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Journal of Marital and Family Therapy

doi: 10.1111/j.1752-0606.2011.00257.x
January 2012, Vol. 38, No. 1, 82–100

FAMILY-BASED INTERVENTIONS FOR CHILD


AND ADOLESCENT DISORDERS
Nadine J. Kaslow
Emory University

Michelle Robbins Broth


Georgia Gwinnett College

Chaundrissa Oyeshiku Smith and Marietta H. Collins


Emory University

Emotional and behavioral symptoms and disorders are prevalent in children and adoles-
cents. There has been a burgeoning literature supporting evidence-based treatments for
these disorders. Increasingly, family-based interventions have been gaining prominence
and demonstrating effectiveness for myriad childhood and adolescent disorders. This
article presents the current evidence in support of family-based interventions for mood,
anxiety, attention-deficit hyperactivity, disruptive behavior, pervasive developmental
particularly autism spectrum, and eating disorders. This review details recent data from
randomized controlled trials (RCTs) and promising interventions not yet examined using
a randomized controlled methodology. It highlights the evidence base supporting various
specific family-based interventions, some of which are disorder dependent. A practitioner
perspective is then offered with regard to recommendations for future practice and
training. The article closes with a summary and directions for future research.

One evidence-based practice gaining in popularity for child and adolescent mental disor-
ders is family-based interventions. Family-based interventions may include the following sub-
systems: parents, parents and children, entire families, multiple families, and families and the
systems in which they are embedded (multisystemic). Recent reviews pay attention to systemic
interventions that fall under the rubric of family-based interventions, including family therapy
(Bray & Stanton, 2009; Carr, 2009; Diamond & Josephson, 2005; Sexton, Alexander, &
Mease, 2004). These reviews suggest that for a range of disorders in youth, family interven-
tions, including family therapy, may be effective, either as the sole treatment or in conjunc-
tion with other modalities, and outcomes are most positive when parents are engaged in the
treatment and efforts are made to enhance parenting and ameliorate maladaptive family envi-
ronments.
This article reviews RCTs for family-based interventions focusing on outcome studies pub-
lished since 2003, when the last review was presented in the Journal of Marital and Family Ther-
apy (Northey, Wells, Silverman, & Bailey, 2003). Building on that review, this article examines
family-based interventions for disorders that are prominent in youth: mood, anxiety, attention-
deficit, disruptive behavior, pervasive developmental, and eating. We are not including in this
review conduct disorders (CD) or delinquency or substance-related disorders because these are
included in depth in other articles within this special issue. Studies were found using Google
Scholar, PSYCHINFO, and MEDLINE, putting together disorder and family intervention
terms. Study selection was universal. Programs are listed as promising if there are some data to
support their efficacy, but no full-scale RCT. Sections present conclusions from prior reviews,
recent findings from RCTs, and promising interventions not yet tested via RCTs. Following the

Nadine J. Kaslow, PhD., ABPP, Chaundrissa Oyeshiku Smith, PhD., ABPP, and Marietta H. Collins, PhD,
Department of Psychiatry and Behavioral Sciences, Emory University; Michelle Robbins Broth, PhD,
Department of Psychology, Georgia Gwinnett College.
Address correspondence to Nadine J. Kaslow, Department of Psychiatry and Behavioral Sciences, Grady
Health System, 80 Jesse Hill Jr Drive, Atlanta, Georgia 30303; E-mail: nkaslow@emory.edu

82 JOURNAL OF MARITAL AND FAMILY THERAPY January 2012


provision of a summary of the research and a discussion of future directions, concluding
comments are offered from a practitioner perspective.

DEPRESSION

Primary Findings from Prior Review


Northey et al. (2003) noted the dearth of rigorous research on family-based interventions
for youth depression. They discussed four studies that used parents or families to treat adoles-
cent depression. Two studies of the Coping with Depression Program for Adolescents
(CWD-A; Lewinsohn, Clarke, Hops, & Andrews, 1990; Lewinsohn, Clarke, Rohde, Hops, &
Seeley, 1996) revealed that relative to a wait-list control group, CWD-A with and without the
parental component showed reductions in adolescents’ depression symptoms. No differences
were found between the two CWD-A groups, suggesting that the parental component offered
little benefit beyond the intervention with the adolescents only. In the second set of studies,
Brent et al. (1997) (Kolko, Brent, Baugher, Bridge, & Birmaher, 2000) found that individual
cognitive behavior therapy (ICBT) had a greater impact on adolescents’ depressive symptoms
than Systemic Behavior Family Therapy (SBFT). There was no difference between ICBT and
SBFT with regard to family functioning. After the Northey review was published, parents
reported that the SBFT was the least credible of the three treatments (Stein et al., 2001), raising
questions about buy-in. These studies raise questions about whether incorporating family ther-
apy for adolescent depression provides additional benefit.

