Sweden

Last updated : 29.11.2024
Country of origin
USA
Last reviewed:
Age group
0-5 years
6-10 years
11-14 years
15-18/19 years
Target group
Families of Children with Conduct Problems
Programme setting(s)
Family
Level(s) of intervention
Indicated prevention

The Family Check-Up (FCU) is a parent management training (PMT) intervention targeting parents of children with conduct issues. The intervention focuses on enhancing specific parenting skills and is part of the second generation of parent training programs designed to reduce externalizing behaviour problems, substance use, and child depression. 

FCU is based on the Oregon PMT model but has been designed to be ecologically more valid as it is tailored to the needs and motivation of families, grounded in a structured assessment and feedback phase during the first three sessions. Essential elements of the intervention include a norm-referenced assessment, an observational session with the parent and child and a feedback session delivered using motivational interviewing.

The FCU begins with an assessment phase that evaluates family strengths and risks, summarized in a family profile used for feedback. This phase includes three sessions: a brief interview and introduction to the model, a recording of interactions between a parent and the child in specific situations and a feedback session to discuss the family profile. The next phase involves tailored interventions based on the family’s needs and motivation. Parent training interventions, categorized into three skill areas: supporting positive behaviour, setting healthy limits and building family relationships are suggested and selected based on the needs and motivation identified during the feedback session. In an extended clinical context, other available evidence-based interventions can also be considered.

Ghaderi et al. (2018) conducted a study in Sweden to evaluate the effectiveness of the Family Check-Up (FCU) in a randomized controlled trial. They compared a group that received the FCU intervention with a group that received the internet-based parent-training program iComet. The study involved 231 families with children aged 10-13 who exhibited conduct problems. The primary aim was to assess and compare the outcomes of these interventions, with follow-ups at 1 and 2 years post-treatment
 

Links to this programme in other registries
Early Intervention Foundation (UK)
Blue Prints
Contact details

Alyssa Schneider
PO Box 5175 Eugene, OR 97405. 415-685-0023
Alyssa[at]nwpreventionscience.org
 

Show link
0
Evidence rating
Possibly beneficial
Studies overview

Ghaderi and colleagues’ main research goal was to compare the effects of FCU to iComet for children and adolescents (10–13 years old) with conduct problems, on externalizing behaviours, social adaptation, family conflict and warmth, and general psychological health, as reported by themselves, their parents and teachers. They found that both FCU and iComet showed short- and long-term effects on the main outcome variables. For conduct problems, the short-term effect size was large (d = 1.10, p = 0.001) and showed a significant interaction effect (d = 0.30, p = 0.02) in favor of the Family Check-Up compared to iComet. Inattention showed moderate short-term effect sizes (d = 0.58, p = 0.001) with no significant interaction. For impulsivity/hyperactivity problems, the short-term effect size was moderate (d = 0.69, p = 0.001) with no significant interaction.

Parents (but not children or teachers) reported enhancements on several of the secondary outcome variables in the expected directions both for the FCU and the iComet (emotional symptoms, peer problems, prosocial behaviors, child secrecy and disclosure, family warmth and family conflict). Neither the FCU nor the iComet significantly improved parental knowledge, parental solicitation, parental control, or the quality of the relationship between the parents. A significantly larger proportion of children in the FCU recovered compared to the iComet both from pre- to post-treatment and at 1-year follow-up with regard to oppositional defiant behaviours as defined by the Disruptive Behaviour Disorders Rating Scale. Although this pattern was seen at a 2-years follow-up as well, the difference was not statistically significant (Ghaderi et al., 2018).

 

References of studies

Studies Included in the Assessment: 

Ghaderi, A., Kadesjö, C., Björnsdotter, A., & Enebrink, P. (2018). Randomized effectiveness Trial of the Family Check-Up versus Internet-delivered Parent Training (iComet) for Families of Children with Conduct Problems. Scientific Reports, 8(1). https://doi.org/10.1038/s41598-018-29550-z

Studies not Included in the Assessment: 

Connell, A.M., Seidman, S., Ha, T., Stormshak, E. A., Westling, E., Wilson, M., & Shaw, D. (2022). Long-term effects of the Family Check-Up on suicidality in childhood and adolescence: Integrative data analysis of three randomized trials. Prevention Science. https://doi.org/10.1007/s11121-022-01370-8

Garbacz, S. A., Stormshak, E. A., McIntyre, L. L., Bolt, D., & Huang, M. (2023). Family-centered prevention during elementary school to reduce growth in emotional and behavior problems. Journal of Emotional and Behavioral Disorders, 96, 24–35. https://doi.org/10.1177/10634266221143720

Lundgren, J., Ryding, J., Ghaderi, A., & Bernhardsson, S. (2023, October). Swedish parents’ satisfaction and experience of facilitators and barriers with family check-up: A mixed methods study. Scandinavian journal of psychology. https://pubmed.ncbi.nlm.nih.gov/36891962/

Mauricio, A.M., Rudo-Stern, J., Dishion, T.J. et al. (2021). Facilitators and Barriers in Cross-Country Transport of Evidence-based Preventive Interventions: a Case Study Using the Family Check-Up. Prevention Science, 22, 73–83. https://link.springer.com/article/10.1007/s11121-018-0929-y

Seidman, S., Connell, A., Stormshak, E. et al. (2022). Disrupting Maternal Transmission of Depression: Using Integrative Data Analysis (IDA) to Examine Indirect Effects of the Family Check-Up (FCU) Across Three Randomized Trials. Prevention Science. https://doi.org/10.1007/s11121-022-01471-4

Stormshak, DeGarmo, D., Garbacz, S. A., McIntyre, L. L., & Caruthers, A. (2021). Using motivational interviewing to improve parenting skills and prevent problem behavior during the transition to kindergarten. Prevention Science, 22, 747-757. https://doi.org/10.1007/s11121-020-01102-w

Stormshak, E. A., Caruthers, A., Chronister, K. M., DeGarmo, D. D., Stapleton, J., Falkenstein, C., DeVargas, E., & Nash, W. (2019). Reducing risk behavior with family-centered prevention during the young adult years. Prevention Science, 2(3), 321–330. https://doi.org/10.1007/s11121-018-0917-2. PMID: 29951974; PMCID: PMC6310108

Countries where evaluated
Sweden
Protective factor(s) addressed
Family: Verbal reasoning / non-violent parent-child discipline
Family: attachment to and support from parents
Family: opportunities/rewards for prosocial involvement with parents
Family: positive family management
Risk factor(s) addressed
Family: family management problems
Family: family conflict
Outcomes targeted
Depression or anxiety
Social behaviour (including conduct problems)
Positive relationships
Substance use
Description of programme
The family check-up intervention is comprised of three sessions. First, there is a meeting with the parents to do a pre-assessment and better understand their concerns about their child. During the second session, which includes videotaping parent-child interaction behaviours, motivational interviewing is used to encourage work on targeted areas. The last session provides structured feedback that is based on the results of the assessment and that emphasizes parenting and family strengths yet draws attention to possible areas of change. Depending on the results of the first phase, parent training interventions are suggested and chosen based on the needs and motivation that emerged during the feedback session. Referral and coordination with other services for areas of concern are provided, as well as continued services, are offered for parents who need to work on a specific targeted area.
Implementation Experiences
Feedback date
Contact details

Name: Patric Bengtsson

Email: patric.bengtsson[at]vgregion.se

 

Main obstacles
We have implemented the model over many years and have run into different obstacles in the implementation process. We are a small organisation whom implement evidence based models in external organisations and agencies. One of the main obstacles related to individual providers has been that the model initially has been perceived as complicated by them, because it includes a few steps which agencies may not always be used to. Such as eg. coding questionnaires and coding video observations. 
How they overcame the obstacles
We are letting the trainees know early in the process that this initial feeling of complexity will disappear after a few families. Letting them know there is an up hill at first and that it's part of the learning process.
Lessons learnt
We have gotten quite far, but there is always room for improvement. 
Strengths
It's evidence based, with strong evidence. It's a short intervention with a high outcome. Drop out rate is very low. It's often well liked by families. Good way of developing alliance with clients. 
Weaknesses
The model can initially seem complicated to the providers. 
Opportunities
Possible to implement in many different settings. Allows sharing experiences across boarders. 
Threats
Incorrect implementation of the model. Drifting from the original concept. 
Recommendations
If you are an individual professional interested in implementing FCU, you need to make sure your management is behind you in the decision. You need to make sure you get the time needed to learn the model. If you are training FCU providers in your organisation make sure all the staff is informed and under stand the model, so they understand the function of FCU in your organisation. Make sure the leadership is properly informed about the model and aware of all the things that needs to be in place. 
Number of implementations
1
Country
Sweden
Last updated : 15.02.2023
Country of origin
Sweden
Last reviewed:
Age group
No defined Age group
20-25 years
Target group
Nightlife goers, young adults
Programme setting(s)
Environmental setting
Community
Level(s) of intervention
Environmental prevention

STAD uses both formal and informal control measures to address binge drinking in bars and clubs, but also underlines the need for community support of such measures. The working method, developed in Stockholm between 1995 and 2001 aims to create a better and safer bar and pub environment by reducing alcohol related problems such as violence and injuries. The STAD method is based on a structured and long-term effort, consists of three parts: Multi-agency partnership between government agencies and the industry, Two-day training Responsible Beverage Service for bar staff and bar management, and Improved (cooperative) enforcement by and with police.

Links to this programme in other registries
No link
Contact details

Johanna Gripenberg
STAD - Centre for Psychiatric Research | Karolinska Institutet & Region Stockholm
johanna.gripenberg[at]sll.se

Evidence rating
Possibly beneficial
Studies overview

Wallin and colleagues (2003) found that the intervention was robustly effective in reducing violence in and around bars in Stockholm by means of a significant reduction in police-recorded violence (29%). The choice of control area and model specification did overall not affect this outcome. The sequels of the STAD programmes in Sweden seem to have had smaller effects than the original programme implemented in Stockholm (Trolldal, Brännström et al., 2013). One contributing factor was that not all programme components were implemented in the municipalities (Trolldal, Haggård et al., 2013). This is in line with the evidence that the pioneering versions of prevention programmes usually yield larger effects than the widely disseminated sequel programmes that operate on a more fragmentary basis.

In a cost-savings analysis, the 29% reduction in violence translated to a cost-savings ratio of 1:39 (Månsdotter et al., 2007). Furthermore, the program as implemented in Stockholm demonstrated a reduction in alcohol service to underaged using the mystery shopping method(Wallin & Andreasson, 2004) and also overserving using professional male actors (i.e., pseudo-patrons) trained to act alcohol-intoxicated while attempting to purchase alcohol (Wallin et al., 2002, 2005). An expert panel standardized the scene of obvious alcohol intoxication and each attempt was monitored by one observer.

A pre- (2003) and post (2004 and 2008) -intervention design study (Gripenberg et al. 2007, 2011) in high-risk licensed premises in central Stockholm assessed the STAD-CaD effects on the frequency of doormen intervention towards obviously drug-intoxicated guests at licensed premises. Professional male actors were trained to act impaired by cocaine/amphetamines while trying to enter licensed premises with doormen. An expert panel standardized the scene of drug intoxication and each attempt was monitored by one observer. At the follow-up study in 2008 the doormen intervened in 65.5% of the attempts, a significant improvement compared to 27.0% at the first follow-up in 2004 and to 7.5% at baseline in 2003. Within the project, it was also shown that staff at establishments reported own decreased self-reported drug use in 2007/2008 compared to 2001, and also that they observed a reduction in drug-intoxicated patrons (Gripenberg et al.2011). A study by Elgan et al. (2021) showed effects of the STAD model when applied to sports settings.

References of studies

Andréasson, S., Lindewald, B., and Rehnman, C. (2000). Over-serving patrons in licensed premises in Stockholm. Addiction 95, 359-363.

Brännström, L., Trolldal, B., and Menke, M. (2016). Spatial spillover effects of a community action programme targeting on-licensed premises on violent assaults: evidence from a natural experiment. J Epidemiol Community Health 70(3), 226-30.

Elgan, T. H., Durbeej, N., Holder, H. D., & Gripenberg, J. (2021). Effects of a multi‐component alcohol prevention intervention at sporting events: a quasi‐experimental control group study. Addiction, 116(10), 2663-2672.

Gripenberg Abdon, J. (2012). Drug use at licensed premises: prevalence and prevention. Doctoral thesis at the Department of Public Health Sciences/Clinical Neuroscience, Karolinska Insitutet.

Gripenberg Abdon, J., Wallin, E., and Andréasson, S. (2011). The “Clubs against Drugs” program in Stockholm, Sweden: two cross-sectional surveys examining drug use among staff at licensed premises. Substance abuse treatment, prevention, and policy 6, 2.

Gripenberg Abdon, J., Wallin, E., & Andréasson, S. (2011). Long-term effects of a community-based intervention: 5-year follow-up of “Clubs against Drugs”. Addiction (Abingdon, England), 106(11), 1997–2004. https://doi.org/10.1111/j.1360-0443.2011.03573.x

Gripenberg, J., Wallin, E., and Andréasson, S. (2007). Effects of a community-based drug use prevention program targeting licensed premises. Subst Use Misuse 42, 1883-1898.

Haggård, U., Trolldal, B., Kvillemo, P., and Guldbrandsson, K. (2015). Implementation of a multicomponent Responsible Beverage Service programme in Sweden – a qualitative study of promoting and hindering factors. Nordic Studies on Alcohol and Drugs 32, 73-90.

Månsdotter, A.M., Rydberg, M.K., Wallin, E., Lindholm, L.A., and Andréasson, S. (2007). A cost-effectiveness analysis of alcohol prevention targeting licensed premises. Eur J Public Health17, 618-623.

Norrgård, E., Wikström, E., Pickering, C., Gripenberg, J., and Spak, F. (2014). Environmental and capacity requirements are critical for implementing and sustaining a drug prevention program: a multiple case study of “Clubs against drugs”. Substance abuse treatment, prevention, and policy 9, 6.

Norström, T., & Trolldal, B. (2013). Was the STAD programme really that successful? Nordic Studies on Alcohol and Drugs, 30(3), 171–178. https://doi.org/10.2478/nsad-2013-0014

Trolldal, B., Brännström, L., Paschall, M.J., and Leifman, H. (2013). Effects of a multi-component responsible beverage service programme on violent assaults in Sweden. Addiction 108, 89-96.

Trolldal, B., Haggård, U., and Guldbrandsson, K. (2013). Factors associated with implementation of a multicomponent responsible beverage service program–results from two surveys in 290 Swedish municipalities. Substance abuse treatment, prevention, and policy 8, 11.

Wallin, E. (2004). Responsible beverage service – effects of a community action project. Doctoral thesis at the Department of Public Health, Karolinska Institutet.

Wallin, E., and Andréasson, S. (2004). Can I have a beer, please? A study of alcohol service to young adults on licensed premises in Stockholm. Prevention science 5, 221-229.

Wallin, E., and Andréasson, S. (2005). Public opinion on alcohol service at licensed premises: a population survey in Stockholm, Sweden 1999-2000. Health Policy 72, 265-278.

Wallin, E., Gripenberg, J., and Andréasson, S. (2002). Too drunk for a beer? A study of overserving in Stockholm.Addiction 97, 901-907.

Wallin, E., Gripenberg, J., and Andréasson, S. (2005). Overserving at licensed premises in Stockholm: effects of a community action program. J Stud Alcohol 66, 806-814.

Wallin, E., Lindewald, B., and Andréasson, S. (2004). Institutionalization of a community action program targeting licensed premises in Stockholm, Sweden. Evaluation Rev 28, 396-419.

Wallin, E., Norström, T., and Andréasson, S. (2003). Alcohol prevention targeting licensed premises: a study of effects on violence. J Stud Alcohol 64, 270-277.

Wallin, E., Norström, T., and Andréasson, S. (2003). Effects of a community action programme on responsible beverage service (RBS). Nordisk Alkohol Narkotikatidskrift 20, 97-100.

Countries where evaluated
Sweden
Protective factor(s) addressed
Environmental: Enforcement strategy in on-site alcohol-selling premise
Environmental: Police control of surrounding areas or Hot Spots
Environmental: RBS (Responsible Beverage Service) available
Environmental: Regular and obvious staff surveillance and reinforcement in on-site alcohol-selling premise
Risk factor(s) addressed
Community: laws and norms favourable to substance use and antisocial behaviour
Community: perceived availability of drugs/alcohol
Environmental physical: Absence of guardianship by enforcement agents in on-site alcohol-selling premise and surroundings
Environmental physical: High density of licensed alcohol-on-site premises
Environmental physical: High number of intoxicated patrons in on-site alcohol-selling premise
Environmental physical: Lack of opportunities for participation in positive and prosocial development
Environmental physical: Level of crowdedness in on-site alcohol-selling premise
Environmental physical: Music volume in on-site alcohol-selling premise
Environmental physical: Police underenforcement / low presence in public spaces
Individual and peers: favourable attitude towards alcohol/drug use
Individual and peers: favourable attitudes towards anti-social behaviour
No defined risk factors
Outcomes targeted
Emergency visits
Substance use
Alcohol use
Use of illicit drugs
Substance-related behaviours
Crime
Other behaviour outcomes
Sexual violence
Social behaviour (including conduct problems)
Violence
Description of programme

The work is based on a well-developed multi-agency partnership between several authorities and service industry associations, including for instance nightclub owners, police authorities, alcohol licensing board that all contribute to steering and working groups as well as the co-creation of intervention activities. The combined expertise and commitment by bars, nightclubs and restaurants offer an interesting and well evaluated training package. RBS-training of bar staff is highly recommended by the Stockholm licensing board for licensed premises that stay open after 01:00AM. Participants pay a fee for the RBS-training that finances the coordination, administration, and execution of the training. The training covers topics such as the medical effects of alcohol, alcohol legislation, age checking, and conflict management. Part of the Stockholm approach is also an adapted enforcement strategy of the authorities (police and licensing board) that enforce the alcohol law. The strategy can be summarised by a more cooperative or coaching enforcement instead of a more controlling way of working towards the hospitality industry. As an example, the police contribute structurally to the RBS-training for bar and security staff and management, and they are encouraged to have a coaching dialogue with the staff at establishments when they perform compliance checks. This work has shown to have an effect on a number or outcomes such as violence (Wallin et al 2003; Norström, & Trolldal, 2013) and has shown to save 39 Euros for every one Euro invested in the program (Månsdotter et al, 2007). This has led to the institutionalization (Wallin, Lindewald, & Andréasson, 2004) of the program in Stockholm, and a widespread dissemination to more than 200 of Sweden’s 290 municipalities (Haggård et al., 2015). Furthermore, within the STAD in Europe project (www.stadineurope.eu), the implementation model was piloted in several other countries such as Spain (focus on Ibotellón), Netherlands (focus on big festivals), UK (focus on preloading) and Czech Republic (focus on nightlife and age-limit compliance).

During the work with the RBS-program in the Stockholm nightlife, concerns were raised about the illicit drug situation. Based on the STAD RBS-programme the multi-component illicit drug use prevention intervention, CaD, was developed. In this programme, media advocacy became one important additional intervention component. The CaD-programme has proven to have an effect on for instance increased doormen refusal or intervention rates towards obviously drug-intoxicated patrons (Gripenberg et al. 2007, 2011). This programme has been disseminated to Sweden’s municipalities and counties (Norrgård, et al., 2014), and has, as of 2019, been disseminated to more than 50 municipalities.

Implementation Experiences
Feedback date
Contact details

patrick.widell[a]polisen.se

Main obstacles

With respect to individual professionals

Resources and understanding.

With respect to social context

- The big turn over in staff
- Engaging the night club business

With respect to organisational and economic context

We had to show what kind of benefits one could get if working with this method

How they overcame the obstacles

With respect to individual professionals

We focused on mobilization and engaging them

With respect to social context

Worked together with our partners

With respect to organisational and economic context

We had to show what kind of benefits one could get if working with this method.

Lessons learnt

With respect to individual professionals

- Long term thinking
- Even big problems can be prevented
- Work together
- Let everyone know - What´s in it for me

With respect to social context

Don´t give up! Keep on doing what you do!

With respect to organisational and economic context

Long term funding
Written agreement

Strengths

Partnership
Community mobilization
Good results

Weaknesses

The night club industry economic reasons to join

Opportunities

Use the same strategy in different fields, that is football arenas, drugs etc

Threats

Corona pandemic

Recommendations

With respect to individual professionals

Identify the right persons

With respect to social context

Adjust the method to your own context

With respect to organisational and economic context

Write an agreement and define the specific goals for the method, your own and your common goals

Number of implementations
1
Country
Sweden
Feedback date
Contact details

johanna.gripenber[a]sll.se

Main obstacles

With respect to individual professionals

Lots of effort to mobilize and developing a structure for collaboration with all the different stakeholders such as football clubs, arena corporations, licensed premises, municipality, police authority, and licensing board. Developing a good structure for collaboration is fundamental for the co-production process that was used in the program.

Another obstacle was to find training components suitable for all target groups working at the arenas. In the STAD-model implemented in the nightlife setting, staff participate in a 2-day training in responsible beverage service. At large sporting events there are a large number of extra staff working and having them taking part of a 2-day training is not feasible.

With respect to social context

In Sweden, as in many other countries, football is the most popular sport and alcohol and intoxication is often associated with football. In Sweden, all types of alcohol is sold inside the arenas at restaurants, bars, and kiosks. In fact, high levels of alcohol consumption and intoxication has been acceptable at football events in Sweden.

With respect to organisational and economic context

To develop a productive organizational structure when the stakeholders are so different from local municipalities to large international corporations that own the sport arenas and to define what roles each stakeholder have. A challenge concerning the economic context is that the alcohol industry utilizes sporting events as a marketing setting for their products. As a result, alcohol and intoxication has become normalized at football events.

How they overcame the obstacles

With respect to individual professionals

We put a lot of resources into mobilizing all stakeholders and identifying "what's in it for us" arguments for all the different stakeholders. We formed a project structure to aid collaboration and co-production. A steering group and a reference group was formed. Different working groups were formed that developed and worked with all the intervention strategies such as training, communication, and policy. In co-production, we developed a three types of training. 1. two-day responsible beverage service training for managers and full-time staff at licensed premises, 2. a brief digital training for all staff, including extra staff (e. g. entrance staff, security staff, staff at kiosks, and serving staff) working at the football events, and 3. a kick-off training that was held before the start of each season and targeted all staff in managerial positions. 

With respect to social context

We conducted a baseline assessment to evaluate intoxication levels among spectators and to assess how easy it was for highly intoxicated spectators to enter the arenas and to buy alcohol inside the arenas. The figures showed poor results which were used to inform the public and all stakeholders about the situation at the arenas. We used media advocacy and different communication strategies to highlight the connection between alcohol and alcohol-related problems such as bad language, injuries, and violence. We conducted a national survey among the general public asking about their opinion on alcohol and football. The results were used to communicate the public's low acceptability for alcohol intoxication at sporting events and high support for prevention strategies.

