How to Assess Whether Outpatient Treatment Is Successful

¶ … gathered using a number of key word searches and combinations of terms, such as "adolescent," "substance abuse," "treatment," "drug," "outcome," "drug abuse, "juvenile drug abusers," juvenile drug use," "juvenile drug treatment," "adolescent drug treatment," and "adolescent drug use." These key word searches were conducted in online databases such as PsychInfo, PubMed, NCBI, JSTOR, National Institute of Mental Health, National Criminal Justice Reference Service, and Google Scholar. These searches resulted in a number of studies that appeared useful for this analysis.

The five chosen were chosen because of common key words and their relevance to this study's focus on if adolescent males with substance disorder are given inpatient treatment instead of outpatient treatment whether they will have a greater chance of maintaining their sobriety. Description and Technique Article Branson, Clemmey, and Mukherjee (2013). This study is a sample size 48 adolescents with roughly half Latino and half African-American, male and female.

Treatment was outpatient only so is helpful only in so far as it is able to give some background on outpatient therapies and their success rates. The focus of the study is on reducing attrition by incorporating text message reminders of therapy sessions to patients. The study found that text messages reduced attrition rates. Also, only 4% of the sample did not receive text messages throughout the duration of the trial due to phone complications.

The comparability of the groups in the study is that it consists mainly of minorities, who are all receiving outpatient treatment, so the focus is tight. They are different after treatment in that there is a higher rate of success (completion) due to text message reminders. Pretest attrition rates are in the 40%ile, while post-test attrition rates are much better with completion being in the 60%ile range. The demographic of the study is largely homogenous in that it consists of minority population (African-American and Latino).

There was negligible attrition in the trial sample. Hawthorne's effect was not taken into consideration as there was no mention of it in the study. The reliability and validity of the measures used in the study are substantial: there is no significant temporal validity other than the one study of the sample, in which a 7-month span passed for the trial study to be complete. Thus, the temporal framework is 7 months.

The criterion and construct are valid, with the outcome signifying that text messaging does reduce attrition and the construct validity does show that appropriate inferences can be made about the usefulness of text message reminders in getting youths to complete outpatient treatment. The external validity of this study may be more than meets the eye as it could indicate that one key to increasing outpatient treatment success rate is to use the tools of the young generation, cell phones, to remind them of their need to attend treatment.

Text message is a simple way to send that message, which conveys a sense of care that the recipient can sense even in such a simple way. This may relate to the problem of the adolescent male substance abuser in that it provides a "way into" the user's life and gives the support needed to offer a "way out" of the substance abuse. Article 2: Esposito-Smythers, Spirito, Kahler, Hunt and Monti (2011). This study examines CBT protocol as treatment for adolescents with substance abuse disorder and suicidality. The sample is randomized.

The study is a clinical trial. Treatments were integrated outpatient CBT. Results showed that outpatient treatment was successful in reducing suicide attempts, inpatient stays, emergency visits, as well as arrests. Adolescents had reduced suicidal ideation as well as reduction in alcohol and marijuana use. Groups are comparable in age and ethnicity, with the overwhelming majority (80%ile) Caucasian. There is no baseline heterogeneity, as sample is mainly homogenous and treatment is similar and sample users have same dependencies. Pre-treatment, patients show higher suicidality; post-treatment this risk is reduced.

The demographic of the group does not appear to be a concern of the researchers and there is no indication of attrition or of consideration given to the Hawthorne effect. The temporal validity of the study may be of some use considering the time frame used and the essence of the study's impact, which focuses on CBT outpatient treatment, an applicable therapy for adolescents.

The appropriateness of inferences regarding construct validity appear accurate and the criterion validity is consistent as variables match outcomes and CBT appears to be a model with applicability to the subject. The study has external validity in that it can be used as a basis for further research, which the researchers advocate in their concluding remarks, as they point out that they cannot say with certainty that integrated CBT is the main reason for successful outcomes or whether other outpatient treatments would be as effective.

For this study, it showed to be so, but more research must be conducted in order to bear this out. Article 3: Friedman, Terras, and Ali (1998). This study is an outpatient sample of 70% male participants, collected randomly from cities in four states (Ohio, Texas, Pennsylvania, Oregon) and the inpatient sample is half male-hale female percentile. Pre-test, participants were assessed using ADAD and post-test as well. Study was conducted in order to test prognosticators and variable predictors.

Results showed that less than half of variables were effective in predicting outcomes in either outpatient or inpatient cases of adolescent substance users seeking treatment. The variables were based on 157 historical cases of adolescent inpatient substance users and 296 historical cases of adolescent outpatients seeking treatment. The groups were heterogenous and there were signs of baseline heterogeneity in that several variables produced different results across the board, such as age, gender, attribution, therapy. The demographics were not considered as significant given the random sample size.

And the study showed no sign of attrition awareness of consideration for the Hawthorne effect. The outcome criterion validity was a reduction in substance use. Of the variables, 12 were helpful in predicting inpatient outcome, 15 in predicting outpatient outcome. Two variables were equally bad in predicting outcome in both inpatient and outpatient outcome -- school and failure to view substance use as detrimental.

Prognosticators were also not the same for adolescents as historically seen for adults, which indicates that the study may have some external validity as a basis point for future research. The example given in the study is that increased substance use in follow-up sessions was a predictor in adults of increased substance use at admission -- but in adolescents this showed to be the case only for outpatients. The study has external validity in that it creates a framework for predictive variables that may be of use in the field.

