Evaluation of Culturally Informed and Flexible Family-Based Treatment for Adolescents (CIFFTA) implemented in community-based settings.

Effective family-based interventions are needed for youth who are experiencing emotional and behavioral difficulties and who are impacted by powerful environmental stressors. Culturally Informed and Flexible Family-Based Treatment for Adolescents (CIFFTA) is a manualized and evidence-based, multicomponent family-based treatment that has been shown to be efficacious in research settings. The purpose of this paper is to report on the effectiveness of implementing CIFFTA for the treatment of Latino and Black youth and families in community settings. Utilization of services offered and changes in youth presenting problems and family functioning were used to evaluate the program. Two hundred thirty-two youth (11-18 years of age) and their caregivers were recruited over 2 years and CIFFTA was delivered by experienced masters-level family therapists over a 12-16-week period. Seventy-six percent met the 8-session criteria for retention in treatment and 71% completed treatment. Results showed significant improvements in youth behavioral and emotional presenting problems, reduction in family conflict and improvement in family cohesion and communication. Caregiver well-being such as reductions in parental stress, relational frustration, and improvement in parental confidence also showed significant improvement. Analyses of reliable change indices showed a substantial improvement in youth who entered the program in the clinical range of presenting problems. The findings point to CIFFTA's ability to retain youth and families who tend to underutilize needed services, to significant reductions in presenting problems, and to improvements in family functioning when implemented in a community setting.

Haitian and Haitian American experiences of racism and socioethnic discrimination in Miami-Dade county: At-risk and court-involved youth.

We examine how juvenile justice-involved youth of Haitian descent in Miami-Dade County cope with structural racism and its impact on their mental health. Drawing on longitudinal ethnography, psychosocial assessment data, and a family-based clinical intervention funded by the National Institute on Drug Abuse, this article explores youth narratives of discrimination prior to and during the COVID-19 pandemic. We use critical race theory and theory of practice to understand youths' perceptions as racialized bodies and stigmatized selves, highlighting the experiences and perspectives of a particular black immigrant group, ethnic beings caught up in the everyday practices of racialization, sociocultural marginalization, and racism. We frame these experiences as a variation of the complex continuum of structural racism and racial domination in the US. These experiences have caused anger, fear, anxiety, chronic anticipatory distress, and hopelessness among youth of Haitian descent. We conclude with some recommendations for therapeutic support that encourages youth to process their experiences, promotes their development of a positive self-concept, and provides them with mind-body techniques to attenuate the physical impacts of discriminatory events. The clinical trial registration number for this study intervention is NCT03876171.

Comparing individually based and family-based treatments for internalizing, externalizing, and family symptoms in Latino youth.

Rigorous randomized trials that test promising culturally centered treatments for Latino youth and families are needed. This study adds to the knowledge base by comparing the efficacy of Culturally Informed and Flexible Family Treatment for Adolescents (CIFFTA) to an Individually Oriented Treatment-As-Usual (ITAU) in its ability to retain Latino youth and families in treatment, reduce internalizing and externalizing child symptoms, and improve family functioning. CIFFTA uses an adaptive/flexible approach to deliver individual therapy, family therapy, and psycho-educational modules tailored to each family's unique clinical and cultural characteristics. Two hundred Latino adolescents 11-14 years of age completed a baseline assessment, were randomly assigned to CIFFTA or ITAU, then were assessed again after 16 weeks of intervention. Results show that CIFFTA had significantly higher retention (83%) than ITAU (71%), OR = 2.05, p = .036. Youth in both conditions showed significant reductions in youth and parent reported externalizing and internalizing behaviors, and there were no differences in change between conditions. Parents in CIFFTA reported significantly greater reductions in family conflict, d = 0.38, p = .025 than in ITAU. In CIFFTA, children of less acculturated Latino parents showed more improvement than the children of more acculturated parents. In ITAU, the reverse was true, children of more acculturated parents reported more improvement. This evidence of CIFFTA's impact on retention, family conflict, and differential effect depending on cultural values and behaviors, has important implications for the field of Latino psychology and family treatment.

Juvenile justice-involved Haitian families' experiences of structural racism and socioethnic discrimination.

