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Functional Family Therapy (FFT)

Functional Family Therapy (FFT)

A short-term family therapy intervention and juvenile diversion program helping at-risk children and delinquent youth to overcome adolescent behavior problems, conduct disorder, substance abuse, and delinquency.

Fact Sheet

Program Outcomes

  • Delinquency and Criminal Behavior
  • Illicit Drug Use

Program Type

  • Family Therapy
  • Gang Prevention and Reduction
  • Juvenile Justice, Other

Program Setting

  • Correctional Facility
  • Mental Health/Treatment Center
  • Social Services
  • Transitional Between Contexts

Continuum of Intervention

  • Selective Prevention
  • Indicated Prevention

Age

  • Early Adolescence (12-14) - Middle School
  • Late Adolescence (15-18) - High School

Gender

  • Both

Race/Ethnicity

  • All

Endorsements

Blueprints: Model
Crime Solutions: Effective
OJJDP Model Programs: Effective

Program Information Contact

Holly DeMaranville
FFT Communications Director
1251 NW Elford Dr.
Seattle, WA 98177
Phone: (206) 369-5894 - cell
Fax: (206) 453-3631
Email: hollyfft@comcast.net
Website: www.fftinc.com

Program Developer/Owner

James F. Alexander, Ph.D
University of Utah


Brief Description of the Program

Functional Family Therapy (FFT) is a short-term (approximately 30 hours), family-based therapeutic intervention for delinquent youth at risk for institutionalization and their families. FFT is designed to improve within-family attributions, family communication and supportiveness while decreasing intense negativity and dysfunctional patterns of behavior. Parenting skills, youth compliance, and the complete range of behaviors (cognitive, emotional, and behavioral) domains are targeted for change based on the specific risk and protective factor profile of each family. FFT should be implemented with a team of 3-8 master's level therapists, with caseloads of 10-12 families, with oversight by a licensed clinical therapist.

Outcomes

Studies across several locations demonstrated program benefits for recidivism among juveniles:

  • In a Utah study, FFT families showed significant improvement compared to no treatment and alternative treatment groups in rates of reoffense (26% versus 47%-73%), juvenile court records of siblings of targeted youth (20% versus 40%-63%), and recidivism among serious delinquent youth (60% versus 89%-93).
  • In an Ohio study, FFT families showed significant improvement compared to usual services in recidivism after 28 months (11% versus 67%) and after 60 months (9% versus 41%).
  • In a Swedish study with a 2-year follow-up, FFT families showed improvement compared to a usual-treatment group in recidivism (41% versus 82%) and in youth and parent reports of externalizing and internalizing symptoms.
  • In a Washington State study, FFT families who worked with a competent therapist showed significant improvement in 18-month recidivism (44% versus 50%-54%) compared to families in control groups or working with not competent therapists.
  • A meta-analysis of effect size for eight evaluations of FFT (Aos et al., 2011) reported an adjusted mean effect size of -.32.

Alexander & Parsons (1973) reported that compared to all comparison groups, both intervention group participants and their siblings had a significantly lower:

  • Recidivism rates

Gordon (1995); Gordon, Graves, & Arbuthnot (1995) reported that compared to the usual care comparison group, intervention group participants had significantly reduced:

  • Recidivism (posttest and follow-up)

Hansson, Cedarblad, & Hook (2000) reported that compared to the usual care comparison group, intervention group participants showed significant reductions in:

  • Recidivism (posttest and follow-up)

Waldron et al. (2001) reported that at posttest, but not at follow-up, intervention group participants showed significant reduction compared to the control group in:

  • Marijuana use (frequency)

Barnoski (2004) reported that after 18 months, compared to the control group, intervention group participants demonstrated a significant reduction in:

  • Felony recidivism (high adherence subgroup only)

Sexton & Turner (2010) reported that compared to the control group, intervention group participants demonstrated a significant reduction in:

  • Felony recidivism (high adherence subgroup only)

Friedman (1989) reported no main program effects.

Slesnick & Prestopnik (2009) reported that at posttest, compared to the usual care control group, intervention group participants reported significantly reduced:

  • Days of drug or alcohol use

Celinska. Furrer, & Cheng (2013), reported that at posttest, compared to the control group, intervention group participants demonstrated significantly greater improvement in:

  • Life domain functioning (program deliverer measure)
  • Child internalizing and externalizing behaviors (program deliverer measure)
  • Child risk behaviors (program deliverer measure)

Hansson et al. (2004) reported that over the 18 months after first program contact, compared to the matched comparison group, intervention group participants showed significantly reduced:

  • Recidivism

Gottfredson et al (2018) reported that after 18 months, compared to the control group, intervention group participants had significantly fewer:

  • New drug charges
  • Delinquent adjudications

Humayun et al. (2017) found no significant beneficial program effects.

Program effects on Risk and Protective Factors:

  • Improvements in family interaction patterns (Alexander & Parsons, 1973)
  • Maternal improvements (over time) on symptom checklists evaluating depression, anxiety, and somatization were significant for the FFT group only (Hansson, Cederblad, & Hook (2000)

Brief Evaluation Methodology

Study 1

Alexander & Parsons (1973) evaluated the program in a randomized controlled trial in which 99 delinquent adolescents and their families were randomized to the intervention group (n=46) or to one of three comparison groups: a no-treatment control group (n=10), a client-centered family therapy comparison group (n=19), or a psychodynamic family therapy comparison group (n=11). Administrative records were used to collect data on recidivism, defined as any new court referral, over an observation period lasting between 6 and 18 months after program completion. An analysis in Klein, Alexander, & Parsons (1977) examined siblings of the initial youth sample at 2.5-3.5 months after program completion.

Study 2

Barton et al. (1985) evaluated the program in a quasi-experimental design to compare 74 delinquent youth from a Utah juvenile facility to a comparison group constructed using simple matching. Data on frequency and severity of recidivism offenses over a 15-month observation period. In two additional studies, Barton et al. (1985) also examined effectiveness of the FFT model when performed by undergraduate paraprofessionals and when performed by state workers and probation officers.

Study 3

Gordon, Graves, & Arbuthnot (1995) examined FFT with 54 rural, low SES, Caucasian youth in Ohio using a quasi-experimental design with non-random assignment to groups (matched assignment with more severe cases assigned to FFT). Administrative data on recidivism were collected at 28- and 60-month follow-ups.

Study 4

Hansson, Cedarblad, & Hook (2000) tested the program in a randomized controlled trial where 89 delinquent Swedish youth and their families were assigned to either the intervention condition (n=49) or a usual treatment control group (n=40). Data on recidivism were collected at 12 and 24 months after program completion. Data on youth internalizing and externalizing behaviors were collected at pretest and a 2-year follow-up.

Study 5

Waldron et al. (2001) tested the program in a randomized controlled trial, where 120 delinquent New Mexico youth were randomly assigned to the FFT intervention group (n=30), an individual cognitive-behavioral therapy (CBT) comparison group (n=31), a combined FFT and CBT group (n=29), or a psychoeducational comparison group (n=30). Outcomes were frequency and intensity of marijuana use, measured at baseline, posttest, and 3-month follow-up.

Study 6

Barnoski (2004) evaluated the program in a randomized controlled trial where delinquent youth in Washington State were randomly assigned to the FFT intervention group (n=427) or a wait-list control group (n=323). Data on recidivism (all, felony only, violent felony) were collected at 6, 12, and 18 months after program completion.

Study 7

Sexton & Turner (2010) evaluated the program in a randomized controlled trial. Eligible delinquent youth from 917 families were stratified by county and then randomly assigned in equal proportions to the FFT intervention group or a probation-as-usual comparison group. The authors tested the moderating effects of therapist adherence and family risk/protective factors on felony and misdemeanor recidivism, with data collected for two years after program completion.

Study 8

Aos et al. (2011) conducted a meta-analysis of 8 studies of the FFT program.

Study 9

Friedman (1989) evaluated the program in a randomized controlled trial of adolescent drug abusers who were randomized to the FFT intervention group (n=85) or an alternate parent-focused comparison group (n=50). Outcomes included child internalizing/externalizing behaviors and behavioral problems, assessed at baseline and posttest (9 months after program completion).

Study 10

Slesnick & Prestopnick (2009) tested the program in a randomized controlled trial of runaway adolescents with alcohol problems in New Mexico. Participants were randomized to one of three conditions: an ecologically-based family therapy intervention condition (n=37), an office-based FFT intervention condition (n=40), or a usual care comparison group (n=42). Primary outcomes included substance use and psychological functioning, measured at baseline, posttest and two follow-ups occurring 6 and 15 months after baseline.

Study 11

Celinska, Furrer, & Cheng (2013) tested the intervention using a quasi-experimental design comparing youth with aggressive behavioral problems who were referred to either the FFT intervention group (n=36) or a usual care comparison group (n=36). Primary outcomes included behavioral problems and child internalizing/externalizing behaviors, measured at baseline and posttest.

Study 12

Hansson et al (2004) evaluated the program using a quasi-experimental design in one Swedish county. Participants were delinquent youth referred to the FFT intervention group (n=45) and a comparison group (n=43) constructed using simple matching. Administrative data on recidivism were collected for 18 months after baseline.

Study 13

Gottfredson et al. (2018) and Thornberry et al. (2018) evaluated the program in a randomized controlled trial that recruited participant families from one Philadelphia juvenile court. Participants were 129 delinquent adolescent males and their families, randomized into the FFT intervention group (n=66) or a treatment-as-usual family therapy comparison group (n=63). Primary outcomes of interest were delinquency/recidivism, substance use, and gang involvement. Self-report assessments occurred at baseline and 6 months post-randomization, while data on recidivism were collected from official sources for 18 months after randomization.

Study 14

Humayun et al. (2017) used a randomized controlled trial to examine youth criminal offenders ages 10-17 and their parents. A total of 111 families were randomly assigned to a treatment group receiving FFT plus management-as-usual services (N = 65) or to a control group receiving management-as-usual services only (N = 46). Youth were assessed at posttest (six months after assignment) and at one-year follow-up (18 months after assignment). Outcome measures included self-reported delinquency, official conviction, conduct disorder, oppositional defiant disorder, negative and positive behavior toward parents, and parenting quality.

Study 1

Alexander, J. F., & Parsons, B. V. (1973). Short-term behavioral intervention with delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 81, 219-225.


Study 13

Gottfredson, D. C., Kearley, B., Thornberry, T. P., Slothower, M., Devlin, D., & Fader, J. J. (2018). Scaling-up evidence-based programs using a public funding stream: A randomized trial of Functional Family Therapy for court-involved youth. Prevention Science, 1-15. doi 10.1007/s11121-018-0936-z


Risk Factors

Individual: Antisocial/aggressive behavior, Early initiation of antisocial behavior, Early initiation of drug use, Favorable attitudes towards antisocial behavior, Favorable attitudes towards drug use, Gang involvement, Hyperactivity, Rebelliousness, Substance use*

Peer: Interaction with antisocial peers, Peer substance use

Family: Family conflict/violence, Family history of problem behavior, Neglectful parenting, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use, Poor family management, Violent discipline

Protective Factors

Individual: Clear standards for behavior, Problem solving skills, Prosocial behavior, Prosocial involvement, Skills for social interaction

Peer: Interaction with prosocial peers

Family: Attachment to parents, Non-violent discipline, Opportunities for prosocial involvement with parents, Parent social support, Rewards for prosocial involvement with parents

See also: Functional Family Therapy (FFT) Logic Model (PDF)

FFT is designed for youth aged 11-18 at risk for, and/or presenting with, delinquency, violence, substance use, Conduct Disorder, Oppositional Defiant Disorder, or Disruptive Behavior Disorder. It has also been used for adolescents at risk for foster care placement.

Race/Ethnicity/Gender Details

FFT has been applied with a wide range of population demographics, with non-White youth representing 10-60 percent of the sample.

Training Certification Process

The primary goal of the FFT implementation and certification process is the successful replication of the FFT program as well as its long-term viability at individual community sites. The FFT Site Certification is a 3-phase process:

Phase 1 - Clinical Training: The initial goal of the first phase of FFT implementation is to impact the service delivery context so that the local FFT program builds a lasting infrastructure that supports clinicians to take maximum advantage of FFT training/consultation. By the end of Phase I, FFT's objective is for local clinicians to demonstrate strong adherence and high competence in the FFT model. Assessment of this goal is based on data gathered through the FFT Clinical Service System, FFT weekly consultations, and during phase I FFT training activities. Phase I should last between one year and 18 months. Periodically during Phase I, FFT personnel provide the site feedback to identify progress toward Phase I implementation goals. By the eighth month of implementation, FFT will begin discussions to identify steps toward starting Phase II of the Site Certification process.

Phase II - Supervision Training: The goal of the second phase of FFT implementation is to assist the site in creating greater self-sufficiency in FFT, while also maintaining and enhancing site adherence/competence in the FFT model. The essential goal of this phase is to develop competent on-site FFT supervision. During Phase II, FFT trains a site's extern to become the on-site supervisor. This person attends two 2-day supervisor trainings, and then is supported by FFT through monthly phone consultation. FFT provides one 1-day on-site training or regional training during Phase II. In addition, FFT provides any ongoing consultation as necessary and reviews the site's FFT CSS database to measure site/therapist adherence, service delivery trends, and outcomes. Phase II is a yearlong process.

Phase III - Practice Research Network: The goal of the third phase of FFT implementation is to move into a partnering relationship to assure ongoing model fidelity, as well as impacting issues of staff development, interagency linking, and program expansion. FFT reviews the CSS database for site/therapist adherence, service delivery trends, and client outcomes, and provides a one-day on-site training for continuing education in FFT.

