Treatment

As children enter adolescence, parenting becomes more complex. Conduct problems may emerge for the first time during this period, or existing problems may become more varied and severe. Associations with peer groups play an increasingly important role in a teenager's life as direct parental supervision diminishes. Nationally, there are several indicators that the number of young people who are experiencing severe problems during adolescence is increasing. For example, the number of juveniles in custody rose 30% from 1975 to 1985 (Children in Custody, 1989), and there was a 250% increase in residential care from 1965 to 1985 (Doughtery, Saxe, Cross, & Silverman, 1987). Delinquency in the schools has also increased dramatically (Rubel, 1977, cited in Harootunian, 1986; U.S. Department of Education, 1989). There is evidence that the peak age for committing violent offenses has shifted downward (Blumstein, Cohen, & Farrington, 1988). According to self-reports of participation in criminal activities, at the peak age of 17, up to 35% of males report engaging in at least one serious violent offense (i.e., aggravated assault, robbery, or rape) (Elliott, 1994).

Conduct problems in childhood and early adolescence can set in motion a developmental sequence (see Loeber, Keenan, Green, Lahey, & Thomas, 1993) that results in a host of problems, including drug use (Kellam, Brown, Rubin, & Ensminger, 1993; Pulkkinen, 1983), delinquency (Olweus, 1979; Patterson, 1982), and an array of negative adult outcomes (e.g., Elder, Caspi, & Downey, 1983; Holmes & Robins, 1988). In early to mid-adolescence, antisocial, sexual, and drug-use behaviors tend to correlate as a problem behavior syndrome (Hawkins, Catalano, & Miller, 1992; Jessor & Jessor, 1975). Interventions that target antisocial behavior and its correlates in early adolescence can be cost effective in that they influence the later course of conduct disorders and prevent escalations in seriousness and variety of problem behaviors (Dishion & Andrews, in press). This paper examines the efficacy of family therapy' in the treatment of adolescent conduct disorders and specifically focuses on the period after the Shadish et al. (1993) meta-analysis that included studies conducted from 1963 through 1988. Reviewed are more recent outcome studies (i.e., 1989-1994) conducted with samples of adolescents referred for conduct disorders and delinquency and their families, trends in service delivery models, and barriers to treatment implementation. Cost-effectiveness data are presented when available. First, conclusions from reviews and meta-analyses on studies conducted prior to 1988 will be discussed briefly.

REVIEW STUDIES AND META-ANALYSES

In the late 1980s in a comprehensive review of treatment research, Kazdin (1987) identified family interventions, relative to other treatment approaches, as the most promising methods for the treatment of child and adolescent conduct disorders. This general conclusion received support from the meta-analysis conducted by Shadish et al. (1993), who analyzed results from 163 studies, including journal articles, book chapters, dissertations, and unpublished manuscripts. Studies which were included met three criteria: random assignment, clinically distressed subjects, and examination of a marital (n = 62) or family (n = 101) therapy.

Specific to conduct disorder (n = 18), family therapy had a significant effect size (d = .53, n = 18). These studies were divided into those focusing on treating cases where aggression was the primary referral complaint (d = .61, n = 5) and those focusing on delinquency symptoms (d = .34, n = 3). Behaviorally oriented treatments yielded an effect size of d = .55 (n = 13), and systemic approaches yielded an effect size of d = .26 (n = 8). The effect size for humanistic

treatments for conduct disorder was d = -.15 (n = 1); eclectic was d = .57 (n = 7). Other subsets of relevant studies were also reviewed. Eleven studies examined parent management training, yielding an effect size of .41, and 11 looked at effect size for studies using multiple behavioral strategies (d = .83). Other recent meta-analyses (e.g., Hazelrigg, Cooper, & Borduin, 1987) and reviews (e.g., Loeber & Hay, 1994; Tolan, Cromwell, & Brasswell, 1986) have emphasized the role of the family in the development and maintenance of conduct disorders and delinquency and have endorsed the use of family therapy as a relatively well-validated treatment approach (Dumas, 1989; Patterson, Dishion, & Chamberlain, 1993).