Objective: This article examines how Haitian families with youth interfacing with the juvenile justice system cope with structural racism and socioethnic discrimination (RSD). Background: Haitian families' experiences of discrimination based on their histories, immigrant status, and positionality illustrates the need for more scientific scrutiny of the experiences of RSD among Black immigrant groups. This National Institute on Drug Abuse (NIDA)-funded study details the narratives of and responses to RSD experienced by Haitian families interfacing with the juvenile justice system. Method: Data are drawn from psychosocial assessment tools, therapeutic sessions, and ethnographic interviews conducted with Haitian families participating in a family-based therapeutic intervention. Using critical race theory, we foreground the voices of those negatively impacted and use Bourdieu's theory of practice to examine the intersectionality of race and ethnicity in this population's experiences of RSD. Results: The different experiences of and responses to RSD among youth and caregivers of Haitian descent are both a variation of the complex continuum of structural racism in the United States and unique to their immigrant experience of marginalization and cultural invalidation by public institutions, community members, and peers. Conclusion: Professionals working with this population must be sensitive to the ways these experiences impact young people's identity development processes, their health, and well-being. Haitian caregivers should be encouraged to protect their children by engaging in racial and socioethnic socialization that validates their RSD experiences. Implications: Understanding the intergenerational experiences of RSD among Black, immigrant groups and encouraging family dialogue and adolescent support will strengthen family cohesion during this period of racial reckoning.

Stress and Resilience: Key Correlates of Mental Health and Substance Use in the Hispanic Community Health Study of Latino Youth.

This study examined associations of immigrant generation, acculturation, and sources of stress and resilience with four outcomes-depression symptoms, anxiety symptoms, alcohol susceptibility, and smoking susceptibility. We used data from 1466 youth (ages 8-16) enrolled in the Hispanic Community Health Study of Latino Youth (SOL Youth), a probability sample of Hispanic/Latino youth living in Chicago (IL), Miami (FL), Bronx (NY), and San Diego (CA). We found no evidence of an immigrant paradox. Greater children's acculturative stress was associated with depression/anxiety symptoms; greater parent's acculturative stress was associated with smoking susceptibility. Family functioning and children's ethnic identity were associated with fewer depression/anxiety symptoms and lower alcohol/smoking susceptibility. Although acculturation-related stressors increase youths' risks for poor mental health and substance use, the development of positive ethnic identities and close, well-functioning family support systems can help protect Latino/Hispanic children from the negative behavioral and health-related consequences of stress.

Computer Informed and Flexible Family-Based Treatment for Adolescents: A Randomized Clinical Trial for at-Risk Racial/Ethnic Minority Adolescents.

Family interventions have been shown to be effective for adolescents with behavior problems. Current literature supports both adaptive treatments and technology-assisted interventions as highly promising innovations for treating at-risk adolescents. The purpose of this investigation was to develop and test the efficacy of a computer-assisted version of an established office-based multicomponent family therapy. Eighty Hispanic and Black Non-Hispanic adolescents and their families participated in the study and were randomized to either Immediate Computer-Assisted CIFFTA or Delayed Computer-Assisted CIFFTA. Significant between-groups effects were found from baseline to posttreatment showing the superiority of the Immediate CA CIFFTA condition on both the Conduct Disorder (B = -5.17, SE = 1.73, p < .01, CI [-8.55, -1.79]) and Socialized Aggression (B = -2.04, SE = .83, p < .05, CI [-3.67, -.41]) subscales of the Revised Behavior Problem Checklist, on the Youth Self Report Externalizing scale (B = -4.22, SE = 1.40, p < .01, CI [-6.95, -1.48]), and on both the parent (B = 1.34, SE = .50, p < .01, CI [.36, 2.32]) and adolescent (B = 1.31, SE = .46, p < .01, CI [.41, 2.21]) reports of the Family Environment Scale's family cohesion subscale. Baseline to 6-weeks posttreatment (T1-T3) analyses showed that these significant within-subjects effects were sustained for the treatment group. Results highlight that adolescent behavior problems can be significantly impacted by a computer-assisted intervention that replaces psychoeducational face-to-face meetings with computer-delivered modules.

The Comorbidity of Psychiatric and Substance Use Disorders Among Hispanic Adolescents.