Phase I "Clinical Training" Activities include:
STEP 1: One-day on-site implementation/assessment and CSS training. This initial visit covers implementation issues for both administration and staff. It includes: a 2-hour overview of best practices and the FFT clinical model for referral agents, stakeholders, funders, and agency staff. Additional time is spent in addressing site-specific implementation challenges (i.e., referral criteria, referral process, integration of services, working w/ referral agents, supervision, computers,etc.). The identified FFT team of clinicians is trained in the FFT Clinical Service System, including use of FFT software and assessment protocols.

STEP 2: Two-Day On-Site Clinical Training. The two-day on-site introduction covers the core constructs, phases, assessment and intervention techniques of FFT. Didactic materials include handouts and videotape examples.

STEP 3: Begin Cases (using FFT, the Assessment protocol, and the CSS).

STEP 4: Ongoing Telephone Supervision. Each team receives telephone supervision as a group for one hour per week. Supervision focuses particularly on individual cases and model adherence.

STEP 5: Externship. This intensive, hands on, training experience with actual clients includes supervision from behind the mirrored window. The externship consists of three separate training experiences for three consecutive months. The clinician expected to be trained in Phase Two as the on-site FFT supervisor typically attends this training.

STEP 6: Two-Day Follow-up Visits (3 per site during year 1). The three on-site follow-up training sessions, each of two days in duration, represent more specific focus on implementation issues and processes.

STEP 7: Two-Day Clinical Training. The entire FFT Clinical Team goes to an off-site location for additional team and individual training in the FFT model.

ONGOING: Implementation and Consultation
Implementation and consultation services are directed at helping sites implement FFT with respect to such issues as staff development, interagency linking, and program expansion.

Program Benefits (per individual): $28,951.00
Program Costs (per individual): $3,467.00
Net Present Value (Benefits minus Costs, per individual): $25,484.00
Measured Risk (odds of a positive Net Present Value): $96.00

Source: Washington State Institute for Public Policy All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.

Program Costs

Start-Up Costs

Initial Training and Technical Assistance

FFT brings a program to full functionality over three phases which generally last one year each. Start-up costs are incorporated in phase one of program development. Training is team based with an optimal team size of 5-6 therapists. The cost of phase one training and technical assistance is $36,000, plus an estimated $16,000 for travel for a total of $52,000. Some of these costs will be incurred after the program staff are trained and seeing clients.

Curriculum and Materials

All costs included in training and technical assistance costs above.

Licensing

All costs included in training and technical assistance costs above.

Other Start-Up Costs

Staff salaries during the training period and the cost of developing office space (more space will be needed if implementation is to be office-based).

Intervention Implementation Costs

Ongoing Curriculum and Materials

None.

Staffing

Qualifications: Therapists should have a master’s degree in psychology, social work or a related field. Supervisors must be licensed therapists.

Ratios: Trained supervisors can support up to eight clinicians. Full-time clinicians work with caseloads normally averaging 10-12 “active” cases at any given time.

Time to Deliver Intervention: Requires an average of 12 sessions over a three to four month period. Clinicians spend an average of 2. 5 – 3 hours per family per week for face to face contact, collateral services, travel, case planning and documentation.

Other Implementation Costs

Administrative overhead can be projected at 10-30%, again depending on program size and on where the intervention will occur (home vs. office).

Implementation Support and Fidelity Monitoring Costs

Ongoing Training and Technical Assistance

All costs to support an FFT team are included in the annual fees charged by the purveyor. In addition to the first year cost of $36,000 (plus $16,000 for travel) discussed under Start-Up Costs, year 2 cost is $18,000 (plus $3,500 for travel), and the cost for year 3 and beyond is $7,000 (plus $1,000 for travel) per year.

Fidelity Monitoring and Evaluation

The annual fee includes support for the Clinical Services System (CSS), a web-based application for tracking progress notes, completing assessments, and reporting outcomes in accordance with the model design.

Ongoing License Fees

See above.

Other Implementation Support and Fidelity Monitoring Costs

None.

Other Cost Considerations

The scale of an FFT program can affect costs, with multiple teams being able to take advantage of combined trainings and other required events for implementation. Some states have developed a statewide training process that can also reduce costs.

Year One Cost Example

First year operation of a program with 2 units of eight therapists and two supervisors with FFT conducted in the family home.

Equipment $20,000
Travel $20,000
Overhead at 10% of Staff Cost $144,000
Fringe at 30% $333,000
Staff – therapists (16 FTE) $960,000
Staff - supervisors (2 FTE Masters Clinician) $150,000
Start-up purveyor cost $52,000
Total Year One Cost $1,679,000

With therapist caseloads of 12 and supervisors seeing 5 youth/families and an average service length of 12 weeks, the program could serve approximately 600 youth/families. Average youth/family cost in this example would be $2,800.

Funding Strategies

Funding Overview

Functional Family Therapy, as a type of family therapy, is a prime candidate for Medicaid funding. When FFT is targeted at youth to be diverted from out-of-home placement, the avoided cost of such a placement is usually more than adequate to fund the FFT intervention. A variety of federal formula and discretionary funds are aligned with the program and offer potential sources of start-up funding.

Another option is debt financing. For example, a Social Impact Bond, can provide start-up and initial implementation funding. A Reinvestment Compact is another innovative mechanism to consider for start-up.

Funding Strategies

Improving the Use of Existing Public Funds

Reinvestment: FFT can be funded with money saved by diverting youth from expensive out-of-home placements in the juvenile justice, child welfare, or behavioral health systems into FFT to fund the intervention.

Allocating State or Local General Funds

Many states have chosen to fund FFT with general funds as part of a commitment to evidence-based practices and in an effort to achieve better outcomes for youth, particularly youth involved with the juvenile justice and child welfare systems. Some counties and cities have made additional contributions to fund the program.

Maximizing Federal Funds

Entitlements: Medicaid is an option for funding FFT as a family therapy. This approach requires the state to provide state matching funds, with the state share percentage set by the federal government. This option is limited to the Medicaid eligible portion of the population to be served. States have adopted a variety of different billing structures.

Formula Funds:

  • Juvenile Accountability Block Grant (JABG) Funds are focused on reducing juvenile offending through efforts that promote accountability, including providing effective early intervention through mental health screening and treatment.
  • Office of Juvenile Justice and Delinquency Prevention (OJJDP) Formula Funds support a variety of improvements to delinquency prevention programs and juvenile justice programs in states. Evidence-based programs are an explicit priority for these funds, which are typically administered on a competitive basis from the state administering agency to community-based programs.
  • The Mental Health Services Block Grant (MHSBG) can fund a variety of mental health promotion and intervention activities and is a potential source of support for FFT programs.
  • Title IV-B, Parts 1 & 2 provides fairly flexible funding to state child welfare agencies for child welfare services including prevention and family preservation activities.

Discretionary Grants: Such grants have mostly been used for start-up expenses for FFT programs. Relevant grants are administered by the federal Office of Juvenile Justice and Delinquency Prevention (OJJDP), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Children’s Bureau within the Administration for Children and Families.

Foundation Grants and Public-Private Partnerships

A number of states have used foundation grants to provide start-up funding for FFT programs. Foundations are not as good a source of ongoing implementation funding. A Reinvestment Compact is an example of a relevant public/private partnership, where private funding initiates an intervention such as FFT with the potential of saving money from the avoidance of a costly alternative. Savings are then used to sustain the intervention.

Debt Financing

Program Related Investments, Social Impact Bonds or Municipal Bonds can all potentially be used for start-up and initial implementation funding for programs such as FFT, which target cost avoidance for youth who would otherwise need an expensive alternative such as out-of-home placement. Savings from avoided costs would repay the investment as well as sustain the intervention.

Generating New Revenue

While difficult to put in place, establishing state or local funding streams dedicated to evidence-based services and/or mental health services can provide a fairly stable source of ongoing funding for programs. Special Tax Levies and Sin Taxes have been used to generate revenue for evidence-based mental health services.

Data Sources

All information comes from the responses to a questionnaire submitted by the purveyor, FFT, Inc., to the Annie E. Casey Foundation.

Evaluation Abstract

Program Developer/Owner

James F. Alexander, Ph.D University of Utah Department of Psychology 380 South 1530 East, Room 502 Salt Lake City, Utah 84112-0251 (801) 550-4131 jfafft@aol.com www.fftinc.com

Program Outcomes

  • Delinquency and Criminal Behavior
  • Illicit Drug Use

Program Specifics

Program Type

  • Family Therapy
  • Gang Prevention and Reduction
  • Juvenile Justice, Other

Program Setting

  • Correctional Facility
  • Mental Health/Treatment Center
  • Social Services
  • Transitional Between Contexts

Continuum of Intervention

  • Selective Prevention
  • Indicated Prevention

Program Goals

A short-term family therapy intervention and juvenile diversion program helping at-risk children and delinquent youth to overcome adolescent behavior problems, conduct disorder, substance abuse, and delinquency.

Population Demographics

FFT is designed for youth aged 11-18 at risk for, and/or presenting with, delinquency, violence, substance use, Conduct Disorder, Oppositional Defiant Disorder, or Disruptive Behavior Disorder. It has also been used for adolescents at risk for foster care placement.

Target Population

Age

  • Early Adolescence (12-14) - Middle School
  • Late Adolescence (15-18) - High School

Gender

  • Both

Race/Ethnicity

  • All

Race/Ethnicity/Gender Details

FFT has been applied with a wide range of population demographics, with non-White youth representing 10-60 percent of the sample.

Other Risk and Protective Factors

Family interaction patterns

Risk/Protective Factor Domain

  • Individual
  • Peer
  • Family

Risk/Protective Factors

Risk Factors

Individual: Antisocial/aggressive behavior, Early initiation of antisocial behavior, Early initiation of drug use, Favorable attitudes towards antisocial behavior, Favorable attitudes towards drug use, Gang involvement, Hyperactivity, Rebelliousness, Substance use*

Peer: Interaction with antisocial peers, Peer substance use

Family: Family conflict/violence, Family history of problem behavior, Neglectful parenting, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use, Poor family management, Violent discipline

Protective Factors

Individual: Clear standards for behavior, Problem solving skills, Prosocial behavior, Prosocial involvement, Skills for social interaction

Peer: Interaction with prosocial peers

Family: Attachment to parents, Non-violent discipline, Opportunities for prosocial involvement with parents, Parent social support, Rewards for prosocial involvement with parents

See also: Functional Family Therapy (FFT) Logic Model (PDF)

Brief Description of the Program

Functional Family Therapy (FFT) is a short-term (approximately 30 hours), family-based therapeutic intervention for delinquent youth at risk for institutionalization and their families. FFT is designed to improve within-family attributions, family communication and supportiveness while decreasing intense negativity and dysfunctional patterns of behavior. Parenting skills, youth compliance, and the complete range of behaviors (cognitive, emotional, and behavioral) domains are targeted for change based on the specific risk and protective factor profile of each family. FFT should be implemented with a team of 3-8 master's level therapists, with caseloads of 10-12 families, with oversight by a licensed clinical therapist.

Description of the Program

Functional Family Therapy (FFT) is a prevention/intervention program for youth who have demonstrated a range of maladaptive, acting out behaviors and related syndromes. Intervention services consist primarily of direct contact with family members, in person and telephone; however, services may be coupled with supportive system services such as remedial education, job training and placement and school placement. Some youth are also assigned trackers who advocate for these youth for a period of at least three months after release.

FFT should be implemented with a team of 3-8 master's level therapists, with caseloads of 10-12 families, with oversight by a licensed clinical therapist. FFT is a phasic program with steps, which build upon each other. These phases consist of:

  • Engagement, designed to emphasize within youth and family factors that protect youth and families from early program dropout;
  • Motivation, designed to change maladaptive emotional reactions and beliefs, and increase alliance, trust, hope, and motivation for lasting change;
  • Assessment, designed to clarify individual, family system, and larger system relationships, especially the interpersonal functions of behavior and how they relate to change techniques;
  • Behavior Change, which consists of communication training, specific tasks and technical aids, parenting skills, contracting and response-cost techniques, and youth compliance and skill building;

Generalization, during which family case management is guided by individualized family functional needs, their interface with environmental constraints and resources, and the alliance with the FFT Therapist/Family Case Manager.

Theoretical Rationale

In contrast to therapies named to reflect a theoretical perspective, Functional Family Therapy was named to reflect a set of core theoretical principles, which represents the primary focus (family) and an overriding allegiance to positive outcomes in a model that understands both positive and negative behavior as representations of family relational systems (functional). Thus, FFT has adopted an integrative stance that stresses functionality of the family, the therapy, and the clinical model. FFT represents an integration of systems perspectives and behavioral techniques. The systemic background of FFT emphasizes dynamic and reciprocal processes that need to be identified in referred families. The behavioral background of FFT provides not only specific manualizeable interventions such as contracting, but it also features an urgent awareness of the need for rigorous treatment development--a scientific imperative to systematically examine the effects of intervention and develop strategies for identifying positive change processes.

Theoretical Orientation

  • Behavioral
  • Cognitive Behavioral

Brief Evaluation Methodology

Study 1

Alexander & Parsons (1973) evaluated the program in a randomized controlled trial in which 99 delinquent adolescents and their families were randomized to the intervention group (n=46) or to one of three comparison groups: a no-treatment control group (n=10), a client-centered family therapy comparison group (n=19), or a psychodynamic family therapy comparison group (n=11). Administrative records were used to collect data on recidivism, defined as any new court referral, over an observation period lasting between 6 and 18 months after program completion. An analysis in Klein, Alexander, & Parsons (1977) examined siblings of the initial youth sample at 2.5-3.5 months after program completion.