Much of the published research on the effectiveness of family-oriented treatments for child and adolescent conduct disorders has focused on three major theoretical approaches: behavioral social learning orientations (social learning family therapy [SLFT]); structural family therapy (SFT); and more recently, multitarget ecological treatment (MET) interventions. SLFT has been examined in numerous tightly controlled research trials, whereas SFT has been carefully researched to a somewhat lesser extent. The SFT approach has a well-articulated theoretical basis (e.g., Haley, 1973; Johnson, 1973, 1974, 1975a, 1975b, 1977, 1978) and is widely used in clinical practice. During the past decade, a number of studies using combinations of these orientations in the context of a broad-based ecological approach targeting the family, as well as other settings (e.g., school, peer group), have been conducted. These studies have focused on treatment for older (i.e., adolescent) populations with more advanced or severe symptoms of conduct disorder and delinquency.

OVERVIEW OF THREE MAJOR THEORIES OF FAMILY INTERVENTION

Although the intervention strategies used in these three approaches overlap, they are distinct in terms of their theories of the relation of family change to conduct-disordered and delinquent behavior and in terms of their assumptions about how family processes mediate adolescent problem behaviors and attitudes. The underlying assumptions and mechanisms of change for each of the approaches is briefly reviewed.

Social Learning Family Therapy (SLFT)

SLFT is based on the notion that conduct-problem behavior is inadvertently developed and sustained through daily maladaptive parent-child interactions in the home. There is an extensive body of research involving observations in family homes that confirms that, compared to normal controls, parents of children/adolescents referred for antisocial behavior engage in several processes that promote aggression and suppress prosocial behavior (see Patterson, 1982, for review). Coercive interaction patterns are chief among these. Coercive interaction refers to instances when the deviant behavior of one family member (e.g., the child when he tantrums) is directly reinforced or supported by another (e.g., the mother when she gives in). Positive child behavior is likely to be ignored or punished in referred (versus normal) families, and the child is gradually shaped to produce aversive behaviors that gain parental attention and function to fulfill the child's immediate needs. SLFT is designed to alter the pattern of dysfunctional interchanges and focuses on building parental skills in reinforcement, delivering mild forms of discipline, and negotiating compromises.

Structural Family Therapy (SFT)

SFT addresses issues related to poor family organization, cohesion, and structure. Antisocial behavior is viewed as a logical outcome of a malfunctioning system. The family system is seen as having an equilibrium that it attempts to maintain so that forces of change from within or without the family are met with internal shifts toward self-stabilization. These efforts to self- stabilize will lead to reoganizations of the family system that tend to emerge along hierarchical lines (Sameroff, 1989). In addition to attempting to alter family interactions, SFT targets mechanisms of emotional engagement and distancing, shared family beliefs, and reoganization of family subsystems and hierarchies. With regard to the treatment of conduct problems, this approach has been adapted to fit culturally specific values and beliefs (e.g., Szapocznik, Kurtines, & Fernandez, 1980; Szapocznik, Scopetta, Kurtines, & Aranalde, 1978).

A series of studies conducted in the late 1970s and early 1980s by Alexander and his colleagues focused on court-referred adolescents and used a variation of the SFT approach. Their functional family therapy (FFT) model was aimed at "instituting reciprocity" in families and incorporated interventions from SLFT such as behavioral contracting and a focus on parental supervision and discipline. Outcomes (e.g., Alexander & Parsons, 1973; Alexander & Parsons, 1982; Klein, Alexander, & Parsons, 1977) indicated that FFT produced significantly better outcomes than client-centered, psychodynamic, or no-treatment control groups, both in terms of client recidivism and on measures of family interaction. In one study, long-term effects were found; 3 years after intervention, siblings of FFT cases had significantly fewer court contacts than siblings in the client-centered, psychodynamic, or no-treatment control groups. These findings suggest that FFT provides positive outcomes for adolescents with behavioral problems and may have positive implications for the siblings of these adolescents.

