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Functional Family Therapy (FFT)

Blueprints Program Rating: Model

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. Therapists work with families to assess family behaviors that maintain delinquent behavior, modify dysfunctional family communication, train family members to negotiate effectively, set clear rules about privileges and responsibilities, and generalize changes to community contexts and relationships.

  • 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
  • Delinquency and Criminal Behavior
  • Illicit Drug Use

    Program Type

    • Family Therapy
    • Juvenile Justice, Other

    Program Setting

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

    Continuum of Intervention

    • Selective Prevention (Elevated Risk)
    • Indicated Prevention (Early Symptoms of Problem)

    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. Therapists work with families to assess family behaviors that maintain delinquent behavior, modify dysfunctional family communication, train family members to negotiate effectively, set clear rules about privileges and responsibilities, and generalize changes to community contexts and relationships.

      Population Demographics

      FFT is designed to be implemented with 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.

      Age

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

      Gender

      • Male and Female

      Race/Ethnicity

      • All Race/Ethnicity

      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.

      Family interaction patterns

      • Family
      • Peer
      • Individual
      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, 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

      *Risk/Protective Factor was significantly impacted by the program.

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

      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.

      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.

      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 which 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.

      • Behavioral
      • Cognitive Behavioral

      FFT is supported by 38 years of investigation that has demonstrated improvements with difficult to treat adolescents and their families in a range of settings and delivery sites. FFT has been evaluated in multiple studies in samples across the United States, and in Sweden. Study design has ranged from random assignment to treatment conditions, to quasi-experimental designs that involved matched but not randomly assigned comparison groups, to comparisons with base rates for that population.

      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:

      In a randomized trial in Utah (Alexander & Parsons, 1973) in which 46 families were assigned to FFT and 40 families to other treatments or to a no-treatment control group, a 6- to18-month follow-up following termination of the various treatment programs found that FFT families had a re-offense rate of 26%, compared to 50% for no-treatment controls, 47% for client-centered family group therapy controls, and 73% for the eclectic psychodynamic family therapy group. Overall, post-project court referrals were 50-66% lower in the FFT group.

      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%).

      Barton, Alexander, Waldron, Turner, and Warburton (1985) studied 74 seriously delinquent youth who were incarcerated in a Utah juvenile facility for serious and repeated offenses using a design in which treatment youth were yoked with comparison youth on time of entry and exit into the incarceration and parole systems. 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) and with non-recidivists excluded from both groups, the results were similar (mean frequency = .34 vs..51).

      Barton et al. (1985) also examined effectiveness of the FFT model when performed by undergraduate paraprofessionals compared with prior FFT evaluations that utilized therapists with substantial education, training, and experience. Results obtained by the paraprofessionals (8 undergraduates who received 32 hours of training) were equivalent to those obtained by senior/graduate level therapists in earlier studies. Recidivism rates (court referrals after treatment) were 26% for the undergraduate group, compared with 24-25% with graduate students and more experienced professional therapists trained in FFT. 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 of 51%.

      Barton, et al. (1985) evaluated 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. Subjects were children and adolescents at risk for foster care placement, and therapists were from the State Division of Family Services Social Workers who were given a week-long training in FFT. However, there was no state mandate to use FFT, and only two therapists used FFT (one had an undergraduate degree in psychology and the other had an MSW). 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 cases seen by co-workers during the same time period (49% referred to foster care).

      Friedman (1989) compared the effects of FFT to a parent group model of therapy. While there was no significant difference between FFT or parent groups on any of the 15 outcomes examined, both groups demonstrated significant and similar reduction in substance use/abuse, psychic symptomology, negative family role task behavior and improvements on positive behavior and adolescent communication within the family.

      Gordon and colleagues examined FFT with 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). Results from the 28-month follow-up reported in Gordon et al. (1988) and the 60-month follow-up data were reported in Gordon, Graves, and Arbuthnot (1995). Twenty-seven juveniles were court ordered to attend FFT, and 27 comparison juveniles were believed to have received little or no counseling from mental health professionals. The treatment youth had higher offense rates than the controls at the baseline comparison. At 28 months, the FFT group was found to have 11% recidivism compared to 67% in the regular services group. After 60 months, there remained 23 in the treatment group and 22 in the comparison group. 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 significance (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.

