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Intervention Summary

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Family Behavior Therapy

Family Behavior Therapy (FBT) is an outpatient behavioral treatment aimed at reducing drug and alcohol use in adults and youth along with common co-occurring problem behaviors such as depression, family discord, school and work attendance, and conduct problems in youth. This treatment approach owes its theoretical underpinnings to the Community Reinforcement Approach and includes a validated method of improving enlistment and attendance. Participants attend therapy sessions with at least one significant other, typically a parent (if the participant is under 18) or a cohabitating partner. Treatment typically consists of 15 sessions over 6 months; sessions initially are 90 minutes weekly and gradually decrease to 60 minutes monthly as participants progress in therapy. FBT includes several interventions, including (1) the use of behavioral contracting procedures to establish an environment that facilitates reinforcement for performance of behaviors that are associated with abstinence from drugs, (2) implementation of skill-based interventions to assist in spending less time with individuals and situations that involve drug use and other problem behaviors, (3) skills training to assist in decreasing urges to use drugs and other impulsive behavior problems, (4) communication skills training to assist in establishing social relationships with others who do not use substances and effectively avoiding substance abusers, and (5) training for skills that are associated with getting a job and/or attending school.

Descriptive Information

Areas of Interest Mental health treatment
Substance abuse treatment
Co-occurring disorders
Outcomes Review Date: October 2006
1: Drug use
2: Alcohol use
3: Family relationships
4: Depression
5: Employment/school attendance
6: Conduct disorder symptoms
Outcome Categories Alcohol
Drugs
Education
Employment
Family/relationships
Mental health
Social functioning
Ages 13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Inpatient
Outpatient
Home
Geographic Locations No geographic locations were identified by the developer.
Implementation History As of May 2010, 10 sites have implemented FBT, including 4 outpatient facilities, 3 outpatient and inpatient community sites, and 3 home-based sites.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations FBT has been adapted for use with youth diagnosed with conduct disorder. It has also been used to treat mothers in the child welfare system who abuse substances.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: October 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Azrin, N. H., McMahon, P. T., Donohue, B., Besalel, V. A., Lapinski, K. J., Kogan, E. S., et al. (1994). Behavior therapy for drug abuse: A controlled treatment outcome study. Behaviour Research and Therapy, 32, 857-866.  Pub Med icon

Study 2

Azrin, N. H., Acierno, R., Kogan, E. S., Donohue, B., Besalel, V. A., & McMahon, P. T. (1996). Follow-up results of supportive versus behavioral therapy for illicit drug use. Behaviour Research and Therapy, 34, 41-46.  Pub Med icon

Study 3

Azrin, N. H., Donohue, B., Besalel, V. A., Kogan, E. S., & Acierno, R. (1994). Youth drug abuse treatment: A controlled outcome study. Journal of Child & Adolescent Substance Abuse, 3, 1-15.

Study 4

Azrin, N. H., Donohue, B., Teichner, G. A., Crum, T., Howell, J., & DeCato, L. A. (2001). A controlled evaluation and description of individual-cognitive problem solving and family-behavior therapies in dually diagnosed conduct-disordered and substance-dependent youth. Journal of Child & Adolescent Substance Abuse, 11, 1-41.

Supplementary Materials

DeCato, L. A., Donohue, B., Azrin, N. H., & Teichner, G. A. (2001). Satisfaction of conduct-disordered and substance-abusing youth with their parents. Behavior Modification, 25, 44-61.  Pub Med icon

Donohue, B., & Azrin, N. H. (2001). Family behavior therapy. In E. Wagner & H. Waldron (Eds.), Innovations in adolescent substance abuse interventions. Tarrytown, New York: Pergamon.

Donohue, B., & Azrin, N. H. (2002). Family behavior therapy in a conduct-disordered and substance-abusing adolescent: A case example. Clinical Case Studies, 1, 299-323.

Donohue, B., Azrin, N. H., Lawson, H., Friedlander, J., Teichner, G., & Rindsberg, J. (1998). Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study. Journal of Child & Adolescent Substance Abuse, 8, 1-14.

Donohue, B., Azrin, N. H., Strada, M. J., Silver, N. C., Teichner, G., & Murphy, H. (2004). Psychometric evaluation of self and collateral Timeline Follow-Back reports of drug and alcohol use in a sample of drug-abusing and conduct-disordered adolescents and their parents. Psychology of Addictive Behaviors, 18, 184-189.  Pub Med icon

Donohue, B., DeCato, L. A., Azrin, N. H., & Teichner, G. A. (2001). Satisfaction of parents with their conduct-disordered and substance-abusing youth. Behavior Modification, 25, 21-43.  Pub Med icon

Donohue, B., Teichner, G., Azrin, N., Weintraub, N., Crum, T. A., Murphy, L., et al. (2003). Initial reliability and validity of the Life Satisfaction Scale for Problem Youth in a sample of drug abusing and conduct disordered youth. Journal of Child and Family Studies, 12, 453-464.

