doi: 10.1111/j.1752-0606.2011.00257.x
January 2012, Vol. 38, No. 1, 82–100
Emotional and behavioral symptoms and disorders are prevalent in children and adoles-
cents. There has been a burgeoning literature supporting evidence-based treatments for
these disorders. Increasingly, family-based interventions have been gaining prominence
and demonstrating effectiveness for myriad childhood and adolescent disorders. This
article presents the current evidence in support of family-based interventions for mood,
anxiety, attention-deficit hyperactivity, disruptive behavior, pervasive developmental
particularly autism spectrum, and eating disorders. This review details recent data from
randomized controlled trials (RCTs) and promising interventions not yet examined using
a randomized controlled methodology. It highlights the evidence base supporting various
specific family-based interventions, some of which are disorder dependent. A practitioner
perspective is then offered with regard to recommendations for future practice and
training. The article closes with a summary and directions for future research.
One evidence-based practice gaining in popularity for child and adolescent mental disor-
ders is family-based interventions. Family-based interventions may include the following sub-
systems: parents, parents and children, entire families, multiple families, and families and the
systems in which they are embedded (multisystemic). Recent reviews pay attention to systemic
interventions that fall under the rubric of family-based interventions, including family therapy
(Bray & Stanton, 2009; Carr, 2009; Diamond & Josephson, 2005; Sexton, Alexander, &
Mease, 2004). These reviews suggest that for a range of disorders in youth, family interven-
tions, including family therapy, may be effective, either as the sole treatment or in conjunc-
tion with other modalities, and outcomes are most positive when parents are engaged in the
treatment and efforts are made to enhance parenting and ameliorate maladaptive family envi-
ronments.
This article reviews RCTs for family-based interventions focusing on outcome studies pub-
lished since 2003, when the last review was presented in the Journal of Marital and Family Ther-
apy (Northey, Wells, Silverman, & Bailey, 2003). Building on that review, this article examines
family-based interventions for disorders that are prominent in youth: mood, anxiety, attention-
deficit, disruptive behavior, pervasive developmental, and eating. We are not including in this
review conduct disorders (CD) or delinquency or substance-related disorders because these are
included in depth in other articles within this special issue. Studies were found using Google
Scholar, PSYCHINFO, and MEDLINE, putting together disorder and family intervention
terms. Study selection was universal. Programs are listed as promising if there are some data to
support their efficacy, but no full-scale RCT. Sections present conclusions from prior reviews,
recent findings from RCTs, and promising interventions not yet tested via RCTs. Following the
Nadine J. Kaslow, PhD., ABPP, Chaundrissa Oyeshiku Smith, PhD., ABPP, and Marietta H. Collins, PhD,
Department of Psychiatry and Behavioral Sciences, Emory University; Michelle Robbins Broth, PhD,
Department of Psychology, Georgia Gwinnett College.
Address correspondence to Nadine J. Kaslow, Department of Psychiatry and Behavioral Sciences, Grady
Health System, 80 Jesse Hill Jr Drive, Atlanta, Georgia 30303; E-mail: nkaslow@emory.edu
DEPRESSION
Promising Interventions—Non-RCTs
Two promising family-based interventions exist for the treatment of depression in youth.
The ACTION treatment program offers a developmentally- and gender-sensitive intervention,
alone or with a parent training component, for depressed girls (Stark, Herren, & Fisher, 2009;
Stark et al., 2008). ACTION is associated with a 70% recovery rate when offered alone or in
combination with parent training. Youth whose parents participated had a more positive out-
come than those not assigned to receive that intervention. Another intervention for hospitalized
depressed youth involves the Depression Experience Journal (EJ), a computer-based psychoedu-
cational intervention for families guided by a narrative approach (Demaso, Marcus, Kinnamon,
& Gonzalez-Heydrich, 2006). The EJ uses a web-based forum to focus on mutual self-disclosure
of personal stories about childhood depression. A feasibility study revealed that parents experi-
enced high satisfaction and a low sense of concern for harmfulness with the EJ.
BIPOLAR DISORDER
Promising Interventions—Non-RCTs
West, Henry, and Pavuluri (2007) delineated a child- and family-based booster-session
approach using a CBT framework as a method of maintaining long-term improvement in
ANXIETY DISORDERS
Promising Interventions—Non-RCTs
One article applied Multidimensional Family Therapy (MDFT) to teenagers with comorbid
PTSD and substance abuse problems after exposure to Hurricane Katrina (Rowe & Liddle,
2008). An RCT is underway to provide evidence as to the utility of this treatment for youth
with PTSD and substance abuse difficulties. Another promising intervention is a conjoint
behavioral consultation model delivered in a school setting. The mental health provider con-
sults with the child’s parents and teachers, noting the reciprocal influence between home and
school environments, to enhance the assessment, monitoring, and treatment of the child’s anxi-
ety (Auster, Feeney-Kettler, & Kratochwill, 2006). An alternative to FCBT proposed for treat-
ing OCD in prepubertal children is narrative family therapy, which has received theoretical
justification for young children as well as case study support (McLuckie, 2005). Nonetheless,
empirical work is needed to determine the utility of this approach for childhood anxiety disor-
ders, including OCD. Maid, Smokowski, and Bacallao (2008) advocated for experiential inter-
ventions, such as communications approaches that focus on maladaptive family roles, for
families of children with anxiety disorders. Based on the importance of attachment, such
approaches emphasize the role of parental acceptance, control, and modeling in maintaining
children’s anxiety symptoms.