Recent Findings from RCTs


Since the prior review, RCTs have examined programs with a parental or family component
to treat depression in youth. The only study with children is the Stress-Busters program, a school-
based, cognitive behavior therapy (CBT)-based family education intervention that combines teach-
ing cognitive behavioral, skill-building strategies for youth, sharing those skills with parents, and
having one family education session to enhance generalizability and promote a more supportive
family environment (Asarnow, Scott, & Mintz, 2002). Post-intervention, fourth through sixth grad-
ers who received the Stress-Busters intervention had higher satisfaction and fewer depressive symp-
toms, negative cognitions, and maladaptive coping responses than those in the wait-list control.
One RCT compared CWD-A plus parent to a life skills or tutoring control group for
youth who met criteria for both major depressive disorder (MDD) and CD (Rohde, Clarke,
Mace, Jorgensen, & Seeley, 2004). Post-intervention, but not follow-up, data revealed that
adolescents in the CWD-A-plus-parent group had better rates of recovery from depression than
youth in the control group.
Attachment-Based Family Therapy (ABFT) uses a family systems approach based on attach-
ment theory to treat adolescent depression (Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002;
Diamond, Siqueland, & Diamond, 2003). For parents, ABFT focuses on criticism, disengagement,
personal stressors, and parenting skills. For adolescents, it focuses on affect regulation,
self-concept, motivation, and disengagement. Treatment tasks include relational reframing, alli-
ance-building, reattachment, and promoting competency. In an RCT, ABFT resulted in fewer ado-
lescents meeting criteria for MDD after completing the 12-week program and at 6-month follow-up
than did adolescents in the minimal contact control group (Diamond et al., 2002). ABFT was more
successful in reducing depression and anxiety symptoms, hopelessness, and suicidal ideation and
was linked with greater improvements in mother–adolescent attachment (Diamond et al., 2002).
An enhanced version of the Penn Resiliency Program (PRP) included a parental compo-
nent that provided a manualized, psychoeducational group approach to teach parents compara-
ble skills to their children and train them to use these skills in their parenting (Gillham et al.,
2006). In an RCT, enhanced PRP was more effective than usual care in decreasing depression
and anxiety symptoms through a 1-year follow-up period.
As family psychoeducation (FPE) is covered in another article in this special issue, only
brief mention of its efficacy will be presented. In an RCT, Fristad, Goldberg-Arnold, and
Gavazzi (2003b) found that at 6-month follow-up, families of 8- to 11-year-olds with depression
and bipolar disorder (BD) in the Multifamily Psychoeducational Group (MFPG) reported

January 2012 JOURNAL OF MARITAL AND FAMILY THERAPY 83


greater gains in parental knowledge about childhood symptoms, increased positive emotions
and family interactions, more positive perceptions of parental and peer support from the chil-
dren, and greater use of appropriate services than those in the wait-list control group. Another
pilot RCT found that at 3-month follow-up, families of depressed adolescents receiving 12 ses-
sions of in-home FPE had higher treatment satisfaction, greater improvement in adolescent–
parent relationships, and a greater decline in depressive symptoms than families in the usual
treatment control group (Sanford et al., 2006).

Promising Interventions—Non-RCTs
Two promising family-based interventions exist for the treatment of depression in youth.
The ACTION treatment program offers a developmentally- and gender-sensitive intervention,
alone or with a parent training component, for depressed girls (Stark, Herren, & Fisher, 2009;
Stark et al., 2008). ACTION is associated with a 70% recovery rate when offered alone or in
combination with parent training. Youth whose parents participated had a more positive out-
come than those not assigned to receive that intervention. Another intervention for hospitalized
depressed youth involves the Depression Experience Journal (EJ), a computer-based psychoedu-
cational intervention for families guided by a narrative approach (Demaso, Marcus, Kinnamon,
& Gonzalez-Heydrich, 2006). The EJ uses a web-based forum to focus on mutual self-disclosure
of personal stories about childhood depression. A feasibility study revealed that parents experi-
enced high satisfaction and a low sense of concern for harmfulness with the EJ.

BIPOLAR DISORDER

Primary Findings from Prior Reviews


The prior review did not focus on BD. A more recent review describes four interventions
implemented with differing levels of empirical rigor (Young & Fristad, 2007). These approaches
involve children and caregivers, are cognitive behavioral, target a range of skills, and have a
psychoeducational component. Although the authors note that these approaches are promising,
they argue that larger, more rigorous studies are needed and that these approaches represent an
initial step in the psychosocial treatment and management of childhood BD.

Recent Findings from RCTs


Miklowitz et al. (2004) randomly assigned adolescents with BD I, II, or NOS to pharmaco-
therapy with either family-focused treatment (FFT) or enhanced care (EC), and the participants
were followed for 2 years. FFT included psychoeducation and training in communication and
problem-solving skills, whereas EC involved three relapse prevention-focused family sessions
only. FFT was more beneficial than EC regarding recovery from and trajectory of depressive
symptoms; the comparable benefit regarding manic symptoms favored FFT over EC but did
not reach statistical significance. The beneficial effect of FFT was moderated by the family’s
level of EE (Miklowitz et al., 2009).
Fristad, Gavazzi, and Mackinaw-Koons (2003a) developed MFPG, used for caregivers in
families of children with BD as well as depression. In one RCT with 8- to 11-year-old children
with BD or MDD or DD, MFPG increased knowledge about mood disorders, improved skills,
heightened sense of support, and was linked to overall positive attitudes toward treatment post-
treatment as compared to a wait-list control (Fristad, Goldberg-Arnold, & Gavazzi, 2002).
A second, larger RCT of children with BD or MDD or DD found that those in the MFPG
condition showed a decline in mood symptoms posttreatment relative to those wait-listed
(Fristad, Verducci, Walters, & Young, 2009). The benefit of MFPG was mediated by parents’
beliefs about treatment and their utilization of quality services (Mendenhall, Fristad, & Early,
2009). Individual Family Psychoeducation (IFP) improved children’s mood symptoms and
reduced families’ levels of EE (Fristad, 2006).

Promising Interventions—Non-RCTs
West, Henry, and Pavuluri (2007) delineated a child- and family-based booster-session
approach using a CBT framework as a method of maintaining long-term improvement in

84 JOURNAL OF MARITAL AND FAMILY THERAPY January 2012


medication adherence and relapse prevention for families of 5- to 17-years-olds with BD.
An open trial yielded positive outcomes in terms of reduced symptoms and improved function-
ing. A combined child- and family-focused group intervention based on a CBT framework for
6- to 12-year-olds with BD was associated with children’s decreased manic symptoms and
improved psychosocial functioning, and enhanced parental coping (West et al., 2009). The
RAINBOW program, which incorporates CBT and interpersonal therapy techniques based on
the FFT approach, is for 8- to 12-year-olds with BD (Pavuluri et al., 2004). The program has
been associated with a reduction in children’s BD symptoms and improvements in functioning
and has been found to be feasible and satisfying to families (Pavuluri et al., 2004). The afore-
mentioned programs need to be evaluated in RCTs in comparison with appropriate control
groups before their efficacy is well established.