Multitarget Ecological Treatment (MET)

MET approaches combine interventions from SLFT and SFT as well as from treatment approaches based on research outside of family therapy models. The MET approach focuses on treating adolescents with severe conduct problems (Chamberlain, 1990; Chamberlain & Reid, 1991; Henggeler, Melton, & Smith, 1992; Mann, Borduin, Henggeler, & Blaske, 1990). Studies on cognitive processing styles (e.g., cognitive distortions of aggressive youngsters) (Dodge, 1990) and negative peer processes (e.g., deviant peer contact and values) (Elliott, Huizinga, & Ageton, 1985) have been clearly shown to characterize conduct-disordered adolescents. These styles are increasingly targeted for multiproblem families with severe conduct-disordered and delinquent adolescents. Implementation of MET interventions, while more complex, intensive, and restrictive than outpatient family therapy, show promise for the treatment of multistressed families for whom outpatient treatment is not sufficient.

Most MET approaches are based on the assumption that there are multiple causes and correlates of delinquency and that youth antisocial behavior is related to important processes occurring in multiple settings, including their families, peer systems, schools, and communities. Interventions are simultaneously conducted in these multiple settings, and promoting behavior change in the youth's natural environment is emphasized. Treatment is structured, task-oriented, and for the most part focused on the present. Individual treatment plans are flexible, depending on the individual's identified problems targeted for change. Family interventions are seen as central to amelioration of the adolescent's conduct problems. Family interventions focus on increasing parenting skills and empowering parents with resources to sustain positive changes made during

treatment. Increasing parental expressions of affection, use of effective nonviolent discipline, and effective monitoring of their youngster are frequently targets of treatment. Another typical goal of MET approaches is to decrease the youth's association with and influence by deviant peers and to increase contact and affiliation with prosocial peers.

REVIEW OF RECENT STUDIES (1988-1994) WITH FAMILIES OF ADOLESCENTS

Studies conducted since 1988 that used these three approaches to family intervention are presented in Table 1. (All tables and figures omitted) In order to identify relevant studies, we used two methods for reviewing the recent literature; we conducted a PsychLit search using key phrases such as family therapy, adolescent, treatment, and conduct disorder. We also searched relevant journals such as the Journal of Consulting and Clinical Psychology and Behavior Therapy.

Many family therapy studies and case reports have been published since 1988; the seven studies selected to be reviewed in this paper were based on three criteria: (a) they had a control or comparison group, (b) they involved a specific method of family intervention, and (c) they measured the effectiveness of treatment for adolescents referred for conduct disorder and/or delinquency. Table 1 briefly summarizes the research designs, types of measures used, significant findings, and cost of treatment or number of treatment hours. These studies focused on populations of youngsters with conduct problems of varying severity, used an array of measurement strategies, and used different service delivery methods (reviewed below). Therefore, results cannot be directly compared across studies to assess the efficacy of one approach o family therapy versus another. Instead, these studies taken together indicate that family therapy interventions appear to decrease adolescent conduct problems and delinquent behavior when compared to individual therapy, treatment as usual, or no therapy.

Bank, Marlowe, Reid, Patterson, and Weinrott (1991) compared the effects of outpatient family therapy using a social learning approach, to individual treatment provided through the juvenile department for chronically delinquent youth. After treatment, both groups showed significant drops in their arrest and incarceration rates from baseline levels. However, youths and families who received SLFT showed significantly fewer incidents of incarceration both at the end of treatment and 1 year following treatment than the group of youths who were treated individually. This study supports previous findings that outpatient family therapy is an effective form of treatment. However, the small sample size limits the generalizability of the findings.

Dishion and Andrews (in press) compared the effects of parent group treatment, adolescent group treatment, and combined parent and adolescent groups, with two control group conditions (self-directed and no treatment) for 158 families with teenagers who were at risk for conduct problems and substance use. The parent group condition was superior to the other conditions in producing reduced family conflict as measured by direct observation of family interactions and parent reports. At l-year follow-up, teachers reported less externalizing behavior for subjects whose parents participated in the parent group and significantly higher levels of externalizing behavior for those who participated in the adolescent group treatment condition. This study adds to the growing body of literature that supports family-based interventions.