Study 2

Barton et al. (1985) evaluated the program in a quasi-experimental design to compare 74 delinquent youth from a Utah juvenile facility to a comparison group constructed using simple matching. Data on frequency and severity of recidivism offenses over a 15-month observation period. In two additional studies, Barton et al. (1985) also examined effectiveness of the FFT model when performed by undergraduate paraprofessionals and when performed by state workers and probation officers.

Study 3

Gordon, Graves, & Arbuthnot (1995) examined FFT with 54 rural, low SES, Caucasian youth in Ohio using a quasi-experimental design with non-random assignment to groups (matched assignment with more severe cases assigned to FFT). Administrative data on recidivism were collected at 28- and 60-month follow-ups.

Study 4

Hansson, Cedarblad, & Hook (2000) tested the program in a randomized controlled trial where 89 delinquent Swedish youth and their families were assigned to either the intervention condition (n=49) or a usual treatment control group (n=40). Data on recidivism were collected at 12 and 24 months after program completion. Data on youth internalizing and externalizing behaviors were collected at pretest and a 2-year follow-up.

Study 5

Waldron et al. (2001) tested the program in a randomized controlled trial, where 120 delinquent New Mexico youth were randomly assigned to the FFT intervention group (n=30), an individual cognitive-behavioral therapy (CBT) comparison group (n=31), a combined FFT and CBT group (n=29), or a psychoeducational comparison group (n=30). Outcomes were frequency and intensity of marijuana use, measured at baseline, posttest, and 3-month follow-up.

Study 6

Barnoski (2004) evaluated the program in a randomized controlled trial where delinquent youth in Washington State were randomly assigned to the FFT intervention group (n=427) or a wait-list control group (n=323). Data on recidivism (all, felony only, violent felony) were collected at 6, 12, and 18 months after program completion.

Study 7

Sexton & Turner (2010) evaluated the program in a randomized controlled trial. Eligible delinquent youth from 917 families were stratified by county and then randomly assigned in equal proportions to the FFT intervention group or a probation-as-usual comparison group. The authors tested the moderating effects of therapist adherence and family risk/protective factors on felony and misdemeanor recidivism, with data collected for two years after program completion.

Study 8

Aos et al. (2011) conducted a meta-analysis of 8 studies of the FFT program.

Study 9

Friedman (1989) evaluated the program in a randomized controlled trial of adolescent drug abusers who were randomized to the FFT intervention group (n=85) or an alternate parent-focused comparison group (n=50). Outcomes included child internalizing/externalizing behaviors and behavioral problems, assessed at baseline and posttest (9 months after program completion).

Study 10

Slesnick & Prestopnick (2009) tested the program in a randomized controlled trial of runaway adolescents with alcohol problems in New Mexico. Participants were randomized to one of three conditions: an ecologically-based family therapy intervention condition (n=37), an office-based FFT intervention condition (n=40), or a usual care comparison group (n=42). Primary outcomes included substance use and psychological functioning, measured at baseline, posttest and two follow-ups occurring 6 and 15 months after baseline.

Study 11

Celinska, Furrer, & Cheng (2013) tested the intervention using a quasi-experimental design comparing youth with aggressive behavioral problems who were referred to either the FFT intervention group (n=36) or a usual care comparison group (n=36). Primary outcomes included behavioral problems and child internalizing/externalizing behaviors, measured at baseline and posttest.

Study 12

Hansson et al (2004) evaluated the program using a quasi-experimental design in one Swedish county. Participants were delinquent youth referred to the FFT intervention group (n=45) and a comparison group (n=43) constructed using simple matching. Administrative data on recidivism were collected for 18 months after baseline.

Study 13

Gottfredson et al. (2018) and Thornberry et al. (2018) evaluated the program in a randomized controlled trial that recruited participant families from one Philadelphia juvenile court. Participants were 129 delinquent adolescent males and their families, randomized into the FFT intervention group (n=66) or a treatment-as-usual family therapy comparison group (n=63). Primary outcomes of interest were delinquency/recidivism, substance use, and gang involvement. Self-report assessments occurred at baseline and 6 months post-randomization, while data on recidivism were collected from official sources for 18 months after randomization.

Study 14

Humayun et al. (2017) used a randomized controlled trial to examine youth criminal offenders ages 10-17 and their parents. A total of 111 families were randomly assigned to a treatment group receiving FFT plus management-as-usual services (N = 65) or to a control group receiving management-as-usual services only (N = 46). Youth were assessed at posttest (six months after assignment) and at one-year follow-up (18 months after assignment). Outcome measures included self-reported delinquency, official conviction, conduct disorder, oppositional defiant disorder, negative and positive behavior toward parents, and parenting quality.

Outcomes (Brief, over all studies)

A meta-analysis of effect size for eight evaluations of FFT (Aos et al., 2011) reported a mean unadjusted effect size of -.59 and an adjusted mean effect size of -.32, demonstrating that FFT is a cost effective approach for reducing juvenile crime.

Overall, FFT has produced statistically significant reductions in recidivism, out-of-home placement, or subsequent sibling referral, compared with controls (random, yoked, and non-random). These have been conducted on delinquent youth ranging in severity up to seriously delinquent youth. These studies have included follow-up periods from six months to three years, with one study involving a five year follow-up period (arrest rate as an adult for FFT treated youth was 9 percent compared to a 41 percent rate for alternative treatment).

Studies of therapist adherence to the FFT program demonstrated program effectiveness for the high adherent therapists, but recidivism rates for the clients of low adherent therapists were near or higher than those of the control group.

Specifically:

Study 1

Alexander & Parsons (1973) reported that relative to all comparison groups, intervention group participants had a significantly lower recidivism rate over the observation period, which lasted between 6 and 18 months by case. A follow-up study with the siblings of the targeted youth (Klein, Alexander, & Parsons, 1977) found that at 2.5 to 3.5 years after intervention, significantly fewer siblings of identified delinquents whose families received FFT had juvenile court records (20%) compared to families receiving no or other interventions (40% to 63%).

Study 2

Barton et al. (1985) reported that at the end of the 15-month posttreatment follow-up period, significantly fewer youth in the FFT group had been charged with committing an offense as compared to alternative treatment group (60% vs. 93%, respectively). Also, the frequency of offenses in the FFT group was significantly lower than in the alternative treatment group (mean frequency = .20 vs. .47, respectively) and with non-recidivists excluded from both groups, the results were similar (mean frequency = .34 vs. .51).

Study 3

Gordon, Graves, & Arbuthnot (1995) reported that at 28 months follow-up, intervention groups were significantly less likely to recidivate compared to the usual care comparison group. At 60 months, intervention group participants had a significantly lower overall rate of recidivism (combined misdemeanor and felony) and a marginally significant reduction in misdemeanor offenses compared to the usual care comparison group.

Study 4

Hansson, Cederblad, & Hook (2000) reported that at the 2 year follow-up, the FFT group had significantly lower rates of recidivism (41% vs. 82%) than the treatment as usual control group. The FFT group was also associated with greater reductions in youth and parent reports of externalizing and internalizing symptoms.

Study 5

Waldron et al. (2001) reported that compared to the psychoeducational control group, intervention group participants reported significantly reduced frequency of marijuana use at posttest but not at follow-up.

Study 6

Barnoski (2004) reported no statistically significant differences for three types of recidivism (felony, misdemeanor, and violent felony). However, when FFT was delivered with fidelity, participants in the high fidelity intervention group had significantly lower rates of felony recidivism and marginally significant reductions in violent felony recidivism compared to the control group.

Study 7

Sexton & Turner (2010) reported no main effects, though subgroup analyses showed significant reductions in felony recidivism for the high adherence (implementation fidelity) intervention subgroup compared to the control group.

Study 9

Friedman (1989) reported no significant differences between the FFT group and the parent group method comparison group.

Study 10

Slesnick & Prestopnik (2009) reported that compared to the usual care comparison group, intervention group participants reported a significantly lower percentage of days of drug or alcohol use.

Study 11

Celinska, Furrer, & Cheng. (2013) found that,compared to the control group, intervention group participants showed significant improvement in: life domain functioning related to family, school, and vocation; child behavioral/emotional needs (impulsivity, depression, anxiety, anger control, substance abuse); and child risk behaviors (suicide risk, self-mutilation, danger to others, sexual aggression, running away, delinquency, fire setting). i:

Study 12

Hansson et al. (2004) reported that at 18 months after first program contact, compared to participants in the matched comparison group, intervention group participants had a significantly lower rate of recidivism.

Study 13

Gottfredson et al. (2018) reported that at 18 months after randomization, compared to the control group, intervention group participants had significantly fewer new drug charges and delinquent adjudications.

Study 14

Humayun et al. (2017) found no significant effects of the program on any of the outcomes at posttest and no significant beneficial effects at the one-year follow-up.

Outcomes

Studies across several locations demonstrated program benefits for recidivism among juveniles:

  • In a Utah study, FFT families showed significant improvement compared to no treatment and alternative treatment groups in rates of reoffense (26% versus 47%-73%), juvenile court records of siblings of targeted youth (20% versus 40%-63%), and recidivism among serious delinquent youth (60% versus 89%-93).
  • In an Ohio study, FFT families showed significant improvement compared to usual services in recidivism after 28 months (11% versus 67%) and after 60 months (9% versus 41%).
  • In a Swedish study with a 2-year follow-up, FFT families showed improvement compared to a usual-treatment group in recidivism (41% versus 82%) and in youth and parent reports of externalizing and internalizing symptoms.
  • In a Washington State study, FFT families who worked with a competent therapist showed significant improvement in 18-month recidivism (44% versus 50%-54%) compared to families in control groups or working with not competent therapists.
  • A meta-analysis of effect size for eight evaluations of FFT (Aos et al., 2011) reported an adjusted mean effect size of -.32.

Alexander & Parsons (1973) reported that compared to all comparison groups, both intervention group participants and their siblings had a significantly lower:

  • Recidivism rates

Gordon (1995); Gordon, Graves, & Arbuthnot (1995) reported that compared to the usual care comparison group, intervention group participants had significantly reduced:

  • Recidivism (posttest and follow-up)

Hansson, Cedarblad, & Hook (2000) reported that compared to the usual care comparison group, intervention group participants showed significant reductions in:

  • Recidivism (posttest and follow-up)

Waldron et al. (2001) reported that at posttest, but not at follow-up, intervention group participants showed significant reduction compared to the control group in:

  • Marijuana use (frequency)

Barnoski (2004) reported that after 18 months, compared to the control group, intervention group participants demonstrated a significant reduction in:

  • Felony recidivism (high adherence subgroup only)

Sexton & Turner (2010) reported that compared to the control group, intervention group participants demonstrated a significant reduction in:

  • Felony recidivism (high adherence subgroup only)

Friedman (1989) reported no main program effects.

Slesnick & Prestopnik (2009) reported that at posttest, compared to the usual care control group, intervention group participants reported significantly reduced:

  • Days of drug or alcohol use

Celinska. Furrer, & Cheng (2013), reported that at posttest, compared to the control group, intervention group participants demonstrated significantly greater improvement in:

  • Life domain functioning (program deliverer measure)
  • Child internalizing and externalizing behaviors (program deliverer measure)
  • Child risk behaviors (program deliverer measure)

Hansson et al. (2004) reported that over the 18 months after first program contact, compared to the matched comparison group, intervention group participants showed significantly reduced:

  • Recidivism

Gottfredson et al (2018) reported that after 18 months, compared to the control group, intervention group participants had significantly fewer:

  • New drug charges
  • Delinquent adjudications

Humayun et al. (2017) found no significant beneficial program effects.

Program effects on Risk and Protective Factors:

  • Improvements in family interaction patterns (Alexander & Parsons, 1973)
  • Maternal improvements (over time) on symptom checklists evaluating depression, anxiety, and somatization were significant for the FFT group only (Hansson, Cederblad, & Hook (2000)

Mediating Effects

One early study (Alexander and Parsons, 1973) examined three mediating process measures based on audiotapes of family interaction – high equality of interaction, few periods of silence, and high frequency of interruptions. The study lacked a formal mediation analysis, but the process measures were associated with both the treatment and recidivism in ways suggesting that FFT reduced recidivism by improving family interactions.

Effect Size

A meta-analysis of effect size for eight evaluations of FFT (Aos et al., 2011) reported a mean unadjusted effect size of -.59 and an adjusted mean effect size of -.32, demonstrating that FFT is a cost effective approach for reducing juvenile crime. The adjustment for methodological quality, outcome relevance, and involvement of the designer in the research reduced the effect size from medium strength to weak strength. Gottfredson et al. (2018) report OR=.28-.38, indicating medium-large to large program effects.

Generalizability

Functional Family Therapy has been replicated by different investigators upon diverse populations, including youth with early behavior indicators of delinquency (e.g., Conduct Disorder, Oppositional Defiant Disorder, or Disruptive Behavior Disorder) to youth who present with serious chronic crimes. These include populations in Utah, Washington, New Mexico, Ohio, New Jersey, Pennsylvania, and Sweden. FFT has been applied with a wide range of population demographics, with non-White youth representing 10-60 percent of the samples.

Limitations

Many of the studies are quasi-experimental; randomized studies have small samples and mixed outcomes.