Family Behavior Therapy Modules 1-8

Outcomes

Outcome 1: Drug use
Description of Measures Illicit drug use was measured by urinalysis, self-report, and family member reports. In most studies, Timeline Followback methods were used for self-reports and family member reports.
Key Findings Three randomized controlled trials showed reduced illicit drug use among FBT participants. A 12-month trial with youth and adults showed that FBT clients were significantly less likely to report using any illicit drugs than supportive therapy clients in months 2 through 12 of treatment (p < .001). At the end of treatment, the average number of days of use each month was 2.1 for FBT clients, compared with 5.4 for supportive therapy clients (p < .02). At an average of 9 months after treatment termination, 71% of supportive therapy clients were using illicit drugs, compared with 42% of FBT clients (p < .02).

In a study of 26 youth, drug use decreased 73% over 6 months of treatment for those in FBT but did not change among those in supportive therapy (p < .02).

A study of youth with conduct disorder compared FBT with individual cognitive therapy. Both samples significantly decreased substance use from an average of 14 days per month to 9 days per month over 6 months of treatment (p < .001). Six months after treatment completion, both groups used drugs about 8 days per month, on average (p < .005).
Studies Measuring Outcome Study 1, Study 2, Study 3, Study 4
Study Designs Experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 2: Alcohol use
Description of Measures Alcohol use was measured by self-reports and other measures. In most cases, Timeline Followback methods were used.
Key Findings In a randomized controlled trial of adults and youth, adult FBT clients decreased frequency of alcohol use by nearly 50%, from an average of 7 days per month to 3.8 days per month over 12 months of treatment, while frequency of alcohol use did not change for those in supportive therapy (p < .001). Youth participating in FBT decreased alcohol use from an average of 2.2 to 1.5 days per month over 6 months of treatment, while those in supportive therapy increased use from an average of 3.2 to 4.5 days per month (p < .05). In a study of youth with conduct disorder, neither FBT nor individual cognitive therapy affected alcohol use.
Studies Measuring Outcome Study 1, Study 3, Study 4
Study Designs Experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 3: Family relationships
Description of Measures Family relationships were measured using the Marital/Couple Happiness Scale, the Parent Satisfaction Scale, and the Youth Satisfaction Scale, which ask respondents to report satisfaction with family members and marital relationships on a scale from 0 to 100 percent.
Key Findings In a sample of youth who used substances, parents' mean satisfaction with youth in FBT increased 30% from pre- to posttreatment, while parents' mean satisfaction with youth in supportive counseling did not change. In a study of youth with conduct disorder, parents' mean satisfaction with youth increased nearly 30% from pre- to posttreatment (p < .001). Youth mean satisfaction with parents increased approximately 11% from pre- to posttreatment (p < .001). Changes in the conduct-disordered youth sample were similar to changes observed in a comparison sample of youth receiving individual cognitive therapy. In another study with a sample of adults, significant changes in marital happiness were not observed.
Studies Measuring Outcome Study 3, Study 4
Study Designs Experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)
Outcome 4: Depression
Description of Measures Depression was measured with the Beck Depression Inventory.
Key Findings In a sample of youth and adults, depression decreased more in FBT participants compared with participants in a nonbehavioral intervention. Beck Depression Inventory scores dropped from an average of 17.9 to 7.2 for FBT participants and from 13.5 to 8.9 for clients in supportive therapy (p < .01). Among youth who used substances, Beck Depression Inventory scores decreased significantly in FBT participants but not in supportive therapy clients. However, supportive therapy clients were also less depressed pretreatment (mean score = 6.5) compared with the FBT clients (mean score = 15.2). Posttreatment, the average score for FBT clients was 5.5, compared with 6.5 for supportive therapy clients (p < .05). Scores among the youth with conduct disorder dropped to a subclinical level of depression posttreatment (p < .001). Posttreatment levels were maintained at 6-month follow-up. Changes in the FBT sample were comparable to those for clients in individual cognitive therapy.
Studies Measuring Outcome Study 1, Study 3, Study 4
Study Designs Experimental
Quality of Research Rating 3.2 (0.0-4.0 scale)
Outcome 5: Employment/school attendance
Description of Measures Days employed or attending school were measured by self-report on the Timeline Followback Interview.
Key Findings In a study of youth and adults, the mean percentage of days employed or in school over the past month increased from 52.2% to 73.6% among FBT clients and decreased slightly from 67.8% to 64.5% among supportive therapy clients (p < .001). Among youth who used substances, mean school/work attendance increased from 50.2% to 65.4% for FBT clients, while it decreased from 79.5% to 68.4% among supportive therapy clients (p < .05). Multiple measures of work and school attendance showed improvement for youth with conduct disorder who participated in FBT. Average hours worked per month over the last 6 months increased from 6.38 to 16.71 (p < .01), a change comparable to that observed for youth in individual cognitive therapy.
Studies Measuring Outcome Study 1, Study 3, Study 4
Study Designs Experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 6: Conduct disorder symptoms
Description of Measures Conduct problems were measured by standardized behavior checklists, self-report, parent reports, and arrest records.
Key Findings Among youth who used substances, the mean number of problems reported on the Quay Problem Behavior Checklist decreased from 22.5 to 14.3 for those in FBT but remained essentially unchanged for those in supportive therapy (p < .05). Multiple measures of conduct problems showed significant pre- to posttreatment improvements in youth diagnosed with conduct disorder. Average scores on the Achenbach Child Behavior Checklist decreased from 74.44 to 63.55. Posttreatment improvement was maintained at 6-month follow-up. Improvements observed in FBT clients were similar to those observed for clients in individual cognitive therapy.
Studies Measuring Outcome Study 3, Study 4
Study Designs Experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
68.3% Male
31.7% Female
91% White
9% Race/ethnicity unspecified
Study 2 13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
74.3% Male
25.7% Female
87.8% White
12.2% Race/ethnicity unspecified
Study 3 13-17 (Adolescent) 77% Male
23% Female
81% White
19% Race/ethnicity unspecified
Study 4 13-17 (Adolescent) 82.1% Male
17.9% Female
79% White
16% Hispanic or Latino
3% Race/ethnicity unspecified
2% Black or African American

