A Manualized Behavioral Therapy Intervention for Youth with Autism Spectrum Disorder and Substance Use Disorder.

Research highlights the increasing overlap of autism spectrum disorder and substance use disorders in young people. However, no behavioral treatments exist addressing this comorbidity despite great need. A team of clinicians developed an integrated behavioral protocol addressing substance use in youth with autism spectrum disorder. The multidisciplinary team developed 12 youth, 7 parent, and 3 joint modules based on established evidence-based therapies shown to have effectiveness separately addressing autism spectrum and substance use. Two cases are discussed to illuminate this integrated intervention. Adaptations to the protocol were made during feedback from patients and their parents. Further research is needed to determine the effectiveness of this preliminary protocol.

Pilot development and feasibility of telehealth Community Reinforcement and Family Training (CRAFT) for early psychosis and substance use.

Substance use is associated with poor outcomes for individuals with early psychosis. Community Reinforcement and Family Training (CRAFT) is an evidence-based approach that helps families to reduce substance use, engage in treatment, and improve family wellbeing, but it has not yet been studied for psychosis and substance use. The present study aimed to develop and evaluate a telehealth intervention utilizing CRAFT for families experiencing early psychosis and substance use. Twenty family members completed six to eight telehealth sessions of CRAFT adapted for early psychosis (CRAFT-EP). Participants completed an assessment battery at baseline, mid- and post-intervention, a three-month follow-up, surveys after each session, and a focus group to measure mean percentage of sessions completed, mean program satisfaction ratings, telehealth preference, and qualitative feedback. Participants had 100% session completion, and program satisfaction was at or near excellent for 99% of sessions. Half of participants preferred a primarily virtual hybrid program, whereas 45% preferred exclusively virtual visits. Communication was the most helpful topic, and participants requested additional written examples and resources. CRAFT-EP is feasible and acceptable to serve as the active intervention in a pilot randomized controlled trial comparing treatment as usual plus CRAFT-EP to treatment as usual.

Treatment Retention and Outcomes with the Adolescent Community Reinforcement Approach in Emerging Adults with Opioid Use.

Treatment retention and engagement of emerging adults with opioid use disorders can be particularly challenging. This study compares treatment outcomes of young adults with primary opioid use (OU) to those with primary marijuana or alcohol use (MAU), who received the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based therapy for the treatment of substance use. The MAU and OU groups were comprised of an outcome sample of 419 young adults ages 18-25. Groups were compared on intake demographics, clinical characteristics, and measures of treatment retention and other associated factors, including treatment initiation and engagement. Outcome measures were administered at A-CRA intake and at 3, 6, and 12 months post-intake. Both groups were similar in treatment retention, initiation, and engagement. Both groups showed a similar decrease in alcohol (p < .001) and marijuana use (p < .001). The OU group had significantly less opioid use at 3 months (p < .001) and maintained this decrease, but did not improve to the level observed in the MAU group at the 12-month follow-up. The Adolescent Community Reinforcement Approach merits further study as a behavioral treatment for young adults with opioid use.

Analyzing components of Community Reinforcement and Family Training (CRAFT): Is treatment entry training sufficient?

Community Reinforcement and Family Training (CRAFT) assists family members with a treatment-resistant loved one. The most consistent outcome of CRAFT is increased treatment entry of the identified treatment-resistant person (IP). This led us to question whether all 6 components of CRAFT are necessary. In a randomized clinical trial, 115 concerned significant others (CSOs) of an IP received 12-14 sessions of the full CRAFT intervention, 4-6 sessions focused on Treatment Entry Training (TEnT), or 12-14 sessions of Al-Anon/Nar-Anon Facilitation (ANF). We monitored treatment entry, attendance, and substance use of the IP and the CSO's mood and functioning. Data were collected at baseline and 4, 6, and 9 months after the baseline. We found significant reductions in time to treatment entry (χ(2)2 = 8.89, p = .01) and greater treatment entry rates for CRAFT (62%; odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.1-6.9) and TEnT (63%; OR = 2.9, 95% CI = 1.2-7.5) compared with ANF (37%), but CRAFT and TEnT did not differ significantly from each other (OR = 1.1, 95% CI = 0.4-2.7). No between-group differences in IP drug use were reported by CSOs, but days of drug use decreased over time for all groups (F(3, 277) = 13.47, p < .0001). Similarly, CSO mood and functioning did not differ between the 3 conditions but improved over time (p < .0001 for all significant measures). We replicated the results of previous trials demonstrating that CRAFT produces greater treatment entry rates than ANF and found similar treatment entry rates for CRAFT and TEnT. This suggests that treatment entry training is sufficient for producing the best established outcome of CRAFT. (PsycINFO Database Record