ANXIETY DISORDERS

Primary Findings from Prior Reviews


Northey et al. (2003) noted that family cognitive behavioral therapy (FCBT) was favor-
able as compared to individual cognitive behavioral therapy (ICBT) in terms of diagnostic
recovery rates, particularly when youth had an anxious parent. Nonetheless, both family- and
individual-based CBT treatments were better than the wait-list control. More recent reviews
have noted that FCBT is better than or equal to ICBT, particularly when parents have anxi-
ety (Creswell & Cartwright-Hatton, 2007); 60–90% of children who received FCBT no longer
met diagnostic criteria following treatment (Ginsburg & Schlossberg, 2002). The efficacy of
FCBT held whether administered in an individual family or group family format, and gains
were maintained for 7 years (Northey et al., 2003). Renshaw, Steketee, and Chambless’ (2005)
review highlighted the benefit of family-based treatments for childhood OCD, particularly
when focused on reducing parents’ excessive accommodation or antagonism of their child’s
OCD symptoms and when parents were trained to serve as co-therapists or coaches of behav-
ioral techniques.

Recent Findings from RCTs


Several RCTs have supported FCBT for childhood anxiety disorders. Wood, Piacentini,
Southam-Gerow, Chu, and Sigman (2006) compared a family-based version of the cognitive
behavioral ‘‘Building Confidence Program’’ (FCBT) and a traditional, individual child-focused
version (ICBT) for 6- to 13- year-olds with SAD, GAD, or social phobia. The FCBT group
received training in parent communication in addition to the exposure and training in coping
skills that both groups received. Although both groups showed pre- and post-treatment
improvements, the FCBT group had greater reductions in child anxiety per experimenter and
parent, but not child, report.
Kendall, Hudson, Gosch, Flannery-Schroeder and Suveg (2008) compared FCBT to ICBT
and a family-based psychoeducational and supportive control group (FESA) for 7- to 14-year-
olds with SAD, GAD, or social phobia. Although children improved in all three conditions,
FCBT and ICBT reduced anxiety symptoms more than FESA (through 1-year follow-up), and
FCBT was superior to ICBT when both parents also had anxiety disorders. In contrast, teach-
ers reported fewer child anxiety symptoms for those in the ICBT group than in the other two
groups.
Based on findings from an RCT comparing FCBT (individual family and group family for-
mats) to a wait-list control, both FCBT conditions showed improvements in children’s OCD
symptoms and diagnostic status between pre- and post-treatment (Barrett, Healy-Farrell, &
March, 2004). Gains (diagnosis free) were maintained through 18-month follow-up (Barrett,
Farrell, Dadds, & Boulter, 2005). Another RCT found improvement in anxiety symptoms and
a behavioral avoidance task among children with OCD who received FCBT compared to those
in a wait-list control (Barrett, Healy, & March, 2003). Moreover, Storch et al. (2007) found
that FCBT was comparably efficacious in reducing symptoms of OCD among 7- to 17-year-
olds whether the treatment was administered weekly or daily. Remission rates were 75% and
80% in the daily and weekly treatment groups post-treatment.

January 2012 JOURNAL OF MARITAL AND FAMILY THERAPY 85


Ginsburg (2009) conducted an RCT to ascertain whether an FCBT—the Coping and
Promoting Strength (CAPS) program—would be more effective in preventing anxiety disorders
than a wait-list control among school-aged children of parents with an anxiety disorder. At
1-year follow-up, 30% of children in the wait-list control group developed an anxiety disorder
compared with 0% in the FCBT (CAPS) group.
Data support a combined CBT and ABFT for adolescents with anxiety disorders (Siqueland,
Rynn, & Diamond, 2005). An RCT comparing CBT or CBT and attachment-based family
therapy (CBT-ABFT) found that both interventions reduced symptoms of anxiety and
depression post-treatment and follow-up.

Promising Interventions—Non-RCTs
One article applied Multidimensional Family Therapy (MDFT) to teenagers with comorbid
PTSD and substance abuse problems after exposure to Hurricane Katrina (Rowe & Liddle,
2008). An RCT is underway to provide evidence as to the utility of this treatment for youth
with PTSD and substance abuse difficulties. Another promising intervention is a conjoint
behavioral consultation model delivered in a school setting. The mental health provider con-
sults with the child’s parents and teachers, noting the reciprocal influence between home and
school environments, to enhance the assessment, monitoring, and treatment of the child’s anxi-
ety (Auster, Feeney-Kettler, & Kratochwill, 2006). An alternative to FCBT proposed for treat-
ing OCD in prepubertal children is narrative family therapy, which has received theoretical
justification for young children as well as case study support (McLuckie, 2005). Nonetheless,
empirical work is needed to determine the utility of this approach for childhood anxiety disor-
ders, including OCD. Maid, Smokowski, and Bacallao (2008) advocated for experiential inter-
ventions, such as communications approaches that focus on maladaptive family roles, for
families of children with anxiety disorders. Based on the importance of attachment, such
approaches emphasize the role of parental acceptance, control, and modeling in maintaining
children’s anxiety symptoms.
Much of the literature has used older elementary school-aged and adolescent samples. In
contrast, a family-based CBT intervention for children as young as four incorporating aspects
from FCBT studied in RCTs and developmental guidance, general behavioral parenting tech-
niques, and parent education has been proposed (Choate-Summers et al., 2008). Initial pilot
data are promising (Freeman et al., 2003).

ATTENTION-DEFICIT HYPERACTIVITY DISORDER

Primary Findings from Prior Reviews


The prior review on attention-deficit hyperactivity disorder (ADHD; Northey et al., 2003)
highlighted parent training programs and RCTs in which parent training alone or in concert
with medication reduced ADHD symptoms in children. Additional reviews of effective interven-
tions for ADHD have been conducted (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004;
Chronis, Jones, & Raggi, 2006) and have attended to psychosocial interventions, including fam-
ily-based interventions. These reviews have revealed that parent- and family-based interventions
are effective in treating ADHD.

