Assessing the Feasibility of Applying Criminological Theory to
the IS Security Context Robert Willison

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Understanding the Offender/Environment Dynamic for Computer
Crimes: Assessing the Feasibility of Applying Criminological Theory to
the IS Security Context
Robert Willison
Department of Informatics, Copenhagen Business School
[email protected]
Abstract
There is currently a paucity of literature
focusing on the relationship between the actual
actions of staff members, who perpetrate some
form of computer abuse, and the organisational
environment in which such actions take place. A
greater understanding of such a relationship may
complement existing security practices by possibly
highlighting new areas for safeguard
implementation. In addition, if insights are
afforded into the actions of dishonest staff, prior to
the actual perpetration of a crime, then
organisations may be able to expand their
preventive scope, rather than relying solely on
technical safeguards to stop the actual commission
of some form of computer abuse. To help facilitate
a greater understanding of the
offender/environment dynamic, this paper assesses
the feasibility of applying criminological theory to
the IS security context. More specifically, three
theories are advanced, which focus on the
offender’s behaviour in a criminal setting. After
opening with a description of the theories, the
paper provides an account of the Barings Bank
collapse. Events highlighted in the case study are
used to assess whether concepts central to the
theories are supported by the data. The paper
concludes by summarising the major findings and
discussing future research possibilities.
1. Introduction
There is currently little written about the
relationship between the actual criminal actions of
staff members, who perpetrate some form of
computer abuse, and the organisational
environment in which such actions take place [1].
Insights into such a relationship may complement
existing IS security practices by possibly
highlighting additional areas in which safeguards
could be introduced. More specifically, if insights
are afforded into the actions of dishonest staff,
prior to the actual perpetration of a crime, then
organisations may be able to expand their
preventive scope. Rather than relying solely on
technical safeguards such as intrusion detection
tools and password system to help stop the
commission of a computer crime, other safeguards
designed to prevent criminal behaviour, prior to
perpetration, would prove to be a useful addition
in the preventive armoury of IS security
practitioners. In an attempt to facilitate a clear
understanding of the offender/environment
dynamic, this paper assesses the feasibility of
applying criminological theory to the IS security
context. Three theories are advanced which
specifically address the offender’s behaviour in the
criminal setting. The paper opens with a
description of the criminological approaches,
which include routine activity theory,
environmental criminology and the rational choice
perspective. This is followed by an account of the
collapse of Barings Bank. Events highlighted in
the account are then drawn on in the discussion
and analysis section, to assess whether concepts
central to the theories are supported by the data.
The paper concludes summarising the findings and
discussing further research possibilities offered by
the three criminological schools of thought
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2. IS Security and Criminological
Theory
In an attempt to provide new insights into the
relationship between the criminal actions of
dishonest employees and their workplace
environment, criminology would appear to be a
potentially fruitful body of knowledge from which
to draw upon. Clarke [2] notes how:
“Most criminological theories have been
concerned with explaining why certain
individuals or groups, exposed to particular
psychological or social influences, or with
particular inherited traits, are more likely to
become involved in delinquency or crime”.
However, in the last four decades, a number of
like-minded theories have emerged which, rather
than focusing on how people become criminals,
address the actual criminal act [2]. Included in
this group are routine activity theory,
environmental criminology and the rational choice
perspective. These theories focus on the
relationship between the offender and the actual
environment in which the crime takes place and it
is for this reason that they are advanced as
potentially useful schools of thought for IS
security research. As a first step in assessing the
feasibility of applying the theories to the IS
security context, this section of the paper describes
the three approaches.
2.1. Routine Activity
Routine Activity Theory is a relative newcomer
to the field of criminology. Cohen and Felson [3]
discuss how changes in what they describe as
‘routine activities’ of society’s members have
impacted on the levels of direct-contact predatory
crimes, i.e. crimes where one or more persons
directly take or damage the person or property of
another. These activities include the provision of
food, shelter, leisure, work, child-rearing, and
sexual outlets. It is argued that these forms of
behaviour influence direct-contact predatory (i.e.
where one or more persons directly take or
damage the person or property of another) crime
rates by impacting on the convergence in time and
space, of the three elements required for a crime to
occur. These elements consist of a likely offender,
a suitable target, and the absence of a capable
guardian, who, if present, would be in a position to
stop a criminal act. As the name suggests, the
offender is the individual who may, or may not,
decide to perpetrate a crime. A target may be a
person or object that is attacked or taken by the
offender. This might include, for instance, a man
the offender wants to rob or a car he wishes to
steal. What also determines a target is whether or
not the entity, which forms the basis for a target,
either lacks or has present, a capable guardian.
Thus for example, a house where the owner is
present is afforded a capable guardian. If,
however, the owner is at work, the property lacks a
capable guardian and consequently represents
much more of a target to the potential offender.
Cohen and Felson [3] assert that it takes merely
the absence of one of these three elements for a
crime not to occur. So for example, drawing on
U.S.A. census data and victimisation surveys, they
reveal how between 1960-1970, daytime
residential burglary increased by 15%. They
partly explain this rise by noting how the decade
also witnessed an increase of females in the
workforce and a rise in the number of individuals
living along. As a consequence, there was a
related rise in the number of properties left vacant
and lacking a capable guardian during the working
day.
Routine activity theory is still in a period of
transition, as witnessed by the efforts of Felson [4]
to extend its scope. In an attempt to accommodate
Hirschi’s [5] social control theory, Felson [4]
proposes the incorporation of another element, that
of the ‘intimate handler’, to illustrate how people
can act as a ‘brake’ on the activities of offenders.
In his book Causes of Delinquency, Hirschi [5]
argues that there are four factors that constitute a
social bond between an individual and society.
These include commitments, attachments,
involvements and beliefs. Felson uses the word
‘handle’ to summarise the four elements. By
doing so he argues that the social bond (and hence
handle) is a key element in informal social control.
The ‘intimate handler’ represents the individual
who is able to exert this form of social control.
The handler is normally someone who is
recognised by, and has sufficient knowledge, of
the potential offender. Hence the mere presence of
a person known to the potential offender may act
as a form of ‘handling’, and consequently a
deterrent, by reminding the offender of their social
bonds. By incorporating the concept of the
handled offender and the intimate handler into
routine activity theory, Felson argues that just as a
target must be lacking a capable guardian for the
commission of a crime, so too must the offender
be lacking an intimate handler.
Furthermore, as a means of enhancing its
contribution to crime prevention, Clarke [6]
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advocates that routine activity theory could
incorporate the category of ‘crime facilitators’.
These relate to items such as cars, guns, and credit
cards, which act as tools for specific crimes – as
well as dis-inhibitors such as alcohol, which
facilitate the precipitation of crimes. Clarke [6]
argues that if we appreciate how these facilitators
are used, it may be possible to identify points were
safeguards can be introduced.
2.2. Environmental Criminology
Environmental criminology has provided
considerable insight into the ‘search’ patterns of
offenders and illustrated how the majority of
crimes are committed within areas visited by
offenders during their routine work and leisure
pursuits [7]. Offenders develop an ‘action space’
in which these everyday pursuits take place and
through such activities acquire a detailed
knowledge of this environment, leading to what
these authors describe as an ‘awareness space’.
Like the rational choice perspective, Brantingham
and Brantingham [7] argue that the motivated
individual engages in a ‘multi-staged decision
process’ prior to the commission – or not as the
case may be – of a crime. Such a process is
informed through knowledge gathered from the
offender’s awareness space. Furthermore, they
argue that a specific environment emits cues
relating to its spatial, cultural, legal and
psychological characteristics. With experience, an
offender is able to discern certain sequences and
configurations of these cues associated with a
‘good’ target.
2.3. Rational Choice Perspective
The rational choice perspective focuses on the
decision-making processes of offenders [8, 9, 10].
The approach assumes that crimes are chosen by
the offender, as a suitable course of action, with
the intention of deriving some type of benefit.
Obvious examples are cash or material goods, but
a broader reading of the term ‘benefits’ allows for
the inclusion of other forms, such as prestige, fun,
excitement, sexual gratification, and domination.
Joyriding is an example of how the benefits may
take the intangible forms of fun and excitement.
Of further importance to the rational choice
perspective is the division of criminal choices into
two groups, viz., ‘involvement’ and ‘event’
decisions. The former refers to decisions an
offender makes regarding their criminal careers.
The latter refers to those decisions made during
the actual commission of a crime. These decisions
are based on the offender’s perceptions of the
situation. Hence, the decision to carry out a
particular criminal act emerges from a reasoning
that the associated risks and efforts are outweighed
by the perceived rewards. In other words, the
decision to carry out a particular criminal act
represents an assessment by the offender that the
particular situation offers an opportunity. Given
this, an opportunity can be seen as a subjective
relationship between an offender and their
environment.
The approach further assumes that choices are
characterised by what is termed ‘bounded’ or
‘limited’ rationality. In other words, criminal
decision making is at times less than perfect, as a
consequence of the conditions under which
decisions are made. With the associated risks and
uncertainty in offending, criminals may make
decisions without the knowledge of all the
potential costs and benefits (i.e. the risks, efforts
and rewards). Devoid of all the necessary
information, offenders may resort to ‘rules of
thumb’ when perpetrating offences, or rely on a
tried and tested general approach that may be
called into action when unexpected situations
arise.
3. Case Study: The Collapse of Barings
Bank
On the 26th February 1995, administrators were
appointed by the High Court in London (UK) to
manage the affairs of Baring Plc. following the
identification of substantial losses incurred by a
related overseas subsidiary known as Baring
Futures Singapore. This section of the paper
provides an account of the major factors that were
instrumental in the collapse of Barings. The
purpose of the account is two fold. First the reader
is afforded an understanding of the collapse.
Secondly, data drawn from this case study is then
used in the ‘Discussion and Analysis’ section to
assess whether events highlighted in the account
support concepts, which are central to the three
criminological theories. Two points should be
noted here. First, given the limitations on space,
the account is simplified, highlighting areas most
obviously covered by the theories. Secondly, the
account is based on the Bank of England: Report
of the Board of Banking Supervision Inquiry into
the Circumstances of the Collapse of Barings [11]
and Stephen Fay’s The Collapse of Barings [12].
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3.1. Brief History and Background of
Barings Bank
Prior to its collapse, Baring Brothers & Co. had
been the oldest merchant bank in the City’s square
mile. Founded initially as a partnership in 1762,
the bank had managed to remain independent and
privately controlled. After a near fatal business
venture in Argentina, Baring Brothers & Co. was
established in 1890 to succeed the partnership. In
1985 the share capital of Baring Brothers & Co.
was acquired by Barings plc, which became the
parent company of the Barings Group. Apart from
Baring Brothers & Co., the other two principal
operating companies of Barings plc were Baring
Securities Limited and Baring Asset Management,
which played no part in the collapse (and hence
will not be referred to again in this account).
Baring Securities Limited had commenced
business in 1984, specialising in Far East
Securities. The company expanded rapidly. In the
first five years of trading, Baring Securities
Limited opened nineteen subsidiary offices. Aside
from the traditional business activities carried out
by Baring Brothers & Co., Baring Securities
Limited represented Barings first involvement in
the securities business.
3.2. Creation and Management of Baring
Futures Singapore
Baring Futures Singapore was one of the new
offices that opened during the expansion of Baring
Securities Limited, and was formed to specialise in
exchange-traded futures and options (i.e. these
were Baring Futures Singapore’s bank products).
More precisely, Baring Futures Singapore would
execute client business on the Singaporean Stock
Exchange (SIMEX) on behalf of Baring Securities
Limited and Baring Securities Japan. This client
business, also referred to as ‘agency’ business, was
managed by Mike Killian (Head of Global Equity
Futures and Options Sales) in Tokyo. Baring
Futures Singapore would accumulate profits
through commission charged to clients.
Nick Leeson, a pivotal figure in the collapse of
Barings, was asked by Killian to apply for the post
of settlements manager. Leeson had acquired the
necessary experience through working in the
settlement’s section of a Baring Securities Limited
department, which specialised in Japanese futures
and options. He accepted the offer, and his name,
once submitted to the Management Committee,
was approved.
Previously in 1987, Baring Securities had
opened their first Singaporean office in the form of
Baring Securities Singapore. The managing
director of Baring Securities Singapore was James
Bax. He oversaw a business which traded equities
(but not derivatives) on SIMEX. Bax’s second-incommand
was Simon Jones, who acted as the
Chief Operating Officer of Baring Securities
Singapore. This position included responsibility
for the back office, which settled Baring Securities
Singapore’s equity trading.
Leeson moved to Singapore in early March
1992. Initial problems in the management of
Baring Futures Singapore were created shortly
afterwards, by the actions of Ian Martin (Baring
Securities Limited’s Finance Director). Despite
the fact that Mike Killian had asked Leeson to run
the back office (i.e., the settlements section) of
Baring Futures Singapore, Martin instructed Jones
and Killian that Leeson would be in charge of the
front and back offices. By so doing, Martin was
breaching one of the golden rules of management,
which states that there should be a strict
segregation of duties between trading and
settlement.
The supervisory failings with regard to Barings
Futures Singapore were compounded by the
actions of Jones and Bax, who took little interest
in the new subsidiary, despite the fact that both
were, on paper at least, responsible for Leeson at a
regional level.
Mike Killian further rejected the idea that there
was a reporting line between himself and Leeson.
Yet this runs contrary to what Leeson argues, who
cites Killian as one of the people who managed
him in 1992. Hence from the very start of
Leeson’s employment at Baring Futures
Singapore, there was considerable confusion over
two key areas: first, what his job responsibilities
were, and secondly, who managed him.