Adolescent Community Reinforcement Approach implementation and treatment outcomes for youth with opioid problem use.

BACKGROUND: This paper compares adolescents with primary opioid problem use (OPU) to those with primary marijuana or alcohol problem use (MAPU) who received up to six months of Adolescent Community Reinforcement Approach (A-CRA), an empirically supported treatment. METHODS: Intake clinical characteristics, treatment implementation measures, and clinical outcomes of two substance problem groups (OPU and MAPU) were compared using data from 1712 adolescents receiving A-CRA treatment. Data were collected at intake and 3, 6, and 12 months post-intake. RESULTS: At intake, adolescents in the OPU group were more likely than those in the MAPU group to be Caucasian, older, female, and not attending school; report greater substance and mental health problems; and engage in social and health risk behaviors. There was statistical equivalence between groups in rates of A-CRA treatment initiation, engagement, retention, and satisfaction. Both groups decreased significantly on most substance use outcomes, with the OPU group showing greater improvement; however, the OPU group had more severe problems at intake and continued to report higher frequency of opioid use and more days of emotional problems and residential treatment over 12 months. CONCLUSIONS: The feasibility and acceptability of A-CRA for OPUs was demonstrated. Despite significantly greater improvement by the OPU group, they did not improve to the level of the MAPU group over 12 months, suggesting that they may benefit from A-CRA continuing care up to 12 months, medication to address opioid withdrawal and craving, and the inclusion of opioid-focused A-CRA procedures.

The effect of therapists' adherence and competence in delivering the adolescent community reinforcement approach on client outcomes.

[Correction Notice: An Erratum for this article was reported in Vol 31(1) of Psychology of Addictive Behaviors (see record 2016-59284-001). In the article, the disclosed interest for Mark D. Godley in the author note is misrepresented. The accurate representation is that the organization employing Mark D. Godley, Chestnut Health Systems, receives fees for A-CRA training. In addition, the disclosed interest statement for Jane Ellen Smith and Robert J. Meyers should read Jane Ellen Smith and Robert J. Meyers each have private consulting businesses that conduct workshops on CRA or A-CRA; they also receive royalties on the CRA book. All versions of this article have been corrected.] Central to the debate over the implementation of empirically supported treatments is whether therapist skill has a measurable, positive relationship with client outcome. The fidelity and skill with which therapists deliver treatments have been studied under the constructs of adherence and competence. Evidence for a relationship between adherence and competence and client outcomes has been mixed, possibly due to small sample sizes, potentially inadequate measures for rating therapists' skill, and limited statistical methods. The current study used a data set in which 91 therapists provided services to 384 clients from the Assertive Adolescent and Family Treatment project. Therapists trained to deliver the Adolescent Community Reinforcement Approach (A-CRA) submitted audiorecorded sessions to independent raters during their training process. Measures of adherence and competence derived from session ratings were examined in a multilevel model for associations with client substance use outcomes at 3-, 6-, and 12-month follow-ups. Therapist competence was significantly predictive of decreases in clients' days of substance use. Therapist adherence was not predictive of client substance use outcomes in the full sample; however, when only those clients who completed the 12-month follow-up were included, between-therapists adherence was found to be predictive of a decrease in client substance use. This study adds to the evidence that competence in the delivery of treatment is associated with better client treatment outcomes. Adherence may be associated with better treatment outcomes as it was in follow-up completers. Future research should investigate the nature of the relationship between protocol-specific adherence and competence and client outcomes. (PsycINFO Database Record

Developing Community Reinforcement and Family Training (CRAFT) for Parents of Treatment-Resistant Adolescents.