With respect to organisational and economic context

We had meetings with all stakeholders to get to know them and to assess their motivation to engage in alcohol prevention. Based on the needs assessment we then developed strategies to increase the stakeholders' motivation and to identify "what's in it for us". By developing the strategies in co-production with the stakeholders, the stakeholders' sense of ownership was increased. We also communicated experiences from the nightlife where licensed premises have found that it is more profitable to train staff and have them sell alcohol responsibly rather than to overserve.

 

Lessons learnt

With respect to individual professionals

It is feasible to adapt STADs model in responsible beverage service to other settings, in this case large football events. However, it is important to stress that you need to put lots of efforts into mobilizing stakeholders, developing structures for collaboration and co-production, and nurturing the collaboration. Conducting needs assessment and baseline measurements is very helpful in the process to mobilize the community and stakeholders. In addition, media advocacy was a strategy that was used successfully in the mobilization process and also to bring attention to alcohol and intoxication at football events.

With respect to social context

It is important to conduct needs assessments and baseline measurements in order to understand the social context of the setting where the strategies are to be implemented. The results from our population survey was helpful to motivate and engage the stakeholders so that they felt that they had support for alcohol prevention work in the arenas.

With respect to organisational and economic context

It is really important to identify arguments for "what's in it for us" for all the different stakeholders in order to motivate them. We also want to stress the use of co-production to increase the stakeholders' sense of ownership. Our earlier results from research on responsible beverage service in the nightlife (eg., reduction of violence by 29% and a cost-effectiveness ratio of 1:39) have been a good marketing strategy for us to mobilize the stakeholders.

Strengths

One strength was that this intervention was an adapted version of our previously developed intervention in responsible beverage service in the nightlife setting, which has demonstrated a reduction in violence by 29% and a cost-effectiveness ratio of 1:39. The fact that STAD was already known and with a very good reputation among some of the stakeholders also facilitated the implementation. Another related, but important strength is that the intervention at the football arenas was evaluated with regard to both process and effects. The results have been published in a number of scientific peer-reviewed articles.

Weaknesses

The assessments that we have conducted requires research competence and the large data we have collected was quite costly. For instance, we collected over 10 000 breath alcohol concentration measurements. We should stress that we conducted a rigorous research project, but this is not a requirement for future implementation of the program.

Opportunities

We developed the intervention for large sporting events and implemented the multicomponent intervention at Swedish Premier League Football matches. However, the intervention can easily be implemented at other large sporting events.

Threats

One threat is that others may not realize that this is a multicomponent intervention and that all components are required, i.e. mobilization and collaboration, training, enforcement, and communication, in order to achieve the results seen in Sweden.

Recommendations

With respect to individual professionals

You need to put lots of efforts into mobilizing stakeholders, developing structures for collaboration and coproduction, and nurturing the collaboration. Conducting needs assessment and baseline measurements is very helpful in the process to mobilize the community and stakeholders. In addition, media advocacy was a strategy that was used successfully in the mobilization process and also to bring attention to alcohol and intoxication at football events.

With respect to social context

Needs assessment is crucial in order to understand the social context of the setting where the strategies are to be implemented.

With respect to organisational and economic context

It is crucial to identify arguments for "what's in it for us" for all the different stakeholders in order to motivate them. Co-production is also a crucial component of the intervention to increase the stakeholders' engagement and sense of ownership.

Note from the authors

STAD-model in Responsible Beverage Service Tailored to Large Sporting Events (Football)

Year of implementation: 2015

Number of implementations
1
Country
Sweden
Feedback date
Last updated : 07.05.2019
Country of origin
Sweden
Last reviewed:
Age group
0-5 years
6-10 years
11-14 years
Target group
Children aged 4-12 years who display externalizing behaviour
Programme setting(s)
School
Level(s) of intervention
Indicated prevention

The programme incorporates a systemic school-based model for early detection and intervention. It is aimed at 4-12 year old children who display externalizing behaviour. The Marte Meo model aims to enhance the teachers’ ability to support children. Children and teacher/parent interactions are videoed and then analysed in order to identify the child’s particular support needs. In this programme, the Marte Meo model is combined with coordination meetings whereby teachers, parents and significant others in the child’s life come together to discuss the progress of the child and the intervention.

Links to this programme in other registries
No link
Contact details

Ulf Axberg
Department of Psychology
Göteberg University
Child and Adolescent Pediatric Services
Hospital of Skaraborg
SE-405 30
Sweden
Email: ulf.axborg[a]psy.gu.se

Evidence rating
Additional studies recommended
Studies overview

The programme has been evaluated in one quasi-experimental in Sweden using a small sample (n = 50 over both groups) of 4 to 12 year old children who display externalising behaviours. Overall, the comparison group changed for the worse, whereas the intervention group demonstrated a significant reduction in symptom scores. However, the difference between the groups did not reach statistical significance. The intervention group demonstrated a significant reduction in pre-test and posttest ratings of children’s symptom scores on the CBCL internalising, externalising and total symptom scores, as well as the TRF externalising and total scores and on the CTRS. There was no significant change on the TRF internalising syndrome scale.

References of studies

*Axberg, U., Hansson, K., Broberg, A. G., & Wirtberg, I. (2006). The Development of a Systemic School‐Based Intervention: Marte Meo and Coordination Meetings. Family process, 45(3), 375-389.

Countries where evaluated
Sweden
Protective factor(s) addressed
No defined protective factors
Risk factor(s) addressed
Individual and peers: other
Outcomes targeted
Other behaviour outcomes
Description of programme

The programme incorporates a systemic school-based model for early detection and intervention. It is aimed at 4-12 year old children who display externalizing behaviour. The collaborative model incorporates the Marte Meo intervention and coordination meetings.

There are two basic elements in MM: analysis and intervention. The first step is to make a 5–10-minute video recording of the child interacting with his or her parent or teacher. The therapist uses the prototype of developmental and supportive dialogue to analyse and select sequences from the video recording. The dialogical structure is organized into seven principal elements: (1) the adult seeks to locate the child’s focus of attention; (2) the adult confirms the child’s focus of attention; (3) the adult actively awaits the child’s reaction; (4) the adult names the on-going and forthcoming actions, events, experiences, feelings, and anticipated experience; (5) the adult confirms desired behaviour approvingly; (6) the adult triangulates the child in relation to ‘‘the world’’ by introducing persons, objects, and phenomena to the child; and (7) the adult takes responsibility for an adjusted and reciprocal ending.

After analysis, the therapist and adult together view and discuss sequences previously selected by the therapist. The focus of the discussion is to help the adult to see the supportive needs of the child and to stimulate the adult to modify his or her behaviour in a way that will promote the child’s development. Relevant communicative behaviour that will help to achieve this goal is identified from the film sequence. Finally, the adult is given the task of practicing these new types of behaviour in daily situations. During the next recording and reviewing, feedback is obtained regarding whether the previous intervention has been helpful and is leading toward the desired goal.

Coordination meetings (CM) implies that a coordinator, parent(s), teacher(s), special needs teacher(s), and sometimes other people who are considered particularly important for the child come together on a regular basis to discuss the child and the intervention. The rationale for the use of coordination meetings includes addressing many different domains of children’s lives, the necessity of targeting interventions in the same direction, the use of collaborative problem solving, the risk of the development of problem-affirmative communication around the child, the importance of sharing and discussing thoughts and feelings around the child’s behaviour with the adults in the family-school system and the assumption that the educating and socializing of children and young people is a responsibility shared between the family and the child’s social and professional networks.

Last updated : 09.01.2024
Country of origin
USA
Last reviewed:
Age group
11-14 years
15-18/19 years
Target group
Male young offenders aged 12-18 years
Programme setting(s)
Community
Juvenile justice setting
Mental health/treatment centre
School
Level(s) of intervention
Indicated prevention
Selective prevention

Aggression Replacement Training consists of three major components: Skillstreaming, to teach prosocial behaviours; Anger Control Training, to reduce and control aggression; and Moral Education, to promote higher levels of moral reasoning. Together, these three components allow youth to not only develop prosocial values, but also learn concrete techniques promoting overt prosocial behaviour and inhibiting antisocial behaviour. The training curriculum is somewhat flexible in length, but the core components require at least 10 weeks of multiple sessions in each of the three areas.

Links to this programme in other registries
Norway - Ungsinn a.
Norway - Ungsinn b.
The Netherlands - Databank Effectieve Jeugdinterventies
Finland - Kasvun Tuki
Contact details

Barry Glick
New York State Division for Youth
Phone: +1 (718) 665-5500

Evidence rating
Additional studies recommended
Studies overview

The programme has been evaluated in one randomised controlled trial in Norway, and four quasi-experimental studies, one each in Norway, Sweden, the UK and Turkey.

In the RCT, 14 adolescents aged 14 to 20 years, and 25 children aged 7 to 12 years who displayed behaviour problems participated. Adolescents in the intervention group had a non-significant increase in social skills and decrease in problem behaviours, while those in the control group showed a non-significant decrease in both, social skills and problem behaviour. There was a significant improvement on social skills and problems among children in the intervention group from pre to post intervention, but a non-significant change among children in the control group. Significance of difference between groups is not reported.

The Norwegian QED included 47 youth aged 12-14 years receiving ART and 18 youths as controls. Participants in the ART group indicated significant improvement, but participants in the comparison group did not, in general, indicate improvement - the ART group demonstrated significant improvement on 9 out of 10 tests; the comparison group demonstrated improvement on 2 out of 10 tests. However, (due to a relatively small sample and ‘heterogeneous’ groups), the intervention effect (group x time interaction) was not statistically significant.

The Swedish study included 64 adolescents, with a mean age of 17 years, placed at the institutions for compulsory treatment. Two institutions administered the intervention and two served as controls. It is not mentioned how the groups were allocated. There were no significant effects, but it should be noted that all four institutions were compared rather than intervention and control groups.

The UK study was conducted with 41 adolescents aged 11 to 17 years. Non-parametric statistical tests demonstrated no significant improvements in the intervention participant’s social skills or problem behaviours.

The Turkey study was conducted with 65 adolescents, with a mean age of 16 years, from juvenile and youth prisons. The study found significant intervention effects only on 1/10 measures of anger and aggression, and on the secondary outcome of problem-solving skills.

An additional Swedish study by Larden et al. examined the effects of ART on adult offenders' criminal recidivism and found no effects of reoffending (Larden et a. 2017). The ART program is originally designed for adolescents, and it might be that the program should be adjusted for adults.

References of studies

Currie, M. Wood, C., Williams, B. & Bates, G. (2012). Aggression Replacement Training (ART) in Australia: A longitudinal youth justice evaluation. Psychiatry, Psychology and Law, 19(4), 577-604.

*Gundersen, K., & Svartdal, F. (2006). Aggression replacement training in Norway: Outcome evaluation of 11 Norwegian student projects. Scandinavian journal of educational research, 50(1), 63-81.

Grimes, S. (2015). An evaluation of Aggression Replacement Training: the impact of a multi-component, CBT-based intervention on the problem behaviours, pro-social skills and moral development of pupils in English secondary schools(Doctoral dissertation, University of Nottingham).

Kaya, F., & Buzlu, S. (2016). Effects of aggression replacement training on problem solving, anger and aggressive behaviour among adolescents with criminal attempts in Turkey: A quasi-experimental study. Archives of psychiatric nursing, 30(6), 729-735.

Lardén, M., Nordén, E., Forsman, M., & Långström, N. (2018).Effectiveness of aggression replacement training inreducing criminal recidivism among convicted adult offenders. Criminal behaviour and mental health, 28(6), 476-491

*Luke Moynahan & Børge Strømgren (2005) Preliminary results of Aggression Replacement Training for Norwegian youth with aggressive behaviour and with a different diagnosis, Psychology, Crime & Law, 11:4, 411-419, DOI: 10.1080/10683160500256784

*Holmqvist, R., Hill, T., & Lang, A. (2007). Effects of aggression replacement training in young offender institutions. International journal of offender therapy and comparative criminology.

Glick, B., & Goldstein, A. (1987). Aggression Replacement Training. Journal of Counseling and Development, 65, 356-362.

Goldstein, A., & Glick, B. (1994). Aggression Replacement Training: Curriculum and Evaluation. Simulation and Gaming, 25, 9-25.

Nugent, W.R., Bruley, C., & Allen, P. (1998). The effects of Aggression Replacement Training on antisocial behavior in a runaway shelter. Research on Social Work Practice, 8, 637-656.

Washington State Institute for Public Policy. (2004). Outcome evaluation of Washington State's research-based programmes for juvenile offenders. Olympia, WA: WSIPP.

Countries where evaluated
Norway
Sweden
Protective factor(s) addressed
Individual and peers: clear morals and standards of behaviour
Individual and peers: individual/peers other
Risk factor(s) addressed
Individual and peers: other
Outcomes targeted
Emotional well-being
Emotion regulation, coping, resilience
Other behaviour outcomes
Violence
Description of programme

Aggression Replacement Training consists of three major components: Skillstreaming, to teach prosocial behaviours; Anger Control Training, to reduce and control aggression; and Moral Education, to promote higher levels of moral reasoning. Together, these three components allow youth to not only develop prosocial values, but also learn concrete techniques promoting overt prosocial behaviour and inhibiting antisocial behaviour. The training curriculum is somewhat flexible in length, but the core components require at least 10 weeks of multiple sessions in each of the three areas.

(1) Structured Learning Training, or Skillstreaming, consists of a curriculum of skillstreaming skills (a broad array of interpersonal and daily living skills) taught through modelling, role-playing, and performance feedback; moral reasoning dilemmas; and anger control training steps. Skillstreaming facilitates prosocial behaviour. The skills fall into one of six families: beginning social skills, advanced social skills, skills for dealing with feelings, alternatives to aggression, skills dealing with stress, and planning skills.

(2) Anger Control Training enables youth to control their level of anger arousal. Youth are trained to respond to their hassles with a chain of behaviours that include identifying triggers, identifying cues, using reminders to stay calm, using reducers such as deep breathing to lower the level of anger, and using self-evaluation.

(3) Moral Education increases youths' sense of fairness, justice, and concern for the right of others. Participants meet in small groups in which individuals are functioning at different levels of moral reasoning. A group leader then describes scenarios and real life situations posing moral dilemmas, and participants fully examine and discuss these scenarios and possible solutions to it.

Implementation Experiences
Feedback date
Contact details

Peter Bleumer
pbleumer[a]iae.nl

Tim Tiemissen
timtiemissen[a]gmail.com

Main obstacles

With respect to individual professionals

The client group is complex to work with, and this requires experience and training. New trainers, having completed a five-day course on how to deliver the intervention, have different struggles with their first aggression replacement training groups (6-10 people). The struggles new trainers often face are how to deliver the programme sensitively in the setting where they work without sacrificing too much of the programme’s integrity (i.e. following the treatment manuals), group management and trainee resistance and delivering training procedures in a methodical, correct way (usually moral reasoning training is found to be quite difficult at first, as is making effective use of cognitive-behavioural therapy techniques and effectively conducting role play).

With respect to social context

Every social structure has delimiting systemic elements that impact on how a programme can be delivered. In an enclosed forensic psychiatric setting, a floor effect (aggression is already at a high level in prison) can have an impact on how clients can benefit from the training. In schools, there is a curriculum and the programme must be made to fit that curriculum, and in outpatient clinics clients might not show up. Patients might not be intrinsically motivated to take part in the aggression replacement training. In addition, people and practitioners can be stubborn and decide to leave certain things out of the protocol that have an impact on the quality of the intervention.

With respect to organisational and economic context

Aggression replacement training remains under-researched. Conducting randomised controlled trials costs a lot of time and money and conducting research with this client group is difficult because of high dropout rates. Motivating organisations to monitor programme effects remains a challenge.

How they overcame the obstacles

With respect to individual professionals

There are programme integrity checklists, and new trainers can receive coaching on the job. Twice a year, aggression replacement trainers come to a supervision day during which their aggression replacement training skills are fine-tuned and kept ‘on model’.

With respect to social context

When a new organisation starts aggression replacement training, we take extra care to develop a package that fits not only the context but also the specific client group to which it is delivered. As a result, we spend time with programme mangers helping them plan ART sessions, helping with pre- and post- measurements and setting up a supervision structure within the organisation to take care of trainers (because it’s quite complex working with people with aggression problems).

With respect to organisational and economic context

Try to keep an open mind and encourage people to work together instead of seeing one another as competitors.

Lessons learnt

With respect to individual professionals

Giving new trainers the support that they need and modelling and practising with effective training/treatment procedures helps new ART practitioners gain confidence and experience success in delivering the treatment.

With respect to social context

So many people have been trained in various settings. Keeping in contact with these people is a challenge but is important to maintain or attain a level of congruence in the way aggression replacement training is delivered. In addition, there needs to be a balance between wanting to share our material and giving people the freedom to add to it, making it fit in their organisational context and maintaining programme integrity.

With respect to organisational and economic context

Try to emphasise the value of treating aggressive behaviour over competing in a healthcare market (the term says enough).

Strengths
  •  Paying attention to participants motivation and their social support to take part in aggression replacement training reduces drop out.
  • Modelling training procedures and practising them makes new aggression replacement trainers more competent than when they just talk about doing it.
  • Working together with different service providers helps set the stage for intervention success.
  • Making use of the programme integrity checks keeps you on model as a trainer.
  • Evaluating intervention participants and scoring and discussing changes in aggressive behaviour halfway through the intervention helps participants finish the full programme.
  • Practising difficult client encounters through role play helps you deal with them in the real word.
Weaknesses
  • It is difficult to stay in contact with everyone we have trained.
  • It is difficult to maintain programme integrity when so many different institutions are delivering ART.
  • It is hard to motivate institutions to evaluate programmes.
Opportunities

Aggression replacement training is delivered all over the world. However, it remains understudied (in the sense of methodological quality), and this is an opportunity. It would be great if the presupposed working principles would be systematically tested using experimental or quasi-experimental designs.

Threats

People tend to favour developing something new over first researching whether that something works in the first place. Methodologically sound research on ART is needed before we start to change the intervention.

Recommendations

With respect to individual professionals

Always work in couples; make sure the organisations provide a room to deliver the training and the necessary materials and also time, etc.

With respect to social context

Really try to engage the client group and pay attention to motivational problems prior to delivering the intervention. Try to get people around the client involved in the treatment, i.e. a partner or parent who can give a client positive feedback when they succesfully employ what they have learnt in aggression replacement training.

With respect to organisational and economic context

Try to get people around the client involved in the treatment, i.e. a partner or parent who can give a client positive feedback when they succesfully employ what they have learnt in aggression replacement training.

Note from the authors

See website (in Dutch): http://www.goldstein.nl/

https://www.nji.nl/nl/Databank/Databank-Effectieve-Jeugdinterventies/ART-Aggression-Replacement-Training

Number of implementations
1
Country
Netherlands
Last updated : 18.06.2024
Country of origin
Sweden
Last reviewed:
Age group
0-5 years
6-10 years
11-14 years
Target group
Parents of children who have symptoms or a diagnosis of behavioural disorders
Programme setting(s)
Community
Level(s) of intervention
Indicated prevention
Selective prevention

COPE is a manualised large-group community-based parent education programme. Groups can consist of 25-30 parents who meet with one or two trained group leaders for weekly 2-hour sessions over 10 weeks. The programme is mostly participant-driven and includes review and discussion within subgroups.

A new strategy is taught at each session, including strategies for giving attention to positive behaviour, balancing time and attention among siblings, ignoring minor disruptions, managing transitions, planning ahead and using reward systems. Parents are also taught a general approach to child management problems, referred to as PASTE-ing problems.

Links to this programme in other registries
No link
Contact details

Charles E. Cunningham, PhD. Professor
Jack Laidlaw Chair in Patient-Centered Health Care of Psychiatry and Behavioral Neurosciences McMaster University
Email: cunnic[a]hhsc.ca
Phone number: 905-521-2100, extension 77307
Website: http://www.rfts.ca/cope/index.html

Evidence rating
Likely to be beneficial
Studies overview

The programme has been evaluated in one quasi-experimental study in Sweden with 133 families. The study had four group, one of which was a control group, while the other three groups received the intervention but were different in the behaviour symptoms the children displayed: clinical, nonclinical high level, nonclinical low level. The study indicated that COPE significantly reduced behaviour problems (ODD symptoms and hyperactivity/impulsivity) for children with high levels of problems, compared to the control group, but not low symptom or clinical groups. There was no effect on inattention, social competence deficits or peer problems. In terms of parent outcomes (stress and perceived parental control), both the nonclinical groups showed significant improvements compared to the control, but not the clinical group.

References of studies

*Thorell, L. (2009). The Community Parent Education Programme (COPE): Treatment Effects in a Clinical and a Community-based Sample. Clin Child Psychology Psychiatry. 14; 373.

Countries where evaluated
Sweden
Protective factor(s) addressed
No defined protective factors
Risk factor(s) addressed
Family: family management problems
Outcomes targeted
Other behaviour outcomes
Description of programme

COPE is a manualised large-group community-based parent education programme. Groups can consist of 25-30 parents who meet with one or two trained group leaders for weekly 2-hour sessions over 10 weeks.

To allow active participation, parents are divided into subgroups (5-7 members in each) and seated around separate tables. The programme is, to a large extent, participant-driven and discussions are held both within the subgroups and in the large group. Each meeting is structured and includes the following phases: 1) informal social activities; 2) review of homework in subgroups; 3) large-group discussions of homework projects; 4) subgroups formulate solutions to videotaped vignettes of a problematic situation; 5) large-group discussions of proposed solutions; 6) leader models group’s solution; 7) subgroups brainstorm application; 8) dyads rehearse strategies; 9) homework planning; and 10) leader summarizes and closes session.

At each session, a new strategy is taught. The COPE programme, for example, included strategies for giving attention to positive behaviour, balancing time and attention among siblings, ignoring minor disruptions, managing transitions, planning ahead and using reward systems. The parents are also taught the general approach to child management problems, referred to as PASTE-ing problems. This includes: (P) picking one soluble problem, (A) analysing the advantages and disadvantages of alternative solutions, (S) selecting the most promising alternative, (T) Trying it out, and (E) evaluating the outcome.

Last updated : 09.01.2024
Country of origin
USA
Last reviewed:
Age group
11-14 years
15-18/19 years
Target group
Young offenders aged 12-17 years
Programme setting(s)
Community
Family
Juvenile justice setting
Level(s) of intervention
Targeted intervention

Multisystemic Therapy® (MST®) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behaviour in juvenile offenders. The MST programme seeks to improve the real-world functioning of young people by changing their natural settings — home, school and neighbourhood — in ways that promote prosocial behaviour while decreasing antisocial behaviour. Therapists work with young people and their families to address the known causes of delinquency on an individualised yet comprehensive basis. By using the strengths in each system (family, peers, school and neighbourhood) to facilitate change, MST addresses the multiple factors known to be related to delinquency across the key systems within which young people are embedded. The extent of treatment varies by family according to clinical need. Therapists generally spend more time with families in the initial weeks (meeting daily if necessary) and gradually reduce the frequency of their meetings (to as infrequently as once a week) over the three- to five-month course of treatment.

