Assessing the Feasibility of Applying Criminological Theory to
\nthe IS Security Context Robert Willison<\/p>\n
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\nUnderstanding the Offender\/Environment Dynamic for Computer
\nCrimes: Assessing the Feasibility of Applying Criminological Theory to
\nthe IS Security Context
\nRobert Willison
\nDepartment of Informatics, Copenhagen Business School
\nrw.inf@cbs.dk
\nAbstract
\nThere is currently a paucity of literature
\nfocusing on the relationship between the actual
\nactions of staff members, who perpetrate some
\nform of computer abuse, and the organisational
\nenvironment in which such actions take place. A
\ngreater understanding of such a relationship may
\ncomplement existing security practices by possibly
\nhighlighting new areas for safeguard
\nimplementation. In addition, if insights are
\nafforded into the actions of dishonest staff, prior to
\nthe actual perpetration of a crime, then
\norganisations may be able to expand their
\npreventive scope, rather than relying solely on
\ntechnical safeguards to stop the actual commission
\nof some form of computer abuse. To help facilitate
\na greater understanding of the
\noffender\/environment dynamic, this paper assesses
\nthe feasibility of applying criminological theory to
\nthe IS security context. More specifically, three
\ntheories are advanced, which focus on the
\noffender\u2019s behaviour in a criminal setting. After
\nopening with a description of the theories, the
\npaper provides an account of the Barings Bank
\ncollapse. Events highlighted in the case study are
\nused to assess whether concepts central to the
\ntheories are supported by the data. The paper
\nconcludes by summarising the major findings and
\ndiscussing future research possibilities.
\n1. Introduction
\nThere is currently little written about the
\nrelationship between the actual criminal actions of
\nstaff members, who perpetrate some form of
\ncomputer abuse, and the organisational
\nenvironment in which such actions take place [1].
\nInsights into such a relationship may complement
\nexisting IS security practices by possibly
\nhighlighting additional areas in which safeguards
\ncould be introduced. More specifically, if insights
\nare afforded into the actions of dishonest staff,
\nprior to the actual perpetration of a crime, then
\norganisations may be able to expand their
\npreventive scope. Rather than relying solely on
\ntechnical safeguards such as intrusion detection
\ntools and password system to help stop the
\ncommission of a computer crime, other safeguards
\ndesigned to prevent criminal behaviour, prior to
\nperpetration, would prove to be a useful addition
\nin the preventive armoury of IS security
\npractitioners. In an attempt to facilitate a clear
\nunderstanding of the offender\/environment
\ndynamic, this paper assesses the feasibility of
\napplying criminological theory to the IS security
\ncontext. Three theories are advanced which
\nspecifically address the offender\u2019s behaviour in the
\ncriminal setting. The paper opens with a
\ndescription of the criminological approaches,
\nwhich include routine activity theory,
\nenvironmental criminology and the rational choice
\nperspective. This is followed by an account of the
\ncollapse of Barings Bank. Events highlighted in
\nthe account are then drawn on in the discussion
\nand analysis section, to assess whether concepts
\ncentral to the theories are supported by the data.
\nThe paper concludes summarising the findings and
\ndiscussing further research possibilities offered by
\nthe three criminological schools of thought
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\n2. IS Security and Criminological
\nTheory
\nIn an attempt to provide new insights into the
\nrelationship between the criminal actions of
\ndishonest employees and their workplace
\nenvironment, criminology would appear to be a
\npotentially fruitful body of knowledge from which
\nto draw upon. Clarke [2] notes how:
\n\u201cMost criminological theories have been
\nconcerned with explaining why certain
\nindividuals or groups, exposed to particular
\npsychological or social influences, or with
\nparticular inherited traits, are more likely to
\nbecome involved in delinquency or crime\u201d.
\nHowever, in the last four decades, a number of
\nlike-minded theories have emerged which, rather
\nthan focusing on how people become criminals,
\naddress the actual criminal act [2]. Included in
\nthis group are routine activity theory,
\nenvironmental criminology and the rational choice
\nperspective. These theories focus on the
\nrelationship between the offender and the actual
\nenvironment in which the crime takes place and it
\nis for this reason that they are advanced as
\npotentially useful schools of thought for IS
\nsecurity research. As a first step in assessing the
\nfeasibility of applying the theories to the IS
\nsecurity context, this section of the paper describes
\nthe three approaches.
\n2.1. Routine Activity
\nRoutine Activity Theory is a relative newcomer
\nto the field of criminology. Cohen and Felson [3]
\ndiscuss how changes in what they describe as
\n\u2018routine activities\u2019 of society\u2019s members have
\nimpacted on the levels of direct-contact predatory
\ncrimes, i.e. crimes where one or more persons
\ndirectly take or damage the person or property of
\nanother. These activities include the provision of
\nfood, shelter, leisure, work, child-rearing, and
\nsexual outlets. It is argued that these forms of
\nbehaviour influence direct-contact predatory (i.e.
\nwhere one or more persons directly take or
\ndamage the person or property of another) crime
\nrates by impacting on the convergence in time and
\nspace, of the three elements required for a crime to
\noccur. These elements consist of a likely offender,
\na suitable target, and the absence of a capable
\nguardian, who, if present, would be in a position to
\nstop a criminal act. As the name suggests, the
\noffender is the individual who may, or may not,
\ndecide to perpetrate a crime. A target may be a
\nperson or object that is attacked or taken by the
\noffender. This might include, for instance, a man
\nthe offender wants to rob or a car he wishes to
\nsteal. What also determines a target is whether or
\nnot the entity, which forms the basis for a target,
\neither lacks or has present, a capable guardian.
\nThus for example, a house where the owner is
\npresent is afforded a capable guardian. If,
\nhowever, the owner is at work, the property lacks a
\ncapable guardian and consequently represents
\nmuch more of a target to the potential offender.
\nCohen and Felson [3] assert that it takes merely
\nthe absence of one of these three elements for a
\ncrime not to occur. So for example, drawing on
\nU.S.A. census data and victimisation surveys, they
\nreveal how between 1960-1970, daytime
\nresidential burglary increased by 15%. They
\npartly explain this rise by noting how the decade
\nalso witnessed an increase of females in the
\nworkforce and a rise in the number of individuals
\nliving along. As a consequence, there was a
\nrelated rise in the number of properties left vacant
\nand lacking a capable guardian during the working
\nday.
\nRoutine activity theory is still in a period of
\ntransition, as witnessed by the efforts of Felson [4]
\nto extend its scope. In an attempt to accommodate
\nHirschi\u2019s [5] social control theory, Felson [4]
\nproposes the incorporation of another element, that
\nof the \u2018intimate handler\u2019, to illustrate how people
\ncan act as a \u2018brake\u2019 on the activities of offenders.
\nIn his book Causes of Delinquency, Hirschi [5]
\nargues that there are four factors that constitute a
\nsocial bond between an individual and society.
\nThese include commitments, attachments,
\ninvolvements and beliefs. Felson uses the word
\n\u2018handle\u2019 to summarise the four elements. By
\ndoing so he argues that the social bond (and hence
\nhandle) is a key element in informal social control.
\nThe \u2018intimate handler\u2019 represents the individual
\nwho is able to exert this form of social control.
\nThe handler is normally someone who is
\nrecognised by, and has sufficient knowledge, of
\nthe potential offender. Hence the mere presence of
\na person known to the potential offender may act
\nas a form of \u2018handling\u2019, and consequently a
\ndeterrent, by reminding the offender of their social
\nbonds. By incorporating the concept of the
\nhandled offender and the intimate handler into
\nroutine activity theory, Felson argues that just as a
\ntarget must be lacking a capable guardian for the
\ncommission of a crime, so too must the offender
\nbe lacking an intimate handler.
\nFurthermore, as a means of enhancing its
\ncontribution to crime prevention, Clarke [6]
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\nadvocates that routine activity theory could
\nincorporate the category of \u2018crime facilitators\u2019.
\nThese relate to items such as cars, guns, and credit
\ncards, which act as tools for specific crimes – as
\nwell as dis-inhibitors such as alcohol, which
\nfacilitate the precipitation of crimes. Clarke [6]
\nargues that if we appreciate how these facilitators
\nare used, it may be possible to identify points were
\nsafeguards can be introduced.
\n2.2. Environmental Criminology
\nEnvironmental criminology has provided
\nconsiderable insight into the \u2018search\u2019 patterns of
\noffenders and illustrated how the majority of
\ncrimes are committed within areas visited by
\noffenders during their routine work and leisure
\npursuits [7]. Offenders develop an \u2018action space\u2019
\nin which these everyday pursuits take place and
\nthrough such activities acquire a detailed
\nknowledge of this environment, leading to what
\nthese authors describe as an \u2018awareness space\u2019.
\nLike the rational choice perspective, Brantingham
\nand Brantingham [7] argue that the motivated
\nindividual engages in a \u2018multi-staged decision
\nprocess\u2019 prior to the commission – or not as the
\ncase may be – of a crime. Such a process is
\ninformed through knowledge gathered from the
\noffender\u2019s awareness space. Furthermore, they
\nargue that a specific environment emits cues
\nrelating to its spatial, cultural, legal and
\npsychological characteristics. With experience, an
\noffender is able to discern certain sequences and
\nconfigurations of these cues associated with a
\n\u2018good\u2019 target.
\n2.3. Rational Choice Perspective
\nThe rational choice perspective focuses on the
\ndecision-making processes of offenders [8, 9, 10].
\nThe approach assumes that crimes are chosen by
\nthe offender, as a suitable course of action, with
\nthe intention of deriving some type of benefit.
\nObvious examples are cash or material goods, but
\na broader reading of the term \u2018benefits\u2019 allows for
\nthe inclusion of other forms, such as prestige, fun,
\nexcitement, sexual gratification, and domination.
\nJoyriding is an example of how the benefits may
\ntake the intangible forms of fun and excitement.
\nOf further importance to the rational choice
\nperspective is the division of criminal choices into
\ntwo groups, viz., \u2018involvement\u2019 and \u2018event\u2019
\ndecisions. The former refers to decisions an
\noffender makes regarding their criminal careers.
\nThe latter refers to those decisions made during
\nthe actual commission of a crime. These decisions
\nare based on the offender\u2019s perceptions of the
\nsituation. Hence, the decision to carry out a
\nparticular criminal act emerges from a reasoning
\nthat the associated risks and efforts are outweighed
\nby the perceived rewards. In other words, the
\ndecision to carry out a particular criminal act
\nrepresents an assessment by the offender that the
\nparticular situation offers an opportunity. Given
\nthis, an opportunity can be seen as a subjective
\nrelationship between an offender and their
\nenvironment.
\nThe approach further assumes that choices are
\ncharacterised by what is termed \u2018bounded\u2019 or
\n\u2018limited\u2019 rationality. In other words, criminal
\ndecision making is at times less than perfect, as a
\nconsequence of the conditions under which
\ndecisions are made. With the associated risks and
\nuncertainty in offending, criminals may make
\ndecisions without the knowledge of all the
\npotential costs and benefits (i.e. the risks, efforts
\nand rewards). Devoid of all the necessary
\ninformation, offenders may resort to \u2018rules of
\nthumb\u2019 when perpetrating offences, or rely on a
\ntried and tested general approach that may be
\ncalled into action when unexpected situations
\narise.
\n3. Case Study: The Collapse of Barings
\nBank
\nOn the 26th February 1995, administrators were
\nappointed by the High Court in London (UK) to
\nmanage the affairs of Baring Plc. following the
\nidentification of substantial losses incurred by a
\nrelated overseas subsidiary known as Baring
\nFutures Singapore. This section of the paper
\nprovides an account of the major factors that were
\ninstrumental in the collapse of Barings. The
\npurpose of the account is two fold. First the reader
\nis afforded an understanding of the collapse.
\nSecondly, data drawn from this case study is then
\nused in the \u2018Discussion and Analysis\u2019 section to
\nassess whether events highlighted in the account
\nsupport concepts, which are central to the three
\ncriminological theories. Two points should be
\nnoted here. First, given the limitations on space,
\nthe account is simplified, highlighting areas most
\nobviously covered by the theories. Secondly, the
\naccount is based on the Bank of England: Report
\nof the Board of Banking Supervision Inquiry into
\nthe Circumstances of the Collapse of Barings [11]
\nand Stephen Fay\u2019s The Collapse of Barings [12].
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\n3.1. Brief History and Background of
\nBarings Bank
\nPrior to its collapse, Baring Brothers & Co. had
\nbeen the oldest merchant bank in the City\u2019s square
\nmile. Founded initially as a partnership in 1762,
\nthe bank had managed to remain independent and
\nprivately controlled. After a near fatal business
\nventure in Argentina, Baring Brothers & Co. was
\nestablished in 1890 to succeed the partnership. In
\n1985 the share capital of Baring Brothers & Co.
\nwas acquired by Barings plc, which became the
\nparent company of the Barings Group. Apart from
\nBaring Brothers & Co., the other two principal
\noperating companies of Barings plc were Baring
\nSecurities Limited and Baring Asset Management,
\nwhich played no part in the collapse (and hence
\nwill not be referred to again in this account).
\nBaring Securities Limited had commenced
\nbusiness in 1984, specialising in Far East
\nSecurities. The company expanded rapidly. In the
\nfirst five years of trading, Baring Securities
\nLimited opened nineteen subsidiary offices. Aside
\nfrom the traditional business activities carried out
\nby Baring Brothers & Co., Baring Securities
\nLimited represented Barings first involvement in
\nthe securities business.
\n3.2. Creation and Management of Baring
\nFutures Singapore
\nBaring Futures Singapore was one of the new
\noffices that opened during the expansion of Baring
\nSecurities Limited, and was formed to specialise in
\nexchange-traded futures and options (i.e. these
\nwere Baring Futures Singapore\u2019s bank products).
\nMore precisely, Baring Futures Singapore would
\nexecute client business on the Singaporean Stock
\nExchange (SIMEX) on behalf of Baring Securities
\nLimited and Baring Securities Japan. This client
\nbusiness, also referred to as \u2018agency\u2019 business, was
\nmanaged by Mike Killian (Head of Global Equity
\nFutures and Options Sales) in Tokyo. Baring
\nFutures Singapore would accumulate profits
\nthrough commission charged to clients.
\nNick Leeson, a pivotal figure in the collapse of
\nBarings, was asked by Killian to apply for the post
\nof settlements manager. Leeson had acquired the
\nnecessary experience through working in the
\nsettlement\u2019s section of a Baring Securities Limited
\ndepartment, which specialised in Japanese futures
\nand options. He accepted the offer, and his name,
\nonce submitted to the Management Committee,
\nwas approved.
\nPreviously in 1987, Baring Securities had
\nopened their first Singaporean office in the form of
\nBaring Securities Singapore. The managing
\ndirector of Baring Securities Singapore was James
\nBax. He oversaw a business which traded equities
\n(but not derivatives) on SIMEX. Bax\u2019s second-incommand
\nwas Simon Jones, who acted as the
\nChief Operating Officer of Baring Securities
\nSingapore. This position included responsibility
\nfor the back office, which settled Baring Securities
\nSingapore\u2019s equity trading.
\nLeeson moved to Singapore in early March
\n1992. Initial problems in the management of
\nBaring Futures Singapore were created shortly
\nafterwards, by the actions of Ian Martin (Baring
\nSecurities Limited\u2019s Finance Director). Despite
\nthe fact that Mike Killian had asked Leeson to run
\nthe back office (i.e., the settlements section) of
\nBaring Futures Singapore, Martin instructed Jones
\nand Killian that Leeson would be in charge of the
\nfront and back offices. By so doing, Martin was
\nbreaching one of the golden rules of management,
\nwhich states that there should be a strict
\nsegregation of duties between trading and
\nsettlement.