Szapocznik et al. (1989) conducted a study examining the effects of SFT, individual therapy, and recreational/no formal therapy in 69 Hispanic boys with behavioral and emotional problems. Parent report data revealed that all groups showed significant improvement after treatment. At I- year follow-up, adolescents in the family therapy condition improved, adolescents in the child therapy condition deteriorated, and those in the control group showed no change from pretreatment. Child self-report data revealed that all groups improved after treatment and at I- year follow-up, but the youths and families receiving SFT did not significantly improve more than the other groups. Similar to findings in the other studies described above, family therapy had a positive effect on reducing the number of problem behaviors in adolescent boys. In this study, family therapy also seemed to be more effective than individual therapy according to parents.

An important strength of the Szapocznik et al. (1989) study was that it examined the effects of family treatment designed for a particular cultural group, Hispanic boys and their families. Many previous studies have focused on the treatment of conduct disorder in somewhat heterogeneous populations of European-Americans or have studied diverse cultural groups without taking into consideration how cultural differences may affect treatment. Szapocznik et al. (1989) spent many years exploring what expectations Hispanic families had for treatment and found that the SFT was well-suited for this population because it targeted intergenerational conflict and culturally determined behavioral conflicts prevalent in Hispanic families (Szapocznik et al., 1980, 1986; Szapocznik, Scopetta, & King, 1978; Szapocznik, Scopetta, Kurtines, & Aranalde, 1978). More research is needed to ascertain whether the interventions that are available are indeed effective with different cultural groups. Also, more research is needed to determine what types of interventions need to be developed or tailored to take into account cultural differences.

In two studies, Chamberlain (1990) and Chamberlain and Reid (1991) examined the effectiveness of treatment foster care/SLFT for adolescents and their families. In these studies adjudicated, delinquent youth and a second sample with severe conduct and emotional problems were assigned to treatment in treatment foster care or in other residential settings. In both studies, the groups in treatment foster care who received SLFT as part of their program were incarcerated or hospitalized significantly less than the comparison groups. Although sample sizes in these studies were small, treatment foster care was shown to be a more effective form of treatment than group care for these populations. Furthermore, unlike any of the studies previously described, these studies provided cost-effectiveness data that showed that incarceration and hospitalization costs were lower for subjects in the treatment foster care groups than in the control groups.

Two studies conducted by Henggeler et al. (1992) and Mann et al. (1990) examined the effectiveness of multisystemic therapy using a family preservation treatment model. In Study 1, 84 serious juvenile offenders were randomly assigned to receive multisystemic therapy (MST) or treatment as usual offered by the Department of Youth Services. After treatment, the MST youths showed a significantly lower number of arrests and incarcerations and fewer behavior problems on self-report measures than youths treated by the Department of Youth Services. Similarly, in Study 2, according to self-report data, youths and families receiving MST reported fewer behavior problems than youths who received individual therapy. In both studies, family therapy was found to be more effective than treatment as usual and individual therapy, respectively.

Methodological weaknesses of the studies reviewed included relatively small sample sizes per group, somewhat brief follow-up periods, and in one case (i.e., Chamberlain, 1990), use of a matched comparison versus a fully randomized design. Strengths are that these studies all used multiple indicators of outcomes and that the treatments are all manualized so that replication and adaptation of treatments to meet the needs of different cultural and socioeconomic groups can be facilitated.

These recent studies concur with a large body of research on the effectiveness of family therapy treatments for childhood aggression and conduct problems that began to emerge in the 1960s and early 1970s (e.g., Minuchin, 1976; Parsons & Alexander, 1973). Further developments refining family interventions continue today (e.g., Dadds & McHugh, 1992; Prinz & Miller, 1994; Szapocznik et al., 1988; Webster-Stratton, 1991). However, it is widely acknowledged that a substantial number of families experience less than favorable outcomes from family therapy, especially multiply stressed families (Dumas & Wahler, 1983; Miller & Prinz, 1990; Reid & Patterson, 1976; Wahler, 1980). Many families drop out of treatment (Kazdin, 1990), do not initially engage (Szapocznik et al., 1988), show high levels of in-session resistance (Chamberlain, Patterson, Reid, Kavanagh, & Forgatch, 1984), and/or do not maintain treatment gains over time (Kazdin, 1985).