Keywords
No data
Links to this programme in other registries
USA - Blueprints Programs
Norway - NUBU
Norway - Ungsinn
The Netherlands - Databank Effectieve Jeugdinterventies
UK - Early Intervention Foundation Guidebook
Contact details

Mr Marshall Swenson
MST Services
Email: marshall.swenson[a]mstservices.com
Website: www.mstservices.com or www.mstinstitute.org

Evidence rating
Possibly beneficial
Studies overview

The programme has been evaluated in four randomised controlled trials, one each in Norway, Sweden, the UK and the Netherlands.

In Sweden, 156 young people aged 12-17 with a clinical diagnosis of conduct disorder using the DSM-IV-TR were randomly allocated to either receive MST or to continue with treatment as usual. No significant differences between groups was found at post-test or month follow-up  – indicating no effects on child behaviour, social skills, delinquency, alcohol or drug use.

In Norway, 105 young people aged 12-17 years referred for problem behaviour such as law-breaking or other anti-social acts, serious academic difficulties, dysfunctional interpersonal relationships, verbal aggression and threats of hurting others were randomly allocated to MST or regular services. At posttest, there a marginally significant positive intervention effect on internalising and externalisaling behaviour, social competence and family cohesion, but not of family functioning.

In the Netherlands, 256 young people aged 12-18 years displaying severe and violent antisocial behaviour were randomly allocated to MST or usual service. At post-test and six-month post intervention, intervention group adolescents improved significantly more compared to the control group on parent and self-reported externalizing, parent-reported oppositional defiant and conduct disorder, and self-reported property offences. The There were no significant differences in groups in frequency or number of arrests two years after the program ended.   effect on self-reported violence was not significant.

In the UK, 108 young people aged 13-17 years on a court referral order for treatment, supervision, or following imprisonment were randomized into MST or Youth Offending Teams control group. The number of offenses between the two study groups did not differ at post-test, and 6-month follow-up but became significant (p<.001) at the 12-month follow-up assessment. There was a significant difference between groups, favouring MST, on the measure of six-month period of no offences, although the effects at different assessments points is not disentangled. Sub-group analyses showed this was significant for non-violent offences, and not for violent offences. Out of 21 tests for secondary outcome measures, 5 (24%) were significant, including aggression and delinquency.

I a quasi-experimental study in the Netherlands (Eeren et al., 2018), 697 adolescents with an average age of 15 years, were allocated to either the FFT intervention or the MST intervention according to the Risk-Need-Responsivity model. The FFT intervention is thereby seen as the control group. In this aspect, results of the comparison showed no significant differences between outcomes. Only the engagement in school or work after the treatment was higher in the group who completed MST.

References of studies

Outcome evaluations/results:

Asscher, J. J., Deković, M., Manders, W. A., van der Laan, P. H., Prins, P. J.M., van Arum, S., & Dutch MST Cost-Effectiveness Study Group. (2014). Sustainability of the effects of multisystemic therapy for juvenile delinquents in The Netherlands: effects on delinquency and recidivism. Journal of Experimental Criminology, 10(2), 227-243.

Asscher, J. J., Deković, M., Manders, W. A., Van der Laan, P. H., Prins, P. J. M., & Dutch MST Cost- Effectiveness Research Group (2012). A randomized clinical trial of Multisystemic Therapy in The Netherlands. Journal of Experimental Criminology. doi: 10.1007/s11292-012-9165-9.

Butler, S., Baruch, G., Hickey, N., & Fonagy, P. (2011). A randomized controlled trial of Multisystemic Therapy and a statutory therapeutic intervention for young offenders. Journal of the American Academy of Child and Adolescent Psychiatry, 50(12), 1220-1235.

Löfholm, C., Olsson, T., Sundell, K., & Hansson, K. (2009). Multisystemic therapy with conduct-disordered young people: stability of treatment outcomes two years after treatment. Evidence & Policy, 4, 373-397.

Ogden, T., Hagen, K. A., & Andersen, O. (2007). Sustainability of the effectiveness of a programme of multisystemic treatment (MST) across participant groups in the second year of operation. Journal of Children’s Services, 2, 4-14.

Sundell, K., Hansson, K., Löfholm, C., Olsson, T., Gustle, L-H., & Kadesjö, C. (2008). The transportability of Multisystemic Therapy to Sweden: Short-Term Results From a Randomized Trial of Conduct-Disordered Youths. Journal of Family Psychology, 22, 550-560.

 

Concept papers/other:

*Asscher, J. J., Deković, M., Van der Laan, P. H., Prins, P. J. M. and van Arum, S. (2007), ‘Implementing randomized experiments in criminal justice settings: an evaluation of multi-systemic therapy in the Netherlands’, Journal of Experimental Criminology 3, pp. 113–129.

* Asscher, J. J., Dekovic, M., Manders, W. A., van der Laan, P. H. and Prins, P. J. M. (2013), ‘A randomized controlled trial of the effectiveness of multisystemic therapy in the Netherlands: post-treatment changes and moderator effects’, Journal of Experimental Criminology 9, pp. 169 187.

Borduin, C. M., Henggeler, S. W., Blaske, D. M. and Stain, R. J. (1990), ‘Multisystemic treatment of adolescent sexual offenders’, International Journal of Offender Therapy and Comparative Criminology 35, pp. 105-114.

Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M. and Williams, R. A. (1995), ‘Multisystemic treatment of serious juvenile offenders: long-term prevention of criminality and violence’, Journal of Consulting and Clinical Psychology 63, pp. 569-578.


Borduin, C. M., Schaeffer, C. M. and Heiblum, N. (2009), ‘A randomized clinical trial of Multisystemic Therapy with juvenile sexual offenders: effects on youth social ecology and criminal activity’, Journal of Consulting and Clinical Psychology 77, pp. 26-37.


Brown, T. L., Henggeler, S. W., Schoenwald, S. K., Brondino, M. J. and Pickrel, S. G. (1999), ‘Multisystemic treatment of substance abusing and dependent juvenile delinquents: effects on school attendance at posttreatment and 6-month follow-up’, Children’s Services: Social Policy, Research, and Practice 2, pp. 81-93.


Camp, G. M. and Camp, C. G. (1993), The Corrections Yearbook, Criminal Justice Institute, South Salem, NY.


Dekovic, M., Asscher, J. J., Manders, W. A., Prins, P. J. M. and van der Laan, P. (2012), ‘Within-intervention change: mediators of intervention effects during Multisystemic Therapy’, Journal of Consulting and Clinical Psychology 80, pp. 574-587.

Eeren, H. V., Goossens, L., Scholte, R. H., Busschbach, J. J., & Van der Rijken, R. E. (2018). Multisystemic therapy and functional family therapy compared on their effectiveness using the propensity score method. Journal of Abnormal Child Psychology, 46(5), 1037-1050.

Fain, T., Greathouse, S. M., Turner, S. F. and Weinberg, H. D. (2014), ‘Effectiveness of Multisystemic Therapy for minority youth: outcomes over 8 years in Los Angeles County’, Journal of Juvenile Justice 3, pp. 24-37. 


Henggeler, S. W., Rodick, J. D., Borduin, C. M., Hanson, C. L., Watson, S. M. and Urey, J. R. (1986), ‘Multisystemic treatment of juvenile offenders: effects on adolescent behavior and family interaction’, Developmental Psychology 22, pp. 132-141.


Henggeler, S. W., Borduin, C. M., Melton, G. B., Mann, B. J., Smith, L. A., Hall, J. A., Cone, L., et al. (1991), ‘Effects of multisystemic therapy on drug use and abuse in serious juvenile offenders: a progress report from two outcome studies’, Family Dynamics of Addiction Quarterly 1, pp. 40-51. 


Henggeler, S. W., Melton, G. B. and Smith, L. A. (1992), ‘Family preservation using multisystemic therapy: an effective alternative to incarcerating serious juvenile offenders’, Journal of Consulting and Clinical Psychology 6, pp. 953-961.


Henggeler, S. W., Melton, G. B., Smith, L. A., Schoenwald, S. K. and Hanley, J. H. (1993), ‘Family preservation using multisystemic treatment: long-term followup to a clinical trial with serious juvenile offenders’, Journal of Child and Family Studies 2, pp. 283-293.

Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G. and Hanley, J. H. (1997), ‘Multisystemic Therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination’, Journal of Consulting and Clinical Psychology 65, pp. 821-833.


Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D. and Cunningham, P. B. (1998), Multisystemic treatment of antisocial behavior in children and adolescents, The Guilford Press, New York.


Henggeler, S. W., Pickrel, S. G. and Brondino, M. J. (1999), ‘Multisystemic treatment of substance-abusing and dependent delinquents: outcomes, treatment fidelity, and transportability’, Mental Health Services Research 1, pp. 171-184.


Henggeler, S. W., Clingempeel, W. G., Brondino, M. J. and Pickrel, S. G. (2002), ‘Four-year follow-up of Multisystemic Therapy with substance-abusing and substance-dependent juvenile offenders’, Journal of the American Academy of Child and Adolescent Psychiatry 41, pp. 868-874.


Henggeler, S. W., Letourneau, E. J., Chapman, J. E., Borduin, C. M., Schewe, P. A. and McCart, M. R. (2009), ‘Mediators of change for multisystemic therapy with juvenile sexual offenders’, Journal of Consulting and Clinical Psychology 77, pp. 451-462.


Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D. and Cunningham, P. B. (2009), Multisystemic therapy for antisocial behavior in children and adolescents (2nd edn), The Guilford Press, New York.


Huey, S. J., Henggeler, S. W., Brondino, M. J. and Pickrel, S. G. (2000), ‘Mechanisms of change in multisystemic therapy: reducing delinquent behavior through therapist adherence and improved family and peer functioning’, Journal of Consulting and Clinical Psychology 68, pp. 451 467.

Leschied, A. and Cunningham, A. (2002), Seeking effective interventions for serious young offenders: interim results of a four-year randomized study of multisystemic therapy in Ontario, Canada, Centre for Children and Families in the Justice System, Canada.


Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P. A., McCart, M. R., Chapman, J. E. and Saldana, L. (2009), ‘Multisystemic Therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial’, Journal of Family Psychology 23, pp. 89-102.


Ogden, T. and Halliday-Boykins, C. A. (2004), ‘Multisystemic treatment of antisocial adolescents in Norway: replication of clinical outcomes outside of the US’, Child and Adolelscent Mental Health 9, pp. 77-83.


Ogden, T. and Hagen, K. A. (2006), ‘Multisystemic Therapy of serious behaviour problems in youth: sustainability of therapy effectiveness two years after intake’, Journal of Child and Adolescent Mental Health 11, pp. 142-149.


Ogden, T. and Hagen, K. A. (2009), ‘What works for whom? Gender differences in intake characteristics and treatment outcomes following Multisystemic Therapy’, Journal of Adolescence 32, pp. 1425-1435.


Sawyer, A. M and Borduin, C. M. (2011), ‘Effects of Multisystemic Therapy through midlife: a 21.9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders’, Journal of Consulting and Clinical Psychology 79, pp. 643–652.


Schaeffer, C. M. and Borduin, C. M. (2005), ‘Long-term follow-up to a randomized clinical trial of Multisystemic Therapy with serious and violent juvenile offenders’, Journal of Consulting and Clinical Psychology 73, pp. 445-453.


Schoenwald, S. K., Ward, D. M., Henggeler, S. W., Pickrel, S. G. and Patel, H. (1996), ‘Multisystemic Therapy treatment of substance abusing or dependent adolescent offenders: costs of reducing incarceration, inpatient, and residential placement’, Journal of Child and Family Studies 5, pp. 431-444.


Timmons-Mitchell, J., Bender, M., Kishna, M. A. and Mitchell, C. (2006), ‘An independent effectiveness trial of Multisystemic Therapy with juvenile justice youth’, Journal of Clinical Child and Adolescent Psychology 35, pp. 227-236.


Wagner, D. V., Borduin, C. M., Sawyer, A. M. and Dopp, A R. (2014), ‘Long-term prevention of criminality in siblings of serious and violent juvenile offenders: a 25-year follow-up to a randomized clinical trial of multisystemic therapy’, Journal of Consulting and Clinical Psychology 82, pp. 492-499.


Weiss, B., Han, S., Harris, V., Catron, T., Ngo, V. K., Caron, A., Gallop, R. et al. (2013), ‘An independent randomized clinical trial of Multisystemic Therapy with non-court-referred adolescents with serious conduct problems’, Journal of Consulting and Clinical Psychology 81, pp. 1027-1039.

Countries where evaluated
Netherlands
Norway
Sweden
United Kingdom
Protective factor(s) addressed
Community: opportunities and rewards for prosocial involvement in the community (including religiosity)
Family: attachment to and support from parents
Family: opportunities/rewards for prosocial involvement with parents
Family: parent involvement in learning/education
Family: parent social support
Individual and peers: clear morals and standards of behaviour
Individual and peers: interaction with prosocial peers
Individual and peers: opportunities and rewards for prosocial peers involvement
Individual and peers: Problem solving skills
Individual and peers: skills for social interaction
School and work: commitment and attachment to school
School and work: opportunities for prosocial involvement in education
School and work: rewards and disincentives in school
Risk factor(s) addressed
Community: community disorganisation (crime, drugs, graffiti, abandoned buildings etc)
Community: laws and norms favourable to substance use and antisocial behaviour
Community: low neighbourhood attachment
Family: aggressive or violent parenting
Family: family conflict
Family: family management problems
Family: neglectful parenting
Family: parental attitudes favourable to alcohol/drug use
Family: parental attitudes favourable to anti-social behaviour
Family: parental depression or mental health difficulties
Individual and peers: anti-social behaviour
Individual and peers: early initiation of drug/alcohol use
Individual and peers: interaction with antisocial peers
Individual and peers: peers alcohol/drug use
Individual and peers: rebelliousness and alienation
School and work: low commitment/attachment to school/workplace
Outcomes targeted
Depression or anxiety
Other mental health outcomes
Relations with parents
Relations with peers
Alcohol use
Use of illicit drugs
Crime
Other behaviour outcomes
Violence
Description of programme

Multisystemic Therapy® (MST®) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behaviour across key settings, or systems, within which young people are embedded (family, peers, school and neighbourhood). Because MST emphasises promoting behavioural change in the young person’s natural environment, the programme aims to empower parents with the skills and resources needed to independently address the inevitable difficulties that arise in raising teenagers, and to empower young people to cope with the problems they encounter in the family, peer, school, and neighbourhood domains.

In the context of support and skill building, the therapist places developmentally appropriate demands on adolescents and their families to reduce problem behaviour. Initial therapy sessions identify the strengths and weaknesses of the adolescent, the family and their transactions with extrafamilial systems (e.g. peers, friends, school, parental workplace). Problems identified both by family members and by the therapist are explicitly targeted for change by using the strengths in each system to facilitate such change. Treatment approaches are derived from well-validated strategies such as strategic family therapy, structural family therapy, behavioural parental training and cognitive behavioural therapy.

While MST focuses on addressing the known causes of delinquency on an individualised yet comprehensive basis, several types of interventions are typically identified for serious juvenile offenders and their families. At the family level, MST interventions aim to remove barriers to effective parenting (e.g. parental substance abuse, parental psychopathology, low social support, high stress and marital conflict), to enhance parenting competencies, and to promote affection and communication among family members. Interventions might include introducing systematic monitoring, reward and discipline systems; prompting parents to communicate effectively with each other about adolescent problems; problem solving for day-to-day conflicts; and developing social support networks. At the peer level, interventions are frequently designed to decrease affiliation with delinquent and drug-using peers and to increase affiliation with prosocial peers. Interventions in the school domain may focus on establishing positive lines of communication between parents and teachers, ensuring parental monitoring of the adolescent’s school performance and restructuring after-school hours to support academic efforts. Individual-level interventions generally involve using cognitive behavioural therapy to modify the individual’s social perspective-taking skills, belief system or motivational system, and encouraging the adolescent to deal assertively with negative peer pressure.

A master’s level therapist, with a caseload of four to six families, provides most mental health services and coordinates access to other important services (e.g. medical, educational and recreational). While the therapist is available to the family 24 hours a day, 7 days a week, the direct contact hours per family vary according to clinical need. Generally, the therapist spends more time with the family in the initial weeks of the programme (meeting daily if necessary) and gradually reduces the frequency of their meetings (to as infrequently as once a week) during a three- to five-month course of treatment.

Treatment fidelity is maintained by weekly group supervision meetings involving three to four therapists and a doctoral level or advanced master’s level clinical supervisor. The group reviews the goals of and progress in each case to ensure the multisystemic focus of the therapists’ intervention strategies, identify barriers to success and facilitate the attainment of treatment goals. In addition, an MST expert consultant reviews each case with the team weekly to promote treatment fidelity and favourable clinical outcomes.

The design and implementation of MST interventions are based on the following nine core principles of MST. An extensive description of these principles, with examples that illustrate the translation of these principles into specific intervention strategies, is provided in comprehensive clinical volumes (Henggeler et al., 1998; 2009).

  • The primary purpose of assessment is to understand the ‘fit’ between the identified problems and their broader systemic context.
  • Therapeutic contacts emphasise the positive and use systemic strengths as levers for change.
  • Interventions are designed to promote responsible behaviour and decrease irresponsible behaviour among family members.
  • Interventions are present-focused and action-oriented, targeting specific and well-defined problems.
  • Interventions target sequences of behaviour within and between multiple systems that maintain the identified problems.
  • Interventions are developmentally appropriate and fit the developmental needs of the young person.
  • Interventions are designed to require daily or weekly effort by family members.
  • Intervention effectiveness is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.
  • Interventions are designed to promote treatment generalisation and long-term maintenance of therapeutic change by empowering caregivers to address family members’ needs across multiple systemic contexts.

Intervention variation

The study was a randomised controlled trial with participants randomly allocated either to receive multisystemic therapy (MST) or to continue with treatment as usual. Randomisation was computer-generated at a ratio of 50:50 and with sites used as a blocking variable. Over 12 months, from March 2004, young people aged 12-17 were referred to the study and screened for a clinical diagnosis of conduct disorder using the DSM-IV-TR.

A total of 256 juveniles who were referred for MST between 2006 and 2010 participated in the study. The study took place in three MST institutions in the Netherlands. Adolescents were referred by primary healthcare workers (GPs) or child social workers in 39 % of cases. Of the adolescents, 51 % were referred for treatment as a result of a court order and 11 % were self-referred. Immediately after referral, participants were randomised using a computerised randomisation programme. This programme was executed separately for each site. The randomisation ratio was adjusted in a 1:2 ratio in favour of MST for a 6-month period, due to a low number of referrals.

The programme allocated 147 young people to the intervention group and 109 to the control group. Participants in the control group received an alternative treatment that would have been offered had MST not been available. Mostly, these services included individual treatment (individual counselling or supervision by a probation officer or case manager, 21 %) and family-based interventions (family therapy, parent counselling, parent groups or home-based social services, 53 %). Of this group 7 % received a combination of care (e.g. individual treatment and family counselling) and 4 % were placed in a juvenile detention facility. For various reasons such as moving house or repeated failure to attend treatment sessions, 14 % received no treatment in the end.

Implementation Experiences
Feedback date
Contact details

Terje Ogden
terje.ogden[a]nubu.no
 

Main obstacles

With respect to individual professionals

Some practitioners opposed the manual-driven approach, stating that it was a threat to professional autonomy and to the principle of freedom of method choice. At the clinical level, the lack of specific, explicit therapeutic skills also turned out to be a challenge. Weekly group supervision and consultation in MST, and feedback from families on the therapists’ treatment adherence were collected on a regular basis. But, to our knowledge, no trainees dropped out of training because of these requirements, and the therapists gradually adapted to the skills-oriented approach and the increased transparency of the therapy process.

With respect to social context

The MST and MST/CM programmes were not immediately accepted by the Norwegian public and practitioners. Adolescents with behavioural and substance abuse problems were placed out of home on a regular basis. Moreover, a common objection was that ‘MST may have worked in the United States, but it won’t work here.’ No matter how many studies proved that evidence-based programmes worked in the United States, it was not assumed that the same results would be achieved in Norway. Norway previously had a strong tradition of incarcerating drug-abusing and criminal youth or transferring them to treatment institutions or homes. Home-based treatment of this target group was quite difficult to grasp for the public, politicians and professionals.

In RCTs, treatment-as-usual (TAU) groups in the United States are often exposed to risk factors that are both more severe and more numerous than those in Norway. The prevalence of stressors such as neighbourhoods with high rates of crime and substance abuse is more common in the United States. Moreover, the regular services to which MST was compared in Norway were likely to be more comprehensive and to have more elements of treatment than the regular services offered to comparison groups in previous MST trials in North America. In the United States, ‘regular services’ often consist of probation office visits and referral to social services when deemed necessary. In Norway, they involve a wide array of social services and mental health treatment, including placement in institutions and in-home services.

With respect to organisational and economic context

The new programme challenged the traditional strategy of placing children and youth out of home in institutions or foster homes for longer periods of time. When children and, to a greater extent, youth are treated within their family and local environment, the result can be increased pressure on their social networks, including families, schools and neighbourhoods.

Some local agency leaders were not prepared for the new demands that were put on them and their agencies to establish practical routines for recruiting and training, as well as to support the evidence-based practices of MST. There are still great variations in how much leaders of local agencies and regional services have adapted their leadership style to the needs and demands of MST. Some still claim that it would be better to incarcerate the young offenders. This is as much a policy discussion as a discussion about ‘what works’ for children who act out, and we expect this to be a part of the continuing discussion about ‘punishment or treatment’ in Norwegian society. Efforts to treat drug abuse in family-based treatment programmes such as MST and MST/CM were particularly challenging. There were several challenges and controversies in the process of implementing the evidence-based programmes, particularly in the initial phases. Critics claimed that the ‘relation’ was more important than the ‘evidence’ and that the practitioners had to be more important than the programmes.

How they overcame the obstacles

With respect to individual professionals

In addition, to ensure that they had pragmatic appeal, the interventions were robust enough to adapt to contextual and cultural variations. Norwegian MST therapists and supervisors reported few problems in engaging ethnic minorities in treatment, stating that the highly contextual nature of the model helped to make it possible to adapt the treatment to each family’s cultural needs.

The introduction of the new programme was considered by some to be an implicit critique of regular practice, and the implementation team had to engage in several information and negotiation activities. No systematic strategy was applied in this process, and several ad hoc countermeasures were used, such as information meetings, emails, phone calls and distribution of written information such as journal articles, newspaper articles, etc.

With respect to social context

The power of the RCT replication studies nonetheless influenced attitudes towards MST and MST/CM in Norway, and both are now part of regular practice in Norway.

