Program Profile: Family Therapy for Adolescent Behavior Problems

This program assessed the impact of a nonmanualized family-based treatment approach for adolescent behavior problems. The program is rated Ineffective. Results indicated that the treatment group experienced statistically significant reductions in adolescent-reported externalizing and internalizing behaviors. However, there were no statistically significant differences between groups in caregiver-reported externalizing and internalizing behaviors or in adolescent-reported alcohol or drug use.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

This program used an experimental trial to assess the effectiveness of a family-based treatment approach that targets adolescent conduct problems, delinquency, and substance use and aims to improve family functioning (i.e., problem-solving, communication, attachment) and to decrease adolescent problem behaviors. Manualized family therapy models (for example, Functional Family Therapy or Multisystemic Therapy) have an extensive set of quality assurance procedures to support high-fidelity implementation, such as lengthy treatment manuals, standardized training toolkits, and specific guidelines for ongoing training. However, these models often are not feasible in community-based settings because of high cost, low flexibility, and low sustainability (Hogue et al., 2015). For these reasons, this experiment was conducted to establish whether a nonmanualized model of family therapy is a viable alternative to treat adolescent problem behaviors. The goal was to determine whether a nonmanualized version of family therapy would produce better outcomes (i.e., reduced adolescent problem behaviors) and improve treatment attendance (attributable to caregiver participation), compared with nonfamily treatment approaches.

To be eligible to participate, the primary caregiver and adolescent had to be willing to participate in treatment, and the adolescent had to meet criteria for some form of mental health or substance use disorder based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV–TR; American Psychiatric Association, 2000). Participants were identified from adolescents referred from family service agencies or community programs to outpatient clinical settings (i.e., community mental health clinics, outpatient psychiatry clinics, and drug counseling centers).

Program Components

Families attended a community mental health clinic that provided structural–strategic family therapy as the standard-of-care approach for youth behavioral interventions. Family therapy was facilitated by licensed Marriage and Family Therapists, social workers with family therapy training, or advanced trainees with family therapy experience. Staff also included site supervisors, who were all trained in the structural–strategic orientation (Minuchin and Fishman, 1981). Although several models use this approach (e.g., Functional Family Therapy, Multidimensional Family Therapy, Multisystemic Therapy), common features across all models include intervening directly with family members to repair intrafamilial relationships and addressing problems in the key extrafamilial systems within which family members live and develop.

Signature therapy techniques include convening multiple family members in most sessions, specifying family-based treatment goals, working to bring about in-session change in family interaction patterns to decrease emotional negativity, increasing positive attachments and communication and improving family problem-solving, and intervening with caregivers to improve parenting skills. Depending on the needs of the family, therapy sessions can include individual and group sessions and tend to be offered on a weekly basis.

Study

Hogue and colleagues (2015) conducted a randomized trial to test the impact of Family Therapy on adolescent conduct problems, delinquency, and substance use. Participants were youth from inner-city areas of a large northeastern city, who were referred for services from high schools, family service agencies, and community programs in the area. To be included in the study, adolescent participants had to 1) be between ages 12–18; 2) be willing to participate in treatment along with a primary caregiver; 3) not be enrolled in any other behavioral treatment; 4) have a family whose health benefits met the requirements of study treatment sites, and 5) meet criteria for either the mental health (MH) or substance use (SU) study track. Adolescents were placed in the MH track if they met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV–TR; American Psychiatric Association, 2000) diagnostic criteria for either oppositional defiant disorder or conduct disorder. They were placed in the SU track if they 1) reported at least 1 day of alcohol use to intoxication or illegal drug use in the past 30 days, 2) had one or more DSM-IV-TR symptoms of alcohol or substance dependence/abuse, and 3) met criteria for outpatient SU treatment. Youth who met criteria for both tracks were placed in the SU track.