OBJECTIVE: The comorbidity of psychiatric disorders and substance abuse disorders among adolescents and adults is well-documented in the literature. The current study investigates the relationship between psychiatric and substance use disorders in a sample of treatment-seeking Hispanic adolescents. METHODS: The study uses baseline data (N = 190) from a randomized control trial testing the effectiveness of a family-based treatment for Hispanic adolescents with substance abuse disorder to examine the relationship between psychiatric disorders and substance use patterns at baseline, including types of substances used (both lifetime use and past-month use) and age at onset of substance use, controlling for age and gender. RESULTS: Linear regression models were used to examine predictors of age at onset, while logistic regression models examined predictors of lifetime substance use. Significant findings predicting age at onset for marijuana and alcohol are discussed. In addition, psychiatric profiles were differentially associated with lifetime use of sedatives, stimulants, and hallucinogens, but not alcohol or marijuana. CONCLUSIONS: Findings from this study can be used to help inform the treatment of adolescents seeking mental health and substance use services.

Psychiatric Symptoms, Parental Attachment, and Reasons for Use as Correlates of Heavy Substance Use Among Treatment-Seeking Hispanic Adolescents.

In early adolescence, Hispanics self-report higher drug use rates compared to White and African American peers. Among adolescent users, heavy users have more negative behavioral and health consequences. The purpose of this cross-sectional study is to examine whether psychiatric symptoms, parental attachment, and reasons for use predict heavy alcohol and illicit drug use (more than 10 times in the past three months) among Hispanic adolescents. METHODS: This study examines baseline data from a study evaluating a family based substance abuse treatment program for Hispanic adolescents. Participants were 14-17 years old (N = 156, 44% female). Adolescent reports on the Diagnostic Interview Schedule for Children Predictive Scales measured psychiatric symptoms of major depressive disorder, attention deficit hyperactivity disorder, conduct disorder, and anxiety. The Personal Experiences Inventory measured type and amount of drug use, as well as perceived social and psychological benefits of drug use. The Inventory of Parent and Peer Attachment measured trust, communication, and alienation between adolescents and their mothers. Logistic regression identified correlates of heavy alcohol use and heavy illicit drug use among Hispanic adolescents. RESULTS: Higher social benefits were associated with increased likelihood of heavy alcohol use. Conduct disorder, higher levels of maternal attachment, lower levels of acculturation, and higher levels of psychological benefits of use were associated with an increased likelihood of heavy illicit drug use. CONCLUSION: These findings support the assumption that substance use treatment among Hispanic adolescents must be capable of addressing co-occurring psychiatric disorders, familial relationships, and the individual reasons/motivators to use.

Trauma in Hispanic youth with psychiatric symptoms: Investigating gender and family effects.

OBJECTIVE: Hispanic youth in the general community experience traumatic events and display symptoms of psychological distress more frequently than do Caucasian youth. However, little is known about how traumatic experiences in this ethnic minority population relate to psychopathology in clinical samples and whether these outcomes vary by gender and are impacted by family functioning. We hypothesized that traumatic stress reactions, including posttraumatic stress disorder (PTSD) and internalizing and externalizing symptoms, would vary by gender and by family functioning in a clinical sample of Hispanic youth. METHOD: The current study utilized baseline data from a randomized clinical trial (RCT) involving 200 Hispanic adolescents (122 boys and 78 girls) referred to treatment for experiencing clinical symptoms of 1 or more behavioral disorders and conflictual family relations. The rate of traumatic events, differences in outcomes depending on trauma exposure, and the effects gender, family functioning, and trauma on psychopathology and PTSD symptoms were examined. RESULTS: Analyses revealed that 61% of Hispanic youth in this clinical sample experienced at least 1 traumatic event. Although only 12% of the sample reported PTSD scores in the clinical range, girls reported higher PTSD scores than did boys. Poor family cohesion was particularly detrimental to girls compared with boys and related to internalizing and PTSD symptoms. High family conflict predicted PTSD symptoms in boys but not in girls. CONCLUSIONS: These findings have clinical implications for working with Hispanic populations, suggesting that culturally sensitive interventions should incorporate family-based interventions for individuals who experience trauma to strengthen family bonds and decrease family conflict. (PsycINFO Database Record

Structure of Problem Recognition Questionnaire with Hispanic/Latino Adolescents.