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Drug use 3.6 3.0 2.5 2.0 3.0 3.0 2.9
2: Alcohol use 3.0 3.0 2.5 2.0 3.0 2.5 2.7
3: Family relationships 3.0 3.5 2.5 2.0 3.0 3.0 2.8
4: Depression 4.0 4.0 2.5 2.0 3.5 3.0 3.2
5: Employment/school attendance 3.0 2.5 2.5 2.0 3.0 3.0 2.7
6: Conduct disorder symptoms 3.5 3.5 2.5 2.0 3.0 3.0 2.9

Study Strengths

Researchers used multiple standardized, reliable, and valid measures. The more recent research provided systematic assessment of the reliability and validity of urinalysis and of the Timeline Followback approach, as well as other standardized measures of life and relationship satisfaction. Both self-reports and significant-other reports of treatment outcome were employed, and the use of multiple informants enhanced validity.

Study Weaknesses

The studies of youth and conduct-disordered youth had some overlap of samples. Both treatment intervention groups in the study of conduct-disordered youth showed comparable levels of improvement. Further work is necessary to determine whether FBT influences drug use with this population. Fidelity checks generally were not quantified. Statistical tests were repeated without correction for inflated Type 1 error rate. One-tailed tests were used. However, as indicated by the investigators, the observed pattern of results was consistent across data sets analyzed, and most associated p values were highly reliable. No details were provided on how researchers adjusted for missing data. Differences between participants who dropped out and those who completed treatment were not adequately assessed. In some studies, the researchers failed to report psychometric support for some of their measures.

Readiness for Dissemination
Review Date: October 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Achievement Center, University of Nevada, Las Vegas. (2007). Family Behavior Therapy quality assurance procedures manual. Las Vegas: Author.

Achievement Center, University of Nevada, Las Vegas. (2007). Referral and assessment procedures. Las Vegas: Author.

Donohue, B., & Azrin, N. (2001). Family Behavior Therapy. In E. Wagner & H. Waldron (Eds.), Adolescent substance abuse interventions (pp. 205-227). Oxford, UK: Elsevier Science, Ltd.