\nThe supervisory failings with regard to Barings
\nFutures Singapore were compounded by the
\nactions of Jones and Bax, who took little interest
\nin the new subsidiary, despite the fact that both
\nwere, on paper at least, responsible for Leeson at a
\nregional level.
\nMike Killian further rejected the idea that there
\nwas a reporting line between himself and Leeson.
\nYet this runs contrary to what Leeson argues, who
\ncites Killian as one of the people who managed
\nhim in 1992. Hence from the very start of
\nLeeson\u2019s employment at Baring Futures
\nSingapore, there was considerable confusion over
\ntwo key areas: first, what his job responsibilities
\nwere, and secondly, who managed him.
\nIn early 1993 Leeson started trading on SIMEX
\nin conjunction with Baring Securities Japan\u2019s
\nTokyo traders who (since the collapse of the
\nJapanese stock market in 1990) made their money
\nthrough a type of trading called \u2018arbitrage\u2019,
\notherwise known as \u2018switching\u2019. This section of
\nBaring\u2019s business was known as equity
\nderivatives. Unlike Killian\u2019s business, the trading
\nundertaken by the Baring Securities Japan traders
\nand Leeson was conducted solely to make profits
\nfor Barings and not clients, and can therefore be
\nclassified as proprietary trading. The manager in
\ncharge of the switching business was Fernado
\nGueller, based in Japan.
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\nWhen Peter Norris became CEO of Baring
\nSecurities Limited in March 1993, one of his first
\ndecisions was to make the Financial Products
\nGroup of Baring Brothers & Co. responsible for
\nthe equity derivatives business (i.e., switching).
\nThe actual hand-over of this business did not take
\nplace until late 1993. The manager in charge of
\nthe Financial Products Group was Ron Baker.
\n3.3. Unauthorised Trading Activities
\nConducted by Baring Futures
\nSingapore
\nLeeson was engaged in substantial
\nunauthorised trading on SIMEX through the taking
\nof proprietary positions in futures and options.
\nThis section addresses the trading through a brief
\nexamination of the history of the account (88888)
\nused to book and record the deals.
\n3.3.1. Account 88888. Unauthorised trading of
\nfutures commenced very shortly after the opening
\nof 88888 and carried on until the collapse in late
\nFebruary of 1995. This trading went largely
\nunnoticed for almost two years and eight months.
\nThe only capacity in which Baring Futures
\nSingapore was authorised to transact options was
\nwith regard to agency trading. However, in
\nOctober 1992 Leeson started to sell options, and
\ncontinued to do so until 23rd February, 1995.
\nAt the year-end 1992, losses incurred through
\nthe unauthorised trading were relatively minor,
\nstanding at \u00a32 million. One year later, they had
\ngrown to \u00a323 million, and by 31st December 1994,
\nthe figure amounted to \u00a3208 million. In the space
\nof the following three months, however, this figure
\nhad almost quadrupled to a staggering \u00a3827
\nmillion.
\n3.4. Failure of Internal Controls
\nThe ability of Leeson to establish substantial
\nunauthorised trading positions on SIMEX was
\nafforded by failures in the management, financial,
\nand operating controls in Barings. These failures
\nwere evident in Singapore, Tokyo, and London,
\nand encompassed all levels of control ranging
\nfrom the management committees, the business
\nfunctions and associated organisational units, and
\nthe actual day-to-day operating controls. The
\nfollowing list highlights the areas of failure:
\n\u2022 Failures in the managerial supervision of
\nLeeson.
\n\u2022 Lack of segregation between the front
\nand back offices of Baring Futures
\nSingapore.
\n\u2022 Insufficient action taken by Barings
\nmanagement in response to warning
\nsignals.
\n\u2022 No risk management or compliance
\nfunction in Singapore.
\n\u2022 Weak financial and operational control
\nover the activities and funding of Baring
\nFutures Singapore at Group level.
\n4. Discussion and Analysis
\nIn attempting to assess the feasibility of
\napplying the three criminological theories to the IS
\nsecurity context, this section of the paper examines
\nwhether events highlighted in the case study
\nsupport those concepts which are central to the
\ntheories.
\n4.1. Routine Activity Theory: Intimate
\nHandler\/Unhandled Offender
\nInitial management problems were created at
\nthe inception of Baring Futures Singapore. The
\nBoBS report cites how despite the fact that James
\nBax (Head of Baring Securities Singapore) and his
\nsecond in command, Simon Jones (Chief
\nOperating Officer of Baring Securities Singapore)
\nhad, on paper at least, regional responsibility for
\nLeeson, neither spent much time overseeing his
\nactivities. Although the BoBS report
\nacknowledges there was some contact between the
\ntwo \u2018managers\u2019 and Leeson, it further contends
\nthat both Bax and Jones preferred to focus their
\nenergies on Baring Securities Singapore.
\nAdditionally, Mike Killian, who managed the
\nagency business sent from London and Tokyo, and
\nexecuted by Baring Futures Singapore, rejected the
\nidea of a reporting line between himself and
\nLeeson. Hence, from the start of Leeson\u2019s
\nemployment at Baring Futures Singapore, there
\nwas confusion over who actually managed him.
\nThis confusion manifested itself in a paucity of
\noversight from senior management. There is some
\noverlap here with the theoretical concepts of the
\nintimate handler and the handled offender. The
\nfact that, on the whole, there was an absence of an
\nintimate handler in the form of senior
\nmanagement, provided Leeson with the freedom to
\nundertake his unauthorised trading.
\nHowever, there is a divergence between theory
\nand data with regard to how supervision is actually
\nenacted. With regard to the intimate handler, their
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\npresence is enough to act as a deterrent. But it was
\nnot just the mere physical absence of a manager,
\nwhich aided Leeson in perpetrating his criminal
\nactivities. When Leeson was afforded some
\nsupervision, the evidence suggests that the
\nmanagement problem was compounded by the fact
\nthat Bax, Jones and Ron Baker (who was later
\nresponsible for managing Leeson at a product
\nlevel) had very little understanding of the products
\n(futures and options) he dealt in and the trading
\nprocesses which underpinned this business. In this
\nsense, supervision could not be executed properly
\nowing to the ignorance of managers regarding the
\nnature of business undertaken by Leeson and not,
\nin the case of intimate handlers, owing to their
\nabsence.
\n4.2. Routine Activity Theory: Targets
\nThe Barings case, highlights a possible
\nvariation on the targets concept inscribed in the
\nmodel. Although there is no hard evidence to
\nsuggest it, the obvious assumption would be that
\nLeeson carried out the unauthorised trading for
\npersonal financial gain. Hence the \u2018target\u2019 in this
\nsense would have been the ability to undertake the
\nunauthorised trading, while the benefits
\nrepresented monies derived from the unsanctioned
\nbusiness. However, in his book The Collapse of
\nBarings, Fay [12] argues that behind Leeson\u2019s
\nillegal activities was the desire to become one of
\nthe elite traders on the floor of SIMEX. Leeson
\ngot to know some of these traders owing to the
\nfact that the companies they worked for (First
\nContinental Trading and Spear, Leeds and
\nKellogg) used Baring Futures Singapore for
\nclearing their trades with SIMEX. Admiring the
\nstatus and prestige associated with the elite
\nbrokers, Fay argues that Leeson was keen to
\nemulate their activities and establish himself as a
\nname on the trading floor. To do this, however,
\nrather than taking the conventional route, Leeson
\ncarried out the unauthorised trading, creating
\nfantastic \u2018profits\u2019 through dumping losses in
\naccount 88888.
\nIn this sense, the benefit derived from trading
\nwas not the obvious one of money, but rather the
\nbenefits of prestige and status that were afforded
\nthe top traders. What the two benefits have in
\ncommon is the nature of the target, which was the
\nability to undertake unauthorised trading.
\nAlthough \u2018ability\u2019 has a comparatively intangible
\nnature, it can still be viewed as consistent with
\nroutine activity theory, which views a target as one
\nof the elements necessary for the commission of a
\ncrime. The data not only supports this proposition
\nbut, if we subscribe to Fay\u2019s [12] argument, it can
\nbe seen to support the rational choice perspective,
\nby illustrating how the \u2018benefits\u2019 of crime can
\ncome in many guises. In Leeson\u2019s case, as noted,
\nhis benefits were prestige and status.
\n4.3. Routine Activity Theory:
\nGuardianship Factors
\nCompared with traditional applications, the
\nissue of guardianship is far more complex when
\ndiscussing the collapse of Barings. Indeed, a
\nnumber of safeguard factors can provide
\nguardianship in the banking environment, such as
\ninternal\/external audit, compliance monitoring,
\nrisk management and the like. To some extent,
\nthese guardianship factors can be perceived as still
\nin keeping with routine activity theory, given that
\ntheir presence or absence would play a part in
\ndetermining whether an entity represents a viable
\ntarget.
\nHowever, it should be noted that the elements
\nthat are considered guardianship factors in the
\nBarings case are of a far more complex nature than
\nthose traditionally recognised by routine activity
\ntheory. More specifically, a priori conditions need
\nto be met before they can exist. Take for instance
\nBaring Securities Limited\u2019s internal audit group.
\nA management committee would have decided on
\nits establishment, the size of the group, and the
\npositions that would need to be created. The
\nemployment vacancies would be advertised,
\npeople interviewed and selected. Obviously, only
\nafter its inception could arrangements have been
\nmade for the group to carry out audits in Baring
\nSecurities Limited\u2019s various subsidiaries.
\nOf course, even if guardianship factors like the
\ninternal audit group are introduced into the
\nbanking context, there is no guarantee that their
\nmere existence will provide effective guardianship
\nover the target they purport to safeguard. Rather
\nthey have to exist and be working effectively.
\nThis last assertion can be seen as a slight departure
\nfrom routine activity theory, which asserts that the
\nexistence of a capable guardian would deter a
\ncrime. Obviously of importance here is what
\nexactly constitutes a capable guardian, but routine
\nactivity does emphasise how the mere physical
\npresence\/existence (as also noted with the handled
\noffender) is often sufficient to provide the
\nnecessary guardianship. Hence the presence of an
\nindividual in their home is a good illustration. Yet
\nin the case of Barings, the existence of a
\nProceedings of the 37th Hawaii International Conference on System Sciences – 2004
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\nguardianship factor is not sufficient. They must
\nexist and be effective.
\n4.4. Routine Activity Theory: Facilitators
\nClarke [13] depicts facilitators as coming from
\nthe physical environment. However, the internal
\nthreat posed by staff, and the organisational
\nenvironment in which they work, places a different
\nspin on the concept. As Willison [14] asserts:
\n\u201cMore interesting perhaps is the idea that
\npotential offenders acquire facilitators in the
\ncourse of their work. Unlike their physical
\ncounterparts, these facilitators are cognitive in
\nnature, and \u2026 are assimilated by staff the day
\nthey begin working for a particular company.\u201d
\nEssentially these cognitive facilitators include
\nthose skills and knowledge that a person acquires
\nto perform their jobs. A key point here is that,
\nalthough on the whole these skills are used by
\nemployees for perfectly legal activities, they can
\nalso be used to help facilitate activities of an
\nillegal nature. Perhaps not surprisingly, the BoBS
\nreport highlights numerous instances of Leeson
\nusing his skills in this manner. Indeed, all his
\ncriminal activities were underpinned by
\nknowledge initially acquired to support legitimate
\nwork. This is clearly revealed by the very fact that
\nthe report makes the distinction between
\nauthorised and unauthorised trading.
\nFor Leeson, the knowledge required to
\nundertake the unauthorised trading was gleaned
\nnot just from his experience in Singapore, but also
\nin London where he had previously worked in the
\nlate 1980s and early 1990s. Barings Securities
\nLimited had commenced trading futures and
\noptions in 1989. In the same year Leeson joined
\nthe department which dealt with the settlements
\nside of this business, and began to develop an indepth
\nknowledge of these products. It was his
\nexpertise in this area that landed him the position
\nin Singapore. Furthermore, while Leeson was
\nacquiring the necessary skills and knowledge to
\nundertake his duties, he was also acquiring an indepth
\nunderstanding of the work processes of
\nwhich his duties were an inherent part.
\n4.5. Environmental Criminology: Search
\nPatterns of Offenders
\nData from the case study appears to support this
\ndepiction of a potential offender as an individual
\nwho collates information from their awareness
\nspace and uses it for criminal purposes. Leeson\u2019s
\n\u2018awareness space\u2019 encompassed the offices he
\nroutinely worked in. These included not only
\nBaring Futures Singapore and SIMEX, but also
\nBaring Securities Limited (London) where he had
\nworked prior to moving to the Far East. While
\nperforming his day-to-day duties, Leeson was able
\nto note any weak links in the control environment.
\nPrior to the commencement of the unauthorised
\ntrading, Leeson opened account 88888 to help
\nconceal his aberrant activities. He knew from his
\ntime in London, that as with other accounts, the
\ntrading details of account 88888 would be sent by
\nBaring Futures Singapore to London in the form of
\nfour reports, which included a trade file, which
\ngave details of the day\u2019s trading activity; a price
\nfile, which reported on closing settlements price; a
\nmargin file, listing the initial \u2013 and maintenance \u2013
\nmargin details of each account; and the London
\ngross file, which provided details of BFS\u2019s trading
\nposition. In order to stop details of account 88888
\nreaching London, Leeson instructed Dr. Edmund
\nWong, a computer consultant, to omit details of
\nthe account from three of the four daily trading
\nreports. The exception was the margin file.
\nLeeson was aware that the margin file represented
\na security vulnerability for Baring Securities
\nLimited, simply because it was routinely ignored
\nby staff in London. Conversely, for Leeson, the
\nmargin file represented no risk with regard to
\nhelping to uncover his unauthorised trading, given
\nthe oversight by staff in London. As a
\nconsequence, he was able to ignore it.
\nOf key importance here is the fact that Leeson
\nworked for Barings. This represents a slight
\ndeparture from the offender\u2019s circumstance
\ntraditionally found in the studies of environmental
\ncriminology. For example, Brantingham and
\nBrantingham [7] cite the work of Dufala [15]
\nwhose study addresses convenience store robberies
\nin Tallahassee, Florida. Dufala reports how, for
\nmarketing purposes, the stores were situated near
\nmajor roads. As a consequence, these stores also
\nformed part of the awareness space of offenders
\nwho, like many other urban residents, lived
\nnearby. Leeson\u2019s position, however, would be
\nmore comparable to that of a clerk in one of the
\nshops. Hence, learning his trade and developing
\nknowledge of his target took place in the same
\ncontext.
\nA related point concerns the quality of
\ninformation that the offender is able to garner.
\nAlthough an offender\u2019s rationality is addressed in
\nthe next section of this chapter, the concept of
\nbounded rationality ties in nicely with the
\noffender\u2019s circumstance. Unlike the convenience
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\nstore robbers studied by Dufala [15], Leeson had
\naccess to a relatively high quality of information,
\nwhich enabled him to assess more accurately
\npotential risks, efforts and rewards. Access to
\nsuch information was primarily due to the fact that
\nhe worked for Barings. His employment first with
\nBaring Securities Limited and then Baring Futures
\nSingapore also provided Leeson with both the
\nnecessary time and locations to collate the relevant
\ninformation.
\n4.6. The Rational Choice Perspective
\nThere is considerable evidence in the Barings
\ncase to support the rational choice perspective.