With respect to organisational and economic context

The RCT replication studies made an important contribution to establishing the credibility of the programmes. MST and MST/CM developed in North America seemed to work equally well in Norway. The programmes were initially implemented with no major modification of the original model. Few adaptations were called for in order to make the programmes work in the Norwegian context, and the programmes’ ability to match the individual families’ needs and situations were indicated by the low number of dropouts from treatment, encouraging youth outcomes and positive user evaluations. ‘Core components’ were defined by both the developers and the Norwegian change agents as those with the strongest empirical underpinnings in controlled trials. They appeared to work equally well in Norway and the United States.

An large amount of MST training material has been translated, but it could not be translated back and forth in a rigorous way without totally altering the clinical meaning of the texts. Therefore, English sentences had to be rewritten to make sense in Norwegian. It was considered clinically important that the translation be done by the staff members at the Department for Adolescents, who were all bilingual and specialists in clinical psychology.

To a very small extent, the local services had to transfer funding from existing resources. Long-term financial support from the ministries through the Norwegian Centre for Child Behavioural Development (NCCBD) has been crucial for the sustainability of the fidelity of the programmes and to handle turnover of therapists.

Lessons learnt

With respect to individual professionals

The turning point for many of the therapists happened when the parents receiving PMTO (Parent Management Training — Oregon mode) and MST expressed their satisfaction with the positive changes in their families and in their children’s behaviour. Moreover, the objections and resistance did not reduce the number of practitioners volunteering to learn and practise the programmes.

With respect to social context

The experiences from Norway could serve as a model and inspiration for large-scale implementation of MST in other nations. It is possible to have clear standards for training and evaluation of competence that ensure implementation fidelity and support local efforts.

With respect to organisational and economic context

Federal funding of training and technical support, combined with allowing agency employees to volunteer to participate, is a promising strategy. Moreover, research should be an integrated part of the implementation of MST.

Among the factors that may have contributed to the long-term sustainability and effectiveness of MST in Norway, the following seem to be most important: (1) a genuine interest in and commitment to the national implementation of evidence-based practices at the political and administrative levels, (2) increased interest in evidence-based practices among practitioners, (3) establishing a self-sustaining national centre for implementation and research, (4) the ability of the programme developers to support the implementation and research efforts, and (5) positive evaluations from families and positive media feedback.

Strengths

Home-based treatment, a national centre for training, quality assurance and research, long-term funding, support at the policy level and from the public.

Weaknesses

Expensive, not in accordance with the theoretical orientation of most practitioners in the field (who are eclectic or psychodynamically oriented), competition from non-evidence-based interventions, including treatment institutions and group homes.

Opportunities

Increased capacity and competence in the treatment of serious behavioural problems, including crime and drug abuse; early interventions for adolescents at risk of entering a drug abuse trajectory; and empowering parents, families and networks.

Recommendations

With respect to organisational and economic context

Implement several evidence-based programmes, for instance MST, functional family therapy and Treatment Foster Care Oregon, so that there are opportunities to choose from among them.

Note from the authors

Multisystemic Therapy (MST) & MST/ Contingency Management (CM)   

Number of implementations
1
Country
Norway
Last updated : 02.12.2024
Country of origin
USA
Last reviewed:
Age group
11-14 years
Target group
Young people aged 12-14 years and their families
Programme setting(s)
Community
Family
Level(s) of intervention
Selective prevention
Universal prevention

Strengthening Families 10-14 is a seven-session programme for families with young adolescents that aims to strengthen family protection and resilience-building processes and reduce family risk related to adolescent substance abuse and other problem behaviours. The weekly two-hour sessions include separate parent and child skills-building followed by a family session where parents and children practise the skills they have learned independently, work on conflict resolution and communication, and engage in activities to increase family cohesiveness and positive involvement of the child in the family.

Parents are taught how to clarify expectations based on child development norms relating to adolescent substance use, how to use appropriate disciplinary practices, how to manage strong emotions regarding their children and how to communicate effectively. Children are taught refusal skills to help them deal with peer pressure and other skills for personal and social interaction. These sessions are led by three-person teams and include an average of eight families per session.

Keywords
No data
Links to this programme in other registries
USA - Blueprints Programs
UK - CAYT - mentor-adepis
UK - Early Intervention Foundation Guidebook
Germany - Green List Prevention
Poland - Programy Rekomendowane
Spain - Prevención basada en la Evidencia
Contact details

Dr Cathy Hockaday, PhD
Iowa State University
1087 Lebaron Hall
Ames, IA 50011-4380
United States of America
Phone: 1 (515) 294-7601
E-mail: hockaday[a]iastate.edu
Website: www.extension.iastate.edu/sfp

Show link
0
Evidence rating
Unlikely to be beneficial
Studies overview

The Strengthening Families Programme was developed by Karol Kumpfer for children ages 6-11 in the 1990s and is known as the Utah version. Since that time the Utah Strengthening Families Program has been modified for younger children (ages 3-5) and young teens (ages 13-17). Researchers at Iowa State University collaborated to adapt and study SFP for families with early adolescence (SFP for Parents and Youth 10-14), which is known as the Iowa version or SFP 10-14.

The SFP 10-14 version has been evaluated in several randomised controlled trials (RCTs) in Europe in, respectively, Germany (Baldus et al., 2016; Bröning et al., 2017), Poland (Foxcroft et al., 2017), the UK (Moore, 2009; Segrott et al., 2022) and Sweden (Skärstrand et al., 2014; Jalling et al., 2016). Quasi-experimental evaluations were conducted in the UK (Coombes et al., 2012) and Spain (Ballester et al., 2020; Orte et al., 2015). Moreover, the program is cited by one of the developers (Kumpfer et al., 2018) to be implemented in Italy, the Netherlands, Norway, Slovenia, Austria and France.

In the German RCT (Baldus et al., 2016; Bröning et al., 2017), families with a young person aged 12-13 years were eligible to participate. The programme had a booster session 4-6 months later, and assessments were conducted at post-test, six months (i.e. after the booster) and 18 months after the post-test. The primary outcomes were self-reported lifetime tobacco, alcohol and cannabis use at 18 months. Parents and young people also reported behavioural problems. Only the outcome of lower lifetime tobacco use among the SFP 10-14 group compared to the control group was significant. A secondary analysis in this very small sample and relatively young sample indicates that high-risk groups in the SFP-D condition achieved the best results compared with all other groups, especially in mental health and quality of life.

In the Polish RCT (Foxcroft et al., 2017), communities were randomised and families with children aged 10-14 could participate. The primary outcomes were self-reported alcohol, cigarette and other drug use, alcohol use without parent permission, drunkenness and binge drinking in the past 30 days at 12 months and 24 months after baseline. There were no effects on primary outcomes, parenting skills, parent-child relations or child problem behaviour. Foxcroft et al. (2017) state that their null findings may be due to the 24-month follow-up being insufficient to detect positive effects, selection bias resulting from four communities not being randomised to study conditions, a high level of attrition and the fact that one-third of subjects were aged 13-14.

The Swedish cluster RCT study (Skärstrand et al., 2014) involved children aged approximately 12 years and the programme included additional material on alcohol and drugs. It conducted three yearly assessments i.e. mid-programme, post-test and a one-year follow-up. There was no statistically significant effect at any time point on any measure of self-reported smoking, alcohol or drug use. The evaluators contend that the failure to replicate the positive effects found in USA based studies could be due to failure to implement the program with sufficient fidelity, cultural differences or significant alterations to the content of the SFP 10-14.

In the other Swedish RCT (Jalling et al., 2016), at-risk young people aged 12-18 years (indicated by one delinquent behaviour, bullying, repeated conflicts regarding family rules, use of alcohol, tobacco or drugs, or excessive computer use) were randomised to ParentSteps (described as the Swedish shortened version of the Strengthening Families Program 10–14 although it only involves parent sessions), Comet (a programme aiming to help parents develop parenting skills) or a control group. No effects were found for parent-reported problem child behaviour or adolescent-reported anti-social behaviour, delinquency, alcohol or drug use or psychosocial functioning.

The English study (Moore, 2009) involved children aged 10-14 years. Segrott and colleagues (2022) evaluated this adapted UK version (SFP10-14UK, with seven weekly sessions) which brought together families who identified as likely or not likely to experience or present with challenges within a group setting. This pragmatic cluster-randomised controlled effectiveness trial, with families as the unit of randomization (n=715) measured occasions young people reported drinking alcohol in the last 30 days; drunkenness during the same period, and alcohol/tobacco/substance behaviours (age of initiation, frequency, related problems). No statistically significant differences between the two study conditions were observed at the 24-month follow-up on either of the two primary outcomes (previous 30-day alcohol use and having been drunk in the previous 30 days) (Segrott et al., 2022). The authors highlight the importance of evaluating interventions when they are adapted for new settings.

The programme has been rated as Promising by Blueprints for Healthy Youth Development based on a review of studies conducted world-wide.

References of studies

Studies Included in the Assessment Process:

Jalling, C., Bodin, M., Romelsjö, A., Källmén, H., Durbeej, N., & Tengström, A. (2016). Parent programs for reducing adolescent’s antisocial behavior and substance use: a randomized controlled trial. Journal of child and family studies, 25(3), 811-826.

Foxcroft, D. R., Callen, H., Davies, E. L., & Okulicz-Kozaryn, K. (2017). Effectiveness of the Strengthening Families Programme 10-14 in Poland: Cluster randomized controlled trial. European Journal of Public Health, 27, 494–500.        

Foxcroft, D. R., Callen, H., Davies, E. L., & Okulicz-Kozaryn, K. (2017). Effectiveness of the Strengthening Families Programme 10-14 in Poland: Cluster randomized controlled trial. European Journal of Public Health, 27, 494–500.    

 Skärstrand, E., Sundell, K., & Andréasson, S. (2013). Evaluation of a Swedish version of the Strengthening Families Programme. The European Journal of Public Health, 24(4), 578-584.Baldus, C., Thomsen, M., Sack, P. M., Bröning, M., Arnaud, N., Daubmann, A., & Thomasius, R. (2016). Evaluation of a German version of the Strengthening Families Programme 10-14: A randomized controlled trial. European Journal of Public Health, 26, 953–959.    

Segrott, J., Gillespie, D., Lau, M., Holliday, J., Murphy, S., Foxcroft, D., Hood, K., Scourfield, J., Phillips, C., Roberts, Z., Rothwell, H., Hurlow, C., & Moore, L. (2022). Effectiveness of the Strengthening Families Programme in the UK at preventing substance misuse in 10–14 year-olds: a pragmatic randomised controlled trial. BMJ Open, 12(2), e049647. https://doi.org/10.1136/bmjopen-2021-049647

Studies not Included in the Assessment Process:

Ballester, L., Amer, J., Vives, M., March, M. X., & Pozo, R. (2020). Preventing internalizing and externalizing symptoms in adolescents through a short prevention programme: An analysis of the effectiveness of the universal Strengthening Families Program 11-14. Child and Adolescent Social Work Journal, 37, 1–13.
Reason for exclusion: QED, not RCT. 6-month follow-up, positive outcomes on externalising and internalizing behaviour, no substance use outcome

Bröning, S., Baldus, C., Thomsen  M., Sack, P., Arnaud, A., Thomasius, R. (2017). Children with Elevated Psychosocial Risk Load Benefit Most from a Family-Based Preventive Intervention: Exploratory Differential Analyses from the German “Strengthening Families Program 10–14” Adaptation Trial. In Prevention Science (Vol. 18,  932–942)
Reason for exclusion: secondary analysis

Coombes, L. Allen, D. and Foxcroft, D. (2012), ‘An exploratory pilot study of the Strengthening Families programme 10-14 (UK)’, Drugs: Education, Prevention and Policy 19, 387-396.
Reason for exclusion: “Participant recruitment to the study was slow and many families were reluctant to be randomly allocated, instead indicating a preference for the SFP10–14 (UK) group. Rather than abandoning the trial, a decision was made to proceed as a quasi-experimental study, that is, without randomization” (study protocol)    

Kumpfer, K. L., & Magalhães, C. (2018). Strengthening families program: An evidence-based family intervention for parents of high-risk children and adolescents. Journal of Child & Adolescent Substance Abuse, 27(3), 174-179.        
Reason for exclusion: Review paper on contents and research of SFP. Not an effectiveness study. 

Kumpfer, K. L., Xie, J., & O’Driscoll, R. (2012, April). Effectiveness of a culturally adapted strengthening families program 12–16 years for high-risk Irish families. In Child & Youth Care Forum (Vol. 41, No. 2, pp. 173-195). Springer US.
Reason for exclusion: No follow-up (retrospective pre-test), No substance use related outcomes, No analysis of interaction of selection & maturation, Differential baseline differences not controlled for. 

Moore, L. (2009). Project SFP Cymru: Evaluating the impact of the Strengthening Families 10-14 UK Programme on substance misuse. Trial register: https://www.isrctn.com/ISRCTN63550893&nbsp;

Non-EU studies

Guyll, M., Spoth, R. L., Chao, W., Wicrama, K. A. S. and Russel, D. (2004), ‘Family-focused preventive interventions: evaluating parental risk moderation of substance use trajectories’, Journal of Family Psychology, 18, pp. 293-301.    

Harrison, R. S., Boyle, S. W. and Farley, O. W. (1999), ‘Evaluating the outcomes of family-based intervention for troubled children: a pretest-posttest study’, Research on Social Work Practice 6, pp. 640-655.     

Redmond, C., Spoth, R., Shin, C. and Lepper H. (1999), ‘Modeling long-term parent outcomes of two universal family-focused preventive interventions: one-year follow-up results’, Journal of Consulting and Clinical Psychology 67, pp. 975-984.      

Spoth, R., Redmond, C. and Shin, C. (1998), ‘Direct and indirect latent-variable parenting outcomes of two universal family-focused preventive interventions: extending a public health-oriented research base’, Journal of Consulting and Clinical Psychology 66, pp. 385-399.     

Spoth, R., Redmond, C. and Lepper, H. (1999), ‘Alcohol initiation outcomes of universal family-focused preventive interventions: one- and two-year follow-ups of a controlled study’, Journal of Studies on Alcohol 13, pp. 103-111.

Spoth, R., Reyes, M. L., Redmond, C. and Shin, C. (1999), ‘Assessing a public health approach to delay onset and progression of adolescent substance use: latent transition and loglinear analyses of longitudinal family preventive intervention outcomes,’ Journal of Consulting and Clinical Psychology 67, pp. 619-630.

Spoth, R. L., Redmond, C. and Shin, C. (2000), ‘Reducing adolescents’ aggressive and hostile behaviors’, Archives of Pediatric and Adolescent Medicine 154, pp. 1248-1257.

Spoth, R. L., Redmond, C. and Shin, C. (2001), ‘Randomized trial of brief family interventions for general populations: adolescent substance use outcomes 4 years following baseline’, Journal of Consulting and Clinical Psychology 69, pp. 627-642.

Spoth, R. L., Guyll, M. and Day, S. X. (2002), ‘Universal family-focused interventions in alcohol-use disorder prevention: cost-effectiveness and cost-benefit analyses of two interventions’, Journal of Studies on Alcohol 63, pp. 219-228.

Spoth, R., Guyll, M., Trudeau, L. and Goldberg-Lilehoj, C. (2002), ‘Two studies of proximal outcomes and implementation quality of universal preventive interventions in a community-university collaboration context,’ Journal of Community Psychology 30, pp. 499-518.

Spoth, R. L., Redmond, C., Trudeau, L. and Shin, C. (2002), ‘Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programmes’, Psychology of Addictive Behaviors 2, pp. 129-134.

Spoth, R., Redmond, C., Shin, C. and Azevedo, K. (2004), ‘Brief family intervention effects on adolescent substance initiation: school-level growth curve analysis 6 years following baseline’, Journal of Consulting and Clinical Psychology 72, pp. 535-542.

Spoth, R. L., Clair, S., Shin, C. and Redmond, C. (2006), ‘Long-term effects of universal preventive interventions on methamphetamine use among adolescents’, Archives of Pediatric Adolescent Medicine 160, pp. 876-882.

Trudeau, L., Spoth, R., Randall, G. K. and Azevedo, K. (2007), ‘Longitudinal effects of a universal family-focused intervention on growth patterns of adolescent internalizing symptoms and polysubstance use: gender comparisons,’ Journal of Youth and Adolescence 36, pp. 725-740.

Spoth, R. L., Trudeau, L., Guyll, M., Shin, C. and Redmond, C. (2009), ‘Universal intervention effects on substance use among young adults mediated by delayed adolescent substance initiation’, Journal of Consulting and Clinical Psychology 77, pp. 620-632.

Spoth, R., Clair, S. and Trudeau, L. (2014), ‘Universal family-focused intervention with young adolescents: effects on health-risking sexual behaviors and STDs among young adults’, Prevention Science 15, pp. 47-58.

Countries where evaluated
Germany
Poland
Sweden
United Kingdom
Protective factor(s) addressed
Family: attachment to and support from parents
Family: opportunities/rewards for prosocial involvement with parents
Family: parent social support
Individual and peers: refusal skills and decision making
Individual and peers: skills for social interaction
Risk factor(s) addressed
Family: family conflict
Family: family management problems
Family: neglectful parenting
Family: parental attitudes favourable to alcohol/drug use
Individual and peers: early initiation of drug/alcohol use
Individual and peers: favourable attitude towards alcohol/drug use
Individual and peers: favourable attitudes towards anti-social behaviour
Individual and peers: interaction with antisocial peers
Outcomes targeted
Academic performance
Depression or anxiety
Other mental health outcomes
Relations with parents
Alcohol use
Use of illicit drugs
Smoking (tobacco)
Other behaviour outcomes
Description of programme

The seven-session programme for families with young adolescents is based on the biopsychosocial model and aims to strengthen family protection and resilience-building processes and reduce family risk. Sessions are conducted once weekly for seven weeks. The first six sessions last two hours, consisting of one hour of separate parent and child skills-building followed by a one-hour family session where parents and children practise the skills they have learned independently, work on conflict resolution and communication, and engage in activities to increase family cohesiveness and positive involvement of the child in the family. The final session is a one-hour family interaction session without the concurrent parent and child training sessions.

Parents are taught means of clarifying expectations based on child development norms relating to adolescent substance use, how to use appropriate disciplinary practices, how to manage strong emotions regarding their children and how to communicate effectively. Essential programme content for the parent skills training sessions is contained on videotapes that include family interactions illustrating key concepts. Children are taught refusal skills to help them deal with peer pressure and other skills for personal and social interaction. During the family sessions, family members practise conflict resolution and communication skills and engage in activities designed to increase family cohesiveness and the positive involvement of the child in the family. These sessions are led by three-person teams and include an average of eight families per session. The length of the intervention may depend on where it is delivered, that is, in a school, in a group or at home. The programme is delivered by certified group leaders, site coordinators or supervisors.

The Strengthening Families Programme was developed by Karol Kumpfer for children ages 6-11 in the 90ies and is known as the Utah version. Since that time the Utah Strengthening Families Program has been modified for younger children (ages 3-5) and young teens (ages 13-17).

Researchers at Iowa State University collaborated to adapt and study SFP for families with early adolescents (SFP for Parents and Youth 10-14), which is known at the Iowa version or SFP 10-14.

Intervention variation

In Sweden, a version of the Strengthening Families 10-14 programme adapted to Swedish conditions, including through some modifications to the programme format agreed with the programme’s developer, is implemented. The Swedish version consists of two parts. Part one comprises seven sessions, delivered over seven consecutive weeks in grade 6 (12 years of age); there are six separate sessions for children and their parents, with one joint family session. Part two comprises five sessions, delivered over five consecutive weeks in grade 7 (13 years of age); there are four separate sessions for children and their parents, with one joint family session. This differs from the original programme, where each weekly session includes a separate hour for parent and child, and then one hour with parents and children together.

The programme content is similar to the original Strengthening Families 10-14 programme to a large extent, although some family session topics are omitted due to the change in format/delivery. Whereas the original programme is held in community centres with parent and child sessions run at the same time, for practical reasons, the child sessions in the Swedish version are run during school hours and parent sessions are run separately in the evening, so ‘some family components were lost’. Youth sessions are conducted by class teachers, with the assistance of a group leader. Group leaders conduct parent sessions. All group leaders are trained by certified Strengthening Families 10-14 trainers. The Swedish version also includes some new material in part two, designed to enhance the alcohol and drug content.

Implementation Experiences
Feedback date
Contact details

Cátia Magalhães
catiacmagalhaes[a]gmail.com
 

Main obstacles

With respect to individual professionals

- Recruitment of families when an agency or school start up is always difficult until there is positive word of mouth and agency staff buy-in to get referrals.
- Select and implement and evidence-based programme instead of other programmes that are on offer.

With respect to social context

Once in a while, the resistance to adopting EBPs from other countries arises because of the perceived difficulties in adapting them to new cultures or new situations.
- Initially the weeks of the programme and the number of sessions.

With respect to organisational and economic context

- Financial issues (raise the funds from local foundations and agencies).
- Selecting and implementing EBPs instead of other programmes that are on offer (and can be shorter and less expensive, although with less positive results).

How they overcame the obstacles

With respect to individual professionals

- Called and talked with families and targeted schools.
- Talked with people from the representative agencies of the targeted populations.
- Spread and disseminated EBPs and practices through professionals.

With respect to social context

- Adapt the programme to the unique needs and situational/social context while preserving the programme´s core content.
- Overcome barriers to programme implementation and implement strategies to increase recruitment and retention.

With respect to organisational and economic context

- Spread and disseminate evidence-based programmes and practices through local agencies and local government.
- Cost-effectiveness of EBPs compared with non-EBPs and practices.
- Explain risk and protective factors of the context.

Lessons learnt

With respect to individual professionals

- It is important to select, train and supervise staff (group leader or facilitator) to assure quality implementation.
- Supervision from programme implementer or national/local coordinator.
- Cultural adaptations are needed to maintain fidelity to the original programme.

With respect to social context

- Parents and families want universal family values. So it’s important to become familiar with the targeted population’s cultural values, priorities and characteristics.
- We can adopt EBPs from other countries and have similar positive and significant results.

Strengths

- The programme is durable and has large positive outcomes in its first implementation in Portugal, like in other several countries.
-The material and format are easy to use.
- Sensitivity towards language barriers and cultural factors.
- Topics and session contents.
- Three groups/moments: parents, children and family (parents and children together).

Weaknesses

- Group version is staff-intensive and costly.

Opportunities

- Having existing paid staff or volunteers from the community to implement the programme can help to reduce the staff costs.
- Working with local agencies and government services (e.g. social services, children protection commissions).

Threats

- Financial issues (taking into account economic, national and local context).

Recommendations

With respect to individual professionals

- Good staff selection and training/supervision.
- Training staff in EBPs and core components of the programme.
- Ethnically and linguistically matched to the target population.

With respect to social context

- Disseminate the results and effectiveness of the programme.
- Carefully identify the most pressing problems/risks and protective conditions (helps to guarantee better outcomes).
- Include cultural adaptation of the programme.

With respect to organisational and economic context

- Disseminate the results and effectiveness of the programme.
- Cost-effectiveness studies.
- Develop practical collaborations between practitioners, clients, policymakers, researchers, etc. to improve programme implementation and dissemination.