Motivation is a prominent target for substance use interventions because it is theorized to increase engagement in therapy and predict treatment outcomes. Establishing the validity of measures relevant to motivation among Hispanic/Latino adolescents will improve the resources available for screening and measuring change processes in a multicultural population. We examined the structure of the Problem Recognition Questionnaire (PRQ; Cady, Winters, Jordan, Solberg, & Stinchfield, 1996) with Hispanic/Latino adolescents. Participants were adolescents (n=191) in a randomized controlled trial for substance abuse. Data were collected during a baseline pre-treatment time point and post-treatment time point that was four-months post-baseline. Confirmatory factor analysis (CFA) showed that the three-factor structure proposed by Cady et al. (1996) had a poor fit with pre-treatment data. Follow-up exploratory analyses with principal axis factoring identified an alternate three-factor structure with pre-treatment data (problem recognition, readiness, and treatment resistance). A second CFA showed this three-factor model fit data from participants at the post-treatment time point (n=155). The results provide preliminary evidence for using our proposed factor structure for the PRQ subscales with Hispanic/Latino adolescents. We discuss the dimensions we identified in the context of similar measures and the implications for measuring problem recognition, readiness, and treatment resistance.

Factores que Influencian la Adquisición de Infecciones de Transmisión Sexual y VIH en Mujeres Jóvenes Chilenas que Participaron en la Intervención Online I-STIPI (Factors That Influence the Acquisition of Sexually Transmitted Infections and HIV in Chilean Young Women Who Participated in the Online Intervention I-STIPI).

The aim of this descriptive cross-sectional study was to investigate the following factors associated with sexually transmitted infections and human immunodeficiency virus prevention: (a) knowledge, (b) attitudes, (c) self-efficacy, (d) vulnerability, (e) risky behaviors, (f) preventive behaviors, and (g) internet use among 40 Chilean women between 18 and 24 years who participated in the pilot of an Internet based STI/HIV prevention intervention (I-STIPI). A structured questionnaire available in a secure website was used for data collection and it included questions related to STI and HIV prevention. The results of the study indicated that young women are at risk of acquiring STIs and HIV and have special needs for prevention. Familiarity and frequency of use of internet in this population can be used for STIs and HIV prevention.

A Latent Profile Analysis Investigating Factors Impacting Latino Adolescents' Attendance in Treatment.

In this study, we examined data from 200 families to investigate whether family functioning and adolescent psychiatric symptomatology were associated with differential attendance in a family-based or individually focused intervention for Latino adolescents. Latent profile analysis was used to identify families, and regression models were used to examine whether profiles exhibited differential attendance. Overall, three latent profiles were observed. The first described families where parents and adolescents reported discrepancies on psychiatric symptoms and family conflict. The second profile described families with elevated adolescent psychiatric symptoms but no family conflict. The third profile described families with low family cohesion and high levels of adolescent psychiatric symptoms. For this third profile, attendance in family-based treatment was significantly higher than in individual treatment. Results indicate that a family-based intervention may be better able to address issues of poor family cohesion.

A process-oriented analysis of parent acculturation, parent socio-cultural stress, family processes, and Latina/o youth smoking and depressive symptoms.

Latina/o youth in the U.S. are often characterized by elevated rates of cigarette smoking and depressive symptoms, and these rates appear to vary by youth acculturation and socio-cultural stress. Scholars suggest that parents' cultural experiences may be important determinants of youth smoking and depressive symptoms. However, few studies have examined the influence of parent acculturation and related stressors on Latina/o youth smoking and depressive symptoms. To address this gap in the literature, in the current study we investigated how parent-reported acculturation, perceived discrimination, and negative context of reception affect youth smoking and depressive symptoms through parent reports of familism values and parenting. The longitudinal (4 waves) sample consisted of 302 Latina/o parent-adolescent dyads from Los Angeles (N = 150) and Miami (N = 152). Forty-seven percent of the adolescent sample was female (M age = 14.5 years), and 70% of the parents were mothers (M age = 41.10 years). Parents completed measures of acculturation, perceived discrimination, negative context of reception, familism values, and parenting. Youth completed measures regarding their smoking and symptoms of depression. Structural equation modeling suggested that parents' collectivistic values (Time 1) and perceived discrimination (Time 1) predicted higher parental familism (Time 2), which in turn, predicted higher levels of positive/involved parenting (Time 3). Positive/involved parenting (Time 3), in turn, inversely predicted youth smoking (Time 4). These findings indicate that parents' cultural experiences play important roles in their parenting, which in turn appears to influence Latino/a youth smoking. This study highlights the need for preventive interventions to attend to parents' cultural experiences in the family (collectivistic values, familism values, and parenting) and the community (perceived discrimination).

