The role of parental problems in functional family therapy outcomes

Children and Youth Services Review 106 (2019) 104483

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The role of parental problems in functional family therapy outcomes Katherine E. Limoncelli a b

a,b,⁎

, Kevin T. Wolff

a,b

, Katarzyna Celinska

a,b

T

John Jay College of Criminal Justice, United States of America The Graduate Center, CUNY, United States of America

ARTICLE INFO

ABSTRACT

Keywords: Functional family therapy Missed sessions Parental problems Delinquency Treatment

Functional Family Therapy (FFT) is an evidence-based treatment intervention targeted toward justice-involved adolescents and their families. Prior research suggests that FFT is effective in treating delinquent tendencies, and may also be effective in improving family members' inner strengths, self-efficacy, and psycho-social functioning. While FFT has been demonstrated to reduce youth recidivism, less is known about the role parents may play throughout therapy and how parental problems (i.e., poor knowledge of the child's needs, or inadequate supervision of their child) impede successful treatment. Furthermore, the role of missed therapy sessions is often a neglected area of research, despite having a critical impact on treatment outcomes. Using structural equation modeling, this study explores the effect parental problems have on missed therapy appointments and treatment outcomes using a sample of 117 justice involved youth and their families who participated in FFT. Findings demonstrate that missed therapy sessions act as an important intervening variable between parental problems and therapy incompletion, where parental problems are directly related to missed sessions and missed sessions are directly related to the unsuccessful termination of treatment. Implications for FFT specialists are discussed.

1. Introduction The goal of Functional Family Therapy (FFT) is to employ cognitive behavioral strategies that target adolescent delinquency and family dysfunction through a manualized intervention overseen by a specially trained therapist (Alexander & Sexton, 2002; Sexton & Alexander, 1999; Sexton & Alexander, 2004; Sexton, Alexander, & Gilman, 2004). Youth and their families may be mandated to FFT, such as through Probation services, or be referred by another community agency. Through the engagement, behavioral change, and generalization stages of FFT, the goal of treatment is to ultimately improve prosocial behavior, individual self-efficacy, and communication skills, as well as increase supportive interactions with one another and practice respect for differences (Hartnett, Carr, Hamilton, & Sexton, 2017; Sexton, 2011; Thurston et al., 2015). The FFT intervention targets issues such as youth violence and substance use, but also addresses parental strengths and parenting abilities in order to improve family dynamics and maintain prosocial behaviors practiced throughout the course of therapy. FFT has demonstrated some success in reducing youth recidivism levels, diminishing problem behaviors, and improving family adjustment (Barnowski, 2002; Hartnett, Carr, & Sexton, 2016). Furthermore, the limited body of research has shown that parental guardians may express satisfaction with the FFT intervention, though more research is needed

⁎

regarding the experiences of youth themselves (Celinska, Cheng, & Virgil, 2015; Hartnett et al., 2016). While therapist fidelity to the treatment model is critical for FFT effectiveness, active participation and engagement from the participating parent(s) and adolescent are equally important. Furthermore, a gap in the literature remains as to the role parental issues play throughout the course of therapy and whether missed FFT sessions have a negative impact on therapy outcomes. Parental problems (i.e., poor knowledge, organization, or supervision abilities) and missed therapy appointments are important, yet frequently overlooked, aspects of therapeutic interventions involving youth and their families. Parental involvement and participation are key components of therapeutic interventions, such as cognitive-behavioral therapy (CBT), because empowerment and self-efficacy may be enhanced, thus improving child and family prognosis (Hartnett et al., 2017; Robinson, Strahan, Girz, Wilson, & Boachie, 2013). Poor parent functioning, on the other hand, may pose a significant barrier to effective treatment (Kerig & Alexander, 2012; Reyno & McGrath, 2006); though, this has not yet been assessed in the context of FFT. In addition, session attendance—especially with both parental guardians present—is associated with better child outcomes (Podell & Kendall, 2011). One of the strongest predictors of patient outcome demonstrated across extant literature thus far is session attendance (Tarrier,

Corresponding author at: John Jay College of Criminal Justice, 524 West 59th Street, New York, NY 10019, United States of America. E-mail addresses: [email protected] (K.E. Limoncelli), [email protected] (K.T. Wolff), [email protected] (K. Celinska).

https://doi.org/10.1016/j.childyouth.2019.104483 Received 9 May 2019; Received in revised form 27 August 2019; Accepted 27 August 2019 Available online 29 August 2019 0190-7409/ © 2019 Elsevier Ltd. All rights reserved.

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Sommerfield, Pilgrim, & Faragher, 2000; Xiao, Hayes, Castonguay, McAleavy, & Locke, 2017), and this is therefore deserving of further study within a FFT setting. However, current research on session attendance is limited to adult clinical samples, rather than justice-involved adolescents and their families who may be experiencing other life or behavior disturbances. The present study has important implications for practitioners involved in the juvenile justice system, family court, or family therapy. Understanding the relation between parental problems and treatment outcomes allows for clearer directives and guidelines to be set at the beginning of FFT. This can help maximize client participation, engagement, and understanding. Furthermore, this study assesses the importance of session attendance in a novel therapeutic setting involving justice-involved youth and their families. By taking into consideration the unique problems affecting family attendance, therapists can better target this intervention to families at risk of dropping out or failing to show up for multiple appointments, perhaps allocating the necessary resources to facilitate timely visits and ensure successful completion. Prior to discussing the results of our study, we outline the data and methods used to test these relationships. This study concludes with a discussion of the predictors associated with missed therapy appointments, as well as therapy-specific solutions that may enhance treatment attendance.