BARRIERS TO SUCCESSFUL TREATMENT

Several studies have shown that multiple personal and environmental stressors experienced by family members, particularly parents, derail their efforts to benefit from treatment and make implementation problems more likely (e.g., Dumas & Wahler, 1983; McMahon & Forehand, 1984; Patterson, 1982). Differential effectiveness has been associated with two family-related factors: (a) attrition and (b) family stress and lack of social support and child variables.

Attrition

Families who drop out of treatment have been found to be of lower socioeconomic status, to have mothers who were more depressed (e.g., McMahon, Forehand, Griest, & Wells, 1981), and to be agency (versus self) referred (Chamberlain et al., 1984). Kazdin (1990) assessed parent, child, and family characteristics of treatment completers and dropouts. Families who dropped out had children and adolescents with a greater number of symptoms of conduct disorders and delinquency, lower educational and occupational status, and lower income. Mothers in dropout families reported more depression and higher life event stress scores. Dropout rates of over 50% have been reported in treatment studies with families of conduct-disordered youngsters (e.g., Hawkins & Nederhood, 1987; Johnson, 1988).

In addition to dropout rates, once families are in treatment the issue of family resistance to initial engagement (i.e., losing clients after initial contact but prior to the first treatment session) has been identified by Szapocznik et al. (1988) as a significant barrier to provision of services. For example, of 650 families that made an initial contact requesting treatment, only 250 came in for a screening interview, and 145 completed the intake. They found that the application of strategic/structural family systems engagement strategies significantly improved initial engagement rates.

Family Stress and Lack of Social Support

Wahler and his colleagues (e.g., Dumas & Wahler, 1983; Wahler, 1980; Wahler & Dumas, 1987) have conducted a series of studies that examined the relationship among family socioeconomic disadvantage, social isolation, and outcomes. They found that at follow-up (i.e., 1 year), the probability of treatment failure, based on home observations of child behavior, steadily increased as a function of low socioeconomic status, social isolation, or both. This finding has been replicated in other studies (e.g., Webster-Stratton, 1985).

The impact of stress seems to be somewhat ameliorated if the parent has a relative or close friend from whom they can seek social support. For example, in their study with single parents and conduct-disordered youngsters, Dadds and McHugh (1992) found that maternal perception of social support was the best predictor of treatment responsiveness. Several studies have suggested that inclusion of specific components designed to enhance social support increases the effectiveness of family treatments (e.g., Dadds, Sanders, Behrens, & James, in press; Dadds, Schwartz, & Sanders, 1987; Griest et al., 1982; Miller Prinz, 1990), but these have been conducted with families of younger children with conduct problems and may not be generalizable to adolescent populations.

Child Variables

Specific child factors have also been found to influence treatment efficacy. For example, family therapy interventions have been found to be less effective for older (e.g., over 12.5 years) than younger cases (Dishion, 1984) and for adolescents who engage in both overt (e.g., aggression) and covert (e.g., stealing) conduct problems (Reid & Hendricks, 1973). In general, family therapy, although shown to be effective, is more difficult to implement for adolescent populations from multistressed families and may be a necessary component of treatment but perhaps not a sufficient strategy, in and of itself, for producing clinically significant behavior change. This notion will be discussed further in a subsequent section.

The interpretation of the role of family therapy in the SLFT and SFT studies is more straightforward than in the MET studies due to the inclusion of other treatments in those models. In the MET models, adolescents with more severe conduct disorders and delinquency are usually treated, and outcomes focus on comparisons among groups on placement rates in restrictive settings (i.e., incarceration, hospitalization). The MET treatment models reflect changes occurring during the past decade in terms of how intervention services are being delivered to conduct problem children, adolescents, and their families.

