Functional Family Therapy for Adolescent Disruptive Behavior: RCT

Olseth, A. R., Hagen, K. A., Keles, S., & Bjørnebekk, G. (2024). Functional family therapy for adolescent disruptive behavior in Norway: Results from a randomized controlled trial. Journal of Family Psychology, 38(4), 548–558. https://doi.org/10.1037/fam0001213

Rationale

Adolescent disruptive behavior is associated with severe long-term consequences for youths and society (Colman et al., 2009; Caspi et al., 2016). While the importance of early intervention is well-established, effective treatments for this population are limited (McCart et al., 2023).

Functional Family Therapy (FFT) is an evidence-based intervention aimed at reducing adolescent disruptive behavior, with extensive testing in juvenile justice populations showing positive outcomes compared to treatment as usual (TAU) (Vardanian et al., 2020).

However, less is known about its effectiveness in non-juvenile justice settings and in comparison to TAU in different cultural contexts (McCart et al., 2023).

In Norway, where there is no separate juvenile justice system, FFT is offered through Child Welfare Services (CWS) for youths with severe disruptive behavior.

The effectiveness of FFT compared to the diverse range of treatments typically offered in Norwegian CWS (constituting TAU) has not been previously examined.

This comparison is crucial because TAU in Norway may differ significantly from TAU in other countries where FFT has been studied, potentially including evidence-based practices like Multisystemic Therapy (Ogden & Hagen, 2018).

This study aims to examine the effectiveness of FFT compared to TAU in a context where criminal charges or justice system involvement is not a requirement for referral.

By directly comparing FFT to the existing services (TAU) in Norway’s CWS, this research addresses an important gap in understanding how FFT performs relative to established practices in diverse settings and populations.

This comparison is essential for informing policy decisions about implementing new interventions versus enhancing existing services in the Norwegian child welfare context.

Method

The study employed a randomized controlled trial design with two treatment conditions: Functional Family Therapy (FFT) and Treatment as Usual (TAU).

TAU refers to the standard or typical treatment that participants would receive if they were not part of the study. It represents the existing services or interventions that are normally available and provided in the regular care setting.

TAU serves as a control condition, allowing researchers to compare the new or experimental treatment (in this case, FFT) against the current standard of care. This comparison helps determine if the new treatment offers any advantages over existing practices.

Participants were assessed at three time points: pretest (intake), posttest (6 months after pretest), and follow-up (18 months after pretest).

Procedure

Between 2013 and 2017, families were recruited from Child Welfare Services (CWS) in Norway. After initial assessment and consent, participants were randomly assigned to either FFT or TAU.

At each time point, data was collected from youths, parents, and teachers.

FFT was delivered by trained therapists, while TAU consisted of various treatments typically offered by CWS or Family Counselling Services.

Sample

The study included 159 youths (45.9% female) with a mean age of 14.72 years (SD = 1.47). Participants were referred to CWS for severe disruptive behavior.

The sample included youths with immigrant backgrounds (15.2%) and various family situations (26.1% parents living together, 67.3% parents living apart, 6.5% in long-term foster care or adoption).

Measures

• Child Behavior Checklist (CBCL) and Teacher Report Form (TRF): Assessed aggressive behavior, rule-breaking behavior, internalizing problems, social skills, academic performance, and adaptive functioning.
• Self-Reported Delinquency (SRD): Measured youth-reported delinquent behaviors.
• Negative Peers Scale: Assessed youth involvement with antisocial peers.
• Social Skills Rating System (SSRS): Measured social skills as reported by parents and teachers.
• Drug Use: Assessed youth drug use (not analyzed due to low frequencies).

Statistical measures

The study used latent curve models (LCMs) to analyze treatment effects. Unconditional LCMs examined overall change in the entire sample, while conditional LCMs assessed differences between FFT and TAU groups. Multiple imputation was used to handle missing data.

Results

Hypothesis 1: FFT would lead to greater reduction in parent-reported youth problem behavior and greater increase in parent-reported social skills compared to TAU.

Result: Not supported. No significant differences were found between FFT and TAU groups in parent-reported outcomes from pretest to posttest.

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Hypothesis 2: FFT would lead to greater improvement in teacher-reported school performance and social skills, and greater reduction in teacher-reported problem behavior compared to TAU.

Result: Not supported. No significant differences were found between FFT and TAU groups in teacher-reported outcomes from pretest to posttest.

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Hypothesis 3: FFT would lead to greater reduction in youth self-reported delinquency, drug abuse, and contact with deviant peers compared to TAU.

Result: Not supported. No significant differences were found between FFT and TAU groups in youth-reported outcomes from pretest to posttest.

Additional finding: A significant intervention effect favoring TAU over FFT was found for parent-reported youth internalizing problems between posttest and follow-up.

Insight

The key finding of this study is that Functional Family Therapy (FFT) did not show superior outcomes compared to Treatment as Usual (TAU) for adolescents with disruptive behavior in Norway’s Child Welfare Services.

This result is particularly informative because it challenges the assumption that evidence-based interventions like FFT will consistently outperform usual care across different contexts and populations.

The study extends previous research by examining FFT’s effectiveness in a non-juvenile justice setting and in a cultural context outside the United States.

