Intervention Summary

Family Behavior Therapy

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

Descriptive Information

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

Quality of Research

Documents Reviewed

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

Study 1

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

Study 2

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

Study 3

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

Study 4

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

Supplementary Materials

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

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

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

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

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

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

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

Family Behavior Therapy Modules 1-8

Outcomes

Outcome 1: Drug use
Description of Measures	Illicit drug use was measured by urinalysis, self-report, and family member reports. In most studies, Timeline Followback methods were used for self-reports and family member reports.
Key Findings	Three randomized controlled trials showed reduced illicit drug use among FBT participants. A 12-month trial with youth and adults showed that FBT clients were significantly less likely to report using any illicit drugs than supportive therapy clients in months 2 through 12 of treatment (p < .001). At the end of treatment, the average number of days of use each month was 2.1 for FBT clients, compared with 5.4 for supportive therapy clients (p < .02). At an average of 9 months after treatment termination, 71% of supportive therapy clients were using illicit drugs, compared with 42% of FBT clients (p < .02). In a study of 26 youth, drug use decreased 73% over 6 months of treatment for those in FBT but did not change among those in supportive therapy (p < .02). A study of youth with conduct disorder compared FBT with individual cognitive therapy. Both samples significantly decreased substance use from an average of 14 days per month to 9 days per month over 6 months of treatment (p < .001). Six months after treatment completion, both groups used drugs about 8 days per month, on average (p < .005).
Studies Measuring Outcome	Study 1, Study 2, Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	2.9 (0.0-4.0 scale)

Outcome 2: Alcohol use
Description of Measures	Alcohol use was measured by self-reports and other measures. In most cases, Timeline Followback methods were used.
Key Findings	In a randomized controlled trial of adults and youth, adult FBT clients decreased frequency of alcohol use by nearly 50%, from an average of 7 days per month to 3.8 days per month over 12 months of treatment, while frequency of alcohol use did not change for those in supportive therapy (p < .001). Youth participating in FBT decreased alcohol use from an average of 2.2 to 1.5 days per month over 6 months of treatment, while those in supportive therapy increased use from an average of 3.2 to 4.5 days per month (p < .05). In a study of youth with conduct disorder, neither FBT nor individual cognitive therapy affected alcohol use.
Studies Measuring Outcome	Study 1, Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 3: Family relationships
Description of Measures	Family relationships were measured using the Marital/Couple Happiness Scale, the Parent Satisfaction Scale, and the Youth Satisfaction Scale, which ask respondents to report satisfaction with family members and marital relationships on a scale from 0 to 100 percent.
Key Findings	In a sample of youth who used substances, parents' mean satisfaction with youth in FBT increased 30% from pre- to posttreatment, while parents' mean satisfaction with youth in supportive counseling did not change. In a study of youth with conduct disorder, parents' mean satisfaction with youth increased nearly 30% from pre- to posttreatment (p < .001). Youth mean satisfaction with parents increased approximately 11% from pre- to posttreatment (p < .001). Changes in the conduct-disordered youth sample were similar to changes observed in a comparison sample of youth receiving individual cognitive therapy. In another study with a sample of adults, significant changes in marital happiness were not observed.
Studies Measuring Outcome	Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	2.8 (0.0-4.0 scale)

Outcome 4: Depression
Description of Measures	Depression was measured with the Beck Depression Inventory.
Key Findings	In a sample of youth and adults, depression decreased more in FBT participants compared with participants in a nonbehavioral intervention. Beck Depression Inventory scores dropped from an average of 17.9 to 7.2 for FBT participants and from 13.5 to 8.9 for clients in supportive therapy (p < .01). Among youth who used substances, Beck Depression Inventory scores decreased significantly in FBT participants but not in supportive therapy clients. However, supportive therapy clients were also less depressed pretreatment (mean score = 6.5) compared with the FBT clients (mean score = 15.2). Posttreatment, the average score for FBT clients was 5.5, compared with 6.5 for supportive therapy clients (p < .05). Scores among the youth with conduct disorder dropped to a subclinical level of depression posttreatment (p < .001). Posttreatment levels were maintained at 6-month follow-up. Changes in the FBT sample were comparable to those for clients in individual cognitive therapy.
Studies Measuring Outcome	Study 1, Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	3.2 (0.0-4.0 scale)

Outcome 5: Employment/school attendance
Description of Measures	Days employed or attending school were measured by self-report on the Timeline Followback Interview.
Key Findings	In a study of youth and adults, the mean percentage of days employed or in school over the past month increased from 52.2% to 73.6% among FBT clients and decreased slightly from 67.8% to 64.5% among supportive therapy clients (p < .001). Among youth who used substances, mean school/work attendance increased from 50.2% to 65.4% for FBT clients, while it decreased from 79.5% to 68.4% among supportive therapy clients (p < .05). Multiple measures of work and school attendance showed improvement for youth with conduct disorder who participated in FBT. Average hours worked per month over the last 6 months increased from 6.38 to 16.71 (p < .01), a change comparable to that observed for youth in individual cognitive therapy.
Studies Measuring Outcome	Study 1, Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 6: Conduct disorder symptoms
Description of Measures	Conduct problems were measured by standardized behavior checklists, self-report, parent reports, and arrest records.
Key Findings	Among youth who used substances, the mean number of problems reported on the Quay Problem Behavior Checklist decreased from 22.5 to 14.3 for those in FBT but remained essentially unchanged for those in supportive therapy (p < .05). Multiple measures of conduct problems showed significant pre- to posttreatment improvements in youth diagnosed with conduct disorder. Average scores on the Achenbach Child Behavior Checklist decreased from 74.44 to 63.55. Posttreatment improvement was maintained at 6-month follow-up. Improvements observed in FBT clients were similar to those observed for clients in individual cognitive therapy.
Studies Measuring Outcome	Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	2.9 (0.0-4.0 scale)

Study Populations

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

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

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

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

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

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

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

Study Strengths

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

Study Weaknesses

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

Readiness for Dissemination

Materials Reviewed

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

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

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

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

Family Behavior Therapy handouts and forms:

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

Family Behavior Therapy interventions:

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

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

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

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

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

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

Dissemination Strengths

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

Dissemination Weaknesses

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

Costs

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

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

Additional Information

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