In early 1993 Leeson started trading on SIMEX
in conjunction with Baring Securities Japan’s
Tokyo traders who (since the collapse of the
Japanese stock market in 1990) made their money
through a type of trading called ‘arbitrage’,
otherwise known as ‘switching’. This section of
Baring’s business was known as equity
derivatives. Unlike Killian’s business, the trading
undertaken by the Baring Securities Japan traders
and Leeson was conducted solely to make profits
for Barings and not clients, and can therefore be
classified as proprietary trading. The manager in
charge of the switching business was Fernado
Gueller, based in Japan.
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When Peter Norris became CEO of Baring
Securities Limited in March 1993, one of his first
decisions was to make the Financial Products
Group of Baring Brothers & Co. responsible for
the equity derivatives business (i.e., switching).
The actual hand-over of this business did not take
place until late 1993. The manager in charge of
the Financial Products Group was Ron Baker.
3.3. Unauthorised Trading Activities
Conducted by Baring Futures
Singapore
Leeson was engaged in substantial
unauthorised trading on SIMEX through the taking
of proprietary positions in futures and options.
This section addresses the trading through a brief
examination of the history of the account (88888)
used to book and record the deals.
3.3.1. Account 88888. Unauthorised trading of
futures commenced very shortly after the opening
of 88888 and carried on until the collapse in late
February of 1995. This trading went largely
unnoticed for almost two years and eight months.
The only capacity in which Baring Futures
Singapore was authorised to transact options was
with regard to agency trading. However, in
October 1992 Leeson started to sell options, and
continued to do so until 23rd February, 1995.
At the year-end 1992, losses incurred through
the unauthorised trading were relatively minor,
standing at £2 million. One year later, they had
grown to £23 million, and by 31st December 1994,
the figure amounted to £208 million. In the space
of the following three months, however, this figure
had almost quadrupled to a staggering £827
million.
3.4. Failure of Internal Controls
The ability of Leeson to establish substantial
unauthorised trading positions on SIMEX was
afforded by failures in the management, financial,
and operating controls in Barings. These failures
were evident in Singapore, Tokyo, and London,
and encompassed all levels of control ranging
from the management committees, the business
functions and associated organisational units, and
the actual day-to-day operating controls. The
following list highlights the areas of failure:
• Failures in the managerial supervision of
Leeson.
• Lack of segregation between the front
and back offices of Baring Futures
Singapore.
• Insufficient action taken by Barings
management in response to warning
signals.
• No risk management or compliance
function in Singapore.
• Weak financial and operational control
over the activities and funding of Baring
Futures Singapore at Group level.
4. Discussion and Analysis
In attempting to assess the feasibility of
applying the three criminological theories to the IS
security context, this section of the paper examines
whether events highlighted in the case study
support those concepts which are central to the
theories.
4.1. Routine Activity Theory: Intimate
Handler/Unhandled Offender
Initial management problems were created at
the inception of Baring Futures Singapore. The
BoBS report cites how despite the fact that James
Bax (Head of Baring Securities Singapore) and his
second in command, Simon Jones (Chief
Operating Officer of Baring Securities Singapore)
had, on paper at least, regional responsibility for
Leeson, neither spent much time overseeing his
activities. Although the BoBS report
acknowledges there was some contact between the
two ‘managers’ and Leeson, it further contends
that both Bax and Jones preferred to focus their
energies on Baring Securities Singapore.
Additionally, Mike Killian, who managed the
agency business sent from London and Tokyo, and
executed by Baring Futures Singapore, rejected the
idea of a reporting line between himself and
Leeson. Hence, from the start of Leeson’s
employment at Baring Futures Singapore, there
was confusion over who actually managed him.
This confusion manifested itself in a paucity of
oversight from senior management. There is some
overlap here with the theoretical concepts of the
intimate handler and the handled offender. The
fact that, on the whole, there was an absence of an
intimate handler in the form of senior
management, provided Leeson with the freedom to
undertake his unauthorised trading.
However, there is a divergence between theory
and data with regard to how supervision is actually
enacted. With regard to the intimate handler, their
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presence is enough to act as a deterrent. But it was
not just the mere physical absence of a manager,
which aided Leeson in perpetrating his criminal
activities. When Leeson was afforded some
supervision, the evidence suggests that the
management problem was compounded by the fact
that Bax, Jones and Ron Baker (who was later
responsible for managing Leeson at a product
level) had very little understanding of the products
(futures and options) he dealt in and the trading
processes which underpinned this business. In this
sense, supervision could not be executed properly
owing to the ignorance of managers regarding the
nature of business undertaken by Leeson and not,
in the case of intimate handlers, owing to their
absence.
4.2. Routine Activity Theory: Targets
The Barings case, highlights a possible
variation on the targets concept inscribed in the
model. Although there is no hard evidence to
suggest it, the obvious assumption would be that
Leeson carried out the unauthorised trading for
personal financial gain. Hence the ‘target’ in this
sense would have been the ability to undertake the
unauthorised trading, while the benefits
represented monies derived from the unsanctioned
business. However, in his book The Collapse of
Barings, Fay [12] argues that behind Leeson’s
illegal activities was the desire to become one of
the elite traders on the floor of SIMEX. Leeson
got to know some of these traders owing to the
fact that the companies they worked for (First
Continental Trading and Spear, Leeds and
Kellogg) used Baring Futures Singapore for
clearing their trades with SIMEX. Admiring the
status and prestige associated with the elite
brokers, Fay argues that Leeson was keen to
emulate their activities and establish himself as a
name on the trading floor. To do this, however,
rather than taking the conventional route, Leeson
carried out the unauthorised trading, creating
fantastic ‘profits’ through dumping losses in
account 88888.
In this sense, the benefit derived from trading
was not the obvious one of money, but rather the
benefits of prestige and status that were afforded
the top traders. What the two benefits have in
common is the nature of the target, which was the
ability to undertake unauthorised trading.
Although ‘ability’ has a comparatively intangible
nature, it can still be viewed as consistent with
routine activity theory, which views a target as one
of the elements necessary for the commission of a
crime. The data not only supports this proposition
but, if we subscribe to Fay’s [12] argument, it can
be seen to support the rational choice perspective,
by illustrating how the ‘benefits’ of crime can
come in many guises. In Leeson’s case, as noted,
his benefits were prestige and status.
4.3. Routine Activity Theory:
Guardianship Factors
Compared with traditional applications, the
issue of guardianship is far more complex when
discussing the collapse of Barings. Indeed, a
number of safeguard factors can provide
guardianship in the banking environment, such as
internal/external audit, compliance monitoring,
risk management and the like. To some extent,
these guardianship factors can be perceived as still
in keeping with routine activity theory, given that
their presence or absence would play a part in
determining whether an entity represents a viable
target.
However, it should be noted that the elements
that are considered guardianship factors in the
Barings case are of a far more complex nature than
those traditionally recognised by routine activity
theory. More specifically, a priori conditions need
to be met before they can exist. Take for instance
Baring Securities Limited’s internal audit group.
A management committee would have decided on
its establishment, the size of the group, and the
positions that would need to be created. The
employment vacancies would be advertised,
people interviewed and selected. Obviously, only
after its inception could arrangements have been
made for the group to carry out audits in Baring
Securities Limited’s various subsidiaries.
Of course, even if guardianship factors like the
internal audit group are introduced into the
banking context, there is no guarantee that their
mere existence will provide effective guardianship
over the target they purport to safeguard. Rather
they have to exist and be working effectively.
This last assertion can be seen as a slight departure
from routine activity theory, which asserts that the
existence of a capable guardian would deter a
crime. Obviously of importance here is what
exactly constitutes a capable guardian, but routine
activity does emphasise how the mere physical
presence/existence (as also noted with the handled
offender) is often sufficient to provide the
necessary guardianship. Hence the presence of an
individual in their home is a good illustration. Yet
in the case of Barings, the existence of a
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guardianship factor is not sufficient. They must
exist and be effective.
4.4. Routine Activity Theory: Facilitators
Clarke [13] depicts facilitators as coming from
the physical environment. However, the internal
threat posed by staff, and the organisational
environment in which they work, places a different
spin on the concept. As Willison [14] asserts:
“More interesting perhaps is the idea that
potential offenders acquire facilitators in the
course of their work. Unlike their physical
counterparts, these facilitators are cognitive in
nature, and … are assimilated by staff the day
they begin working for a particular company.”
Essentially these cognitive facilitators include
those skills and knowledge that a person acquires
to perform their jobs. A key point here is that,
although on the whole these skills are used by
employees for perfectly legal activities, they can
also be used to help facilitate activities of an
illegal nature. Perhaps not surprisingly, the BoBS
report highlights numerous instances of Leeson
using his skills in this manner. Indeed, all his
criminal activities were underpinned by
knowledge initially acquired to support legitimate
work. This is clearly revealed by the very fact that
the report makes the distinction between
authorised and unauthorised trading.
For Leeson, the knowledge required to
undertake the unauthorised trading was gleaned
not just from his experience in Singapore, but also
in London where he had previously worked in the
late 1980s and early 1990s. Barings Securities
Limited had commenced trading futures and
options in 1989. In the same year Leeson joined
the department which dealt with the settlements
side of this business, and began to develop an indepth
knowledge of these products. It was his
expertise in this area that landed him the position
in Singapore. Furthermore, while Leeson was
acquiring the necessary skills and knowledge to
undertake his duties, he was also acquiring an indepth
understanding of the work processes of
which his duties were an inherent part.
4.5. Environmental Criminology: Search
Patterns of Offenders
Data from the case study appears to support this
depiction of a potential offender as an individual
who collates information from their awareness
space and uses it for criminal purposes. Leeson’s
‘awareness space’ encompassed the offices he
routinely worked in. These included not only
Baring Futures Singapore and SIMEX, but also
Baring Securities Limited (London) where he had
worked prior to moving to the Far East. While
performing his day-to-day duties, Leeson was able
to note any weak links in the control environment.
Prior to the commencement of the unauthorised
trading, Leeson opened account 88888 to help
conceal his aberrant activities. He knew from his
time in London, that as with other accounts, the
trading details of account 88888 would be sent by
Baring Futures Singapore to London in the form of
four reports, which included a trade file, which
gave details of the day’s trading activity; a price
file, which reported on closing settlements price; a
margin file, listing the initial – and maintenance –
margin details of each account; and the London
gross file, which provided details of BFS’s trading
position. In order to stop details of account 88888
reaching London, Leeson instructed Dr. Edmund
Wong, a computer consultant, to omit details of
the account from three of the four daily trading
reports. The exception was the margin file.
Leeson was aware that the margin file represented
a security vulnerability for Baring Securities
Limited, simply because it was routinely ignored
by staff in London. Conversely, for Leeson, the
margin file represented no risk with regard to
helping to uncover his unauthorised trading, given
the oversight by staff in London. As a
consequence, he was able to ignore it.
Of key importance here is the fact that Leeson
worked for Barings. This represents a slight
departure from the offender’s circumstance
traditionally found in the studies of environmental
criminology. For example, Brantingham and
Brantingham [7] cite the work of Dufala [15]
whose study addresses convenience store robberies
in Tallahassee, Florida. Dufala reports how, for
marketing purposes, the stores were situated near
major roads. As a consequence, these stores also
formed part of the awareness space of offenders
who, like many other urban residents, lived
nearby. Leeson’s position, however, would be
more comparable to that of a clerk in one of the
shops. Hence, learning his trade and developing
knowledge of his target took place in the same
context.
A related point concerns the quality of
information that the offender is able to garner.
Although an offender’s rationality is addressed in
the next section of this chapter, the concept of
bounded rationality ties in nicely with the
offender’s circumstance. Unlike the convenience
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store robbers studied by Dufala [15], Leeson had
access to a relatively high quality of information,
which enabled him to assess more accurately
potential risks, efforts and rewards. Access to
such information was primarily due to the fact that
he worked for Barings. His employment first with
Baring Securities Limited and then Baring Futures
Singapore also provided Leeson with both the
necessary time and locations to collate the relevant
information.
4.6. The Rational Choice Perspective
There is considerable evidence in the Barings
case to support the rational choice perspective.
Prior to the commencement of the unauthorised
trading, Leeson clearly planned and executed
actions that afforded the necessary conditions to
initiate the unsanctioned business. One example
concerns the manipulation of funding from
London. When Leeson first started work at Baring
Futures Singapore, he informed Gordon Bowser
(Head of Futures and Options Settlements in
London) that owing to the manner in which
SIMEX made margin calls (margin is a form of
deposit which is paid when derivatives are traded),
it would be difficult for Baring Futures Singapore
to raise in time the appropriate monies to meet the
requests. Leeson argued that it would be far easier
if the funds could be advanced from London prior
to the margin calls. What Bowser did not know
was that the ‘problem’ of meeting SIMEX margin
calls was pure fiction on Leeson’s behalf.
Unfortunately, Bowser believed him and agreed to
the request. This meant that Leeson could call for
funds from London without specifying the trading
account to which the request related. Through his
careful planning, Leeson had gained a ‘safe’
source of funding. The reconciliation between
accounts and funding would have proved a useful
safeguard, but by succeeding in gaining advanced
funds prior to margin calls, Leeson knew this
safeguard would be negated.
During the commission of the fraud, Leeson
continued to demonstrate the actions of a rational
offender. When losses began to accrue as a result
of his unauthorised trading, these were placed in
account 88888. In order to hide these losses, and
in order to avoid detection, Leeson created false
journal entries, generated fictitious transactions
and sold a large number of options. From early
1993 he masked the month end balance of the
account by making a journal adjustment, crediting
88888 with a sum which would leave the balance
at zero. He would then make an additional journal
adjustment by debiting the same amount to the
SIMEX clearing bank account maintained by
Baring Futures Singapore. After the month end
reconciliation, the transaction was simply
reversed. Although this technique was used on
numerous occasions to hide the balance of account
88888, another method involved the selling of
options. Leeson would simply take the premiums
collected through the sale of options, and offset
this amount against the losses residing in 88888.