Recent Findings from RCTs


Since the 2003 review, additional RCTs have underscored the value of parent training pro-
gram as part of treatment protocols for children and some adolescents with ADHD symptoms.
Three well-known and empirically supported behavioral family-based interventions have been
used to treat ADHD: Parent–Child Interaction Therapy (PCIT; Eyberg, Boggs, & Algina,
1995; Eyberg, 1988), Triple P—Positive Parenting Program (Sanders, 1999), and The Incredible
Years (IY; Webster-Stratton & Hancock, 1998).
Parent–Child Interaction Therapy enhances parent–child interaction patterns, subsequently
improving the quality of the parent–child relationship. It includes parent- and child-directed
interactions. In an early RCT of PCIT with preschool-aged children, not reviewed earlier, data
revealed that at post-intervention, mothers reported less hyperactive behavior and children were

86 JOURNAL OF MARITAL AND FAMILY THERAPY January 2012


less likely to meet the diagnostic criteria for ADHD (Nixon, 2001). PCIT has been shown to
be effective among culturally diverse children with ADHD and behavior problems (Matos,
Bauermeister, & Bernal, 2009); among 4- to 6-year-old children with ADHD symptoms, moth-
ers who participated in PCIT reported a decrease in hyperactivity and inattentive behaviors
at post-intervention compared to wait-list control, and these reductions were maintained at
3-month follow-up.
Triple P, a multi-level parenting intervention, provides support to parents to prevent
behavior and emotional problems in children. Using myriad formats (media, group, individual,
self-directed) with the parents, it incorporates five levels of intervention that correspond to the
severity of the child’s behavior problems, with higher levels being associated with the more
severe behavior problems. Training techniques, such as the use of the guided participation,
behavioral rehearsal, and self-regulation of parental skills, are central. In a 2002 RCT not
reviewed earlier, preschoolers with co-occurring ADHD and oppositional defiant disorder
(ODD) behaviors exhibited decreased level of parent-reported child behavior problems com-
pared to control after parents participated in the Triple P program (Bor, Sanders, & Markie-
Dadds, 2002). Enhanced Triple P decreased child behavior problems among 5- to 9-year-olds
with diagnosed ADHD compared to wait-list control, with findings maintained at 3-month fol-
low-up (Hoath & Sanders, 2002).
The IY incorporates intervention at multiple levels, including parent, teacher (classroom),
and child training to prevent, reduce, and treat externalizing problems in children aged 2–10.
The parent training components include BASIC, ADVANCE, and EDUCATION programs
that focus on parenting skills, interpersonal skills, and academic skills respectively. The BASIC
program emphasizes skills such as interactive play, positive reinforcement, and non-averse disci-
pline strategies. IY has produced recent evidence related to reducing ADHD behaviors. Jones,
Daley, Hutchings, Bywater, and Eames (2007) found that the IY program resulted in decreased
levels of parent-reported hyperactivity, impulsivity, and inattention compared to wait-list con-
trol among 3- to 4-year-old children.
Other programs that include a behavioral family intervention component and that have
demonstrated initial efficacy through RCTs include the Child Life and Attention Skills Program
(Pfiffner et al., 2007). Compared to peers assigned randomly to the control group, 7- to 11-year-
olds with ADHD-inattentive type in this active psychosocial treatment integrated across home
and school settings had fewer inattention and sluggish cognitive tempo symptoms and more
improved social and organizational skills at follow-up based upon parent and teacher ratings.

Promising Interventions—Non-RCTs
Family-based interventions to treat ADHD improve communication patterns between teen-
agers and their parents (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001). However, these
studies have not used an RCT methodology, and thus it is premature to assess their efficacy.
Other family-based treatment modalities, including meditation, have been evaluated, although
data are preliminary and RCTs have yet to be conducted (Harrison, Manocha, & Rubia, 2004).

OPPOSITIONAL DEFIANT DISORDER

Primary Findings from Prior Reviews


In the Northey et al. (2003) review, parent training was the primary evidence-based family
treatment for ODD. Additional reviews and meta-analyses attest to the efficacy of parent train-
ing to treat oppositional defiant behaviors (Lundahl, Risser, & Lovejoy, 2006; Reyno &
McGrath, 2006). Interventions specifically for diagnosable ODD remain limited.
Meta-analyses of PCIT for oppositional defiant symptoms have found large effect sizes for
studies evaluating PCIT to comparison groups and moderate effect sizes for modified, briefer
versions of PCIT (Thomas & Zimmer-Gembeck, 2007). RCTs of PCIT have found reductions
in youth problem behavior including oppositional defiant behaviors. Early RCTs showed the
efficacy of PCIT in reducing oppositional behavior in children compared to wait-list control
(McNeil, Capage, Bahl, & Blanc, 1999; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998),
with treatment gains maintained at 3- and 6-year post-intervention (Hood & Eyberg, 2003).

January 2012 JOURNAL OF MARITAL AND FAMILY THERAPY 87


Triple P has been the focus of several meta-analyses addressing oppositional behavior, with
overall positive effect sizes related to child problem behavior ranging from .35 to .70 (de Graaf,
Speetjens, Smit, de Wolff, & Tavecchio, 2008; Nowak & Heinrichs, 2008; Thomas & Zimmer-
Gembeck, 2007). These effects occur across settings, countries, and family types, as well as with
mothers who are depressed, parents at-risk for child maltreatment, and families with children
with developmental disabilities (Heinrichs, 2006; Nowak & Heinrichs, 2008; Plant & Sanders,
2007; Roberts, Mazzucchelli, Studman, & Sanders, 2006; Sanders, Markie-Dadds, Tully, &
Bor, 2000a; Sanders et al., 2004).