\nPrior to the commencement of the unauthorised
\ntrading, Leeson clearly planned and executed
\nactions that afforded the necessary conditions to
\ninitiate the unsanctioned business. One example
\nconcerns the manipulation of funding from
\nLondon. When Leeson first started work at Baring
\nFutures Singapore, he informed Gordon Bowser
\n(Head of Futures and Options Settlements in
\nLondon) that owing to the manner in which
\nSIMEX made margin calls (margin is a form of
\ndeposit which is paid when derivatives are traded),
\nit would be difficult for Baring Futures Singapore
\nto raise in time the appropriate monies to meet the
\nrequests. Leeson argued that it would be far easier
\nif the funds could be advanced from London prior
\nto the margin calls. What Bowser did not know
\nwas that the \u2018problem\u2019 of meeting SIMEX margin
\ncalls was pure fiction on Leeson\u2019s behalf.
\nUnfortunately, Bowser believed him and agreed to
\nthe request. This meant that Leeson could call for
\nfunds from London without specifying the trading
\naccount to which the request related. Through his
\ncareful planning, Leeson had gained a \u2018safe\u2019
\nsource of funding. The reconciliation between
\naccounts and funding would have proved a useful
\nsafeguard, but by succeeding in gaining advanced
\nfunds prior to margin calls, Leeson knew this
\nsafeguard would be negated.
\nDuring the commission of the fraud, Leeson
\ncontinued to demonstrate the actions of a rational
\noffender. When losses began to accrue as a result
\nof his unauthorised trading, these were placed in
\naccount 88888. In order to hide these losses, and
\nin order to avoid detection, Leeson created false
\njournal entries, generated fictitious transactions
\nand sold a large number of options. From early
\n1993 he masked the month end balance of the
\naccount by making a journal adjustment, crediting
\n88888 with a sum which would leave the balance
\nat zero. He would then make an additional journal
\nadjustment by debiting the same amount to the
\nSIMEX clearing bank account maintained by
\nBaring Futures Singapore. After the month end
\nreconciliation, the transaction was simply
\nreversed. Although this technique was used on
\nnumerous occasions to hide the balance of account
\n88888, another method involved the selling of
\noptions. Leeson would simply take the premiums
\ncollected through the sale of options, and offset
\nthis amount against the losses residing in 88888.
\nIn effect, he was in a position to manipulate his
\nenvironment to reduce the risk of his fraud being
\nuncovered.
\n5. Conclusion
\nThis section concludes the paper by
\nsummarising the major findings of the discussion
\nand analysis section and advances future research
\npossibilities offered by the criminological theories.
\nOf the three approaches, routine activity theory
\nappears to offer with regard to IS security. The
\nconcept of \u2018handling\u2019 can be seen to lack the
\nnecessary sophistication to theoretically
\naccommodate and explain the supervisory failings
\nin Barings. This lack of conceptual sophistication
\nis further evident when discussing the issue of
\nguardianship. A determining factor in the utility
\nof both concepts is the complexity of the crime to
\nwhich they are applied. Routine activity when
\nfirst advocated restricted its application to \u2018direct
\ncontact predatory crimes\u2019 i.e. where one or more
\npersons directly take or damage the person or
\nproperty of another. This is a far cry from
\nunauthorised trading on SIMEX. However, when
\ndiscussing the usefulness of the aforementioned
\nconcepts, the issue of granularity should be
\nintroduced into the debate. The Barings case is
\nextremely detailed, encompassing many
\nindividuals and organisations, and as noted the
\nhandling and guardianship concepts find it
\ndifficult to accommodate such complexity. That
\nsaid the concepts might prove more fruitful when
\napplied to less complex cases of computer abuse.
\nThe concept of targets is likewise drawn from
\nroutine activity theory. Traditionally, examples of
\nthis concept take a physical form, including cars to
\nsteal, banks to rob and houses to burgle. Although
\nthe target in the Barings case proved to be the
\nability to undertake trading, and hence represents a
\ndeparture from its physical counterparts, this is
\nstill consistent with routine activity\u2019s theoretical
\nproposition, which views a target as one of the
\nelements necessary for the commission of a crime.
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\nThe final major input from routine activity
\nrelates to facilitators. While acknowledging the
\ntangible nature of some facilitators, the case study
\nsupports the idea of intangible cognitive
\nfacilitators. Indeed, any understanding of
\ncomputer crime must be able to account for and
\nconsider how cognitive facilitators are used for the
\ncommission of such crimes. In this sense, the
\nfacilitators concept is easily translated into the
\nfield of IS security.
\n5.1. Environmental Criminology
\nLike facilitators, the theoretical concepts of
\nenvironmental criminology are easily translated
\ninto the IS security field. The Barings case
\nprovides supporting evidence, illustrating how
\nknowledge of security provisions was used by
\nLeeson to his advantage. The search patterns of
\noffenders, married with cognitive facilitators,
\nprovide a useful theoretical grounding in
\nunderstanding how a rogue employee combines
\nknowledge of the environment with the skills
\nacquired through work to perpetrate a fraud.
\n5.2. Rational choice perspective
\nData from the case study further supports the
\nidea of a rational offender. Leeson clearly planned
\nand executed actions that allowed him to initiate
\nhis unauthorised trading. During the period in
\nwhich his aberrant trading took place, he
\ncontinued to demonstrate the actions of a rational
\noffender. When losses accrued as a result of the
\ntrading, not only did Leeson place them in a
\nspecially designated account (88888), he also
\ninstigated actions to hide the losses and avoid
\ndetection.
\n5.3. Future Research
\nGiven these findings, future research could
\ncover the following areas. First, the theories could
\nbe applied to cases less complex in nature than the
\nBarings collapse. Individual incidents of computer
\nabuse would provide complementary findings for
\nassessing the feasibility of applying the three
\ntheories to the IS security context. Routine
\nActivity theory, in particular, may offer more
\nfruitful findings when applied to less complex
\ncases.
\nSecondly, prevention strategies based around
\nthe three theories could be examined and
\nconsidered for the IS security field. Are the
\nprevention strategies feasible for the IS context
\nand do they offer fresh perspectives for security
\npractitioners and academics
\nThirdly, complementary criminological
\nconcepts could be imported to reinforce the use of
\nthe theories, and help to develop more informed
\nprevention strategies. For example, the concept of
\ncrime \u2018scripts\u2019 has been advanced by Cornish [16].
\nAs the name suggests, the concept compare a
\ncrime to a theatrical script. The method helps to
\nbreak down a crime into individual, but related,
\nstages or \u2018scenes\u2019. Each identifiable stage allows
\nfor consideration of the specific context, \u2018props\u2019,
\nthe actions of the offender and their rational
\nchoices which underpin such actions. In
\nconjunction with the rational choice perspective,
\nthe scripts concept can give a greater
\nunderstanding of the procedural stages of a
\nspecific crime. Once this is achieved, security
\nstrategies can identify prevention points and
\nincrease the risks and efforts and reduce the
\nrewards.
\nA final point to consider concerns the
\nrelationship between IS security and theory. One
\nof the general deficiencies of IS security is the lack
\nof theory both used and advocated by academics in
\nthe field. The position taken in this paper is that in
\norder to understand computer crime and computer
\ncriminals, the academic discipline, which can
\npotentially offer substantial insight into this area is
\ncriminology. Given the multi-disciplined nature of
\ncriminology, drawing from psychology, sociology,
\nlaw, social policy and economics, it can be seen to
\noffer a voluminous body of knowledge which IS
\nsecurity academics can use.
\n6. References
\n[1] Willison, R. (2002) Opportunities for Computer
\nAbuse: Assessing a Crime Specific Approach in the
\nCase of Barings Bank. PhD thesis. London School of
\nEconomics and Political Science.
\n[2] Clarke, R. (ed.) (1997) Situational Crime Prevention
\n: Successful Case Studies. 2nd ed. Albany, NY.
\nHarrow and Heston.
\n[3] Cohen, L. and Felson, M. (1979) Social Change and
\nCrime Rate Trends : A Routine Activity Approach.
\nAmerican Sociological Review 44: 588-608.
\n[4] Felson, M. (1986) Linking Criminal Choices,
\nRoutine Activities, Informal Control, and Criminal
\nOutcomes. In D. Cornish and R. Cornish (eds.), The
\nReasoning Criminal : Rational Choice Perspectives on
\nOffending. New York. Springer-Verlag.
\nProceedings of the 37th Hawaii International Conference on System Sciences – 2004
\n0-7695-2056-1\/04 $17.00 (C) 2004 IEEE 9
\n[5] Hirschi, T. (1969) Causes of Delinquency.
\nBerkeley and Los Angeles. University of California
\nPress.
\n[6] Clarke, R. (ed.) (1992) Situational Crime Prevention
\n: Successful Case Studies. Albany, NY. Harrow and
\nHeston..
\n[7] Brantingham, P. and Brantingham, P. (1991)
\nEnvironmental Criminology. (2nd ed.). Prospect
\nHeights, IL. Waveland Press.
\n[8] Clarke, R. and Cornish, D. (1985) Modelling
\nOffender\u2019s Decisions : A Framework for Policy and
\nResearch. In M. Tonry and N. Morris (eds.), Crime and
\nJustice : An Annual Review of Research. Vol. 6.
\nChicago. University of Chicago Press.
\n[9] Cornish, D. and Clarke, R. (1986) Situational
\nPrevention, Displacement of Crime and Rational Choice
\nTheory. In K. Heal, and G. Laycock (eds.), Situational
\nCrime Prevention: From Theory into Practice. London.
\nH.M.S.O.
\n[10] Clarke, R. and Cornish, D. (2000) Rational Choice.
\nIn R. Paternoster and R. Bachman (eds.), Explaining
\nCrime and Criminals: Essays in Contemporary
\nCriminological Theory. Los Angeles, CA. Roxbury
\nPublishing Company.
\n[11] Board of Banking Supervision (1995) Report of the
\nBoard of Banking Supervision Inquiry into the
\nCircumstances of the Collapse of Barings. London.
\nHMSO.
\n[12] Fay, S. (1996) The Collapse of Barings. London.
\nRichard Cohen Books.
\n[13] Clarke, R. (1995) Situational Crime Prevention. In
\nM. Tonry and D. Farrington (eds.). Building a Safer
\nSociety. Strategic Approaches to Crime Prevention.
\nCrime and Justice: A Review of Research. Vol. 19.
\nChicago. University of Chicago Press.
\n[14] Willison, R. (2000) Reducing Computer Fraud
\nThrough Situational Crime Prevention. In S. Qing and
\nJ. H.P. Eloff (eds.), Information Security for Global
\nInformation Infrastructures. Boston. Kluwer Academic
\nPress.
\n[15] Dufala, D. (1976) Convenience Stores: Armed
\nRobbery and Physical Environmental Features.
\nAmerican Behavioral Scientist 20: 227-246.
\n[16] Cornish, D. (1994) The Procedural Analysis of
\nOffending and its Relevance for Situational Prevention.
\nCrime Prevention Studies. 3.
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Article Dissection 5<\/p>\n
Order Description<\/p>\n
Read the attached article and address the following in a 1-2 page paper: A. Describe the purpose\/aims of the study. B. Note the theory\/ evidence-based intervention\/or policy being applied; also note whether the author\u2019s use of theory is explicit or implicit and briefly explain why. Identify the key concepts. Are their definitions clear Do they fit with the theoretical framework provided C. Describe the methodology (sample, design, analytic strategy) employed. Does the method fit with the theoretical framework \u2013 consider the type of sample selected, the types of variables included, the approach to data collection and analysis. Are the key variables, and their operationalization, what you expected based on the introduction If the analysis is sophisticated, does the author do a good job tutoring the reader so you can appreciate the analytic approach D. Describe the key findings of the study. Overall, what does this study contribute to basic and\/or applied knowledge E. What are the key limitations and implications for practice of the study \u2013 note those mentioned by the author as well as additional limitations and implications you observed (make sure to distinguish between the limitations\/implications you identify and those identified by the authors). F. What do you think are some good next steps\/good questions to ask for future research This paper should be in APA format. Please answer each bullet thoroughly and clearly. This paper needs to be in APA format (Double spaced, 12 font Times New Roman, Reference page, and Citations<\/p>\n
The evidence base for family therapy and systemic
\ninterventions for child-focused problems
\nAlan Carra
\nThis review updates similar articles published in the Journal of Family
\nTherapy in 2001 and 2009. It presents evidence from meta-analyses, systematic
\nliterature reviews and controlled trials for the effectiveness of
\nsystemic interventions for families of children and adolescents with
\nvarious difficulties. In this context, systemic interventions include both
\nfamily therapy and other family-based approaches such as parent training.
\nThe evidence supports the effectiveness of systemic interventions
\neither alone or as part of multi-modal programmes for sleep, feeding and
\nattachment problems in infancy; child abuse and neglect; conduct problems
\n(including childhood behavioural difficulties, attention deficit hyperactivity
\ndisorder, delinquency and drug misuse); emotional problems
\n(including anxiety, depression, grief, bipolar disorder and self-harm);
\neating disorders (including anorexia, bulimia and obesity); somatic problems
\n(including enuresis, encopresis, medically unexplained symptoms
\nand poorly controlled asthma and diabetes) and first episode psychosis.
\nIntroduction
\nThis article summarizes the evidence base for systemic practice with
\nchild-focused problems and updates previous similar articles (Carr,
\n2000, 2009). It is also a companion article to a review of research on
\nsystemic interventions for adult-focused problems (Carr, 2014). In this
\narticle a broad definition of systemic practices has been used, covering
\nfamily therapy and other family-based interventions such as parent
\ntraining or multisystemic therapy, which engage family members or
\nmembers of the families\u2019 wider networks in the process of resolving
\nproblems for young people from birth up to the age of 18 years.
\nOne-to-one services (such as home visiting for vulnerable mothers of
\nyoung children) and complex interventions (such as multi-component
\ncare packages for people with intellectual and developmental disabilities),
\nwhich are arguably systemic interventions but which differ in
\na Professor of Clinical Psychology, School of Psychology, Newman Building, University
\nCollege Dublin, Belfield, Dublin 4, Ireland. E-mail: alan.carr@ucd.ie
\nbs_bs_banner
\nJournal of Family Therapy (2014) 36: 107\u2013157
\ndoi: 10.1111\/1467-6427.12032
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nmany practical ways from family therapy, were excluded from this
\nreview.
\nSprenkle (2012) edited a special issue of the Journal and Marital and
\nFamily Therapy on research and concluded that a large and growing
\nevidence base now supports the effectiveness of systemic interventions.
\nThis work updates previous special issues of the Journal and
\nMarital and Family Therapy (Pinsof and Wynne, 1995; Sprenkle, 2002).
\nShadish and Baldwin (2003) reviewed twenty meta-analyses of systemic
\ninterventions for a wide range of child and adult-focused problems.
\nThe average effect size across all meta-analyses was 0.65 after
\ntherapy and 0.52 at 6\u201312-months follow up. These results show that,
\noverall, the average treated family fared better after therapy and at
\nfollow up than over 71 per cent of families in control groups.
\nIf there is little doubt now about the fact that family therapy works,
\nthe next key question to address is its cost-effectiveness. In an important
\nseries of US studies, Crane and Christenson (2012) showed that
\nfamily therapy reduces health service usage, especially for frequent
\nservice users, and that family therapy is associated with greater benefits
\nthan individual therapy. The medical cost offset associated with
\nfamily therapy covers the cost of providing therapy and in many cases
\nleads to overall cost savings. Crane drew these conclusions from
\nstudies of a US health maintenance organization with 180,000 subscribers,
\nthe Medicaid system of the State of Kansas, CIGNA Behavioural
\nHealth which is a division of a health insurance company with
\nnine million subscribers, and a US family therapy training clinic.