Much of the literature has used older elementary school-aged and adolescent samples. In
contrast, a family-based CBT intervention for children as young as four incorporating aspects
from FCBT studied in RCTs and developmental guidance, general behavioral parenting tech-
niques, and parent education has been proposed (Choate-Summers et al., 2008). Initial pilot
data are promising (Freeman et al., 2003).
Promising Interventions—Non-RCTs
Family-based interventions to treat ADHD improve communication patterns between teen-
agers and their parents (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001). However, these
studies have not used an RCT methodology, and thus it is premature to assess their efficacy.
Other family-based treatment modalities, including meditation, have been evaluated, although
data are preliminary and RCTs have yet to be conducted (Harrison, Manocha, & Rubia, 2004).
Promising Interventions—Non-RCTs
In the last several years, there has been a paucity of new, family-based interventions for
ODD. This may be due to the well-established evidence base. Nevertheless, adaptations to exist-
ing programs that combine treating ODD with other disorders do exist. The SPOKES project
(Scott et al., 2009) combines IY with a program to assist youth who experience literacy prob-
lems. An evaluation of this program, which included randomization, found that in addition to
gains in reading skills, ODD symptoms were reduced by 50% among 6-year-old children of
caregivers who received the program compared to caregivers in the control condition.
Promising Interventions—Non-RCTs
Development of parent education, parent-initiated, or parent-managed intervention pro-
grams is one method espoused for expanding services for children with ASD (Bibby, Eikeseth,
Martin, Mudford, & Reeves, 2002). In these methods, parents are taught specific procedures to
teach skills to their children through parent trainers. Trainers demonstrate techniques that
reduce problem behaviors, respond contingently to appropriate behavior, improve nonverbal
and verbal communication skills, and increase appropriate play behavior (Symon, 2005). Par-
ents learn these techniques and consistently apply them to interactions with their children at
home. The following is a brief overview of some examples of these programs.
In Pivotal Response Training (PRT; Koegel, Symon, & Koegel, 2002), trained parent vol-
unteers are matched to parents and others seeking assistance. Findings support parents’ abilities
to master the techniques and then train other caregivers to use the techniques with their chil-
dren. Findings highlight the value of parents as active partners in their children’s education.
The Social Communication, Emotional Regulation, and Transactional Support (SCERTS)
Model uses a multidisciplinary approach to enhance the communication and socioemotional
abilities of early intervention–aged children with ASD (Prizant, Wetherby, Rubin, & Laurent,
2003). This model targets the core developmental deficiencies of children with ASD. Goals for
each core component are delineated and treatment is designed for each individual child’s
strengths and weaknesses. SCERTS is derived from tenets of evidenced-based practices, ASD
scholars, and researchers, and it integrates current understanding of the learning styles of ASD
individuals. Its design reflects current and emerging ‘‘recommended’’ practices.
Relationship-focused (RF) interventions have been proposed as an effective early interven-
tion for ASD children (Mahoney & Perales, 2005). RF interventions address the socioemotional
and developmental needs of young children by encouraging parents to use strategies to encour-
age interactive responsiveness with their children. RF interventions improve the cognitive and
communication functioning of young children.
EATING DISORDERS
Promising Interventions—Non-RCTs
Other research has focused on additional clinical constructs and method of intervention
dissemination. Dallos (2004) has argued for incorporating an attachment-based perspective into
systemic family therapy for adolescents with eating disorders, noting the intergenerational
transmission of insecure or avoidant attachment, the avoidance of conflict in family dynamics,
and problems in discussing feelings and relationships among family members. In addition, an
innovative approach to the dissemination of family therapy for treating adolescent AN using
videoconferencing (‘‘telehealth’’) to access underserved (e.g., rural) populations has been pre-
sented (Goldfield & Boachie, 2003). Proponents of this approach note patient satisfaction with
treatment along with significant weight gain.
Finally, some researchers are developing family-oriented preventive interventions aimed at
preventing the onset of disordered eating behaviors among those at risk. For example, a nine-
session multiple-family group experience has been proposed, focusing on psychoeducation
Few interventions examined via RCTs target family factors associated with youth depres-
sion (Restifo & Bogels, 2009). Stress-Busters with the parent component appears effective with
elementary school-aged children, although the added benefit of the parental component has yet
to be empirically supported as it has not been tested against Stress-Busters alone. For adoles-
cent depression, there is initial support for a variety of family-based interventions: CWD-A
with a parent component, ABFT, PRP with a parent component, MFPG, and FPE. More stud-
ies are needed that target depressed children. The programs that appear promising need to be
compared to other treatment modalities and to other types of family-based interventions.