Recent Findings from RCTs


The efficacy of PCIT for treating oppositional defiant behaviors has been tested in numer-
ous RCTs. Nixon, Sweeney, Erickson, and Touyz (2003) found decreases post-intervention in
preschool-aged children’s externalizing behaviors among parents who received standard PCIT
or an abbreviated modified version compared to wait-list control. Findings were maintained at
one- and 2-year follow-up (Nixon, Sweeney, Erickson, & Touyz, 2004). RCTs have shown
PCIT to reduce oppositional behavior among distinct populations, such as preschoolers with
mental retardation and co-occurring ODD (Bagner & Eyberg, 2007). More recent RCTs focus-
ing on cultural adaptations for Mexican American families (McCabe & Yeh, 2009) and Chinese
children (Leung, Tsang, Heung, & Yiu, 2009) have shown PCIT to be more efficacious than
treatment as usual in reducing oppositional defiant behaviors (McCabe & Yeh, 2009). PCIT
conducted with parents at-risk for child maltreatment reduced parenting stress and parent-
reported child behavior problems (Chaffin et al., 2004; Timmer et al., 2006).
A number of RCTs of Triple P for oppositional defiant problems were conducted in the
1990s and early 2000s (Bor et al., 2002; Hoath & Sanders, 2002; Sanders & McFarland, 2000;
Sanders, Montgomery, & Brechman-Toussaint, 2000b; Sanders et al., 2000a). Recent RCTs
have examined variants of the program (Markie-Dadds & Sanders, 2006; Plant & Sanders,
2007), international implementation (Leung, Sanders, Leung, Mak, & Lau, 2003), and dissemi-
nation (Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009). Reductions in preschoolers oppo-
sitional and disruptive behaviors were found in families who participated in self-directed Triple
P compared to the wait-list control (Markie-Dadds & Sanders, 2006). Triple P has maintained
these effects 3-years post-intervention (Sanders, Bor, & Morawska, 2007).
A recent RCT examining various IY versions (parent training, parent training + teacher
training, child + teacher training, child + parent training + teacher) to wait-list control
resulted in decreases in oppositional problem behaviors in all groups compared to control groups
(Webster-Stratton, Reid, & Hammond, 2004). In an analysis of the IY program among Head
Start populations, sites were randomized to implement IY programs within facilities and were
compared to Head Start facilities that did not implement the program (Reid, Webster-Stratton, &
Baydar, 2004). The study found that IY reduced oppositional behavior and conduct problems
among preschool-aged children who exhibited higher baseline levels of problem behavior.

Promising Interventions—Non-RCTs
In the last several years, there has been a paucity of new, family-based interventions for
ODD. This may be due to the well-established evidence base. Nevertheless, adaptations to exist-
ing programs that combine treating ODD with other disorders do exist. The SPOKES project
(Scott et al., 2009) combines IY with a program to assist youth who experience literacy prob-
lems. An evaluation of this program, which included randomization, found that in addition to
gains in reading skills, ODD symptoms were reduced by 50% among 6-year-old children of
caregivers who received the program compared to caregivers in the control condition.

PERVASIVE DEVELOPMENTAL DISORDERS: AUTISM SPECTRUM


DISORDERS

Primary Findings from Prior Reviews


The prior version of this article did not include a section on autism spectrum disorders
(ASD). No prior reviews could be located that focused on family-based interventions for ASD.

88 JOURNAL OF MARITAL AND FAMILY THERAPY January 2012


Recent Findings from RCTs
One study evaluated a theoretically based, parent-targeted social communication pilot
intervention within an enhanced versus standard care randomized design (Aldred, Green, &
Adams, 2004). Both groups had routine care; the intervention trained and educated parents in
adapted communication tailored to the individual competencies of their children. Results
showed improvement in the treatment group compared to the controls on the primary (Autism
Diagnostic Observation Schedule) and most secondary measures. Studies such as this laid the
groundwork for a larger-scale intervention trial that was published recently (Green et al., 2010).
Specifically, toddlers with autism were assigned randomly to a parent-mediated communica-
tion-focused (Preschool Autism Communication Trial [PACT]) intervention plus treatment as
usual or treatment as usual only. At the 13-month endpoint, although both groups showed a
reduction in symptom severity, this reduction was more evident in the group in the PACT inter-
vention. In addition, this parent-mediated intervention was associated with more positive paren-
tal synchronous responses to their child, more child initiations with their parents, and greater
parent–child shared attention (Green et al., 2010).
A sophisticated RCT with ASD toddlers assessed whether caregiver-mediated joint engage-
ment tasks increased caregiver–child joint engagement (Kasari, Gulsrud, Wong, Kwon, &
Locke, 2010). Compared to caregivers and toddlers in the wait-list control condition, the inter-
vention group demonstrated improvements in joint attention responsiveness and diversity of
functional play acts with skill maintenance at 1-year follow-up.

Promising Interventions—Non-RCTs
Development of parent education, parent-initiated, or parent-managed intervention pro-
grams is one method espoused for expanding services for children with ASD (Bibby, Eikeseth,
Martin, Mudford, & Reeves, 2002). In these methods, parents are taught specific procedures to
teach skills to their children through parent trainers. Trainers demonstrate techniques that
reduce problem behaviors, respond contingently to appropriate behavior, improve nonverbal
and verbal communication skills, and increase appropriate play behavior (Symon, 2005). Par-
ents learn these techniques and consistently apply them to interactions with their children at
home. The following is a brief overview of some examples of these programs.
In Pivotal Response Training (PRT; Koegel, Symon, & Koegel, 2002), trained parent vol-
unteers are matched to parents and others seeking assistance. Findings support parents’ abilities
to master the techniques and then train other caregivers to use the techniques with their chil-
dren. Findings highlight the value of parents as active partners in their children’s education.
The Social Communication, Emotional Regulation, and Transactional Support (SCERTS)
Model uses a multidisciplinary approach to enhance the communication and socioemotional
abilities of early intervention–aged children with ASD (Prizant, Wetherby, Rubin, & Laurent,
2003). This model targets the core developmental deficiencies of children with ASD. Goals for
each core component are delineated and treatment is designed for each individual child’s
strengths and weaknesses. SCERTS is derived from tenets of evidenced-based practices, ASD
scholars, and researchers, and it integrates current understanding of the learning styles of ASD
individuals. Its design reflects current and emerging ‘‘recommended’’ practices.
Relationship-focused (RF) interventions have been proposed as an effective early interven-
tion for ASD children (Mahoney & Perales, 2005). RF interventions address the socioemotional
and developmental needs of young children by encouraging parents to use strategies to encour-
age interactive responsiveness with their children. RF interventions improve the cognitive and
communication functioning of young children.