\nWhile evidence for the overall efficacy, effectiveness and costeffectiveness
\nof systemic interventions is vital for healthcare policy
\ndevelopment and management, detailed research findings on what
\nworks for whom are required by family therapists who wish to engage
\nin research-informed practice. The remainder of this article focuses
\non precisely this issue. As with previous versions of this review, extensive
\ncomputer and manual literature searches were conducted for
\nsystemic interventions with a wide range of problems of childhood
\nand adolescence. For the present review the search extended to July
\n2013. Major databases, family therapy journals and child and adolescent
\nmental health journals were searched, as well as key textbooks on
\nevidence-based practice. Where available, meta-analyses and systematic
\nreview articles were selected for review, since these constitute the
\nstrongest form of evidence. If such articles were unavailable, controlled
\ntrials, which constitute the next highest level of evidence, were
\nselected. Only in the absence of such trials were uncontrolled studies
\n108 Alan Carr
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nselected. It was intended that this article be primarily a review of the
\nreviews, with a major focus on substantive findings of interest
\nto practicing therapists rather than on methodological issues. This
\noverall review strategy was adopted to permit the strongest possible
\ncase to be made for systemic evidence-based practices for a wide range
\nof child-focused problems and to offer useful guidance for therapists,
\nwithin the space constraints of a single article. Below, the results of the
\nreview are presented under the following headings: problems of
\ninfancy, child abuse and neglect, conduct problems, emotional problems,
\neating disorders, somatic problems and psychosis.
\nProblems of infancy
\nFamily-based interventions are effective for a proportion of families in
\nwhich infants have sleeping, feeding and attachment problems. These
\ndifficulties occur in about one- quarter to one-third of infants and are
\nof concern because they may compromise family adjustment and later
\nchild development (Zennah, 2012).
\nSleep problems
\nFamily-based behavioural programmes are an effective treatment for
\nsettling and night waking problems, which are the most prevalent
\nsleep difficulties in infancy (Hill, 2011). In these programmes parents
\nare coached in reducing or eliminating children\u2019s daytime naps,
\ndeveloping positive bedtime routines, reducing parent\u2013child contact
\nat bedtime or during episodes of night waking and introducing scheduled
\nwaking where children are awoken 15\u201360 minutes before the
\nchild\u2019s spontaneous waking time and then resettled. A systematic
\nreview of 52 studies of family-based behavioural programmes for
\nsleep problems in young children by Mindell et al. (2006), and of nine
\nrandomized controlled trails of family-based and pharmacological
\ninterventions by Ramchandani et al. (2000) indicate that both familybased
\nand pharmacological interventions are effective in the short
\nterm but only systemic interventions have positive long-term effects
\non children\u2019s sleep problems.
\nFeeding problems
\nSevere feeding problems in infancy, which may be associated with a
\nfailure to thrive, include self-feeding difficulties, swallowing problems,
\nEvidence-base for family therapy with children 109
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nfrequent vomiting and, in the most extreme cases, food refusal. With
\nfood refusal there is refusal to eat all or most foods, resulting in
\ndependence on supplemental tube feeds or a failure to meet caloric
\nneeds. Family-based behavioural programmes are particularly effective
\nin addressing food refusal (Kedesdy and Budd, 1998; Sharp et al.,
\n2010). Such programmes involve parents prompting, shaping and
\nreinforcing successive approximations to appropriate feeding behaviour
\nwhile concurrently preventing children from escaping from the
\nfeeding situation, ignoring inappropriate feeding responses and
\nmaking the feeding environment pleasant for the child. Small spoonfuls
\nof preferred foods are initially used in these programmes. Gradually,
\nbite sizes are increased and non-preferred nutritious food is
\nblended with preferred food. In a systematic review of forty-eight
\ncontrolled single case and group studies, Sharp et al. (2010) concluded
\nthat such programmes were effective in ameliorating severe feeding
\nproblems and improving weight gain in infants and children, particularly
\nthose with developmental disabilities.
\nAttachment problems
\nInfant attachment insecurity is a risk factor for internalizing (Madigan
\net al., 2013) and externalizing (Fearon et al., 2010) problems in childhood
\nand adult psychological difficulties (Dozier et al., 2008). A range
\nof short-term and long-term evidence-based family interventions,
\neach supported by a series of controlled trials, has been developed to
\nfoster attachment security in families with varying degrees of vulnerability
\n(Berlin et al., 2008; Zeanah et al., 2011). For high-risk families
\nin which parents have histories of childhood adversity and whose
\ncurrent families are characterized by high levels of stress, low levels of
\nsupport and domestic violence or child abuse, intensive longer term
\ninterventions have been shown to be effective in improving attachment
\nsecurity. These involve weekly clinical sessions or home visiting
\nand span 1\u20132 years. For example, child\u2013parent psychotherapy
\ninvolves weekly dyadic sessions with mothers and children for about a
\nyear (Lieberman and Van Horn, 2005). Child\u2013parent psychotherapy
\nhelps mothers resolve ambivalent feelings about their infants by
\nlinking them to their own adverse childhood experiences and current
\nlife stresses in the context of a supportive long-term therapeutic
\nalliance. For less vulnerable families, briefer interventions involving a
\nfew carefully structured home-visiting sessions and video feedback on
\nparent\u2013child interaction have been shown to be effective in improving
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\nattachment security. For example, with Juffer et al.\u2019s (2007) video
\nfeedback intervention to promote positive parenting, in four home
\nvisits parents are given feedback on videotapes of their interactions
\nwith their infants, written materials on attachment, and an opportunity
\nto discuss the impact of their own family of origin experiences on
\nthe way they interact with their infants.
\nThe results of this review suggest that in developing services for
\nfamilies of infants with sleeping and feeding problems only relatively
\nbrief outpatient programmes are required involving up to fifteen
\nsessions over 3\u20134 months for each episode of treatment. For attachment
\nproblems, the intensity of intervention needs to be matched to
\nthe level of family vulnerability.
\nChild abuse and neglect
\nSystemic interventions are effective in a proportion of cases of child
\nabuse and neglect. These problems have devastating effects on the
\npsychological development of children (Myers, 2011). In a series of
\nmeta-analyses of international studies Stoltenborgh et al. (2011, 2012,
\n2013a, 2013b) found prevalence rates based on self-reports of 22.6
\nper cent for physical abuse, 12.7 per cent for contact sexual abuse,
\n36.3 per cent for emotional abuse, 16.3 per cent for physical neglect
\nand 18.4 per cent for emotional neglect.
\nPhysical abuse and neglect
\nSystematic narrative reviews concur that for physical child abuse and
\nneglect, effective therapy is family-based and structured. It extends
\nover periods of at least 6 months and addresses specific problems in
\nrelevant subsystems, including children\u2019s post-traumatic adjustment
\nproblems; parenting skills deficits and the overall supportiveness
\nof the family and social network (Chaffin and Friedrich, 2004;
\nEdgeworth and Carr, 2000; MacDonald, 2001; MacLeod and Nelson,
\n2000; Skowron and Reinemann, 2005; Tolan et al., 2005). Cognitive
\nbehavioural family therapy (Kolko, 1996; Kolko and Swenson, 2002;
\nRynyon and Deblinger, 2013), parent\u2013child interaction therapy
\n(Chaffin et al., 2004; Hembree-Kigin and McNeil, 1995; Timmer et al.,
\n2005), and multisystemic therapy (Brunk et al., 1987; Henggeler et al.,
\n2009) are manualized approaches to family-based treatment that have
\nbeen shown in randomized controlled trials to reduce the risk of
\nfurther physical child abuse.
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\nCognitive behavioural family therapy for physical abuse. In a controlled trial
\nKolko (1996) found that at 1-year follow up conjoint cognitive behavioural
\nfamily therapy and concurrent parent and child cognitive
\nbehavioural therapy were both more effective than routine services in
\nreducing the risk of further abuse in families of schoolaged children in
\nwhich physical abuse had occurred. The sixteen-session programme
\ninvolved helping parents and children develop skills for regulating
\nangry emotions, communicating and managing conflict and developing
\nalternatives to physical punishment as a disciplinary strategy
\n(Kolko and Swenson, 2002).
\nParent\u2013child interaction therapy for physical abuse. In a controlled trial of
\nparent\u2013child interaction therapy, Chaffin et al. (2004) found that at
\n2-years follow up only 19 per cent of parents who participated in
\nparent\u2013child interaction therapy had a re-report for physical abuse
\ncompared with 49 per cent of parents assigned to standard treatment.
\nParent\u2013child interaction therapy involved sessions that aimed to
\nenhance parents\u2019 motivation to engage in parent training; seven sessions
\ndevoted to the live coaching of parents and children in positive
\nchild-directed interactions and seven sessions devoted to the live
\ncoaching of parents and children in the behavioural management of
\ndiscipline issues, using time-out and related procedures.
\nMultisystemic therapy for physical abuse and neglect. Brunk et al. (1987)
\ncompared the effectiveness of multisystemic therapy and group-based
\nbehavioural parent training in families where physical abuse or neglect
\nhad occurred. Families who received multisystemic therapy showed
\ngreater improvements in family problems and parent\u2013child interactions
\nafter treatment than those who engaged in group-based behavioural
\nparent training. Multisystemic therapy involved joining with
\nfamily members and members of their wider social and professional
\nnetwork, reframing interaction patterns and prescribing tasks to alter
\nproblematic interaction patterns within specific subsystems (Henggeler
\net al., 2009). Therapists designed intervention plans on a per-case basis
\nin light of family assessments. They used individual, couple, family and
\nnetwork meetings in these plans and received regular supervision to
\nfacilitate this process, carrying small caseloads of four to six families.
\nSexual abuse
\nFor child sexual abuse, trauma-focused cognitive behavioural therapy
\nfor both the abused young people and their non-abusing parents has
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\nbeen shown to reduce the symptoms of post-traumatic stress disorder
\nand improve overall adjustment (Deblinger and Heflinger, 1996). In
\na systematic review of thirty-three trials, twenty-seven of which evaluated
\ntrauma-focused cognitive behavioural therapy, Leenarts et al.
\n(2012) found that patients treated with this approach fared better
\nthan those who received standard care. The results of this review
\nsuggest that trauma-focused cognitive behavioural therapy is the best
\nsupported treatment for children following childhood maltreatment.
\nTrauma-focused cognitive behavioural therapy involves concurrent
\nsessions for abused children and their non-abusing parents in group
\nor individual formats, with periodic conjoint parent\u2013child sessions,
\nWhere intra-familial sexual abuse has occurred it is essential that
\noffenders live separately from victims until they have completed a
\ntreatment programme and been assessed as being at low risk for
\nre-offending (Doren, 2006). The child-focused component involves
\nexposure to abuse-related memories to facilitate habituation to them;
\nrelaxation and coping skills training; learning assertiveness and safety
\nskills and addressing victimization, sexual development and identity
\nissues. Concurrent work with non-abusing parents and conjoint sessions
\nwith abused children and non-abusing parents focus on helping
\nparents develop supportive and protective relationships with their
\nchildren and develop support networks for themselves.
\nThe results of this review suggest that in developing services for
\nfamilies in which abuse or neglect has occurred, programmes that
\nbegin with a comprehensive network assessment and include, along
\nwith regular family therapy sessions, the option of parent-focused
\nand child-focused interventions should be prioritized. Programmes
\nshould span at least 6 months, with the intensity of input matched to
\nfamilies\u2019 needs. Therapists should carry small caseloads of fewer than
\nten cases.
\nConduct problems
\nFamily-based systemic interventions are effective for a proportion of
\ncases of childhood behaviour problems (or oppositional defiant disorder),
\nattention deficit hyperactivity disorder (ADHD), pervasive
\nadolescent conduct problems and drug misuse. All these difficulties
\nare of concern because they may lead to comorbid academic, emotional
\nand relationship problems and, in the long-term, to adult
\nadjustment difficulties (Pliszka, 2008). They are also relatively
\ncommon. In a review of community surveys, Merikangas et al. (2009)
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\nfound that the median prevalence rate for disruptive behaviour disorders
\n(including oppositional defiant disorder and conduct disorder)
\nwas 6 per cent; for ADHD it was 3\u20134 per cent and for adolescent
\nsubstance use disorders it was 5 per cent. Prevalence rates for these
\ntypes of problems ranged from 1\u201324 per cent across studies and were
\nall more common in boys.
\nChildhood behaviour problems
\nChildhood behaviour problems are maintained by both personal
\nattributes (such as self-regulation problems) on the one hand, and
\ncontextual factors (such as problematic parenting practices) on the
\nother. Treatment programmes have been developed to target each of
\nthese sets of factors. Many meta-analyses and systematic reviews covering
\nan evidence base of over 100 studies conclude that behavioural
\nparent training is particularly effective in ameliorating childhood
\nbehaviour problems, leading to improvement in 60\u201370 per cent of
\nchildren, with gains maintained at a 1-year follow up, particularly if
\nperiodic review sessions are offered (Barlow et al., 2002; Behan and
\nCarr, 2000; Brestan and Eyberg, 1998; Burke et al., 2002; Comer
\net al., 2013; Coren et al., 2002; Farrington and Welsh, 2003; Kazdin,
\n2007; Leijten et al., 2013; Lundahl, et al., 2008; Michelson et al.,
\n2013; Nixon, 2002; Nock, 2003; Nowak and Heinrichs, 2008;
\nSerketich and Dumas, 1996). Behavioural parent training also has a
\npositive impact on parental adjustment problems. For example, in
\nmeta-analyses of parent training studies Serketich and Dumas (1996)
\nfound an effect size of 0.44 and McCart et al. (2006) found an effect
\nsize of 0.33 for parental adjustment. Thus, the average participant in
\nparent training fared better than 63\u201365 per cent of control group
\ncases. Behavioural parent training is far more effective than individual
\ntherapy. For example, in a meta-analysis of thirty studies of
\nbehavioural parenting training and forty-one studies of individual
\ntherapy, McCart et al. (2006) found effect sizes of 0.45 for parent
\ntraining and 0.23 for individual therapy. Meta-analyses also show
\nthat behavioural parent training is as effective in routine community
\nsettings as it is in specialist programme development clinics
\n(Michelson et al., 2013). Furthermore, the inclusion of fathers in
\nparent training leads to greater improvement in child behaviour
\nproblems and parenting practices (Lundahl et al., 2008) and the
\nmore intensive programmes are more effective (Nowak and
\nHeinrichs, 2008).
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\nA critical element of behavioural parent training, which derives
\nfrom Gerald Patterson\u2019s seminal work at the Oregon Social Learning
\nCentre, is helping parents develop skills for increasing the frequency
\nof children\u2019s prosocial behaviour (through attending, reinforcement
\nand engaging in child-directed interactions) and reducing the frequency
\nof antisocial behaviour (through ignoring, time-out, contingency
\ncontracts and engaging in parent directed interactions)
\n(Forgatch and Paterson, 2010).
\nImmediate feedback, video feedback and video modelling have
\nbeen used in effective behavioural parent training programmes. With
\nvideo feedback, parents learn child management skills by watching
\nvideotaped episodes of themselves using parenting skills with their
\nown children. With immediate feedback, parents are directly coached
\nin child-management skills through a \u2018bug in the ear\u2019 while the therapist
\nobserves their interaction with their children from behind a oneway
\nmirror. Eyberg\u2019s parent\u2013child interaction therapy for parents of
\npreschoolers is a good example of this approach (Zisser and Eyberg,
\n2010). With video modelling, parents learn child management skills
\nthrough viewing video clips of actors illustrating successful and unsuccessful
\nparenting skills. Webster-Stratton\u2019s Incredible Years programme
\nis an example of this type of approach (Webster-Stratton and
\nReid, 2010).