Number of implementations
1
Country
Portugal
Feedback date
Contact details

Joan Amer
joan.amer[a]uib.es
 

Main obstacles

With respect to individual professionals

Lack of training and need of understanding of the theory of change of the programme. Temporary jobs, which mean lack of stability: changes in professionals from one application to other.

With respect to social context

Need of network and social support within neighbourhoods. Need of cooperation between social services and educational services.
Seasonal job market. Lack of bond with communities, due to unstable housing.

With respect to organisational and economic context

  1. Eventually, in some applications, specific support had to be implemented for some children who disrupted the functioning of the sessions.
  2. In other cases, the protocol had to be implemented in order to exclude some participants that fullfilled the requirements of exclusion criteria. This is the case of some children with active antisocial behaviour. This rarely happened and it was because these children were not detected at the selection process prior to the programme.
How they overcame the obstacles

With respect to individual professionals

Improvement of the system of selection of professionals, better connections with those NGOs with competent and experimented professionals.
Increase and improvement of training: further hours of training, more dedication to emotional techniques and roleplaying.

With respect to social context

Better networking with professionals in the communities: preparatory sessions, linking and bonding with relevant educational professionals.
Utilisation of social networks (web etc.) for improving communication.

With respect to organisational and economic context

  1. Once the specific educational needs were identified, the implementation team (educators, coordinator and members of our research group) would decide the type of adapations of the programme.
  2. Principally, specific support to the child would be implemented (sometimes with the participation of some collaborator from the university).
  3. Different strategies were also prepared for the child to make sure that she or he acquires the essential contents and participates as much as possible in the dynamics of the group.
Lessons learnt

With respect to individual professionals

The importance of experienced professionals, but also of availability for learning and adherence to the programme.

With respect to social context

The counterpart: social service, school and/or NGO that you are working with is critical for the quality of the implementation.

With respect to organisational and economic context

The opportunity to implement a standardised academic programme with elements of community and family intervention.

Strengths
  1. Taking into account the results and the evaluation of the Spanish programme, we are able to state that SFP can be successfully adopted without compromising effectiveness. Our results suggest that the validated programme for the Spanish population (PCF) accomplishes its objectives and is valid for positively modifying protection and risk factors. Furthermore, effectiveness of the culturally adapted programme is tested in parents, children and families. Training for parents increases their parenting skills; training for children enhances their social capacities and personal development; and family training improves both positive relations at home and parental implication.
  2. This programme addresses issues that an "insider" or "autochthonous" (using the terms of the questionnaire) may not have considered. Different aspects are incorporated. External perspective offers new ideas and proposals.
  3. The allochthonous component of the programme makes the results more valuable. It is feasible to implement succesfully a programme of these characteristics: results of the applications in the Spanish adaptation are consistent with those obtained by SFP in reference applications (Kumpfer, 2003; Kumpfer et al., 2008), demonstrating its effectiveness.
  4. Spanish adaptation of the programme (PCF) has demonstrated that the programme is valid to work with populations that are socially and culturally different. Results of this adaptation demonstrate that the programme is able to be effective both in Spain and internationally.
  5. Overall evaluation is positive. We are satisfied with the results. Last, we specially appreciate and highlight the innovative component of the programme within family intervention
  6. The protocol has been implemented without major or significant difficulties. In the case of families with uncovered basic needs, we had the support of professionals from social services. These professonials also monitored the demands of those families.
Weaknesses

Previous to the implementation of the programme, aspects such as physical punishment were not included in the Spanish adaptation.

Opportunities
  1. It is important to share the specific experiences, implementations and outcomes in different countries and settings in order to exchange experience and improve/polish the programme. In this sense, initiatives such as this questionnaire are very useful.
  2. Adaptations were made taking into account both the curriculum and the objectives of the programme. Adaptations implied modifications of formal aspects such as language and the presentation of resources. New activities and proposals were introduced to facilitate the performance of the sessions. Also incentives for children were revised.
  3. Context adaptation consisted mostly of modifications in language aspects, teaching proposals, games, illustrations, songs.
  4. Recent restrictive legislation on tobacco has had an important impact on levels of consumption.
  5. Advertising of alcohol (allowed) — even though legislation is becoming more restrictive.
Threats
  1. The Balearic Islands are an important mass tourism destination in Western Europe. Different implementations of the programme have been executed in coastal populations with high risk levels of social exclusion. Social exclusion in tourist resorts is principally due to the characteristics of the labour force in the tourism sector in the Balearic Islands: it is an unskilled, seasonal, intensive and low-wage workforce.
  2. In the case of our applications in the Balearics, seasonality of the tourist economy impacts in the scheduling of the programme. Parents can have serious difficulties attending the sessions during peak tourist season.
  3. The Balearic Islands have the highest rate of school drop out in Spain, greater than the average of the European Union.
  4. Age restrictions for going out — there is a permissive culture. The phenomenon of "Botellón": outdoor alcohol drinking.
  5. Negative attitudes towards illicit drug users — stereotypes or social prejudice can arise. It is frequently associated with crime.
Recommendations

With respect to individual professionals

Proper selection of trainers, and proper training. Training with both a theoretical background but also a practical focus (emotional techniques, leading group skills, roleplaying, etc.).

With respect to social context

It is important, first, to be aware of the level of cultural adaptation needed in each country or context and, second, to make use of the evaluation as a tool for permanent improvement of the programme.

With respect to organisational and economic context

  1. Organisational culture of the institution where the implementation takes place is important.
  2. Regarding economic context, characteristics of jobs of parents influence the level of participation. In our case, seasonal and unskilled jobs are predominant. Also the environment for adolescents is relevant. In the case of the Balearic Islands (Spain), there is easy acces to the job market (abandoning school) and a high presence in the resorts of leisure lifestyles with drug abuse due to the type of tourism.
Note from the authors

Family Competence Program (Spanish SFP)
PCF7-12 (Spanish adaptation of SFP6-11);  2015 on the PCF12-16 (adaptation)  

Number of implementations
1
Country
Spain
Feedback date
Contact details

Robert O'Driscoll
robert.odriscoll[a]hse.ie

Main obstacles

With respect to individual professionals

Staffing.

With respect to social context

The need to make sure that a needs assessment was conducted in the communities where the programme was intended to be implemented.

With respect to organisational and economic context

A lack of consistent organisational support.

How they overcame the obstacles

With respect to individual professionals

We developed an interagency implementation model. The key stakeholders included the Health Service Executive, local and regional drugs and alcohol task forces, the Child and Family Agency (TUSLA), the Gardaí (Community Policing) and Young Person’s Probation.

With respect to social context

Consulted with local service providers, who in turn consulted with service users around the need for and their willingness to participate in the SFP.

With respect to organisational and economic context

Sometimes sheer determination was required to overcome the lack of support from senior management and administrators.

Lessons learnt

With respect to individual professionals

The important lessons learnt were multi-level. Funding and management support were necessary at all levels; well-trained staff and facilities committed to the programme implementation and sustainment were needed. Including the families as much as possible in the planning, implementation and evaluation of programmes was necessary. It is important to create a space within the implementation infrastructure and architecture for the implementers to come together and work through the tensions and dilemmas that are likely to arise throughout the implementation process, so that the problems do not become embedded or become obstacles to the implementation process. Having well-qualified coordinators to guide the implementation process and to ensure programme fidelity and support the programme team was important.

With respect to social context

  • Implementing an evidence-based programme requires a well thought out implementation plan with commitment from all major stakeholders. It was interesting to see the competition among stakeholders for recognition of individual and agency-level commitments and the political climate that a successful implementation can create. It is worth noting that each agency wants to be recognised and associated with a successful programme, sometimes above and beyond the level of commitment they may have given to the implementation process, and very few want to work on or be associated with working through the problems that arise during the implementation.
  • An implementation team needs to be created around the SFP so that experience can accumulate over time.

With respect to organisational and economic context

A successful and sustained implementation of SFP requires a local “Champion” to promote the programme within and outside the organisational context. Programmes must be evaluated and the findings shared within the wider network of service providers, regionally at least and nationally if possible. The evidence will support the future sustainability of the programme in terms of funding and political support and contribute to an accumulating evidence base for the programme. An alliance with the programme developer can help to overcome organisational obstacles to the successful implementation of SFP.

Strengths

The evidence base for the programme is the strength of SFP.

Weaknesses

The resource-intensive nature of the programme.

Opportunities

The interagency model of service delivery can be used for other types of programme implementation but also contributes to the development of a strong network of distributed expertise that can be harnessed on behalf of vulnerable service users.

Threats

The political environment that can accrue around an evidence-based programme like SFP. Administrators and funders trying to implement a programme without the necessary knowledge and skills around the nuances of practice.

Recommendations

With respect to individual professionals

Make every effort to train staff well in the programme and to ensure that they have the requisite skills to work with families individually and in a group setting. To make evidence-based programmes like SFP part of the undergraduate curriculum.

With respect to social context

Undertake a needs analysis of the communities where SFP is intended to be implemented to make sure it is the correct fit for the local context.

With respect to organisational and economic context

Ensure adequate funding by evaluating programmes and publishing the results. Keeping administrative and funding support out of the practice environment while balancing the need for ongoing management support to sustain the programme with fidelity over time.

Number of implementations
1
Country
Ireland
Feedback date
Main obstacles

With respect to individual professionals

We implemented the RCT in 19 schools in Stockholm. The main obstacle was recruiting leaders to the programme to deliver both the children’s sessions, the parents’ sessions and the family sessions. We were planning to train teachers to deliver the children’s sessions, but they were not allowed to work extra hours during the evenings for the parents’ and family sessions.

With respect to social context

Recruiting schools, as this was an RCT and schools were randomly allocated to the programme and control groups.

With respect to organisational and economic context

Since this was a study, we had a limited budget.

How they overcame the obstacles

With respect to individual professionals

We resolved that obstacle by training retired schoolteachers to be in charge of the parents’ sessions in the evenings (on the same day that their children had their sessions). The retired schoolteachers also took part in the children’s sessions during the day, so they could make links between the children’s and parents’ sessions. We also changed the original programme format, in that we only had two family sessions in order to make it possible for children and parents to be together in the evening.

With respect to social context

We offered the control schools the chance to implement the programme after the study was over.

With respect to organisational and economic context

We had to make some alterations to the programme format and limit the family sessions.

Lessons learnt

With respect to individual professionals

It is hard to balance cultural adaptation and programme fidelity.

With respect to social context

Go out in person to the schools and talk about the study and the importance of taking part.

Strengths

The Swedish version does not differ significantly from the SFP 10-14 in terms of content. All the core components, like communication skills, family bonding, peer resistance skills, stress management, handling emotions, and communicating rules and consequences in relation to household chores, as well as expectations concerning substance use, are intact. Even though some of the family session components were omitted, we tried to make up for this by introducing links between the children’s and parents’sessions, and by adding extra weight to the content of the two existing family sessions.

Weaknesses

We were not able to hold all the family sessions.

Threats

It is not an easy task to adapt intervention programmes from one context or country to another. You must be able to culturally adapt the programme without losing the core components.

Note from the authors

Steg-för-Steg - a Swedish version of the Strengthening Families Program 10-14 (SFP 10-14)

Number of implementations
1
Country
Sweden
Feedback date
Main obstacles

With respect to individual professionals

  • Dominant practices to help parents are group discussions under the supervision of psychologists. Evidence-based educational and manualised programmes are not used.
  • Multiplicity of actors and actions
  • Heterogeneity and low level of training for family support professionals
  • Inexperience and reluctance to implement educational programmes for parents
  • No culture of scientific evaluation
  • Reluctance in relation to the project itself, in particular the commitment of families over time (14 weeks)

With respect to social context

  • Multiplicity of actors to inform and convince
  • Astonishment to see support for parenthood in the field of health
  • Frequent opposition in principle by the professionals involved in traditional forms of support to parenthood (standardised programme, Anglo-Saxon programme, caricature of behaviouralism)
  • Difficulties in choosing families: risk of touching "those who do not need it"

With respect to organisational and economic context

  • Municipal doubts during the first implementation of the programme:
    • Fear f not having qualified staff to play the role of facilitator
    • Financial cst (average announced = 15,000 euros for year 1)
      • appointment of a municipal coordinator of the programme plus four facilitators
      • funding of their working hours, training and facilitation of the 14 sessions
      • logistics: organisation of information meetings, provision of rooms adapted for the training and animation of the sessions
  • Low external "visibility" of the project for elected representatives (few families, unlike the "conference" mode)
How they overcame the obstacles

With respect to individual professionals

  • Slow progress of implementation on each site
  • On each site of implementation:
    • Several meetings setting up detailed infrmation about the programme: origin, concepts, principles, philosophy and ethics, results
    • Systematic invitatin of professionals involved in supporting families at our meetings
    • Distributing infrmation to the largest possible number of professionals from various fields (social, education, sport, culture) in contact with families
  • Positioning of the programme in the educational field, in complementarity with other parenting support actions
  • Presentation of the work done for SFP's cultural adaptation
  • Reinforcement of the training of those responsible for the programme’s implementation (at the theoretical level and at the level of action) highlighting the programme’s philosophy and its ethics

With respect to social context

  • Enthusiasm and perseverance
  • Clear and explicit, intense and diversified communications with elected representatives, funders, professionals and parents
  • Involvement and appreciation of local partners in reflection and implementation
  • Identification of cities as privileged partners in the implementation, valuing the benefits to them, in terms of training their teams
  • Targeting living areas of low income families

With respect to organisational and economic context

  • For the first implementations of PSFP in France:
  • Natinal funding
  • Supprt of decentralised departmental services: prefecture, social cohesion, city policy
  • Inclusion or support of PSFP to a device already in place: city health workshop, local education plan
  • Enthusiasm of professionals during the discovery of the programme
  • Interest, enthusiasm and satisfaction of parents
  • Interest of the elected officials
Lessons learnt

With respect to individual professionals

  • Interest in and necessity of a long phase of presentation and explanations to the greatest possible number of professionals on each site of implementation
  • Interest in and need to broaden the base of the professionals concerned; mobilisation of professionals in contact with families, not just those already involved in parenting support
  • Interest in and need for strengthening training, both in its content and in the number of people benefiting from it
  • Added value of the implementation and training process:
    • Individual: strengthening the prfessional skills in parenting support
    • Collective: better mutual knowledge and articulation between the professionals on each side

With respect to social context

  • Relevance of the association with the cities, recognized as a strong local partner, identified in the diversified support for families (social, educational, prevention, culture, sports, leisure) and already working in a network
  • Give incentives to cities (elected policy makers and local professionals) for the implementation and management of the programme
  • Need to obtain a commitment from elected representatives through a partnership agreement

With respect to organisational and economic context

  • Adaptation to the context and searching for local support are essential
  • Support from the cities in their search for funding
Strengths
  • The programme itself:
    • Its cncrete and experiential aspect for parents
    • The assciation of 3 time periods: parents / children / families
    • Quick enthusiasm frm trained professionals and parents
    • The ethics f facilitation
    • Orientation to parenting skills, mental health promotion
Weaknesses
  • Heaviness of initial investment, especially financial
Opportunities
  • Expansion of programme’s positioning
    • In the fight against the misuse f screen time
    • In the fight against social inequalities in health
Threats
  • Enough rigour to keep the programme in its original form, in 14 sessions and 3 time-periods (parents / children / families) and avoid losing fidelity
  • Enough perseverance in the training of professionals who develop and facilitate
Recommendations

With respect to individual professionals

  • Involve local professionals in setting up the programme
  • Analyse the training needs of developers and professionals
  • To be attentive to ethics of the facilitation of a programme that values parents
  • Strengthen training

With respect to social context

  • Analyse the appropriateness of the programme to local standards of support for parenting
  • Carefully choose target audiences
  • Broaden the objectives of the programme in the fight against the abuse of screens

With respect to organisational and economic context

  • Rely on existing partners or networks
  • Provide funding
Note from the authors

Programme de Soutien aux Familles et à la Parentalité 6-11 ans - French adaptation of the Strengthening Families Program

Number of implementations
1
Country
France
Feedback date
Contact details

Dina Kyritsi (Psychologist, MA, MBPsS)

dina_kyritsi[a]yahoo.gr

Main obstacles

With respect to individual professionals

Competition between the facilitators, especially in the youth sessions (which are delivered by two professionals  ), was an issue that we tried to overcome. Not all our facilitators had attended the same training course and most of them had never worked together as a team. The Strengthening Families Programme SFP10-14 presupposes good chemistry between the three facilitators who are responsible for a given group of families. In addition, it was important for the programme’s facilitators to always come very well prepared for the sessions. Their initial training was not enough, without investing personal time in preparing and practising for the sessions.  Cultural accommodation of the SFP10-14 for Greece provided strong grounds to warrant a pre-implementation stage in future planning, wherein all the facilitators meet and go through every activity of the sessions together to ensure a uniform understanding of its function and purpose within the session.  It is hard to evaluate how well the SFP10-14 was implemented in every group or the variation in the implementation between different groups. The post-implementation interview data could possibly point to weaknesses in the programme itself or how well the programme was executed. At the moment, there is no standardised tool to measure how well the sessions were delivered (external observers or a self-evaluation by the facilitators themselves could perhaps have served this purpose).  

With respect to social context

It was hard for our participants to follow the English-language DVDs with Greek subtitles that we utilised during the first implementation of the programme (we ended up reshooting the DVDs with Greek actors). In several vignettes (e.g., the shoplifting vignette), the responses of parents in the video were much milder than what would be ‘natural’ for a Greek parent, which made the DVD families ‘too good to be true’ in our participants’ eyes. It was hard to find something equivalent to replace such scenes, as this would have required rewriting the script, without having the option to consult or obtain permission from the programme’s US authors. Using ‘chores’ as a behaviour management tool was another core concept of the US programme that we found hard to intregrate into Greek family practice, as assisting with the household chores is usually not a highly valued behaviour in Greece for an adolescent pupil (frequently not even by his or her parents, who would prefer that he or she studies instead).
As regards the general social context, the parents were reluctant at some points to consider the methods proposed by the programme; they felt that they were somehow ‘American’ and they would be realistically hard to implement with their youth. In addition, several parameters related to background work for the implementation were very different from the US. For example, fortunately volunteerism is still common in the US, whereas in Greece - especially after our deep economic recession - there is no place for volunteerism, as everybody is striving to make ends meet. We had to consider not only the SFP10-14 families, but also our facilitators, who often had to leave their own, young children unsupervised, in order to undertake unpaid work for the programme.

With respect to organisational and economic context

It was hard to obtain license from the Greek Ministry of Education to access public schools, in order to inform parents and young people about the programme and recruit participants. Our country is not very open to innovative healthcare initiatives that are not centrally organised by the state.
Furthermore, as already argued, much of the facilitators’ work went beyond the SFP10-14 sessions. A flexible financial planning was able to account for the extra work that typically arises at the stage of adaptation (e.g., private, one-to-one time with the families who faced special challenges, identified when special needs came up during the sessions, or feedback from the facilitators, such as the observation diaries that they were asked to complete following each session). The financial demands are quite different between countries in which the SFP10-14 has been implemented for years and is running smoothly and countries in which the programme is being first introduced, such as Greece.

How they overcame the obstacles

With respect to individual professionals

An effort was made to build positive relations, empathy and team spirit within the Greek SFP10-14 team and to ensure the best match between the facilitators and our groups of families. In addition, we prepared plans and small maps for the facilitators’ use, as ‘personal assistants’, and we organised the various materials that the facilitators would need to use during each session. The Greek SFP10-14 manual has also included helpful tips proposed by the facilitators who had already delivered the programme in Greece.

With respect to social context

We reshot the DVDs using much simpler language. We replaced specific activities and chores that were considered ‘too American’ (e.g., billiards, bowling, gardening, cleaning the basement etc.) with more plausible alternatives. We replaced a few scenes that seemed ‘unnatural’ (e.g., the parents’ response to shoplifting). We also made sure that our DVDs did not include families of ethnicities that rarely immigrate to Greece (e.g., no coloured families were included, as in the UK DVD set; the Greek video portays an immigrant family of Filipino descent instead).
In addition, the adaptation of the DVDs has had to account to an extent for the difference in parenting values. It also required skilful handling on the part of the facilitators, who often anticipated the families’ concerns or opposition, before they were explicitly expressed in the group by the families.

With respect to organisational and economic context

We made every effort to highlight the affiliation of the US SFP10-14 with the Agia Sophia Hospital for Children, which is a University Clinic and the largest paediatric hospital in Greece and has formed for years the official basis of the Greek programme. This affiliation added weight to our endeavour in the eyes of officials in the Ministry of Education and the School Division of the Municipality of Athens as well as in the eyes of the participant families.
As to the financial demands, volunteer work was additionally required, in order to overcome financial shortage.
 

Lessons learnt

With respect to individual professionals

Our practice pointed to the need for supervision and evaluation of the programme’s facilitators, not only of the programme. Given that the pool of certified facilitators in Greece is necessarily limited (as very few training sessions have been offered), there were not many alternatives in case that something did not work out as planned. As with every project, tasks and deliverables need to be extremely clear right from the start (which is not easy when adapting an allochthonous programme, where several things may come up that were not prescribed, creating tension when several deliverables are not predicted from the outset).  

With respect to social context

It is important not to get carried away with the original material and to make sure that you test every  adaptation of the original material on several samples from the target population in advance, so as to ensure that all parts of the programme are meaningful in terms of language and cultural norms. When implementing an allochthonous programme  , you need to be faithful yet creative.

With respect to organisational and economic context

The programme’s protocol should explicitly allow time for the work required outside the sessions, instead of focusing on session delivery only. Especially in Greece where the SFP10-14 has not received any backing from the national health system or well-established agencies (which have supported the program in the US and the UK), project planning should allow time, space and a budget for the introduction, familiarisation, promotion and dissemination of the programme, rather than implementation only.

Strengths

1)    The SFP10-14 can be adapted successfully to other contexts (wider community/society, multiple settings) without compromising effectiveness.
2)    An allochtonous programme draws on the scientific advances of a different country. Most programmes produced in the same cultural context draw on a similar pool of resources and are based on the same mentality, the same ‘air’, the same dead ends. An allocthonous programme can bring a very refreshing innovation with a different perspective, which therefore prevents it from encountering the same, old dead ends. In addition, the Greeks generally trust scientifically based and tested allocthonous interventions (at least healthcare initiatives from North America and the UK).
3)    Therefore, it is feasible to successfully implement an allochthonous programme without compromising effectiveness.
4)    All parts of the US protocol were effective and continued to play their part; surprisingly, even the slogans (i.e, the SFP10-14 creeds or mottos), which are not common in Greece (except in advertisements) and thus would not normally be expected to work well in the context of a healthcare programme.
The US SFP10-14 addresses a very diverse socioeconomic and structural context. As long as you maintain this feauture, the programme will remain effective. For example, the home of a poor family in Greece may be different from the home of a poor family in the US, but the DVDs for both countries explicitly include both affluent and less affluent households, so that a Greek family of low socioeconomic status would also feel included.