EATING DISORDERS

Primary Findings from Prior Reviews


Eating disorders were not addressed in the prior review. However, there are two earlier
reviews of family-based interventions for eating disorders in youth. The first reviewed treatments
for anorexia nervosa (AN) and noted weak support across various medical and behavioral inter-
ventions (Bulik, Berkman, Brownley, Sedway, & Lohr, 2007). Yet, they concluded that family-based

January 2012 JOURNAL OF MARITAL AND FAMILY THERAPY 89


interventions were efficacious with adolescents (Bulik et al., 2007). In contrast, the second review
examined only family-based interventions for AN and concluded that any improvements noted
were minimal and often at the expense of a rise in bulimic symptoms (Bergh et al., 2006).

Recent Findings from RCTs


Data from RCTs of family therapy for eating disorders in adolescents reveal support for
those with AN (Cottrell & Boston, 2002). The Maudsley approach (Eisler et al., 2000) has
received the largest amount of empirical attention, including successful dissemination beyond
the original investigators (Loeb et al., 2007) and reduced hospital readmission rates (Rhodes &
Madden, 2005). It combines strategic and structural family therapy techniques along with prac-
tical guidance toward improving eating behaviors and promoting weight gain (Lock & Le
Grange, 2005). This intervention involves a family meal that allows the therapist to identify
problematic patterns that interfere with healthy eating and to coach the parents accordingly.
An essential part of treatment involves externalizing the disordered eating behavior as an illness
in order to reduce parental blaming of the adolescent.
One RCT compared short-term (10 sessions over 6 months) versus long-term (20 sessions
over 12 months) family-based therapy for adolescents with AN using the Maudsley model
(Lock, Agras, Bryson, & Kraemer, 2005).This RCT found that both treatments were equally
effective, although the longer treatment was more effective for adolescents from non-intact fam-
ilies and those with more severe obsessive–compulsive thinking around eating (Lock et al.,
2005). Based on long-term follow-up, adolescents who received the short-term intervention did
not differ from those who had received the long-term intervention (Lock, Couturier, & Agras,
2006). In addition to improvement in symptoms for the adolescents, the Maudsley model has
been associated with improved family functioning, including less enmeshment and rigidity and
more cohesion, adaptability, expressiveness, and competence (Wallin & Kronvall, 2002).
Eisler, Simic, Russell, and Dare (2007) conducted an RCT comparing ‘‘conjoint family
therapy’’ (CFT) to ‘‘separated family therapy’’ (SFT) for adolescents with AN. Post-intervention,
both treatments appeared comparably effective, with one exception: families with higher levels of
maternal criticism fared less well with CFT than SFT (Eisler et al., 2000). At the 5-year follow-
up, both treatments appeared equally effective, with 75% of teenagers showing no symptoms of
an eating disorder, no deaths, and only 8% of those who had achieved a healthy weight having
relapsed. As with the initial study, adolescents in families with higher levels of maternal criticism
continued at the follow-up to do less well if they had received CFT than SFT (Eisler et al., 2007).
Such findings highlight the need to assess family dynamics in determining the most appropriate
course of treatment with this population.
In contrast to family-based interventions for AN, only one RCT was found for family-
based methods for BN (Le Grange, Crosby, Rathouz, & Leventhal, 2007). Results revealed that
a manualized, family-based intervention was associated with more abstinent bingeing and purg-
ing behavior at the end of treatment than was supportive psychotherapy, although such differ-
ences were mitigated at 6-month follow-up. The benefit of family-based treatment was strongest
among those with fewer eating concerns (Le Grange, Crosby, & Lock, 2008).

Promising Interventions—Non-RCTs
Other research has focused on additional clinical constructs and method of intervention
dissemination. Dallos (2004) has argued for incorporating an attachment-based perspective into
systemic family therapy for adolescents with eating disorders, noting the intergenerational
transmission of insecure or avoidant attachment, the avoidance of conflict in family dynamics,
and problems in discussing feelings and relationships among family members. In addition, an
innovative approach to the dissemination of family therapy for treating adolescent AN using
videoconferencing (‘‘telehealth’’) to access underserved (e.g., rural) populations has been pre-
sented (Goldfield & Boachie, 2003). Proponents of this approach note patient satisfaction with
treatment along with significant weight gain.
Finally, some researchers are developing family-oriented preventive interventions aimed at
preventing the onset of disordered eating behaviors among those at risk. For example, a nine-
session multiple-family group experience has been proposed, focusing on psychoeducation

90 JOURNAL OF MARITAL AND FAMILY THERAPY January 2012


related to sociocultural factors, body image, healthy eating habits, family communication, and
dealing with teasing (Clemency & Rayle, 2006).