\nThe effectiveness of behavioural parent training programmes may
\nbe enhanced by concurrently engaging children in therapy that aims
\nto remediate deficits in self-regulation skills, such as managing emotions
\nand social problem-solving (Kazdin, 2010; Webster-Stratton and
\nReid, 2010).
\nIn a meta-analysis of thirty-one studies, Reyno and McGrath (2006)
\nfound that parents with limited social support, high levels of povertyrelated
\nstress, and mental health problems derived the least benefit
\nfrom behavioural parent training. To address these barriers to effective
\nparent training, adjunctive interventions that address parental vulnerabilities
\nhave been added to standard parent training programmes,
\nwith positive incremental benefits. For example, Thomas and
\nZimmer-Gembeck (2007) found that enhanced versions of the parent\u2013
\nchild interaction therapy (Zisser and Eyberg, 2010) and triple-P
\n(Sanders and Murphy-Brennan 2010) programmes, which included
\nadditional sessions on parental support and stress management, were
\nfar more effective than standard versions of these programmes.
\nThe results of this review suggest that in developing services for
\nfamilies where childhood behaviour problems are a central concern,
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\nbehavioural parent training should be offered, with the option of
\nadditional child-focused and parent-focused interventions being
\noffered where the assessment indicates particular vulnerabilities in
\nthese subsystems. Programmes should span at least 6 months, with the
\nintensity of input matched to families\u2019 needs. Each aspect of the
\nprogramme should involve about ten to twenty sessions, depending
\non need.
\nAttention and overactivity problems
\nADHD is currently the most commonly used term for a syndrome,
\nusually present from infancy, characterized by persistent overactivity,
\nimpulsivity and difficulties sustaining attention. Available evidence
\nsuggests that vulnerability to attentional and overactivity problems,
\nunlike the oppositional behavioural problems discussed in the section
\nabove, is largely constitutional (Thapar et al., 2013).
\nThe results of meta-analyses suggest that a proportion of preschool
\nchildren with ADHD show significant improvement in response to
\nbehavioural parent training (Lee et al., 2012; Rajwan et al., 2012). For
\nchildren who do not respond to systemic interventions alone, systematic
\nreviews concur that systemic interventions for ADHD are best
\noffered as elements of multi-modal programmes involving stimulant
\nmedication (Anastopoulos et al., 2005; DuPaul et al., 2012; Friemoth,
\n2005; Hinshaw et al., 2007; Jadad et al., 1999; Klassen et al., 1999;
\nNolan and Carr, 2000; Schachar et al., 2002). For example, Hinshaw
\net al. (2007) in a review of fourteen randomized controlled trials,
\nconcluded that about 70 per cent of children with ADHD benefited
\nfrom multi-modal programmes. Multi-modal programmes typically
\ninclude stimulant treatment of children with drugs such as methylphenidate
\ncombined with family therapy or parent training; schoolbased
\nbehavioural programmes and coping skills training for
\nchildren. Family therapy for ADHD focuses on helping families
\ndevelop patterns of organization conducive to effective child management
\n(Anastopoulos et al., 2005). Such patterns of organization
\ninclude a high level of parental co-operation in problem-solving and
\nchild management; a clear intergenerational hierarchy between
\nparents and children; warm supportive family relationships; clear
\ncommunication and clear, moderately flexible, rules, roles and routines.
\nSchool-based behavioural programmes involve the extension of
\nhome-based behavioural programmes into the school setting through
\nhome\u2013school, parent\u2013teacher liaison meetings (DuPaul et al., 2012).
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\nCoping skills training focuses on coaching children in the skills
\nrequired for managing their attention, impulsivity, aggression and
\noveractivity (Hinshaw, 2005).
\nMedicated children with ADHD show a reduction in symptomatology
\nand an improvement in both academic and social functioning,
\nalthough the positive effects dissipate when medication ceases if
\nsystemic interventions to improve symptom control, such as those
\noutlined above, have not been provided concurrently with the
\nmedication. One of the most remarkable findings of the multi-modal
\ntreatment study of ADHD (MTA) \u2013 the largest ever long-term controlled
\ntrial of stimulant medication for ADHD involving over 500
\npatients \u2013 is that stimulant medication ceased to have a therapeutic
\neffect after 3 years (Swanson and Volkow, 2009). It also led to a
\nreduction in height gain of about 2 cm and a reduction in weight gain
\nof about 2 kg. Furthermore, it did not prevent adolescent substance
\nmisuse as expected. The MTA trial showed that tolerance to medication
\nused to treat ADHD occurs and this medication has negative side
\neffects. These findings underline the importance of using medication
\nto reduce ADHD symptoms to manageable levels for a time-limited
\nperiod, while children and their parents engage in systemic interventions
\nto develop skills to manage symptoms.
\nThese results suggest that in developing services for families where
\nchildren have attention and overactivity problems, multi-modal treatment
\nwhich includes family, school and child-focused interventions
\ncombined with stimulant therapy, spanning at least 6 months in the
\nfirst instance, is the treatment of choice. For effective long-term treatment,
\ninfrequent but sustained contact with a multidisciplinary service
\nover the course of the child\u2019s development should be made available
\nso that at transitional points in each yearly cycle (such as entering a
\nnew school classes each autumn) and at transitional points within the
\nlife cycle (such as entering adolescence, changing school or moving
\nhouse) increased service contact may be offered.
\nPervasive conduct problems in adolescence
\nAbout one-third of children with childhood behaviour problems
\ndevelop conduct disorder, which is a pervasive and persistent pattern
\nof antisocial behaviour that extends beyond the family into the community.
\nAdolescent self-regulation and skills deficits, problematic parenting
\npractices and extra-familial factors such as deviant peer group
\nmembership, high stress and low social support maintain conduct
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\ndisorder and are targeted by effective treatment programmes
\n(Murrihy et al., 2010).
\nIn a meta-analysis of twenty-four studies Baldwin et al. (2012) evaluated
\nthe effectiveness of brief strategic family therapy (Robbins et al.,
\n2010), functional family therapy (Alexander et al., 2013), multisystemic
\ntherapy (Henggeler and Schaeffer, 2010) and multidimensional family
\ntherapy (MDTF) (Liddle, 2010). They found that all four forms of
\nfamily therapy were effective compared with non-treatment control
\ngroups (with an effect size of 0.7) and somewhat more effective than
\ntreatment as usual or alternative treatments (where the effect sizes were
\nabout 0.2). These results showed that the average case treated with
\nfamily therapy fared better than 76 per cent of untreated patients and
\n58 per cent of patients who engaged in alternative treatments. These
\nresults are consistent with those from a previous meta-analysis of eight
\nfamily-based treatment studies of adolescent conduct disorder conducted
\nby Woolfenden et al. (2002). They found that family-based
\ntreatments, including functional family therapy, multisystemic therapy
\nand treatment foster care were more effective than routine treatment.
\nThese family-based treatments significantly reduced time spent in
\ninstitutions, the risk or re-arrest and recidivism 1\u20133 years following
\ntreatment. For each of these approaches, organizations to facilitate the
\nlarge-scale transport of treatments to community settings have been
\ndeveloped along with quality assurance systems to support treatment
\nfidelity in these settings (Henggeler and Sheidow, 2012). These effective
\nfamily-based interventions for adolescent conduct disorder fall on
\na continuum of care which extends from functional family therapy and
\nbrief strategic therapy through more intensive multisystemic therapy
\nto very intensive treatment foster care. What follows are brief outlines
\nof three of these models.
\nFunctional family therapy. This model was developed initially by James
\nAlexander at the University of Utah and more recently by Tom Sexton
\nat the University of Indiana (Alexander et al., 2013; Sexton, 2011). It is
\na manualized model of systemic family therapy for adolescent conduct
\ndisorder. It involves distinct stages of engagement where the emphasis
\nis on forming a therapeutic alliance with family members, behaviour
\nchange, where the focus is on facilitating competent family problemsolving
\nand generalization, where families learn to use new skills in a
\nrange of situations and to deal with setbacks. Whole family sessions are
\nconducted on a weekly basis. Treatment spans eight to thirty sessions
\nover 3\u20136 months. In a systematic review of twenty-seven clinical trials of
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\nfunctional family therapy, Alexander et al. (2013) concluded that this
\napproach is effective in reducing recidivism by up to 70 per cent in
\nadolescent offenders with conduct disorders from a variety of ethnic
\ngroups over follow-up periods of up to 5 years, compared with those
\nreceiving routine services. It also leads to a reduction in conduct
\nproblems in the siblings of offenders. In a review of a series of largescale
\neffectiveness studies, Sexton and Alexander (2003) found that
\nfunctional family therapy was $5,000\u201312,000 less expensive per case
\nthan juvenile detention or residential treatment and led to cost savings
\nfor victims and the criminal justice system of over $13,000 per case. The
\nsame review concluded that in a large-scale effectiveness study the
\ndrop-out rate for functional family therapy was about 10 per cent
\ncompared to the usual drop-out rates of 50\u201370 per cent in the routine
\ncommunity treatment of adolescent offenders.
\nMultisystemic therapy. This model was developed at Medical University
\nof South Carolina by Scott Henggeler and his team (Henggeler et al.,
\n2009). Multisystemic therapy combines intensive family therapy with
\nindividual skills training for adolescents and intervention in the wider
\nschool and inter-agency network. Multisystemic therapy involves
\nhelping adolescents, families and involved professionals understand
\nhow adolescent conduct problems are maintained by recursive
\nsequences of interaction within the youngsters\u2019 family and social
\nnetwork. It uses individual and family strengths to develop and implement
\naction plans and new skills to disrupt these problem maintaining
\npatterns. Furthermore, it supports families to follow through on
\naction plans, helping them use new insights and skills to handle new
\nproblem situations and monitoring progress in a systematic way.
\nMultisystemic therapy involves regular, frequent home-based
\nfamily and individual therapy sessions with additional sessions in
\nschool or community settings over 3 to 6 months. Therapists carry low
\ncaseloads of no more than five cases and provide 24-hour, 7-day
\navailability for crisis management. In a meta-analysis of eleven studies
\nevaluating the effectiveness of multisystemic therapy, Borduin et al.
\n(2004) found a post-treatment effect size of 0.55, which indicates that
\nthe average treated case fared better than 72 per cent of control group
\ncases receiving standard services. Positive effects were maintained up
\nto 4 years after treatment.
\nMultisystemic therapy had a greater impact on improving
\nfamily relations than on improving individual adjustment or peer
\nrelations. In a systematic review of eighteen studies Henggeler and
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\nSchaeffer (2010) concluded that, compared with treatment-as-usual,
\nmultisystemic therapy led to significant improvements in individual
\nand family adjustment, which contributed in turn to significant reductions
\nin conduct problems, psychological adjustment, drug use, school
\nabsence, out-of home placement and recidivism. Improvements were
\nfound to be sustained at long-term follow up for up to 14 years and
\nentailed significant savings in placement, juvenile justice and crime
\nvictim costs.
\nMultidimensional treatment foster care. This model was developed at the
\nOregon Social Learning Centre by Patricia Chamberlain and her team
\n(Chamberlain, 2003). Multidimensional treatment foster care combines
\nprocedures similar to multisystemic therapy, with specialist
\nfoster placement in which foster parents use behavioural principles to
\nhelp adolescents modify their conduct problems. Treatment fostercare
\nparents are carefully selected and before an adolescent is placed
\nwith them they undergo intensive training. This focuses on the use of
\nbehavioural parenting skills for managing antisocial behaviour and
\ndeveloping positive relationships with antisocial adolescents. They
\nalso receive ongoing support and consultancy throughout placements
\nthat last 6\u20139 months. Concurrently, the young person or their biological
\nfamily engage in weekly family therapy with a focus on parents
\ndeveloping behavioural parenting practices and families developing
\ncommunication and problem-solving skills. Adolescents also engage in
\nindividual therapy, and wider systems consultations are carried out
\nwith the youngsters\u2019 teachers, probation officers and other involved
\nprofessionals, to ensure all relevant members of youngsters\u2019 social
\nsystems are cooperating in ways that promote their improvement.
\nAbout 85 per cent of adolescents return to their parents\u2019 home after
\ntreatment foster care. In a review of three studies of treatment foster
\ncare for delinquent male and female adolescents Smith and
\nChamberlain (2010) found that, compared with care in a group home
\nfor delinquents, multidimensional treatment foster care significantly
\nreduced running away from placement as well as the re-arrest rate
\nand self-reported violent behaviour. The benefits of multidimensional
\ntreatment foster care were due to the improvement in the parents\u2019
\nskills in managing adolescents in a consistent, fair and non-violent
\nway, and reductions in the adolescents\u2019 involvement with deviant
\npeers. These positive outcomes of multidimensional treatment foster
\ncare entailed cost savings of over $40,000 per case in juvenile justice
\nand crime victim costs (Chamberlain and Smith, 2003).
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\nFrom this review it may be concluded that, in developing services
\nfor families of adolescents with conduct disorder, it is most efficient to
\noffer services on a continuum of care. Less severe cases may be offered
\nup to thirty sessions of functional family therapy over a 6-month
\nperiod. Moderately severe cases and those that do not respond to
\ncircumscribed family interventions may be offered up to 20 hours per
\nmonth of multisystemic therapy over a period of up to 6 months.
\nExtremely severe cases and those who are unresponsive to intensive
\nmultisystemic therapy may be offered treatment foster care for a
\nperiod of up to year and this may then be followed with ongoing
\nmultisystemic intervention. It is essential that such a service involves
\nhigh levels of supervision and low caseloads for front-line clinicians
\nbecause of the high stress load that these cases entail and the consequent
\nrisk of therapist burnout.
\nDrug misuse in adolescence
\nIn a systematic narrative review of forty-five trials of treatments for
\nadolescent drug users, Tanner-Smith et al. (2013) concluded that
\nfamily therapy is more effective than other types of treatment including
\ncognitive behavioural therapy, motivational interviewing, psychoeducation
\nand various forms of individual and group counselling. A
\nseries of systematic reviews and meta-analyses support the effectiveness
\nof family therapy programmes in the treatment of adolescent drug
\nmisuse (Austin et al., 2005; Baldwin et al., 2012; Becker and Curry,
\n2008; Rowe, 2012; Vaughn and Howard, 2004; Waldron and Turner,
\n2008). Effective programmes include MDTF (Liddle, 2010), brief strategic
\nfamily therapy (Robbins et al., 2010), functional family therapy
\n(Waldron and Brody, 2010) and multisystemic therapy (Henggeler and
\nSchaeffer, 2010). These programmes also lead to the amelioration of
\nconduct problems (mentioned in the previous section), family functioning
\nand school performance, as well as leading to a reduction in contact
\nwith deviant peers (Rowe, 2012). Brief outlines of MDTF and brief
\nstrategic family therapy are given below to indicate the type of clinical
\npractices associated with these evidence-based models.