We describe a project focused on training parents to facilitate their treatment-resistant adolescent's treatment entry and to manage their child after entry into community-based treatment. Controlled studies show that Community Reinforcement and Family Training (CRAFT) is a unilateral treatment that fosters treatment entry of adults; however, there are no controlled trials for parents with a substance-abusing child. We examined the behavioral parent training literature to guide us in tailoring CRAFT for parents of adolescents. We discuss adaptations to CRAFT, outcomes and experiences gained from a brief pilot of the revised CRAFT program, and the future directions of this work.

Reasons for entering treatment reported by initially treatment-resistant patients with substance use disorders.

Many individuals with substance use disorders are resistant to entering formal treatment, despite the negative consequences that plague their own lives and the lives of concerned significant others (CSOs). Community Reinforcement and Family Training (CRAFT) has been developed as an effective strategy for helping family members who are concerned about the alcohol/drug use of a loved one who refuses to seek treatment. The present study explored reasons and feelings that played a part in these resistant individuals' (identified patients [IPs]) decision to begin treatment. Written statements and feelings of 36 initially treatment-refusing IPs, who were engaged into treatment via their CRAFT-trained CSOs, were examined upon entering treatment. Self-report forms assessed three complementary domains about entering treatment: (1) feelings about coming for treatment, (2) important reasons for entering treatment, and (3) reasons for entering treatment narratives. It was shown that the occurrences of self-reported positive emotions and statements that expressed a positive wish for change outweighed negative feelings and statements. Although conceivably these CRAFT-exposed IPs may have provided different responses than other treatment-seeking populations, the current study's strong IP reports of positive feelings, reasons, and narrative statements regarding treatment entry nonetheless address potential concerns that treatment-refusing IPs might only enter treatment if felt coerced by family members and while experiencing salient negative feelings overall.

Engagement of pleasant activities in patients with substance use disorders: a correlational study.

BACKGROUND: There is a growing awareness that the treatment of patients with substance use disorders (SUDs) should target increasing patients' involvement in alternative pleasant reinforcers that compete with the reinforcing effects of substance use. The present cross-sectional study sought to identify factors that promote or impede engaging in pleasant activities. METHODS: Patients with SUDs (N = 265) were assessed at treatment entry on sociodemographic characteristics, primary type of substance (ie, alcohol or illicit drugs), addiction severity, craving, personality factors, and psychiatric distress. RESULTS: Regression analyses identified dissimilar predictor sets underlying frequency, enjoyability, and cross-product ratings, highlighting the multifaceted behavioral nature of activity engagement. Personality measures showed the strongest associations with patients' activity engagement, with extraversion as the key predictor. CONCLUSIONS: The present findings emphasize the complexity of patients' involvement in pleasant non-substance-related activities and further investigation is necessary to gain more insight into the underlying mechanisms of activity engagement.

A comparison of treatment outcomes for adolescent community reinforcement approach participants with and without co-occurring problems.

This study examined the relationship between Adolescent Community Reinforcement Approach (A-CRA) participation with treatment engagement, retention, and satisfaction, and with substance use and emotional problem outcomes. Participants had substance use disorders (SUD) only or co-occurring substance use and psychiatric problems. Those with co-occurring problems reported more days of substance use and emotional problems at intake to treatment than those with SUD only. All groups received equivalent exposure to A-CRA during treatment implementation. At the 12-month follow-up, adolescents classified as externalizers (n = 468) or those with both externalizing and internalizing problems (n = 674) had significantly greater improvement in their days of abstinence and substance problems relative to adolescents with substance use disorders only (n = 666). Additionally, adolescents reporting symptoms of internalizing (n = 154), externalizing, or both externalizing and internalizing disorders had significantly greater improvements in days of emotional problems relative to adolescents with SUD only.