SUMMARY AND FUTURE DIRECTIONS

Few interventions examined via RCTs target family factors associated with youth depres-
sion (Restifo & Bogels, 2009). Stress-Busters with the parent component appears effective with
elementary school-aged children, although the added benefit of the parental component has yet
to be empirically supported as it has not been tested against Stress-Busters alone. For adoles-
cent depression, there is initial support for a variety of family-based interventions: CWD-A
with a parent component, ABFT, PRP with a parent component, MFPG, and FPE. More stud-
ies are needed that target depressed children. The programs that appear promising need to be
compared to other treatment modalities and to other types of family-based interventions.
Pilot data from non-RCTs and initial data from RCTs suggest that family-based interven-
tions for youth with BD are beneficial, particularly FFT and MFPG. Given the high levels of
conflict and stress, along with parental psychopathology, in families of children with BD, the
importance of involving parents in the treatment of youth with BD is clear. However, the
empirical study of family-based interventions is in its infancy, and further research needs to test
the different protocols available to date against appropriate controls and, eventually, against
each other to determine optimal benefit for youth living with BD and their families.
Several RCTs provide compelling evidence for family-based interventions for children with
anxiety disorders. The strongest support is for Family Cognitive Behavior Therapy (FCBT), and
researchers from a number of laboratories have presented data that support the efficacy of this
intervention. In addition, some data support the value of ABFT plus CBT (CBT-ABFT). Future
RCTs targeting anxious youth and their families should be conducted with larger sample sizes and
with younger children, incorporating developmentally appropriate considerations into the model.
Family-based interventions should be evaluated for their benefit regarding different diagnostic
categories, such as complex trauma. Promising family-based interventions for children with anxi-
ety should be tested through more rigorous empirical means to determine their efficacy.
Three evidence-based family-based interventions appear promising for youth, particularly
young children and those in elementary and middle school, with ADHD: PCIT, Triple P—
Positive Parenting Program (Triple P), and IY. However, only a few RCTs have examined each
of these treatments for this population. Family-based programs should be developed and exam-
ined in conjunction with pharmacological interventions. More RCTs are needed with a broader
age range of youth with ADHD, particularly adolescents, and more empirical attention is
needed to test novel treatments.
PCIT, Triple P, and IY effectively reduce ODD and its related symptoms. These parenting
programs have support for preschool- and early elementary–aged youth. The effectiveness of
training programs for parents with children with ODD decreases as children age (Connor &
Doerfler, 2009). As a result, more youth-focused interventions, rather than family-based inter-
ventions, are used with older children with greater frequency (Garland, Hawley, Brookman-
Frazee, & Hurlburt, 2008). It would be valuable to develop and evaluate developmentally
appropriate adaptations of these parent programs to target older youth, which would mean
including parenting, individual child, and family systems–oriented protocols.
Family-based interventions for ASD have received limited empirical examination. Parent
education or parent-managed interventions have been developed in response to the need for fam-
ily-based interventions for ASD. Comparatively speaking, gains from parent-managed interven-
tion programs are not as large as those from centers or clinics specializing treating ASD. Most
studies of family-based interventions for ASD have been criticized for their lack of systematic
effectiveness evidence (Aldred et al., 2004), although this is improving. Researchers cite small
sample sizes, absence of blind conditions, and prevalence of nonrandomized designs with inade-
quate power. RCTs are needed, despite the difficulty of conducting such investigations with this
population (Odom, Boyd, & Hall, 2009). Future research should examine comprehensive inter-
ventions for ASD that incorporate a family-based intervention, including parent management
(Lord et al., 2005). The development of such interventions can be guided by models such as the

January 2012 JOURNAL OF MARITAL AND FAMILY THERAPY 91


Ziggurate Model, which offers a framework for designing comprehensive interventions (Aspy
& Grossman, 2007). Given the methodological challenges of examining psychosocial inter-
ventions for ASD, the evaluation of comprehensive psychosocial treatments will need to
include initial efficacy studies to establish interventions as promising, the implementation of
RCTs to test the efficacy of these interventions in controlled conditions, and investigations
of the effectiveness of these interventions in community and less controlled contexts (Smith
et al., 2007).
Overall, the literature on family-based interventions for the treatment of eating disorders in
adolescents has produced promising findings, particularly regarding AN. The Maudsley
approach, with its combination of structural and strategic family therapy techniques along with
practical guidance around healthy eating habits, has been associated with psychological and
physical improvement in adolescents with AN. Although there is substantial support for fam-
ily-based interventions for adolescents with AN, more research is needed in two areas. First,
empirical inquiry is needed to determine the benefit of family-based approaches for adolescents
who have BN. Second, future studies should examine mediators and moderators of successful
family-based interventions for youth with eating disorders, including long-term follow-up and
persistence of psychological and physical improvements.
In general, the study methodologies have improved during the past decade, with greater
use of RCTs and growing consideration given to treatment fidelity. While most of the studies
used heterogeneous samples with regard to race or ethnicity, few studies focused specifically on
examining culturally informed family interventions for specific racial or ethnic groups. How-
ever, limited attention has been paid to nonreactive dependent variables. Further, very few of
the studies actively targeted youth with comorbid psychiatric disorders (Rohde et al., 2004).
Although more attention has been paid to the conduct of follow-up assessments (Eisler et al.,
2007), few of the study designs included long-term follow-up protocols. In addition, there is rel-
atively limited replication of study findings related to different treatment approaches across
groups of investigators. Although for some disorders not discussed in this article (CDs, sub-
stance use disorders) there has been demonstrated effectiveness in ‘‘real-world’’ community set-
tings and examinations of cost-effectiveness, less attention to dissemination and cost-
effectiveness research has been conducted for the disorders reviewed in this article. Finally, a
dearth of investigation has considered mechanisms of change in their study designs and analy-
ses (Mendenhall et al., 2009; Miklowitz et al., 2009).
This review focused on family-based interventions for standard psychiatric disorders. No
attention was paid to family-based interventions for subthreshold conditions, and such research
is warranted. Further, as the field shifts toward a more relational understanding of disorders
(Beach, Wamboldt, Kaslow, Heyman, & Reiss, 2006b; Beach et al., 2006a; Heyman et al.,
2009; Wamboldt et al., 2010), it will be important to develop, test, and disseminate family-
based interventions for relational problems or disorders.
It behooves investigators to consider the relevance of their interventions across racial or
ethnic groups, to develop and test cultural adaptations of their work, and to create culturally
competent interventions from the ground up. Similar attention should be paid to other sociode-
mographic differences that might influence intervention relevance and effectiveness (e.g., gender,
sexual orientation, social class, religious status, and country of origin). Fortunately, some inter-
ventions have strong support across racial and ethnic groups (e.g., MDFT).
Future research across diagnostic categories could be strengthened if more dissemination
studies were conducted. Ideally, such studies would be carried out collaboratively between
researchers and clinicians and possibly include a community advisory board comprising families
and youth for whom the services are targeted.

