Childhood Behavioral and Emotional Disorders

These disorders cover a wide spectrum, with evidence for family therapy’s effectiveness strong for some problems, moderate for others, and scant for some.

The strongest evidence is for oppositional defiant disorder, where the Oregon Social Learning Center’s parent training (PT) model is one of the best validated treatments in the whole field of psychotherapy. PT came out of the observational research of Gerald Patterson (1971) and his colleagues on problematic family interaction patterns of kids with oppositional defiant disorder. These include coercive behaviors (yelling, physical aggression, focus on disapproval statements, and negative commands) and other forms of poor parenting (such as ineffective consequences and low rates of positive attention). Parents and children get into negative, escalating, reinforcing chains of coercive interaction.

PT works with parents to teach them to shape more constructive child behavior by setting a goal and reinforcing the child’s successive approximations toward that goal. To manage escalating behavioral interactions, parents are taught a variety of techniques, including time-outs (generally 5 minutes) to isolate the child until the outburst subsides. If children resist the time-out, minutes are added and then a privilege taken away. Children generally learn to cooperate rather than lose privileges. Parents are also taught how to monitor their children’s outside relationships and to make effective requests (short and simple).

Over a wide range of studies, PT has been found effective in diminishing childhood behavioral and emotional disorders. As summarized by Northey, Wells, Silverman, and Bailey (2003): “Parent Training for oppositional behavior problems on children is one of the most well-researched treatment modalities in child psychology and there is incontrovertible evidence for its short-term effectiveness, especially with younger opposition behavior problem children (i.e., ages 6 to 12 years)” (p. 103). There is also increasing evidence that PT is effective in treating attention deficit/hyperactivity disorder (ADHD) in particular. There is more limited research on family therapy for “internalizing” problems in children, especially anxiety and depression, and no conclusions can be drawn except that results seem to be comparable to individual therapy (Northey et al., 2003).

Anorexia Nervosa in Adolescence

Anorexia nervosa has confounded individual treatment approaches. Outcomes for standard treatment are not optimistic. Across studies, only 44% of patients followed at least 4 years after the onset of illness are considered recovered—that is, being within 15% of ideal body weight—while one-quarter of patients remain seriously ill, and another 5% have succumbed to the illness and died. Rates of death for adults with chronic anorexia nervosa are even higher (Le Grange & Lock, 2007).

The extraordinarily creative team at the Philadelphia Child Guidance Clinic led by Salvador Minuchin was the first to tackle family therapy for anorexia nervosa (Minuchin et al., 1978), an intractable disorder with few successful psychosocial treatment options. Although not a systematic evaluation study, this work stimulated the development of other models, the best evaluated one being the Maudsley family treatment model developed in London from a structural family therapy base (Le Grange, Binford, & Loeb, 2005). The Maudsley model was developed for adolescents who are living with their families. It is a relatively short-term model (often 20 sessions over 6 months) in which the therapist intervenes assertively in the first stages of illness. Unlike standard approaches where parents are given general and mild advice about how to manage their child’s eating, the Maudsley approach puts the parents directly in charge of getting their daughter or son to eat. The parents assert their hierarchical authority to insist that the adolescent eat responsibly and healthily. The whole family is encouraged to “externalize” the anorexia by viewing it as something that takes over or tricks the adolescent rather than being a part of the adolescent’s personality.

Echoing psychoeducational models for schizophrenia, the Maudsley approach does not view parents as causes of the eating disorder. Rather parents are encouraged to use their creative resources to move their child toward health by feeding their child the type and amounts of food needed to restore health. After ideal body weight has been restored and other indicators of health are on track, the adolescent regains responsibility for self-feeding. In later stages of therapy, the therapist turns to issues of normal adolescent development by supporting the adolescent’s autonomy, establishing appropriate parent–child boundaries, and helping parents with their own individual and marital needs as appropriate.

The Maudsley model has been found effective in numerous clinical trials (Le Grange et al., 2005). Over a variety of studies, 70% of patients reach a healthy weight by the end of treatment, while a majority of girls have started or resumed menstruation. At 5 years post-treatment, 75 to 90% of patients are fully recovered and no more than 10 to 15% remain seriously ill. These results are best for younger adolescents and for those whose illness have not yet become chronic. This model of family therapy has found its way into an increasing number of treatment facilities in the United States after the publication of a user-friendly treatment manual (Locke et al., 2002).