problem solving (Celinska, Sung, Kim, & Valdimarsdottir, 2018). Juveniles who participate in FFT with a therapist adhering strongly to the treatment model are significantly less likely to recidivate 12 months post-treatment than youth in a low-adherence group or control group (Sexton & Turner, 2010). Furthermore, therapists with larger caseloads and more experience working with difficult youth and families may achieve greater treatment fidelity (Turner, Robbins, Early, Blankenship, & Weaver, 2018). Children who participated in FFT also demonstrate significantly lower odds of recidivism than youth in individual therapy or mentoring across a range of offenses, including drug offenses, property offenses, and technical violations (Celinska et al., 2018), though this may be partially due to a general “therapeutic intervention” philosophy rather than one embodying control and discipline (Lipsey, 2009). While the quality of FFT therapists and fidelity to the treatment model is critical (Sexton & Turner, 2010), the motivation to participate in the intervention should arise from both the youth and his or her family. Hartnett et al. (2016) found that parents randomly assigned to participate in a FFT program in Ireland reported significant improvements in their child's problems after treatment, and both youth and their parents reported improved family adjustment (i.e., better communication and problem-solving skills). The importance of family participation has been explored across both qualitative and mixedmethods studies. For example, Celinska et al. (2015) compared FFT program perceptions with standardized therapeutic outcomes and found that parents reported greater satisfaction with FFT and FFT therapists than did youth, as well as greater engagement in the intervention, higher levels of trust in the therapist, and more positive discernments of family dynamic changes. However, to enhance treatment efficacy, FFT practitioners must work in partnership with family members, using collaborative language rather than dictating steps (McPherson, Kerr, Casey, & Marshall, 2017). From their work with adolescents in Scotland, McPherson et al., 2017 found that satisfaction with FFT alone does little to shed light on how families truly experience participation in therapy; rather, the dynamic intervention should stress the importance of feeling welcomed and able to easily contact the practitioner when needed. In addition, parental involvement may diminish if parents feel criticized or unsupported during the family therapy sessions (Haine-Schlagel, Brookman-Fazee, Fettes, BakerEriczén, & Garland, 2012). In analyses of gender and racial differences, some research demonstrates that female adolescents who received FFT may have lower recidivism rates than males, but that treatment for both genders is effective overall (Baglivio et al., 2014). Other research has not found a significant difference between genders on youth outcomes (Celinska & Cheng, 2017; Lipsey, 2009). While there is little evidence of FFT efficacy with racial/ethnic minority samples, Darnell and Schuler (2015) found that Latino and African American youth who received FFT, relative to comparison youth, had a significantly lower likelihood of an out-of-home placement (OHP) during the first two months following release from court-ordered OHPs; though, this effect disappears in later months. This line of research should be replicated, however, given that African American families are significantly less likely to receive quality mental health care than other racial or ethnic groups (AdkinsonBradley, 2011). Treatment model adherence is of paramount importance to FFT success, where specially trained therapists with high fidelity to the manualized treatment model facilitate improved outcomes for youth and their families (Sexton & Turner, 2010). In addition, the quality of therapy implementation has emerged as one of the major correlates of treatment effectiveness across juvenile interventions (Lipsey, 2009). While family members have reported positive experiences with FFT specifically (Hartnett et al., 2017), these positive perceptions may not hold as strongly for youth. Interestingly, Celinska et al. (2015) found that satisfaction with the FFT therapist was inversely related to the number of sessions for youth, suggesting that youth might benefit from

2. Literature review 2.1. Functional family therapy: background and scope Functional Family Therapy (FFT) is an effective, evidence-based intervention for at-risk adolescents and family members first developed in the 1970s (Alexander & Sexton, 2002; Celinska, 2015; Robbins, Alexander, Turner, & Hollimon, 2016; Sexton, Alexander, & Mease, 2003; Sexton & Turner, 2010). It is a manualized intervention combining systemic and cognitive-behavioral theories tailored to meet the unique needs of youth and their families, specifically related to cognitions, emotions, and relationships (Celinska, 2015; Robbins et al., 2016; Sexton & Alexander, 1999). The FFT clinical model consists of five components: engagement, motivation, relational assessment, behavioral change, and generalization (Alexander, Waldron, Robbins, & Neeb, 2013). FFT generally involves 12 to 14 sessions over a three-tosix month period (Kerig & Alexander, 2012; Thurston et al., 2015) and addresses concerns such as youth violence, substance abuse, and other antisocial or delinquent behaviors the youth demonstrates (Darnell & Schuler, 2015; Robbins et al., 2016; Sexton & Alexander, 1999; White, Frick, Lawing, & Bauer, 2013). FFT is generally targeted toward youth ages 11 through 18, and the treatment may take place in a community setting or the family home under the direction of a therapist specially trained in the program's delivery (Kerig & Alexander, 2012; Thurston et al., 2015). Preliminary evidence suggests that FFT is relatively effective in improving family members' inner strengths, self-efficacy, and psycho-social functioning (Baglivio, Jackowski, Greenwald, & Wolff, 2014; Hartnett et al., 2017; Marshall, Hamilton, & Cairns, 2018). The ultimate goal of treatment is to replace maladaptive behavior with greater reciprocal communication and respect for differences, eventually enabling the family to use their resources effectively and use skills they learned in therapy to prevent relapse (Alexander & Parsons, 1973; Thurston et al., 2015). Improved parent skill-sets include increased supportive interactions, greater supervision, and effective discipline (Marshall et al., 2018). It may also be a cost-effective intervention; for example, in Washington DC, FFT reduces arrests on average by 22.6%, and each prevented arrest subsequently saves local criminal justice agencies approximately $26,000 and federal agencies an estimated $6000 (Taxy, Liberman, Roman, & Downey, 2012). The effectiveness of FFT is well established within the United States, as well as internationally. FFT can aid in reducing recidivism and enhancing family communication, stressing the importance of family 2

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a shorter therapy dosage and should be provided with more opportunities to voice their opinions during treatment. Overall, parental involvement in FFT is important for the successful treatment of youth (Kerig & Alexander, 2012), as active family involvement elicits positive change benefitting the entire family unit, rather than the youth alone.

before or during the course of family therapy can help improve child outcomes (Cunningham & Henggeler, 1999; Ireland, Sanders, & MarkieDadds, 2003). Furthermore, the impact of parental problems on session attendance and therapy completion has not yet been considered in the context of FFT specifically.