Randomization to study condition was conducted at the completion of baseline interviews and based on four variables: ethnicity (Hispanic, African American, other), sex, juvenile justice involvement (yes or no), and study track (MH or SU). Participants were randomly assigned to either 1) Usual Care-Family Therapy (UC-FT), a single community mental health clinic that practiced nonmanualized, structural-strategic family therapy as the routine standard of care for youth behavior problems and featured licensed Marriage and Family Therapists (MFTs) (treatment group); or 2) a Usual Care-Other (UC-Other) control group, which consisted of five treatment sites typically known for treating problem behaviors (e.g., community mental health clinics, outpatient psychiatry clinics, and drug counseling centers) offering a full spectrum of therapeutic services normally available to adolescent clients, including cognitive–behavioral therapy or motivational interviewing. None of the sites in the UC-Other condition conducted family therapy as a routine intervention, nor did they contain a supervisor or staff therapist who reported being a licensed MFT. All six study sites were outpatient clinical settings that accepted referrals and were easily accessible via public transportation.

Of the 205 study participants, 104 were assigned to the UC-FT group, and 101 to the UC-Other group. Overall, 52 percent of the sample were male. The average age of participants was 15.7 years. More than half (59 percent) were Hispanic, 21 percent were African American, 15 percent were multiracial, and 6 percent were other. Caregivers included 171 biological mothers, 7 biological fathers, 4 adoptive parents, 1 stepparent, 2 foster parents, 12 biological grandmothers, and 8 other relatives. In terms of household composition, 66 percent were headed by single parents, 26 percent by two parents, 6 percent by grandparents, and 2 percent by some other combination. However, the only statistically significant difference between the UC-FT treatment group and the UC-Other control group was that control group participants were more likely to have a household member involved in illegal activities.

The outcomes of interest were 1) adolescent- and parent-reported internalizing and externalizing behaviors, and 2) adolescent-reported substance use and delinquency. Analyses were conducted using a two-study condition by four repeated measures intent-to-treat design. Study condition (UC-FT versus UC-Other) and study track (MH versus SU) were used to test the initial status of each outcome of interest and any change over time. A latent growth curve model was used to assess adolescent and caregiver reports of externalizing and internalizing behaviors, which were measured using the Child Behavior Checklist and the Youth Self Report. A two-part growth model was used to assess delinquency and substance use, using the National Youth Survey Self-Report Delinquency Scale and the Timeline Follow Back Method. Outcomes were measured at baseline and at 3, 6, and 12 months. The study authors did not conduct subgroup analyses.

Usual Care-Family Therapy (UC-FT) treatment group therapists (n = 14) were licensed marriage and family therapists (MFTs), social workers with family therapy training, or advanced trainees with family therapy experience. Site supervisors were trained in the structural-strategic orientation (Minuchin and Fishman 1981). All therapists received regular in-house training and supervision to promote family-based case conceptualization and use of structural-strategic FT treatment techniques. Alternatively, there were no Usual Care-Other (UC-Other) control group sites that had a supervisor or staff therapist who reported being a licensed marriage and family therapist or completing a postgraduate training program in family therapy (Hogue et al. 2015).

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.: American Psychiatric Association.

Henderson, Craig E., Aaron Hogue, and Sarah Dauber. 2019. “Family Therapy Techniques and One-Year Clinical Outcomes Among Adolescents in Usual Care for Behavior Problems.” Journal of Consulting and Clinical Psychology 87(3):308–12.

Hogue, Aaron, and Sarah Dauber. 2013. “Assessing Fidelity to Evidence-Based Practices in Usual Care: The Example of Family Therapy for Adolescent Behavior Problems.” Evaluation and Program Planning 37:21–30.

Hogue, Aaron, Sarah Dauber, and Craig E. Henderson. 2014. “Therapist Self-Report of Evidence-Based Practices in Usual Care for Adolescent Behavior Problems: Factor and Construct Validity.” Administration and Policy in Mental Health 41(1):1–21.

Hogue, Aaron, Sarah Dauber, and Craig E. Henderson. 2017. “Benchmarking Family Therapy for Adolescent Behavior Problems in Usual Care: Fidelity, Outcomes, and Therapist Performance Differences.” Administration and Policy in Mental Health 44:626–41.

Hogue, Aaron, Sarah Dauber, Emily Lichvar, Molly Bobek, and Craig E. Henderson. 2015. “Validity of Therapy of Self-Report of Fidelity to Evidence-Based Practices for Adolescent Behavior Problems: Correspondence between Therapists and Observers.” Administration and Policy in Mental Health 42(2):229–43.

Minuchin, Salvador, and H. Charles Fishman. 1981. Family Therapy Techniques. Cambridge, Mass.: Harvard University Press.