The efficacy of two adolescent substance abuse treatments and the impact of comorbid depression: results of a small randomized controlled trial.

OBJECTIVE: The purpose of this randomized trial was to investigate the efficacy of 2 behavioral treatments focusing on different change mechanisms in ameliorating a borderline personality disorder constellation of behaviors and substance use in adolescents referred by juvenile diversion programs. METHODS: Forty adolescents 14-17 years of age and meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for borderline personality disorder and substance use disorders were randomized to integrative borderline personality disorder-oriented adolescent family therapy (I-BAFT) or individual drug counseling. This design allowed a comparison of 2 manualized interventions, 1 family based and 1 individually oriented. Profiles of clinical change were used to detect impact and estimate treatment effect sizes. RESULTS: Primary analyses showed that both interventions had a clinically significant impact on borderline personality disorder behaviors 12 months after baseline but with no differential treatment effects. The impact on substance use was more complex. Subgroup analyses revealed that adolescents with depression had significantly more severe profiles of borderline personality disorder and substance use. These youths were the only group to show reductions in substance use, but they only did so if they received the I-BAFT intervention. Study data also documented the high dosage of intensive residential treatment needed by this population. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Results highlight the intensive treatment needs of juvenile justice-involved youths with co-occurring substance use and borderline personality disorder including depression, the hybrid outpatient and residential treatment often required by this population, and the promise of a family-oriented approach, particularly for youths with severe symptoms and co-occurring depression. (PsycINFO Database Record

Pilot testing an internet-based STI and HIV prevention intervention with Chilean women.

PURPOSE: The incidence of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) is high among young Chilean women, and there are no STI or HIV prevention interventions available to them that incorporate technology. The purpose of this study was to investigate the preliminary efficacy of an Internet-based STI and HIV prevention intervention (I-STIPI) for Chilean young women on measures of STI- and HIV-related information, motivation, behavioral skills, and preventive behaviors. DESIGN: This is a pretest-posttest study. Forty young Chilean women between 18 and 24 years of age participated in an investigation of the I-STIPI's preliminary efficacy on STI and HIV prevention-related outcomes between baseline and a postintervention assessment. The intervention consisted of four online modules. Data collection was conducted in Santiago, Chile. Paired-samples t test analysis was used to determine whether there were significant differences in each of the outcome variables. FINDINGS: After receiving I-STIPI, women reported a significant increase in levels of STI- and HIV-related knowledge, attitudes toward the use of condoms and perceived self-efficacy, and a reduction of risky sexual behaviors with uncommitted partners. CONCLUSIONS: The I-STIPI showed promise as an Internet-based intervention that can reduce barriers to accessing preventive interventions and increase STI and HIV preventive behaviors in young Chilean women. CLINICAL RELEVANCE: The study provided important information about the ability of an Internet-based intervention to reduce young women's risk factors and to provide positive preliminary efficacy on STI- and HIV-related outcomes. Internet-based interventions can eliminate many barriers to receiving prevention interventions and may prove to be cost effective.

Self-harm among Hispanic adolescents: investigating the role of culture-related stressors.

PURPOSE: Suicide is the third leading cause of death among adolescents. Research shows Hispanic adolescents report disproportionate rates of both suicidal ideation and attempts. The purpose of the present study was twofold. First, the present study aimed to document the presence of suicidal ideation and self-harm behavior in a large heterogeneous sample of Hispanic adolescents. Second, this study sought to identify specific and unique culturally relevant stressors that were associated with the higher self-reported suicidal thoughts and self-harm among Hispanic males and females separately. METHODS: Data were collected on 1,651 Hispanic adolescents who completed the Hispanic Stress Inventory-Adolescent Version. RESULTS: Results of both rates and culture-related stressors that associated with the high rates of suicidal ideation are presented. Of the eight subscales measured in the Hispanic Stress Inventory-Adolescent, four subscales were predictive of either suicidal ideation or self-harm. For males, Acculturation Gap Stress was associated with suicidal thoughts and Discrimination Stress was associated with both suicidal thoughts and self-harm behavior. For females, Family Drug Stress was associated with suicidal thoughts. Acculturation Gap Stress, Family Drug Stress, and Immigration Stress were all significantly associated with self-harm behaviors. CONCLUSIONS: Findings are discussed as they inform future culturally competent prevention interventions and future research studies.