In effect, he was in a position to manipulate his
environment to reduce the risk of his fraud being
uncovered.
5. Conclusion
This section concludes the paper by
summarising the major findings of the discussion
and analysis section and advances future research
possibilities offered by the criminological theories.
Of the three approaches, routine activity theory
appears to offer with regard to IS security. The
concept of ‘handling’ can be seen to lack the
necessary sophistication to theoretically
accommodate and explain the supervisory failings
in Barings. This lack of conceptual sophistication
is further evident when discussing the issue of
guardianship. A determining factor in the utility
of both concepts is the complexity of the crime to
which they are applied. Routine activity when
first advocated restricted its application to ‘direct
contact predatory crimes’ i.e. where one or more
persons directly take or damage the person or
property of another. This is a far cry from
unauthorised trading on SIMEX. However, when
discussing the usefulness of the aforementioned
concepts, the issue of granularity should be
introduced into the debate. The Barings case is
extremely detailed, encompassing many
individuals and organisations, and as noted the
handling and guardianship concepts find it
difficult to accommodate such complexity. That
said the concepts might prove more fruitful when
applied to less complex cases of computer abuse.
The concept of targets is likewise drawn from
routine activity theory. Traditionally, examples of
this concept take a physical form, including cars to
steal, banks to rob and houses to burgle. Although
the target in the Barings case proved to be the
ability to undertake trading, and hence represents a
departure from its physical counterparts, this is
still consistent with routine activity’s theoretical
proposition, which views a target as one of the
elements necessary for the commission of a crime.
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The final major input from routine activity
relates to facilitators. While acknowledging the
tangible nature of some facilitators, the case study
supports the idea of intangible cognitive
facilitators. Indeed, any understanding of
computer crime must be able to account for and
consider how cognitive facilitators are used for the
commission of such crimes. In this sense, the
facilitators concept is easily translated into the
field of IS security.
5.1. Environmental Criminology
Like facilitators, the theoretical concepts of
environmental criminology are easily translated
into the IS security field. The Barings case
provides supporting evidence, illustrating how
knowledge of security provisions was used by
Leeson to his advantage. The search patterns of
offenders, married with cognitive facilitators,
provide a useful theoretical grounding in
understanding how a rogue employee combines
knowledge of the environment with the skills
acquired through work to perpetrate a fraud.
5.2. Rational choice perspective
Data from the case study further supports the
idea of a rational offender. Leeson clearly planned
and executed actions that allowed him to initiate
his unauthorised trading. During the period in
which his aberrant trading took place, he
continued to demonstrate the actions of a rational
offender. When losses accrued as a result of the
trading, not only did Leeson place them in a
specially designated account (88888), he also
instigated actions to hide the losses and avoid
detection.
5.3. Future Research
Given these findings, future research could
cover the following areas. First, the theories could
be applied to cases less complex in nature than the
Barings collapse. Individual incidents of computer
abuse would provide complementary findings for
assessing the feasibility of applying the three
theories to the IS security context. Routine
Activity theory, in particular, may offer more
fruitful findings when applied to less complex
cases.
Secondly, prevention strategies based around
the three theories could be examined and
considered for the IS security field. Are the
prevention strategies feasible for the IS context
and do they offer fresh perspectives for security
practitioners and academics?
Thirdly, complementary criminological
concepts could be imported to reinforce the use of
the theories, and help to develop more informed
prevention strategies. For example, the concept of
crime ‘scripts’ has been advanced by Cornish [16].
As the name suggests, the concept compare a
crime to a theatrical script. The method helps to
break down a crime into individual, but related,
stages or ‘scenes’. Each identifiable stage allows
for consideration of the specific context, ‘props’,
the actions of the offender and their rational
choices which underpin such actions. In
conjunction with the rational choice perspective,
the scripts concept can give a greater
understanding of the procedural stages of a
specific crime. Once this is achieved, security
strategies can identify prevention points and
increase the risks and efforts and reduce the
rewards.
A final point to consider concerns the
relationship between IS security and theory. One
of the general deficiencies of IS security is the lack
of theory both used and advocated by academics in
the field. The position taken in this paper is that in
order to understand computer crime and computer
criminals, the academic discipline, which can
potentially offer substantial insight into this area is
criminology. Given the multi-disciplined nature of
criminology, drawing from psychology, sociology,
law, social policy and economics, it can be seen to
offer a voluminous body of knowledge which IS
security academics can use.
6. References
[1] Willison, R. (2002) Opportunities for Computer
Abuse: Assessing a Crime Specific Approach in the
Case of Barings Bank. PhD thesis. London School of
Economics and Political Science.
[2] Clarke, R. (ed.) (1997) Situational Crime Prevention
: Successful Case Studies. 2nd ed. Albany, NY.
Harrow and Heston.
[3] Cohen, L. and Felson, M. (1979) Social Change and
Crime Rate Trends : A Routine Activity Approach.
American Sociological Review 44: 588-608.
[4] Felson, M. (1986) Linking Criminal Choices,
Routine Activities, Informal Control, and Criminal
Outcomes. In D. Cornish and R. Cornish (eds.), The
Reasoning Criminal : Rational Choice Perspectives on
Offending. New York. Springer-Verlag.
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[5] Hirschi, T. (1969) Causes of Delinquency.
Berkeley and Los Angeles. University of California
Press.
[6] Clarke, R. (ed.) (1992) Situational Crime Prevention
: Successful Case Studies. Albany, NY. Harrow and
Heston..
[7] Brantingham, P. and Brantingham, P. (1991)
Environmental Criminology. (2nd ed.). Prospect
Heights, IL. Waveland Press.
[8] Clarke, R. and Cornish, D. (1985) Modelling
Offender’s Decisions : A Framework for Policy and
Research. In M. Tonry and N. Morris (eds.), Crime and
Justice : An Annual Review of Research. Vol. 6.
Chicago. University of Chicago Press.
[9] Cornish, D. and Clarke, R. (1986) Situational
Prevention, Displacement of Crime and Rational Choice
Theory. In K. Heal, and G. Laycock (eds.), Situational
Crime Prevention: From Theory into Practice. London.
H.M.S.O.
[10] Clarke, R. and Cornish, D. (2000) Rational Choice.
In R. Paternoster and R. Bachman (eds.), Explaining
Crime and Criminals: Essays in Contemporary
Criminological Theory. Los Angeles, CA. Roxbury
Publishing Company.
[11] Board of Banking Supervision (1995) Report of the
Board of Banking Supervision Inquiry into the
Circumstances of the Collapse of Barings. London.
HMSO.
[12] Fay, S. (1996) The Collapse of Barings. London.
Richard Cohen Books.
[13] Clarke, R. (1995) Situational Crime Prevention. In
M. Tonry and D. Farrington (eds.). Building a Safer
Society. Strategic Approaches to Crime Prevention.
Crime and Justice: A Review of Research. Vol. 19.
Chicago. University of Chicago Press.
[14] Willison, R. (2000) Reducing Computer Fraud
Through Situational Crime Prevention. In S. Qing and
J. H.P. Eloff (eds.), Information Security for Global
Information Infrastructures. Boston. Kluwer Academic
Press.
[15] Dufala, D. (1976) Convenience Stores: Armed
Robbery and Physical Environmental Features.
American Behavioral Scientist 20: 227-246.
[16] Cornish, D. (1994) The Procedural Analysis of
Offending and its Relevance for Situational Prevention.
Crime Prevention Studies. 3.
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Article Dissection 5

Order Description

Read the attached article and address the following in a 1-2 page paper: A. Describe the purpose/aims of the study. B. Note the theory/ evidence-based intervention/or policy being applied; also note whether the author’s use of theory is explicit or implicit and briefly explain why. Identify the key concepts. Are their definitions clear? Do they fit with the theoretical framework provided? C. Describe the methodology (sample, design, analytic strategy) employed. Does the method fit with the theoretical framework? – consider the type of sample selected, the types of variables included, the approach to data collection and analysis. Are the key variables, and their operationalization, what you expected based on the introduction? If the analysis is sophisticated, does the author do a good job tutoring the reader so you can appreciate the analytic approach? D. Describe the key findings of the study. Overall, what does this study contribute to basic and/or applied knowledge? E. What are the key limitations and implications for practice of the study? – note those mentioned by the author as well as additional limitations and implications you observed (make sure to distinguish between the limitations/implications you identify and those identified by the authors). F. What do you think are some good next steps/good questions to ask for future research? This paper should be in APA format. Please answer each bullet thoroughly and clearly. This paper needs to be in APA format (Double spaced, 12 font Times New Roman, Reference page, and Citations

The evidence base for family therapy and systemic
interventions for child-focused problems
Alan Carra
This review updates similar articles published in the Journal of Family
Therapy in 2001 and 2009. It presents evidence from meta-analyses, systematic
literature reviews and controlled trials for the effectiveness of
systemic interventions for families of children and adolescents with
various difficulties. In this context, systemic interventions include both
family therapy and other family-based approaches such as parent training.
The evidence supports the effectiveness of systemic interventions
either alone or as part of multi-modal programmes for sleep, feeding and
attachment problems in infancy; child abuse and neglect; conduct problems
(including childhood behavioural difficulties, attention deficit hyperactivity
disorder, delinquency and drug misuse); emotional problems
(including anxiety, depression, grief, bipolar disorder and self-harm);
eating disorders (including anorexia, bulimia and obesity); somatic problems
(including enuresis, encopresis, medically unexplained symptoms
and poorly controlled asthma and diabetes) and first episode psychosis.
Introduction
This article summarizes the evidence base for systemic practice with
child-focused problems and updates previous similar articles (Carr,
2000, 2009). It is also a companion article to a review of research on
systemic interventions for adult-focused problems (Carr, 2014). In this
article a broad definition of systemic practices has been used, covering
family therapy and other family-based interventions such as parent
training or multisystemic therapy, which engage family members or
members of the families’ wider networks in the process of resolving
problems for young people from birth up to the age of 18 years.
One-to-one services (such as home visiting for vulnerable mothers of
young children) and complex interventions (such as multi-component
care packages for people with intellectual and developmental disabilities),
which are arguably systemic interventions but which differ in
a Professor of Clinical Psychology, School of Psychology, Newman Building, University
College Dublin, Belfield, Dublin 4, Ireland. E-mail: [email protected]
bs_bs_banner
Journal of Family Therapy (2014) 36: 107–157
doi: 10.1111/1467-6427.12032
© 2014 The Association for Family Therapy and Systemic Practice
many practical ways from family therapy, were excluded from this
review.
Sprenkle (2012) edited a special issue of the Journal and Marital and
Family Therapy on research and concluded that a large and growing
evidence base now supports the effectiveness of systemic interventions.
This work updates previous special issues of the Journal and
Marital and Family Therapy (Pinsof and Wynne, 1995; Sprenkle, 2002).
Shadish and Baldwin (2003) reviewed twenty meta-analyses of systemic
interventions for a wide range of child and adult-focused problems.
The average effect size across all meta-analyses was 0.65 after
therapy and 0.52 at 6–12-months follow up. These results show that,
overall, the average treated family fared better after therapy and at
follow up than over 71 per cent of families in control groups.
If there is little doubt now about the fact that family therapy works,
the next key question to address is its cost-effectiveness. In an important
series of US studies, Crane and Christenson (2012) showed that
family therapy reduces health service usage, especially for frequent
service users, and that family therapy is associated with greater benefits
than individual therapy. The medical cost offset associated with
family therapy covers the cost of providing therapy and in many cases
leads to overall cost savings. Crane drew these conclusions from
studies of a US health maintenance organization with 180,000 subscribers,
the Medicaid system of the State of Kansas, CIGNA Behavioural
Health which is a division of a health insurance company with
nine million subscribers, and a US family therapy training clinic.
While evidence for the overall efficacy, effectiveness and costeffectiveness
of systemic interventions is vital for healthcare policy
development and management, detailed research findings on what
works for whom are required by family therapists who wish to engage
in research-informed practice. The remainder of this article focuses
on precisely this issue. As with previous versions of this review, extensive
computer and manual literature searches were conducted for
systemic interventions with a wide range of problems of childhood
and adolescence. For the present review the search extended to July
2013. Major databases, family therapy journals and child and adolescent
mental health journals were searched, as well as key textbooks on
evidence-based practice. Where available, meta-analyses and systematic
review articles were selected for review, since these constitute the
strongest form of evidence. If such articles were unavailable, controlled
trials, which constitute the next highest level of evidence, were
selected. Only in the absence of such trials were uncontrolled studies
108 Alan Carr
© 2014 The Association for Family Therapy and Systemic Practice
selected. It was intended that this article be primarily a review of the
reviews, with a major focus on substantive findings of interest
to practicing therapists rather than on methodological issues. This
overall review strategy was adopted to permit the strongest possible
case to be made for systemic evidence-based practices for a wide range
of child-focused problems and to offer useful guidance for therapists,
within the space constraints of a single article. Below, the results of the
review are presented under the following headings: problems of
infancy, child abuse and neglect, conduct problems, emotional problems,
eating disorders, somatic problems and psychosis.
Problems of infancy
Family-based interventions are effective for a proportion of families in
which infants have sleeping, feeding and attachment problems. These
difficulties occur in about one- quarter to one-third of infants and are
of concern because they may compromise family adjustment and later
child development (Zennah, 2012).