The findings suggest that the effectiveness of interventions may vary depending on factors such as the target population’s characteristics, the severity of disruptive behavior, and the quality of usual care services available.

Further research could explore:

1. The specific components of TAU that led to comparable outcomes with FFT.
2. The effectiveness of FFT for different subgroups within the Norwegian CWS population.
3. The impact of voluntary versus mandated participation on treatment outcomes.
4. The long-term trajectories of youth who receive FFT versus TAU beyond the 18-month follow-up.
5. Strengths:

Strengths

• Randomized controlled trial design
• Multiple informants (youth, parents, teachers)
• Assessment at three time points (pretest, posttest, follow-up)
• Use of both clinical and functional outcome measures
• Implementation in real-world clinical settings
• Inclusion of an active control group (TAU)
• Use of advanced statistical methods (latent curve models)

Limitations

• High dropout rates and potential differential attrition between treatment groups
• Incomplete enrollment data for one site
• Exclusion of some referred cases by FFT leaders
• Limited generalizability due to the study being conducted only in certain parts of Norway
• Lack of information about specific components of TAU
• Inability to control for variations in treatment adherence and quality across sites
• Potential bias in teacher reports due to changes in respondents across time points

These limitations may affect the internal and external validity of the findings, potentially underestimating or overestimating treatment effects.

Clinical Implications

The results of this study have significant implications for clinical practice and policy in adolescent mental health services:

1. Evidence-based interventions may not always outperform usual care in different cultural contexts or service settings. This highlights the importance of conducting effectiveness studies in diverse populations and settings before widespread implementation.
2. The comparable outcomes between FFT and TAU suggest that existing services in Norway’s Child Welfare System may be relatively effective for treating adolescent disruptive behavior. This underscores the value of evaluating and potentially enhancing current practices rather than solely focusing on importing new interventions.
3. The finding that TAU showed better long-term outcomes for internalizing problems suggests that some components of usual care may be particularly beneficial for addressing emotional issues. This indicates a need for comprehensive interventions that target both externalizing and internalizing problems.
4. The lack of significant improvements in school-related outcomes for both FFT and TAU groups highlights the need for interventions that more effectively address academic and behavioral issues in educational settings.
5. The variability in outcomes may be influenced by factors such as the severity of disruptive behavior, voluntary versus mandated participation, and the quality of implementation. These factors should be considered when selecting and adapting interventions for specific populations.
6. The study emphasizes the importance of conducting long-term follow-ups to assess the sustainability of treatment effects and identify any delayed or emerging differences between interventions.
7. For policymakers and service providers, the results suggest that careful consideration should be given to the cost-effectiveness of implementing new interventions versus improving existing services.

References

Primary reference

Olseth, A. R., Hagen, K. A., Keles, S., & Bjørnebekk, G. (2024). Functional family therapy for adolescent disruptive behavior in Norway: Results from a randomized controlled trial. Journal of Family Psychology, 38(4), 548–558. https://doi.org/10.1037/fam0001213

Other references

Caspi, A., Houts, R. M., Belsky, D. W., Harrington, H., Hogan, S., Ramrakha, S., Poulton, R., & Moffitt, T. E. (2016). Childhood forecasting of a small segment of the population with large economic burden. Nature Human Behaviour, 1(1), Article 0005. https://doi.org/10.1038/s41562-016-0005

Colman, I., Murray, J., Abbott, R. A., Maughan, B., Kuh, D., Croudace, T. J., & Jones, P. B. (2009). Outcomes of conduct problems in adolescence: 40 year follow-up of national cohort. The BMJ, 338, Article a2981. https://doi.org/10.1136/bmj.a2981

McCart, M. R., Sheidow, A. J., & Jaramillo, J. (2023). Evidence base update of psychosocial treatments for adolescents with disruptive behavior. Journal of Clinical Child and Adolescent Psychology, 52(4), 447–474. https://doi.org/10.1080/15374416.2022.2145566

Ogden, T., & Hagen, K. A. (2018). Adolescent mental health: Prevention and intervention (2nd ed.). Routledge. https://doi.org/10.4324/9781315295374

Vardanian, M. M., Scavenius, C., Granski, M., & Chacko, A. (2020). An international examination of the effectiveness of Functional Family Therapy (FFT) in a Danish community sample. Journal of Marital and Family Therapy, 46(2), 289–303. https://doi.org/10.1111/jmft.12405

Keep Learning

Socratic questions for a college class to discuss this paper:

1. How might cultural differences between Norway and the United States impact the effectiveness of interventions like Functional Family Therapy?
2. What ethical considerations arise when implementing evidence-based interventions in new contexts or populations?
3. How can researchers balance the need for rigorous evaluation of interventions with the practical constraints of real-world clinical settings?
4. What are the potential implications of finding no significant differences between an evidence-based intervention and treatment as usual?
5. How might the voluntary nature of participation in this study affect the generalizability of the results to settings where treatment is mandated?
6. What strategies could be employed to improve the retention of participants in longitudinal studies of adolescent interventions?
7. How should policymakers and clinical directors interpret and act upon the results of this study in making decisions about service provision?
8. What additional measures or data collection methods could have strengthened this study’s ability to explain the observed outcomes?