CLINICAL RESPONSES FROM THE AUTHORS

Implications for Practice


Many ecologically and systemically based approaches are effective for various childhood
and adolescent disorders. For some disorders, the research seems to nicely guide practitioners
with regard to what treatment is likely to be most beneficial. When this is the case, we should

92 JOURNAL OF MARITAL AND FAMILY THERAPY January 2012


do our best to have our clinical work reflect this knowledge base. However, for most disorders,
it is not one specific family-based intervention program that is the treatment of choice. Rather,
multiple interventions appear to have value. Thus, as clinicians, we often have multiple treat-
ments to choose from and can select a program that is most consistent with our own personal
and professional predilections.
It is imperative that family clinicians be cognizant of and trained in the pertinent evidence
base so that they can most effectively integrate evidence-based practices into their direct service
endeavors with families (Northey, 2009). As clinicians, it is valuable to receive the encourage-
ment, training, and support to learn and utilize different evidence-based family intervention
practices for youth. Doing so affords one the opportunity to have one’s clinical work guided by
a research-informed perspective (Karam & Sprenkle, 2010). The availability of treatment manu-
als is extremely useful, as are training tapes. It is most helpful when systems or organizations
provide the institutional resources to ensure the appropriate incorporation of such methodolo-
gies. It is most appreciated when investigators provide articles in the literature that describe the
‘‘nuts and bolts’’ of doing the intervention program and when they include sections of their
research articles that speak directly to clinicians.
However, from a clinician’s perspective, there are a number of obstacles to incorporating
into one’s practice or agency setting evidence-based family intervention practices in a consistent
and comprehensive fashion. For example, to date, unfortunately, most of the research described
in this review has not been adequately or thoroughly tested in ‘‘real-world’’ settings. Perhaps a
more appropriate way to phrase this would be that RCTs often times limit, by their very nat-
ure, the ‘‘real worldness’’ of treatment intervention research. Most of the work described falls
under the rubric of efficacy rather than effectiveness research. There are, of course, some excep-
tions to this, as functional family therapy (Henggeler, Schoenwald, Borduin, Rowland, &
Cunningham, 2009; Sexton, 2009) and multisystemic therapy have been disseminated more
widely, particularly with youth with CDs or delinquency and substance use disorders. However,
from a clinician’s or healthcare system perspective, these programs are resource-intensive and
many communities are not equipped to support their implementation. When they are possible
to implement, it often occurs when agencies or systems support their implementation (Northey
& Hodgson, 2008). As more and more training programs teach students these evidence-based
practices, a growing number of clinicians are utilizing them in their practices. More concerted
efforts on the part of both practitioners and researchers are needed to find realistic ways to
bring these evidence-based practices into the community.
In addition to resource challenges related to dissemination, the utility of the interventions
in community settings outside a research context is unclear. As youth typically present to our
offices with comorbid disorders, the relevance and efficacy of the interventions described in this
review, which are designed for a particular target or diagnostic group, raise questions for family
therapists about their relevance to day-to-day clinical practice.
There also are practical challenges for individual clinicians adopting evidence-based prac-
tices in practice setting. Several of these intervention programs can only be taught by for-profit
purveyor organizations that charge agencies considerable money for training and supervision.
Other protocols are much easier to learn through continuing education workshops, and these
approaches may be more likely to be utilized by practitioners. However, even for these latter
protocols, sometimes they are not adopted because the average clinician may not find them to
be particularly clinically appealing or directly applicable to their practice.
While some practitioners or community settings will implement an evidence-based practice
in its complete form, most are likely to adopt a common factors approach, in which we flexibly
use conceptualizations and techniques from multiple evidence-based protocols to guide our
efforts (Sprenkle, Davis, & Lebow, 2009). It is more likely, feasible, and realistic that people
will use strategies that cut across protocols to guide our endeavors. These include developing a
systemic formulation, forging a systemic therapeutic alliance, offering education, ameliorating
the presenting problem and associated symptoms, teaching cognitive and behavioral skills, pro-
viding affect regulation strategies, enhancing problem-solving, teaching parenting skills, manag-
ing negative interactions, enhancing relationships and attachments, building cohesion ⁄
support ⁄ intimacy ⁄ communication, restructuring relationships, and engaging larger systems. It is

January 2012 JOURNAL OF MARITAL AND FAMILY THERAPY 93


hoped that more research will be helpful on a common factors approach, as to date there is
limited empirical evidence to support this perspective. This may be an ideal topic for family-
based practitioners and researchers to investigate collaboratively.
Despite the aforementioned philosophical and practical impediments to the adoption of
evidence-based practices (Northey & Hodgson, 2008), we need to do our best to find creative
solutions to these challenges. In addition, whenever possible, it is advantageous to utilize the
protocols in a fashion that demonstrates a high level of fidelity to the program, as model fidel-
ity appears to be key to positive outcomes (Sexton & Turner, 2010).

Implications for Training


As practitioners who educate and train future clinicians in family-based interventions, it
behooves us to utilize a competency-based approach to training (Berman et al., 2006; Celano,
Smith, & Kaslow, 2010; Kaslow, Celano, & Stanton, 2005; Nelson et al., 2007). One core com-
petency for all disciplines associated with family practice is interventions. Understanding and
applying evidence-based family models is an essential component of the intervention compe-
tency. As such, it is helpful for training programs to teach students and supervisees some of the
most well-established intervention protocols. While it is not possible to train in all such proto-
cols, substantive exposure lays the framework for not only effective practice but also an invest-
ment in learning new evidence-based programs as they become available and as one’s caseload
demands. However, although it is essential that as practitioners we become familiar and
informed about the various evidence-based models, in most instances an integration of research
findings into ‘‘real-world’’ practice is more likely to occur than rigid application of existing evi-
dence-based family intervention models. This is likely to be the case as such interventions have
yet to be documented to be effective with families across racial, ethnic, and cultural groups.
In addition to teaching specific evidence-based protocols, with the growing emphasis on a
common factors approach (Blow, Sprenkle, & Davis, 2007; Sprenkle et al., 2009), training and
supervisory programs should educate trainees about the common factors that inform the
change process in family interventions and teach students the approach and techniques relevant
to multiple evidence-based practices that can be incorporated into all treatments. In addition,
and even more importantly, it is essential that all programs that train family-based clinicians
infuse research into their curriculum in a fashion that results in all family therapists honoring
the relevant evidence and integrating this evidence into their clinical efforts with families
(Karam & Sprenkle, 2010).

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