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.

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.

The Community Reinforcement Approach: History and New Directions

This article provides an overview of 2 closely linked treatment approaches for the substance abusing client: The Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT). In 1973, Hunt and Azrin created CRA in an attempt to restructure an individual’s “community” so that a sober lifestyle was more rewarding than one dominated by alcohol. One salient CRA premise was that an individual’s substance abuse recovery was heavily influenced by his or her social and occupational environment. Sisson and Azrin (1986) later built upon this premise in their work with a new type of client; the loved one of an alcoholic individual who refused to enter treatment. This program was an early version of CRAFT, which is an intervention that works through a nonusing individual to affect the behavior of a substance abuser. This article provides an empirical review of the evolution of these 2 interventions, including their application to illicit drug using clients. It also outlines the clinical procedures that comprise CRA and CRAFT, and considers future research directions.

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.

The community reinforcement approach to the treatment of substance use disorders

Empirical support is presented for the Community Reinforcement Approach (CRA), a broad-spectrum cognitive-behavioral treatment for substance use disorders. At the core of CRA is the belief that an individual's environment can play a powerful role in encouraging or discouraging drinking and drug use. Consequently, it attempts to rearrange contingencies so that sober behavior is more rewarding than substance-abusing behavior. Originally tested in the early 1970s with a small sample of alcohol-dependent inpatients, it has repeatedly proven to be successful over the years with larger, diverse populations. Empirical backing is also presented for a new variant of CRA that works through family members to engage treatment-resistant individuals into substance abuse treatment.

Bleak and hopeless no more. Engagement Of reluctant substance-abusing runaway youth and their families

Runaway/homeless shelters document high levels of substance abuse among runaway youth, at least double that of school youth. These youth present a constellation of problems and research suggests that this population may be unique in the range and intensity of associated problems. Most studies to date have collected self-report data on these youth; virtually no research has examined treatment effectiveness with the population. Given the void of treatment outcome research with these youths, there is need for identifying potent interventions. Given that issues of engagement and retention must assume prominence in the development of new treatments, this article presents a family-based treatment engagement strategy successfully employed with a sample of substance-abusing youth staying in a southwestern shelter. Youth and primary caretakers are engaged separately by the therapist utilizing motivating factors appropriate to context of the families' lives and to the developmental position of the client.

Community reinforcement and family training (CRAFT): engaging unmotivated drug users in treatment

Although motivation for drug abuse treatment is a substantial problem, unilateral intervention through concerned significant others (CSOs) represents a promising method for engaging unmotivated individuals. The Community Reinforcement and Family Training (CRAFT) program, based on principles of reinforcement was developed for this specific purpose. In Phase I, CSOs received the CRAFT intervention, whereby they were taught skills for modifying a loved one's drug-using behavior and for enhancing treatment engagement. CSOs were evaluated at 3 and 6 months. In Phase II, engaged drug users received treatment using the Community Reinforcement Approach (CRA). A total of 62 CSOs participated in this evaluation of the effectiveness of CRAFT. CSOs completed, on average, 87% of offered treatment sessions. During the 6-month study period, 74% succeeded in engaging their resistant loved one in treatment. Reported abstinence both from illicit drugs and alcohol increased significantly for drug users engaged in treatment, but not for unengaged cases. All CSOs showed significant reduction in depression, anxiety, anger, and physical symptoms, with average scores dropping into the normal range on all measures. CRAFT provides a promising alternative to confrontational and detachment approaches in counseling CSOs to help their loved ones.

Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members

In a randomized clinical trial, 130 concerned significant others (CSOs) were offered 1 of 3 different counseling approaches: (a) an Al-Anon facilitation therapy designed to encourage involvement in the 12-step program, (b) a Johnson Institute intervention to prepare for a confrontational family meeting, or (c) a community reinforcement and family training (CRAFT) approach teaching behavior change skills to use at home. All were manual-guided, with 12 hr of contact. Follow-up interviews continued for 12 months, with 94% completed. The CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment (64%) as compared with the more commonly practiced Al-Anon (13%) and Johnson interventions (30%). Two previously reported aspects of the Johnson intervention were replicated: that most CSOs decide not to go through with the family confrontation (70% in this study) and that among those who do, most (75%) succeed in getting the drinker into treatment. All 3 approaches were associated with similar improvement in CSO functioning and relationship quality. Overall treatment engagement rates were higher for CSOs who were parents than for spouses. On average, treatment engagement occurred after 4 to 6 sessions.

Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members

In a randomized clinical trial, 130 concerned significant others (CSOs) were offered 1 of 3 different counseling approaches: (a) an Al-Anon facilitation therapy designed to encourage involvement in the 12-step program, (b) a Johnson Institute intervention to prepare for a confrontational family meeting, or (c) a community reinforcement and family training (CRAFT) approach teaching behavior change skills to use at home. All were manual-guided, with 12 hr of contact. Follow-up interviews continued for 12 months, with 94% completed. The CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment (64%) as compared with the more commonly practiced Al-Anon (13%) and Johnson interventions (30%). Two previously reported aspects of the Johnson intervention were replicated: that most CSOs decide not to go through with the family confrontation (70% in this study) and that among those who do, most (75%) succeed in getting the drinker into treatment. All 3 approaches were associated with similar improvement in CSO functioning and relationship quality. Overall treatment engagement rates were higher for CSOs who were parents than for spouses. On average, treatment engagement occurred after 4 to 6 sessions.

The community-reinforcement approach

The community-reinforcement approach (CRA) is an alcoholism treatment approach that aims to achieve abstinence by eliminating positive reinforcement for drinking and enhancing positive reinforcement for sobriety. CRA integrates several treatment components, including building the client's motivation to quit drinking, helping the client initiate sobriety, analyzing the client's drinking pattern, increasing positive reinforcement, learning new coping behaviors, and involving significant others in the recovery process. These components can be adjusted to the individual client's needs to achieve optimal treatment outcome. In addition, treatment outcome can be influenced by factors such as therapist style and initial treatment intensity. Several studies have provided evidence for CRA's effectiveness in achieving abstinence. Furthermore, CRA has been successfully integrated with a variety of other treatment approaches, such as family therapy and motivational interviewing, and has been tested in the treatment of other drug abuse.

The community reinforcement approach with homeless alcohol-dependent individuals

Homeless alcohol-dependent individuals were randomly assigned to receive either a behavioral intervention (i.e., the Community Reinforcement Approach [CRA]) or the standard treatment (STD) at a large day shelter. Ninety-one men and 15 women participated. The majority of participants were White (64%), but both Hispanic (19%) and Native American (13%) individuals were represented as well. Overall, the decline in drinking levels from intake through follow-ups was significant. As predicted, CRA participants significantly outperformed STD group members on drinking measures across the 5 follow-ups, which ranged from 2 months to 1 year after intake. Both conditions showed marked improvement in employment and housing stability.

The community reinforcement approach with homeless alcohol-dependent individuals

Homeless alcohol-dependent individuals were randomly assigned to receive either a behavioral intervention (i.e., the Community Reinforcement Approach [CRA]) or the standard treatment (STD) at a large day shelter. Ninety-one men and 15 women participated. The majority of participants were White (64%), but both Hispanic (19%) and Native American (13%) individuals were represented as well. Overall, the decline in drinking levels from intake through follow-ups was significant. As predicted, CRA participants significantly outperformed STD group members on drinking measures across the 5 follow-ups, which ranged from 2 months to 1 year after intake. Both conditions showed marked improvement in employment and housing stability.

Getting off the fence: procedures to engage treatment-resistant drinkers

Historically there have been few options for individuals seeking help for treatment-resistant loved ones with substance abuse problems. This article describes a program with empirical backing called Community Reinforcement and Family Training (CRAFT). This cognitive-behavioral treatment teaches the concerned significant other how to use behavioral principles to reduce the loved one's drinking and to encourage the drinker to seek treatment. Additionally it assists the concerned significant other in alleviating other types of stress and in introducing meaningful reinforcers into his or her own life.

Are reconstructed self-reports of drinking reliable?

When follow-up interviews are missed, researchers sometimes try to reconstruct the data that would have been obtained by asking clients to recall the missed interval when they are interviewed at a later point. Are such data reliable? The reliability of remote reconstruction was estimated by asking 57 participants in a clinical trial to recall their drinking for the 12-month follow-up interval when interviewed, on average, 33 weeks later. These reports were obtained after delays averaging 231 days. These reconstructed reports were compared with the same clients' self-reports obtained during the 12-month interview. Reconstructed data were found to be reasonably accurate estimates of clients' reports at the time of original interview on global alcohol use variables including percentage of drinking days and total volume of consumption. No systematic bias was found for over-reporting or under-reporting at the point of reconstruction. However, on some variables (e.g. total drinks consumed), clients on average reported more drinking at the reconstruction period than during the initial interview. Discrepancies between initial and reconstructed reports were found to be unrelated to the length of delay in the second interview or to client characteristics.

