Concurrent Treatment of Substance Abuse, Child Neglect, Bipolar Disorder, Post-Traumatic Stress Disorder, and Domestic Violence: A Case Examination Involving Family Behavior Therapy

Nathan H. Azrin: A Case Study in Research Translation in Behavior Science

Nathan H. Azrin (1930-2013) contributed extensively to the fields of experimental and applied behavior analysis. His creative and prolific research programs covered a wide range of experimental and applied areas that resulted in 160 articles and several books published over a period of almost 6 decades. As a result, his career illustrates an unparalleled example of translational work in behavior analysis, which has had a major impact not only within our field, but across disciplines and outside academia. In the current article we present a summary of Azrin's wide ranging contributions in the areas of punishment, behavioral engineering, conditioned reinforcement and token economies, feeding disorders, toilet training, overcorrection, habit disorders, in-class behavior, job finding, marital therapy, and substance abuse. In addition, we use scientometric evidence to gain an insight on Azrin's general approach to treatment evaluation and programmatic research. The analysis of Azrin's approach to research, we believe, holds important lessons to behavior analysts today with an interest in the applied and translational sectors of our science.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40614-020-00278-4.

Cognitive-Behavioral Treatment of PTSD With a Young Boy and His Mother Following the Experience of Chronic Domestic Violence

This case study follows a 7-year-old boy who presented with symptoms of posttraumatic stress disorder (PTSD) following exposure to domestic violence beginning at a very young age. During evaluation of this young boy’s symptoms, it became evident that his mother also was experiencing symptoms of PTSD. Consequently, treatment for both this young boy and his mother was proposed. Cognitive-behavioral therapy (CBT) has been used widely with both children and adults to treat PTSD. Fortunately, treatments have been tailored for young children (e.g., trauma-focused CBT [TF-CBT]; preschool PTSD treatment [PPT]) and for adults (e.g., cognitive processing therapy [CPT]). In the current case study, a combination of PPT and TF-CBT was utilized to treat this young boy, and CPT was utilized to treat his mother. With this course of treatment, this young boy demonstrated decreases in his PTSD symptoms and gained an understanding of coping skills and cognitive restructuring. His mother also demonstrated decreases in her PTSD symptoms. Overall, this dyad showed qualitative improvements in their general emotional and behavioral functioning, their individual self-regulation abilities, their social interactions, and their relationship. This case study provides evidence for the importance of treating both young child and parent when both have been exposed to and traumatized by domestic violence. Furthermore, this case study provides a framework for other health service providers to implement conjoint treatment of similarly traumatized families.

A scoping review of evidence-based interventions available to parents of maltreated children ages 0-5 involved with child welfare services

Parents referred to child welfare services for child maltreatment often struggle against chronic risk factors including violence, substance abuse, mental health concerns, and poverty, which impinge upon their ability to be sensitive caregivers. The first line of intervention within the child welfare context is to modify parenting behavior. This scoping review comprehensively surveyed all available literature to map the extent and range of research activity around the types of interventions available within a child welfare context to parents of infants and toddlers (0-5 years of age), to identify the facilitators and/or barriers to the uptake of interventions, and to check that interventions match the risk factors faced by parents. This scoping review engaged in stringent screening of studies based upon inclusion/exclusion criteria. Sixty-five articles involving forty-two interventions met inclusion criteria. Interventions generally aimed to improve parenting practices, the relationship between parent and child, and/or attachment security, along with reducing child abuse and/or neglect. A notable finding of this scoping review is that at present, interventions for parents of children ages 0-5 involved with the child welfare system are most frequently measured via case study and quasi-experimental designs, with randomized control trials making up 26.2% of included study designs.

Interventions to address parenting and parental substance abuse: conceptual and methodological considerations

Parental substance abuse is a serious problem affecting the well-being of children and families. The co-occurrence of parental substance abuse and problematic parenting is recognized as a major public health concern. This review focuses on 21 outcome studies that tested dual treatment of substance abuse and parenting. A summary of theoretical conceptualizations of the connections between substance abuse and parenting provides a backdrop for the review. Outcomes of the dual treatment studies were generally positive with respect to reduction of parental substance use and improvement of parenting. Research in this area varied in methodological rigor and needs to overcome challenges regarding design issues, sampling frame, and complexities inherent in such a high-risk population. This area of work can be strengthened by randomized controlled trials, use of mixed-methods outcome measures, consideration of parent involvement with child protective services, involvement of significant others in treatment, provision of concrete supports for treatment attendance and facilitative public policies.