Sleep problems
Family-based behavioural programmes are an effective treatment for
settling and night waking problems, which are the most prevalent
sleep difficulties in infancy (Hill, 2011). In these programmes parents
are coached in reducing or eliminating children’s daytime naps,
developing positive bedtime routines, reducing parent–child contact
at bedtime or during episodes of night waking and introducing scheduled
waking where children are awoken 15–60 minutes before the
child’s spontaneous waking time and then resettled. A systematic
review of 52 studies of family-based behavioural programmes for
sleep problems in young children by Mindell et al. (2006), and of nine
randomized controlled trails of family-based and pharmacological
interventions by Ramchandani et al. (2000) indicate that both familybased
and pharmacological interventions are effective in the short
term but only systemic interventions have positive long-term effects
on children’s sleep problems.
Feeding problems
Severe feeding problems in infancy, which may be associated with a
failure to thrive, include self-feeding difficulties, swallowing problems,
Evidence-base for family therapy with children 109
© 2014 The Association for Family Therapy and Systemic Practice
frequent vomiting and, in the most extreme cases, food refusal. With
food refusal there is refusal to eat all or most foods, resulting in
dependence on supplemental tube feeds or a failure to meet caloric
needs. Family-based behavioural programmes are particularly effective
in addressing food refusal (Kedesdy and Budd, 1998; Sharp et al.,
2010). Such programmes involve parents prompting, shaping and
reinforcing successive approximations to appropriate feeding behaviour
while concurrently preventing children from escaping from the
feeding situation, ignoring inappropriate feeding responses and
making the feeding environment pleasant for the child. Small spoonfuls
of preferred foods are initially used in these programmes. Gradually,
bite sizes are increased and non-preferred nutritious food is
blended with preferred food. In a systematic review of forty-eight
controlled single case and group studies, Sharp et al. (2010) concluded
that such programmes were effective in ameliorating severe feeding
problems and improving weight gain in infants and children, particularly
those with developmental disabilities.
Attachment problems
Infant attachment insecurity is a risk factor for internalizing (Madigan
et al., 2013) and externalizing (Fearon et al., 2010) problems in childhood
and adult psychological difficulties (Dozier et al., 2008). A range
of short-term and long-term evidence-based family interventions,
each supported by a series of controlled trials, has been developed to
foster attachment security in families with varying degrees of vulnerability
(Berlin et al., 2008; Zeanah et al., 2011). For high-risk families
in which parents have histories of childhood adversity and whose
current families are characterized by high levels of stress, low levels of
support and domestic violence or child abuse, intensive longer term
interventions have been shown to be effective in improving attachment
security. These involve weekly clinical sessions or home visiting
and span 1–2 years. For example, child–parent psychotherapy
involves weekly dyadic sessions with mothers and children for about a
year (Lieberman and Van Horn, 2005). Child–parent psychotherapy
helps mothers resolve ambivalent feelings about their infants by
linking them to their own adverse childhood experiences and current
life stresses in the context of a supportive long-term therapeutic
alliance. For less vulnerable families, briefer interventions involving a
few carefully structured home-visiting sessions and video feedback on
parent–child interaction have been shown to be effective in improving
110 Alan Carr
© 2014 The Association for Family Therapy and Systemic Practice
attachment security. For example, with Juffer et al.’s (2007) video
feedback intervention to promote positive parenting, in four home
visits parents are given feedback on videotapes of their interactions
with their infants, written materials on attachment, and an opportunity
to discuss the impact of their own family of origin experiences on
the way they interact with their infants.
The results of this review suggest that in developing services for
families of infants with sleeping and feeding problems only relatively
brief outpatient programmes are required involving up to fifteen
sessions over 3–4 months for each episode of treatment. For attachment
problems, the intensity of intervention needs to be matched to
the level of family vulnerability.
Child abuse and neglect
Systemic interventions are effective in a proportion of cases of child
abuse and neglect. These problems have devastating effects on the
psychological development of children (Myers, 2011). In a series of
meta-analyses of international studies Stoltenborgh et al. (2011, 2012,
2013a, 2013b) found prevalence rates based on self-reports of 22.6
per cent for physical abuse, 12.7 per cent for contact sexual abuse,
36.3 per cent for emotional abuse, 16.3 per cent for physical neglect
and 18.4 per cent for emotional neglect.
Physical abuse and neglect
Systematic narrative reviews concur that for physical child abuse and
neglect, effective therapy is family-based and structured. It extends
over periods of at least 6 months and addresses specific problems in
relevant subsystems, including children’s post-traumatic adjustment
problems; parenting skills deficits and the overall supportiveness
of the family and social network (Chaffin and Friedrich, 2004;
Edgeworth and Carr, 2000; MacDonald, 2001; MacLeod and Nelson,
2000; Skowron and Reinemann, 2005; Tolan et al., 2005). Cognitive
behavioural family therapy (Kolko, 1996; Kolko and Swenson, 2002;
Rynyon and Deblinger, 2013), parent–child interaction therapy
(Chaffin et al., 2004; Hembree-Kigin and McNeil, 1995; Timmer et al.,
2005), and multisystemic therapy (Brunk et al., 1987; Henggeler et al.,
2009) are manualized approaches to family-based treatment that have
been shown in randomized controlled trials to reduce the risk of
further physical child abuse.
Evidence-base for family therapy with children 111
© 2014 The Association for Family Therapy and Systemic Practice
Cognitive behavioural family therapy for physical abuse. In a controlled trial
Kolko (1996) found that at 1-year follow up conjoint cognitive behavioural
family therapy and concurrent parent and child cognitive
behavioural therapy were both more effective than routine services in
reducing the risk of further abuse in families of schoolaged children in
which physical abuse had occurred. The sixteen-session programme
involved helping parents and children develop skills for regulating
angry emotions, communicating and managing conflict and developing
alternatives to physical punishment as a disciplinary strategy
(Kolko and Swenson, 2002).
Parent–child interaction therapy for physical abuse. In a controlled trial of
parent–child interaction therapy, Chaffin et al. (2004) found that at
2-years follow up only 19 per cent of parents who participated in
parent–child interaction therapy had a re-report for physical abuse
compared with 49 per cent of parents assigned to standard treatment.
Parent–child interaction therapy involved sessions that aimed to
enhance parents’ motivation to engage in parent training; seven sessions
devoted to the live coaching of parents and children in positive
child-directed interactions and seven sessions devoted to the live
coaching of parents and children in the behavioural management of
discipline issues, using time-out and related procedures.
Multisystemic therapy for physical abuse and neglect. Brunk et al. (1987)
compared the effectiveness of multisystemic therapy and group-based
behavioural parent training in families where physical abuse or neglect
had occurred. Families who received multisystemic therapy showed
greater improvements in family problems and parent–child interactions
after treatment than those who engaged in group-based behavioural
parent training. Multisystemic therapy involved joining with
family members and members of their wider social and professional
network, reframing interaction patterns and prescribing tasks to alter
problematic interaction patterns within specific subsystems (Henggeler
et al., 2009). Therapists designed intervention plans on a per-case basis
in light of family assessments. They used individual, couple, family and
network meetings in these plans and received regular supervision to
facilitate this process, carrying small caseloads of four to six families.
Sexual abuse
For child sexual abuse, trauma-focused cognitive behavioural therapy
for both the abused young people and their non-abusing parents has
112 Alan Carr
© 2014 The Association for Family Therapy and Systemic Practice
been shown to reduce the symptoms of post-traumatic stress disorder
and improve overall adjustment (Deblinger and Heflinger, 1996). In
a systematic review of thirty-three trials, twenty-seven of which evaluated
trauma-focused cognitive behavioural therapy, Leenarts et al.
(2012) found that patients treated with this approach fared better
than those who received standard care. The results of this review
suggest that trauma-focused cognitive behavioural therapy is the best
supported treatment for children following childhood maltreatment.
Trauma-focused cognitive behavioural therapy involves concurrent
sessions for abused children and their non-abusing parents in group
or individual formats, with periodic conjoint parent–child sessions,
Where intra-familial sexual abuse has occurred it is essential that
offenders live separately from victims until they have completed a
treatment programme and been assessed as being at low risk for
re-offending (Doren, 2006). The child-focused component involves
exposure to abuse-related memories to facilitate habituation to them;
relaxation and coping skills training; learning assertiveness and safety
skills and addressing victimization, sexual development and identity
issues. Concurrent work with non-abusing parents and conjoint sessions
with abused children and non-abusing parents focus on helping
parents develop supportive and protective relationships with their
children and develop support networks for themselves.
The results of this review suggest that in developing services for
families in which abuse or neglect has occurred, programmes that
begin with a comprehensive network assessment and include, along
with regular family therapy sessions, the option of parent-focused
and child-focused interventions should be prioritized. Programmes
should span at least 6 months, with the intensity of input matched to
families’ needs. Therapists should carry small caseloads of fewer than
ten cases.
Conduct problems
Family-based systemic interventions are effective for a proportion of
cases of childhood behaviour problems (or oppositional defiant disorder),
attention deficit hyperactivity disorder (ADHD), pervasive
adolescent conduct problems and drug misuse. All these difficulties
are of concern because they may lead to comorbid academic, emotional
and relationship problems and, in the long-term, to adult
adjustment difficulties (Pliszka, 2008). They are also relatively
common. In a review of community surveys, Merikangas et al. (2009)
Evidence-base for family therapy with children 113
© 2014 The Association for Family Therapy and Systemic Practice
found that the median prevalence rate for disruptive behaviour disorders
(including oppositional defiant disorder and conduct disorder)
was 6 per cent; for ADHD it was 3–4 per cent and for adolescent
substance use disorders it was 5 per cent. Prevalence rates for these
types of problems ranged from 1–24 per cent across studies and were
all more common in boys.
Childhood behaviour problems
Childhood behaviour problems are maintained by both personal
attributes (such as self-regulation problems) on the one hand, and
contextual factors (such as problematic parenting practices) on the
other. Treatment programmes have been developed to target each of
these sets of factors. Many meta-analyses and systematic reviews covering
an evidence base of over 100 studies conclude that behavioural
parent training is particularly effective in ameliorating childhood
behaviour problems, leading to improvement in 60–70 per cent of
children, with gains maintained at a 1-year follow up, particularly if
periodic review sessions are offered (Barlow et al., 2002; Behan and
Carr, 2000; Brestan and Eyberg, 1998; Burke et al., 2002; Comer
et al., 2013; Coren et al., 2002; Farrington and Welsh, 2003; Kazdin,
2007; Leijten et al., 2013; Lundahl, et al., 2008; Michelson et al.,
2013; Nixon, 2002; Nock, 2003; Nowak and Heinrichs, 2008;
Serketich and Dumas, 1996). Behavioural parent training also has a
positive impact on parental adjustment problems. For example, in
meta-analyses of parent training studies Serketich and Dumas (1996)
found an effect size of 0.44 and McCart et al. (2006) found an effect
size of 0.33 for parental adjustment. Thus, the average participant in
parent training fared better than 63–65 per cent of control group
cases. Behavioural parent training is far more effective than individual
therapy. For example, in a meta-analysis of thirty studies of
behavioural parenting training and forty-one studies of individual
therapy, McCart et al. (2006) found effect sizes of 0.45 for parent
training and 0.23 for individual therapy. Meta-analyses also show
that behavioural parent training is as effective in routine community
settings as it is in specialist programme development clinics
(Michelson et al., 2013). Furthermore, the inclusion of fathers in
parent training leads to greater improvement in child behaviour
problems and parenting practices (Lundahl et al., 2008) and the
more intensive programmes are more effective (Nowak and
Heinrichs, 2008).
114 Alan Carr
© 2014 The Association for Family Therapy and Systemic Practice
A critical element of behavioural parent training, which derives
from Gerald Patterson’s seminal work at the Oregon Social Learning
Centre, is helping parents develop skills for increasing the frequency
of children’s prosocial behaviour (through attending, reinforcement
and engaging in child-directed interactions) and reducing the frequency
of antisocial behaviour (through ignoring, time-out, contingency
contracts and engaging in parent directed interactions)
(Forgatch and Paterson, 2010).
Immediate feedback, video feedback and video modelling have
been used in effective behavioural parent training programmes. With
video feedback, parents learn child management skills by watching
videotaped episodes of themselves using parenting skills with their
own children. With immediate feedback, parents are directly coached
in child-management skills through a ‘bug in the ear’ while the therapist
observes their interaction with their children from behind a oneway
mirror. Eyberg’s parent–child interaction therapy for parents of
preschoolers is a good example of this approach (Zisser and Eyberg,
2010). With video modelling, parents learn child management skills
through viewing video clips of actors illustrating successful and unsuccessful
parenting skills. Webster-Stratton’s Incredible Years programme
is an example of this type of approach (Webster-Stratton and
Reid, 2010).
The effectiveness of behavioural parent training programmes may
be enhanced by concurrently engaging children in therapy that aims
to remediate deficits in self-regulation skills, such as managing emotions
and social problem-solving (Kazdin, 2010; Webster-Stratton and
Reid, 2010).
In a meta-analysis of thirty-one studies, Reyno and McGrath (2006)
found that parents with limited social support, high levels of povertyrelated
stress, and mental health problems derived the least benefit
from behavioural parent training. To address these barriers to effective
parent training, adjunctive interventions that address parental vulnerabilities
have been added to standard parent training programmes,
with positive incremental benefits. For example, Thomas and
Zimmer-Gembeck (2007) found that enhanced versions of the parent–
child interaction therapy (Zisser and Eyberg, 2010) and triple-P
(Sanders and Murphy-Brennan 2010) programmes, which included
additional sessions on parental support and stress management, were
far more effective than standard versions of these programmes.