OVERVIEW OF SERVICE MODELS THAT INCLUDE FAMILY INTERVENTION

Increased emphasis has been placed on establishing integrated service delivery systems, including continuums of care that range from universally delivered prevention interventions (e.g., Bierman et al., 1992; Reid, 1993) to highly restrictive treatments in psychiatric hospitals or incarceration in the juvenile justice system. Two service delivery systems that are increasingly used to implement the MET treatment approaches for severely conduct disordered adolescents are family preservation (FP) services and treatment foster care (TFC). Combined with outpatient

family therapy, these service delivery alternatives represent a continuum of intensity, restrictiveness, and cost (see Figure 1).

Outpatient family therapy usually occurs weekly in a clinic setting, and sessions typically last from 60 to 90 minutes. FP services typically occur over a 2- to 4-month period in the family's home and vary from 1 to 30 hours per week. TFC typically lasts from 6 to 9 months, the child is placed in the home of a trained and supervised community family, the child's biological (or adoptive) family comes to the clinic for weekly sessions, and there are frequent home visits.

Referrals to outpatient treatment are made by an array of professionals or by the families themselves. The length of treatment varied in the studies reported in Table 1, with 12 to 46 hours of contact typically occurring weekly in a clinic setting.

FP services(2) are usually delivered when a child/adolescent is determined to be at risk for removal from his or her home by either the courts or child welfare social service agencies. Common features of this service model are: the intervention takes place primarily in the family's home, the family is considered the client, and the services have an ecological perspective and involve working in collaboration with community supports and services (Stroul & Goldman, 1990). Several recent reviews of the effectiveness of FP have been conducted (e.g., Rivera & Kutash, 1994; Wells, in press). Although evaluations have yielded generally positive results, the investigations have been criticized for methodological weaknesses, including use of a single outcome criterion, no random assignment, nonequivalent control groups, and small sample sizes. Some of the more rigorous studies (e.g., Feldman, 1991; Yuan, McDonald, Wheeler, Struckman- Johnson, & Rivest, 1990) have yielded less positive results. However, based on promising initial results, and in response to the escalating numbers of children and adolescents being placed in out-of-home care settings, federal legislation was passed in 1993 (P.L. 103-66) that will provide over a billion dollars to states over a 5-year period to implement early intervention, prevention, and FP programs.

The Homebuilders model, developed in Tacoma, Washington (Kinney, Haapala, & Booth, 1991; Kinney, Madsen, Fleming, & Haapala, 1977), is designed specifically to prevent out-of-home placements, has been implemented in over half of the states, and has been the subject of considerable evaluation efforts during the past 15 years (e.g., Rossi, 1992; Wells & Biegel, 1992). Services are short term (i.e., from 4 to 12 weeks) and intensive; families are seen for an average of 8 to 10 hours per week. Services are typically available on a 24-hour basis, as needed. The goal is to resolve the crisis precipitating the referral to out-of-home care and to improve family functioning. Various therapeutic orientations are used within this service model(e.g., Bandura, 1985; Henggeler, Melton, Smith, Schoenwald, & Hanley, 1993).

Polsky (1986) estimated the cost of FP services as ranging from $3,000 to $5,000 per episode, as compared to the cost of foster care which was estimated at $5,000 per year; group homes were estimated at $10,000 per year, detention at $20,000 per year, residential treatment centers at $30,000 per year, and hospitalization at $40,000 per year.(3) In a more recent report, Kinney et al. (1991) reported an average cost of $2,700 per child in FP versus $7,813 in foster care. Other analyses have confirmed that the FP service model appears to be cost effective (see Berry, 1992; Michigan Department of Social Services, 1993; New York City Department of Juvenile Justice, 1993). According to Wells (cited in Rivera & Kutash, 1994), the methodologies used to

determine the cost effectiveness of FP programs are fraught with difficulties and should be interpreted cautiously. For example, most do not include costs for follow-up services.