\nMDTF. This model was developed by Howard Liddle and his team
\nat the Centre for Treatment Research on Adolescent Drug Abuse at
\nthe University of Miami (Liddle, 2010). MDTF involves assessment
\nand intervention in four domains: including (i) adolescents, (ii)
\nparents, (iii) interactions within the family and (iv) family interactions
\nwith other agencies such as schools and courts. Three distinct phases
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\ncharacterize MDFT and these include engaging families in treatment;
\nworking with themes central to recovery and consolidating treatment
\ngains and disengagement. MDFT involves between sixteen and
\ntwenty-five sessions over 4\u20136 months. Treatment sessions may include
\nadolescents, parents, whole families and involved professionals and
\nmay be held in the clinic, home, school, court or other relevant
\nagencies. Rowe and Liddle (2008) conducted a thorough review of the
\nevidence base for MDFT and concluded that it is effective in reducing
\nalcohol and drug misuse, behavioural problems, emotional symptoms,
\nnegative peer associations, school failure and family difficulties associated
\nwith drug misuse.
\nBrief strategic family therapy. This model was developed at the Centre for
\nFamily Studies at the University of Miami by Jos\u00e8 Szapocznik and his
\nteam (Robbins et al., 2010). Brief strategic family therapy aims to
\nresolve adolescent drug misuse by improving family interactions that
\nare directly related to substance use. This is achieved within the context
\nof conjoint family therapy sessions by coaching family members to
\nmodify such interactions when they occur and to engage in more
\nfunctional interactions. The main techniques used in brief strategic
\nfamily therapy are engaging with families, identifying maladaptive
\ninteractions and family strengths and restructuring maladaptive family
\ninteractions. The model was developed for use with minority ethnicity
\nfamilies, particularly Hispanic families, and therapists facilitate healthy
\nfamily interactions based on appropriate cultural norms. Where there
\nare difficulties engaging with whole families, the therapists work with
\nmotivated family members to engage less motivated family members in
\ntreatment. Where parents cannot be engaged in treatment, a oneperson
\nadaptation of brief strategic family therapy has been developed.
\nBrief strategic family therapy involves twelve to thirty sessions over 3\u20136
\nmonths, with treatment duration and intensity being determined by
\nproblem severity. In a thorough review of research on this approach,
\nSantisteban et al. (2006) concluded that it was effective in engaging
\nadolescents and their families in treatment, reducing drug abuse and
\nrecidivism and improving family relationships. There is also empirical
\nsupport from controlled trials for the efficacy of its strategic engagement
\ntechniques for inducting resistant family members in treatment,
\nand for one-person family therapy in cases where parents resist
\nengagement in treatment.
\nThis review suggests that services for adolescent drug misuse
\nshould involve an intensive family engagement process and thorough
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\nassessment, followed by regular family sessions over a 3\u20136 month
\nperiod, coupled with direct work with youngsters and other involved
\nprofessionals. The intensity of therapy should be matched to the
\nseverity of the youngster\u2019s difficulties. Where appropriate, medical
\nassessment, detoxification or methadone maintenance should also be
\nprovided.
\nEmotional problems
\nFamily-based systemic interventions are effective for a proportion of
\ncases with anxiety disorders, depression, grief following parental
\nbereavement, bipolar disorder and self-harm. All these emotional
\nproblems cause youngsters and their families considerable distress
\nand in many cases prevent young people from completing developmental
\ntasks such as school attendance and developing peer relationships.
\nIn a review of community surveys, Merikangas et al. (2009)
\nfound that the median prevalence rate for anxiety disorders was 8 per
\ncent, with a range of 2\u201324 per cent; the median prevalence rate for
\nmajor depression was 4 per cent, with a range of 0.2\u201317 per cent and
\nthe prevalence of bipolar disorder in young people was under 1 per
\ncent. Between 1.5 and 4 per cent of children under the age of 18 lose
\na parent by death, and a proportion of these show complicated grief
\nreactions (Black, 2002). Community-based studies show that about 10
\nper cent of adolescents report having self-harmed; for some of these
\nteenagers suicidal intent motivates their self-harm; and self-harm is
\nmore common among girls, while completed suicide is more common
\namong boys (Hawton et al., 2012).
\nAnxiety
\nAnxiety disorders in children and adolescents include separation
\nanxiety, selective mutism, phobias, social anxiety disorder, generalized
\nanxiety disorder, obsessive compulsive disorder (OCD) and posttraumatic
\nstress disorder (American Psychiatric Association, 2013;
\nWorld Health Organization, 1992). All are characterized by excessive
\nfear and avoidance of particular internal experiences or external
\nsituations. Systematic reviews of the effectiveness of family-based cognitive
\nbehavioural therapy for child and adolescent anxiety disorders
\nshow that it is at least as effective as individual cognitive behavioural
\ntherapy; more effective than individual therapy in cases where parents
\nalso have anxiety disorders and more effective than individual
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\ninterventions in improving the quality of family functioning (Barmish
\nand Kendall, 2005; Creswell and Cartwright-Hatton, 2007; Diamond
\nand Josephson, 2005; Drake and Ginsburg, 2012; Kaslow et al., 2012;
\nReynolds et al., 2012; Silverman et al., 2008). Barrett\u2019s FRIENDS programme
\nis the best validated family-oriented cognitive behavioural
\ntherapy intervention for childhood anxiety disorders (Barrett and
\nShortt, 2003; Pahl and Barrett, 2010). In this programme children
\nattend ten weekly group sessions and parents join these 90-minute
\nsessions for the last 20 minutes to become familiar with the programme
\ncontent. There are also a couple of dedicated family sessions and
\n1-month and 3-month follow-up sessions for relapse prevention. Both
\nchildren and parents engage in psycho-education about anxiety, which
\nprovides a rationale for anxious children to engage in gradual exposure
\nto feared stimuli, which is essential for effective treatment. Children
\nand parents also engage in communication and problem-solving
\nskills training to enhance the quality of parent\u2013child interaction.
\nIn the child-focused element of the programme youngsters learn
\nanxiety management skills such as relaxation, cognitive coping and
\nusing social support, and use these skills to manage anxiety associated
\nwith gradual exposure to feared stimuli. In the family-based component,
\nparents learn to reward their children\u2019s use of anxiety management
\nskills when facing feared stimuli, ignore their children\u2019s
\navoidant or anxious behaviour and manage their own anxiety.
\nSchool refusal. School refusal is usually due to separation anxiety disorder
\nwhere children avoid separation from parents as this leads to
\nintense anxiety. Systematic reviews have concluded that behavioural
\nfamily therapy leads to recovery for more than two-thirds of patients
\nand this improvement rate is significantly higher than that found for
\nindividual therapy (Elliott, 1999; Heyne and Sauter 2013; King and
\nBernstein, 2001; King et al., 2000; Pina et al., 2009). Effective therapy
\nbegins with a careful systemic assessment to identify anxiety triggers
\nand obstacles to anxiety control and school attendance. Children,
\nparents and teachers are helped to collaboratively develop a returnto-
\nschool plan, which includes coaching children in relaxation, coping
\nand social skills to help them deal with anxiety triggers. Parents and
\nteachers are then helped to support and reinforce children for using
\nanxiety management and social skills to deal with the challenges which
\noccur during their planned return to regular school attendance.
\nOCD. With OCD children compulsively engage in repetitive rituals to
\nreduce anxiety associated with cues such as dirt or lack of symmetry.
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\nIn severe cases, children\u2019s lives become seriously constricted due to
\nthe time and effort they invest in compulsive rituals. Family life comes
\nto be dominated by other family member\u2019s attempts to accommodate
\nto or prevent these rituals. A series of trials has shown that familybased
\ncognitive behavioural exposure and response-prevention treatment
\nis effective in alleviating symptoms in 50\u201370 per cent of cases of
\npaediatric OCD. The best treatment response occurs where such
\ninterventions are combined with selective serotonin re-uptake inhibitors
\n(SSRI) such as sertraline and that family-based cognitive behavioural
\ntherapy is more effective than SSRI alone (Franklin et al., 2010;
\nMoore et al., 2013; Watson and Rees, 2008). Treatment is offered on
\nan individual or group basis to children with concurrent family sessions
\nover about 4 months. Family intervention involves psychoeducation
\nabout OCD and its treatment through exposure and
\nresponse prevention, externalizing the problem, monitoring symptoms
\nand helping parents and siblings support and reward the child
\nfor completing exposure and response-prevention homework exercises.
\nFamily therapy also helps parents and siblings avoid inadvertently
\nreinforcing children\u2019s compulsive rituals. Exposure and
\nresponse prevention is the principal child-focused element of the
\nprogramme. With this, children construct hierarchies of anxietyproviding
\ncues (such as increasingly dirty stimuli) and are exposed to
\nthe cues that elicit anxiety-provoking obsessions (such as ideas about
\ncontamination), commencing with the least anxiety provoking, while
\nnot engaging in compulsive rituals (such as hand washing) until
\nhabituation occurs. They also learn anxiety management skills to help
\nthem cope with the exposure process.
\nThis review suggests that in developing services for children with
\nanxiety disorders, family therapy of up to sixteen sessions should be
\noffered, which allows children to enter into anxiety-provoking situations
\nin a planned way and to manage these through the use of coping
\nskills and parental support.
\nDepression
\nMajor depression is an episodic disorder characterized by low or
\nirritable mood, loss of interest in normal activities and most of the
\nfollowing symptoms: psychomotor agitation or retardation, fatigue,
\nlow self-esteem, pessimism, inappropriate excessive guilt, suicidal
\nideation, impaired concentration and sleep and appetite disturbance
\n(American Psychiatric Association, 2013; World Health Organization,
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\n1992). Episodes may last from a few weeks to a number of months and
\nrecur periodically over the life cycle with inter-episode intervals
\nvarying from a few months to a number of years. Integrative theories
\nof depression propose that episodes occur when genetically vulnerable
\nindividuals find themselves involved in stressful family systems in
\nwhich there is limited access to socially supportive relationships (Abela
\nand Hankin, 2008). Family-based therapy aims to reduce stress and
\nincrease support for young people in their families. But other factors
\nalso provide a rationale for family therapy. Not all young people
\nrespond to antidepressant medication (Goodyer et al., 2007). Moreover,
\nsome young people do not wish to take medication because of its
\nside effects and in some instances parents or clinicians are concerned
\nthat medication may increase the risk of suicide. Finally, research on
\nadult depression has shown that relapse rates in the year following
\npharmacotherapy are about double those following psychotherapy
\n(Vittengl et al., 2007).
\nStark et al. (2012) reviewed twenty-five trials of family-based treatment
\nprogrammes for child and adolescent depression. In these
\nstudies a variety of formats was used, including conjoint family
\nsessions; for example, Diamond\u2019s (2005) attachment-based family
\ntherapy; child-focused cognitive behavioural therapy (Stark et al.,
\n2010) or interpersonal therapy (Jacobson and Mufson, 2010) sessions
\ncombined with some family or parent sessions; and concurrent groupbased
\nparent and child training sessions (such as Lewinsohn\u2019s coping
\nwith depression course (Clark and DeBar, 2010). Stark et al. (2012)
\nconcluded that family-based treatments for child and adolescent
\ndepression were as effective as well-established therapies such as individual
\ncognitive behavioural therapy or interpersonal therapy and led
\nto remission in two-thirds to three-quarters of cases at 6-months follow
\nup. They were also more effective than individual therapy in maintaining
\npost-treatment improvement. Effective family-based interventions
\naim to decrease the family stress to which youngsters are
\nexposed and enhance the availability of social support within the
\nfamily context. Core features of effective family interventions include
\npsycho-education about depression; the relational reframing of
\ndepression-maintaining family interaction patterns; the facilitation of
\nclear parent\u2013child communication; the promotion of systematic
\nfamily-based problem-solving and of secure parent\u2013child attachment;
\nthe disruption of negative critical parent\u2013child interactions and
\nhelping children develop skills for managing negative mood states
\nand changing their pessimistic belief systems. With respect to clinical
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\npractice and service development, family therapy for episodes of
\nadolescent depression is relatively brief, requiring about twelve sessions.
\nBecause major depression is a recurrent disorder, services
\nshould make long term re-referral arrangements so that intervention
\nis offered promptly in further episodes. Systemic therapy services
\nshould be organized so as to permit the option of multi-modal treatment
\nwith family therapy and antidepressant medication in cases
\nunresponsive to family therapy.
\nGrief
\nA number of single group outcome studies and controlled trials show
\nthat effective therapy for grief reactions following parental bereavement
\nmay include a combination of family and individual interventions
\n(Black and Urbanowicz, 1987; Cohen et al., 2006; Kissane
\nand Bloch, 2002; Kissane et al., 2006; Rotheram-Borus et al., 2004;
\nSandler et al., 1992, 2003, 2010). Family intervention involves engaging
\nfamilies in treatment, facilitating family grieving and family
\nsupport, decreasing parent\u2013child conflict and helping families to reorganize
\nso as to cope with the demands of daily living in the absence of
\nthe deceased parent. The individual component of treatment involves
\nexposure of the child to traumatic grief-related memories and images
\nuntil a degree of habituation occurs. This may be facilitated by viewing
\nphotos, audio and video recordings of the deceased and developing
\na coherent narrative with the child about their past life with the
\ndeceased and a way to preserve a positive relationship with the
\nmemory of the deceased parent. With respect to clinical practice and
\nservice development, family therapy for grief following the loss of a
\nparent is relatively brief, requiring about twelve sessions.
\nBipolar disorder
\nBipolar disorder is a recurrent episodic mood disorder with a predominantly
\ngenetic basis, characterized by episodes of mania or hypomania,
\ndepression and mixed mood states (American Psychiatric Association,
\n2013; World Health Organization, 1992). The primary treatment for
\nbipolar disorder is pharmacological and involves the initial treatment
\nof acute manic, hypomanic, depressive or mixed episodes and the
\nsubsequent prevention of further episodes with mood-stabilizing medication
\nsuch as lithium (Kowatch et al., 2009). Bipolar disorder typically
\nfirst occurs in late adolescence or early adulthood and its course, even
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\nwhen treated with mood-stabilizing medication, is significantly affected
\nby stressful life events and family circumstances on the one hand, and
\nfamily support on the other. The high frequency of relapses among
\nyoung people with bipolar disorder provides the rationale for the
\ndevelopment of relapse-prevention interventions.
\nPsycho-educational family therapy aims to prevent relapses by
\nreducing family stress and enhancing family support for youngsters
\nwith bipolar disorder who are concurrently taking mood-stabilizing
\nmedication such as lithium (Miklowitz, 2008). Family therapy for
\nbipolar disorder typically spans twelve to twenty-one sessions and
\nincludes psycho-education about the condition and its management,
\nand family communication and problem-solving skills training. The
\nresults of a series of studies suggest that psycho-educational family
\ntherapy may be helpful in adolescent bipolar disorder in increasing
\nknowledge about the condition, improving family relationships and
\nameliorating symptoms of depression and mania (Fristad, 2006:
\nFristad et al., 2002, 2003, 2009; Miklowitz et al., 2004; Pavuluri et al.,
\n2004; West et al., 2009). With respect to clinical practice and service
\ndevelopment, family therapy for bipolar disorder in adolescence is
\nrelatively brief, requiring up to twenty-one sessions, and should be
\noffered as part of a multi-modal programme that includes moodstabilizing
\nmedication such as lithium.
\nSelf-harm
\nA complex constellation of risk factors has been identified for self-harm
\nin adolescence. They include the characteristics of the young person
\n(such as the presence of psychological disorder) and features of the
\nsocial context (such as family difficulties) (Hawton et al., 2012; Ougrin
\net al., 2012). Both sets of factors are targeted in family-based treatment
\nfor self-harm in adolescence. A series of studies has found that a range
\nof specialized family therapy interventions improves the adjustment of
\nadolescents who have self-harmed, although family interventions are
\nnot always more effective than alternative treatments in reducing the
\nrecurrence of self-harm (Asarnow et al., 2011; Diamond et al., 2010,
\nHarrington et al., 1998; Huey et al., 2004; Katz et al., 2004; King et al.,
\n2006, 2009; Rathus and Miller 2002; Rotheram-Borus et al., 2000).