A controlled evaluation of family behavior therapy in concurrent child neglect and drug abuse

OBJECTIVE

Approximately 50% of child protective service (CPS) referrals abuse drugs; yet, existing treatment studies in this population have been limited to case examinations. Therefore, a family-based behavioral therapy was evaluated in mothers referred from CPS for child neglect and drug abuse utilizing a controlled experimental design.

METHOD

Seventy-two mothers evidencing drug abuse or dependence and child neglect were randomly assigned to family behavior therapy (FBT) or treatment as usual (TAU). Participants were assessed at baseline, 6 months, and 10 months postrandomization.

RESULTS

As hypothesized, intent-to-treat repeated measures analyses revealed mothers referred for child neglect not due to their children being exposed to illicit drugs demonstrated better outcomes in child maltreatment potential from baseline to 6- and 10-month postrandomization assessments when assigned to FBT, as compared with TAU mothers and FBT mothers who were referred due to child drug exposure. Similar results occurred for hard drug use from baseline to 6 and 10 months postrandomization. However, TAU mothers referred due to child drug exposure were also found to decrease their hard drug use more than TAU mothers of non-drug-exposed children and FBT mothers of drug-exposed children at 6 and 10 months postrandomization. Although effect sizes for mothers assigned to FBT were slightly larger for marijuana use than TAU (medium vs. large), these differences were not statistically significant. Specific to secondary outcomes, mothers in FBT, relative to TAU, increased time employed from baseline to 6 and 10 months postrandomization. Mothers in FBT, compared to TAU, also decreased HIV risk from baseline to 6 months postrandomization. There were no differences in outcome between FBT and TAU for number of days children were in CPS custody and alcohol intoxication, although FBT mothers demonstrated marginal decreases (p = .058) in incarceration from baseline to 6 months postrandomization relative to TAU mothers.

CONCLUSION

Family-based behavioral treatment programs offer promise in mothers who have been reported to CPS for concurrent substance abuse and child neglect of their children. However, continued intervention development in this population is very much needed.

A Culturally Sensitive Approach to Treating Substance Abuse in Athletes Using Evidence-Supported Methods

Substance abuse in athletes is both prevalent and dangerous, leading to its international recognition as a public health concern. In recent controlled trials, behavioral prevention programs have been shown to reduce alcohol use in collegiate student athletes who are at-risk for alcohol abuse, with outcomes appearing to be enhanced when family members are prescriptively involved. However, no interventions have been found to decrease alcohol or drug use frequency in controlled trials involving athletes who have been diagnosed with substance abuse, and no prescribed clinical interventions for substance abuse have been tailored to accommodate the unique needs of competitive athletes. As an initial step in this development, we review an evidenced-supported behavioral treatment program modified for use with athletes. Optimizing the support of significant others, this innovative treatment approach comprehensively targets multiple areas of mental health while emphasizing cultural enlightenment. Recommendations are offered, including the great need for controlled treatment outcome research specific to substance abuse in athletes.

Incorporating a Healthy Living Curriculum within Family Behavior Therapy: A Clinical Case Example in a Woman with a History of Domestic Violence, Child Neglect, Drug Abuse, and Obesity

Women reported to child protective service agencies frequently report problems that significantly interfere with the health and well-being of their children and themselves. Behavioral treatment programs appear to be effective in managing these co-existing problems, such as domestic violence and substance abuse. However, evidence-supported interventions are rarely exemplified in complicated clinical cases, especially within child welfare settings. Therefore, in this case example, we describe the process of adapting an evidence-supported treatment to assist in managing significant co-existing health-related problems in a mother who was referred due to child neglect and drug abuse. At the conclusion of therapy, the participant reported improvements in perceived family relationships, illicit drug use, child maltreatment potential, whereas other health-related outcomes were mixed. Most improvements were maintained at 4-month follow-up. Issues relevant to implementing evidence-based treatments within community contexts are discussed, including methods of increasing the likelihood of valid outcome assessment, managing treatment integrity, and adjusting standardized treatments to accommodate co-occurring problems.