Weaknesses

1)    Assessment of the effects of the SFP10-14 should not focus on prevention only. The budget for any cultural accommodation of the SFP10-14 in Europe was offered by the alcohol industry, perhaps with the effect that assessment focused heavily on alcohol prevention. Our implementation suggested that the true potential of the programme is highlighted only, when measures of family well-being are introduced. It is the Strengthening Families Program, after all! Our results (obtained from a battery of valid tests coupled with participant interviews) suggest that the programme did make a significant difference to the families’ lives (in terms of communication, conflict resolution, quality time together etc.), although we obtained non-significant results for most alcohol-related measures. A question of course would be how long after implementation do we measure the programme’s effectiveness as prevention (only longitudinal research could achieve this with validity) and also how can one measure effects in prevention, when the majority of the adolescent participants have zero contact with alcohol or drugs as a starting point during the sessions (floor effects are to be expected…). When an allochthonous programme is introduced, it is only natural that you have to adapt not only the programme, but also the allochthonous assessment, which usually depends on the funding resources of a foreign country and thus may obscure the true potential of the specific programme in your own country.
2)    10-14 does not necessarily correspond to the same age range across cultures. In several cases, our Greek participant parents reacted negatively, when the sessions made reference to drug use (e.g., the mention of ‘cannabis’), as they felt that their adolescents were too young to know about drugs. The SFP10-14 probably encompasses two quite different age groups already, with quite different challenges and needs.

Opportunities

1)    There is a fine line between being faithful to the original programme and coming up with materials that are too ideal for the country’s reality and are therefore perceived as artificial. It is important that the participants feel as if the programme were written exclusively for them, rather than as if they are being pushed towards believing that the programme is relevant to their own lives. In practice, things that seem awkward need to be replaced (even if 3 in a sample of 10 say that they are OK), rather than having the facilitators try to persuade the participants that they are OK, because the original programme includes them. The SFP is effective, only if the participants feel that it is.
2)    All references to non-relevant cultural context were omitted and replaced with their nearest, culturally appropriate equivalent. As an example, nobody gets a driving licence in Greece before the age of 18. Therefore, the mother’s anxiety in the video that her teenage son might drive drunk was replaced by anxiety that the boy might get into the car of an older friend who drinks and drives, or anxiety that he might get into a stranger’s car, when invited to do so, because of alcohol that is impeding his judgement. All such alterations were based on common sense, testing, feedback from the SFP10-14 pilot participants, survey feedback from an independent advisory group (our ‘panel of experts’) and data gathered from all our facilitators, who recorded their own subjective experience in delivering each session.
3)    We adjusted the time allocated to each activity during the SFP10-14 sessions, depending on the participants’ ability to follow as well as the relative weight of each activity. All our facilitators found it impossible to follow the rigid US time plan.
4)    As an exception, we allowed younger siblings (below 10 years) to attend, if a family really wanted to attend, but had nowhere to leave their younger child (We could not afford day care for the younger siblings’ during our sessions, as the US programme did).
5)    Finally, we provided extra services to several participant families for free, which was not included in the programme’s protocol. All the participant parents asked for some private counselling time, some feedback about special issues that the facilitators might have identified in relation to their child or their family during the sessions as well as feedback about their test results. Our team of psychologists did give them this extra time, but focused on remaining facilitators rather than family therapists. We also referred families to external services (e.g., the Municipality, public hospitals etc.), where they could continue receiving support after the programme, depending on the nature of their needs. We made use of our professional status, in order to intervene and ensure that they booked an appointment quickly, when it was hard for them to do so on their own. We helped a few families become eligible for discounts in specific supermarkets in the city. All the above were not included in the SFP protocol, but professional responsibility and human concern did not allow leaving individual families without any support, after they completed the programme.
 

Threats

By nature, the SFP10-14 targets a variety of heterogeneous domains and has a variety of objectives. A real threat to the programme would be to split it into parts, with each part being used independently. In this way, apart from unity, the programme would lose its validity and effectiveness. We witnessed such an attempt, when official agencies of status that work with addiction in Greece expressed their interest in showing the videos for sessions 5 and 6 only (i.e., the DVDs that focus on addiction) to the families of young people with addictions. Other professionals expressed a wish to use only the SFP10-14 tools and materials that specifically address stress and coping, etc. The possibility that the programme could be split into pieces in this way is still a big threat, as there is no centralised supervision at the moment and the holder of the original copyright is so far away from Greece (in kilometres).

Recommendations

With respect to individual professionals

It is crucial that the facilitators are higly motivated and very well prepared for each session that they deliver. The sessions entail much more than executing the instructions of the SFP10-14 manual (which nevertheless need to be very simple and explicit, so that the sessions are implemented in a uniform manner).

With respect to social context

1)    Implementation requires envisaging the actual practice of the sessions, deciding which activities you could save time from (i.e., time management — more than the ‘optional activities’ of the manual) and anticipating possible resistance from parents to the parts that feel too foreign to them. How will you defend the cultural appropriateness of your SFP?
2)    A group with a lot of children in the younger age range (10-12 years) will probably be more challenging, making it harder to fulfil the session targets. Youth sessions need to carefully invite a relatively uniform, in terms of age, group of pupils.

With respect to organisational and economic context

1)    The SFP10-14 utilises a pool of very impressive materials and posters, which, however, need to be covered very quickly in the sessions, due to time constraints. In practice, this might prove impossible, when the participants are not fluent readers (as in the case of our participant immigrant parents). You may need to sacrifice aesthetic quality, in order to maximise comprehension (colours, typeface, language) and to minimize the related costs of course.

2)    Finally, there has to be a uniform policy about how to handle very personal or ‘touchy’ issues that might be disclosed during the sessions, as the participants gradually open up. For example, at family session 6 (when all our parents were certain that their children were too young to know about drugs and a few even asked the facilitators to refrain from talking about drugs, because ‘the kids are still innocent’), a 10-year-old boy disclosed in front of the group that he had smoked hashish  at school. The boy was really innocent: he did not realise the significance of what he was saying. How do you handle this? Implementation needs to include a uniform policy about such issues, to be followed by all faciliators for the benefit of the programme.

Note from the authors

Strengthening Families Program, SFP10-14

Implemented in Athens between 2009-2013

Number of implementations
1
Country
Greece
Last updated : 09.01.2024
Country of origin
USA
Last reviewed:
Age group
11-14 years
15-18/19 years
Target group
Young offenders aged 12-16 years
Programme setting(s)
Community
Family
Juvenile justice setting
Level(s) of intervention
Targeted intervention

Treatment Foster Care Oregon (TFCO), formerly Multidimensional Treatment Foster Care, is an alternative to group or residential treatment, incarceration or hospitalisation for adolescents who have problems with chronic antisocial behaviour, emotional disturbance and delinquency. Community families are recruited, trained and closely supervised to provide TFCO-placed adolescents with treatment and intensive supervision at home, in school and in the community; clear and consistent limits with follow-through on consequences; positive reinforcement for appropriate behaviour; a relationship with a mentoring adult; and separation from delinquent peers. TFCO utilises a behaviour modification programme based on a three-level points system through which young people are provided with structured daily feedback.

As they accumulate points, they are given more freedom from adult supervision. Individual and family therapy is provided, and case managers closely supervise and support young people and their foster families through daily phone calls and weekly foster parent group meetings. There is an emphasis on teaching interpersonal skills and on participation in positive social activities including sports, hobbies and other forms of recreation. Placements in foster parent homes typically last for about six months. Aftercare services remain in place for as long as the parents want, but typically about one year.



Keywords
No data
Links to this programme in other registries
USA - Blueprints Programs
Norway - NUBU
The Netherlands - Databank Effectieve Jeugdinterventies
UK - Early Intervention Foundation Guidebook
Contact details

The Michael Rutter Centre for Children and Young People
South London and Maudsley NHS Trust
Email: jolanta.hernik[a]kcl.ac.uk
Website: www.tfcoregon.com

Evidence rating
Possibly beneficial
Studies overview

The programme has been evaluated in one randomised controlled trial in Sweden, and three quasi-experimental studies, one in Sweden nad two in the UK.

In Sweden, 46 young people aged 12 and 17 years old, meeting the diagnostic criteria for conduct disorder according to the DSM-UV-TR and at risk for immediate out-of-home placement were randomly allocated to MTFC or usual services. At post-test, significantly fewer youth in the MTFC group were placed in locked settings. Two years after the intervention ended, there was no effect on being placed in locked settings or substance abuse. Youth receiving MTFC were significantly less likely to engage in violent crime during the study period. There was no effect on parent or self-reported behaviour.

In the Swedish quasi-experimental study, 35 youth with a mean age of 15.4 years, diagnosed of a conduct disorder according to the DSM-IV and at risk of immediate out-of-home placement participated. Based on data collected immediately post intervention and 12 months later, the intervention had significant positive effects on parent and self-reported externalising behaviour and parent reported internalising behaviour, but not on self-reported internalising behaviour and psychiatric symptoms.

In the UK, 47 serious and persistent offenders facing an imminent custodial sentence participated. 23 received the intervention and 24 were either sentenced to custody or in four cases sentenced to an intensive supervision and surveillance programme. At posttest, the youth receiving the intervention were significantly less likely to be reconvicted. Only 22% of youth receiving MTFC compared to 50% of the comparison group had re-entered custody.

In another UK study, participants were youth aged 11 to 16 yeas and in a placement which was unstable, at risk of breakdown or not meeting their assessed needs or at risk of custody or secure care and were showing complex or severe emotional difficulties and/or challenging behaviour. 34 youth were randomised to MTFC or control, and a further 92 young people receiving MTFC and 93 receiving control services were included. There was no significant difference between groups. After adjusting for initial risk, the study found that young people who had been more disruptive at baseline were significantly less so at follow-up if they had received MTFC.

References of studies

Outcome evaluations/results:

Biehal, N., & Ellison, S., & Sinclair, I. (2011). Intensive fostering: An independent evaluation of MTFC in an English setting. Children and Youth Services Review, 33, 2043-2049.

Biehal, N., Dixon, J., Parry, E., Sinclair, I., Greenlaw, J., Roberts, C. and Roby, A. (2012), ‘The care placements evaluation (CaPE) evaluation of multidimensional treatment foster care for adolescents (MTFC-A)’.

Hansson, K., & Olsson, M. (2012). Effects of multidimensional treatment foster care (MTFC): Results from a RCT study in Sweden. Children and Youth Services Review, 1929-2936.

Westermark, PK, Hansson, K. & Olsson, M. (2011). Multidimensional treatment foster care (MFTC): Results from an independent replication. Journal of Family Therapy, 33: 20-41

 

Concept papers/other:

*Bergström, M. and Höjman, L. (2015), ‘Is multidimensional treatment foster care (MTFC) more effective than treatment as usual in a three-year follow-up? Results from MTFC in a Swedish setting’, European Journal of Social Work 19, pp. 1-17.

Chamberlain, P. (1990), ‘Comparative evaluation of specialized foster care for seriously delinquent youths: a first step’, Community Alternatives: International Journal of Family Care 2, pp. 21-36.

Chamberlain, P. and Reid, J. B. (1991), ‘Using a specialized foster care treatment model for children and adolescents leaving the state mental hospital,’ Oregon Social Learning Centre (draft).


Chamberlain, P., Moreland, S. and Reid, K. (1992), ‘Enhanced services and stipends for foster parents: effects on retention rates and outcomes for children’, Child Welfare League of America 71, pp. 387-401.


Chamberlain, P. and Reid, J. B. (1994), ‘Differences in risk factors and adjustment for male and female delinquents in treatment foster care’, Journal of Child and Family Studies 3, pp. 23-39.


Chamberlain, P., Ray, J. and Moore, K. (1996), ‘Characteristics of residential care for adolescent offenders: a comparison of assumptions and practices in two models’, Journal of Child and Family Studies 5, pp. 285-297.

Chamberlain, P. (1997), ‘The effectiveness of group versus family treatment settings for adolescent juvenile offenders’, paper presented at the Society for Research on Child Development Symposium, Washington DC, 3 April 1997.

Chamberlain, P. and Reid, J. (1998), ‘Comparison of two community alternatives to incarceration for chronic juvenile offenders’, Journal of Consulting and Clinical Psychology 5, pp. 857-863.


Chamberlain, P., Leve, L. D. and DeGarmo, D. S. (2007), ‘Multidimensional Treatment Foster Care for girls in the juvenile justice system: 2-year follow-up of a randomized clinical trial’, Journal of Consulting and Clinical Psychology 75, pp. 187-193.

Eddy, J. M. and Chamberlain, P. (2000), ‘Family management and deviant peer association as mediators of the impact of treatment condition on youth antisocial behavior’, Journal of Consulting and Clinical Psychology 68, pp. 857-863.

Eddy, J., Whaley, R. and Chamberlain, P. (2004), ‘The prevention of violent behavior by chronic and serious male juvenile offenders: a 2-year follow-up of a randomized clinical trial’, Journal of Emotional and Behavioral Disorders 12, pp. 2-8.

Fisher, P. A. and Kim, H. K. (2007), ‘Intervention effects on foster preschoolers’ attachment-related behaviors from a randomized trial’, Prevention Science 8, pp. 161-170.


Kerr, D. C. R., Leve, L. D. and Chamberlain, P. (2009), ‘Pregnancy rates among juvenile justice girls in two randomized controlled trials of Multidimensional Treatment Foster Care’, Journal of Counseling and Clinical Psychology 77, pp. 588-593.


Leve, L. D. and Chamberlain, P. (2005), ‘Association with delinquent peers: intervention effects for youth in the juvenile justice system’, Journal of Abnormal Child Psychology 33, pp. 339-347.


Leve, L. D., Chamberlain, P. and Reid, J. B. (2005), ‘Intervention outcomes for girls referred from juvenile justice: effects on delinquency’, Journal of Consulting and Clinical Psychology 73, pp. 1181-1185.


Leve, L. D. and Chamberlain, P. (2007), ‘A randomized evaluation of Multidimensional Treatment Foster Care: effects on school attendance and homework completion in juvenile justice girls’, Research on Social Work Practice 17, pp. 657-663.

Leve, L. D., Kerr, D. C. R. and Harold, G. T. (2013), ‘Young adult outcomes associated with teen pregnancy among high-risk girls in a randomized-controlled trial of Multidimensional Treatment Foster Care’, Journal of Child & Adolescent Substance Abuse 22, pp. 421-434.


*Rhoades, K. A., Chamberlain, P., Roberts, R. and Leve, L. D. (2013), ‘MTFC for high-risk adolescent girls: a comparison of outcomes in England and the United States’, Journal of Child and Adolescent Substance Use 22, pp. 435-449.


Rhoades, K. A., Leve, L. D., Harold, G., Kim, H. K. and Chamberlain, P. (2014), ‘Drug use trajectories after a randomized controlled trial of MTFC: associations with partner drug use’, Journal of Research on Adolescence 24, pp. 40-54.


Smith, D. K., Chamberlain, P. and Eddy, J. M. (2010), ‘Preliminary support for Multidimensional Treatment Foster Care in reducing substance use in delinquent boys’, Journal of Child and Adolescent Substance Abuse 19, pp. 343-358.


Van Ryzin, M. J. and Leve, L. D. (2012), ‘Affiliation with delinquent peers as a mediator of the effects of Multidimensional Treatment Foster Care for delinquent girls’, Journal of Consulting and Clinical Psychology 80, pp. 588-596.


Countries where evaluated
Sweden
United Kingdom
Protective factor(s) addressed
Community: opportunities and rewards for prosocial involvement in the community (including religiosity)
Family: attachment to and support from parents
Family: opportunities/rewards for prosocial involvement with parents
Family: parent social support
Individual and peers: clear morals and standards of behaviour
Individual and peers: interaction with prosocial peers
Individual and peers: opportunities and rewards for prosocial peers involvement
Individual and peers: Problem solving skills
Individual and peers: skills for social interaction
School and work: rewards and disincentives in school
Risk factor(s) addressed
Family: family management problems
Individual and peers: anti-social behaviour
Individual and peers: favourable attitudes towards anti-social behaviour
Individual and peers: interaction with antisocial peers
Outcomes targeted
Academic performance
Alcohol use
Use of illicit drugs
Crime
Risky sex, STIs, teen pregnancy
Violence
Description of programme

The Treatment Foster Care Oregon (TFCO) programme was developed as an alternative to institutional, residential or group care placement for teenagers with histories of chronic and severe criminal behaviour. In most communities, such juveniles are placed in out-of-home care settings before closed custody incarceration. Typically, these settings include some type of group home or cottage on a larger institutional campus, where young people live with others who have similar problems and histories of offending. On a continuum of care, TFCO is a relatively non-restrictive community-based placement that can be used instead of residential or group care or for young people transitioning back into the community from such settings. TFCO is less expensive than placement in group, residential or institutional care settings.


The fundamental philosophy behind the programme is reinforcement and encouragement of young people. Before placement, the case manager meets with an adolescent in detention to review the programme model and programme components. TFCO adolescents go through a behaviour modification programme that is based on a three-level points system through which they are provided with structured daily feedback. The young people have the opportunity to earn points throughout the day for expected activities outlined in the treatment, including going to class on school days. They lose points for any type of rule infraction, including in terms of attitude. The system emphasises positive achievements, and point loss is handled matter-of-factly. Once a young person earns a total of 2 100 points (this usually takes three weeks), they are able to ascend to a higher level. At each level, the young person is able to benefit from a more extended list of privileges, including home visits. At level three, they are even able to be involved in community activities without direct adult supervision.

There is an emphasis on teaching interpersonal skills and on participation in positive social activities including sports, hobbies and other forms of recreation.
Once the programme begins and an adolescent has been placed with a TFCO family, daily telephone contact is made and behaviours are assessed through the Parent Daily Report. These calls are brief and are designed to monitor the occurrence of problems during the past 24 hours. Points earned and lost are also tracked, along with any incidents that may be affecting treatment. The young person is also assigned to an individual therapist, who provides support and assists in teaching skills needed to relate successfully to adults and peers. Meetings with the individual therapist occur on a weekly basis. Family therapy sessions help parents to prepare for the young person’s return home and help them become to more effective at supervising, encouraging, supporting and following through with consequences. Parents are then able to practise these skills during home visits once the child has reached level two of the programme. They work through a modification of the points system being used in the TFCO home, which more closely aligns with the TFCO system as time goes on, and home visits become longer and more frequent.

Another component of the programme is school monitoring. The young person has a school card, which they carry to class, and teachers sign off on attendance, behaviour and homework completion. The cards are collected daily by the TFCO parents, and the teacher ratings transfer into points in the daily programme. Once the programme has been completed (typically after six to nine months) and the young person has returned home, the family continue to receive aftercare support. Case managers remain on call to the family, and the points system remains in place. Parents can participate in group sessions with other families, where they can continue to learn specific parenting skills, as well as receiving feedback and support from other parents. Aftercare services remain in place for as long as the parents want, but typically about one year.

Last updated : 29.11.2024
Country of origin
Italy
Last reviewed:
Age group
11-14 years
Target group
Children aged 12-14 years
Programme setting(s)
School
Level(s) of intervention
Universal prevention

Unplugged is a school-based programme that incorporates components focusing on critical thinking, decision making, problem solving, creative thinking, effective communication, interpersonal relationship skills, self-awareness, empathy, coping with emotions and stress, normative beliefs, and knowledge about the harmful health effects of drugs. The curriculum consists of 12 one-hour units taught once a week by class teachers who have previously attended a 2.5-day training course.

Keywords
No data
Links to this programme in other registries
Germany - Green List Prevention
UK - CAYT - mentor-adepis
Poland - Programy rekomendowane
Contact details

Professor Federica Vigna-Taglianti, PhD
University of Torino
Regione Gonzole, 10 - 10043 Orbassano (TO),
Italy
Email: federica.vignataglianti[a]unito.it

Johan Jongbloet
HOGENT university of applied sciences and arts
Valentin Vaerwyckweg 1, 9000 Gent,
Belgium
Email: Johan.jongbloet[a]hogent.be

Professor Fabrizio Faggiano, PhD
Avogadro University
Via Solaroli 1
Novara, Italy
Email: fabrizio.faggiano[a]uniupo.it

Show link
0
Evidence rating
Beneficial
Studies overview

The programme has been evaluated in a cluster randomised controlled trial (RCT) involving children aged 12-14 years in several European countries: Austria, Belgium, Germany, Greece, Italy, Spain and Sweden (Caria et al., 2010; Faggiano et al., 2007, 2008, 2010; Giannotta et al., 2014; Vigna-Taglianti et al., 2009, 2014). There were also two cluster RCTs in the Czech Republic (Miovsky et al., 2012; Jandáč et al., 2021) involving children with a mean age of respectively 11.8 years and 15 years.

For the cross-country study at post-test, exposure to Unplugged was associated with a statistically significant lower prevalence of self-reported daily use of cigarettes, episodes of drunkenness and cannabis use in the past 30 days in the intervention condition compared with the control condition. Young people receiving the programme were less likely than those in the control condition to move from non-smoking or sporadic smoking to daily smoking. Similar patterns emerged in the use of other substances. An analysis by gender found that delayed progression and enhanced regression were higher in the intervention condition among boys, whereas no, minimal or reverse differences were observed among girls.

At 18-month follow-up (Faggiano et al., 2010; Vigna-Taglianti et al., 2014), the use of tobacco and frequency of drunkenness was lower among students in the intervention condition compared to those in the control condition. Students in the intervention condition showed higher tendencies to remain non-users of tobacco or to regress from occasional to no use. The number of students reporting no drunkenness in the past 30 days was higher among students in the intervention condition compared to those in the control condition. Intervention condition participants also reported fewer alcohol-related behaviour problems compared to controls. Further, participants who reported not drinking at baseline were more likely to retain this status at follow-up after participating in the intervention, and those who reported drinking only occasionally at baseline showed a slower progression towards frequent drinking by follow-up if they participated in the intervention. When considering cannabis use, the proportion of persistent non-users was higher among the intervention condition than the control condition. All of these differences were statistically significant.

The first Czech study (Miovsky et al., 2012) found a statistically significant effect favouring the intervention, with intervention participants less likely than those in the control condition to have smoked cigarettes in the last 30 days at 3-, 15- and 24-months post-intervention. At the other two time periods (1 and 12 months), differences between conditions in 30-day cigarette use were not statistically significant. There were no statistically significant differences between intervention and control conditions on lifetime cigarette prevalence rates.


The second Czech study (Jandáč et al., 2021) consisted of 70 schools randomly selected with stratification according to their affiliation with a region and size, assigned to one of three groups (the control group, the intervention group 1 and the intervention group 2 exposed to the Unplugged intervention and n-Prevention. The n-Prevention programme is a follow-up (12 months) programme and consists of four lessons providing a general background addressing social norms, social beliefs, refusal skills and gender-specific differences, neurological aspects and the effects of substance use.  Children from families where the mother reported using alcohol weekly or less frequently, however, reported a decrease in drunkenness in the last 30 days compared to the control group. However, the study found no statistically measurable effect on drinking among children who came from families where the mother uses alcohol more than weekly.  These results were observed at a 24-month follow-up, which implies that the Unplugged programme may not be sufficient for high-risk children. Moreover, it is unclear how randomisation took place, and what the drop-out rate and baseline equivalence was. Additionally, in this study, a universal programme was used as a targeted intervention.