2.2. Parental involvement in therapy

2.3. Missed therapy sessions and client outcomes

While adherence to a manualized FFT treatment model is essential, the role of parents and other key family members (i.e., siblings, grandparents) throughout the course of family therapy or parent management training is also vital (Kerig & Alexander, 2012; Shirk & Karver, 2003). Though much research on treatment efficacy is concerned with youth outcomes, less is known about the function of parents in either facilitating or hindering justice-involved youth and family success. Family members with problems such as substance abuse, poverty, or mental illness may prevent their adolescent child from recovering successfully (Reyno & McGrath, 2006) and may even result in premature dropout (Bagner & Graziano, 2012; Fernandez & Eyberg, 2009). High parenting demands and stressors are associated with increased conflict in the household and more punitive disciplinary practices (Haydicky, Shecter, Wiener, & Ducharme, 2015; Putnick et al., 2008; Webster-Stratton, 1990). In an evaluation of a mindfulness-based cognitive therapy for youth with ADHD and their parents, the parents reported reduced parenting stress and more mindful parenting (Haydicky et al., 2015). Specifically, mothers reported significant improvements in anger management, as well as an interest and awareness of their child's emotions, while the youth reported fewer conduct problems and issues with their peers (Haydicky et al., 2015). Effective family therapy also helps increase adolescent-parent relationships (Coatsworth, Duncan, Greenberg, & Nix, 2010; Haydicky et al., 2015). Parenting practices can significantly improve following therapy, which may subsequently improve parent-child relationships. However, parental involvement in therapy has become synonymous with maternal involvement (Podell & Kendall, 2011). In FFT, where both maternal and paternal issues may impact child conduct, neglecting the role of fathers over the course of “family” treatment constitutes a serious limitation. In a family CBT program for anxious youth, Podell and Kendall (2011) found that greater rates of session attendance with both parents, along with greater mother and father engagement, were associated with improved child outcomes. Furthermore, engaging both parents can increase feelings of empowerment and enhanced self-efficacy, which help parents take control of their child's condition and assist with recovery (Hartnett et al., 2017; Robinson et al., 2013). While gender differences do not seem to significantly affect FFT outcomes for youth (Celinska & Cheng, 2017), gender can still impact family relationships in vulnerable household settings (Montgomery, Chaviano, Rayburn, & McWey, 2016). Mothers and fathers may parent sons and daughters differently; girls may be more closely monitored and boys granted more independence (Montgomery et al., 2016). Family therapies should also consider the involvement of grandparents, as over 1.5 million children are estimated to live in grandparent-headed households without a biological parent present (Strong, Bean, & Feinauer, 2010). Families headed by grandparents may present their own unique needs and challenges hampering successful treatment, and uniquely tailored FFT programs must be able to address such concerns. In their assessment of children who participated in child psychotherapy, Haine-Schlagel et al. (2012) note that poor parent functioning may inhibit effective treatment if such needs are not properly addressed; though, parents with mental health issues or substance abuse, for example, may elicit greater attention and intensity of program delivery strategies from therapists. In addition, Haine-Schlagel et al. (2012) did not find a significant relationship between parent functioning and parental involvement. This differs from earlier literature, which suggests that addressing parent mental health problems

One of the most significant, yet frequently neglected components of therapeutic interventions is session attendance. Missed therapy sessions are often an overlooked feature of psychotherapy (Gans & Counselman, 1996), but should not be dismissed as trivial events. Missed sessions have both a time and financial cost (Xiao et al., 2017), involving both patients and therapists on matters such as responsibility, self-interest, and power (Gans & Counselman, 1996). A missed session occurs whenever a therapist, patient, or both do not meet at a scheduled time (Gans & Counselman, 1996). Some missed sessions are canceled sessions, which occur whenever a therapist or patient gives prior notice to the other regarding their inability or unwillingness to attend. Other missed sessions involve no-shows, and are frequently due to the patient's emotional state (Gans & Counselman, 1996). The effect of session nonattendance on client outcomes has been previously assessed among adult populations. For example, Tarrier et al. (2000) found that the number of missed therapy sessions, residential status, and co-morbid generalized anxiety disorder explained approximately 40% of the patient's treatment outcome within a sample of adult patients with PTSD. Furthermore, the strongest predictor of patient outcome was inconsistent attendance at therapy (Tarrier et al., 2000). Among a sample of adult psychotherapy clients, Xiao et al. (2017) found clients who “no-showed,” but not those who canceled, had a reduced rate of symptom change and that larger effects occurred before session three. Skule et al. (2017) further found that high dropout rates are a common occurrence among young patients, as well as those with personality disorders (see also Swift & Greenberg, 2012). Among youth and family samples, prior literature has demonstrated that mothers have greater session attendance and engagement ratings than fathers, and higher levels of attendance and engagement are subsequently related to better treatment outcomes (Lundahl, Tollefson, Risser, & Lovejoy, 2007; Podell & Kendall, 2011; Tully et al., 2017). Parents with boys tend to be more involved with therapy sessions than parents with girls (Haine-Schlagel et al., 2012), which is consistent with prior research demonstrating that parents with sons attended therapy sessions more often than parents with daughters (Israel, Thomsen, Langeveld, & Stormark, 2007). Missing several therapy sessions, as well as premature termination of therapy, poses significant challenges for adolescents with mental health problems (Branson, Clemmey, & Mukherjee, 2013). However, adolescents who receive text message reminders from their therapist have significantly higher rates of attendance as well as greater satisfaction with the therapist and intervention (Branson et al., 2013). While youth characteristics associated with treatment dropout include ethnic minority status, severe symptom presentation, ADHD, and conduct problems (Branson et al., 2013), less is known about parental characteristics impacting treatment failure in a FFT intervention. In the present study, we build on prior literature by investigating the effect of parental problems on missed therapy sessions, as well as the effect of missed sessions on unsuccessful termination of FFT treatment. Furthermore, we explore a potential direct association between parenting problems and unsuccessful therapy completion. 2.4. Hypotheses We hypothesize that: 1) Parental problems are directly related to missed sessions 2) Missed sessions are directly related to treatment outcomes 3