Family Behavior Therapy handouts and forms:

  • Aftercare Call After Completion of Program
  • Assessment File Completion Checklist
  • Assessment Summary
  • Authorization for Release of Confidential Information From Court/Child Protective Services
  • Authorization To Release Confidential Information to Court/Child Protective Services
  • Call to Caseworker If Noncompliance to Session
  • Client Contact Sheet
  • Client File Table of Contents
  • Client Progress Form
  • Client Scheduled Appointment Form
  • Demographics Form
  • Description of Program Forms in Client Charts
  • Family Assessment Progress Notes
  • Family Treatment Progress Notes
  • FBT Program Policies
  • General Authorization for Release of Confidential Information
  • General Authorization To Release Confidential Information
  • Home Safety and Beautification Assessment
  • Incident Report
  • Initial Phone Prescreen Criterion Form
  • Life Satisfaction Scale
  • Log of Contacts
  • Monthly Client Progress Call to Caseworker
  • Ongoing Treatment Calls
  • Outstanding Session Progress Notes
  • Post Retention Call 1
  • Potential Changes in Treatment Protocol
  • Pre-Assessment Checklist
  • Progress Notes Relevant to Correspondence Occurring Outside of Assessment/Treatment Sessions
  • Quality Assurance Client Chart Review
  • Reminder Phone Call 3 Days Prior to 1st Scheduled Treatment Session
  • Status of Referral Form
  • Suicide Protocol Checklist
  • Termination Report
  • Time Line Follow-Back (Significant Other)
  • Treatment File Completion Checklist
  • Treatment Folder Table of Contents
  • Treatment Referral Form
  • Urine Analysis Procedures

Family Behavior Therapy interventions:

  • Arousal Management
  • Assurance of Basic Necessities and Safety
  • Catching My Child Being Good
  • Communication Skills Training
  • Development of Behavioral Goals
  • Development of Treatment Plan
  • Financial Management and Planning
  • Home Safety and Beautification Tour
  • I've Got a Great Family
  • Job Club
  • Positive Practice
  • Self Control
  • Standardized Methods of Managing Noncompliance
  • Stimulus Control

Family Behavior Therapy Web site, http://www.unlv.edu/centers/achievement/index.html

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 4.0 3.8 3.8

Dissemination Strengths

Implementation materials include a fully scripted manual for clinicians that adequately facilitates delivery of the treatment strategies. Numerous checklists, detailed documentation forms, and activity sheets are available to provide implementation structure. Initial and follow-up trainings are available for potential implementers in a variety of formats. Extensive implementation support also is available. Protocol adherence checklists, rating forms, and audiotape assessments are provided to support quality assurance.

Dissemination Weaknesses

Space requirements for implementation and a staffing matrix are not provided in implementation materials. Quality assurance materials seem to emphasize task completion more heavily than the qualitative aspects of clinician competence.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Family Behavior Therapy: A Step-by-Step Approach to Adult Substance Abuse (manual that includes CD-ROM with protocol checklists and program forms) About $48 each Yes, at least one of the manuals is required
Family Behavior Therapy: A Step-by-Step Approach to Adolescent Substance Abuse (manual that includes CD-ROM with protocol checklists and program forms) About $48 each Yes, at least one of the manuals is required
Initial 2-day, on-site training workshop Contact the developer Yes, if certification is desired
1-day, on-site booster workshop Contact the developer Yes, if certification is desired
Annual case reviews Contact the developer Yes, if certification is desired
Annual audiotape integrity checks Contact the developer Yes, if certification is desired
Half-day, on-site consultation to review FBT clinic integration Contact the developer No

Additional Information

The cost of training and consultation can be negotiated with qualified FBT trainers. Nonprofit organizations with limited funding for training may be able to access training for free (excluding travel expenses).

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

* Azrin, N. H., Acierno, R., Kogan, E. S., Donohue, B., Besalel, V. A., & McMahon, P. T. (1996). Follow-up results of supportive versus behavioral therapy for illicit drug use. Behaviour Research and Therapy, 34, 41-46.  Pub Med icon

* Azrin, N. H., Donohue, B., Besalel, V. A., Kogan, E. S., & Acierno, R. (1994). Youth drug abuse treatment: A controlled outcome study. Journal of Child and Adolescent Substance Abuse, 3, 1-15.

* Azrin, N. H., Donohue, B., Teichner, G. A., Crum, T., Howell, J., & DeCato, L. A. (2001). A controlled evaluation and description of individual-cognitive problem solving and family-behavior therapies in dually diagnosed conduct-disordered and substance-dependent youth. Journal of Child and Adolescent Substance Abuse, 11, 1-41.

* Azrin, N. H., McMahon, P. T., Donohue, B., Besalel, V. A., Lapinski, K. J., Kogan, E. S., et al. (1994). Behavior therapy for drug abuse: A controlled treatment outcome study. Behaviour Research and Therapy, 32, 857-866.  Pub Med icon

Donohue, B., & Azrin, N. H. (2002). Family behavior therapy in a conduct-disordered and substance-abusing adolescent: A case example. Clinical Case Studies, 1, 299-323.

Contact Information

To learn more about implementation or research, contact:
Bradley Donohue, Ph.D.
(702) 557-5111
bradley.donohue@unlv.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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