\nFamily-based approaches that improve adjustment share a number of
\ncommon features. They begin by engaging the young people and their
\nfamilies in an initial risk-assessment process and proceed to the development
\nof a clear plan for risk reduction that includes individual
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\ntherapy for adolescents combined with systemic therapy for members
\nof their family and social support networks. Attachment-based
\nfamily therapy, multisystemic therapy, dialectical behaviour therapy
\ncombined with multi-family therapy, and nominated support network
\ntherapy are well developed protocols with some or all of these
\ncharacteristics.
\nAttachment-based family therapy. Attachment-based family therapy was
\noriginally developed for adolescent depression, as noted above, but it
\nhas been adapted for use with self-harming teenagers (Diamond et al.,
\n2013). This approach aims to repair ruptures in adolescent\u2013parent
\nattachment relationships. Re-attachment is facilitated by first helping
\nfamily members to access their longing for greater closeness and
\ncommit to rebuilding trust. In individual sessions adolescents are
\nhelped to articulate their experiences of attachment failures and agree
\nto discuss these experiences with their parents. In concurrent sessions
\nparents explore how their own intergenerational legacies affect their
\nparenting style. This helps them to develop greater empathy for their
\nadolescents\u2019 experiences. When the adolescents and parents are
\nready, conjoint family therapy sessions are convened in which the
\nadolescents share their concerns, receive empathic support from their
\nparents and usually become more willing to consider their own contributions
\nto family conflict. This respectful and emotional dialogue
\nserves as a corrective attachment experience that rebuilds trust
\nbetween adolescents and parents. As conflict decreases, therapy
\nfocuses on helping adolescents pursue developmentally appropriate
\nactivities to promote their competency and autonomy. In this context,
\nparents serve as the secure base from which the adolescents receive
\nsupport, advice and encouragement in exploring these new opportunities.
\nIn a controlled trial of adolescents at risk for suicide, Diamond
\net al. (2010) found that 3 months of attachment-based family therapy
\nwas more effective than routine treatment in reducing suicidal ideation
\nand depressive symptoms at 6-months follow up.
\nMultisystemic therapy. Multisystemic therapy was originally developed
\nfor adolescent conduct disorder, as noted above, but it has been
\nadapted for use with adolescents who have severe mental health
\nproblems, including attempted suicide (Henggeler et al., 2002).
\nMultisystemic therapy involves assessment of suicide risk, followed by
\nintensive family therapy to enhance family support combined with
\nindividual skills training for adolescents to help them develop mood
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\nregulation and social problem-solving skills, and intervention in the
\nwider school and inter-agency network to reduce stress and enhance
\nsupport for the adolescent. It involves regular, frequent home-based
\nfamily and individual therapy sessions with additional sessions in the
\nschool or community settings over 3\u20136 months. Huey et al. (2004)
\nevaluated the effectiveness of multisystemic therapy for suicidal adolescents
\nin a randomized controlled study of 156 African-American
\nadolescents at risk for suicide referred for emergency psychiatric
\nhospitalization. Compared with emergency hospitalization and treatment
\nby a multidisciplinary psychiatric team, Huey et al. found that
\nmultisystemic therapy was significantly more effective in decreasing
\nrates of attempted suicide at a 1-year follow up.
\nDialectical behaviour therapy and multi-family therapy. Dialectical behaviour
\ntherapy, which was originally developed for adults with borderline
\npersonality disorder, has been adapted for use with adolescents who
\nhave attempted suicide (Miller et al., 2007). This adaptation involves
\nindividual therapy for adolescents combined with multi-family
\npsycho-educational therapy. The multi-family psycho-educational
\ntherapy helps family members understand self-harming behaviour
\nand develop skills for protecting and supporting self-harming adolescents.
\nThe individual therapy component includes modules on mindfulness,
\ndistress tolerance, emotion regulation and interpersonal
\neffectiveness skills to address problems in the areas of identity, impulsivity,
\nemotional liability and relationship problems, respectively. Evidence
\nfrom two controlled outcome studies support the effectiveness
\nof dialectical behaviour therapy with adolescents who have attempted
\nsuicide. In a study of suicidal adolescents with borderline personality
\nfeatures, Rathus and Miller (2002) compared the outcome for twentynine
\npatients who received dialectical behaviour therapy plus psychoeducational
\nmulti-family therapy and eighty-two patients who
\nreceived psychodynamic therapy plus family therapy. In each programme
\nthe participants attended therapy twice weekly. Both programmes
\nled to reductions in suicidal ideation. Significantly more
\npatients completed the dialectical behaviour therapy programme and
\nsignificantly fewer were hospitalized during treatment. In a further
\nstudy of sixty-two suicidal adolescent in-patients, Katz et al. (2004)
\nfound that both dialectical behaviour therapy and routine in-patient
\ncare led to significant reductions in self-harming behaviour, depressive
\nsymptoms and suicidal ideation but dialectical behaviour therapy
\nled to significantly greater reductions in behaviour problems.
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\nYouth-nominated support team. The youth-nominated support team is a
\nmanualized systemic intervention for adolescents who have attempted
\nsuicide, in which adolescents nominate a parent or guardian and
\nthree other people from their family, peer group, school or community
\nto be members of their support team (King et al. 2000). For each
\npatient, support team members receive psycho-education explaining
\nhow the adolescent\u2019s psychological difficulties led to the suicide
\nattempt, the treatment plan and the role that support team members
\ncan play in helping the adolescent towards recovery and managing
\nsituations where there is a risk of further self-harm. Support team
\nmembers are encouraged to maintain weekly contact with the adolescent
\nand are contacted regularly by the treatment team to facilitate
\nthis process. King et al. (2006) evaluated the youth-nominated
\nsupport team programme in a randomized controlled trial of 197 girls
\nand eighty-two boys who had attempted suicide and been hospitalized.
\nThey found that, compared with routine treatment with psychotherapy
\nand antidepressant medication, the youth-nominated
\nsupport team programme led to decreased suicidal ideation and
\nmood-related functional impairment in girls at 6-months follow up
\nbut had no significant impact on boys.
\nSystemic services for young people who self-harm should involve
\nprompt intensive initial individual and family assessment followed by
\nsystemic intervention, including both individual and family sessions to
\nreduce individual and family-based risk factors. Such therapy may
\ninvolve regular session over a 3\u20136 month period. Systemic therapy
\nservices for youngsters at risk for suicide should be organized so as to
\npermit the option of brief hospitalization or residential placement in
\ncircumstances where families are assessed as lacking the resources for
\nimmediate risk reduction on an outpatient basis.
\nEating disorders
\nAn excessive concern with the control of body weight and shape along
\nwith an inadequate and unhealthy pattern of eating are the central
\nfeatures of anorexia nervosa and bulimia nervosa. The former is
\ncharacterized primarily by weight loss and the latter by a cyclical
\npattern of bingeing and purging (American Psychiatric Association,
\n2013; World Health Organization, 1992). The average prevalence
\nrates for anorexia nervosa and bulimia nervosa among young women
\nare about 0.3\u20130.5 per cent and 1\u20134 per cent, respectively (Hoek, 2006;
\nKeel, 2010). Childhood obesity occurs where there is a body mass
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\nindex above the 95th percentile with reference to age-specific and
\nsex-specific growth charts (Reilly, 2010). In Europe the prevalence of
\nobesity among children and adolescents is about 5 per cent and in the
\nUSA it is about 15 per cent (Wang and Lim, 2012). Anorexia, bulimia
\nand obesity are of concern because they lead to long-term physical or
\nmental health problems. Family therapy is effective for a proportion of
\nchildren and adolescents with eating disorders.
\nAnorexia nervosa
\nA series of systematic reviews and meta-analyses covering a total of
\nseven controlled and six uncontrolled trials allow the following conclusions
\nto be drawn about the effectiveness of family therapy for
\nanorexia nervosa in adolescents (Couturier et al., 2013; Eisler, 2005,
\nLock, 2011; Robin and Le Grange, 2010; Smith and Cook-Cottone,
\n2011; Stuhldreher et al., 2012; Wilson and Fairburn, 2007). After
\ntreatment, between half and two-thirds of patients achieve a healthy
\nweight. At 6-months to 6-years follow up, 60\u201390 per cent have fully
\nrecovered and no more than 10\u201315 per cent are seriously ill. In the
\nlong term the negligible relapse rate following family therapy is
\nsuperior to the moderate outcomes for individually oriented therapies.
\nThe outcome for family therapy is also far superior to the high
\nrelapse rate following in-patient treatment, which is 25\u201330 per cent
\nfollowing first admission and 55\u201375 per cent for second and further
\nadmissions. Outpatient family-based treatment is also more costeffective
\nthan in-patient treatment. Evidence-based family therapy
\nfor anorexia can be effectively disseminated and implemented in
\ncommunity-based clinical settings. In the Maudsley model for treating
\nadolescent anorexia, which is the approach with the strongest empirical
\nsupport, family therapy for adolescent anorexia progresses
\nthrough three phases (Lock and Le Grange, 2013). The first involves
\nhelping parents work together to refeed their youngster. This is followed
\nin the second phase with facilitating family support for the
\nyoungster in developing an autonomous, healthy eating pattern. In
\nthe final phase the focus is on helping the young person develop an
\nage-appropriate lifestyle. Treatment typically involves between ten
\nand twenty one-hour sessions over a 6\u201312-month period.
\nBulimia nervosa
\nTwo trials of family therapy for bulimia in adolescence, using the
\nMaudsley model, show that it is more effective than supportive therapy
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\n(Le Grange and Lock, 2010) and as effective as cognitive behavioural
\ntherapy (Schmidt et al., 2007), which is considered to be the treatment
\nof choice for bulimia in adults, due its strong empirical support (Wilson
\nand Fairburn, 2007). In both trials, at 6-months follow up, over 70 per
\ncent of cases treated with family therapy showed partial or complete
\nrecovery. Family therapy for adolescent bulimia involves helping
\nparents work together to supervise the young person during mealtimes
\nand afterwards, to break the binge-purge cycle. As with anorexia, this is
\nfollowed by helping families support their youngsters in developing
\nautonomous, healthy eating patterns, and age appropriate lifestyles
\n(Le Grange and Locke, 2007).
\nObesity
\nSystematic narrative reviews and meta-analyses of controlled and
\nuncontrolled trials of treatments for obesity in children converge on
\nthe following conclusions (Epstein, 2003; Feng, 2011; Jelalian and
\nSaelens, 1999; Jelalian et al., 2007; Kitzmann and Beech, 2011;
\nKitzmann et al., 2010; Nowicka and Flodmark, 2008; Seo and Sa,
\n2010; Young et al., 2007). Family-based behavioural weight reduction
\nprogrammes are more effective than dietary education and other
\nroutine interventions. They lead to a 5\u201320 per cent reduction in
\nweight after treatment and at a 10-year follow up 30 per cent of
\npatients are no longer obese. Childhood obesity is due predominantly
\nto lifestyle factors including poor diet and lack of exercise and so
\nfamily-based behavioural treatment programmes focus on lifestyle
\nchange. Specific dietary and exercise routines are agreed and implemented
\nand parents reinforce young people for adhering to these
\nroutines (Jelalian et al., 2007). An important development in the treatment
\nof obesity is the standardized obesity family therapy in Malmo in
\nSweden. It is based on systemic and solution-focused theories and has
\nhad a positive effect on the degree of obesity, physical fitness, selfesteem
\nand family functioning in several studies (Nowicka and
\nFlodmark, 2011).
\nIn planning systemic services for young people with eating disorders
\nit should be expected that treatment of anorexia or bulimia will
\nspan 6\u201312 months, with the first ten sessions occurring weekly and the
\nlater sessions occurring fortnightly and then monthly. For obesity,
\ntherapy may span ten to twenty sessions followed by periodic, infrequent
\nreview sessions over a number of years to help youngsters
\nmaintain weight loss.
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\nSomatic problems
\nFamily-based interventions are helpful in a proportion of cases for the
\nfollowing somatic problems: enuresis, encopresis, recurrent abdominal
\npain and both poorly controlled asthma and diabetes.
\nEnuresis
\nIn a systematic review and a meta-analysis of randomized controlled
\ntrials, Glazener et al., (2004, 2009) found that family-based urine
\nalarm programmes were an effective treatment for childhood nocturnal
\nenuresis (bed-wetting). These programmes involve coaching the
\nchild and parents to use an enuresis alarm, which alerts the child as
\nsoon as micturition begins. Family-based urine alarm programmes, if
\nused over 12\u201316 weeks, are effective in about 60\u201390 per cent per cent
\nof patients (Brown et al., 2011; Houts, 2010). With a urine alarm the
\nurine wets a pad that closes a circuit and sets off the urine alarm,
\nwaking the child, who gradually learns over multiple occasions by a
\nconditioning process to wake before voiding the bladder. In family
\nsessions, parents and children are helped to understand this process
\nand plan to implement the urine alarm-based programme at home. In
\nfamily-based urine alarm programmes, parents reinforce children for
\nsuccess in maintaining dry beds using star-charts.
\nEncopresis
\nIn a narrative review of 42 studies, McGrath et al. (2000) found that
\nfor childhood encopresis (soiling), multi-modal programmes involving
\nmedical assessment and intervention followed by behavioural
\nfamily therapy were effective for 43\u201375 per cent of patients. Initially a
\npaediatric medical assessment is conducted and if a faecal mass has
\ndeveloped in the colon, this is cleared with an enema. A balanced diet
\ncontaining an appropriate level of roughage and regular laxative use
\nare arranged. Effective behavioural family therapy involves psychoeducation
\nabout encopresis and its management, coupled with a
\nreward programme, where parents reinforce appropriate daily
\ntoileting routines. There is some evidence that a narrative approach
\nmay be more effective than a behavioural approach to family therapy
\nfor encopresis. Silver et al. (1998) found success rates of 63 and 37 per
\ncent for narrative and behavioural family therapy, respectively. With
\nnarrative family therapy the soiling problem was externalized and
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\nreferred to as \u2018sneaky poo\u2019. Therapy focused on parents and children
\ncollaborating to outwit this externalized personification of encopresis
\n(White, 2007).
\nRecurrent abdominal pain
\nResults of 4 trials have shown that behavioural family therapy is
\neffective in alleviating recurrent abdominal pain, often associated
\nwith repeated school absence, and for which no biomedical cause is
\nevident (Finney et al., 1989; Robins et al. 2005; Sanders et al., 1989,
\n1994). Such programmes involve family psycho-education about
\nrecurrent abdominal pain and its management, relaxation and
\ncoping skills training to help children manage stomach pain, which is
\noften anxiety-based, and contingency management implemented by
\nparents to motivate their children to engage in normal daily routines,
\nincluding school attendance. This conclusion is consistent with
\nthose of other systematic narrative reviews (Banez and Gallagher,
\n2006; Sprenger et al., 2011; Spirito and Kazak, 2006; Weydert et al.,
\n2003).
\nPoorly controlled asthma
\nAsthma, a chronic respiratory disease with a prevalence rate of about
\n10 per cent among children, can lead to significant restrictions in daily
\nactivity, repeated hospitalization. If it is very poorly controlled, asthma
\nis potentially fatal (Currie and Baker, 2012). The course of asthma is
\ndetermined by the interaction between abnormal physiological processes
\nof the respiratory system, to which some youngsters have a
\npredisposition, physical environmental triggers and psychosocial processes.