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3) Parental problems are directly related to treatment outcomes

3.2. Measures 3.2.1. Dependent measures In this study, we utilize two dependent variables to capture the impact parental problems may have during the course of FFT. The first measure, missed therapy sessions, is continuous and is measured as the ratio between sessions missed to all total sessions scheduled (missed sessions / sessions missed + sessions attended) for each case in our sample. The total number of sessions ranged from a minimum of 4 to a maximum of 40 (mean = 16.5, SD = 7.74), while the average proportion of sessions missed was 0.275, or just over one-quarter of sessions scheduled. The second dependent variable is dichotomous and captures whether treatment was unsuccessfully terminated prior to completion (coded “0” if no and “1” if yes). Of the analysis sample, a total of 26 youth (22%) terminated treatment prior to completion. For both of these measures, we used data collected by the therapists for each family unit during the 2005 to 2011 study period.

3. Data, measures, and analytic strategy 3.1. Data Data for this study were collected between the years 2005 and 2011 and came from Middlesex County, New Jersey. During the data collection period, a total of 140 youth enrolled in the Children at Risk Resources and Interventions– Youth Intensive Intervention Program (CARRI-YIIP) and participated in a Functional Family Therapy program. This group included youth referred to the CARRI-YIIP by Probation (36%), Family Crisis Intervention Unit (11%), Family Court (10%), and Divisions of Youth and Family Services (3.5%), among others. Fifty-two percent of the cases were mandated to participate in the FFT program. To be eligible, youth had to be between the ages of 11 and 17 and reside in Middlesex County. Youth also had to have past involvement with at least one of the following agencies: Family Court, Probation, County Youth Detention, Division of Youth and Family Services, and the Family Crisis Intervention Unit. Additionally, all youth had a history of risk factors for delinquent behavior, including incidents of aggression toward people and/or animals, the destruction of property, chronic truancy, violation of societal rules and norms, and/ or history of theft and deceit. Finally, youth had to have at least one ‘involved’ parent or guardian. Youth with serious mental health or substance abuse issues were ineligible to participate in FFT. From a full sample of 140 youth, 23 were excluded because of incomplete data, resulting in an analytic sample of 117 youth.1 Many of the measures included in the current study were drawn from the Strength and Needs Assessment (SNA), a revised version of the Child and Adolescent Needs and Strengths Assessment (CANS) (Lyons, 2009). Completed by a trained therapist, the SNA gauges clients' level of functioning across multiple life domains and assesses their strengths and risks to evaluate client’ progress. The SNA assesses seven main domains: (1) life domain functioning, (2) child strengths, (3) acculturation, (4) caregiver strengths, (5) caregiver needs, (6) child behavioral/emotional needs, and (7) child risk behaviors. Together, the caregiver strengths and caregiver needs domains—the main focus of this study—comprise 11 of the 55 total items (20%) (Celinska et al., 2018). Caregiver strengths refer to parents' involvement with their children as well as the degree of household stability, while caregiver needs encompass mental or physical health problems. The SNA has been used in past research on clinical assessment as well program evaluation (Lyons, 2009; Celinska et al., 2013; Celinska et al., 2018), and exhibits adequate construct and predictive validity as well as interrater reliability (Anderson & Estle, 2001; Anderson, Lyons, Giles, Price, & Estle, 2003; Lyons, 2009; Lyons, Weiner, & Lyons, 2004). In addition, data on session attendance and outcomes were taken from the Services Tracking Form (STF), an instrument that tracks the number of therapy sessions, time spent in therapy, and referral information. This 3-page long instrument was developed in cooperation with FFT therapists. Therapists filled out STF together with the SNA. One part was completed before the therapy started and the second component was completed after the therapy ended. STF includes questions on referral sources, intervention logistics (such as number of sessions, number of missed sessions, number of sessions in the first phase, etc.) and the therapists' ratings of their clients.

3.2.2. Key independent measures We use individual items from the SNA to measure the strengths and challenges experienced by the youths' caregivers at the time treatment began. Below is a description of the measures used in the current study. All variables reflect the state of the caregiver over the 30 days prior to the initiation of treatment. Key parental problem variables derived from the “strengths” portion of the SNA include supervision, involvement, knowledge, organization, social resources, and residential stability. Supervision is a measure of child monitoring and discipline skills, distinguishing those parents with good monitoring and discipline skills (=0), those who have adequate skills but occasionally need help or assistance (=1), and those with moderate to severe difficulties monitoring or disciplining their child (=2). Involvement refers to the adult caregiver's ability to act as an effective advocate for their child. It differentiates among those caregivers who can act effectively as advocates (=0), those who are open to seeking help and information for their children (=1), and those who do not wish to participate in services or who wish for the child to be removed from their care (=2).2 Knowledge indicates the caregiver's awareness of the child's needs and strengths, and distinguishes parents who are knowledge about these domains (=0) from those who are generally knowledgeable but require additional information (=1) and those who have a moderate to severe lack of information that may lead to negative outcomes for the child (=2). Organization is a measure of how organized and efficient the caregiver is in their household. It distinguishes between caregivers who are well organized and efficient (=0), those who have minimal difficulties including forgetfulness (=1), and those who have moderate to severe difficulty organizing and maintain their household to support needed services (=2). Social Resources refer to social networks that assist in raising or rearing the child, distinguishing among guardians who have significant and active family/friend networks (=0), those who have some family/friend networks actively engaged (=1), and those who have little to no social network that can help with raising the child (=2). Finally, Residential Stability connotes stable housing. Scores differentiate between those caregivers who have stable housing for the foreseeable future (=0), those who have relatively stable housing but have moved in the last three months (=1), and those who have moved multiple times in the past year and/or experienced recent homelessness (=2). 2 A total of four youth had parents who indicated that they did not wish to participate in services or wished for their child to be removed from their care (coded 2 in the current analysis). Further examination of these four cases revealed that all four of them were mandated to treatment and that none of them left FFT treatment without completing the course of treatment satisfactorily. The full model was re-estimated with these cases removed and the substantive conclusions remained unchanged.

