The Effectiveness of Functional Family Therapy in Reducing Adolescent Mental Health Risk and Family Adjustment Difficulties in an Irish Context

• Date: 01 June 2016
• Author: Alan Carr,Dan Hartnett,Thomas Sexton
• Published date: 01 June 2016
• DOI: http://doi.org/10.1111/famp.12195

The Effectiveness of Functional Family Therapy in

Reducing Adolescent Mental Health Risk and Family

Adjustment Difficulties in an Irish Context

DAN HARTNETT*

ALAN CARR*

THOMAS SEXTON

†

To evaluate the effectiveness of Functional Family Therapy (FFT) 42 cases were random-

ized to FFT and 55 to a waiting-list control group. Minimization procedures controlled the

effects of potentially confounding baseline variables. Cases were treated by a team of five

therapists who implemented FFT with a moderate degree of fidelity. Rates of clinical recov-

ery were significantly higher in the FFT group than in the control group. Compared to the

comparison group, parents in the FFT group reported significantly greater improvement in

adolescent problems on the Strengths and Difficulties Questionnaire (SDQ) and both par-

ents and adolescents reported improvements in family adjustment on the Systemic Clinical

Outcomes and Routine Evaluation (SCORE). In addition, 93% of youth and families in the

treatment condition completed FFT. Improvements shown immediately after treatment

were sustained at 3-month follow-up. Results provide a current demonstration of FFT’s

effectiveness for youth with behavior problems in community-based settings, expand our

understanding of the range of positive outcomes of FFT to include mental health risk and

family-defined problem severity and impact, and suggests that it is an effective interven-

tion when implemented in an Irish context.

Keywords: Functional Family Therapy; Systemic Cl inical Outcomes and Routine

Evaluation; Strengths and Difficulties Questionnaire

Fam Proc 55:287–304, 2016

Adolescent behavior problems have historically been viewed as one of the most diff icult

areas of practice for prevention and intervention specialists (Carr, 2014; Sexton,

2011). The problems experienced by adolescents are significant because of their preva-

lence and intractability. Youth and families are often viewed as treatment resistant, lack-

ing motivation, and being untreatable by traditional prevention and intervention

programs (Alexander, Sexton, & Robbins, 2002). International epidemiological studies

suggest that between 17% and 22% of adolescents suffer from a significant developmental,

emotional, or behavioral problem (Costello, Mustillo, Keeler, & Angold, 2004; Kazdin,

*School of Psychology, University College Dublin, Dublin, Ireland.

†

Department of Counseling and Educational Psychology, Indiana University, Bloomington, IN.

Correspondence concerning this article should be addressed to Alan Carr, Department of Clinical Psy-

chology, School of Psychology, University College Dublin, Newman Building, Belfield, Dublin 4, Ireland.

E-mail: alan.carr@ucd.ie.

We acknowledge with thanks funding support from Archways, an Atlantic Philanthropies grantee and a

recipient of funding from the Irish Youth Justice Service for this project. Thanks to the following thera-

pists who participated in the project: Alice Ann Lee, Bernie Hunter-McCabe, Stephen McBride, Clare Gra-

ham, Sandra Mangan. Thanks to Astrid van Dam for providing expert supervision.

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Family Process, Vol. 55, No. 2, 2016 ©2015 Family Process Institute

doi: 10.1111/famp.12195

2003; Merikangas, Nakamura, & Kessler, 2009). In Ireland, where the study described in

this paper was conducted, two large community surveys have shown that up to 20% of ado-

lescents have significant behavioral and mental health problems (Lynch, Mills, Daly, &

Fitzpatrick, 2006; Martin, Carr, Burke, Carroll, & Byrne, 2006). High rates of mental

health disorders also exist among youth involved in the juvenile justice system, the popu-

lation for which FFT was originally developed, with an estimated 50–80% of delinquent

adolescents meeting the criteria for a mental health problem such as conduct or sub-

stance-related disorders (Hogan, 2003; Kazdin, 2000; Lyons, Baerger, Quigley, Erlich, &

Griffin, 2001; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002).

Family therapy programs have shown particular promise in ameliorating adolescent

behavioral problems, and Functional Family Therapy (FFT) has consistently been identi-

fied in authoritative international reviews as one such program (Baldwin, Christian, Ber-

keljon, Shadish, & Bean, 2012; Carr, 2014; Henggeler & Sheidow, 2012; Sexton & Datchi,

2014; Von Sydow, Retzlaff, Beher, Haun, & Schweitzer, 2013). FFT is an evidence-based

treatment for adolescent behavioral problems, conduct disorder, substance misuse, and

delinquency (Alexander & Parsons, 1982; Alexander, Waldron, Robbins, & Neeb, 2013;

Sexton, 2011). FFT is based on an ecological multifactorial model of risk and protective

factors involved in the development of conduct problems. The FFT clinical practice model

has three distinct phases: engagement, behavior change, and generalization. Ther apist

goals and interventions appropriate to each phase are described in a treatment manual

(Sexton & Alexander, 2004). Therapists meet regularly, usually on a weekly basis for

about 3 or 4 months, with the adolescents and their families in conjoint sessions. Therapy

duration is matched to family need and problem severity, but is short-term. During these

sessions therapists develop a therapeutic alliance with family members; help families

develop better parenting practices, communication, and problem-solving skills; and help

families to use these skills independently to generalize progress made within therapy to

home and community contexts.

A series of evaluation studies has shown that FFT is effective in reducing criminal

activity by up to 60%, reducing treatment dropout from 50% to 20%, and early studies

found improvements in family functioning in areas such as communication and problem-

solving (Alexander et al., 2013; Baldwin et al., 2012; Henggeler & Sheidow, 2012; Sexton,

2011). Furthermore, there is evidence that treatment fidelity mediates outcom e in FFT,

with cases treated by therapists who adhere to the model having better outcomes than

those treated by low-adherent therapists, especially in cases at high risk due to family dis-

organization or deviant peer group membership (Barnoski, 2002; Graham, Carr, Rooney,

Sexton, & Wilson Satterfield, 2014; Sexton & Turner, 2010). For example, Graham et al.

(2014), in an Irish study, found that therapy-completers treated by high-adherent thera-

pists had a more favorable outcome than dropouts or those treated by low-adh erent thera-

pists. Almost 60% of cases treated by high-adherent therapists were clinically recovered

after FFT. In contrast, the worst outcome occurred for dropouts, none of whom were recov-

ered at follow-up. The outcome of cases treated by low-adherent therapists fell between

these two extremes. Just under 20% of these were clinically recovered after treatment.

This was also the first study of FFT in the Republic of Ireland. It had all the limitations

associated with a retrospective archival study. The prospective randomized-controlled

trial described in this paper was conducted to overcome the limitations of this initial

study, and to further evaluate the effectiveness of FFT within an Irish context.

This study had two specific goals. The first was to assess the effectiveness of FFT in

ameliorating adolescent psychological problems and family adjustment. Most early studies

of FFT focused on recidivism as the primary measure of positive outcome; few evaluated

outcomes of FFT in broader domains of youth behavior and mental health (For a review

see Alexander et al., 2013, Chapter 3). In this study we included measures of youth behav-

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