TFC(4) is reserved for cases where removal from home has already been deemed necessary, typically by a juvenile court judge or county mental health caseworker, and is considered to be the least restrictive form of residential care (Stroul, 1989). TFC is a widely used service delivery model and is often an alternative to incarceration or hospitalization (Rivera & Kutash, 1994). Webb (1988) reported that two thirds of TFC programs described their populations as children and adolescents with severe emotional and/or behavioral disturbances. Most TFC programs share the following common features: foster parents are carefully selected, trained, and closely supervised; one child/adolescent is placed in each home; a support system is created for TFC parents; and family therapy for the biological, adoptive, or other aftercare resource is a key part of the TFC program (Chamberlain, 1994; Meadowcroft, 1989). Case managers with small caseloads (i.e., maximum of 10) (Program Standards for Treatment Foster Care, 1991) coordinate all aspects of the treatment plan which, for adolescents, usually includes (a) family therapy; (b) TFC family support, training, and supervision; (c) individual therapy; (d) coordination with parole/probation/mental health workers; and (e) school monitoring and interventions. As with FP programs, various therapeutic orientations can be used within this service model. Most outcome studies have evaluated discharge data (i.e., placement of the child in a less restrictive setting at discharge), which range from a low success rate of 62% to a high of 89% (Stroul, 1989). Although numerous reports on TFC program outcomes have been published during the past decade (e.g., Bryant & Snodgrass, 1992; Hawkins, Almeida, & Samet, 1990; Hawkins, Meadowcroft, Trout, & Luster, 1985; Jones, 1990; Lee, Clark, & Boyd, 1994; Mikkelesen, Bereika, & McKenzie, 1993), only two have used control group designs (Chamberlain, 1990; Chamberlain & Reid, 1991), and these had small sample sizes and limited follow-up periods. Although increased experimental rigor is needed in studies evaluating this service model (see Meadowcroft, Thomlison, & Chamberlain, 1994), in general, studies on the TFC model have reported favorable outcomes in terms of the efficacy of treatment for children and adolescents who would otherwise be treated in more restrictive settings.

TFC is typically the least expensive in the range of residential services (Stroul & Friedman, 1986). Reported costs per day range from $35 to $150 (Stroul, 1989). Several reports indicate that costs of TFC compare favorably to other forms of residential care (e.g., Beggs, 1987; Bryant, 1981; Chamberlain & Reid, 1991; Hawkins et al., 1990), to incarceration (Chamberlain, 1990), and to inpatient hospitalization (Mikkelsen et al., 1993).

Costs for each of these service delivery models can be compared to the next most restrictive alternative. Although MET approaches are more intensive, restrictive, and expensive than outpatient family therapy, several evaluations of service delivery systems have found that delivery of a range of services is associated with positive outcomes (e.g., Fraser & Haapala, 1985; Jones, Magura, & Shyne, 1991).

THE ROLE OF FAMILY THERAPY IN SERVICE DELIVERY SYSTEMS

Family therapy appears to be a key component of the service package. For example, in a large- scale evaluation of services to status offenders in the state of Florida (Nugent, Carpenter, & Parks, 1993), the use of family therapy was examined in the context of two types of services, (a)

family preservation programs or (b) family reunification programs, over a 3-year period (1988- 1991). In family preservation programs, the goal was to keep adolescents at home; in reunification service programs it was to reunite adolescents who are placed outside of their homes or who have run away. A replication design was used in which findings from the first year were tested against those for the two subsequent years. Participants included a total of 10,191 families: 8,398 who participated in family preservation programs, and 1,343 who were in family reunification programs. Relevant findings were that participation in family therapy, as well as the number of sessions of family therapy, were significant predictors of the success of family preservation and family reunification efforts. Specifically, while there was no effect observed for individual or group counseling, families receiving 5 sessions of family therapy were twice as likely to remain together as were those who received none, and families who had 10 sessions were two and a half times more likely to remain together. In terms of family reunification, as the number of group counseling sessions increased, the probability of family reunification decreased. Families who received family therapy, however, were about three and one half times more likely to reunite than those who received none. The positive effects associated with the use of family therapy replicated across all 3 years. Although powerful because of its scope, the Nugent et al. (1993) study does not allow for causal conclusions due to the epidemiological (versus experimental) nature of the design. It is entirely possible that those who participated in family therapy were healthier than those who did not; however, the implications for practice, as articulated by those authors, seem clear:

Family therapists have argued that many child and adolescent problems require treating the family as a whole as opposed to treating the identified client with individual or group methods. The results of this study are clearly consistent with such claims, although they do not prove them. (p. 63)

This conclusion is in accord with a meta-analysis on outcomes in residential care (Garrett, 1985) in which individual and group therapies had no impact on recidivism whereas family therapy was more effective. Also, Barton, Alexander, Waldron, Turner, and Warburton (1985) found that for institutionalized delinquents, recidivism 15 months after release was significantly less among those who received family therapy (60%) than among those in the control group (93%).