1

In order to assess whether those youth who were excluded were different from the retained youth, t-tests were conducted to test for differences across all included measures. No differences between the analysis sample and the full sample were found in terms of demographics or risk/needs assessment scores, suggesting that the analysis sample is more-or-less representative to the original sample. 4

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Potential parental problems derived from the “needs” portion of the SNA include physical, mental health, substance use, developmental, and safety needs. Physical needs measure general health, categorized as the caregiver being generally healthy (=0), is in recovery from some medical/physical problems (=1), and has medical/physical problems that interfere or make it impossible to parent effectively (=2). Mental Health is a measure of any mental health difficulties, categorized as no mental health needs (=0), in recovery for some mental health issues (=1), and the presence of mental health concerns that interfere or make it impossible to parent the child (=2). Finally, Substance Use is a measure of whether the caregiver has any substance use difficulties (coded 0–2), with higher values indicating more severe difficulties that interfere with their capacity to parent.3

estimated is shown in Fig. 1. Prior to our multivariate assessment, Spearman's rank correlations were utilized to explore the relationships present between the key variables used in the analysis. In addition to assessing the possibility of collinearity issues, these bivariate relationships provide preliminary evidence of proposed relationships between parental problems and youth outcomes (missed therapy sessions and treatment outcomes). Importantly, Spearman's rho is a nonparametric measure of correlation, a more appropriate statistical measure of association than the traditional Pearson's correlation coefficient given the categorical nature of many of the measures included in the current study. Following our bivariate analysis we assess the relationship between parental problems and missed therapy sessions as well as the effect of both on treatment outcomes using structural equation modeling. Our hypothesized model is shown in Fig. 1. As can be seen in the figure, we are interested in the potential of parental problems to impact treatment failure due to their impact on missed therapy sessions. The traditional requirements for mediation include a significant effect of the predictor on the presumed mediator and on the distal outcome, a significant direct effect of the mediator on the outcome, and a significant indirect effect of the predictor on the outcome via the mediator (Judd, Kenny, & McClelland, 2001; MacKinnon & Dwyer, 1993). However, it has been argued that this approach can be too restrictive due to low statistical power (e.g., MacKinnon, Lockwood, Hoffman, West, & Sheets, 2002). Accordingly, it has been suggested that researchers consider approaches that focus on the joint significance of the paths between the predictor and mediator and from the mediator to the outcome. In the absence of a direct effect of the predictor on the outcome, MacKinnon et al. (2002) refer to hypothesized mediators as intervening variables rather than as mediators in the traditional sense. Accordingly, in the current study, if we were to find a direct effect of parental problems on therapy outcomes, we would consider missed sessions a mediating variable. However, if a direct effect between parental problems and therapeutic outcomes is not observed, we would consider missed sessions an intervening variable. Intervening variables are those which are affected by the independent variable that can, in turn, impact the focal outcome and thus are theoretically and substantively meaningful even in the absence of a statistically significant direct effect (Sandler, Schoenfelder, Wolchik, & MacKinnon, 2011). Finally, the current study employs a bootstrapping process to test for an indirect effect of parental problems on therapeutic outcomes through its impact on missed therapy sessions. Developed by Hayes and Preacher (2010), bootstrapping is a nonparametric resampling procedure, and involves repeatedly sampling from the full data set in order to generate a sampling distribution for each of the obtained results. Created by extracting 5000 bootstrap draws, a sampling distribution of the indirect effect, complete with a confidence interval, can be obtained. A confidence interval that does not include zero provides evidence of a significant indirect effect (Hayes, 2009). Past research has demonstrated this method is superior to Baron and Kenny's (1986) mediation tests when analyzing a dichotomous outcome because it does not assume that the sampling distribution of the indirect effect is normally distributed. The fit of the SEM model was evaluated using a number of fit indices including the root mean square error of approximation (RMSEA), comparative fit index (CFI), and the Tucker Lewis Index (TLI).

3.2.3. Control variables In order to rule out the any potentially spurious relationship between parental measures and our outcome variables, we control for a number of youth characteristics that could impact missed sessions or the termination of treatment. In addition to demographic measures (age, race, sex), we control for issues related to school achievement, oppositional behavior, conduct problems, and substance abuse. Each of these measures was drawn from the strengths and needs assessment. School problems is a measure of how the youth was doing in school at the time treatment began, categorized as the child is doing well, the child is doing adequate although problems exist, or the child having moderate or severe problems at school (coded 0–2), with higher values indicating a greater extent of school-related problems. Oppositional behavior is a measure of defiant behavior toward authority figures and distinguishes those with no problems (=0), from those with a history or minor problems (=1) and those with clear or dangerous oppositional behavior (=2). Conduct problems is a measure of antisocial behavior coded in a similar fashion (0–2), with higher levels indicating more severe conduct issues. Finally, Substance use differentiates between youth with no evidence of substance use (=0) from those with a history or suspicion of substance use (=1) from those with clear evidence of substance use that is causing issues for the youth (=2). 3.3. Analytic strategy The current analysis uses a combination of statistical approaches to examine the relationship between parental problems, missed therapy sessions, and treatment outcomes. Given the uncertainty surrounding the structure of our parental problems construct, an exploratory factor analysis (EFA) was performed in order to examine the relationships present between our hypothesized latent construct (parental problems) and each of its measured indicators drawn from the SNA. Results of this analysis suggested that a total of four factors should be retained. Specifically, while the measures of parental involvement, knowledge, organization, resources, and supervision were all seen to load significantly on a single factor, parental mental health, substance abuse issues, as well as problems with residential stability, were distinct. For that reason, these three measures were included in the models described below as separate indicators in addition to the latent variable we refer to as parental problems. Once the factor structure was confirmed, we tested a predictive measurement model in which missed therapy sessions was included as an intervening variable between the background predictive variables (parental problems, youth demographics and youth characteristics) and unsuccessful termination of treatment. A simplified version of the structural equation model