Study 1

Alexander & Parsons (1973):

  • Small N and “minor exceptions” to randomization
  • Inconsistent measurement period for recidivism outcome with no adjustment for time at risk
  • No control for baseline outcome
  • Small sample from one county
  • No tests for differential attrition

Study 2

Barton et al. (1985):

  • QED, matching unclear

Study 3

Gordon (1995); Gordon, Graves, & Arbuthnot (1995):

  • QED with simple matching
  • Attrition greater than 5% and no tests for differential attrition

Study 4

Hansson, Cedarblad, & Hook (2000):

  • Possible violation of ITT in survey data analysis
  • Possible incomplete tests for differential attrition

Study 5

Waldron et al. (2001):

  • Dropped some participants because they did not attend at least one therapy session
  • Program effect disappeared at 3-month follow-up
  • Small FFT sample from a single drug abuse center

Study 6

Barnoski (2004):

  • No main program effects
  • Analysis not specified

Study 7

Sexton & Turner (2010):

  • No main program effects

Study 9

Friedman (1989):

  • No main effects
  • No tests for differential attrition
  • Some baseline differences

Study 10

Slesnick & Prestopnik (2009):

  • Limited behavioral effects
  • One baseline group difference

Study 11

Celinska, Furrer, & Cheng (2013):

  • QED with simple matching
  • Assessments completed by program deliverers
  • No information on measure validity/reliability

Study 12

Hansson et al. (2004):

  • Baseline equivalence established for limited measures
  • Possible violation of ITT in survey data analysis
  • Incomplete tests for differential attrition

Study 13

Gottfredson et al. (2018):

  • Not always possible to control for baseline outcomes
  • Effects at follow-up but not at posttest

Study 14

Humayun et al. (2017)

  • Incomplete tests for baseline equivalence
  • Incomplete tests for differential attrition
  • No significant and beneficial program effects

Notes

Rhode et al. (2014) evaluated FFT in combination with Adolescent Coping with Depression (CWD). It did not evaluate FFT separately. One condition presented FFT followed by CWD, and another presented CWD followed by FFT, and a third presented both simultaneously. It is possible to compare FFT to CWD at the 10-week midpoint of the program, before the second component had been added. However, there were no treatment differences at that point.

Rohde, P., Waldron, H. B., Turner, C. W., Brody, J., & Jorgensen, J. (2014). Sequenced versus coordinated treatment for adolescents with comorbid depressive and substance use disorders. Journal of Consulting and Clinical Psychology, 82(2), 342–348.

Endorsements

Blueprints: Model
Crime Solutions: Effective
OJJDP Model Programs: Effective

Peer Implementation Sites

Site Name: The Salvation Army Syracuse Area Services
Address: 677 South Salina Street, Syracuse NY 13202
Contact Person’s name: Sidney Germinio, LMFT
E-mail: sidney.germinio@USE.salvationarmy.org
Phone: 315-479-1369
How many years doing FFT: 15 years

Main referral population (JJ, MH, etc): At inception, our program began as a collaboration with the Department of Juvenile Probation to serve a high risk juvenile justice population, since that time we have expanded to accept referrals from the Department of Children and Family Services, local mental health providers, schools and have a two grant funded positions: one that serves gang involved or affiliated youth and one that serves kids identified as trauma survivors.

Site Name: Robins' Nest, Inc.
Address: 42 S. Delsea Dr., Glassboro, NJ 08028
Contact Person’s name: J.R. Griffin, LCSW
E-mail: jgriffin@robinsnestinc.org
Phone: 856-881-8689 x. 750
How many years doing FFT: 8
Main referral population (JJ, MH, etc): Behavioral Health, Juvenile Justice

Site Name: Carya
Address: 200 1000 8th Ave SW, Calgary AB Canada
Contact Person’s name: Elsa Campos
E-mail: elsac@caryacalgary.ca
Phone:403-705-7557
How many years doing FFT: 4
Main referral population (JJ, MH, etc): schools, justice, health, mental health, child welfare, self

Site Name: Grace Harbour, Inc.
Address: 200 Westpark Drive, Suite 325, Peachtree City, Georgia 30269
Contact Person’s name: Kevin Freeman
E-mail: dr.freeman@gharbour.net
Phone: 770-486-1140
How many years doing FFT: 4
Main referral population (JJ, MH, etc): JJ

Program Information Contact

Holly DeMaranville
FFT Communications Director
1251 NW Elford Dr.
Seattle, WA 98177
Phone: (206) 369-5894 - cell
Fax: (206) 453-3631
Email: hollyfft@comcast.net
Website: www.fftinc.com

References

Study 1

Certified Alexander, J. F., & Parsons, B. V. (1973). Short-term behavioral intervention with delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 81, 219-225.

Alexander, J. F., & Parsons, B. V. (1973). Short-term behavioral intervention with delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 81, 219-225.

Klein, N. C., Alexander, J. F., & Parsons, B. V. (1977). Impact of family systems intervention on recidivism and sibling delinquency: A model of primary prevention and program evaluation. Journal of Consulting and Clinical Psychology, 45, 469-474.

Study 2

Barton, C., Alexander, J. F., Waldron, H., Turner, C. W., & Warburton, J. (1985). Generalizing treatment effects of Functional Family Therapy: Three replications. The American Journal of Family Therapy, 13, 16-26.

Study 3

Gordon, D. A. (1995). Functional Family Therapy for delinquents. In R. R. Ross, D. H. Antonowicz, & G. K. Dhaliwal (Eds.), Going straight: Effective delinquency prevention and offender rehabilitation (pp.163-178). Ottawa, Ontario, Canada: Air Training and Publications.

Gordon, D. A., Graves, K., & Arbuthnot, J. (1995). The effect of Functional Family Therapy for delinquents on adult criminal behavior. Criminal Justice and Behavior, 22(1), 60-73.

Study 4

Hansson, K., Cederblad, M., & Höök, B. (2000). Functional Family Therapy: A method for treating juvenile delinquents. Socialvetenskaplig tidskrift, 3, 231-243.

Hansson, K., Cederblad, M., & Hook, B. (2000). Functional Family Therapy: A method for treating juvenile delinquents. Socialvetenskaplig tidskrift, 3, 231-243.

Hansson, K., Johansson, P., Drott-Emnglen, G., & Benderix, Y. (2004). Funktionell familjeterapi I barnpsykiatrisk praxis: Om behandling av ungdomskriminaliet utanfor universitesforskningen. Nordisk Psykologi, 56(4), 304-320.

Study 5

Waldron, H. B., Slesnick, N., Brody, J. L., Turner, C. W., & Peterson, T. R. (2001). Treatment outcomes for adolescent substance abuse at 4- and 7-month assessments. Journal of Consulting and Clinical Psychology, 69, 802-813.

Study 6

Barnoski, R. (2004). Outcome evaluation of Washington state's research-based programs for juvenile offenders. (Document No. 04-01-1201). Olympia, WA: Washington State Institute for Public Policy.

Study 7

Sexton, T., & Turner, C. W. (2010). The effectiveness of Functional Family Therapy for youth with behavioral problems in a community practice setting. Journal of Family Psychology, 24(3), 339-348.

Study 8

Aos, S., Lee, S., Drake, E., Pennucci, A., Klima, T., Miller, M., . . . Burley, M. (2011). Return on investment: Evidence-based options to improve statewide outcomes. (Document No. 11-07-1201A). Olympia, WA: Washington State Institute for Public Policy.

Study 9

Friedman, A. (1989). Family therapy vs. parent groups: Effects on adolescent drug abusers. The American Journal of Family Therapy, 17(4), 335-347.

Study 10

Slesnick, N., & Prestopnik, J. (2009). Comparison of family therapy outcome with alcohol-abusing, runaway adolescents. Journal of Marital and Family Therapy, 35(3), 255-277.

Study 11

Celinska, K., Furrer, S., & Cheng, C. C. (2013). An outcome-based evaluation of Functional Family Therapy for youth with behavior problems. OJJDP Journal of Juvenile Justice, 2(2), 23-36.

Study 12

Hansson, K., Johansson, Drott-Englén, G, & Benderix, Y. (2004). Functional Family Therapy in child psychiatric practice. Nordisk Psykologi, 56(4), 304-320.

Study 13

Certified Gottfredson, D. C., Kearley, B., Thornberry, T. P., Slothower, M., Devlin, D., & Fader, J. J. (2018). Scaling-up evidence-based programs using a public funding stream: A randomized trial of Functional Family Therapy for court-involved youth. Prevention Science, 1-15. doi 10.1007/s11121-018-0936-z

Gottfredson, D. C., Kearley, B., Thornberry, T. P., Slothower, M., Devlin, D., & Fader, J. J. (2018). Scaling-up evidence-based programs using a public funding stream: A randomized trial of Functional Family Therapy for court-involved youth. Prevention Science, 1-15. doi 10.1007/s11121-018-0936-z

Thornberry, T. P., Kearley, B., Gottfredson, D. C., Slothower, M. P., Devlin, D. N., & Fader, J. J. (2018). Reducing crime among youth at risk for gang involvement: A randomized trial. Criminology & Public Policy, 17(4), 953-989. doi:10.1111/1745-9133.12395

Study 14

Humayun, S., Herlitz, L., Chesnokov, M., Doolan, M., Landau., S., & Scott, S. (2017). Randomized controlled trial of Functional Family Therapy for offending and antisocial behavior in UK youth. Journal of Child Psychology and Psychiatry, 58(9) 1023–1032. doi:10.1111/jcpp.12743

Study 1

Evaluation Methodology

Design:

Recruitment: A total of 99 delinquent adolescents were referred by the Salt Lake County Juvenile Court to the Family Clinic at the University of Utah from October 1970 to January 1972. All eligible participants had committed a behavioral or status offense including running away, being “declared ungovernable,” truancy, shoplifting, and possession of alcohol, tobacco, or “soft drugs.” The study also examined the siblings of the sample youth.

Assignment: Though a total of 99 families were randomized, the authors report only the numbers of the 86 families for whom records could be found. Thus, these 86 families were randomly assigned to either the intervention group (n=46) or to one of three comparison groups: (1) Client-centered family groups program (n =19); (2) Psychodynamic family program (n =11); or (3) No treatment control (n =10). However, the text noted that randomized occurred “with minor exceptions due to program availability,” which suggests deviations from full random assignment. Also, the follow-up periods varied for individual families. The period length will affect the likelihood of recidivism, but the authors stated that “across groups the period was comparable.”

An additional post hoc control group (n=46) was created by random selection from several hundred eligible court cases that were not initially assigned to any group. The second additional comparison group included 2,800 cases seen countywide during 1971. Because these two groups were examined on a post-hoc basis, they were not included in the statistical analysis.

Assessments/Attrition: Data on recidivism were collected anywhere between 6 to 18 months following program completion for the eligible youth and from 2.5-3.5 years for siblings of the eligible youth. In terms of available data, approximately 13% of the randomized participants could not be linked to the court records used in the study.

Sample:

Participating adolescents were majority female (55.8%) and ranged from 13 to 16 years old.

Measures:

Data on adolescent recidivism were collected from court records. Recidivism was defined as a new court referral, but the geographic coverage of the courts was unclear. In a follow-up, Klein, Alexander, & Parsons (1977) collected data on court referrals for the siblings of original participants for 2.5-3.5 years after program completion.

Analysis:

The effects of the program were evaluated using chi-square tests to assess differences in recidivism by group.

Intent-to-Treat: Intent-to-treat analysis was utilized, since participants who dropped out of treatment were included.

Outcomes

Implementation Fidelity:

The study reported that the sessions for the treatment group had, as desired, significantly more equality in talk time, less silence, and more interruptions than the sessions for the control group. Otherwise, the study noted that 12 of 46 cases (26%) of the treatment group dropped the program before completion and that therapists were regularly supervised throughout program delivery.

Baseline Equivalence:

The authors stated that subjects were compared on demographic variables (i.e., age, SES, sex), prior recidivism rates, and pretest scores on the three interaction measures, and no differences were found among the groups. However, these figures were not presented.

Differential Attrition:

There was an overall loss of approximately 13% of subjects who could not be matched with state records. There were no tests for those missing records.

Posttest:

Over the posttest observation period, which lasted between 6 and 18 months depending on participant, tests showed significant overall differences across the four conditions. The intervention group participants had a lower rate of recidivism incidents (26%) compared to participants in the no-treatment control group (50%), the client-centered family therapy comparison group (47%), and the psychodynamic family therapy comparison group (73%). The intervention group recidivism rate was also lower than the post-hoc randomized comparison group (48%) and the county-wide recidivism rate (51%).

Long-Term:

There was no long-term follow-up for the original sample, because part of the sample was followed for less than 12 months after completion of the program. However, the study of siblings (Klein, Alexander, and Parsons, 1977) examined a period of 2.5 to 3.5 years after intervention. It found that significantly fewer siblings of the identified delinquents whose families received FFT had juvenile court records (20%) compared to families receiving no or other interventions (40% to 63%).

Study 2


Seriously Delinquent Adolescents
Study 1 of 3

Design: Seventy-four seriously delinquent youth who were incarcerated in a Utah juvenile facility for serious and repeated offenses were the subjects of the study. The youth were divided into two groups, the FFT group and a group who were given traditional services. The two groups were equivalent in frequency and severity of offenses during the 30-month period before incarceration. A presumption of the sampling procedure was that the youth who were judged to be "equivalently noxious to the community," or who had equivalent severity of offenses were likely to be incarcerated for similar lengths of time. Youth were yoked by time of entry and exit into the incarceration and parole systems in order to homogenize sources of variance, such as police vigilance or judicial sentencing rigor. Three weeks before release from the state institution, both groups began interventions. FFT interventions included family therapy and support services such as remedial education, job training and placement and school placement. The services continued for an average of 30 hours of contracted services for each family.

Sample: Seventy-four delinquent adolescents incarcerated in a Utah state training school were subjects of this study. The 30 youth selected for FFT had been referred by state personnel and were deemed able to return to a community living arrangement (which included at least one adult who had served them as a parent for more than three years). Alternative treatment subjects included 44 youth who were similar to the FFT youth with respect to severity of offenses, living arrangements, ethnicity, age, SES, educational level and number. Demographic information specific to race and sex was not included in the study.

Measures: Two primary dependent measures were used: number (frequency) of offenses and recidivism. Severity of offenses was also examined using the State of Utah's code which assigns quantitative rankings to types of offenses committed.