The results of this review suggest that in developing services for
families where childhood behaviour problems are a central concern,
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behavioural parent training should be offered, with the option of
additional child-focused and parent-focused interventions being
offered where the assessment indicates particular vulnerabilities in
these subsystems. Programmes should span at least 6 months, with the
intensity of input matched to families’ needs. Each aspect of the
programme should involve about ten to twenty sessions, depending
on need.
Attention and overactivity problems
ADHD is currently the most commonly used term for a syndrome,
usually present from infancy, characterized by persistent overactivity,
impulsivity and difficulties sustaining attention. Available evidence
suggests that vulnerability to attentional and overactivity problems,
unlike the oppositional behavioural problems discussed in the section
above, is largely constitutional (Thapar et al., 2013).
The results of meta-analyses suggest that a proportion of preschool
children with ADHD show significant improvement in response to
behavioural parent training (Lee et al., 2012; Rajwan et al., 2012). For
children who do not respond to systemic interventions alone, systematic
reviews concur that systemic interventions for ADHD are best
offered as elements of multi-modal programmes involving stimulant
medication (Anastopoulos et al., 2005; DuPaul et al., 2012; Friemoth,
2005; Hinshaw et al., 2007; Jadad et al., 1999; Klassen et al., 1999;
Nolan and Carr, 2000; Schachar et al., 2002). For example, Hinshaw
et al. (2007) in a review of fourteen randomized controlled trials,
concluded that about 70 per cent of children with ADHD benefited
from multi-modal programmes. Multi-modal programmes typically
include stimulant treatment of children with drugs such as methylphenidate
combined with family therapy or parent training; schoolbased
behavioural programmes and coping skills training for
children. Family therapy for ADHD focuses on helping families
develop patterns of organization conducive to effective child management
(Anastopoulos et al., 2005). Such patterns of organization
include a high level of parental co-operation in problem-solving and
child management; a clear intergenerational hierarchy between
parents and children; warm supportive family relationships; clear
communication and clear, moderately flexible, rules, roles and routines.
School-based behavioural programmes involve the extension of
home-based behavioural programmes into the school setting through
home–school, parent–teacher liaison meetings (DuPaul et al., 2012).
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Coping skills training focuses on coaching children in the skills
required for managing their attention, impulsivity, aggression and
overactivity (Hinshaw, 2005).
Medicated children with ADHD show a reduction in symptomatology
and an improvement in both academic and social functioning,
although the positive effects dissipate when medication ceases if
systemic interventions to improve symptom control, such as those
outlined above, have not been provided concurrently with the
medication. One of the most remarkable findings of the multi-modal
treatment study of ADHD (MTA) – the largest ever long-term controlled
trial of stimulant medication for ADHD involving over 500
patients – is that stimulant medication ceased to have a therapeutic
effect after 3 years (Swanson and Volkow, 2009). It also led to a
reduction in height gain of about 2 cm and a reduction in weight gain
of about 2 kg. Furthermore, it did not prevent adolescent substance
misuse as expected. The MTA trial showed that tolerance to medication
used to treat ADHD occurs and this medication has negative side
effects. These findings underline the importance of using medication
to reduce ADHD symptoms to manageable levels for a time-limited
period, while children and their parents engage in systemic interventions
to develop skills to manage symptoms.
These results suggest that in developing services for families where
children have attention and overactivity problems, multi-modal treatment
which includes family, school and child-focused interventions
combined with stimulant therapy, spanning at least 6 months in the
first instance, is the treatment of choice. For effective long-term treatment,
infrequent but sustained contact with a multidisciplinary service
over the course of the child’s development should be made available
so that at transitional points in each yearly cycle (such as entering a
new school classes each autumn) and at transitional points within the
life cycle (such as entering adolescence, changing school or moving
house) increased service contact may be offered.
Pervasive conduct problems in adolescence
About one-third of children with childhood behaviour problems
develop conduct disorder, which is a pervasive and persistent pattern
of antisocial behaviour that extends beyond the family into the community.
Adolescent self-regulation and skills deficits, problematic parenting
practices and extra-familial factors such as deviant peer group
membership, high stress and low social support maintain conduct
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disorder and are targeted by effective treatment programmes
(Murrihy et al., 2010).
In a meta-analysis of twenty-four studies Baldwin et al. (2012) evaluated
the effectiveness of brief strategic family therapy (Robbins et al.,
2010), functional family therapy (Alexander et al., 2013), multisystemic
therapy (Henggeler and Schaeffer, 2010) and multidimensional family
therapy (MDTF) (Liddle, 2010). They found that all four forms of
family therapy were effective compared with non-treatment control
groups (with an effect size of 0.7) and somewhat more effective than
treatment as usual or alternative treatments (where the effect sizes were
about 0.2). These results showed that the average case treated with
family therapy fared better than 76 per cent of untreated patients and
58 per cent of patients who engaged in alternative treatments. These
results are consistent with those from a previous meta-analysis of eight
family-based treatment studies of adolescent conduct disorder conducted
by Woolfenden et al. (2002). They found that family-based
treatments, including functional family therapy, multisystemic therapy
and treatment foster care were more effective than routine treatment.
These family-based treatments significantly reduced time spent in
institutions, the risk or re-arrest and recidivism 1–3 years following
treatment. For each of these approaches, organizations to facilitate the
large-scale transport of treatments to community settings have been
developed along with quality assurance systems to support treatment
fidelity in these settings (Henggeler and Sheidow, 2012). These effective
family-based interventions for adolescent conduct disorder fall on
a continuum of care which extends from functional family therapy and
brief strategic therapy through more intensive multisystemic therapy
to very intensive treatment foster care. What follows are brief outlines
of three of these models.
Functional family therapy. This model was developed initially by James
Alexander at the University of Utah and more recently by Tom Sexton
at the University of Indiana (Alexander et al., 2013; Sexton, 2011). It is
a manualized model of systemic family therapy for adolescent conduct
disorder. It involves distinct stages of engagement where the emphasis
is on forming a therapeutic alliance with family members, behaviour
change, where the focus is on facilitating competent family problemsolving
and generalization, where families learn to use new skills in a
range of situations and to deal with setbacks. Whole family sessions are
conducted on a weekly basis. Treatment spans eight to thirty sessions
over 3–6 months. In a systematic review of twenty-seven clinical trials of
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functional family therapy, Alexander et al. (2013) concluded that this
approach is effective in reducing recidivism by up to 70 per cent in
adolescent offenders with conduct disorders from a variety of ethnic
groups over follow-up periods of up to 5 years, compared with those
receiving routine services. It also leads to a reduction in conduct
problems in the siblings of offenders. In a review of a series of largescale
effectiveness studies, Sexton and Alexander (2003) found that
functional family therapy was $5,000–12,000 less expensive per case
than juvenile detention or residential treatment and led to cost savings
for victims and the criminal justice system of over $13,000 per case. The
same review concluded that in a large-scale effectiveness study the
drop-out rate for functional family therapy was about 10 per cent
compared to the usual drop-out rates of 50–70 per cent in the routine
community treatment of adolescent offenders.
Multisystemic therapy. This model was developed at Medical University
of South Carolina by Scott Henggeler and his team (Henggeler et al.,
2009). Multisystemic therapy combines intensive family therapy with
individual skills training for adolescents and intervention in the wider
school and inter-agency network. Multisystemic therapy involves
helping adolescents, families and involved professionals understand
how adolescent conduct problems are maintained by recursive
sequences of interaction within the youngsters’ family and social
network. It uses individual and family strengths to develop and implement
action plans and new skills to disrupt these problem maintaining
patterns. Furthermore, it supports families to follow through on
action plans, helping them use new insights and skills to handle new
problem situations and monitoring progress in a systematic way.
Multisystemic therapy involves regular, frequent home-based
family and individual therapy sessions with additional sessions in
school or community settings over 3 to 6 months. Therapists carry low
caseloads of no more than five cases and provide 24-hour, 7-day
availability for crisis management. In a meta-analysis of eleven studies
evaluating the effectiveness of multisystemic therapy, Borduin et al.
(2004) found a post-treatment effect size of 0.55, which indicates that
the average treated case fared better than 72 per cent of control group
cases receiving standard services. Positive effects were maintained up
to 4 years after treatment.
Multisystemic therapy had a greater impact on improving
family relations than on improving individual adjustment or peer
relations. In a systematic review of eighteen studies Henggeler and
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Schaeffer (2010) concluded that, compared with treatment-as-usual,
multisystemic therapy led to significant improvements in individual
and family adjustment, which contributed in turn to significant reductions
in conduct problems, psychological adjustment, drug use, school
absence, out-of home placement and recidivism. Improvements were
found to be sustained at long-term follow up for up to 14 years and
entailed significant savings in placement, juvenile justice and crime
victim costs.
Multidimensional treatment foster care. This model was developed at the
Oregon Social Learning Centre by Patricia Chamberlain and her team
(Chamberlain, 2003). Multidimensional treatment foster care combines
procedures similar to multisystemic therapy, with specialist
foster placement in which foster parents use behavioural principles to
help adolescents modify their conduct problems. Treatment fostercare
parents are carefully selected and before an adolescent is placed
with them they undergo intensive training. This focuses on the use of
behavioural parenting skills for managing antisocial behaviour and
developing positive relationships with antisocial adolescents. They
also receive ongoing support and consultancy throughout placements
that last 6–9 months. Concurrently, the young person or their biological
family engage in weekly family therapy with a focus on parents
developing behavioural parenting practices and families developing
communication and problem-solving skills. Adolescents also engage in
individual therapy, and wider systems consultations are carried out
with the youngsters’ teachers, probation officers and other involved
professionals, to ensure all relevant members of youngsters’ social
systems are cooperating in ways that promote their improvement.
About 85 per cent of adolescents return to their parents’ home after
treatment foster care. In a review of three studies of treatment foster
care for delinquent male and female adolescents Smith and
Chamberlain (2010) found that, compared with care in a group home
for delinquents, multidimensional treatment foster care significantly
reduced running away from placement as well as the re-arrest rate
and self-reported violent behaviour. The benefits of multidimensional
treatment foster care were due to the improvement in the parents’
skills in managing adolescents in a consistent, fair and non-violent
way, and reductions in the adolescents’ involvement with deviant
peers. These positive outcomes of multidimensional treatment foster
care entailed cost savings of over $40,000 per case in juvenile justice
and crime victim costs (Chamberlain and Smith, 2003).
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From this review it may be concluded that, in developing services
for families of adolescents with conduct disorder, it is most efficient to
offer services on a continuum of care. Less severe cases may be offered
up to thirty sessions of functional family therapy over a 6-month
period. Moderately severe cases and those that do not respond to
circumscribed family interventions may be offered up to 20 hours per
month of multisystemic therapy over a period of up to 6 months.
Extremely severe cases and those who are unresponsive to intensive
multisystemic therapy may be offered treatment foster care for a
period of up to year and this may then be followed with ongoing
multisystemic intervention. It is essential that such a service involves
high levels of supervision and low caseloads for front-line clinicians
because of the high stress load that these cases entail and the consequent
risk of therapist burnout.
Drug misuse in adolescence
In a systematic narrative review of forty-five trials of treatments for
adolescent drug users, Tanner-Smith et al. (2013) concluded that
family therapy is more effective than other types of treatment including
cognitive behavioural therapy, motivational interviewing, psychoeducation
and various forms of individual and group counselling. A
series of systematic reviews and meta-analyses support the effectiveness
of family therapy programmes in the treatment of adolescent drug
misuse (Austin et al., 2005; Baldwin et al., 2012; Becker and Curry,
2008; Rowe, 2012; Vaughn and Howard, 2004; Waldron and Turner,
2008). Effective programmes include MDTF (Liddle, 2010), brief strategic
family therapy (Robbins et al., 2010), functional family therapy
(Waldron and Brody, 2010) and multisystemic therapy (Henggeler and
Schaeffer, 2010). These programmes also lead to the amelioration of
conduct problems (mentioned in the previous section), family functioning
and school performance, as well as leading to a reduction in contact
with deviant peers (Rowe, 2012). Brief outlines of MDTF and brief
strategic family therapy are given below to indicate the type of clinical
practices associated with these evidence-based models.
MDTF. This model was developed by Howard Liddle and his team
at the Centre for Treatment Research on Adolescent Drug Abuse at
the University of Miami (Liddle, 2010). MDTF involves assessment
and intervention in four domains: including (i) adolescents, (ii)
parents, (iii) interactions within the family and (iv) family interactions
with other agencies such as schools and courts. Three distinct phases
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characterize MDFT and these include engaging families in treatment;
working with themes central to recovery and consolidating treatment
gains and disengagement. MDFT involves between sixteen and
twenty-five sessions over 4–6 months. Treatment sessions may include
adolescents, parents, whole families and involved professionals and
may be held in the clinic, home, school, court or other relevant
agencies. Rowe and Liddle (2008) conducted a thorough review of the
evidence base for MDFT and concluded that it is effective in reducing
alcohol and drug misuse, behavioural problems, emotional symptoms,
negative peer associations, school failure and family difficulties associated
with drug misuse.
Brief strategic family therapy. This model was developed at the Centre for
Family Studies at the University of Miami by Josè Szapocznik and his
team (Robbins et al., 2010). Brief strategic family therapy aims to
resolve adolescent drug misuse by improving family interactions that
are directly related to substance use. This is achieved within the context
of conjoint family therapy sessions by coaching family members to
modify such interactions when they occur and to engage in more
functional interactions. The main techniques used in brief strategic
family therapy are engaging with families, identifying maladaptive
interactions and family strengths and restructuring maladaptive family
interactions. The model was developed for use with minority ethnicity
families, particularly Hispanic families, and therapists facilitate healthy
family interactions based on appropriate cultural norms. Where there
are difficulties engaging with whole families, the therapists work with
motivated family members to engage less motivated family members in
treatment. Where parents cannot be engaged in treatment, a oneperson
adaptation of brief strategic family therapy has been developed.