4. Results 4.1. Descriptive results Descriptive statistics for all measures included in the current analysis are provided in Table 1. The mean age of youth included in the analysis was 15.6 (SD = 1.65), 31% were Non-white, and just over half of the sample was male (56%). Around one-fifth (22%) of youth terminated treatment unsuccessfully, and the average proportion of

3

Importantly, the SNA also includes measures of the caregiver's developmental and safety needs. However, these measures observed did not load on our latent measure of parental problems, nor were they significantly related to either outcome of interest. For that reason they were excluded from the present analysis. 5

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Parental Risks and Needs Involvement

Knowledge Organization

Parental Problems

Missed Sessions

Resources

Unsuccessful Termination of Treatment

Supervision Mental Health Substance Abuse

Residential Stability Fig. 1.

unrelated to unsuccessful termination of treatment. Finally, of the youth characteristics considered, issues at school were positively associated with missed therapy sessions (rho = 0.236, p < .05) and the termination of treatment (rho = 0.226, p < .05).

Table 1 Descriptive Statistics for the Analysis of Parental Problems and FFT. Dependent variable

Mean

SD

Min

Max

Termination of treatment Key mediating variable Ratio of missed to attended sessions

0.22

–

0

1

0.276

0.195

0

1

Key independent variables Parental problems (Latent) Parental involvement Parental knowledge Parental organization Parental resources Parental supervision Parental mental health problems Parental substance abuse Parental residential stability

0.551 0.856 0.466 0.839 1.076 0.322 0.093 0.144

0.564 0.631 0.609 0.762 0.764 0.521 – 0.376

0 0 0 0 0 0 0 0

2 2 2 2 2 3 1 2

Youth control variables Sex (Male = 1) Age at referral Black (=1) Hispanic (=1) School problems Oppositional behavior Conduct problems Youth substance use

0.568 15.589 0.322 0.271 1.102 1.322 0.602 0.576

– 1.649 0.469 0.446 0.841 0.715 0.642 0.633

0 10.22 0 0 0 0 0 0

1 18.71 1 1 2 2 2 2

4.3. Structural equation modeling Table 3 presents the results of the fully-specified structural equation model examining the effects of parental problems on therapeutic outcomes. The Root Mean Square Error of Approximation (RMSEA) for the final model was 0.57 (90% CI: 0.00–0.126), the Comparative Fit Index (CFI) was 0.983, and the Tucker- Lewis Index (TLI) was 0.966. Generally accepted cutoff values for these indices are values less than or equal to 0.06 for the RMSEA and greater than or equal to 0.95 for both the CFI and TLI (Hu & Bentler, 1999). With this in mind, the developed model appears to fit the data adequately. As seen in Table 3, the bivariate associations observed above were replicated in the multivariate analysis controlling for all aforementioned demographic and youth-level characteristics. Although parental problems did not have a direct effect on treatment failure (B = −0.259, CI [−0.780, 0.407]), higher values on this latent variable were associated with a greater proportion of missed sessions (B = 0.074, CI [0.024, 0.154]), which in turn was related to the termination of treatment (B = 3.653, CI [2.203, 4.766]). This suggests that missed sessions plays an intervening role in the relationship between parental problems and treatment outcomes. Youth whose parents who are experiencing more challenges missed a greater proportion of therapy sessions, and thus are more likely to terminate their treatment unsuccessfully. In addition, parental substance abuse was significantly related to missed sessions (B = 0.141, CI [0.034, 0.251]), although there was no evidence of an effect on the termination of treatment. Parental residential stability was also significantly related to missed sessions (B = 0.132, CI [0.059, 0.221]), but not treatment termination. Finally, youth having more problems in school missed a greater number of therapy sessions (B = 0.066, CI [0.025, 0.104]) and were more likely to terminate treatment unsuccessfully (B = 0.454, CI [0.015, 0.924]). The implications of these results for both research and practice are discussed below.

missed to total sessions was 0.276 (SD = 0.195). 4.2. Bivariate analysis Table 2 presents the bivariate associations between each of the measures utilized in the current study. Of the variables included in the present study, only a handful was significantly associated with the outcomes of interest. Unsurprisingly, the distal outcome (termination of treatment) was positively associated with the ratio of missed-to-total sessions (rho = 0.459, p < .05). In addition, our composite measure of parental problems was positively and significantly associated with the ratio of missed sessions (rho = 0.294, p < .05), but was unrelated to treatment termination (p > .05). Parental substance abuse was also significantly related to both missed sessions (rho = 0.269, p < .05) and treatment termination (rho = 0.181, p < .05) in the anticipated direction. Parental residential stability was also significantly related to the number of missed sessions (rho = 0.294, p < .05), but was 6

Children and Youth Services Review 106 (2019) 104483

Outcomes

Predictors

B

95% CI

Missed sessions

Parental problems (Latent) Parental mental health problems Parental substance abuse Parental residential stability Sex (Male = 1) Age at referral Black Hispanic School problems Oppositional behavior Conduct problems Youth substance use Missed sessions Parental problems (Latent) Parental mental health problems Parental substance abuse Parental residential stability Sex (Male = 1) Age at referral Black Hispanic School problems Oppositional behavior Conduct problems Youth substance use

0.074*

[0.024–0.154]

−0.042

[−0.119–0.023]

0.141*

[0.034–0.251]

0.132*

[0.059–0.221]

0.039 0.010 0.010 −0.073 0.066* 0.012 −0.025 −0.017 3.653* −0.259

[−0.040–0.117] [−0.022–0.042] [−0.085–0.094] [−0.158–0.002] [0.025–0.104] [−0.037–0.061] [−0.078–0.036] [−0.079–0.040] [2.203–4.766] [−0.780–0.407]