For example, assumptions that schooling (education) and positive/negative associations with substance abuse would be indicators of outcomes showed to be misleading and there was no correlation between the two. This is a strength of the study. One weakness of the study's external validity is its weakness in methodology in that treatment phases were not homogenous and samples and focus of the study was too wide to produce any substantial findings.

More research must be conducted in order to corroborate findings, but the study serves as a useful starting point in understanding predictors. Article 4: Waldron, Slesnick, and Brody (2001). This study is a randomized sample involved in a clinical trial used to assess different forms of therapy -- CBT, family therapy, combined individual and family, and group intervention. The sample size was 114 adolescents who were substance users.

This study focuses primarily on outpatient therapy so does not give any reference to inpatient treatment although it does recognize that "treatment outcomes may differ for youths in inpatient" settings. The sample was heterogenous with Anglo Americans and Hispanic-Americans, although the majority were Anglos and the study may be not have much external validity in terms of applying un-acculturated Hispanics, African-Americans, Native Americans or other minorities.

The groups are comparable in terms of substance use (marijuana) but more research is needed in terms of identifying effective treatment modalities, as numerous modalities were used in this study. Hawthorne's effect was not taken into consideration as there was no mention of it in the study. Thus, the reliability of this study is hampered by its inclusion of several modalities and its validity is kept in a narrow window in terms of substance and sample.

Likewise, the treatment sessions per each case were not equal, which is a limitation in terms of construct validity and temporal validity. Inferences made, however, appear to be appropriate and with the proper associations, so there is some construct validity to this study. The problem with this study's external validity is that it only examines outpatient treatment, with a majority of the sample being Anglo and English speaking Hispanic-Americans. It may allow a research to make generalizations about this demographic adolescent male substance user.

The strength of this study's external validity is that it is focused on one substance and not on several. But again it does allows several treatment modalities which can alter the tightness of the study's usefulness for generalizations. Article 5: Williams, Chang, and Addiction Centre Adolescent Research Group (2000). This study is a comprehensive and comparative review of studies performed on the treatment provided to adolescents suffering from substance abuse. The sampling probability is systematic in nature and therefore indicative of a tight-focus of outcomes related to patient treatments.

The study finds that most available research is not strong in the methodological department. Those that are strong indicate that the majority of adolescents who are treated for substance abuse go on to show decreased usage of substances with a concomitant drop-off in life problems as a result in the immediate year after the end of the treatment program. The studies yield an average rate of non-substance usage for sustained period of 6 months to be 38% (range, 30-55) and slightly lower at 32% for period of 12 months (range, 14-47).

Variables typically related to positive outcome of treatment are: completion of treatment, a low usage level of substances prior to treatment (the more heavily the individual uses, the harder it is for treatment to work), and the support structure of friends/family/peers in terms of keeping the patient away from the usage of substances. These are the most consistent factors in determining positive outcome.

The overall results of the studies suggest that any treatment is better than no treatment at all but there is not enough evidential support for a sufficient comparison of the different types of treatments; thus, the study cannot say which treatment is superior or why. One exception can be made, which is that the studies do indicate that outpatient family therapy is the best form of outpatient treatment because it includes the patient and the support structure, which is crucial for forming the basis of a positive outcome.

Thus, the internal validity of the study is strong as it maintains consistency in terms of its analysis of variables. Inconsistent methodology is used in the studies as time frames are not standardized with some evaluations occurring at the end of treatment with others being evaluated post-treatment up to 6 years. Typical evaluation occurs at 6-month and 12-month points post-treatment. The definition of "success" also varies from one study to the other.

Methods of reporting of success are also weak, as completion of treatment phase in and of itself is often viewed as success. The reliability of this study is in its systematic review of other studies: there is temporal validity in its examination of the 48 studies from several years; there is reliability validity as it serves as systematic review; there is criterion validity as its criteria is fully recognized, and there is construct validity as it provides a total qualitative review of the studies.

The strength of the external validity of the study is evident in its ability to produce generalized inferences about the state of literature on adolescent substance abuse: there needs to be more consistency and stronger methodology, as is seen in the way in which studies' reports are kept, for the sake of better accuracy and understanding of success rates of adolescent substance use treatment phases.

Critique of the Most Robust Article The most robust study is the systematic review of Williams, Chang and the Addiction Centre Adolescent Research Group (2000) because it provides an extensive overview of the positives and negatives of research conducted in the field of adolescent substance abuse and the effects of treatment modalities.

The most notable feature of the study is its emphasis on the need for tighter or strong methodologies as those used in the majority of studies do not provide consistent frameworks, time studies, treatment phases, sample groups, demographic particulars, or follow-up conclusions. The study is also important because it stresses the need for better definition of terms within studies so that what is meant by key words like "success rate" can be better understood and have more external validity.

As it stands, there is too much room for interpretation and leeway regarding words, meanings and contextual interpretations. The study also notes that there are consistent variables in predicting outcomes that need to be paid closer attention, such as actual completion of treatment as opposed to attrition rates. Completion of treatment as well as types of treatment are areas that this study shows require more focus.

In relation to the question of whether inpatient or outpatient treatments are more successful, the study offers little insight because its main purpose is to view the adequacy of the literature in this field, whereas the question posed here is more detailed and specific to a precise modality -- which is essentially what the study advocates: greater precision and tighter methodology.

Thus, the study offers a good basis of support for investigating the question and it also offers a substantial guide for erecting the framework for the study because it examines a number of previous studies and critiques them with respect to what they do poorly and what they do well. In this sense, the study is robust because it acts as a guide for future researchers in terms of providing research guide posts.

Part of the problem of not being able to make any concrete determinations about which is better, inpatient or outpatient treatment, or which therapy is the best.