Brief strategic family therapy involves twelve to thirty sessions over 3–6
months, with treatment duration and intensity being determined by
problem severity. In a thorough review of research on this approach,
Santisteban et al. (2006) concluded that it was effective in engaging
adolescents and their families in treatment, reducing drug abuse and
recidivism and improving family relationships. There is also empirical
support from controlled trials for the efficacy of its strategic engagement
techniques for inducting resistant family members in treatment,
and for one-person family therapy in cases where parents resist
engagement in treatment.
This review suggests that services for adolescent drug misuse
should involve an intensive family engagement process and thorough
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assessment, followed by regular family sessions over a 3–6 month
period, coupled with direct work with youngsters and other involved
professionals. The intensity of therapy should be matched to the
severity of the youngster’s difficulties. Where appropriate, medical
assessment, detoxification or methadone maintenance should also be
provided.
Emotional problems
Family-based systemic interventions are effective for a proportion of
cases with anxiety disorders, depression, grief following parental
bereavement, bipolar disorder and self-harm. All these emotional
problems cause youngsters and their families considerable distress
and in many cases prevent young people from completing developmental
tasks such as school attendance and developing peer relationships.
In a review of community surveys, Merikangas et al. (2009)
found that the median prevalence rate for anxiety disorders was 8 per
cent, with a range of 2–24 per cent; the median prevalence rate for
major depression was 4 per cent, with a range of 0.2–17 per cent and
the prevalence of bipolar disorder in young people was under 1 per
cent. Between 1.5 and 4 per cent of children under the age of 18 lose
a parent by death, and a proportion of these show complicated grief
reactions (Black, 2002). Community-based studies show that about 10
per cent of adolescents report having self-harmed; for some of these
teenagers suicidal intent motivates their self-harm; and self-harm is
more common among girls, while completed suicide is more common
among boys (Hawton et al., 2012).
Anxiety
Anxiety disorders in children and adolescents include separation
anxiety, selective mutism, phobias, social anxiety disorder, generalized
anxiety disorder, obsessive compulsive disorder (OCD) and posttraumatic
stress disorder (American Psychiatric Association, 2013;
World Health Organization, 1992). All are characterized by excessive
fear and avoidance of particular internal experiences or external
situations. Systematic reviews of the effectiveness of family-based cognitive
behavioural therapy for child and adolescent anxiety disorders
show that it is at least as effective as individual cognitive behavioural
therapy; more effective than individual therapy in cases where parents
also have anxiety disorders and more effective than individual
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interventions in improving the quality of family functioning (Barmish
and Kendall, 2005; Creswell and Cartwright-Hatton, 2007; Diamond
and Josephson, 2005; Drake and Ginsburg, 2012; Kaslow et al., 2012;
Reynolds et al., 2012; Silverman et al., 2008). Barrett’s FRIENDS programme
is the best validated family-oriented cognitive behavioural
therapy intervention for childhood anxiety disorders (Barrett and
Shortt, 2003; Pahl and Barrett, 2010). In this programme children
attend ten weekly group sessions and parents join these 90-minute
sessions for the last 20 minutes to become familiar with the programme
content. There are also a couple of dedicated family sessions and
1-month and 3-month follow-up sessions for relapse prevention. Both
children and parents engage in psycho-education about anxiety, which
provides a rationale for anxious children to engage in gradual exposure
to feared stimuli, which is essential for effective treatment. Children
and parents also engage in communication and problem-solving
skills training to enhance the quality of parent–child interaction.
In the child-focused element of the programme youngsters learn
anxiety management skills such as relaxation, cognitive coping and
using social support, and use these skills to manage anxiety associated
with gradual exposure to feared stimuli. In the family-based component,
parents learn to reward their children’s use of anxiety management
skills when facing feared stimuli, ignore their children’s
avoidant or anxious behaviour and manage their own anxiety.
School refusal. School refusal is usually due to separation anxiety disorder
where children avoid separation from parents as this leads to
intense anxiety. Systematic reviews have concluded that behavioural
family therapy leads to recovery for more than two-thirds of patients
and this improvement rate is significantly higher than that found for
individual therapy (Elliott, 1999; Heyne and Sauter 2013; King and
Bernstein, 2001; King et al., 2000; Pina et al., 2009). Effective therapy
begins with a careful systemic assessment to identify anxiety triggers
and obstacles to anxiety control and school attendance. Children,
parents and teachers are helped to collaboratively develop a returnto-
school plan, which includes coaching children in relaxation, coping
and social skills to help them deal with anxiety triggers. Parents and
teachers are then helped to support and reinforce children for using
anxiety management and social skills to deal with the challenges which
occur during their planned return to regular school attendance.
OCD. With OCD children compulsively engage in repetitive rituals to
reduce anxiety associated with cues such as dirt or lack of symmetry.
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In severe cases, children’s lives become seriously constricted due to
the time and effort they invest in compulsive rituals. Family life comes
to be dominated by other family member’s attempts to accommodate
to or prevent these rituals. A series of trials has shown that familybased
cognitive behavioural exposure and response-prevention treatment
is effective in alleviating symptoms in 50–70 per cent of cases of
paediatric OCD. The best treatment response occurs where such
interventions are combined with selective serotonin re-uptake inhibitors
(SSRI) such as sertraline and that family-based cognitive behavioural
therapy is more effective than SSRI alone (Franklin et al., 2010;
Moore et al., 2013; Watson and Rees, 2008). Treatment is offered on
an individual or group basis to children with concurrent family sessions
over about 4 months. Family intervention involves psychoeducation
about OCD and its treatment through exposure and
response prevention, externalizing the problem, monitoring symptoms
and helping parents and siblings support and reward the child
for completing exposure and response-prevention homework exercises.
Family therapy also helps parents and siblings avoid inadvertently
reinforcing children’s compulsive rituals. Exposure and
response prevention is the principal child-focused element of the
programme. With this, children construct hierarchies of anxietyproviding
cues (such as increasingly dirty stimuli) and are exposed to
the cues that elicit anxiety-provoking obsessions (such as ideas about
contamination), commencing with the least anxiety provoking, while
not engaging in compulsive rituals (such as hand washing) until
habituation occurs. They also learn anxiety management skills to help
them cope with the exposure process.
This review suggests that in developing services for children with
anxiety disorders, family therapy of up to sixteen sessions should be
offered, which allows children to enter into anxiety-provoking situations
in a planned way and to manage these through the use of coping
skills and parental support.
Depression
Major depression is an episodic disorder characterized by low or
irritable mood, loss of interest in normal activities and most of the
following symptoms: psychomotor agitation or retardation, fatigue,
low self-esteem, pessimism, inappropriate excessive guilt, suicidal
ideation, impaired concentration and sleep and appetite disturbance
(American Psychiatric Association, 2013; World Health Organization,
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1992). Episodes may last from a few weeks to a number of months and
recur periodically over the life cycle with inter-episode intervals
varying from a few months to a number of years. Integrative theories
of depression propose that episodes occur when genetically vulnerable
individuals find themselves involved in stressful family systems in
which there is limited access to socially supportive relationships (Abela
and Hankin, 2008). Family-based therapy aims to reduce stress and
increase support for young people in their families. But other factors
also provide a rationale for family therapy. Not all young people
respond to antidepressant medication (Goodyer et al., 2007). Moreover,
some young people do not wish to take medication because of its
side effects and in some instances parents or clinicians are concerned
that medication may increase the risk of suicide. Finally, research on
adult depression has shown that relapse rates in the year following
pharmacotherapy are about double those following psychotherapy
(Vittengl et al., 2007).
Stark et al. (2012) reviewed twenty-five trials of family-based treatment
programmes for child and adolescent depression. In these
studies a variety of formats was used, including conjoint family
sessions; for example, Diamond’s (2005) attachment-based family
therapy; child-focused cognitive behavioural therapy (Stark et al.,
2010) or interpersonal therapy (Jacobson and Mufson, 2010) sessions
combined with some family or parent sessions; and concurrent groupbased
parent and child training sessions (such as Lewinsohn’s coping
with depression course (Clark and DeBar, 2010). Stark et al. (2012)
concluded that family-based treatments for child and adolescent
depression were as effective as well-established therapies such as individual
cognitive behavioural therapy or interpersonal therapy and led
to remission in two-thirds to three-quarters of cases at 6-months follow
up. They were also more effective than individual therapy in maintaining
post-treatment improvement. Effective family-based interventions
aim to decrease the family stress to which youngsters are
exposed and enhance the availability of social support within the
family context. Core features of effective family interventions include
psycho-education about depression; the relational reframing of
depression-maintaining family interaction patterns; the facilitation of
clear parent–child communication; the promotion of systematic
family-based problem-solving and of secure parent–child attachment;
the disruption of negative critical parent–child interactions and
helping children develop skills for managing negative mood states
and changing their pessimistic belief systems. With respect to clinical
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practice and service development, family therapy for episodes of
adolescent depression is relatively brief, requiring about twelve sessions.
Because major depression is a recurrent disorder, services
should make long term re-referral arrangements so that intervention
is offered promptly in further episodes. Systemic therapy services
should be organized so as to permit the option of multi-modal treatment
with family therapy and antidepressant medication in cases
unresponsive to family therapy.
Grief
A number of single group outcome studies and controlled trials show
that effective therapy for grief reactions following parental bereavement
may include a combination of family and individual interventions
(Black and Urbanowicz, 1987; Cohen et al., 2006; Kissane
and Bloch, 2002; Kissane et al., 2006; Rotheram-Borus et al., 2004;
Sandler et al., 1992, 2003, 2010). Family intervention involves engaging
families in treatment, facilitating family grieving and family
support, decreasing parent–child conflict and helping families to reorganize
so as to cope with the demands of daily living in the absence of
the deceased parent. The individual component of treatment involves
exposure of the child to traumatic grief-related memories and images
until a degree of habituation occurs. This may be facilitated by viewing
photos, audio and video recordings of the deceased and developing
a coherent narrative with the child about their past life with the
deceased and a way to preserve a positive relationship with the
memory of the deceased parent. With respect to clinical practice and
service development, family therapy for grief following the loss of a
parent is relatively brief, requiring about twelve sessions.
Bipolar disorder
Bipolar disorder is a recurrent episodic mood disorder with a predominantly
genetic basis, characterized by episodes of mania or hypomania,
depression and mixed mood states (American Psychiatric Association,
2013; World Health Organization, 1992). The primary treatment for
bipolar disorder is pharmacological and involves the initial treatment
of acute manic, hypomanic, depressive or mixed episodes and the
subsequent prevention of further episodes with mood-stabilizing medication
such as lithium (Kowatch et al., 2009). Bipolar disorder typically
first occurs in late adolescence or early adulthood and its course, even
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when treated with mood-stabilizing medication, is significantly affected
by stressful life events and family circumstances on the one hand, and
family support on the other. The high frequency of relapses among
young people with bipolar disorder provides the rationale for the
development of relapse-prevention interventions.
Psycho-educational family therapy aims to prevent relapses by
reducing family stress and enhancing family support for youngsters
with bipolar disorder who are concurrently taking mood-stabilizing
medication such as lithium (Miklowitz, 2008). Family therapy for
bipolar disorder typically spans twelve to twenty-one sessions and
includes psycho-education about the condition and its management,
and family communication and problem-solving skills training. The
results of a series of studies suggest that psycho-educational family
therapy may be helpful in adolescent bipolar disorder in increasing
knowledge about the condition, improving family relationships and
ameliorating symptoms of depression and mania (Fristad, 2006:
Fristad et al., 2002, 2003, 2009; Miklowitz et al., 2004; Pavuluri et al.,
2004; West et al., 2009). With respect to clinical practice and service
development, family therapy for bipolar disorder in adolescence is
relatively brief, requiring up to twenty-one sessions, and should be
offered as part of a multi-modal programme that includes moodstabilizing
medication such as lithium.
Self-harm
A complex constellation of risk factors has been identified for self-harm
in adolescence. They include the characteristics of the young person
(such as the presence of psychological disorder) and features of the
social context (such as family difficulties) (Hawton et al., 2012; Ougrin
et al., 2012). Both sets of factors are targeted in family-based treatment
for self-harm in adolescence. A series of studies has found that a range
of specialized family therapy interventions improves the adjustment of
adolescents who have self-harmed, although family interventions are
not always more effective than alternative treatments in reducing the
recurrence of self-harm (Asarnow et al., 2011; Diamond et al., 2010,
Harrington et al., 1998; Huey et al., 2004; Katz et al., 2004; King et al.,
2006, 2009; Rathus and Miller 2002; Rotheram-Borus et al., 2000).
Family-based approaches that improve adjustment share a number of
common features. They begin by engaging the young people and their
families in an initial risk-assessment process and proceed to the development
of a clear plan for risk reduction that includes individual
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therapy for adolescents combined with systemic therapy for members
of their family and social support networks. Attachment-based
family therapy, multisystemic therapy, dialectical behaviour therapy
combined with multi-family therapy, and nominated support network
therapy are well developed protocols with some or all of these
characteristics.