GENERALIZATION OF STUDY FINDINGS TO PRACTICE

Weisz, Weiss, and Donenberg (1992) made the distinction between research therapy and clinic therapy. In the former, specifically recruited samples were relatively homogeneous, therapy was focused, therapists were well-trained in the techniques, and treatment integrity was monitored. In clinic therapy, samples were heterogeneous and had more co-morbid disorders, therapy was less focused, therapist training was less intensive, treatment manuals were not used, and there tended to be no monitoring of treatment integrity. Findings from clinic studies were less positive than those from research-based therapy studies, and the authors question the generalizability of meta- analyses based on research to actual clinic practice. In Shadish et al. (1993), meta-analysis results from dissertations were 40% smaller than from published studies. It may well be the case that results from published research overestimate the effectiveness of family therapy and other child and adolescent therapies as they are actually practiced in community, non-research-based settings.

CONCLUSIONS

More studies are needed to test the general efficacy of family therapy versus alternate treatments. Although results are generally supportive of family therapy, there are some negative findings. For example, in the Shadish et al. (1993) meta-analysis, family therapies in general had a reliably lower effect size than individual child-adolescent approaches. This finding was contradicted by the large-sample Florida Network Study which found that there was no relation (or a negative one) between the provision of group/individual counseling and family preservation, while provision of family therapy increased the likelihood that families would remain intact or be reunited. Family therapy may have a synergistic effect when used in the context of multitarget, ecologically based interventions, but this possibility has yet to be empirically examined.

Resistance to participation in family treatment is a significant barrier to delivering effective treatment. There is evidence that supporting multistressed families decreases their resistance in family therapy (Miller & Prinz, 1990; Patterson & Forgatch, 1985). With the advent of early prevention programs and service delivery continuums in local communities in the 1990s, there may be an improvement in parents' willingness and ability to participate in more intensive therapies later should they be indicated. Child conduct problems might be identified earlier, allowing families to benefit from less restrictive and expensive treatments. Currently, a services research project at the Johns Hopkins University is examining the question of whether participation in early intervention makes it more likely that later intervention will be more effective or need to be less intensive (P. Leaf, personal communication, June 14, 1994). Since the 1974 Juvenile Justice and Delinquency Prevention Act, there has been a vast increase in community-based residential programs for adolescents with severe conduct disorders and delinquency. The inclusion of a family therapy component in both prevention and treatment programs appears to be strongly indicated.

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NOTES

1 Gurman, Kniskem, and Pinsof (1986) define family therapy as follows:

any psychotherapeutic endeavor that explicitly focuses on altering the interactions between or among family members and seeks to improve the functioning of the family unit, or its subsystems, and/or the functioning of individual members of the family. (p. 565)

2 Also sometimes referred to as in-home services, family-based services, intensive family services.

3 All cost figures should be adjusted for inflation.

4 Also referred to as therapeutic foster care, specialized foster care, professional parenting, intensive foster care.

Support for this project was provided by Grant No. R01 MH47458 from the Center for Studies of Violent Behavior and Traumatic Stress, National Institute of Mental Health, U.S. PHS, and Grant No. P50 MH46690 from the Prevention Research Branch, National Institute of Mental Health, U.S. PHS.

Reprints may be requested from Patricia Chamberlain, Oregon Social Learning Center, 207 East 5th Avenue, Suite 202, Eugene, OR 97401.

Patricia Chamberlain, PhD, is Clinic Director and Research Scientist at the Oregon Social Learning Center, 207 East 5th Avenue, Suite 202, Eugene, OR 97401.

Julie Gilbert Rosicky, MS, is a Therapist at the Oregon Social Learning Center, 207 East 5th Avenue, Suite 202, Eugene, OR 97401.