0.234

[−0.365–1.003]

0.199

[−1.102–1.266]

0.261

[−0.427–1.001]

−0.19 0.194 0.123 −0.028 0.454* −0.379 −0.038 −0.214

[−0.826–0.395] [−0.056–0.437] [−0.554–0.842] [−0.947–0.752] [0.015–0.924] [−0.868–0.133] [−0.564–0.446] [−0.686–0.315]

1 −0.1048 −0.1037 0.1676 −0.0286 1 0.1291 0.1859⁎ 0.3031⁎ 0.3571⁎ −0.0065 0.1314 1 −0.1956⁎ 0.1831⁎ −0.1052 0.0209 −0.0081 −0.0039 −0.0347 −0.0645 −0.0684

1 0.1955⁎ 0.1266 0.2759⁎ 0.1566 0.0574 0.1003 −0.055

1 0.1789 −0.0199 0.0803 −0.0848 −0.1293

1 0.1428 0.0128 0.0432

1 −0.0241 0.3254⁎

1 0.1262

1

Table 3 Assessing effect of parental problems on treatment outcomes.

Unsuccessful termination of treatment

Boot strapping analyses was conducted with 5000 resamples; Standardized Effects Shown; * p < .05; RMSEA = 0.057; TLI = 0.966; CFI = 0.983.

5. Discussion Clinical studies have found that parental guardians play a vital role in family therapy interventions, but this role had not been assessed in the context of FFT. The purpose of this study was to assess the association between parental problems and FFT therapy outcomes (i.e., failure), as well as parental problems and missed therapy appointments. In addition, we examined the association between missed sessions and treatment failure. The findings in this study demonstrate that parental problems, such as lack of knowledge, involvement, or supervision, can contribute to treatment failure through their effect on missed therapy sessions. We found that adolescents who started therapy with parental guardians with few strengths (or, more weaknesses), as measured by the Strengths and Needs Assessment, missed a greater proportion of FFT sessions. In the structural portion of the model, parental substance abuse and residential stability (or, lack thereof) were also significantly related to missed therapy sessions, as was poor student academic attainment. While the parental problems construct was not directly related to treatment termination, the ratio of missed sessions and the youth characteristic of school problems were both significantly related to treatment failure. Future research should consider how parental problems, missed sessions, and early termination of FFT affect longerterm treatment outcomes. The significant and direct relationship between the role of parental problems on missed sessions, along with the significant relation between parental substance abuse and missed sessions, had not previously been assessed within FFT. A lack of parental supervision or awareness has previously been linked to poorer child outcomes (McEvoy & Welker, 2000) and the relation between these variables has been clearly outlined in theoretical frameworks (see Hirschi, 1969). For our sample of participants, it may be that those guardians who are actively dealing

p < .05. p < .01. ⁎⁎

⁎

Missed Sessions Unsuccessful termination Sex (Male = 1) Age at referral Black Hispanic Other/mixed Race School problems Oppositional behavior Conduct problems Youth substance use Parental problems Parental MHP Parental substance abuse Parental residential stability

1 0.4591⁎ 0.1203 0.0736 0.0272 −0.0983 −0.0402 0.2356⁎ 0.1291 −0.0728 0.0498 0.2937⁎ −0.0042 0.2688⁎ 0.2935⁎

1 0.0098 0.1318 0.0274 −0.0483 0.0405 0.2265⁎ −0.0548 −0.0405 0.0369 0.006 0.044 0.1812⁎ 0.1447⁎⁎

1 0.2052⁎ −0.0943 −0.0065 −0.0145 0.0653 0.0535 0.1544 0.1832⁎ 0.006 0.0141 −0.0145 −0.0013

1 0.086 −0.1371 0.0603 −0.0388 0.0635 0.0555 0.3525⁎ −0.0134 −0.0407 0.0068 −0.1173

1 −0.4204⁎ −0.2210⁎ −0.2576⁎ −0.0233 0.0575 0.0167 −0.1188 −0.093 0.0285 0.0947

1 0.0684 0.1057 −0.2168⁎ 0.0306 0.131 −0.0241 −0.1028 0.0418

11 9 8 6

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Table 2 Bivariate correlations.

1

2

3

4

5

7

10

12

13

14

15

K.E. Limoncelli, et al.

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K.E. Limoncelli, et al.

with the ramifications of substance abuse or dependence are also more likely to miss therapy sessions with their child and terminate treatment prematurely. Skule et al. (2017) found a significant relation between greater alcohol use and the count of missed therapy sessions among a sample of adult group psychotherapy patients, while other factors such as levels of depression, demographic factors, or the type of treatment service were not related to session attendance. While Slesnick (2001) failed to find a relationship between level of substance abuse and treatment attendance, their sample was limited to adolescents only. Our findings shed light on the critical role of family members within the therapeutic treatment of justice-involved youth. The onus of treatment attendance cannot be placed solely on adolescents. Missed sessions were significantly and positively related to treatment failure. This finding is consistent with prior research, but had not yet been observed in the context of FFT. Current scholarship on missed sessions and treatment dropout has primarily been limited to adult samples who participated in dialectical behavior therapy (DBT), treatment for PTSD, or general psychotherapy, though there is a growing body of research exploring treatment dropout among youth with externalizing disorders. Rusch et al. (2008) found that women who failed to complete DBT were angrier and more anxious than completers. In addition, Landes, Chalker, and Comtois (2016) found that DBT patients who are younger in age, evidence greater distress levels, and who demonstrate an inability to accept their emotional responses at baseline were more likely to drop out of treatment. Given that multiple parties are involved in the FFT setting (i.e., children and their family members), children or guardians possessing these traits at the beginning of treatment may also be more likely to miss sessions or drop out of therapy. In other therapeutic settings, Tarrier et al. (2000) found that the number of missed therapy sessions was the strongest predictor of treatment outcomes for adults with PTSD. Therapy “no-shows” also negatively impact symptom change, and these effects are largest before the third session (Xiao et al., 2017). This finding is critical, given that the first few sessions of FFT are focused on treatment engagement and goals. Early treatment stages in therapy, such as DBT or FFT, are an important foundation for establishing treatment goals, engagement, and commitment expectations with clients posing multiple problems (Coyle et al., 2019). Limited research has focused on barriers to success in family therapy for children with externalizing disorders and developmental delays. Bagner and Graziano (2012) found that minority status and family structure predict treatment dropout, while maternal education status predicts therapeutic outcome. In addition, Fernandez and Eyberg (2009) found that problems such as maternal distress and lowered maternal intellectual functioning are related to treatment dropout. Altogether, these insights are important for treatment providers and other criminal justice professionals involved in juvenile or family court, especially since these factors shed light on both individual-level and cumulative-level risk factors of session nonattendance and treatment failure. For FFT specifically, it remains critical that therapists clearly outline what is expected throughout the course of therapy, work together with the clients to clarify their goals for treatment, address potential barriers to treatment at the parent-level, acknowledge the adolescent's autonomy, and ensure that all parties are engaged in treatment and understand how to achieve success in therapy (Coyle et al., 2019). The role of academic attainment, measured here as low school achievement, was significantly associated with both missed sessions and treatment failure. This was the sole youth-level factor significantly related to both missed therapy and termination. Previous research has made similar connections. For example, academic failure is often correlated with antisocial behavior, and low school achievement can predict misconduct independent of socioeconomic status and program interventions (McEvoy & Welker, 2000). In this regard, academic failure may moderate the relationship between youth-level factors and perpetual delinquency, which may play a role in not only missed sessions, but also failing out of treatment. Furthermore, family members play a