Pilot data from non-RCTs and initial data from RCTs suggest that family-based interven-
tions for youth with BD are beneficial, particularly FFT and MFPG. Given the high levels of
conflict and stress, along with parental psychopathology, in families of children with BD, the
importance of involving parents in the treatment of youth with BD is clear. However, the
empirical study of family-based interventions is in its infancy, and further research needs to test
the different protocols available to date against appropriate controls and, eventually, against
each other to determine optimal benefit for youth living with BD and their families.
Several RCTs provide compelling evidence for family-based interventions for children with
anxiety disorders. The strongest support is for Family Cognitive Behavior Therapy (FCBT), and
researchers from a number of laboratories have presented data that support the efficacy of this
intervention. In addition, some data support the value of ABFT plus CBT (CBT-ABFT). Future
RCTs targeting anxious youth and their families should be conducted with larger sample sizes and
with younger children, incorporating developmentally appropriate considerations into the model.
Family-based interventions should be evaluated for their benefit regarding different diagnostic
categories, such as complex trauma. Promising family-based interventions for children with anxi-
ety should be tested through more rigorous empirical means to determine their efficacy.
Three evidence-based family-based interventions appear promising for youth, particularly
young children and those in elementary and middle school, with ADHD: PCIT, Triple P—
Positive Parenting Program (Triple P), and IY. However, only a few RCTs have examined each
of these treatments for this population. Family-based programs should be developed and exam-
ined in conjunction with pharmacological interventions. More RCTs are needed with a broader
age range of youth with ADHD, particularly adolescents, and more empirical attention is
needed to test novel treatments.
PCIT, Triple P, and IY effectively reduce ODD and its related symptoms. These parenting
programs have support for preschool- and early elementary–aged youth. The effectiveness of
training programs for parents with children with ODD decreases as children age (Connor &
Doerfler, 2009). As a result, more youth-focused interventions, rather than family-based inter-
ventions, are used with older children with greater frequency (Garland, Hawley, Brookman-
Frazee, & Hurlburt, 2008). It would be valuable to develop and evaluate developmentally
appropriate adaptations of these parent programs to target older youth, which would mean
including parenting, individual child, and family systems–oriented protocols.
Family-based interventions for ASD have received limited empirical examination. Parent
education or parent-managed interventions have been developed in response to the need for fam-
ily-based interventions for ASD. Comparatively speaking, gains from parent-managed interven-
tion programs are not as large as those from centers or clinics specializing treating ASD. Most
studies of family-based interventions for ASD have been criticized for their lack of systematic
effectiveness evidence (Aldred et al., 2004), although this is improving. Researchers cite small
sample sizes, absence of blind conditions, and prevalence of nonrandomized designs with inade-
quate power. RCTs are needed, despite the difficulty of conducting such investigations with this
population (Odom, Boyd, & Hall, 2009). Future research should examine comprehensive inter-
ventions for ASD that incorporate a family-based intervention, including parent management
(Lord et al., 2005). The development of such interventions can be guided by models such as the
REFERENCES
Aldred, C., Green, J., & Adams, C. E. (2004). A new social communication intervention for children with autism:
Pilot randomised controlled study suggesting effectiveness. Journal of Child Psychology and Psychiatry, 45,
1420–1430.
Asarnow, J. R., Scott, C. V., & Mintz, J. (2002). A combined cognitive-behavioral family education intervention
for depression in children: A treatment development study. Cognitive Therapy and Research, 26, 221–229.
Aspy, R., & Grossman, B. G. (2007). The Ziggurat model: A framework for designing comprehensive interventions
for individuals with high-functioning autism and asperger syndrome. Plano, TX: Autism Asperbger.
Auster, E. R., Feeney-Kettler, K. A., & Kratochwill, T. R. (2006). Conjoint behavioral consultation: Application
to the school-based treatment of anxiety disorders. Education and Treatment of Children, 29, 243–256.
Bagner, D. M., & Eyberg, S. M. (2007). Parent-Child Interaction Therapy for disruptive behavior in children
with mental retardation: A randomized controlled trial. Journal of Clinical Child and Adolescent Psychology,
36, 418–429.
Barkley, R. A., Edwards, G., Laneri, M., Fletcher, K., & Metevia, L. (2001). The efficacy of problem-solving
communication training alone, behavior management training alone, and their combination for parent-
adolescent conflict in teenagers with ADHD and ODD. Journal of Consulting and Clinical Psychology, 69,
926–944.
Barrett, P., Farrell, L., Dadds, M., & Boulter, N. (2005). Cognitive-behavioral family treatment of childhood
obsessive-compulsive disorder: Long-term follow-up and predictors of outcome. Journal of the American
Academy of Child and Adolescent Psychiatry, 44, 1005–1014.
Barrett, P., Healy, L., & March, J. S. (2003). Behavioral avoidance test for childhood obsessive-compulsive
disorder: A home-based observation. American Journal of Psychotherapy, 57, 80–100.
All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.