\nIn a systematic review of twenty studies, Brinkley et al. (2002)
\nconcluded that family-based interventions for asthma spanning up to
\neight sessions were more effective than individual therapy. These
\nincluded psycho-education to improve their understanding of the
\ncondition, medication management and environmental trigger management,
\nrelaxation training to help young people reduce physiological
\narousal, skills training to increase adherence to asthma
\nmanagement programmes and conjoint family therapy sessions to
\nempower family members to work together to manage asthma effectively.
\nThese conclusions have been supported by results of some (for
\nexample, Ng et al., 2008) but not all (for example, Celano et al., 2012)
\nrecent trials.
\nEvidence-base for family therapy with children 135
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nPoorly controlled diabetes
\nType 1 diabetes is an endocrine disorder characterized by complete
\npancreatic failure (Levy, 2011). The long-term outcome for poorly
\ncontrolled diabetes may include blindness and leg amputation. For
\nyoungsters with diabetes normal blood glucose levels are achieved
\nthrough a regime involving a combination of insulin injections, balanced
\ndiet, exercise and the self-monitoring of blood glucose. In a
\nsystematic review of eleven studies Farrell et al. (2002) found that
\nfamily-based programmes of ten to twenty sessions were effective in
\nhelping young people control their diabetes, and that different types
\nof programmes were appropriate for young people at different stages
\nof the life cycle. For youngsters newly diagnosed with diabetes,
\npsycho-educational programmes that helped families understand the
\ncondition and its management were particularly effective. Familybased
\nbehavioural programmes, where parents rewarded youngsters
\nfor adhering to their diabetic regimes, were particularly effective with
\npre-adolescent children, whereas family-based communication and
\nproblem-solving skills training programmes were particularly effective
\nfor families with adolescents, since these programmes gave families
\nskills for negotiating diabetic management issues in a manner
\nappropriate for adolescents. In a meta-analysis of fifteen trials of
\nvarious types of interventions, Hood et al. (2010) concluded that those
\nthat targeted emotional, social or family processes that facilitate diabetes
\nmanagement were more effective in promoting glycaemic
\ncontrol than interventions just targeting a direct, behavioural process,
\nsuch as increasing the frequency of blood glucose monitoring. Behavioural
\nfamily systems therapy has the strongest empirical support as a
\nfamily-based intervention for treating families of poorly controlled
\ndiabetic adolescents (Harris et al. 2009).
\nThis review suggests that family therapy may be incorporated into
\nmulti-modal, multidisciplinary paediatric programmes for a number
\nof somatic conditions including enuresis, encopresis, recurrent
\nabdominal pain and both poorly controlled asthma and diabetes.
\nSystemic intervention for these conditions should be offered following
\nthorough paediatric medical assessment, and typically interventions
\nare brief, ranging from eight to twelve sessions.
\nFirst episode psychosis
\nFirst episode psychosis is a condition characterized by positive symptoms
\n(such as delusions and hallucinations), negative symptoms (such
\n136 Alan Carr
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nas lack of goal-directed behaviour and flattened affect), and disorganized
\nthinking, behaviour and emotions (American Psychiatric
\nAssociation, 2013; World Health Organization, 1992). First episode
\npsychosis typically occurs in late adolescence. It is exceptionally distressing
\nfor the young person and the family. Complete recovery may
\noccur for a proportion of young people, especially if they receive early
\nintervention and if their families are supportive. However, where
\npsychosis persists or a chronic relapsing pattern develops eventually a
\ndiagnosis of schizophrenia may be given. Antipsychotic medication is
\nthe primary treatment for the symptoms of first episode psychosis.
\nPharmacological interventions may be combined with family interventions
\nin which the primary aim is to facilitate a supportive family
\nenvironment and so prevent the development of a chronic relapsing
\ncondition. Reviews of controlled trials show that combining antipsychotic
\nmedication with psycho-educational family therapy (Kuipers
\net al., 2002) reduces relapse rates in first episode psychosis and that
\nmulti-family psycho-educational therapy (McFarlane, 2002) is particularly
\neffective (Bird et al., 2010; McFarlane et al., 2012; Onwumere
\net al., 2011).
\nPsycho-educational family therapy for schizophrenia involves
\npsycho-education, based on the stress-vulnerability or bio-psychosocial
\nmodels of psychosis (McFarlane et al., 2012), with a view to
\nhelping families understand and manage the condition, antipsychotic
\nmedication, related stresses and early warning signs of relapse. Psychoeducational
\nfamily therapy also aims to reduce negative family processes
\nassociated with relapse, specifically high levels of expressed
\nemotion, stigma, communication deviance and stresses related to transitions
\nin the life cycle. Emphasis is placed on blame reduction and the
\npositive role that family members can play in supporting the young
\nperson\u2019s recovery. Psycho-educational family therapy also helps families
\ndevelop communication and problem-solving skills. Skills training
\ncommonly involves modelling, rehearsal, feedback and discussion.
\nEffective interventions typically span 9\u201312 months and are usually
\noffered in a phased format, with initial sessions occurring more frequently
\nthan later sessions and crisis intervention as required.
\nFrom this review it may be concluded that systemic therapy services
\nfor families of people with first episode psychosis should be offered
\nwithin the context of multi-modal programmes that include antipsychotic
\nmedication. Because of the potential for relapse, services should
\nmake re-referral arrangements, so intervention is offered promptly in
\nlater episodes.
\nEvidence-base for family therapy with children 137
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nDiscussion
\nA number of comments may be made about the evidence reviewed in
\nthis article. For a wide range of child-focused problems systemic interventions
\nare effective. These interventions are brief, rarely involving
\nmore than twenty sessions, and may be offered by a range of professionals
\non an outpatient basis. Treatment manuals have been developed
\nfor many systemic interventions and these may be flexibly used
\nby clinicians in treating individual patients. Moreover, most evidencebased
\nsystemic interventions have been developed within the cognitive
\n-behavioural, structural and strategic traditions. The implications
\nof these findings are discussed in the final section of the companion
\narticle in this issue (Carr, 2014).
\nThe results of this review are broadly consistent with the important
\nrole accorded to family involvement in the treatment of children and
\nyoung people in authoritative clinical guidelines such as those published
\nby the UK National Institute for Clinical Excellence (NICE)
\nfor a range of problems, including conduct disorder (NICE, 2013a),
\nADHD (NICE, 2013b), drug misuse (NICE, 2007), some anxiety disorders
\n(for example, NICE, 2005a), mood disorders (NICE, 2005b,
\n2006), eating disorders (NICE, 2004), certain somatic problems (for
\nexample, NICE, 2009, 2010) and psychosis in adolescence (NICE,
\n2013c).
\nA broad definition of systemic intervention has been adopted in this
\narticle, in comparison with that taken in other reviews of the field of
\nfamily therapy for child-focused problems (for example, Kaslow et al.,
\n2012; Retzlaff, et al., 2013). There are pros and cons to adopting a
\nbroad definition. On the positive side, it provides the widest scope of
\nevidence on which to draw in support of systemic practice. This is
\nimportant in a climate where there is increasing pressure to point to
\na significant evidence base to justify funding family therapy services. It
\nalso offers the family therapists reading this review guidance on
\nfamily-based treatment procedures that may usefully be incorporated
\ninto their systemic practice. However, the broad definition of systemic
\nintervention used in this article potentially blurs the unique contribution
\nof the practices developed within the tradition of systemic family
\ntherapy, as distinct from interventions in which parents are included
\nin an adjunctive role to facilitate individually focused therapy, or
\nfamily-based approaches that integrate distinctly systemic ideas and
\npractices with those of other therapeutic traditions, notably cognitive
\nbehavioural therapy.
\n138 Alan Carr
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nThe findings of this review have implications for research, training
\nand practice. With respect to research, more studies are needed on
\nthe effectiveness of distinctly systemic interventions for child abuse,
\nproblems of early childhood and emotional problems in young
\npeople. More research is also required on social constructionist and
\nnarrative approaches to systemic practice which, though widely used,
\nhave rarely been evaluated. With respect to training, the systemic
\nevidence-based interventions reviewed in this article should be incorporated
\nin family therapy training programmes and continuing
\nprofessional development short courses for experienced systemic
\npractitioners. This argument has recently been endorsed in the UK
\nand the USA in statements of the core competencies of systemic
\ntherapists (Northey, 2011; Stratton et al., 2011). With respect to
\nroutine practice, family therapists should work towards incorporating
\nthe types of practices described in this article and in the treatment
\nresources listed below when working with families of children and
\nadolescents with the types of problems considered in this article.
\nTreatment resources
\nSleep problems
\nMindell, J. and Owens, J. (2009) A Clinical Guide to Paediatric Sleep: Diagnosis and
\nManagement of Sleep Problems (2nd edn). Philadelphia: Lippincott Williams and
\nWilkins.
\nFeeding problems
\nKedesdy, J. and Budd, K. (1998) Childhood Feeding Disorders: Behavioural Assessment
\nand Intervention. Baltimore: Paul. H. Brookes.
\nAttachment problems
\nBerlin, L. and Ziv, Y. (2005) Enhancing Early Attachments. Theory, Research, Intervention
\nand Policy. New York: Guilford.
\nPhysical abuse
\nKolko, D. and Swenson, C. (2002) Assessing and Treating Physically Abused Children
\nand Their Families: A Cognitive Behavioural Approach. Thousand Oaks: Sage.
\nRynyon, M. and Deblinger, E. (2013) Combined Parent\u2013child Cognitive Behavioural
\nTherapy. An Approach to Empower Families At-Risk for Child Physical Abuse. New
\nYork: Oxford University Press.
\nEvidence-base for family therapy with children 139
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nChild sexual abuse
\nDeblinger, A. and Heflinger, A. (1996) Treating Sexually Abused Children and their
\nNon-offending Parents: A Cognitive Behavioural Approach. Thousand Oaks: Sage.
\nChildhood behaviour problems
\nDadds, M. and Hawes, D. (2006) Integrated Family Intervention for Child Conduct
\nProblems. Brisbane: Australian Academic Press.
\nKazdin, A. (2005) Parent Management Training. Oxford; Oxford University Press.
\nIncredible Years Programme (n.d.) Retrieved 8 January 2014 from http:\/\/www
\n.incredibleyears.com\/.
\nParents Plus Programme (n.d.) Retrieved 8 January 2014 from http:\/\/www
\n.parentsplus.ie\/.
\nParent\u2013Child Interaction Therapy (n.d.) Retrieved 8 January 2014 from http:\/\/
\npcit.phhp.ufl.edu\/.
\nTriple P (n.d.) Retrieved 8 January 2014 from https:\/\/www.essaybishop.com\/write-my-essay\/triplep.net\/.
\nAttention deficit hyperactivity disorder
\nBarkley, R. (2005) Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis
\nand Treatment (3rd edn). New York. Guilford.
\nAdolescent conduct disorder
\nAlexander, J. Waldron, H., Robbins, M. and Neeb, A. (2013) Functional Family
\nTherapy for Adolescent Behaviour Problems. Washington: American Psychological
\nAssociation.
\nChamberlain, P. (1994) Family Connections: A Treatment Foster Care Model for Adolescents
\nwith Delinquency. Eugen: Northwest Media.
\nChamberlain, P. (2003) Treating Chronic Juvenile Offenders: Advances Made Through
\nthe Oregon Multidimensional Treatment Foster Care Model. Washington: American
\nPsychological Association.
\nChamberlain, P. and Smith, D. (2003) Antisocial behaviour in children and adolescents.
\nThe Oregon multidimensional treatment foster care model. In A.
\nKazdin and J. Weisz (eds) Evidence-based Psychotherapies for Children and Adolescents
\n(pp. 281\u2013300). New York: Guilford.
\nHenggeler, S., Schoenwald, S., Bordin, C., Rowland, M. and Cunningham, P.
\n(2009) Multisystemic Therapy for Antisocial Behaviour in Children and Adolescents
\n(2nd edn). New York: Guilford.
\nSexton, T. (2011) Functional Family Therapy in Clinical Practice. New York:
\nRoutledge.
\nAdolescent drug misuse
\nLiddle, H. A. (2002) Multidimensional Family Therapy Treatment (MDFT) for Adolescent
\nCannabis Users. Vol. 5. Rockville: US Department of Health and Human
\n140 Alan Carr
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nServices. Retrieved 8 January 2014 from http:\/\/lib.adai.washington.edu\/
\nclearinghouse\/downloads\/Multidimensional-Family-Therapy-for-Adolescent-
\nCannabis-Users-207.pdf.
\nSzapocznik, J., Hervis, O. and Schwartz, S. (2002) Brief Strategic Family Therapy for
\nAdolescent Drug Abuse. Rockville: National Institute for Drug Abuse. Retrieved
\n8 January 2014 from http:\/\/archives.drugabuse.gov\/TXManuals\/BSFT\/
\nBSFTIndex.html.
\nAnxiety
\nKearney, C. and Albano, A. (2007) When Children Refuse School. Therapist Guide
\n(2nd edn). New York: Oxford University Press.
\nDepression
\nDiamond, G., Diamond, G. and Levy, S. (2013) Attachment-based Family Therapy for
\nDepressed Adolescents. Washington: American Psychological Association.
\nGrief
\nCohen, J., Mannarino, A. and Deblinger, E. (2006) Treating Trauma and Traumatic
\nGrief in Children and Adolescents. New York: Guilford.
\nKissane, D. and Bloch, S. (2002) Family Focused Grief Therapy: A Model of
\nFamily-centred Care during Palliative Care and Bereavement. Buckingham: Open
\nUniversity Press.
\nBipolar disorder
\nMiklowitz, D. (2008) Bipolar Disorder: A Family-Focused Treatment Approach (2nd
\nedn). New York: Guilford.
\nSelf-harm in adolescence
\nHenggeler, S., Schoenwald, S., Rowland, M. and Cunningham, P. (2002)
\nMultisystemic Treatment of Children and Adolescents with Serious Emotional Disturbance.
\nNew York: Guilford.
\nJurich, A. (2008) Family Therapy with Suicidal Adolescents. New York: Routledge.
\nKing, C., Kramer, A. and Preuss, L. (2000) Youth-Nominated Support Team Intervention
\nManual. Ann Arbor: Department of Psychiatry, University of Michigan.
\nMiller, A., Rathus, J. and Linehan, M. (2007) Dialectical Behaviour Therapy with
\nSuicidal Adolescents. New York: Guilford.
\nEating disorders
\nLe Grange, D. and Locke, J. (2007) Treating Bulimia in Adolescents. A Family-based
\nApproach. New York: Guilford.
\nEvidence-base for family therapy with children 141
\n\u00a9 2014 The Association for Family Therapy and Systemic Practice
\nLock, J. and Le Grange, D. (2013) Treatment Manual for Anorexia Nervosa. A Family
\nBased Approach (2nd edn). New York: Guilford.
\nEnuresis
\nHerbert, M. (1996) Toilet Training, Bedwetting and Soiling. Leicester: British Psychological
\nSociety.
\nEncopresis
\nBuchanan, A. (1992) Children Who Soil. Assessment and Treatment. Chichester: Wiley.
\nPsychosis
\nKuipers, L., Leff, J. and Lam, D. (2002) Family Work for Schizophrenia (2nd edn).
\nLondon: Gaskell.
\nMcFarlane, W. (2002) Multifamily Groups in the Treatment of Severe Psychiatric Disorders.
\nNew York: Guilford.
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