Safety and Efficacy of Exposure-Based Risk Reduction Through Family Therapy for Co-occurring Substance Use Problems and Posttraumatic Stress Disorder Symptoms Among Adolescents: A Randomized Clinical Trial
Open accessAbstract
Importance: No empirically supported treatments have been evaluated to address co-occurring substance use problems (SUP) and posttraumatic stress disorder (PTSD) symptoms among adolescents in an integrative fashion. This lack is partially owing to untested clinical lore suggesting that delivery of exposure-based PTSD treatments to youth with SUP might be iatrogenic. Objective: To determine whether an exposure-based, integrative intervention for adolescents with SUP and PTSD symptoms-risk reduction through family therapy (RRFT)-resulted in improved outcomes relative to a treatment-as-usual (TAU) control condition consisting primarily of trauma-focused cognitive behavioral therapy. Design, Setting, and Participants: This randomized clinical trial enrolled 124 participants who were recruited from November 1, 2012, through January 30, 2017. Adolescents (aged 13-18 years) who engaged in nontobacco substance use at least once during the past 90 days, experienced at least 1 interpersonal traumatic event, and reported 5 or more PTSD symptoms were enrolled. Blinded assessments were collected at baseline and at 3, 6, 12, and 18 months after baseline. Recruitment and treatment took place in community-based child advocacy centers in the Southeastern United States. Data were analyzed from August 2 through October 4, 2018, and were based on intention to treat. Interventions: Participants were randomized to receive RRFT (n = 61) or TAU (n = 63). Main Outcomes and Measures: Primary outcomes focused on number of nontobacco substance-using days measured with the timeline follow-back method and PTSD symptom severity using the UCLA (University of California, Los Angeles) PTSD Reaction Index for DSM-IV completed by adolescents and caregivers. Secondary outcomes focused on marijuana, alcohol, and polysubstance use and PTSD criterion standard (re-experiencing, avoidance, and hyperarousal) symptom severity. Results: In all, 124 adolescents (mean [SD] age, 15.4 [1.3] years; 108 female [87.1%]) were randomized. For primary outcomes relative to TAU, RRFT yielded significantly greater reductions in substance-using days from baseline to month 12 (event rate [ER], 0.28; 95% CI, 0.12-0.65) and month 18 (ER, 0.10; 95% CI, 0.04-0.24). Significant reductions in PTSD symptoms were observed within groups for RRFT from baseline to months 3 (β = -9.25; 95% CI, -12.95 to -5.55), 6 (β = -16.63; 95% CI = -20.40 to -12.87), 12 (β = -17.51; 95% CI, -21.62 to -13.40), and 18 (β = -19.02; 95% CI, -23.07 to -14.96) and for TAU from baseline to months 3 (β = -9.62; 95% CI, -13.16 to -6.08), 6 (β = -13.73; 95% CI, -17.43 to -10.03), 12 (β = -15.53; 95% CI, -19.52 to -11.55), and 18 (β = -13.88; 95% CI, -17.69 to -10.09); however, between-group differences were not observed. Conclusions and Relevance: In this study, RRFT and TAU demonstrated within-group improvements in SUP and PTSD symptoms, with greater improvement for substance use and PTSD avoidance and hyperarousal symptoms among adolescents randomized to RRFT compared with TAU. No evidence of the worsening of SUP was observed in either condition. These results suggest that this exposure-based treatment is safe, feasibly delivered by community-based clinicians, and offers an effective approach to inform clinical practice. Trial Registration: ClinicalTrials.gov Identifier: NCT01751035.
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The largest and highest-quality study in this literature was a randomized trial of 124 middle adolescents, mostly girls, comparing RRFT, an integrated SUD and exposure-based PTSD treatment, with TF-CBT.
“The largest and strongest quality study in the current literature is an RCT of middle adolescents (n=124, Mage=15.4, 87% girls) that compared RRFT, an integrated SUD and exposure-based PTSD treatment (described above), to TF-CBT [29].”
From Interventions for prevention and treatment of substance use in youth with traumatic childhood experiences: a systematic review and synthesis of the literature (2024) · cites this paper as [29]
The Abstract reports an RCT of 124 adolescents (mean age 15.4 years; 87.1% female) comparing integrated, exposure-based RRFT with treatment as usual consisting primarily of TF-CBT. The Discussion calls it the first full-scale RCT in this area, but the paper does not assess whether it was the highest-quality study in the literature; the comparator was not exclusively TF-CBT. (LLM, conf=0.86)
Experimental — accuracy not yet measuredExposure therapy was the focus of only two interventions, RRFT and D-CPT; these trials had robust sustained PTSD outcomes and reported no adverse effects of exposure therapy, despite detailed monitoring, when exposure components followed an extensive safety and skill-building phase.
“Although exposure therapy was only the focus of two interventions (i.e., RRFT and D-CPT), these trials had robust sustained PTSD outcomes and did not report any adverse effects of exposure therapy, despite detailed monitoring, when exposure components were preceded by an extensive safety and skill-building phase [29, 55].”