Attachment-based family therapy. Attachment-based family therapy was
originally developed for adolescent depression, as noted above, but it
has been adapted for use with self-harming teenagers (Diamond et al.,
2013). This approach aims to repair ruptures in adolescent–parent
attachment relationships. Re-attachment is facilitated by first helping
family members to access their longing for greater closeness and
commit to rebuilding trust. In individual sessions adolescents are
helped to articulate their experiences of attachment failures and agree
to discuss these experiences with their parents. In concurrent sessions
parents explore how their own intergenerational legacies affect their
parenting style. This helps them to develop greater empathy for their
adolescents’ experiences. When the adolescents and parents are
ready, conjoint family therapy sessions are convened in which the
adolescents share their concerns, receive empathic support from their
parents and usually become more willing to consider their own contributions
to family conflict. This respectful and emotional dialogue
serves as a corrective attachment experience that rebuilds trust
between adolescents and parents. As conflict decreases, therapy
focuses on helping adolescents pursue developmentally appropriate
activities to promote their competency and autonomy. In this context,
parents serve as the secure base from which the adolescents receive
support, advice and encouragement in exploring these new opportunities.
In a controlled trial of adolescents at risk for suicide, Diamond
et al. (2010) found that 3 months of attachment-based family therapy
was more effective than routine treatment in reducing suicidal ideation
and depressive symptoms at 6-months follow up.
Multisystemic therapy. Multisystemic therapy was originally developed
for adolescent conduct disorder, as noted above, but it has been
adapted for use with adolescents who have severe mental health
problems, including attempted suicide (Henggeler et al., 2002).
Multisystemic therapy involves assessment of suicide risk, followed by
intensive family therapy to enhance family support combined with
individual skills training for adolescents to help them develop mood
Evidence-base for family therapy with children 129
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regulation and social problem-solving skills, and intervention in the
wider school and inter-agency network to reduce stress and enhance
support for the adolescent. It involves regular, frequent home-based
family and individual therapy sessions with additional sessions in the
school or community settings over 3–6 months. Huey et al. (2004)
evaluated the effectiveness of multisystemic therapy for suicidal adolescents
in a randomized controlled study of 156 African-American
adolescents at risk for suicide referred for emergency psychiatric
hospitalization. Compared with emergency hospitalization and treatment
by a multidisciplinary psychiatric team, Huey et al. found that
multisystemic therapy was significantly more effective in decreasing
rates of attempted suicide at a 1-year follow up.
Dialectical behaviour therapy and multi-family therapy. Dialectical behaviour
therapy, which was originally developed for adults with borderline
personality disorder, has been adapted for use with adolescents who
have attempted suicide (Miller et al., 2007). This adaptation involves
individual therapy for adolescents combined with multi-family
psycho-educational therapy. The multi-family psycho-educational
therapy helps family members understand self-harming behaviour
and develop skills for protecting and supporting self-harming adolescents.
The individual therapy component includes modules on mindfulness,
distress tolerance, emotion regulation and interpersonal
effectiveness skills to address problems in the areas of identity, impulsivity,
emotional liability and relationship problems, respectively. Evidence
from two controlled outcome studies support the effectiveness
of dialectical behaviour therapy with adolescents who have attempted
suicide. In a study of suicidal adolescents with borderline personality
features, Rathus and Miller (2002) compared the outcome for twentynine
patients who received dialectical behaviour therapy plus psychoeducational
multi-family therapy and eighty-two patients who
received psychodynamic therapy plus family therapy. In each programme
the participants attended therapy twice weekly. Both programmes
led to reductions in suicidal ideation. Significantly more
patients completed the dialectical behaviour therapy programme and
significantly fewer were hospitalized during treatment. In a further
study of sixty-two suicidal adolescent in-patients, Katz et al. (2004)
found that both dialectical behaviour therapy and routine in-patient
care led to significant reductions in self-harming behaviour, depressive
symptoms and suicidal ideation but dialectical behaviour therapy
led to significantly greater reductions in behaviour problems.
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© 2014 The Association for Family Therapy and Systemic Practice
Youth-nominated support team. The youth-nominated support team is a
manualized systemic intervention for adolescents who have attempted
suicide, in which adolescents nominate a parent or guardian and
three other people from their family, peer group, school or community
to be members of their support team (King et al. 2000). For each
patient, support team members receive psycho-education explaining
how the adolescent’s psychological difficulties led to the suicide
attempt, the treatment plan and the role that support team members
can play in helping the adolescent towards recovery and managing
situations where there is a risk of further self-harm. Support team
members are encouraged to maintain weekly contact with the adolescent
and are contacted regularly by the treatment team to facilitate
this process. King et al. (2006) evaluated the youth-nominated
support team programme in a randomized controlled trial of 197 girls
and eighty-two boys who had attempted suicide and been hospitalized.
They found that, compared with routine treatment with psychotherapy
and antidepressant medication, the youth-nominated
support team programme led to decreased suicidal ideation and
mood-related functional impairment in girls at 6-months follow up
but had no significant impact on boys.
Systemic services for young people who self-harm should involve
prompt intensive initial individual and family assessment followed by
systemic intervention, including both individual and family sessions to
reduce individual and family-based risk factors. Such therapy may
involve regular session over a 3–6 month period. Systemic therapy
services for youngsters at risk for suicide should be organized so as to
permit the option of brief hospitalization or residential placement in
circumstances where families are assessed as lacking the resources for
immediate risk reduction on an outpatient basis.
Eating disorders
An excessive concern with the control of body weight and shape along
with an inadequate and unhealthy pattern of eating are the central
features of anorexia nervosa and bulimia nervosa. The former is
characterized primarily by weight loss and the latter by a cyclical
pattern of bingeing and purging (American Psychiatric Association,
2013; World Health Organization, 1992). The average prevalence
rates for anorexia nervosa and bulimia nervosa among young women
are about 0.3–0.5 per cent and 1–4 per cent, respectively (Hoek, 2006;
Keel, 2010). Childhood obesity occurs where there is a body mass
Evidence-base for family therapy with children 131
© 2014 The Association for Family Therapy and Systemic Practice
index above the 95th percentile with reference to age-specific and
sex-specific growth charts (Reilly, 2010). In Europe the prevalence of
obesity among children and adolescents is about 5 per cent and in the
USA it is about 15 per cent (Wang and Lim, 2012). Anorexia, bulimia
and obesity are of concern because they lead to long-term physical or
mental health problems. Family therapy is effective for a proportion of
children and adolescents with eating disorders.
Anorexia nervosa
A series of systematic reviews and meta-analyses covering a total of
seven controlled and six uncontrolled trials allow the following conclusions
to be drawn about the effectiveness of family therapy for
anorexia nervosa in adolescents (Couturier et al., 2013; Eisler, 2005,
Lock, 2011; Robin and Le Grange, 2010; Smith and Cook-Cottone,
2011; Stuhldreher et al., 2012; Wilson and Fairburn, 2007). After
treatment, between half and two-thirds of patients achieve a healthy
weight. At 6-months to 6-years follow up, 60–90 per cent have fully
recovered and no more than 10–15 per cent are seriously ill. In the
long term the negligible relapse rate following family therapy is
superior to the moderate outcomes for individually oriented therapies.
The outcome for family therapy is also far superior to the high
relapse rate following in-patient treatment, which is 25–30 per cent
following first admission and 55–75 per cent for second and further
admissions. Outpatient family-based treatment is also more costeffective
than in-patient treatment. Evidence-based family therapy
for anorexia can be effectively disseminated and implemented in
community-based clinical settings. In the Maudsley model for treating
adolescent anorexia, which is the approach with the strongest empirical
support, family therapy for adolescent anorexia progresses
through three phases (Lock and Le Grange, 2013). The first involves
helping parents work together to refeed their youngster. This is followed
in the second phase with facilitating family support for the
youngster in developing an autonomous, healthy eating pattern. In
the final phase the focus is on helping the young person develop an
age-appropriate lifestyle. Treatment typically involves between ten
and twenty one-hour sessions over a 6–12-month period.
Bulimia nervosa
Two trials of family therapy for bulimia in adolescence, using the
Maudsley model, show that it is more effective than supportive therapy
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© 2014 The Association for Family Therapy and Systemic Practice
(Le Grange and Lock, 2010) and as effective as cognitive behavioural
therapy (Schmidt et al., 2007), which is considered to be the treatment
of choice for bulimia in adults, due its strong empirical support (Wilson
and Fairburn, 2007). In both trials, at 6-months follow up, over 70 per
cent of cases treated with family therapy showed partial or complete
recovery. Family therapy for adolescent bulimia involves helping
parents work together to supervise the young person during mealtimes
and afterwards, to break the binge-purge cycle. As with anorexia, this is
followed by helping families support their youngsters in developing
autonomous, healthy eating patterns, and age appropriate lifestyles
(Le Grange and Locke, 2007).
Obesity
Systematic narrative reviews and meta-analyses of controlled and
uncontrolled trials of treatments for obesity in children converge on
the following conclusions (Epstein, 2003; Feng, 2011; Jelalian and
Saelens, 1999; Jelalian et al., 2007; Kitzmann and Beech, 2011;
Kitzmann et al., 2010; Nowicka and Flodmark, 2008; Seo and Sa,
2010; Young et al., 2007). Family-based behavioural weight reduction
programmes are more effective than dietary education and other
routine interventions. They lead to a 5–20 per cent reduction in
weight after treatment and at a 10-year follow up 30 per cent of
patients are no longer obese. Childhood obesity is due predominantly
to lifestyle factors including poor diet and lack of exercise and so
family-based behavioural treatment programmes focus on lifestyle
change. Specific dietary and exercise routines are agreed and implemented
and parents reinforce young people for adhering to these
routines (Jelalian et al., 2007). An important development in the treatment
of obesity is the standardized obesity family therapy in Malmo in
Sweden. It is based on systemic and solution-focused theories and has
had a positive effect on the degree of obesity, physical fitness, selfesteem
and family functioning in several studies (Nowicka and
Flodmark, 2011).
In planning systemic services for young people with eating disorders
it should be expected that treatment of anorexia or bulimia will
span 6–12 months, with the first ten sessions occurring weekly and the
later sessions occurring fortnightly and then monthly. For obesity,
therapy may span ten to twenty sessions followed by periodic, infrequent
review sessions over a number of years to help youngsters
maintain weight loss.
Evidence-base for family therapy with children 133
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Somatic problems
Family-based interventions are helpful in a proportion of cases for the
following somatic problems: enuresis, encopresis, recurrent abdominal
pain and both poorly controlled asthma and diabetes.
Enuresis
In a systematic review and a meta-analysis of randomized controlled
trials, Glazener et al., (2004, 2009) found that family-based urine
alarm programmes were an effective treatment for childhood nocturnal
enuresis (bed-wetting). These programmes involve coaching the
child and parents to use an enuresis alarm, which alerts the child as
soon as micturition begins. Family-based urine alarm programmes, if
used over 12–16 weeks, are effective in about 60–90 per cent per cent
of patients (Brown et al., 2011; Houts, 2010). With a urine alarm the
urine wets a pad that closes a circuit and sets off the urine alarm,
waking the child, who gradually learns over multiple occasions by a
conditioning process to wake before voiding the bladder. In family
sessions, parents and children are helped to understand this process
and plan to implement the urine alarm-based programme at home. In
family-based urine alarm programmes, parents reinforce children for
success in maintaining dry beds using star-charts.
Encopresis
In a narrative review of 42 studies, McGrath et al. (2000) found that
for childhood encopresis (soiling), multi-modal programmes involving
medical assessment and intervention followed by behavioural
family therapy were effective for 43–75 per cent of patients. Initially a
paediatric medical assessment is conducted and if a faecal mass has
developed in the colon, this is cleared with an enema. A balanced diet
containing an appropriate level of roughage and regular laxative use
are arranged. Effective behavioural family therapy involves psychoeducation
about encopresis and its management, coupled with a
reward programme, where parents reinforce appropriate daily
toileting routines. There is some evidence that a narrative approach
may be more effective than a behavioural approach to family therapy
for encopresis. Silver et al. (1998) found success rates of 63 and 37 per
cent for narrative and behavioural family therapy, respectively. With
narrative family therapy the soiling problem was externalized and
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© 2014 The Association for Family Therapy and Systemic Practice
referred to as ‘sneaky poo’. Therapy focused on parents and children
collaborating to outwit this externalized personification of encopresis
(White, 2007).
Recurrent abdominal pain
Results of 4 trials have shown that behavioural family therapy is
effective in alleviating recurrent abdominal pain, often associated
with repeated school absence, and for which no biomedical cause is
evident (Finney et al., 1989; Robins et al. 2005; Sanders et al., 1989,
1994). Such programmes involve family psycho-education about
recurrent abdominal pain and its management, relaxation and
coping skills training to help children manage stomach pain, which is
often anxiety-based, and contingency management implemented by
parents to motivate their children to engage in normal daily routines,
including school attendance. This conclusion is consistent with
those of other systematic narrative reviews (Banez and Gallagher,
2006; Sprenger et al., 2011; Spirito and Kazak, 2006; Weydert et al.,
2003).
Poorly controlled asthma
Asthma, a chronic respiratory disease with a prevalence rate of about
10 per cent among children, can lead to significant restrictions in daily
activity, repeated hospitalization. If it is very poorly controlled, asthma
is potentially fatal (Currie and Baker, 2012). The course of asthma is
determined by the interaction between abnormal physiological processes
of the respiratory system, to which some youngsters have a
predisposition, physical environmental triggers and psychosocial processes.
In a systematic review of twenty studies, Brinkley et al. (2002)
concluded that family-based interventions for asthma spanning up to
eight sessions were more effective than individual therapy. These
included psycho-education to improve their understanding of the
condition, medication management and environmental trigger management,
relaxation training to help young people reduce physiological
arousal, skills training to increase adherence to asthma
management programmes and conjoint family therapy sessions to
empower family members to work together to manage asthma effectively.