Analysis: A 2X2 ANOVA was used to compare the two groups for recidivism and frequency of offense.

Outcomes: At the end of the 15-month posttreatment follow-up period, 60% of the FFT group had been charged with committing an offense, whereas 93% of the alternative treatment group had been charged with an offense. The frequency of offenses in the FFT group was lower than in the alternative treatment group (mean frequency = .20 vs.47, respectively). With non-recidivists excluded from both groups, the results were similar (mean frequency = .34 vs.51).

Paraprofessional Therapists
Study 2 of 3

Design: The goal of this study was to evaluate the effectiveness of the FFT model when performed by undergraduate paraprofessionals compared with the types of providers used in prior FFT evaluations, therapists with substantial education, training, and experience. Therapy outcomes and measures of family process were evaluated.

Subjects: 27 status delinquents (adolescents with offenses including runaway, truancy, sexual promiscuity, possession of alcohol, and ungovernability) who were referred by probation workers. Eight undergraduates were selected for therapist training in the FFT model and received 32 hours of training. An average of 10 sessions was provided by the paraprofessionals to the status delinquents in a clinic.

Outcomes: Results obtained by the paraprofessionals were equivalent to those obtained by senior/graduate level therapists in earlier studies. Recidivism rates (court referrals after treatment) were 26% for the FFT group, compared with 24-25% with graduate students trained in FFT and rates obtained with more experienced professional therapists. A one-sample binomial test showed that this rate was also lower than the population base rate of this juvenile court district as a whole (51%). Changes in the family processes characteristic of families with delinquent youth, specifically, decreases in family defensiveness, were seen with this sample, and were reported to be similar to those decreases in defensiveness in prior FFT studies (statistics were not provided).

Foster Placement
Study 3 of 3

Design: The goal of this study was to evaluate the effectiveness of the FFT model when performed by state workers and probation officers compared with prior FFT evaluations that utilized therapists with substantial education, training, and experience. Therapy outcomes and measures of family process were evaluated.

Subjects: 109 children and adolescents at risk for foster care placement were referred by workers who investigate cases for protective or alternative custody. Reasons included status delinquent offenses, school problems, and custody issues/ineffective parenting. Therapists were from the State Division of Family Services Social Workers. All 22 were given a week-long training in FFT after they had worked for Family Services for some time. However, there was no state mandate to use FFT, and only 2 therapists used FFT (one had an undergraduate degree in psychology and the other had a MSW).

Measures: The trained FFT therapists' rates of referrals for foster care placement (72 hours or more prior to FFT training and after FFT training were completed) were compared with those of their co-workers and to their own pre-training rates.

Outcomes: Comparisons of cases treated by the trained workers before and after their training showed significant decreases in rates of referrals (from 48% to 11%). Comparisons of cases treated by the trained workers following their training (11% referred to foster care) were significantly lower than the 216 cases seen by co-workers during the same time period (49% referred to foster care).

Brief Bullets

  • When used with seriously delinquent youth, at 15 months post-treatment, 60% of the FFT group had been charged with committing an offense, whereas 93% of the alternative treatment group had been charged with an offense.
  • FFT was found to be as effective with small studies of trained undergraduates and state workers compared with traditional FFT therapists (graduate students and professional therapists).
  • Lower foster placement referrals among youth at risk for outplacement treated by caseworkers in Child Welfare system.

Study 3

Evaluation Methodology

Design: This study was a quasi-experimental design with non-random assignment to groups. Follow-up data were gathered from court archival materials. Twenty-seven juveniles were court ordered to attend FFT. The median number of 1.5 hour, in home, family sessions was 16 (range 7 to 38), extending over an average of 5.5 months. The therapists and probation officers were in contact one to two times per month. Twenty-seven additional juveniles who were adjudicated delinquents and status offenders, who came before the court at the same time, and who were not placed outside the home, were selected as controls and it was believed they received little or no counseling from mental health professionals. The treatment youth had higher offense rates than the controls at the baseline comparison. Therapists were 2nd to 4th year graduate students in psychology, and had 30 hours of training in FFT. The initial follow-up period reported in Gordon (1995) was 28 months. The follow-up period of the current study was 32 months later than that (i.e., 60 months), when the original youth were adults.

Subjects: 27 juveniles (15 male, 12 female) and their families completed FFT, and 27 juveniles (23 males, 4 females) and their families served as a control group. The subjects were largely from low socioeconomic backgrounds and lived in rural areas. Subjects were 100% non-Hispanic white.

Measures: Recidivism, which was defined in this study as conviction in adult or juvenile court for anything other than traffic offenses.

Analyses: Chi-square analyses were used to compare recidivism rates between groups and subgroups.

Outcomes

28 month follow-up (Gordon, 1995): FFT group was found to have 11% recidivism compared to 67% in the regular services group at 28-month follow-up.

60 month follow-up (Gordon, Graves, & Arbuthnot, 1995): After 60 months, there remained 23 in the treatment group and 22 in the comparison group (less than 20% attrition). When felony and misdemeanor recidivism rates were combined, the overall rates for FFT (8.7%) were significantly lower than for the comparison group (40.9%). For the misdemeanor group, there was a trend toward significant (p<.10), with a 4.3% recidivism rate for FFT participants and 27.3% for the comparison group. For felonies, the 4.3% (FFT) and 13.6% (comparison) difference was not statistically significant.

Brief Bullets

  • After 28 months, the FFT group had 11% recidivism compared to 67% in the regular services group.
  • At a 60 month follow-up when the youth had become adults, when felony and misdemeanor recidivism rates were combined, the overall rates for FFT (9%) were significantly lower than for the comparison group (41%). Differences in misdemeanor recidivism rates tended toward significant for the FFT group (4%) and 27% for controls, but differences for felonies were not significant.

Limitations: Data was unavailable for 9 subjects, and there is no analysis of differential attrition. The design used a non-randomized procedure, with juveniles at highest risk of recidivating being placed in the treatment group.

Study 4

Evaluation Methodology

Design:

Recruitment: The study screened all young people taken into police custody in Lund, Sweden between June 1993 and June 1995. After excluding young people reported to Social Services and young people already undergoing treatment provided by social services or Child Psychiatry, there was a total sample of 89 young people and their families.

Assignment: The study stated that random assignment was used, however no details on the method of assignment were provided. Also, it appears that consent followed randomization, with no information provided on consent rates: The treatment group included 49 participants and the business as usual control group included 40 participants.

Assessments/Attrition: The study conducted a survey at pretest and 2-year follow-up, and it also collected recidivism information at the one- and two-year follow-ups. Recidivism information was obtained from administrative records and was available for all participants, however only 19 (47.5%) of the 40 comparison group families were interviewed before treatment and 17 (42.5%) were interviewed after treatment. The study also reported additional attrition for individual questions or measures. Among the treatment group, 41 participants (84%) completed the follow-up survey.

Sample: Participants were mostly boys (87%) and approximately 15 years of age.

Measures: The study used administrative records of rearrest, defined as being taken into custody by the police or being referred to Social Services again, however offered few additional details. In addition, participants completed survey measures: 1) the Symptom Check List describing psychological and emotional symptoms (alpha .79), 2) the Child Behavior Checklist on child competence and behaviors, completed by parents, 3) the Sense of Coherence questionnaire, measuring attitudes to life that can increase resistance to stress and are supportive of good health, and 4) the Self-Reported Antisociality questionnaire for rate of criminal and/or antisocial behavior.

Analysis: The study compared recidivism rates among participants one year and two years after the start of the intervention using a chi-square analysis.

Intent-to-Treat: The study used all available data for the recidivism measure, but in analyzing the survey data, it excluded the control group due to attrition and excluded treatment youth at sub-clinical levels at pretest.

Outcomes

Implementation Fidelity: The study did not include any measures of fidelity, noting only that all but one of the 49 treatment families competed the therapy.

Baseline Equivalence: The study found no statistical difference between conditions at baseline for gender or age. The study also collected information on the behaviors of participants at baseline (including truancy, running away from home, theft, assault, etc) but for only 47 (95.9%) of the treatment group and 19 (47.5%) of the control group. It reported two differences between conditions, but did not report what those differences were.

Differential Attrition: For the survey measures with attrition, the study stated that there is evidence that those families in the control group who did complete the survey at the 2-year follow-up were more likely to be those families whose children did not recidivate. As a result, the study only included survey results from the treatment group at the 2-year follow-up.

Posttest: The study found a significantly lower proportion of participants in the treatment group recidivated one year after the start of the intervention, as compared to the control group.

Long-Term: Two years after the start of the intervention, a significantly lower proportion of treatment group participants recidivated, as compared to the control group.

The study reported that more than half of treatment group participants who reported clinical levels of emotional symptoms and problem behaviors at the pretest had normal clinical values at the follow-up, however it did not report if this change was significant, nor did it compare results in the control group. The study also reported more mothers in the treatment group had fewer emotional symptoms at the two-year follow-up, as compared to mothers in the control group. However, the study also did not include significance tests and only 38% of control group mothers were included.

Study 5

Evaluation Methodology

Design: 120 adolescent boys (n =96) and girls (n =24) were referred to the University of New Mexico Center for Family and Adolescent Research for drug-abuse treatment. After initial assessment, adolescents were randomly assigned into one of four treatment conditions: FFT (n =30), individual community-based therapy (CBT; n =31), a combination of FFT and CBT (joint; n =29), or a psychoeducational group (n =30). Six Ph.D.- and M.S.W.-level therapists were trained by Dr. Alexander and provided therapy. Adolescents were offered 12 weeks of therapy provided at the University of New Mexico; 24 hours for the joint intervention (i.e., 1 hour of FFT and 1 hour of CBT per week). There was on-site supervision by Dr. Waldron, and follow-up consultations with Dr. Alexander as requested (approximately 2 per year). Follow-up assessments were conducted at 4 (i.e., end of treatment) and 7 months (i.e., 3 months post treatment).

Subjects: 114 adolescents, aged 13-17, completed all surveys. Subjects were substance abusing or dependent adolescents (typically marijuana), frequently comorbid with Conduct Disorder and internalizing problems, threat of incarceration, school problems, and probation. Subjects were primarily White and Hispanic/Latino, though some subjects were Native American and of other ethnicities.

Measures: Because marijuana was the predominant drug of choice for the youth in this sample, the primary substance use outcome measures were (1) percentage of days marijuana was used and (2) percentage of youth achieving minimal use, as reported in the Timeline follow-back interview (TLFB). Collateral reports, urine drug screenings, and other measures were obtained to examine convergent validity of the TLFB. The POSIT, measuring 10 functional areas of adolescent substance abuse, and the CBCL (internalizing and externalizing scales) were also administered.

Analyses: Preliminary analyses were conducted. The next analyses evaluated the convergent validity of the primary outcome measure. Finally, analyses (repeated measures ANOVAs) examined adolescent marijuana use, other adolescent substance use, primary caregiver substance use, family conflict, and internalizing and externalizing behavior across treatment conditions. Pretreatment to 4-month and 7-month change in clinically significant marijuana use was assessed with a Wilcoxon's signed ranks test procedure within each condition.

Outcomes

Percentage of days of marijuana use: The 4 (treatment) by 3 (time) repeated measures ANOVA revealed a nonsignificant main effect for treatment condition, a significant main effect for time, and a significant interaction between time and treatment condition. Simple main effects for time were found for FFT (p <.001), joint (p <.005), and group (p <.004), while the time simple effect was not significant within the CBT condition. A priori comparisons using repeated measures F -tests with a Bonferroni adjustment of alpha =.0125 were conducted for each of the four treatment conditions from pretreatment to 4-month follow-up. Youth in the FFT condition (p <.001) and in the joint condition (p <.01) showed significant reductions in marijuana use (55% to 25% and 57% to 38%, respectively). The youth in the CBT and group conditions did not have a significant reduction in marijuana use. To examine the stability of change from pretreatment to the 7-month follow-up, a second set of four planned comparisons with the same Bonferroni adjustment were conducted. Youth in the joint treatment condition maintained a significant reduction from pretreatment to 7-month follow-up (p <.008, 57% to 36%). Youth in the FFT group were not significantly different from pretreatment to the 7-month follow-up, though the difference was marginally significant (p<.085; 55% to 40%), suggesting that the changes at 4 months were not maintained at 7 months. The youth in the group condition significantly reduced their substance use from pretreatment to 7 months (p <.01, 66% to 42%), and the youth in the CBT condition did not change significantly from pretreatment to 7 months. Finally, simple effects within time periods were examined, and Bonferroni adjusted comparisons among the 4-month means indicated that the FFT condition had a significantly lower rate of marijuana use than did the CBT and group treatment conditions but that FFT was not significantly different from the joint condition. None of the between-treatment effects was statistically significant for the 7-month measurement period.

Reduction to minimal use: From pretreatment to 4 months, significant reductions from heavy to minimal use in the prevalence of marijuana use were found for the FFT (87% to 55%), CBT (97% to 72%) and joint interventions (90% to 56%), but not in the group condition, and significant numbers of youth had achieved minimal-use levels in the FFT, CBT, and joint interventions. At 7 months, reductions from heavy to minimal use were significant for the FFT condition (87% to 62%), the joint condition (90% to 56%), and the group condition (97% to 69%), but not the CBT condition (97% to 83%). Thus, both of the family therapy conditions had significant changes in heavy marijuana use from pretreatment to the 4-month assessment, and this reduction persisted until the 7-month assessment. The initial changes in CBT from pretreatment to 4 months did not persist through the 7-month assessment. Finally, the changes in the group condition did not emerge until the 7-month assessment.