From Interventions for prevention and treatment of substance use in youth with traumatic childhood experiences: a systematic review and synthesis of the literature (2024) · cites this paper as [29]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredOf the existing treatment literature, RRFT provides the strongest evidence for treatment of co-occurring trauma-related symptoms and substance use disorder, having a rigorous design and significant outcomes 18 months after treatment.
“Of the existing treatment literature, RRFT provides the strongest evidence for treatment of co-occurring trauma-related symptoms and SUD, having a rigorous design and significant outcomes 18-months after treatment [29].”
From Interventions for prevention and treatment of substance use in youth with traumatic childhood experiences: a systematic review and synthesis of the literature (2024) · cites this paper as [29]
The Discussion describes this as the first full-scale randomized trial of integrated exposure-based treatment for adolescents with co-occurring substance use problems and PTSD symptoms. The results report significant substance-use and some PTSD symptom outcomes at 18 months, but the assessments were 18 months after baseline, not 18 months after treatment. The paper does not establish that RRFT has the strongest evidence across the broader treatment literature, and overall PTSD symptom improvement did not differ significantly from treatment as usual. (LLM, conf=0.88)
Experimental — accuracy not yet measuredOnly two of the ten intervention randomized controlled trials were rated strong in global quality, while others were limited by low retention rates and use of substance use outcome measures without well-documented reliability and validity.
“Only two of the ten intervention RCTs were rated “strong” global quality [29, 54], while others were limited by low retention rates and use of SU outcome measures without well documented reliability and validity.”
From Interventions for prevention and treatment of substance use in youth with traumatic childhood experiences: a systematic review and synthesis of the literature (2024) · cites this paper as [29]
The Abstract identifies this paper as a randomized clinical trial, and Strengths and Limitations describes rigorous methods and high retention (109 of 124 participants). The paper does not itself report a “strong” global-quality rating or establish that two of ten intervention trials received that rating; those are assessments made by the citing document. (LLM, conf=0.79)
Experimental — accuracy not yet measuredTF-CBT may be used less often in youth with co-occurring SUDs because clinicians worry that exposure-based therapy could destabilize them.
“TF-CBT may be underutilized among youth with co-occurring SUDs, due to clinical hesitations that exposure-based therapies may destabilize patients with co-occurring SUDs [20, 29].”
Two other manualized models integrated family and individual CBT interventions for SUD and ID, including posttraumatic stress disorder, and a handful of studies have examined brief interventions targeting both SU and ID in adolescents.
“Two other manualized models [25-27] integrated family and individual CBT interventions for SUD and ID, including posttraumatic stress disorder; a handful of studies have examined brief interventions targeting both SU and ID in adolescents [28].”
From Family Support Protocol for Adolescent Internalizing Disorders: Protocol for a Pre-Post Quantitative Treatment Development Study (2024) · cites this paper as [27]
Reported adverse effects included no adverse events in RRFT, discomfort in the group format of WHC due to privacy and stigma concerns, and increased use of as-needed medication following the residential-based Turning the Tides group intervention.
“these included no adverse events in RRFT [29], discomfort in group format of WHC due to concerns about privacy and stigma [59], and increased use of as needed medication following the residential-based Turning the Tides group intervention [61].”
From Interventions for prevention and treatment of substance use in youth with traumatic childhood experiences: a systematic review and synthesis of the literature (2024) · cites this paper as [29]
Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.
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- Authors
- Danielson, C. K., Adams, Z., McCart, M. R., Chapman, J. E., Sheidow, A. J., Walker, J., Smalling, A., & de Arellano, M. A.
- Affiliations
- Medical University of South Carolina (US)
- Indiana University Indianapolis (US)
- Oregon Social Learning Center (US)
- Dee Norton Child Advocacy Center, Charleston, South Carolina
- Department of Psychiatry & Behavioral Sciences, National Crime Victims Research & Treatment Center, Medical University of South Carolina, Charleston
- Corresponding author
- Danielson, Carla Kmett
- ORCID
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2020-06-01
- Volume
- 77
- Issue
- 6
- Pages
- 574
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC7042939
- OpenAlex
- W3005001166
- Cited by
- 51
- References
- 46
- Citations by year
- 2026: 9 · 2025: 8 · 2024: 8 · 2023: 8 · 2022: 7 · 2021: 6 · 2020: 4 · 2019: 1
- FWCI
- 2.50
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Psychiatry (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- IUScholarWorks (Indiana University) (submittedVersion)
- Funders
- National Institute of Mental Health (R01MH112209)
- National Institute on Drug Abuse (K23DA038257, R01DA031285, K24DA039783)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Keywords
- post-traumatic stress disorder, problematic substance use, adolescents, family therapy, exposure therapy, trauma-focused cognitive behavioral therapy, integrative therapy, cannabis use, alcohol consumption, polydrug use, PTSD symptom severity, treatment safety, iatrogenic disease, child advocacy centers, interpersonal trauma
- MeSH terms
- Adolescent, Family Therapy, Female, Humans, Implosive Therapy, Male, Stress Disorders, Post-Traumatic, Cognitive Behavioral Therapy, Substance-Related Disorders, Risk Reduction Behavior
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