      Hansson and colleagues (Hansson, Cederblad, & Hook, 2000) used a randomized design to evaluate the effect of FFT on arrested youth in Lund, Sweden. At the 2 year follow-up, the FFT group had significantly lower rates of recidivism (41% vs. 82%) than the treatment as usual group. The FFT group was associated with greater reductions in youth and parent reports of externalizing and internalizing symptoms. Maternal improvements (over time) on symptom checklists evaluating depression, anxiety, and somatization were significant for the FFT group only. Using a quasi-experimental design, Hansson and colleagues (2004) replicated these findings in a community-based setting. In this replication, FFT was delivered within a framework of cooperation between social welfare, child psychiatry, and a drug treatment unit. Compared to treatment as usual, the FFT condition showed improved family functioning and fewer psychiatric symptoms (both internalizing and externalizing) after treatment. Both parents and youth showed higher optimism and valued the treatment highly. The pattern of results in this community-based replication was similar to the earlier university-based research with the same method. These articles (Study 4) were written in Swedish and provided an English overview, so the studies were not able to be assessed on quality of program design.

      In Albuquerque, Waldron, Slesnick, Brody, Turner, and Peterson (2001) examined the impact of FFT on 120 adolescents who were randomly assigned into FFT or another treatment condition. They first examined the percentage of days of marijuana use. 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.

      Next, Waldron et al. (2001) examined the reduction from heavy to minimal marijuana use. Overall, 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. Initial changes in CBT from pretreatment to 4 months did not persist through the 7-month assessment. Finally, changes in the group condition did not emerge until the 7-month assessment. More specifically, from pretreatment to four 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. Significant numbers of youths had achieved minimal-use levels in the FFT, joint, and CBT 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%).

      Barnoski (2004) evaluated FFT, one of four programs selected for statewide implementation by Washington's juvenile courts. FFT was found overall to show no statistically significant differences for three types of recidivism (felony, misdemeanor, and violent felony). However, 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.

      Celinska et al. (2013) found that, for a diverse sample of 72 New Jersey adolescent with behavior problems, the FFT subjects improved more on three scales than a comparison group of subjects undergoing individual therapy or mentoring: 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).

      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.

      One study done in Albuquerque examined outcomes relating to marijuana use:

      • FFT youth (either alone or in combination with another therapy) showed significant reductions at four months in marijuana use (55% to 25% and 57% to 38%, respectively), while the other therapy and control groups did not.
      • FFT youth showed significant reductions in heavy to minimal marijuana use at four months (87% to 55%), as did the other therapy and the combined FFT and therapy groups, while the control group did not.

      Program effects on Risk and Protective Factors:

      • Improvements in family interaction patterns (Alexander & Parsons, 1973)

      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 mediating process measures were associated with both the treatment and recidivism in ways suggesting that FFT reduced recidivism by improving family interactions.

      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.

      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, and Sweden. FFT has been applied with a wide range of population demographics, with non-White youth representing 10-60 percent of the sample. It has also been effective with both males and females. FFT has also been used with adolescents at risk for foster care placement.

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

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

      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

      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.

      Aos, S., Lee, S., Drake, E., Pennucci, A., Klima, T., Miller, M., ... Burley, M. (July, 2011). Return on Investment: Evidence-Based Options to Improve Statewide Outcomes(Document No. 11-07-1201A). Olympia: Washington State Institute for Public Policy.

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

      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.

      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.

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

      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.

      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.

      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.

      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.

      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.

      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.

      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

      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.

      Alexander & Parsons, 1973

      Evaluation Methodology

      Design: 99 court-referred juvenile 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. Follow-up data were available on 86 families. Forty-six families were randomly assigned, upon detention, to FFT. An additional 40 families were randomly assigned (with minor exceptions due to program availability) 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). Two additional groups provided comparison data, including 46 post-hoc selected no-treatment controls who were randomly selected from several hundred court cases referred during the project period but not assigned treatment due to program availability. The second additional comparison group represents recidivism rates for 2,800 cases seen countywide during 1971, some of whom received various treatments, while many did not. Because these two latter groups were examined only on a post-hoc basis, they were not included in the statistical analysis. Approximately 10 weeks of therapy were provided in a clinic.

      Baseline Equivalency: 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.

      Sample: 99 court-referred juvenile 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. Follow-up data were available on 86 families of 38 males and 48 females. Subjects were 13-16 years old, living in a moderate sized city. They were predominantly White, lower to middle SES. A process evaluation was conducted on a subset of the sample: The first 20 treatment families completing the program, 10 client-centered program families, and 10 no-treatment controls.

      Measures: Process measures included measures of (1) talk time; (2) silence; and (3) interruptions. Outcome measures included juvenile court records which were examined following termination from FFT for re-referral for behavioral offense (i.e., recidivism).

      Analysis: Process measures were examined using one-way analyses of variance. Outcome measures, i.e., recidivism rates, were calculated for the four groups (FFT, 2 alternative treatments, no-treatment control). Chi-square analyses were conducted to assess differences in recidivism for the groups. Intent to treat analysis was utilized, since cases that dropped out of treatment were included.