Intramuscular head and neck myxoma: report of a case and review of the literature

Intramuscular myxoma of the head and neck is a rare lesion with only six cases documented in the literature. The tumor demonstrates a benign clinical course without a tendency to recur and is occasionally associated with fibrous dysplasia. It thus deserves to be considered in a separate class from other soft tissue myxomas. The seventh case of a head and neck intramuscular myxoma is presented and the clinical, pathological, and CT characteristics of this tumor are reviewed.

Prevalence of dental caries and dental fluorosis in areas with negligible, optimal, and above-optimal fluoride concentrations in drinking water

The prevalence of dental caries and dental fluorosis was assessed in 1,123 children aged 8 to 16 years who were lifelong residents of areas with negligible, optimal, and above-optimal concentrations of natural fluoride in drinking water. Caries prevalence in the optimal fluoride area was 38.1% lower than it was in the negligible fluoride area, and, in the higher-than-optimal fluoride areas, even greater caries protection was evident. Caries protection was compromised in children with severe fluorosis. Findings do not support the contention that definite increases in the prevalence of fluorosis are occurring in communities with negligible and optimal water-fluoride concentrations because of increased total fluoride consumption from various sources.

Combined fluoride, school-based program in a fluoride-deficient area: results of an 11-year study

In 1972, a school-based fluoride program was initiated in elementary schools in Nelson County, VA, a fluoride-deficient area. For 11 years, participating children ingested daily in school a 1-mgm fluoride tablet and rinsed weekly with a .2% sodium fluoride solution. They also received fluoride dentifrice and toothbrushes for home use. The program was extended into junior high school in 1978 and into high school in 1980. In 1983, dental examinations of children aged 6 to 17 years, who had continuously participated in the program for 1 to 11 years depending on school grade, showed a mean prevalence of 3.12 DMFS, which was 65% lower than the corresponding score of 9.02 DMFS for children of the same ages at the baseline examinations. The preventive program inhibited decay in all types of surfaces: 54% in occlusal surfaces; 59% in buccolingual surfaces; and 90% in mesiodistal surfaces.

Eight-year evaluation of a combined fluoride program in a nonfluoride area

The purpose of this study is to measure the long-term effects of a combination of self-applied fluoride methods among schoolchildren living in a rural area with low concentrations of fluoride in drinking water. Participating children rinse weekly with a 0.2% sodium fluoride solution and ingest daily a 1-mg fluoride tablet in school under supervision of their teachers, and received fluoride toothpaste and toothbrushes for use at home. In 1980, dental examinations of children ages 6-14, who had continuously participated in the program for 1 to 8 years, depending on their school grade, had an overall mean caries prevalence of 3.22 DMFS, 49% lower than the corresponding mean score of 6.31 DMFS for children of the same ages at the baseline examination. The preventive program inhibited decay in all types of tooth surfaces: 37% in occlusal, 41% in buccolingual, and a striking 86% in mesiodistal. At each succeeding follow-up survey, benefits have continued to improve; the reductions in caries prevalence were 18% after 2 years, 35% after 4 years, 45% after 6 years, and 49% after 8 years. Findings in approximal tooth surfaces have also continued to improve as the length of the program has increased; reductions in caries in mesiodistal surfaces were 32%, 69%, 85%, and 86% after 2,4,6, and 8 years, respectively. Internal analyses of data indicate that the decline in dental caries prevalence resulted from the fluoride program and not from an unexplained natural decline in caries prevalence. The self-applied combined fluoride regimen used in this program has been shown to produce a pronounced anticaries effect.

A new method for assessing the prevalence of dental fluorosis--the Tooth Surface Index of Fluorosis

A new index for measuring the prevalence of dental fluorosis, the Tooth Surface Index of Fluorosis (TSIF), was used to assess the condition in the permanent teeth of 807 children, aged 8 to 16, who had resided all their lives in one of seven Illinois communities with an optimal concentration of fluoride in its water or with 2, 3, or 4 times the optimal concentration. Fluorosis was absent in 84.5% of all tooth surfaces examined in the community with optimal fluoride. In contract, only 31.9% of tooth surfaces had no fluorosis in the community with 4-times the optimal fluoride level. In the optimal fluoride area, 79% of facial surfaces of maxillary anterior teeth, which are esthetically conspicuous, had no fluorosis, whereas only 15.8% of these surfaces in the 4-times optimal area were unaffected. The percentages of all tooth surfaces affected by fluorosis characterized by staining, pitting, or both were 1%, 8%, 19%, and 38%, respectively, in communities with 1-, 2-, 3-, and 4- times optimal fluoride. Differences in fluorosis based on maximum score for all tooth surfaces in a child were statistically significant (an extended chi 2 statistic) among all communities. First molars and incisors in children 8 to 10 years old were affected by more fluorosis than were the same teeth in children 13 to 16 years old. These teeth had been erupted for about 5 years longer in the older age group. The difference might result from abrasion or remineralization of these teeth in the older children or from greater consumption of fluoride by the younger children during tooth development.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of dental caries and dental fluorosis in areas with optimal and above-optimal water fluoride concentrations