Lecrique et al. (2019) conducted an RCT in France to assess the effectiveness of the intervention on drug use among adolescents. Measures were taken at baseline and 6 and 8 months follow-up. The results showed that at the 8-month follow-up, the probability of consumption of cigarettes (OR=0.36; p<0.01), being drunk (OR=0.23, p<0.01) or using cannabis (OR=0.31, p<0.05) in the last 30 days was higher in the control group compared to the intervention group. In the intervention group, there was an improvement in other outcomes including psychosocial skills, reduced peer perception of substances and increased knowledge of the effects of substances. However, the study is a non-peer-reviewed report, it is not clear how randomisation was carried out, and there is no information on the level of attrition.

The RCTs conducted in Slovakia (Orosová et al., 2020; Abrinkova et al., 2021; Curova et al., 2021; Orosova et al., 2022) were not included in the assessment as the quality of the randomisation was low. The outcome measurement took place shortly after implementation in a quite young target group (11).

References of studies

Studies Included in the Assessment: 

Caria, M. P., Faggiano, F., Bellocco, R., & Galanti, M. R., & EU-Dap Study Group. (2010). Effects of a school-based prevention programme on European adolescents’ patterns of alcohol use. Journal of Adolescent Health, 48(2), 182-188

Faggiano, F., Richardson, C., Bohrn, K., & Galanti, M. R. (2007). A cluster randomized controlled trial of school-based prevention of tobacco, alcohol and drug use: The EU-Dap design and study population. Preventive Medicine, 44(2), 170-173.

Faggiano, F., Galanti, M. R., Bohrn, K., Burkhart, G., Vigna-Taglianti, F., Cuomo, L., Fabiani, L., & EU-Dap Study Group. (2008). The effectiveness of a school-based substance abuse prevention programme: EU-Dap cluster randomized controlled trial. Preventive Medicine, 47(5-6), 537-543.

Faggiano, F., Vigna-Taglianti, F., Burkhart, G., Bohrn, K., Cuomo, L., Gregori, D., Panella, M., & EU-Dap Study Group. (2010). The effectiveness of a school-based substance abuse prevention programme: 18-month follow-up of the EU-Dap cluster randomized controlled trial. Drug and Alcohol Dependence, 108(1-2), 56-64.

Giannotta, F., Vigna-Taglianti, F., Galanti, M. R., Scatigna, M., & Faggiano, F. (2014). Short-term mediating factors of a school-based intervention to prevent youth substance use in Europe. Journal of Adolescent Health, 54(5), 565-573.

Lecrique JM. Évaluation d’Unplugged dans le Loiret, programme de prévention de l’usage de substances psychoactives au collège.Saint‑Maurice : Santé publique France; mai 2019. 2 p.Rapport complet disponible à partir de l’URL: http://www.santepubliquefrance.fr/

Miovsky, M., Novak, P., Stastina, L., Gabrhelik, R., Jurystova, L., & Vopravil, J. (2012). The effect of the school-based Unplugged preventive intervention on tobacco use in the Czech Republic. Adicciones, 24(3), 211-218.

Vigna-Taglianti, F., Vadrucci, S., Faggiano, F., Burkhart, G., Siliquini, R., & Galanti, M. R. (2009). Is universal prevention against youths’ substance misuse really universal? Gender-specific effects in the EU-Dap school-based prevention trial. Journal of Epidemiology and Community Health, 63(9), 722-728. 
 
Vigna-Taglianti, F. D., Galanti, M. R., Burkhart, G., Caria, M. P., Vadrucci, S., & Faggiano, F. (2014). “Unplugged,” a European school-based programme for substance use prevention among adolescents: Overview of results from the EU-Dap trial. New Directions for Youth Development, 2014(141), 67-82.

Studies not Included in the Assessment: 

Abrinkova, L., Orosová, O., De Jesus, S. N., Gajdošová, B., & Bacikova-Sleskova, M. (2021). Resilience Factors, the School-Based Universal Prevention Program “Unplugged” and Healthy Behavior among Early Adolescents. European Journal of Mental Health, 16(2), 55–75. https://doi.org/10.5708/ejmh.16.2021.2.3

Čurová, V., Orosová, O., Abrinková, L., & Štefaňáková, M. (2021). The Effectiveness of Drug Use Prevention Programs on Substance Use among Slovak Schoolchildren. In Psychology Developments and Applications VII. https://doi.org/10.36315/2021padvii12

Orosová, O., Gajdošová, B., Bacíková-Šléšková, M., Benka, J., & Bavol’ár, J. (2020). Alcohol Consumption among Slovak Schoolchildren: Evaluation of the Effectiveness of the Unplugged Programme. Adiktologie, 20, 89-96

Orosová, O., Gajdošová, B., & Benka, J. (2022). Serial Mediation Models Testing the Effect of a School-Based Prevention Program on Smoking and Alcohol Consumption.  https://doi.org/10.36315/2022padviii15
 

Countries where evaluated
Austria
Belgium
Czechia
Germany
Italy
Spain
Sweden
France
Protective factor(s) addressed
Individual and peers: Problem solving skills
Individual and peers: skills for social interaction
Risk factor(s) addressed
No defined risk factors
Outcomes targeted
Alcohol use
Use of illicit drugs
Smoking (tobacco)
Description of programme

Unplugged is a school-based programme that incorporates components focusing on critical thinking, decision-making, problem-solving, creative thinking, effective communication, interpersonal relationship skills, self-awareness, empathy, coping with emotions and stress, normative beliefs, and knowledge about the harmful health effects of drugs. Unplugged particularly emphasised correcting pupils' beliefs about the pervasiveness of substance use ('normative beliefs') by contrasting these with data from surveys of pupils of the same age which typically reveal that average use levels are lower. 

The curriculum consists of 12 one-hour units taught once a week by class teachers who have previously attended a 2.5-day training course in the lessons and materials, and in how to teach them using methods which encourage interaction between pupils and between pupils and teachers, such as role-play and giving and receiving feedback in small groups. Based on teacher feedback and barriers identified during the first implementations of Unplugged, the revised programme's lessons are: 1. Opening Unplugged, 2. To be or not to be in a group, 3. Choices – Alcohol, Risk and Protection, 4. Your beliefs, norms and information – do they reflect reality? 5. Smoking the cigarette drug – Inform yourself, 6. Express yourself, 7. Get up, stand up, 8. Party Tiger, 9. Drugs - Get informed, 10. Coping competences, 11. Problem solving and decision making, 12. Goal-setting.

Materials can be accessed for free here.

This basic curriculum is ideally supplemented either by meetings led by pupils selected by their classmates, or by workshops for the pupils' parents. While in the implementations for the first trial, the curriculum was moderately well implemented, peer-led activities were rarely conducted, few parents attended the workshops, and an important element – role-play – was generally omitted by teachers.

Implementation Experiences
Feedback date
Contact details

Maria Kyriadikou
mkyriakidou[a]pyxida.org.gr

Main obstacles

With respect to individual professionals

Unplugged is implemented by teachers after training; however, teachers are often unfamiliar with group work and interactive learning methods and may lack the motivation to consistently apply these methods in the classroom.

With respect to social context

Schools often do not provide the necessary time and space to implement prevention programmes like Unplugged. Since it is not part of the school curriculum, its implementation largely depends on teachers' willingness.

With respect to organisational and economic context

Prevention programmes should be officially a part of the school curriculum in order for them to be sustainable.

How they overcame the obstacles

With respect to individual professionals

By offering training that emphasizes interactive methods, allowing teachers to directly experience the benefits, and providing ongoing support as they implement the programme in their classrooms.

With respect to social context

By trying to motivate teachers and school directors in order to allow the programme to be implemented in their school.

With respect to organisational and economic context

By providing the necessary material to teachers and by offering the training for free.

Lessons learnt

With respect to individual professionals

Prevention programmes must consider that teachers typically use conservative teaching methods and adapt the curriculum accordingly by offering alternatives to interactive methods.
Or that prevention programmes should be delivered by professionals who are familiar with group work and interactive methods.

With respect to social context

Prevention programmes should be officially a part of the school curriculum in order for them to be sustainable.

With respect organisational and context

Prevention programmes should be embedded in the organisational context of schools in order for them to have the necessary resources.

Strengths

Attractiveness of the material, effectiveness of the prevention programmes, enthusiastic trainers and teachers.

Weaknesses

Lack of contextual framework for school implementation, limited dissemination, and training materials should be updated with current information on drug abuse.

Opportunities

Prevention of drug abuse among teenagers, professional and personal development of teachers.

Threats

No maintenance of the implementation.

Recommendations

With respect to individual professionals

Put more effort into recruiting and training.

With respect to social context

Assure alliances.

With respect to organisational and economic context

Secure resources.

Number of implementations
1
Country
Greece
Feedback date
Contact details

Juan Carlos Melero
jcmelero[a]edex.es

Main obstacles

With respect to individual professionals

Limited training for secondary school teachers in programme-relevant content, group dynamics, and psychosocial skills.

With respect to social context

1. The diversity of preventive programmes in Spain at present (more than 100 according to the reports of the National Plan on Drugs).
2. A certain lack of motivation on the part of the teaching staff.
3. Difficulty participating in training sessions over several hours.

With respect to organisational and economic context

Due to the ongoing effects of the economic crisis in Spain, securing adequate funding for programmes like Unplugged is challenging.

How they overcame the obstacles

With respect to individual professionals

Providing highly practical training sessions where teachers experience Unplugged’s proposed dynamics. A team of professionals from various Spanish regions meets annually to reflect on and improve the ongoing training process.

With respect to social context

1. Highlighting the available scientific evidence, although it has not been a motivating criterion either.
2. Implementing mechanisms for monitoring presence and online that facilitate the solution of doubts to teachers.
3. Dynamising formative processes of variable duration (between 3 and 10 hours) and looking for dynamics of online training.

With respect to organisational and economic context

Trying to find funding from private companies and, above all, seeking co-financing from the administrations in whose territories the programme is developed.

Lessons learnt

With respect to individual professionals

It may be convenient to devise online training proposals that seek the maximum interaction that enables face-to-face training. We are launching tools of this type in our Ibero-American School of Life Skills: http://escuela.habilidadesparalavida.net/

With respect to social context

Flexibility in programme implementation is essential. Although it is ideal to follow the evaluated technical model strictly, balancing technical rigor with the schools’ capacity for long-term programme adoption is necessary, especially in the context of low societal concern around drugs today.

With respect to organisational and economic context

Although it does not seem easy to achieve, it would be advisable to look for ways in which the educational centres themselves could contribute to the financing of the project activities: training, materials, etc., even if it was a symbolic percentage.

Strengths

Scientific evidence, European value, socio-emotional skills.

Weaknesses

Duration, training, competition with other programmes.

Opportunities

Evidence, recognition by public institutions.

Threats

Sustainability in times of crisis.

Recommendations

With respect to individual professionals

Focus teacher training on developing socio-emotional skills applicable to related topics, such as sex education.

With respect to social context

Explore formative formats that facilitate the participation of teachers, seeking balance and respect for the diversity of existing motivations.

With respect to organisational and economic context

Look for ways of co-financing that contribute to making the programme sustainable without great expense to anyone.

Number of implementations
1
Country
Spain
Feedback date
Contact details

Maria Rosaria Galanti
rosaria.galanti[a]ki.se
 

Main obstacles

With respect to individual professionals

The programme was time consuming and required more school-time than expected.

With respect to social context

None that I am aware of.

With respect to organisational and economic context

Schools in Sweden are autonomous organisations with considerable variation in programmes and pedagogy, which must be considered for successful programme implementation.

How they overcame the obstacles

With respect to individual professionals

During the experimental phase, teachers received support through reinforcement measures and a help desk. However, there was no formal dissemination phase in Sweden.

With respect to organisational and economic context

In the experimental phase, site visits were very helpful in order to "adjust" the programme to organisational constraints.

Lessons learnt

With respect to individual professionals

Demanding programmes such as Unplugged, if adopted at all, have a high potential for unsurveilled modifications/adaptations that, with time, make the programme quite different from that originally developed.
In addition, the lack of specific contextual effects undermines the programme's diffusion.

With respect to organisational and economic context

A structured and manualised programme is more difficult to implement in highly variable organisational settings than an unstructured programme.

Strengths

The scientific environment in which the programme was developed and evaluated, as well as the initial interest shown by recipients.

Weaknesses

The lack of flexibility of the programme to highly variable organisations.

Opportunities

To learn in the school environment.

Threats

The lack of convincing results on many outcomes; the lack of resources for active diffusion and support to the recipients (schools).

Recommendations

With respect to individual professionals

Care about motivation and preparedness to adopt evidence-based demanding programmes.

With respect to social context

Is the goal of the programme shared by political/professional stakeholders? Is it a priority?

With respect to organisational and economic context

Obtain central approval from school authorities whenever possible.

Number of implementations
1
Country
Sweden
Feedback date
Contact details

Martina Feric
martina.feric[a]erf.hr
 

Main obstacles

With respect to individual professionals

Professionals in the schools (social pedagogues) were highly motivated for programme implementation. There was less motivation from the teachers (seeing their involvement in programme as extra (and not paid) job).

With respect to social context

Parent participation was relatively low.

With respect to organisational and economic context

There was the problem to find one school hour extra in school day for programme implementation. Also, in original programme, there are too many activities planned for one lesson (time frame of one lesson in Croatia is 45 minutes) and it wasn't possible to do all activities in 45 minutes. The same problem applied to the parent arm.

How they overcame the obstacles

With respect to individual professionals

Trainers, supervisors, and social pedagogues made special efforts to enhance teacher motivation. This included making training sessions as interactive and enjoyable as possible, addressing teachers’ anticipated concerns, and maintaining flexibility (while preserving programme fidelity) during delivery. Social pedagogues were also present in the classroom for some lessons if teachers found certain lessons challenging.

With respect to social context

Efforts were made to encourage parent participation through various methods, including sharing information at parent meetings, sending personal letters, and displaying posters at schools.

With respect to organisational and economic context

Most of the school used “class hour” to do the Unplugged.
We worked with the teachers and social pedagogues on shortening activities and, at the same time, keeping the integrity of the programme (e.g. changing the introduction game; in some cases quiz was taken in the class and not in the small groups; discussion instead of role-playing with parents).

Lessons learnt

With respect to individual professionals

Time and effort must be invested to “prepare” schools for implementation. This includes presenting the programme to all school staff and clearly communicating organisational needs for implementation. The role of the school principal is crucial, as real support is needed for effective implementation—not just verbal encouragement.

With respect to social context

There is a need for a pilot programme in order to adapt a programme originating elsewhere to this social/cultural context.

With respect to organisational and economic context

The input of participants from programme pilot phase was valuable and had important role in planning organisational aspects of implementation.

Strengths
  1. The advantage of implementing a programme that originated elsewhere is implementing the effective prevention programme with all technical support (training of the people in charge, training of teachers, handbooks, workbooks, protocol for process evaluation etc.). In Croatia there is a lack of model programmes.
  2. The professionals in the schools (social pedagogues) have competencies to deliver the programme and support the teachers in delivery.
Weaknesses

Problem of finding the “space” to deliver a programme in a school day.

Opportunities
  1. Successful implementation of an effective programme from elsewhere with high fidelity is feasible.
  2. Successful implementation of an effective programme can enhance use of quality standards in school-based prevention on national level.  
Threats

The acceptance of tobacco and alcohol use is still high in Croatia and there is a high tolerance towards alcohol use by adults (parents don’t see alcohol and tobacco use as “a big problem”; more like “part of growing up”).

Recommendations

With respect to individual professionals

It is important to assure quality training for programme providers (small groups to ensure maximum interactivity and sharing). If it is possible, supervision should be provided.

With respect to social context

There is a need to invest in preparing schools for programme implementation in the sense of sensitisation and motivation. Having motivated teachers and school counsellors in order to ensure programme fidelity is crucial. Also, it is important to have motivated and supportive school management.

With respect to organisational and economic context

Programme pilot implementation can help to adapt programme delivery to given context and, at the same time, to keep fidelity to the programme.

Note from the authors

Imam stav - Unplugged

Number of implementations
1
Country
Croatia
Feedback date
Main obstacles

With respect to individual professionals

Trained school-based prevention specialists manage the intervention effectively. However, there is limited information on how class teachers are implementing the intervention.

With respect to social context

The intervention is getting old and outdated.

With respect to organisational and economic context

Length of the intervention; 12 lessons to be implemented in one academic school year in all classes in 6th grade (e.g., if one school has 3 classes in a grade this leaves us with 36 lessons to be implemented by how many teachers?)
Cost related to coloured workbook that every child should have.
For some (definitely not for all) costs of + time devoted to the training.

How they overcame the obstacles

With respect to individual professionals

A 2-day training was provided for Unplugged implementation.

With respect to social context

We tried to develop and implement other interventions.

With respect to organisational and economic context

Motivating the implementers.
Implementers were motivated and informed about the importance of maintaining fidelity, with only minor content and delivery modifications permitted.

Lessons learnt

With respect to individual professionals

Emphasize training, clear explanation, motivation, and education.

With respect to social context

Interventions must be multicomponent, addressing more types of risk behaviours, involving more target groups, systematic.
Collaboration with intervention deliverers is essential.

With respect to organisational and economic context

Reducing the number of lessons and replacing coloured workbooks with black-and-white worksheets may improve feasibility.

Strengths

Used and evaluated in Europe widely, High level promotion.

Weaknesses

No successor at hand.

Opportunities

Important lessons learnt from research outcomes.

Threats

Intervention is getting old, Low control of all aspects of fidelity.

Recommendations

With respect to individual professionals

Needs to be revised/updated prior to implementation.

With respect to social context

Needs to be revised/updated prior to implementation.

With respect to organisational and economic context

Needs to be revised/updated prior to implementation.

Number of implementations
1
Country
Czechia
Feedback date
Contact details

Sanela Talić
sanela[a]institut-utrip.si

 

Main obstacles

With respect to individual professionals

  1. If the teachers voluntarily participated in the training and implementation, the results and their commitment were on a high level.
  2. Another problem was with inclusion of the Unplugged lessons in regular curriculum. Some teachers were claiming that they don't have available lessons for Unplugged although they have flexible curriculum (which means they have many possibilites to incorporate Unplugged lessons in usual lessons). They are afraid to be autonomous so they follow their handbooks because they feel safer that way and don't want to interrupt their routine - there is no cross-curricular integration. Because of the extent of some lessons, those couldn't be implemented in one school hour (45 minutes).
  3. They also think that drug prevention is mostly providing information on drugs and as they don't have knowledge they are not competent to do preventive work.
  4. There are some cases where teachers want to use Unplugged lessons within school camps and do all lessons in a few consecutive days. That approach strongly deviates from the original plan and we don’t recommend it (this is no longer “Unplugged”) – but we don’t have control over it.

With respect to social context

  1. Opinion of some teachers was that prevention should start in early school years (even before) and that parents should be more cooperative. According to their experiences children do not have basic set of manners and values (when they enter the school). Pupils bring family problems to school and all attention is given to solving those problems. It means there is less time for education and learning or strengthening different life skills. They don't feel competent for problem solving, building authority, productive teaching etc.
  2. Low participation of parents.
  3. Prevention in general is not considered as something we do “before problems occur” and often it is connected with substance use. There is no overview over who does the prevention in schools, how it is done, the only thing that matters is that “prevention activities” in a year plan are ticked.
  4. It is very hard to find motivated teachers who are willing to do additional “prevention work”. Schools are not obliged to do “prevention”; at least, the Ministry of Education doesn’t have any expectations, rules and standards regarding prevention work in schools.
  5. In our opinion, wider implementation of quality standards (and the programme) is also hampered by incorrect relations between Ministry of Health and Ministry of Education (prevention programmes are financed by Ministry of Health without agreement or cooperation with Ministry of Education).
How they overcame the obstacles

With respect to individual professionals

Teachers felt more confident knowing that I'm a teacher by profession and that am aware of situation mentioned above. As I am a teacher and know that there are a lot of possibilities to incorporate other content (like Unplugged), I helped them to make a plan, share ideas and experiences from other schools. After the training they realised that drug prevention is not just talking and giving information about drugs. As most of the teachers usually like to follow the instructions, the workbook with detailed instructions for every lesson helped them to feel more confident.

We decided that all training activities will be led by a teacher who has been implementing Unplugged since the very beginning. So, there is an impression that the programme is used in practice, that it can be implemented and new teachers get much practical advice and recommendations from a person who has implemented it over many years.

With respect to social context

Through all these years we have been promoting prevention science and its principles, we have been organising “Slovenian Prevention Days” and training for Unplugged. Beside “Unplugged training” we also offer some basic information on what, how and why some approaches work/don’t work/have iatrogenic effects.

This year we finally got in contact with stakeholders from the Ministry of Education and started to think how to ensure enough school hours for prevention programmes only. The main idea is to ensure at least one whole hour a week (for every single class) – from the beginning till they finish the school.

Regarding low participation of parents - Parents do not want to immediately expose themselves and participate in activities that are provided by original workshops. There is not enough time to create safe environment where parents would cooperate without any reservations. That is why we decided to implement school based prevention programme EFFEKT for parents and to take advantage of parents’ meetings for its implementation. The rate of parents who are taking part in it is around 85%. We are still in the pilot phase of it. And in the future we plan to do research on effectiveness of each individual programme and a combination of both.

Lessons learnt

With respect to individual professionals

Every year (with lot of advocacy and promotion of the programme) we manage to find at least one/two teachers from each interested school who are willing to implement Unplugged and all of them are very motivated after the training. Each year we organise at least two training sessions with 15-20 teachers involved. Sometimes principals and school counsellors also come to get necessary information about the programme (before they decide to start implementing it). Then further implementation depends on whether those teachers have the needed support from the principals and other teachers – we contact schools to inform them how important the work is that their teachers are willing to do and how they can support them.

It’s important to keep the contact with all teachers who decided to implement the programme. Also to organise meetings for them (in order to share their experiences, to share with them new things and information they want to hear, etc.).

With respect to social context

One very special cultural characteristic in Slovenia, which is holding back the progress in the field of prevention, is that people who are doing prevention have a negative attitude towards programmes originating from elsewhere even though they do not know the content of the programmes. They want to reinvent the wheel again and again and have been doing that for more than two decades. The only interest of key actors in the field of prevention is how to get more money for their "unique", mostly one-off activities and they do not care about the quality of it. Work is not conducted in a professional way. They agree that prevention is long term process but they often forget that "how you do it" also matters. What we learned with implementation of Unplugged is that we need to bring good practices to our schools, kindergartens, families etc., of course with some minor changes.

Teachers who are implementing the programmes report about “side”/”secondary” effects of the programme (teachers feel more comfortable in class, relationships among teachers and students and among students are better, some even reported fewer instances of aggressive behaviour). We decided to measure also these reported effects and hopefully we will scientifically prove them which will help with promotion of the programme (it would no longer be only “drug” prevention programme).