Brief Bullets

  • In Albuquerque, when four types of therapy were compared to examine percentage of days of marijuana use, youth in the FFT condition and in the joint (FFT+CBT) condition showed significant reductions at four months in marijuana use (55% to 25% and 57% to 38%, respectively). The youth in the CBT and group conditions did not have a significant reduction in marijuana use.
  • Youth in the joint treatment condition maintained a significant reduction from pretreatment to 7-month follow-up (57% to 36%). Youth in the FFT group were marginally significantly different from pretreatment to the 7-month follow-up (p<.085; 55% to 40%). The youth in the group condition significantly reduced their substance use from pretreatment to 7 months (66% to 42%), and the youth in the CBT condition did not change significantly from pretreatment to 7 months.
  • Significant reductions in heavy to minimal marijuana use were found at 4 months for the FFT (87% to 55%), CBT (97% to 72%) and joint interventions (90% to 56%), but not in the group condition. At 7 months, reductions from heavy to minimal use were significant for the FFT condition (87% to 62%), the joint condition (90% to 56%), and the group condition (97% to 69%), but not the CBT condition (97% to 83%).

Limitations

  • Dropped some participants because they did not attend at least one therapy session
  • Program effects disappeared at 3-month follow-up
  • Small FFT sample from a single drug abuse center

Study 6

Evaluation Methodology

Design and Subjects: In 1997, the Washington State Legislature passed the Community Justice Accountability Act (CJAA), with the primary goal of reducing juvenile crime in a cost-effective manner by establishing research-based programs in the state's juvenile courts. FFT was one of the four programs selected for meeting two criteria (sufficient research evidence of the ability to lower recidivism and able to be implemented by Washington's juvenile courts). Recidivism rates were compared between those youth randomly assigned to FFT or the control group. The program began with 427 families (and 323 wait-list controls) and 36 therapists. At 18-month follow-up, there were 387 families in the FFT group and 313 control families. Further, 16 of the 33 remaining therapists were rated by FFT, Inc. as competent or highly competent, and 17 were rated as not competent or borderline.

Measures: Recidivism rates (misdemeanor and felony, felony, and violent felony).

Analyses: Not specified. Likely chi square.

Outcomes

At 18-month follow-up, FFT participants (n =387, compared to control participants n =313), showed no statistically significant differences for the three types of recidivism. However, when FFT was delivered competently (i.e., with fidelity), the program reduced felony recidivism by 30%. Youth seen by the competent therapists had a 17 percent felony recidivism rate compared with 27 percent for the control group, a statistically significant reduction of 38 percent. For violent felony recidivism, the competent therapist group had a 3 percent rate compared with 6 percent for the control group, a 50 percent reduction that was marginally statistically significant at the p =.115 probability level.

Stability of Results: 6-month, 12-month, and 18-month adjusted felony recidivism rates were compared. The reduction in felony recidivism between the control and competent therapist groups at 12 months was 40 percent compared with 38 percent at 18 months, indicating that FFT’s suppression effect on felony recidivism was relatively constant.

Cost-Benefit Analysis: When FFT was delivered by competent therapists, it generated $10.69 in benefits (avoided crime costs) for each dollar spent on the program. When not competently delivered, FFT cost the taxpayer $4.18. Averaging these results for all youth receiving FFT, regardless of therapist competence, resulted in a net savings of $2.77 per dollar of costs.

Brief Bullets

  • FFT was not found to be more effective than other conditions overall, but when FFT was delivered with fidelity, the program significantly reduced felony recidivism by 30% (17% for FFT youth and 27% for the control group) and marginally significantly reduced violent felony recidivism by 50% (3% for FFT youth and 6% for the controls).
  • The cost-benefit analysis indicated that when FFT was delivered by competent therapists, it generated $10.69 in benefits (avoided crime costs) for each dollar spent on the program. When not competently delivered, FFT cost the taxpayer $4.18. Averaging these results for all youth receiving FFT, regardless of therapist competence, resulted in a net savings of $2.77 per dollar of costs.

Study 7

Evaluation Methodology

Design: The project was designed to build on the Barnoski (2002) statewide evaluation by including information on client risk and protective factors, a more comprehensive assessment of treatment adherence, and an expanded subject pool. The project involved 38 therapists and 917 families in 14 different counties that represented both rural and urban settings. After being sentenced to probation, youth who scored moderate to high risk on the Washington State Juvenile Court Administrative Risk Assessment (WSJCR-RA) were assigned to FFT or control conditions. A stratified randomization procedure was used at the county level according to the guidelines developed and mandated by the State Juvenile Justice system using a 1:1 assignment. Eligible adolescents were assigned in the same 1:1 random manner throughout the study as caseload openings permitted. Participants in the treatment-as-usual condition received traditional probation services in their local county. Each of the therapists received systematic training and supervision in FFT.

Subjects: The project involved 38 therapists and 917 families in 14 different counties that represented both urban and rural settings. Adolescents entered the study because they had been adjudicated for a crime and were sentenced to probation. Subjects were 79% male, ranged in age from 13-17 years, and were 78% white, 10% African American, 5% Asian, 3% Native American, and 4% unidentified. The subjects were drug involved (85.4%), used/abused alcohol (80.47%) and exhibited other mental health or behavioral problems (27%). Most had committed felony crime (56.2%), and many had committed misdemeanors (41.5%). Problem behaviors committed by the subjects included weapons crimes (10.4%), gang involvement (16.1%), out of home placements (10.5%), a history of running away from home (14.1%), and school dropout (46.3%).

The FFT therapists were also diverse in demographics and prior professional backgrounds, which allowed for the systematic study of the role of therapist characteristics. Of the therapists, 79% were female and 74% White, 4% African American, 4% Asian, 4% Mexican American, and 4% multiracial. Though none of the therapists had prior experience with FFT, their training (Master’s and Bachelor degree clinicians, most with licenses or certification) and experience (ranged from 1 to 40 years in family therapy, counseling, and both) were otherwise diverse.

Measures: After being sentenced to probation, all youth were administered the preliminary screening version of the Washington State Juvenile Court Administration Risk Assessment (WSJCA). Those youth scoring moderate to high risk were assessed using the full WSJCR (WSJCR-RA). The WSJCA is a 100-item structured interview that is conducted with the youth and their families to assess multiple risk and protective factors in ten domains, including criminal history, school participation, use of free time, employment, peer relationships, family, alcohol and drug history, mental health, attitudes (deviant or prosocial), and social skills. Preliminary analysis of the data indicated that a composite risk index could be formed from the school, leisure, family, mental health, (deviant) attitudes, and (poor) social skills domains. An antisocial peer association domain was independent of this composite risk index, and a protective factors index could be formed from the leisure time, work, prosocial peer influence, positive family influence, prosocial attitudes, and positive social skills domains. The school protective domain was only assessed for the half of the sample that was in school and was thus not included in the composite index.

Treatment adherence ratings were conducted according to the adherence protocol in use during the project. The rating by the clinical supervisors was based on the degree to which the therapist described the case in terms of the core principles of FFT and the degree to which they reported following the manual's specified goals for each phase of the clinical intervention. Therapists’ adherence ratings were gathered over a 2-year period, although some of the cases in the first year were not rated. Likert scale ratings were aggregated into a 4-category system ranging from non-adherence, borderline adherence, adherence, and high adherence. The primary outcome measure was the youth’s adjudicated post treatment criminal behaviors. Criminal recidivism was obtained from official state juvenile justice records. Crimes were classified as misdemeanor, felony, or violent crime.

Analysis: First, a one-way multivariate analysis of variance assessed possible pretreatment differences in the three study samples (control, non-adherent therapists, adherent therapists) to assess possible confounds for interpreting comparisons among the samples. Second, a random regression (HLM) was conducted with the therapist factor as the independent variable to assess possible nesting efforts, resulting from the fact that each therapist treated multiple families. Third, to test the main hypothesis, planned contrasts within a logistic regression analysis were conducted to examine differences between the three study samples on the 12-month, adjudicated recidivism measures of misdemeanor, felony, and violent recidivism. The logistic regression analysis controlled for theoretically specified covariates assessed at pretreatment. Fourth, a 2 x 2 logistic regression analysis was conducted to examine the possible interaction effects of pretreatment family risk and protective factors on the therapist model adherence independent variable, with the presence or absence of criminal recidivism as the dependent variable. Fifth, the possible contribution of therapists' case experience with FFT on recidivism rates of the youth they treated was examined, using a 2 (therapist adherence) by 3 (therapist case experience) repeated measures analysis of covariance (therapist adherence was the between participant factor and therapist experience was the within factor).

Outcomes

Overall, the findings suggest that FFT was effective in reducing youth behavioral problems, although only when the therapists adhered to the treatment model.

Pretreatment Condition Differences: Results indicated a significant effect of Study Sample on the Age, Criminal History, and the Relationship Risk dependent variables. For Age, the control group sample was older than the High Adherent FFT sample. For Criminal History, the control sample had a higher level than the low adherent sample. For Peer Risk, the Low Adherent FFT sample had a higher level than the control sample. These findings led the researchers to control for possible confounding effects of age, criminal history, and relationship risk for comparisons between the three study samples.

Therapist Nesting Effects within Adherence Levels: The results of the logistic regression did not provide evidence of nesting effects for the High Adherence group nor the Low Adherence group on the misdemeanor or felony dependent variables. Subsequent analyses omitted the therapist-nesting variable as an independent variable.

Test of Primary Hypothesis: Effects of Treatment on Adolescent Recidivism. Felony: As hypothesized, the logistic regression analysis for separate independent variables indicated that the comparison of High Adherence versus control sample in felony recidivism rates was statistically significant (i.e., higher recidivism for controls). The control sample was not lower in felony recidivism than the Low Adherence sample. Post hoc comparisons also indicated that the Low Adherence sample had a higher recidivism rate than the High Adherence sample.

Misdemeanor and Violent Recidivism: Analyses were conducted to determine the impact of FFT on misdemeanor and violent felony rates. Results for the misdemeanor measure indicated that the Low Adherence FFT sample was higher than the High Adherence FFT sample rate and not different from the control sample rate. Criminal history, male gender, family risk, relationship risk, and younger ages were also associated with greater risk of misdemeanor recidivism. Comparisons on violent felony recidivism measures indicated that the Low Adherence FFT sample had higher recidivism rates than the High Adherence sample rate or the control group rate.

Further, Sexton and Turner (2010) compared the interactive effects of therapist adherence and family risk or protective factors on outcomes, and found that High Adherence FFT therapists had lower recidivism rates than the Low Adherence FFT therapists within the High Family Risk samples and the Low Family Risk samples (18% and 32%, 12% and 28%, respectively). However, for peer risk, the binary logistic regression indicated that the High Adherence Therapist had a significantly reduced level of recidivism only in the High Relationships Risk group (20% and 33%) but not in the Low Relationship Risk group (15% and 20%, not significant), meaning therapist adherence to the model had an impact when the adolescent in treatment was also exposed to high-risk peers, but adherence was not statistically significant for low risk peers.

Effects of Therapist Adherence and Case Experience on Recidivism Rates: The results of the 2 x 3 repeated measures ANOVA revealed a significant main effect for the Therapist Adherence independent variable, with the Low Adherence FFT sample having a higher composite recidivism score than the High Adherence FFT sample. These results suggested that the Therapist Adherence effect on recidivism emerges early and persists across case experience.

Brief Bullets

  • A follow-up to the Washington study found that the felony recidivism rate for High Adherence therapists was significantly lower, 15%, compared with 22% for controls and 28% with the Low Adherence therapists. For misdemeanor recidivism, Low Adherence therapists' clients had a rate of 50%, compared with control (41%) and High Adherence therapists (35%). For violent felony recidivism, Low Adherence therapists' clients had a rate of 10%, compared with control (6%) and High Adherence therapists (4%; Sexton & Turner, 2010).

Study 8

Meta-analysis

A meta-analysis was conducted using: (1) Alexander & Parsons, 1973; (2) Barnoski, 2004; (3) Barton, et al., 1985; (4) Gordon, et al., 1995; (5) Gordon, 1995; (6) Klein, et al., 1977; (7) Sexton & Turner, 2010; and (8) Alexander, Barton, Gordon, Grotpeter, Hansson, Harrison, Mears, Mihalic, Parsons, Pugh, Schulman, Waldron, & Sexton, 1998.

The adjusted effect size for FFT was -0.32 with a standard error of 0.15 for age 16, and -0.32 with a standard error of 0.29 for age 26.

Study 9

Evaluation Methodology

Design: For this evaluation, Functional Family Therapy (FFT) was compared to a parent group on numerous measures of adolescent substance abuse obtained from both the adolescent clients and their mothers. All families included parents and adolescent drug abusers who were recruited from six outpatient drug-therapy programs. Families were randomly assigned to either the FFT method (n = 85) or the parent group method (n = 50). For the purposes of this evaluation, both programs were delivered in 24 weekly sessions. Post-test data were collected 15 months after initiation of treatment, or approximately 9 months after termination of the 6-month treatment. For the dropout families and early terminators, there was a longer period between termination of treatment and the evaluation.

The FFT model focused on improving family communication, fostering trust and providing feedback to families about their functional dynamics. The parent group method taught active listening skills, constructive confrontation and negotiation of power. The parent group method was based on several existing programs including Parent Effectiveness Training (PET), the Parent Communication Project of the Canadian Addiction Research Foundation, and the Parent Assertiveness Training Program. Both groups were provided with access to individual drug counseling.

Attrition: Of the 169 families that started treatment, 135 (80%) were retained for evaluation 15 months later.