The prevalence of dental caries and dental fluorosis was assessed among 807 schoolchildren in four areas of Illinois where the respective water supplies contained natural fluoride at concentrations of 1, 2, 3, and 4 times the recommended optimal for the geographic area. Mean caries scores in all three above-optimal fluoride areas were significantly lower than in the optimal area. The prevalence of dental fluorosis was characteristically low in the optimal fluoride area. Substantial increases in fluorosis occurred in the above-optimal fluoride areas, with the condition being most pronounced in the 4-times optimal area.

A program self-administered fluorides in a rural school system

In 1972, a self-administered fluoride program was initiated in Nelson County, VA, a fluoride-deficient area. Children in elementary school (grades K-6) ingest daily a 1-mg fluoride tablet, rinse weekly with 0.2% NaF solution and receive fluoride dentifrice for home use. In 1978, dental examinations of elementary schoolchildren (ages 6-12) who had continuously participated in the program for 1 to 6 years showed a prevalence of 2.70 DMFS, 45% lower than the score of 4.89 DMFS for their cohorts at the baseline. The preventive program inhibited dental caries effectively in all types of surfaces, but the reduction in proximal surfaces of 85% is particularly striking. Findings of high school children (ages 13-17) in 1978, who had not participated in the elementary school program for 1-5 years, showed evidence of strong post-treatment effects. At each succeeding follow-up survey, benefits have continued to improve. For elementary school participants, benefits were 17.7% after 2 years, 35.3% after 4 years and 44.8% after 6 years. Weekly fluoride mouthrinsing and daily ingestion of a fluoride tablet are feasible school-based procedures for the prevention of dental caries. Combined with the use of a fluoride dentifrice at home, these procedures have a pronounced cariostatic effect.

Evaluation of a combination of self-administered fluoride procedures for the control of dental caries in a nonfluoride area: findings after four years

Nearly all children who attend elementary school (grades K through 6) in a rural community have participated since 1972 in a school-based caries preventive program consisting of daily ingestion of a 1-mg fluoride tablet and weekly rinsing with a 0.2% sodium fluoride solution. 3they also regularly receive toothbrushes and a fluoride dentifrice for use at home. Examinations conducted after four years showed that the prevalence of dental caries among continuous participants, 7 through 12 years of age, was reduced by 35% compared with baseline findings; mean DMFS scores in 1972 and 1976 were 5.39 and 3.49, respectively. The preventive program inhibited decay in all three types of surfaces: approximal surfaces received about twice the relative protection against decay (70%) as buccolingual surfaces (34%) and more than three times as much as occlusal surfaces (22%). A comparison of estimates of four-year increments of decay taken from cross-sectional data at the baseline and actual increments from the 1972 and 1976 examinations showed that, for children ages 6 through 15, the incremental DMFS score was 41% lower during the period of the program than before its initiation. Findings in older children (ages 13 through 15) in 1976 who had stopped participation when they left elementary school at about age 12 showed evidence of strong posttreatment effects--as great as 31% fewer DMFS for 14-year-old children.

Effect of acidulated phosphate-fluoride chewable tablets in schoolchildren: results after 55 months

Two groups of children initially in the first and second grades chewed, rinsed with, and swallowed an acidulated phosphate-fluoride tablet containing 1 mg of fluoride either once or twice a day in school. A control group of children followed the procedure once a day using a placebo tablet. An interim evaluation after 55 months showed that the children receiving two fluoride tablets daily had a significant reduction in incremental caries on early erupting teeth, which received primarily topical exposure to the fluoride, as well as on late erupting teeth, which received mainly preeruptive, systemic exposure. The findings also suggested that the use of a single fluoride table daily may reduce dental caries, although the presence of a benefit was less definitive than it was for the two-tablet procedure.