These conclusions have been supported by results of some (for
example, Ng et al., 2008) but not all (for example, Celano et al., 2012)
recent trials.
Evidence-base for family therapy with children 135
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Poorly controlled diabetes
Type 1 diabetes is an endocrine disorder characterized by complete
pancreatic failure (Levy, 2011). The long-term outcome for poorly
controlled diabetes may include blindness and leg amputation. For
youngsters with diabetes normal blood glucose levels are achieved
through a regime involving a combination of insulin injections, balanced
diet, exercise and the self-monitoring of blood glucose. In a
systematic review of eleven studies Farrell et al. (2002) found that
family-based programmes of ten to twenty sessions were effective in
helping young people control their diabetes, and that different types
of programmes were appropriate for young people at different stages
of the life cycle. For youngsters newly diagnosed with diabetes,
psycho-educational programmes that helped families understand the
condition and its management were particularly effective. Familybased
behavioural programmes, where parents rewarded youngsters
for adhering to their diabetic regimes, were particularly effective with
pre-adolescent children, whereas family-based communication and
problem-solving skills training programmes were particularly effective
for families with adolescents, since these programmes gave families
skills for negotiating diabetic management issues in a manner
appropriate for adolescents. In a meta-analysis of fifteen trials of
various types of interventions, Hood et al. (2010) concluded that those
that targeted emotional, social or family processes that facilitate diabetes
management were more effective in promoting glycaemic
control than interventions just targeting a direct, behavioural process,
such as increasing the frequency of blood glucose monitoring. Behavioural
family systems therapy has the strongest empirical support as a
family-based intervention for treating families of poorly controlled
diabetic adolescents (Harris et al. 2009).
This review suggests that family therapy may be incorporated into
multi-modal, multidisciplinary paediatric programmes for a number
of somatic conditions including enuresis, encopresis, recurrent
abdominal pain and both poorly controlled asthma and diabetes.
Systemic intervention for these conditions should be offered following
thorough paediatric medical assessment, and typically interventions
are brief, ranging from eight to twelve sessions.
First episode psychosis
First episode psychosis is a condition characterized by positive symptoms
(such as delusions and hallucinations), negative symptoms (such
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© 2014 The Association for Family Therapy and Systemic Practice
as lack of goal-directed behaviour and flattened affect), and disorganized
thinking, behaviour and emotions (American Psychiatric
Association, 2013; World Health Organization, 1992). First episode
psychosis typically occurs in late adolescence. It is exceptionally distressing
for the young person and the family. Complete recovery may
occur for a proportion of young people, especially if they receive early
intervention and if their families are supportive. However, where
psychosis persists or a chronic relapsing pattern develops eventually a
diagnosis of schizophrenia may be given. Antipsychotic medication is
the primary treatment for the symptoms of first episode psychosis.
Pharmacological interventions may be combined with family interventions
in which the primary aim is to facilitate a supportive family
environment and so prevent the development of a chronic relapsing
condition. Reviews of controlled trials show that combining antipsychotic
medication with psycho-educational family therapy (Kuipers
et al., 2002) reduces relapse rates in first episode psychosis and that
multi-family psycho-educational therapy (McFarlane, 2002) is particularly
effective (Bird et al., 2010; McFarlane et al., 2012; Onwumere
et al., 2011).
Psycho-educational family therapy for schizophrenia involves
psycho-education, based on the stress-vulnerability or bio-psychosocial
models of psychosis (McFarlane et al., 2012), with a view to
helping families understand and manage the condition, antipsychotic
medication, related stresses and early warning signs of relapse. Psychoeducational
family therapy also aims to reduce negative family processes
associated with relapse, specifically high levels of expressed
emotion, stigma, communication deviance and stresses related to transitions
in the life cycle. Emphasis is placed on blame reduction and the
positive role that family members can play in supporting the young
person’s recovery. Psycho-educational family therapy also helps families
develop communication and problem-solving skills. Skills training
commonly involves modelling, rehearsal, feedback and discussion.
Effective interventions typically span 9–12 months and are usually
offered in a phased format, with initial sessions occurring more frequently
than later sessions and crisis intervention as required.
From this review it may be concluded that systemic therapy services
for families of people with first episode psychosis should be offered
within the context of multi-modal programmes that include antipsychotic
medication. Because of the potential for relapse, services should
make re-referral arrangements, so intervention is offered promptly in
later episodes.
Evidence-base for family therapy with children 137
© 2014 The Association for Family Therapy and Systemic Practice
Discussion
A number of comments may be made about the evidence reviewed in
this article. For a wide range of child-focused problems systemic interventions
are effective. These interventions are brief, rarely involving
more than twenty sessions, and may be offered by a range of professionals
on an outpatient basis. Treatment manuals have been developed
for many systemic interventions and these may be flexibly used
by clinicians in treating individual patients. Moreover, most evidencebased
systemic interventions have been developed within the cognitive
-behavioural, structural and strategic traditions. The implications
of these findings are discussed in the final section of the companion
article in this issue (Carr, 2014).
The results of this review are broadly consistent with the important
role accorded to family involvement in the treatment of children and
young people in authoritative clinical guidelines such as those published
by the UK National Institute for Clinical Excellence (NICE)
for a range of problems, including conduct disorder (NICE, 2013a),
ADHD (NICE, 2013b), drug misuse (NICE, 2007), some anxiety disorders
(for example, NICE, 2005a), mood disorders (NICE, 2005b,
2006), eating disorders (NICE, 2004), certain somatic problems (for
example, NICE, 2009, 2010) and psychosis in adolescence (NICE,
2013c).
A broad definition of systemic intervention has been adopted in this
article, in comparison with that taken in other reviews of the field of
family therapy for child-focused problems (for example, Kaslow et al.,
2012; Retzlaff, et al., 2013). There are pros and cons to adopting a
broad definition. On the positive side, it provides the widest scope of
evidence on which to draw in support of systemic practice. This is
important in a climate where there is increasing pressure to point to
a significant evidence base to justify funding family therapy services. It
also offers the family therapists reading this review guidance on
family-based treatment procedures that may usefully be incorporated
into their systemic practice. However, the broad definition of systemic
intervention used in this article potentially blurs the unique contribution
of the practices developed within the tradition of systemic family
therapy, as distinct from interventions in which parents are included
in an adjunctive role to facilitate individually focused therapy, or
family-based approaches that integrate distinctly systemic ideas and
practices with those of other therapeutic traditions, notably cognitive
behavioural therapy.
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© 2014 The Association for Family Therapy and Systemic Practice
The findings of this review have implications for research, training
and practice. With respect to research, more studies are needed on
the effectiveness of distinctly systemic interventions for child abuse,
problems of early childhood and emotional problems in young
people. More research is also required on social constructionist and
narrative approaches to systemic practice which, though widely used,
have rarely been evaluated. With respect to training, the systemic
evidence-based interventions reviewed in this article should be incorporated
in family therapy training programmes and continuing
professional development short courses for experienced systemic
practitioners. This argument has recently been endorsed in the UK
and the USA in statements of the core competencies of systemic
therapists (Northey, 2011; Stratton et al., 2011). With respect to
routine practice, family therapists should work towards incorporating
the types of practices described in this article and in the treatment
resources listed below when working with families of children and
adolescents with the types of problems considered in this article.
Treatment resources
Sleep problems
Mindell, J. and Owens, J. (2009) A Clinical Guide to Paediatric Sleep: Diagnosis and
Management of Sleep Problems (2nd edn). Philadelphia: Lippincott Williams and
Wilkins.
Feeding problems
Kedesdy, J. and Budd, K. (1998) Childhood Feeding Disorders: Behavioural Assessment
and Intervention. Baltimore: Paul. H. Brookes.
Attachment problems
Berlin, L. and Ziv, Y. (2005) Enhancing Early Attachments. Theory, Research, Intervention
and Policy. New York: Guilford.
Physical abuse
Kolko, D. and Swenson, C. (2002) Assessing and Treating Physically Abused Children
and Their Families: A Cognitive Behavioural Approach. Thousand Oaks: Sage.
Rynyon, M. and Deblinger, E. (2013) Combined Parent–child Cognitive Behavioural
Therapy. An Approach to Empower Families At-Risk for Child Physical Abuse. New
York: Oxford University Press.
Evidence-base for family therapy with children 139
© 2014 The Association for Family Therapy and Systemic Practice
Child sexual abuse
Deblinger, A. and Heflinger, A. (1996) Treating Sexually Abused Children and their
Non-offending Parents: A Cognitive Behavioural Approach. Thousand Oaks: Sage.
Childhood behaviour problems
Dadds, M. and Hawes, D. (2006) Integrated Family Intervention for Child Conduct
Problems. Brisbane: Australian Academic Press.
Kazdin, A. (2005) Parent Management Training. Oxford; Oxford University Press.
Incredible Years Programme (n.d.) Retrieved 8 January 2014 from http://www
.incredibleyears.com/.
Parents Plus Programme (n.d.) Retrieved 8 January 2014 from http://www
.parentsplus.ie/.
Parent–Child Interaction Therapy (n.d.) Retrieved 8 January 2014 from http://
pcit.phhp.ufl.edu/.
Triple P (n.d.) Retrieved 8 January 2014 from http://www.triplep.net/.
Attention deficit hyperactivity disorder
Barkley, R. (2005) Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis
and Treatment (3rd edn). New York. Guilford.
Adolescent conduct disorder
Alexander, J. Waldron, H., Robbins, M. and Neeb, A. (2013) Functional Family
Therapy for Adolescent Behaviour Problems. Washington: American Psychological
Association.
Chamberlain, P. (1994) Family Connections: A Treatment Foster Care Model for Adolescents
with Delinquency. Eugen: Northwest Media.
Chamberlain, P. (2003) Treating Chronic Juvenile Offenders: Advances Made Through
the Oregon Multidimensional Treatment Foster Care Model. Washington: American
Psychological Association.
Chamberlain, P. and Smith, D. (2003) Antisocial behaviour in children and adolescents.
The Oregon multidimensional treatment foster care model. In A.
Kazdin and J. Weisz (eds) Evidence-based Psychotherapies for Children and Adolescents
(pp. 281–300). New York: Guilford.
Henggeler, S., Schoenwald, S., Bordin, C., Rowland, M. and Cunningham, P.
(2009) Multisystemic Therapy for Antisocial Behaviour in Children and Adolescents
(2nd edn). New York: Guilford.
Sexton, T. (2011) Functional Family Therapy in Clinical Practice. New York:
Routledge.
Adolescent drug misuse
Liddle, H. A. (2002) Multidimensional Family Therapy Treatment (MDFT) for Adolescent
Cannabis Users. Vol. 5. Rockville: US Department of Health and Human
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© 2014 The Association for Family Therapy and Systemic Practice
Services. Retrieved 8 January 2014 from http://lib.adai.washington.edu/
clearinghouse/downloads/Multidimensional-Family-Therapy-for-Adolescent-
Cannabis-Users-207.pdf.
Szapocznik, J., Hervis, O. and Schwartz, S. (2002) Brief Strategic Family Therapy for
Adolescent Drug Abuse. Rockville: National Institute for Drug Abuse. Retrieved
8 January 2014 from http://archives.drugabuse.gov/TXManuals/BSFT/
BSFTIndex.html.
Anxiety
Kearney, C. and Albano, A. (2007) When Children Refuse School. Therapist Guide
(2nd edn). New York: Oxford University Press.
Depression
Diamond, G., Diamond, G. and Levy, S. (2013) Attachment-based Family Therapy for
Depressed Adolescents. Washington: American Psychological Association.
Grief
Cohen, J., Mannarino, A. and Deblinger, E. (2006) Treating Trauma and Traumatic
Grief in Children and Adolescents. New York: Guilford.
Kissane, D. and Bloch, S. (2002) Family Focused Grief Therapy: A Model of
Family-centred Care during Palliative Care and Bereavement. Buckingham: Open
University Press.
Bipolar disorder
Miklowitz, D. (2008) Bipolar Disorder: A Family-Focused Treatment Approach (2nd
edn). New York: Guilford.
Self-harm in adolescence
Henggeler, S., Schoenwald, S., Rowland, M. and Cunningham, P. (2002)
Multisystemic Treatment of Children and Adolescents with Serious Emotional Disturbance.
New York: Guilford.
Jurich, A. (2008) Family Therapy with Suicidal Adolescents. New York: Routledge.
King, C., Kramer, A. and Preuss, L. (2000) Youth-Nominated Support Team Intervention
Manual. Ann Arbor: Department of Psychiatry, University of Michigan.
Miller, A., Rathus, J. and Linehan, M. (2007) Dialectical Behaviour Therapy with
Suicidal Adolescents. New York: Guilford.
Eating disorders
Le Grange, D. and Locke, J. (2007) Treating Bulimia in Adolescents. A Family-based
Approach. New York: Guilford.
Evidence-base for family therapy with children 141
© 2014 The Association for Family Therapy and Systemic Practice
Lock, J. and Le Grange, D. (2013) Treatment Manual for Anorexia Nervosa. A Family
Based Approach (2nd edn). New York: Guilford.
Enuresis
Herbert, M. (1996) Toilet Training, Bedwetting and Soiling. Leicester: British Psychological
Society.
Encopresis
Buchanan, A. (1992) Children Who Soil. Assessment and Treatment. Chichester: Wiley.
Psychosis
Kuipers, L., Leff, J. and Lam, D. (2002) Family Work for Schizophrenia (2nd edn).
London: Gaskell.
McFarlane, W. (2002) Multifamily Groups in the Treatment of Severe Psychiatric Disorders.
New York: Guilford.
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