Problem areas reported by substance abusing individuals and their concerned significant others.

Substance use disorders (SUDs) have a serious impact on several life areas, including family functioning. This study examined problem areas that patients with SUDs and their family members experience in terms of quality of relations, psychological problems, physical distress, and quality of life. A sample of 32 dyads--persons with SUDs and a family member--were recruited from a substance abuse treatment program, and completed the Maudsley Addiction Profile health symptoms section, EuroQol-5D, Relationship Happiness Scale, Dyadic Adjustment Scale, and the Dedication Scale. Family members reported that four significant others were directly affected by patients' addiction-related problems, while patients reported that less than three family members were affected by their addiction. Consistently, family members indicated that they were less content with their relationship than patients and evaluated the consequences of patients' SUDs as more negative and severe than the patients themselves. Furthermore, patients and their family members reported comparable levels of physical and psychological distress and quality of life scores. These systematically obtained findings support the notion that relationships of patients and family members are disrupted and both need help to improve their physical and psychological well-being.

Community Reinforcement and Family Training: a pilot comparison of group and self-directed delivery.

In a randomized clinical pilot study, 40 concerned significant others (CSOs) of treatment-refusing alcohol- and drug-using individuals were randomized to either Community Reinforcement and Family Training (CRAFT) conducted in a group format (Group CRAFT) or a Self-Directed CRAFT condition. Although results indicated no significant between-group difference in engaging treatment-refusing substance-using individuals (referred to as identified patients or IPs) into treatment, the engagement rate in Group CRAFT was similar to rates previously reported with individual CRAFT. For the intent-to-treat analysis, 60% of Group CRAFT CSOs engaged their loved one into treatment, as compared with 40% in Self-Directed CRAFT. Of CSOs in the Group condition who received at least one session of group therapy, 71% engaged their IP into treatment. CSOs in both conditions reported improvements in family cohesion and conflict at the 3- and 6-month follow-up, replicating prior CRAFT findings.

A Large-scale Dissemination and Implementation Model for Evidence-based Treatment and Continuing Care.

Multiple evidence-based treatments for adolescents with substance use disorders are available; however, the diffusion of these treatments in practice remains minimal. A dissemination and implementation model incorporating research-based training components for simultaneous implementation across 33 dispersed sites and over 200 clinical staff is described. Key elements for the diffusion of the Adolescent Community Reinforcement Approach and Assertive Continuing Care were: (a) three years of funding to support local implementation; (b) comprehensive training, including a 3.5 day workshop, bi-weekly coaching calls, and ongoing performance feedback facilitated by a web tool; (c) a clinician certification process; (d) a supervisor certification process to promote long-term sustainability; and (e) random fidelity reviews after certification. Process data are summarized for 167 clinicians and 64 supervisors.

The community reinforcement approach: an update of the evidence.

The Community Reinforcement Approach (CRA), originally developed for individuals with alcohol use disorders, has been successfully employed to treat a variety of substance use disorders for more than 35 years. Based on operant conditioning, CRA helps people rearrange their lifestyles so that healthy, drug-free living becomes rewarding and thereby competes with alcohol and drug use. Consequently, practitioners encourage clients to become progressively involved in alternative non-substance-related pleasant social activities, and to work on enhancing the enjoyment they receive within the "community" of their family and job. Additionally, in the past 10-15 years, researchers have obtained scientific evidence for two off-shoots of CRA that are based on the same operant mechanism. The first variant is Adolescent Community Reinforcement Approach (A-CRA), which targets adolescents with substance use problems and their caregivers. The second approach, Community Reinforcement and Family Training (CRAFT), works through family members to engage treatment-refusing individuals into treatment. An overview of these treatments and their scientific backing is presented.

Development and psychometric evaluation of the pleasant activities list.