Strengths
The program can be effectively adapted to various contexts without losing effectiveness.
If a programme from elsewhere meets the needs of a certain community then it's reasonable to implement it (with adequate minor changes or adaptations). It takes a lot of effort and time to design and to test a new programme.
Programme with an instruction manual that can be easily used.
Weaknesses
The perception of the program as solely a "drug prevention" initiative limits interest among schools.Too long (12 lessons).
Opportunities

Prevention programmes are based on theories which can explain the risk factors for drug use. For example: according to the theory of social learning, individuals learn and develop their personality by observing the behaviour and actions of other people and the consequences of their actions. If for example particular American programme is based on social learning theory, this means that for example focus of the programme (among other focuses) is also in correcting misconceptions. This social influence theory is not characteristic only for people living in U.S. but for all people (we are talking about the human psychology in general). Especially in today's age of globalisation, we (in Europe) are subject to almost the same influences, regardless of where we live. Cultural differences (especially among young people) are now no longer so large and consideration is needed on whether to pay so much attention to cultural adaptation or in other words we shouldn't be so sceptical towards those programmes.

Recommendations

With respect to individual professionals

In every school there are some individuals who are willing to implement quality programmes. It takes time to find them, but once you “have them on board” it is more likely that programme will “live”. It is also important to take into account some other factors that influence the quality of implementation (teachers should have support whenever they need it; it is also important to organise special meetings for teachers who are implementing the programme in schools; etc.)

With respect to social context

Promote the program as a tool for improving classroom relationships rather than strictly for drug prevention.
Regular advocacy for quality prevention in order to “open the door” to a programme.
Contacting schools over and over again about Unplugged training.

With respect to organisational and economic context

  1. This programme should be supported by responsible authorities and professionals.
  2. It's important that implementers (e.g. teachers) are motivated, commited to their work and that they have professional support by National EU-Dap centre.
  3. It's necessary that all lessons are planned from the very beginning of school year, and to take into account that one lesson can be implemented in two school hours (one after another).
  4. Programme itself is relatively cheap for implementation. You only need funding for regular material printing (more you print less you pay), organisation of training, including fee for the trainer, and some coordination costs (e.g. coordinating staff, travel costs…). Comparing to some other “prevention” activities (e.g. one-off lectures or workshops) the cost for each school is much cheaper and they get structured and manualised programme for many years with no additional costs. In the case of national funding (like in our case) the cost for school is zero (free of any charge). At least on the basis of Slovenian experience with Unplugged the programme could be promoted as very cost effective intervention. And there is also no licence fee or regular (e.g. annual) licensing costs to developers etc. like in the case of some other evidence-based programmes.
Note from the authors

“Izštekani” - Unplugged

Number of implementations
1
Country
Slovenia
Feedback date
Contact details

Kelly Cathelijn
Kelly.cathelijn[a]fracarita.org
 

Main obstacles

With respect to individual professionals

Schools struggle to allocate time for the 12 lessons, as it is not part of the standard curriculum.

With respect to social context

The previous program was not tailored to specific target groups, particularly in vocational schools where students are more vulnerable to addiction. The program’s theoretical focus prompted a need for revision.

With respect to organisational and economic context

We have seen that, while schools are interested in working with ‘Unplugged’, the cost of the programme is an obstacle.

How they overcame the obstacles

With respect to individual professionals

We suggest:
1. Six lessons in the first year and six lessons in the second year.
2. Dividing the lessons among several teachers so that each teacher gives one or two lessons in their course.
3. An extracurricular day in which the lessons are implemented.

With respect to social context

We added more collaborative exercises tailored to target groups.

With respect to organisational and economic context

We sought out local community and service clubs (e.g. Rotarians) to support the schools.

Lessons learnt

With respect to individual professionals

During the training we offer various implementation methods.

With respect to social context

A differentiated strategy is essential in drug prevention to effectively reach multiple target groups.

With respect to organisational and economic context

Networking is essential for engaging multiple partners in drug prevention.

Strengths
  1. We provide a lot of exercises, so that teachers can choose which exercise is most appropriate for their class.
  2. The quality of the training is appreciated by 90 % of the teachers.
  3. The brand ‘Unplugged’ is well known in Flanders.
Weaknesses
  1. The cost of the programme.
  2. Schools can’t always find the time to implement the programme in an already full curriculum.
  3. Not all teachers are allowed to attend training sessions because of practical issues in schools.
Opportunities
  1. In some regions of Flanders we haven’t reached all schools.
  2. A lot of schools struggle with digital addiction (gaming, smartphones, tablets, etc.).
  3. Local communities feel the need for an effective drug prevention programme.
Threats
  1. School budgets are continuously under pressure.
  2. Schools are expected to deal with a lot of social problems (bullying, health, etc.). However, schools can’t solve all these problems.
Recommendations

With respect to individual professionals

Ensure that multiple partners are engaged in drug prevention efforts.

With respect to social context

Make sure the programme is implemented following a differentiated strategy to reach different target groups.

With respect to organisational and economic context

Work together with the local networks and schools.

Number of implementations
1
Country
Belgium
Feedback date
Main obstacles

With respect individual professionals

The main obstacle was adjusting the content of the information to the specific needs of the country. Another obstacle was adapting the role-play exercises so that all the targets for each lesson could be reached within one hour.

With respect to social context

Some people are reluctant to see drug prevention programmes implemented in schools.

With respect to organisational and economic context

The costs of the materials were quite high, and since our target was to implement the programme in as many schools as possible (at least two in each of the six districts of Bucharest and in each of the 41 counties of Romania), finding resources for these materials is quite a challenge.

How they overcame the obstacles

With respect to individual professionals

All the materials were adapted based on our national drug use surveys.

With respect to social context

Since Unplugged is a programme that develops life skills in order to prevent young people starting to use drugs, it was easy to change that mentality through parents’ meetings, media activities and focus groups in schools.

With respect to organisational and economic context

We managed to secure governmental resources in order to apply our national drug prevention policies. The Romanian Government considers the fight against illicit drug trafficking and abuse a priority and as a result we were able to reach our target in implementing Unplugged.

Strengths

Content and materials are comprehensive, well-organized, adapted, and practical.

Weaknesses

The costs of printing and the challenges of selecting and developing a network of trained teachers that can implement Unplugged.

Opportunities

Selecting and developing a network of trained teachers that can implement Unplugged.

Threats

Program quality may decline as more classes aim to implement Unplugged.

Recommendations

With respect to individual professionals

Carefully select the professionals who will implement the programme.

With respect to social context

Adapt the materials to the level of knowledge of the beneficiaries.

With respect to organisational and economic context

Unplugged should be implemented with no compromises on the aspects of quality printing and materials.

Number of implementations
1
Country
Romania
Feedback date
Contact details

Serena Vadrucci
serena.vadrucci[a]aslcittaditorino.it

Main obstacles

With respect individual professionals

  • Selection of teachers to be trained and to implement the programme.
  • Involvement of only one teacher per school.
  • Teachers are generally used to working alone, and their team-working attitude can be low.
  • Skill-based units are easily skipped, or implemented with limited interactivity.
  • The programme is ten years old. There are no media activities.
  • Motivation of teachers decreasing year by year.

With respect to social context

  • Schools and teachers with a low socio-economic context can be more difficult to involve.
  • Schools can have difficulties in printing Unplugged materials.
  • Schools can have difficulties paying for the teacher training and for the travel of the teachers to the training location.

With respect to organisational and economic context

  • Organisation of calendar for implementation of the 12 units.
  • Time-consuming programme.
How they overcame the obstacles

With respect individual professionals

  • Criteria for choosing teachers to be trained were shared, discussed and recommended with/to the school principals.
  • When organising the teachers’ training, the participation of at least two teachers per school was encouraged.
  • Unplugged trainers promoted a team-working attitude during the teacher training.
  • During teacher training, the importance of the implementation of skill-based units was underlined.
  • All skill-based units were implemented during teacher training.
  • An update of the original Unplugged material was organised, involving the most active teachers and trainers. Content on drug information and media activities were added, some role play stories and other specific situations were revised. New energisers were created.
  • Booster sessions for teachers were organised each year.
  • The very motivated and enthusiastic teachers were involved in teacher training and booster sessions as "testimonials".
  • Unplugged trainers were proactive in supporting and constantly supervising teachers during the school year, and engaging in a relationship based on reciprocal confidence.

With respect to social context

  • Presentations of the programme to schools with a low socio-economic context and meetings with principals and health educators were organised.
  • Unplugged materials were printed by the regional authority or by the local health office and distributed free of charge to schools.
  • Teacher training was free of charge.
  • Teacher training was organised in the city of the schools involved.

With respect to organisational and economic context

  • Calendar for implementation was carefully decided at the beginning of the school year and re-evaluated at regular intervals, possibly every month.
  • Calendar was decided together with school manager and non-Unplugged teachers of the class.
  • Process monitoring tools are useful to monitor the implementation: these tools were presented and distributed to the teachers during teacher training.
  • Splitting the 12 units across two school years: 6 implemented in the first year and 6 implemented in the second year.
  • Sharing/separating the implementation of the 12 units with another Unplugged teacher.
Lessons learnt

With respect individual professionals

  • It is very important that the teacher is interested in the programme; teachers not well motivated won't implement the programme.
  • Creation of an Unplugged teachers group within the school improves implementation and motivation.
  • During teacher training, working in groups is needed.
  • The importance of implementation of skill-based units must be underlined in teacher training.
  • Booster sessions help to maintain interest. Booster sessions should include the presentation of new scientific results (learning) and sessions dedicated to exchange of experiences between teachers (exchange).
  • Trainers must be proactive in contacts with the teachers.
  • Trainers and teachers must be involved in the revision of the material.

With respect to social context

  • Individual meetings with schools are needed.
  • Specific funding for printing Unplugged materials is needed. Better organisation of teacher training is needed.
  • Location of teacher training must take into account availability of teachers to travel.

With respect to organisational and economic context

  • The results of process evaluation – including implementation of the units and satisfaction of teachers and students about the programme – must be reported and given back to teachers in order for them to change organisation of implementation where needed and increase quality of implementation year by year.
  • A certain level of adaptation of the main standardised model of implementation and some flexibility in allowed changes are needed to ensure the highest implementation rate.
Strengths

Effective programme (evaluated). Standardised teacher handbook. Group of people dedicated to the dissemination (coordination centre). Network of trainers and teachers. Booster sessions for trainers and teachers. Collaboration of regional and local authority. Occasions for teachers to improve teaching. Materials and training at no cost for schools and teachers. Nice materials for pupils.

Weaknesses

Time consuming programme (12 units). Programme is ten years old. Media activities and related contents need to be updated. Dissemination is dependent on continuous funding. Lack of collaboration of local authorities. Competition with other similar programmes.

Opportunities

Networking. Group working. Involvement of teachers in the process. Interest of students. Universal programme. Wide autonomy of schools in choosing programmes. Occasion to promote evidence-based approach.

Threats

Decrease of motivation. Lack of funding. Conflicts among trainers. Slow production of scientific results.  Programme is ten years old. Wide autonomy of schools in choosing programmes: competition with other (non-evaluated) programmes.

Recommendations

With respect individual professionals

  • Special care must be applied in selecting teachers for training and implementation of the programme.
  • Booster sessions should be organised.
  • Create a network for teachers to exchange experiences and be part of the programme.
  • Be proactive in the involvement and supervision of schools and teachers.
  • Constantly promote the alliance of school and health sectors.

With respect to social context

  • Special care must be applied with low socio-economic context schools.
  • Funding for materials and training must be obtained.

With respect to organisational and economic context

  • Process monitoring tools must be provided, collected, analysed and reported.
  • Some flexibility in allowing changes in the model of implementation is needed.
Number of implementations
1
Country
Italy
Feedback date
Contact details

Kathrin Schütte
Landkreis Emsland
Kathrin.schuette[a]emsland.de

Rainer Lüker
Albert-Trautmann-Schule Werlte
rainer.lueker[a]ats-werlte.de

Main obstacles

With respect individual professionals

The different occupational groups approach the topic differently; here a common path had to be found.

With respect to social context

The different schools (special school, high school, etc.) had very different levels of performance

With respect to organisational and economic context

  • From a purely organisational point of view, it has sometimes been difficult to encourage exchanges and motivate professionals. All the professionals have implemented UNPLUGGED as part of their normal job and were not hired specifically for it.
  • There were no financial barriers for the time being, as UNPLUGGED was introduced under Communities That Care and it was considered useful and necessary by the political representatives.
How they overcame the obstacles

With respect individual professionals

Joint training of different professionals and constant exchange of information.

With respect to social context

In cooperation with the specialists, the programme was adapted to the performance level of the different schools.

With respect to organisational and economic context

As a "coordinator" always be approachable and try to motivate the professionals.

Lessons learnt

With respect individual professionals

For the success of the programme "UNPLUGGED" a constant exchange of information and networking are very important.

With respect to social context

Exchanges with professionals, on such topics as understanding and patience, were particularly important, especially for the weaker students.

With respect to organisational and economic context

Provide transparency to professionals, financial donors and decision-makers.

Strengths
  • Many professionals as multipliers who work together profitably through their different approaches.
  • Secure financing.
  • A versatile programme that fully informs students, not only on addictive substances but also on the topics "strengthening your personality" and "self-esteem".
Weaknesses
  • Many professionals who need to be motivated and who work very differently.
  • Partly complicated substance or expressed in a complicated way.
Opportunities
  • Different approach and different perspectives.
  • Very versatile and extensive programme.
Threats
  • Loss of motivation of the various skilled workers, since success cannot be measured immediately with this programme
Recommendations

With respect individual professionals

Different professional groups often work together profitably. The exchange must then be promoted and demanded from the outside.

With respect to social context

Exchange between and motivation of the specialists should be in the foreground. It is only through them that the programme can be implemented effectively.

With respect to organisational and economic context

  • The financing should be secure for a longer period of time (several years).
  • Regular exchange meetings must be carried out.
Number of implementations
1
Country
Germany
Last updated : 18.06.2024
Country of origin
USA
Last reviewed:
Age group
11-14 years
15-18/19 years
Target group
At-risk young people aged between 11-18 years
Programme setting(s)
Family
Juvenile justice setting
Level(s) of intervention
Targeted intervention

Functional Family Therapy (FFT) is a short-term (approximately 30 hours), family-based therapeutic intervention for delinquent young people at risk of institutionalisation and their families. FFT is designed to improve within-family attributions and family communication and supportiveness while decreasing intense negativity and dysfunctional patterns of behaviour. Parenting skills, youth compliance and the complete range of behavioural domains (cognitive, emotional and behavioural) are targeted for change based on the specific risk and protective factor profile of each family. FFT should be implemented by a team of 3-8 master’s level therapists, with caseloads of 10-12 families, overseen by a licensed clinical therapist.

Keywords
No data
Links to this programme in other registries
USA - Blueprints Programs
UK - Early Intervention Foundation Guidebook
Norway - NUBU
Contact details

Professor James F. Alexander, PhD
University of Utah Department of Psychology
380 South 1530 East, Room 502
Salt Lake City
Utah 84112-0251
United States of America
Phone: 1 (801) 550-4131
Email: jfafft[a]aol.com
Website: www.fftinc.com

Thomas Sexton, PhD
FFT Partners, LLC
Email: tom[a]functionalfamilytherapy.com
Website: www.functionalfamilytherapy.com

Evidence rating
Likely to be beneficial
Studies overview

There is some evidence that the programme is effective in reducing behaviour problems among young people.

The programme has been evaluated in two quasi-experimental studies in Europe, respectively in Sweden (Hansson et al., 2000) and in the Netherlands (Eeren et al., 2018). Furthermore, two randomised controlled trials have been conducted in Sweden (Hansson et al., 2004) and in Ireland (Carr et al., 2014).

The quasi-experimental study in Sweden (Hansson et al., 2000) found statistically significant positive effects on child psychiatric symptoms at post-test.

In the second Quasi-experimental study in the Netherlands (Eeren et al., 2018), 697 adolescents with an average age of 15 years, were allocated to either the FFT intervention or the MST intervention according to the Risk-Need-Responsivity model. The FFT intervention is thereby seen as the control group. In this aspect, results of the comparison showed no significant differences between outcomes. Only the engagement in school or work after the treatment was higher in the group who completed MST.

The randomised controlled trial in Sweden (Hansson et al., 2004), involving young people with an average age of 15 arrested for serious offences, found statistically significant positive effects on behaviour (recidivism and internalising and externalising behaviour) at the two-year follow-up.

The study in Ireland (Carr et al., 2014) was conducted with children with an average age of 14 years who met the clinical cut-off for Total Difficulties on the parent-reported Strengths and Difficulties Questionnaire (SDQ). It found statistically significant effects at post-test (3 months) favouring the intervention on participants’ parent- and self-reported problem behaviour (based on some but not all measures).

The programme has been rated as Model by Blueprints for Healthy Youth Development database based on a review of studies conducted world-wide.

References of studies

Carr, A., Hartnett, D., Sexton, T. and Graham, C. (2014), Putting families first: an evaluation of functional family therapy in an Irish context, Archways.

Eeren, H. V., Goossens, L., Scholte, R. H., Busschbach, J. J., & Van der Rijken, R. E. (2018). Multisystemic therapy and functional family therapy compared on their effectiveness using the propensity score method. Journal of Abnormal Child Psychology, 46(5), 1037-1050.

Hansson, K., Cederblad, M. and Hook, B. (2000), ‘Functional family therapy: a method for treating juvenile delinquents’, Social vetenskaplig tidskrift 3, pp. 231-243.

Hansson, K., Johansson, P., Drott-Emnglen, G. and Benderix, Y. (2004), ‘Funktionell familjeterapi I barnpsykiatrisk praxis: om behandling av ungdomskriminaliet utanfor universitesforskningen’, Nordisk Psykologi 56, pp. 304-320.

Papers not included in the Rating:

No control group
Vardanian, M. M., Scavenius, C., Granski, M., & Chacko, A. (2020). An international examination of the effectiveness of functional family therapy (FFT) in a Danish community sample. Journal of marital and family therapy, 46(2), 289-303.

Non-EU-studies (USA & Canada)

Alexander, J. F. and Parsons, B. V. (1973), ‘Short-term behavioral intervention with delinquent families: impact on family process and recidivism’, Journal of Abnormal Psychology 81, pp. 219-225

Aos, S., Lee, S., Drake, E., Pennucci, A., Klima, T., Miller, M., Anderson, L., et al. (2011), Return on investment: evidence-based options to improve statewide outcomes, Washington State Institute for Public Policy, Olympia.

Barnoski, R. (2004), Outcome evaluation of Washington State’s research-based programmes for juvenile offenders (Document No. 04-01-1201), Washington State Institute for Public Policy, Olympia.

Barton, C., Alexander, J. F., Waldron, H., Turner, C. W. and Warburton, J. (1985), ‘Generalizing treatment effects of Functional Family Therapy: three replications’, The American Journal of Family Therapy 13, pp. 16-26.

Celinska, K., Furrer, S. and Cheng, C.-C. (2013), ‘An outcome-based evaluation of Functional Family Therapy for youth with behavior problems’, OJJDP Journal of Juvenile Justice 2, pp. 23-36.

Friedman, A. (1989), ‘Family therapy vs. parent groups: effects on adolescent drug abusers’, The American Journal of Family Therapy 17, pp. 335-347.

Gordon, D. A. (1995), ‘Functional Family Therapy for delinquents’, in Ross, R. R., Antonowicz, D. H. and Dhaliwal G. K. (eds.), Going straight: effective delinquency prevention and offender rehabilitation, Air Training and Publications, Canada.

Gordon, D. A., Graves, K. and Arbuthnot, J. (1995), ‘The effect of Functional Family Therapy for delinquents on adult criminal behavior’, Criminal Justice and Behavior 22, pp. 60-73.

Klein, N. C., Alexander, J. F. and Parsons, B. V. (1977), ‘Impact of family systems intervention on recidivism and sibling delinquency: a model of primary prevention and programme evaluation’, Journal of Consulting and Clinical Psychology 45, pp. 469-474.

Klein, N. C., Alexander, J. F. and Parsons, B. V. (1977), ‘Impact of family systems intervention on recidivism and sibling delinquency: a model of primary prevention and programme evaluation’, Journal of Consulting and Clinical Psychology 45, pp. 469-474.

Sexton, T. and Turner, C. W. (2010), ‘The effectiveness of Functional Family Therapy for youth with behavioral problems in a community practice setting’, Journal of Family Psychology 24, pp. 339-348.

Slesnick, N. and Prestopnik, J. (2009), ‘Comparison of family therapy outcome with alcohol-abusing, runaway adolescents’, Journal of Marital and Family Therapy 35, pp. 255-277. 


Waldron, H. B., Slesnick, N., Brody, J. L., Turner, C. W. and Peterson, T. R. (2001), ‘Treatment outcomes for adolescent substance abuse at 4- and 7-month assessments’, Journal of Consulting and Clinical Psychology 69, pp. 802-813.

Countries where evaluated
Netherlands
Ireland
Sweden
Protective factor(s) addressed
Individual and peers: clear morals and standards of behaviour
Individual and peers: interaction with prosocial peers
Individual and peers: Problem solving skills
Individual and peers: refusal skills and decision making
Individual and peers: skills for social interaction
Risk factor(s) addressed
Individual and peers: anti-social behaviour
Individual and peers: early initiation of drug/alcohol use
Individual and peers: favourable attitude towards alcohol/drug use
Individual and peers: favourable attitudes towards anti-social behaviour
Individual and peers: hyperactivity
Individual and peers: rebelliousness and alienation
Outcomes targeted
Relations with parents
Alcohol use
Use of illicit drugs
Crime
Description of programme

Functional Family Therapy (FFT) is a short-term (approximately 30 hours) prevention/intervention programme for young people who have demonstrated a range of maladaptive, acting-out behaviours and related syndromes. Intervention services consist primarily of direct contact with family members, in person and by telephone; however, services may be coupled with support system services such as remedial education, job training and placement, and school placement. Some young people are also assigned ‘trackers’, who advocate for them for a period of at least three months after release.

FFT should be implemented by a team of 3-8 master’s level therapists, with caseloads of 10-12 families, overseen by a licensed clinical therapist. FFT is a phased programme with steps that build on each other. These phases are:

  • Engagement: designed to emphasise to young people and their families the factors that protect young people and their families from dropping out of the programme early.
  • Motivation: designed to change maladaptive emotional reactions and beliefs, and increase alliance, trust, hope, and motivation for lasting change.
  • Assessment: designed to clarify individual, family system and larger system relationships, especially the interpersonal functions of behaviour and how they relate to change techniques.
  • Behaviour change: consists of communication training, specific tasks and technical aids, parenting skill building, contracting and response-cost techniques, and youth compliance and skill building.
  • Generalisation: during which family case management is guided by individualised family functional needs, their interface with environmental constraints and resources, and the alliance with the FFT therapist/family case manager.
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