Theoretical foundations of the Study of Latino (SOL) Youth: implications for obesity and cardiometabolic risk.

PURPOSE: This article describes the conceptual model developed for the Hispanic Community Health Study/Study of Latino Youth, a multisite epidemiologic study of obesity and cardiometabolic risk among U.S. Hispanic/Latino children. METHODS: Public health, psychology, and sociology research were examined for relevant theories and paradigms. This research, in turn, led us to consider several study design features to best represent both risk and protective factors from multiple levels of influence, as well as the identification of culturally relevant scales to capture identified constructs. RESULTS: The Socio-Ecological Framework, Social Cognitive Theory, family systems theory, and acculturation research informed the specification of our conceptual model. Data are being collected from both children and parents in the household to examine the bidirectional influence of children and their parents, including the potential contribution of intergenerational differences in acculturation as a risk factor. Children and parents are reporting on individual, interpersonal, and perceived organizational and community influences on children's risk for obesity consistent with Socio-Ecological Framework. CONCLUSIONS: Much research has been conducted on obesity, yet conceptual models examining risk and protective factors lack specificity in several areas. Study of Latino Youth is designed to fill a gap in this research and inform future efforts.

Engagement, retention, and abstinence for three types of opioid users in Florida.

Prescription opioid use has grown rapidly, but few studies examined whether users have similar treatment responses as heroin users. Participants were 1,648 opioid users in Florida Access to Recovery (2004-2007). Participants engaged in methadone or buprenorphine maintenance had better retention than those in nonmaintenance treatment. Heroin only users (HO) had better engagement in nonmaintenance treatments and had worse retention than prescription opioid only users (PO). In methadone maintenance, PO were more likely to report opioid abstinence during treatment than heroin and prescription opioid users (H&P). Future research should focus on understanding and improving the treatment experience of opioid use subgroups.

Beyond acculturation: an investigation of the relationship of familism and parenting to behavior problems in Hispanic youth.

In the adolescent research literature, acculturation processes have been linked to the development of serious behavior problems in Hispanic adolescents, but not enough is known about how that process takes place. This article reports an investigation that sought to shed light on empirically plausible mechanisms by which family processes (i.e., familism and parenting practices) may operate as mediators of acculturation-related factors on adolescent problem behaviors among 167 Hispanic sixth- or seventh-grade early adolescents. SEM analyses identified an empirically plausible mediated pathway through which parenting practices may operate as a mediator of the effects of acculturation-related variables on adolescent problem behaviors. Second, although the role of familism as a mediator was not supported, the results did provide support for familism having indirect effects on behavior problems also through parenting practices. The findings are discussed in the context of existing research and clinical developments in the treatment of Hispanic adolescents and families.

Bridging Diversity and Family Systems: Culturally Informed and Flexible Family Based Treatment for Hispanic Adolescents.

There is growing interest in identifying interventions that have been tested and found efficacious with minority families. This interest is fueled in part by the growth of Hispanics in the U.S. as well as by research findings that suggest that Hispanics have better outcomes when treatments are adapted to their unique experiences, and risk and protective factors. Family-based treatments for culturally diverse populations require the integration of advances from both the cultural and family systems domains. Current intervention research has begun to move towards developing and advancing individualized interventions for patients/clients. Adaptive interventions, tailored interventions, adapted interventions, and targeted interventions have all been identified in the literature as appropriate for addressing distinct cultural characteristics which generic interventions may not address effectively. To date, research has focused less on tailored or adaptive interventions partly due to the fact that they require decision rules, more careful implementation, and measurement of individualized outcomes. In this article we present evidence for the usefulness of adaptive interventions that can address not only subgroup variability but within group variability as well. Culturally Informed and Flexible Family-Based Treatment for Adolescents is presented as an adaptive treatment that allows for the tailoring of treatment to the unique clinical and cultural variations of individual adolescents and families, but that does so in a systematic and replicable fashion. By building decision-making processes into the manualized treatment, the transportability of the treatment may be enhanced as family therapists appreciate it's flexibility to address the complexity of clinical work.