vital role in not only therapy, but also in their child's schooling. According to Kearney (2008), broader family and household factors such as poor cohesion, low supervision, high conflict, a sense of detachment, and a lack of support are risk factors for increased school absenteeism. It may be that these same factors translate to a therapeutic setting as well, resulting in missed therapy sessions. Future research should consider the role of delinquent peers as a potential moderator and how their influence translates to therapy, especially since youth academic attainment is significantly related to treatment outcomes. One limitation of this study is the inability to determine whether the parental guardian attending FFT was male or female. Given that previous research has demonstrated that mothers attend therapy more often and exhibit greater treatment engagement than fathers (Lundahl et al., 2007; Podell & Kendall, 2011; Tully et al., 2017), future research should consider treatment outcomes based on the gender of the parent who most often attended. It may be that treatment dropout is more common among families who have a father or father figure attending treatment sessions, especially since fathers' beliefs surrounding therapy as “mother-focused” may pose as a key barrier to successful intervention (Sicouri et al., 2018). Since clinical treatment outcomes for children with externalizing disorders are greatest for families in which both parents attend (Lundahl et al., 2007; Tully et al., 2017), a better understanding of how caretaker gender influences FFT outcomes is warranted. In addition, potential mechanisms by which positive perceptions of therapy are associated with improved therapy outcomes should be further explored in the context of FFT. A second important limitation of this study is the lack of information regarding therapeutic alliance, or the quality of the relationship between the therapist and family members/youth, as well as treatment fidelity. The effect of therapeutic alliance on treatment outcomes is well established across mental health treatment research. Factors associated with poor treatment alliance include clients' negative attitudes to treatment, self-reported depression, and living situations (Barrowclough, Meier, Beardmore, & Emsley, 2010). While substance abuse was not found to be related to alliance (Barrowclough et al., 2010), it may be that the effect of substance abuse on missed sessions results in poorer treatment outcomes. In addition, given that FFT involves both children and their families together as clients, differing opinions regarding therapist helpfulness and perceptions of collaboration (Bachelor, 2013) may impact attendance rates and treatment outcomes. In addition, while fidelity to the model was assured by onand off-site supervision provided by a FFT consultant, this study did not factor in a fidelity measure in the analysis, nor an assessment of therapist adherence to the model and how this may have affected the incidence of missed sessions and treatment dropout. Future research should take into consideration fidelity measures as a key predictor of both missed sessions and treatment outcome. Finally, a third limitation of this study is its small sample size. This small sample was also limited to a single county in New Jersey and, thus, findings may not be generalizable to justice-involved families in other states. The small sample size also precludes a large number of predictors, since including additional predictors may overload the model. Future research on this topic should consider a larger sample size to increase the statistical power of the study, as well as perhaps incorporate a multi-site approach for state or even county-level comparison purposes. 6. Conclusion The goal of FFT is to address youth concerns such as delinquent activity and substance abuse, while simultaneously working together with both the child and their family to enhance communication skills, replace maladaptive behaviors with more prosocial ones, and increase parental self-efficacy and problem-solving capabilities. While FFT aims to reduce youth recidivism and household conflict, the success of this therapy relies on family engagement and motivation. While much 8

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research has placed a focus on youth-level factors impeding successful therapy completion, this research sheds light on family concerns as well. Premature therapy discontinuation is a significant problem, and high dropout rates are a result of poor session attendance. Most important, problems such as poor organization, supervision, and knowledge are associated with increased session nonattendance, and this subsequently has an impact on treatment outcomes. In addition, some families deal with economic challenges and have limited time or resources. The implications of this research extend to FFT therapists and clinicians, as well as FFT administrators or supervisors, should take steps to ensure that families are able to come for their therapy sessions. For example, the therapy could be conducted either at clients' home or in a place close to the clients' home. The therapy hours could be adjusted to fit parents' schedules. Celinska et al. (2013) conducted nearly 150 exit interviews with parents and youth who participated in FFT. They found that logistical issues were the most challenging, potentially impeding families' regular participation. Nearly 20% of parents complained about unreliable transportation, therapy location, and inconvenient therapy session times. Some also mentioned that first sessions were emotionally taxing and that siblings were excluded from participation. Those parental concerns should be addressed a priori, before therapy sessions begin. Otherwise, the therapists and clinicians might be missing those families that need assistance the most.

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