Sample: The sample was predominantly male (60%) and white (89%). The adolescents had a mean age of 17.9 years and a mean education of 9.3 years (which is significantly below the expected education level for individuals of similar age). A total of 44% of the adolescents admitted to having sold drugs, and 40% had been arrested at least once. Substance use among clients was high: In the previous year, 95% of the adolescents had used alcohol, 94% had used marijuana, 69% had used amphetamines and 41% had used cocaine. Of the parents, about 51% lived together, and the remaining were divorced (37%) or separated (8%).

Measures: Both adolescents and their parents were administered a variety of survey instruments.

Client Assessment Battery

A comprehensive, structured interview was administered to each adolescent. The interview gathered information on their personal history, behavior, relationships and attitudes. Additionally, several standardized assessments were administered:

  • Rosenberg Self-Esteem Scale (11 items).
  • Brief Symptom Inventory (53 items).
  • Family Roles Task Scale (25 items).
  • Parent-Adolescent Communication Form (20 items).
  • Family Environment Scale (90 items).

Parent Assessment Battery

The mother of the adolescent also received a structured interview on family history, membership and structure, demographics, SES, living arrangements, how and why the adolescent entered treatment, problems related to drug use and other emotional or behavioral problems of the client. Additionally, several standardized assessments were administered:

  • Family Role Task Behavior Scale (25 items).
  • Parent-Child Relationship Problems Scale (32 items).
  • Emotional/Psychological Problems Inventory (35 items).

Drug Severity Index

A summary score of drug severity was also used as a key outcome variable. The score was based on the sum of multiple frequencies and risk levels for various substances, including opiates, hallucinogens, inhalants, alcohol, marijuana and over-the-counter drugs.

A factor analysis reduced some 65 separate measures to 15 outcome measures: six based on factor scores for the adolescent's data, and nine based on factor scores for the mother data.

Adolescent measures

  1. How well do you get along with your mother?
  2. Negative self-image.
  3. Number of positive role behavior in the family.
  4. Degree of conflict within the family.
  5. Drug severity index.
  6. Adolescent father communication.

Mother measures

  1. Number of adolescent's negative or problem behaviors.
  2. How often have family relations been tense?
  3. Adolescent's delinquency/problems with the law.
  4. How frequently has the adolescent been using drugs in the past 3 months?
  5. Number of mother's negative types of reactions to the adolescent (sub-divided into 19 items).
  6. To what degree do you approve of your adolescent's behavior/attitude during the past months?
  7. How frequently has your adolescent been using alcohol in the past 3 months?
  8. Adolescent has problems in school.
  9. Is the adolescent in conflict with the parent(s)?

Analysis: Multiple regression analysis was used to determine whether either group showed a significantly greater degree of change on any of the 15 factor-score outcome criteria. For the 15 regression equations, classes of independent variables were entered as follows: (1) Those variables on which the two treatment groups to be compared differed significantly or showed a trend towards significant difference in status at admission were entered at step 1 as control variables. (2) The characteristics of the adolescents or families at baseline that correlated to a significant degree with the amount of change in the dependent variable from baseline to follow-up (the change score) were entered as step 2. (3) The value (score) obtained by each subject in the two treatment groups at baseline on the outcome criterion value was entered as step 3. (4) The dichotomous variable designating the assignment of the subject to either of the two treatment groups being compared as the key independent predictor variable in the regression equation was entered as step 4. The dependent variable in each equation was the value (score) obtained by the subject at post-test on the particular outcome criterion variable being analyzed.

Outcomes

Implementation fidelity: All therapists were experienced family counselors. For this study, therapists received instruction in the FFT approach in a two-day workshop, as well as in biweekly case reviews. Additionally, a monitoring procedure was implemented to ensure that therapists adhered to the standardized therapy model. This analysis revealed that only 3% of the sessions were inconsistent with the goals of FFT. There were no significant differences between the two groups in terms of the number of sessions attended. However, families assigned to FFT had significantly more involvement from both parents, when compared to the parent group. There were no significant differences between the two groups of adolescents on either the number of individual or the number of group sessions they attended.

Baseline equivalence: Clients in the parent group were significantly younger and had significantly less education than the FFT group.

Differential attrition: In the parent group, a disproportionate number of parents did not show for any of the therapy sessions. Otherwise, the study did not report on tests for differential attrition.

Post-test: There was no significant difference between the family therapy or parent groups on any of the 15 analyses performed. Although family therapy proved no better than the parent group, adolescents and their parents from both groups reported several significant improvements including: (1) reductions in adolescent substance use/abuse, (2) decrease in adolescent psychiatric symptomology, (3) decrease in adolescent negative family role task behavior and increase in positive behavior within the family and (4) improvement in adolescent communication with mother and father.

Brief Bullets

  • There was no significant difference between the family therapy or parent groups on any of the 15 outcomes examined.
  • Both groups demonstrated significant and similar reduction in substance use/abuse, psychiatric symptomology, negative family role task behavior and improvements on positive behavior and adolescent communication within the family.

Limitations

  • Since adolescents from both treatment groups also participated in individual counseling sessions, it is difficult to determine if it was the intervention program or the individual counseling sessions that was responsible for change.
  • There were some problems with baseline equivalence, in that adolescents in the parent group were significantly younger and had significantly less education than the family therapy group.
  • No analysis of differential attrition.
  • No program benefits when compared to parent group therapy.

Study 10

Evaluation Methodology

Design: This evaluation examines the effectiveness of two family-based treatments in runaway adolescents with alcohol problems. All participants were recruited through two runaway shelters in Albuquerque, NM. At baseline, 119 participants were randomized to one of three study conditions: (1) ecologically-based family therapy (EBFT; n = 37), (2) office-based functional family therapy (FFT; n = 40) and (3) service as usual (SAU; n = 42). Assessment was conducted at baseline, 3, 9 and 15 months post-baseline.

The sample was one of convenience, and youth were approached while at the shelter and were not otherwise seeking treatment. To be eligible, adolescents had to have a primary alcohol problem (e.g., alcohol dependence) and be between the ages of 12 and 17. Additionally, families had to reside within 60 miles of the research site. Youth were ineligible if they resided with foster families or were wards of the state. Both EBFT and FFT were offered for 16, 50-minute sessions, about one each week for a total of 3-4 months.

The ecologically-based family therapy (EBFT) intervention was modeled after the Homebuilders Family Preservation model. This family-based therapy was conducted at the home of the participant with a therapist/case manager who facilitated meetings and coordinated services based on the family's needs. EBFT focused on communication and parenting skills, as well as a number of behavioral, cognitive and environmental interventions, depending on an assessment of the family's needs. Like FFT, treatment was provided in a non-confrontational, non-hostile tone.

Functional family therapy was similar to the FFT approach described above. Here, the goal was to alter dysfunctional family patterns that contribute to alcohol abuse, running away and other problem behaviors. Unlike home-based versions of FFT, this evaluation focused on an office-based version of therapy in which families travel to the office of the therapist.

The control group consisted of subjects assigned to the Service as usual (SAU) condition. This condition consisted of informal meetings and case management , and was provided by staff at the shelter.

Eligible subjects were randomly assigned to the three conditions using a procedure called urn randomization that successively adjusts probabilities of assignment according to the distribution of age, gender, ethnicity and other variables.

Attrition: Of the 119 participants at baseline, a total of 75 (63%) completed all assessments. This included 23 (62%) in the EBFT condition, 40 (65%) in the FFT condition and 26 (62%) in the SAU condition.

Sample: The sample was 55% female and all participants were between 12 and 17 years old, with a mean of 15.1 years. Race/ethnicity was 5% African American, 29% Anglo, 52% Hispanic and 22% other. All participants were primary alcohol-using and 106 (89%) met DSM-IV criteria for alcohol abuse or dependence. Additionally, 66% of the youth had a diagnosis of marijuana abuse/dependence and 22% had a diagnosis of 'other' substance abuse/dependence. Of the 13 youth not meeting criteria for alcohol abuse or dependence, all showed patterns of problem alcohol use.

Measures: All participants were administered a basic demographic questionnaire that included a urine toxicology screen and a self-reported physical- and sexual-abuse history. Primary caretakers were also provided with five self-report questionnaires (which they were to return to the researchers), but response rate was very low. Other measures included:

  • Substance use: The Form 90, Problem Oriented Screening Instrument for Teenagers (POSIT) and Adolescent Drinking Index (ADI) were used to assess alcohol and drug use patterns. Additionally, urine toxicology screens were collected at baseline and post-test.
  • Psychological functioning: The Youth Self-Report of the Child Behavior Checklist, Beck Depression Inventory, National Youth Survey and Delinquency Scale (NYSDS) and Shaffer's CDISC were all used to assess self-reported delinquency, aggression, depression and anxiety.
  • Family functioning: The Family Environment Scale (FES), Conflict Tactic Scale (CTS) and Parental Bonding Instrument were used to assess conflict resolution, family functioning and parent-child relationships.

Analysis: Treatment differences were assessed using a series of 3 (treatment modality) X 4 (time) repeated measures ANOVAs. The number of treatment sessions was used as a covariate for all analyses. Since the SAU group did not meet with project therapists, the number of outside treatment sessions was taken from a self-report measure. For the other study conditions, the number of sessions were taken from therapist records, and data from outside therapy sessions was taken from self-report. Intent-to-treat analysis was completed with all study participants, although the authors conducted a separate analysis for the treated group.

Outcomes

Implementation fidelity: All therapists were provided with a 2-day training in both FFT and EBFT. All therapists had a master's degree, professional license and between 2 - 5 years of experience. Audiotaped recordings were used for adherence-to-protocol checks. There were differences among groups in the number of sessions attended, with those in EBFT attending more sessions than those in FFT. Additionally, EBFT therapy engaged more participants (defined as more than five sessions attended) than FFT.

Baseline equivalence: The SAU group reported higher scores on the NYSDS than either the FFT or EBFT group. No other differences among groups on demographic characteristics or main variables are reported (p's were set at .10).

Differential attrition: There were no significant differences between those who completed all assessments and those who did not on any dependent variable or demographic characteristic (p's were set to .10).

Post-test:

In the intent-to-treat analysis, only 1 of 19 outcomes differed significantly across groups. The percentage of days of drug or alcohol use significantly decreased for both the ecologically based family therapy (EBFT) and functional family therapy (FFT) groups. All other outcomes failed to show significant differences.

Brief Bullets

  • Both ecologically based family therapy (EBFT) and functional family therapy (FFT) significantly reduced alcohol and drug use when compared to service as usual (SAU).

Limitations

  • Convenience sample from only two runaway shelters in one city.
  • Only 1 of 19 outcome variables attained significance.
  • One outcome difference at baseline.
  • Design included a 10-11 month follow-up, but did not reach one year.

Study 11

Evaluation Methodology

Design:

Recruitment /Sample size: The sample included 72 adolescents ages 11-17 who lived with a parent or guardian and had a history of aggressive behavior, destruction of property, or chronic truancy. Youth with serious criminal behavior, drug or alcohol use, or mental health problems were not eligible. The subjects came from a single county in New Jersey and were referred for help by a diverse set of agencies and service providers in the county.

Study type/Randomization/Intervention: The study used a quasi-experimental design that assigned subjects to FFT (n = 36) or a program of individual therapy or mentoring (n = 36). Subjects in the FFT condition received treatment from the Children at Risk Resources and Interventions – Youth Intensive Intervention Program, while subjects in the comparison condition went first to Youth Case Management, which then referred clients to treatment providers across the county. Subjects in the two conditions were referred to the programs from mostly different sources. FFT subjects came from Probation, the Family Crisis Intervention United, Family Court, and the Divisions of Youth and Family Services (81% of the cases were mandated to participate in FFT); comparison subjects came from various sources, including Children Mobile Response and Stabilization Services, the Division of Youth and Family Services, and parents.

The authors said that the FFT subjects were compared with matched youth, but subjects assigned to each condition were largely referred by different agencies and treated by different organizations. The matching appears to refer to selection of the comparison group by case managers and the agency supervisor who had been trained by research staff in identifying appropriate cases for the study (p. 27). No other information on matching was provided.

Assessment/Attrition: All 72 subjects completed the initial assessment before the intervention and a posttest at discharge from the intervention. The duration of the interventions varied across subjects and families, but the FFT group had a mean of 3.4 months and the comparison group had a mean of 4.5 months.

Sample characteristics: The authors noted that the sample was more diverse than in other FFT evaluations.Most youth were male (61-69%). The sample had a mean age of 15.1-15.5, and consisted of African Americans (36-44%), Latinos (33-36%), whites (14-19%), and others (8%). The study stated that the group was also diverse in terms of reasons for referral to the program.

Measures:

Outcome measures came from the Strengths and Needs Assessment, an instrument constructed specifically for this evaluation. The study stated that that the assessment exhibits face, construct, and predictive validity and also shows good interrater and auditor reliability, but it listed references to previous studies rather than specifics for this data set.

In consultation with each client and family, FFT therapists who delivered the interventions also scored the measures. For the comparison group, case managers scored the measures. Both therapists and case managers received training and ongoing guidance in using the assessment instrument.

The general instrument contains seven dimensions:

  • life domain functioning related to family, school, and vocation,
  • child strengths in areas of family life, personal achievements, and community involvement,
  • acculturation in language and culture,
  • caregiver strengths (involvement with child and stability at home),
  • caregiver needs (mental and physical health problems)
  • child behavioral/emotional needs (impulsivity, depression, anxiety, anger control, substance abuse), and
  • child risk behaviors (suicide risk, self-mutilation, danger to others, sexual aggression, running away, delinquency, fire setting).

Analysis: The analysis used ANCOVA to compare differences across conditions in the change from pretest to posttest.

Outcomes

Implementation fidelity: Each therapist had to complete FFT Site Certification Training and was monitored via a web-based system. Additional support came from calls with a national FFT consultant and from onsite contact with a certified supervisor. However, no fidelity measures were reported.