This paper describes the development of a new 139-item behavioral questionnaire (PAL) assessing the frequency and enjoyability of pleasant activities occurring in the natural environment of patients with substance use disorders. The sample consisted of 265 patients with mainly substance use disorders and 272 healthy controls. Group comparisons indicated that patients reported lower frequency, enjoyability, and cross-product activity scores than controls. This study confirms previous findings that addiction is associated with a decreased level of engagement in pleasant activities. The PAL seems to be a standardized, feasible, and valid instrument to sample non-substance-related rewarding activities in patients' everyday lives.

Treatment outcome for street-living, homeless youth.

Comprehensive intervention for homeless, street living youth that addresses substance use, social stability, physical and mental health issues has received very little attention. In this study, street living youth aged 14-22 were recruited from a drop-in center and randomly assigned to the Community Reinforcement Approach (CRA) or treatment as usual (TAU) through a drop-in center. Findings showed that youth assigned to CRA, compared to TAU, reported significantly reduced substance use (37% vs. 17% reduction), depression (40% vs. 23%) and increased social stability (58% vs. 13%). Youth in both conditions improved in many other behavioral domains including substance use, internalizing and externalizing problems, and emotion and task oriented coping. This study indicates that homeless youth can be engaged into treatment and respond favorably to intervention efforts. However, more treatment development research is needed to address the barriers associated with serving these youth.

A comparison of alcohol and drug disorders: is there evidence for a developmental sequence of drug abuse?

Whereas the model of Jellinek [Q. J. Stud. Alcohol 7 (1952) 673] of a predictable progression of alcoholism is generally supported, there have been few published studies regarding the natural history of illicit drug disorders. Identification of the development of drug abuse and/or dependence can inform clinicians and researchers on issues, such as diagnosis, prognosis, assessment, and prevention. This study employed a new measure adapted from the 46 events described in Jellinek's progression of alcoholism. Nine licit and illicit substances were also included within the cardsort. Fifty-two individuals motivated to enter drug treatment by a loved one were assessed pretreatment. The drug initiation sequence reported by this sample was as follows: alcohol, tobacco, inhalants, marijuana, and then other drugs. Spearman rank correlation coefficients were conducted between the drug sample and that of Jellinek yielding a modest correlation (r=.35, P=.019). These results suggest that Jellinek's model of progression of alcoholism may also apply to the development of drug disorders. However, important differences found between the alcohol and drug progressions are discussed.

The Community Reinforcement Approach.

This chapter reviews two behavioral substance abuse treatments: The Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT). Both of these programs were built on the concept that an individual's recovery is greatly affected by his or her unique environment. This environment, or reinforcing "community," is composed of family, friends, work/school, social activities, and perhaps spiritual affiliations. CRA, the first of these two programs to be developed, was created specifically for the problem drinker (Hunt & Azrin, 1973). The goal of CRA is to rearrange multiple aspects of an individual's "community" so that a clean and sober lifestyle is more rewarding than one that is dominated by alcohol and drugs. Subsequently, CRAFT was developed for the many individuals with substance abuse problems who are vehemently opposed to treatment (Institute of Medicine, 1990). CRAFT works through concerned family members and friends of these treatment refusers in an effort to get them to seek therapy (Sisson & Azrin, 1986). Descriptions and the empirical support for CRA and CRAFT follow.

A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others.

In a randomized clinical trial, 90 concerned significant others (CSOs) of treatment-refusing illicit drug users were assigned to either (a) community reinforcement and family training (CRAFT), which teaches behavior change skills, (b) CRAFT with additional group aftercare sessions after the completion of the individual sessions; or (c) Al-Anon and Nar-Anon facilitation therapy (Al-Nar FT). All protocols received 12 hr of manual-guided individual treatment. Follow-up rates for the CSOs were consistently at least 96%. The CRAFT conditions were significantly more effective than Al-Nar FT in engaging initially unmotivated drug users into treatment. CRAFT alone engaged 58.6%, CRAFT + aftercare engaged 76.7%, and Al-Nar FT engaged 29.0%. No CSO engaged a treatment-refusing loved one once individual sessions had been completed.