      Outcomes

      Alexander & Parsons, 1973
      At 6- to 18-month follow-up following termination of the various treatment programs and control condition, FFT families had a re-offense rate of 26%, compared to 50% for no-treatment controls, 47% for client-centered family group therapy controls, and 73% for the eclectic psychodynamic family therapy group. The additional two comparison groups selected post-hoc had recidivism rates of 48% (random post-hoc) and 51% countywide group. Overall, post-project court referrals were 50-66% lower in the FFT group. When combining the three alternate comparisons to FFT, the difference is significant, p=.006.

      Risk/protective factors: FFT families were significantly improved in the process of family interactions compared to those who received other treatments. They displayed greater equality in interaction and talk time, less silence, and more positive interruptions for clarification and feedback.

      Secondary Prevention Study: Siblings
      Klein, Alexander, and Parsons, 1977
      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%).

      Brief Bullets

      • A randomized trial of FFT families had a re-offense rate of 26%, compared to 50% for no-treatment controls, 47% for client-centered family group therapy controls, and 73% for the eclectic psychodynamic family therapy group.
      • Post-project court referrals were 50-66% lower in the FFT group.
      • 2.5 to 3.5 years after the intervention, significantly fewer siblings of the targeted youth had juvenile court records (20%) compared to families receiving no or other interventions (40% to 63%).

      Limitations: There is no information available on the 13 youth for whom juvenile justice records were not available (i.e., no analysis of differential attrition).

      Barton, Alexander, Waldron, Turner, & Warburton (1985)
      This manuscript describes three separate studies.

      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.

      Adult follow-up
      Gordon, Graves, & Arbuthnot (1995)

      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.

      First Lund, Sweden FFT study
      Hansson, Cederblad, & Hook (2000)
      In Swedish with a short English description.

      Both articles in this study were written in Swedish and provided an English overview. Therefore, the quality of the research design was unable to be assessed.

      Evaluation Methodology

      Design and Subjects: This study, which was one of the first randomized studies on juvenile delinquency in Sweden, examined the effectiveness of FFT versus treatment as usual. FFT services were completed within the context of a University setting with high control over treatment integrity. Evaluations included official registers up to 1 to 2 years post-treatment as well as youth and parent reports of internationalizing and externalizing disorders. Results from the FFT treatment group (n =49) were compared with a treatment-as-usual group (n =40). Subjects were predominantly male youth (average age 15) arrested by police in Lund, Sweden, for serious offenses. Therapists were professionals with graduate level training in mental health services who participated in a training workshop by Dr. Alexander. Treatment was provided in a clinic, and was not time-limited.

      Outcomes

      At 2 year follow-up, the FFT group had significantly lower rates of recidivism (41% vs. 82%) than the treatment as usual group. The FFT group was associated with greater reductions in youth and parent reports of externalizing and internalizing symptoms. Maternal improvements (over time) on symptom checklists evaluating depression, anxiety, and somatization were significant for the FFT group only.

      Brief Bulleted Outcomes

      • At a 2 year follow-up with arrested youth, the FFT group was associated with significantly lower rates of recidivism (41% compared with 82%) and with greater reductions in youth and parent reports of externalizing and internalizing symptoms, compared with a treatment-as-usual group.

      Second Lund, Sweden FFT Study
      Hansson et al. (2004)
      In Swedish with a short English description

      Design and Subjects: Treatment took place within a "frame of cooperation" between social welfare, child psychiatry, and a drug treatment unit. Results from the FFT treatment group (n =45) were compared with a matched treatment-as-usual group (n =17). Therapists in both conditions were community-based practitioners. Training and supervision was provided by Swedish experts in FFT following the descriptions of Alexander and colleagues.

      Outcomes

      The results from the treatment group are compared with treatment as usual. The FFT group showed increased family function and fewer psychiatric symptoms after treatment. Both parents and youth showed higher optimism and valued the treatment highly. The results are similar to the earlier university-based research with the same method.

      Brief Bulleted Outcomes

      • The findings replicated the effectiveness of FFT in a community-based setting, suggesting that FFT can be efficiently transported into real world settings in Sweden.

      Albuquerque replication
      Waldron, Slesnick, Brody, Turner, & Peterson (2001)

      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 therapists provided therapy at any one time. 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. Six therapists: Ph.D.- and M.S.W.- level therapists, trained in a 2-day seminar by Dr. Alexander.

      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%).

      18 month follow-up of statewide implementation and cost-benefit analysis
      Barnoski (2004)

      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.

      Expansion of Barnoski (2002)
      Sexton & Turner (2010)

      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).

      Meta-analysis
      Aos, S., Lee, S., Drake, E., Pennucci, A., Klima, T., Miller, M., Anderson, L., Mayfield, J., & Burley, M. (2011)

      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.

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

      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.

      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.

      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.

      Celinska, Furrer, & Cheng (2013)

      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.