Baseline Equivalence: Tests showed no significant differences between the conditions on gender, race/ethnicity, length of time in the program, and the seven outcome measures.

Differential attrition: All subjects completed both pretest and posttest.

Post-test: Most of the results examined the significance of changes within conditions, showing that both conditions generally improved the outcomes, but Table 5 tested for differences in changes across conditions. These results showed significantly greater improvement in the FFT group for three of the seven outcomes: life domain functioning, child behavioral/socioemotional need, and child risk behaviors.

Long-term effects:

The study did not collect long-term, follow-up data and therefore was not able to demonstrate sustained effects.

Limitations

  • The quasi-experimental design did little in the way of formal matching, and assignment may be biased by differential selection.
  • The therapists delivering the FFT intervention also provided the outcome measures.
  • The study provided no details on reliability and validity of the measures for this data.
  • The sample came from one county in New Jersey.

Study 12

Evaluation Methodology

Design:

Recruitment: The study included 45 families referred by Social Services in one county in Sweden. A social worker referred young people suspected of crimes by the local police, based on his or her clinical judgment. No additional inclusion criteria were provided.

Assignment: The treatment group (N = 45) was matched with 17 comparison individuals, who were also suspected of crime and referred by the police, based on borough, gender, age, type of crime, and proximity of timing of the charge. The study matched the 45 treatment group participants with 43 comparison group individuals, however the analysis only included 17 who were recommended some form of treatment that was comparable with FFT. It is not clear why the other comparison group individuals did not receive the treatment. Note also that most of the analyses focused only on the FFT group, without a comparison group.

Assessments/Attrition: Recidivism was measured for the 18 months after first contact with the study; all other measures were collected before and after treatment. The study had recidivism data on all participants. In the follow-up survey of FFT participants, 36 families (80%) responded.

Sample: The most common type of crimes among participants were theft (40%), assault/robbery/intimidation (26%), and shoplifting (23%). Approximately half of participating young people lived with both parents, 90% of participants were male, and the average age was 15.

Measures: The study used administrative records of recidivism or relapse, but did not define what constituted recidivism. For the FFT treatment group only, participants completed survey measures: 1) the Family Climate questionnaire, used to measure closeness, distance, spontaneity, and chaos, 2) the Family Relationship Scale, measuring relational disturbances in the family. The study stated that these measures had good reliability and validity, but did not report measures, and were self-reported measures, but it was not clear if the adolescent completed the questionnaire or the parent. The study also used 3) the Child Behavior Checklist on child competence and behaviors, elsewhere described as a parent-report, 4) the Youth Self Report, also describing internalizing and externalizing behaviors, and 5) the Symptom Checklist for parent symptoms. The study also reported these measures to have good validity and reliability, without measures. The study also reported results from the Sense of Coherence questionnaire and Stegen’s Ladder of Life measure, but did not provide information on these measures.

Analysis: The study compared recidivism rates among participants 18 months after first contact with the program using a chi-square analysis and no controls. Analyses of the other measures examined change over time within the treatment group and without a control group

Intent-to-Treat: The study used all available data for the recidivism measure, but in analyzing the survey data, it excluded the control group.

Outcomes

Implementation Fidelity: The study did not include any measures of fidelity.

Baseline Equivalence: The study stated that there was no statistical difference between the treatment and comparison group “as regards which official measures were taken by the police,” which may refer to the type of crime for which the subjects were charged.

Differential Attrition: The study reported that there were no significant differences in recidivism among treatment group individuals who participated in the follow-up and those who did not. The study did not report any other tests of differential attrition.

Posttest: The study found a significantly lower proportion of participants in the treatment group recidivated 18 months after first contact, as compared to the control group.

Results limited to the treatment group and without a control group showed improvements from pretest to posttest for somatic complaints, anxiety, social problems, attention problems, aggression, internalized symptoms, externalized symptoms, and a total problem behavior score. There was also improvement in a second measure of withdrawal, anxiety, social problems, cognitive problems, attention problems, criminal behavior, aggression, internalized symptoms, externalized symptoms, and a total measure. In addition, there was improvement in the Stegen Ladder of Life, which measures participant optimism about the future in both current outlook and perception of one year in the future.

Risk and Protective: At the posttest, again for the treatment group only, the results showed higher scores for family closeness, lower distance, and lower chaos, as compared to pretest. For measures of family function, the treatment group reported improvements in attribution, over-involvement, and the total family function score from pretest to posttest. From pretest to posttest, the treatment group reported improvements in parent psychiatric symptoms: somatic, depression, anxiety, anger, paranoia, other, and a total measure.

Long-Term: The follow-up for the recidivism measure is 18 months from first contact with the program, it was unclear if this constituted a long-term follow-up.

Study 13

Evaluation Methodology

Design:

Recruitment: Participants were the families of adolescent males (aged 11-17 years) who were ordered to family services as a condition of probation by one Philadelphia Family Court judge between 15 September 2013 and 4 February 2016. Given the presence of gangs in the city, the youth were considered at high risk for gang involvement. Youth were ineligible for study participation if they had been referred to FFT services in the past year. Out of the 158 families assessed for eligibility, a total of 129 families consented to participation in the study.

Assignment: Participating families (n=129) were randomly assigned to the FFT intervention condition (n=66) or a treatment-as-usual control group (n=63), which received the Family Therapy Treatment Program (FTTP). Both groups received a wide variety of other services besides FFT and FTTP. Also, the authors pointed out a problem of contamination: 21% of control subjects received FFT, while 20% of the intervention group did not receive FFT.

Attrition: Assessments occurred at baseline, 6 months post-randomization, and 18 months post-randomization. The 6-month assessment appears to serve as a posttest, and the 18-month assessment includes 12 months after program end. There was approximately 8% attrition at the 6-month self-report assessment, but the 18-month assessment used official data and there was no attrition.

Sample:

Youth participants were exclusively male and predominantly Black (80%), with an average age of 15 years. Approximately 18% reporting living with both parents; virtually all participants lived with at least one parent. Parent participants were majority female (79%) and Black (80%) with an average age of 41 years. Most reported having a high school diploma or equivalent (78%). Most were currently receiving public assistance (83%).

Measures:

Recidivism was measured at 18 months post-randomization, with data on arrests, prevalence of felony charges, dispositions, percentage adjudicated delinquent, and residential placements collected from official sources. Two researchers coding the measures showed high agreement (94-100%). Delinquency was measured at baseline and 6 months post-randomization using adolescent self-reports on delinquency variety (α=.68-.81). Alcohol and substance abuse were measured at 6 months post-randomization with adolescent self-reports of substance variety (α=.59-.62), alcohol frequency (α=.89-.90), and marijuana frequency (single item), as well as with parent reports of youth substance variety (α=.47-.53) and marijuana frequency (single item). Gang involvement was measured at baseline and 6 months post-randomization with adolescent self-report on a single-item response.

Risk factors:

Gang risk was measured at baseline through adolescent self-reports of current or former gang membership as well as current or former gang membership of family members and close friends. Participants who responded “yes” to any of these questions were considered high risk.

Attitudes towards delinquency/drug abuse were measured at baseline and 6 months post-randomization with parent reports (α =.84-.94) and adolescent self-reports (α=.90).

Analysis:

The effects of the program were evaluated by comparing posttest adjusted means, which were calculated using response-appropriate regression models that controlled for baseline outcomes whenever possible and covariates for pretest predictors that differed significantly across conditions. When baseline outcomes were not available, covariates included all pretest measures that significantly predicted the outcome. The text used a .10 significance level in its interpretation but reported probabilities to allow for use of a .05 level.

Intent-to-Treat: All available data were used.

Outcomes

Implementation Fidelity:

Eighty percent of intervention participants received at least one program session, with 53% completing the program. Fidelity was reviewed by the program consultant in weekly meetings, with the average fidelity rating a 4.1 out of 6 for all clients who began the program.

Baseline Equivalence:

There were significant baseline differences between conditions on four (out of 65) tests: delinquency, violent delinquency, drug use variety, and past residential placements.

Differential Attrition:

Tests for baseline-by-condition attrition examined the interaction of condition and attrition status for each of the pretest variables. There were no significant interactions for the youth, and only one significant interaction for parents. Footnote 5 states, “The control attritors were younger than their post-tested counterparts (35 vs 41) while the treatment attritors were older than their post-tested counterparts (45 vs 41).” There was no attrition at the 18-month follow-up assessment.

Posttest:

At 6 months, 27 tests for outcomes showed no significant effects and 15 tests for risk and protective factors showed no significant effects.

When stratified by baseline gang risk level, at 6 months post-randomization, high gang risk treatment youth had significantly lower self-reports of general delinquency and alcohol frequency, as well as a marginally significant reduction in recent residential placements compared to the high gang risk control group youth.

Long-Term:

The observation period covered at least one year after program completion but results for recidivism mixed the 6-month period of program implementation with the additional 12 months after program end. Over the full 18 months after randomization, compared to the control group, youth in the treatment group had significantly fewer new drug charges and delinquent adjudications. There was a marginally significant reduction in new property charges.

Compared to high risk control group youth over the 18 months after randomization, high gang risk treatment group youth had a significantly lower percentage facing person or property charges (0-18 months), percent and number of arrests (7-18 months), and percent facing felony charges (7-18 months). Low gang risk treatment group youth had significantly fewer drug charges through 18 months post-randomization compared to low gang risk control group participants.

Study 14

Evaluation Methodology

Design:

Recruitment: Youth and parents were recruited from 2008 to 2011 through Offender Services, Support Services, and other crime-prevention agencies in two counties in England. The youth, ages 10-18, had been sentenced for offending or were receiving agency intervention following contact with the police. The study excluded youth not living at home, having a sibling in the study, not speaking fluent English, or showing a severe developmental delay; it excluded parents receiving a parenting program or not speaking fluent English. The total eligible sample was 111 families.

Assignment: After baseline assessment, families were independently randomized to FFT (N = 65) or a control group (N = 46) using constrained adaptive randomization. The randomization ratio was varied to ensure adequate caseloads for FFT therapists and ranged from 3:1 FFT cases to control cases during the early period to 1:3 FFT to control cases at the end.

The management-as-usual control group worked with a case manager who provided counseling and variety of support services to help with youth problems. The control participants did not receive family therapy but were substantially involved with the youth justice agencies in the community, including participation in reparation and victim awareness programs. The intervention group (referred to as FFT-MAU) received both family therapy – from three therapists – and management as usual.

Assessments/Attrition: Assessments came six and 18 months after randomization. With three to six months of FFT, the six-month assessment served as a posttest and the 18-month assessment as a one-year follow-up. The completion rates were 81% at the posttest and 80% at the one-year follow-up.

Sample:

Youth were predominantly male (70%) and White British (90%), with below average IQ (mean = 84). Most lived with single (55%), unemployed (57%) caregivers, 85% of whom were the youth’s biological mother; 60% of caregivers had no education beyond the age of 16.

Measures:

The primary outcome of self-reported delinquency came from questions about 19 criminal acts committed over the last six months (at posttest) or the last 12 months (at follow-up). The measure summed the frequency of each act (alpha = .87).

There were ten secondary outcomes. One measure of convicted offenses came from records in the national computer database. The offenses included community sentences, custodial sentences, and police cautions for minor offenses.

Four measures of symptoms and diagnoses of oppositional defiant disorder and conduct disorder came from parent interviews. Coders used a semi-structured diagnostic interview, with high intercoder reliability (ICCs ranged from .95 to .99). The supplementary document noted that coders did not know of condition assignment.

Four outcomes came from observations of parent-youth interactions. Trained coders rated youth positive behaviors, youth negative behaviors, positive parenting, and negative parenting. Coders did not know of condition assignment, and intercoder reliability was high (ICCs ranged from .74 to .86).

One parent-reported measure of poor child monitoring included items such as not knowing the child’s friends. It had an alpha reliability of .74.

Analysis:

The analysis used linear mixed models with repeated measures, interaction terms for condition-by-time, individual random intercepts, and a control for the baseline outcome. Consistent with randomization, the family (i.e., either youth or parent) served as the unit of analysis. To deal with attrition, the models included any baseline variable associated with missing outcome data as a predictor and, as a result, the covariates varied depending on the outcome.

Intent-to-Treat: The mixed models included all available data, including those with partial completion of the three assessments, although the analysis did not impute missing data.

Outcomes

Implementation Fidelity:

An FFT consultant monitored the session notes of the therapists, and the study reported that fidelity to the FFT model was adequate or better for 77% of cases. About 95% of the FFT group started therapy and 59% completed all five phases of treatment.

Baseline Equivalence:

Table 1 lists condition means at baseline, which appear similar, but it did not include significance tests.

Differential Attrition:

The study tested for relationships of baseline characteristics with missingness and reported (p. 1027) that gender, age, hot topics (i.e., parent-youth interaction), and referral agency were significantly related to missing data for one or more of the outcomes. Other than noting that the models controlled for these measures, the text provided no further information.

Posttest:

For the primary outcome of self-reported delinquency, the program failed to have a significant effect at posttest. The program similarly had no effect on any of the ten secondary outcomes.

Long-Term:

At the one-year follow-up, the program had no effect on the primary outcome of self-reported delinquency. The only significant effect for the ten secondary measures was possibly iatrogenic – the control group had higher observed positive youth behavior.

Contact

Blueprints for Healthy Youth Development
University of Colorado Boulder
Institute of Behavioral Science
UCB 483, Boulder, CO 80309

Email: blueprints@colorado.edu

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Blueprints for Healthy Youth Development is
currently funded by Arnold Ventures (formerly the Laura and John Arnold Foundation) and historically has received funding from the Annie E. Casey Foundation and the Office of Juvenile Justice and Delinquency Prevention.