participants were randomly assigned to conditions using the computerized blocked randomization method. Youth in the Risk Reduction through Family Therapy treatment group (n = 15) received the intervention as described in the Program Description over an average of 23 sessions and an average 34 weeks in treatment. Youth assigned to the control group (n = 15) received treatment as usual, which consisted of psychoeducation, coping, safety planning, and cognitive–behavioral therapy (no one treatment component was consistently delivered to these youth). Family therapy was also provided to youth in the control group. Those in the control group received an average of 13 sessions, and on average, spent 20 weeks in treatment. There were statistically significant differences at baseline between the groups. With the exception of family cohesion, youth in the treatment group, compared with youth in the control group, had higher baseline scores on indicators of posttraumatic stress disorder (PTSD) symptoms, depression symptoms, internalizing symptoms, externalizing symptoms, adolescent-reported substance use, and adolescent- and caregiver-reported family conflict. No statistical adjustments were employed to control for group differences.

Data Collection/Outcome Measures 

The outcomes of interest were adolescent-reported PTSD, parent-reported PTSD, adolescent-reported depression, adolescent-reported internalizing symptoms, adolescent-reported externalizing symptoms, adolescent-reported substance use, adolescent-reported family cohesion, and adolescent-reported family conflict. Participants completed assessments at baseline, posttreatment, and at 3- and 6-month follow-ups (the CrimeSolutions review of this study focused on outcomes at 6 months). PTSD symptoms were assessed with the University of California, Los Angeles PTSD index for DSM–IV (adolescent and caregiver versions). The Child Depression Inventory was used to assess depression symptoms, and the Behavioral Assessment System for Children (youth self-report) was used to assess each adolescent’s internalizing and externalizing symptoms. The timeline follow-back interview was conducted with each participant to identify specific amounts of alcohol and other drugs consumed over the past 90 days. The cohesion and conflict subscales of the Family Environment Scale (adolescent version) were used to assess family cohesion and family conflict. The substance use outcome was modeled as a count-distributed score based on the interview. The remaining outcomes were modeled as continuous variables. 

Statistical Analysis

Because of the nested nature of the data (individual-level outcomes nested in families), two-level mixed-effects regression models were used to evaluate the effectiveness of the treatment on the outcomes of interest. A Poisson mixed-effects regression model was used to evaluate the count-distributed outcome (e.g., the substance use outcome). Variables representing number of sessions and treatment length were initially included in the models to control for treatment intensity. Conclusions did not differ when intensity was controlled; therefore, the results were derived from models without the covariates. No subgroup analysis was conducted.

Study

Research Design/Sample

Danielson and colleagues (2020) conducted a randomized controlled trial examining the effect of the Risk Reduction through Family Therapy intervention on 124 youth participants who were recruited from November 1, 2012, through January 30, 2017. Recruitment and treatment took place at community-based child advocacy centers in the southeastern United States. The sample consisted of adolescents whose ages ranged from 13 to 18 years, who had experienced intimate partner violence (child sexual abuse, physical abuse, physical assault, threat with a weapon, and/or witnessing violence), had reported using at least one nontobacco substance during the past 90 days, and had at least five symptoms of PTSD. Those with pervasive developmental disability, intellectual disability, suicidal or homicidal ideation, active psychosis, or those already engaged in treatment were excluded from the study.

After the baseline assessment, adolescents and their caregivers were urn-randomized to the Risk Reduction through Family Therapy or treatment-as-usual conditions by a trained child advocacy center staff member. This process balanced condition assignment on sex, pretreatment substance use frequency (four or more substance-using days during the past 30 days), and pretreatment PTSD symptom severity (a score of 38 or greater on the University of California, Los Angeles Posttraumatic Stress Disorder Reaction Index). Youth in the treatment group (n = 61) participated in Risk Reduction through Family Therapy, while youth in the control group (n = 63) received treatment as usual, which consisted of weekly, individual child and parent sessions, joint child–parent sessions and graded exposure to trauma cues. Substance use problems were not directly targeted but clinicians could refer their clients to other community agencies for substance use treatment, if desired. Additionally, clinicians in the treatment-as-usual control group completed standard training in trauma-focused cognitive-behavioral therapy and received weekly supervision.   

Youth in the Risk Reduction through Family Therapy treatment group were an average of 15.3 years old, 85.2 percent female, 65.6 percent white, 27.9 percent Black, 4.9 percent Latino, 1.6 percent biracial, and 3.3 percent Hispanic ethnicity. Youth in the treatment-as-usual control group were an average of 15.3 years old, 88.9 percent female, 60.3 percent white, 30.2 percent Black, 6.3 percent Latino, 3.2 percent biracial, and 6.3 percent Hispanic ethnicity. At baseline, 74 percent of all sample participants endorsed alcohol use, 86 percent endorsed marijuana use, 12 percent endorsed other non-nicotine drug use, and youth in both groups reported an average of 3.6 different traumatic event types. There were statistically significant baseline differences between the two groups in total PTSD symptom severity. Specifically, the treatment group had higher scores than the control group at baseline for caregiver reports of PTSD symptom severity (49.10 for the treatment group youth, compared with 42.3 for control group youth). No statistical adjustment was used to account for this difference. There were no statistically significant differences at baseline between treatment and control groups in youth reports on PTSD symptom severity or on any other outcome.  

Data Collection/Outcome Measures

The outcomes of interest included any nontobacco substance use, number of days of substance use, PTSD symptoms reported by adolescents, and PTSD symptoms reported by caregivers. The number of substance-using days was measured using self-reported data at baseline and 3, 6, 12, and 18 months after baseline using the timeline follow-back method. Symptoms of PTSD were assessed at all five time points using the University of California, Los Angeles Posttraumatic Stress Disorder Reaction Index, adolescent and caregiver versions. (The CrimeSolutions review of this study focused on the results at 18 months after baseline.) 

Statistical Analysis

Because of the nested nature of the data, mixed-effects formulations of general linear (continuous; maximum likelihood estimation) and generalized linear (Bernoulli and negative binomial; numerical integration and adaptive quadrature) regression models were used to assess the impact of the treatment on the outcomes. For nonlinear outcomes, the magnitude of effects was reflected by odds ratios and event rates. No subgroup analysis was conducted. 

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: