Adolescents in Couple and Family Therapy
Name of Family Form
Adolescents in Families
The systemic approach of couple and family therapy has always viewed adolescents as a central part of how families function, struggle, and are able to ultimately make successful clinical changes. Life cycle models of family development suggest that the stable relational patters established in families can be disrupted as younger children become adolescents. Changing adolescent behavior and the ability of the family relational system to adapt can be critical stress points for families. In some cases, adolescent behavior and the resulting reactions from parents create family conflict, negativity, and within-family blame that make it difficult for families to successfully solve daily problems. In some cases, adolescent behavior problems emerge overwhelming the family’s ability to manage. The behavioral expression of a youth’s struggles can result in violence, criminal behavior, and other consequences for not only the youth but also those in the families and community. This makes youth problems a systemic one affecting not only individuals and a likely time for community-based intervention. For adolescents and families, this usually means struggles with the justice system and educational system or involvement in the mental system.
Adolescent behavior problems are one of the most difficult and pervasive of those faced by prevention and treatment specialists in the mental health field (Sexton and Alexander 2006). Schools and community-based mental health and counseling services face growing referrals of adolescents with a wide range of complex clinical problems. In fact, survey data gathered over the last decade suggest that the range of adolescent behavior problems including drug use/abuse, violence and school-related behavior problems, as well as suicide, depression, and anxiety are widespread in adolescents of all cultures, ethnicities, and from all communities (Sexton and Alexander 2006).
Couple and family psychology brings a unique systemic perspective to understanding and helping youth and families (Sexton and Stanton 2016). The systemic theoretical models of CFP bring a unique relational perspective to understanding youth behavior as part of a larger family relational system that serves to both maintain problems and as the most likely place for lasting clinical intervention. The evidence-based family-focused clinical treatment models for adolescents, which are based on systemic theoretical principles, have strong research foundations of community-based studies in diverse real-life settings (Sexton et al. 2012; Sexton and Datachi 2014). As a result, CFP offers a unique platform for understanding adolescent behavior (whether problematic or not) and illuminating a pathway for successfully preventing and intervening to help families overcome struggles related to adolescence.
This chapter will briefly focus on the scope of issues facing adolescents and families, a systemic perspective for understanding family and youth clinical problems, and a brief overview of successful ways of clinically intervening with these complex issues. The goal is to illustrate the unique contribution of CFP-based theoretical models and clinical intervention programs that are specifically aimed at understanding and successfully helping families successfully deal with adolescent behavior problems. As such, the focus of this discussion is on the systemic and relational theoretical models understanding problematic youth behavior and the evidence-based treatment prevention and intervention programs for helping youth and families.
Adolescent Behavior Problems
The behavior problems of adolescents are of significant concern in schools, families, and for communities. Conduct problems of adolescents and children are the most common referrals to mental health clinics in the Western hemisphere (Sexton and Alexander 2006). Youth who fall into the broader category of externalizing problems account for between one third and half of all child and adolescent clinic referrals (Kazdin et al. 1992; Sexton et al. 2005).
One perspective in understanding problematic adolescent behavior is the individually focused diagnostic approach. From this perspective adolescent behavior problems are often described as adolescent-focused. There are two broad categories: internalizing and externalizing problems. Internalizing disorders are problems internally directed and include clinical symptoms: anxiety, withdrawal, and depression. Internalizing disorders are problems internally directed and include clinical symptoms which are anxiety, withdrawal, and depression. These adolescents are easily overlooked in families, schools, and communities; however, the impact of internalizing problems in adolescents is signification in regard to later mental health adjustment, school success, peer struggles, and even teen suicide. In addition, internalizing problems of adolescent can set a pattern of psychological and behavioral functioning that becomes a lifelong pattern of struggle.
Externalizing disorders are those directed to others and the environment. They include oppositional, hyperactive, aggressive, and antisocial behaviors. Numerous psychiatric diagnostic categories encompass these areas including attention-deficit and disruptive disorders. Youth referred to the mental health and juvenile justice systems are most likely to be ones who fall into the externalizing behavior disorders category (cite the other chapter). Early-onset (childhood onset) problems that begin in early childhood escalate into more violent behavior later. Only about 20–40% of the male adolescent in this category become serious offenders later in life. Later-onset (adolescent onset) problems that are not there in younger life are there to appear in adolescent years. Between 60% and 80% of youth these youths are later identified as serious offenders.
A third, frequently overlooked group are at risk adolescents. The problems experienced by youth who do not meet the criteria for either internal or externalizing behavior problems may engage in problem behaviors that put them at risk for becoming involved in the mental health or juvenile justice system or to experience future psychiatric problems. These youths might be involved in truancy, vandalism, stealing, drug use, bullying, running away from home, etc. These data led Kazdin (2018) to suggest that prevalence rates for youth behavior problems substantially underestimate the scope of the existing problem. It is important to understand these adolescents because this is the population toward which prevention efforts can be directed to prevent the internalizing and externalizing behavior patterns.
Equally troubling are the significant number of adolescents in need of mental health treatment. Epidemiological studies suggest that between 17% and 22% of adolescents suffer from a significant developmental, emotional, and/or behavioral problem (Kazdin and Whitley 2003). High rates of mental disorders also exist among youth involved in the juvenile justice with an estimated 50–80% of delinquent adolescents meeting the criteria for a mental disorder such as conduct- or substance-related disorders (Kazdin 2018). The economic is significant. Each year, an estimated 600,000 youth cycle through detention centers, with more than 70,000 youth in a juvenile correctional setting on any given day. Generally, though, involvement in the juvenile justice system has been shown to have long-term detrimental effects and makes youth more prone to future antisocial behavior or criminal activity. Adolescents in the juvenile justice and mental health systems alone account for billions of dollars in costs to taxpayers and communities (Elliott 1998).
Family-Based Treatment Approaches for Adolescent Problems
Family therapy plays a central role in the successful treatment family conflict and the resulting youth behavior problems. Probably more than in any other area of psychology, the domain of adolescent behavior problems has seen the development, maturation, and growth of a number of successful “evidence-based” treatment programs (Sexton et al. 2011). Of the prevention and treatment programs options currently available the outcomes suggest that, when implemented with model fidelity and clinical competence that youth and families can change drug use and abuse problems, reduce violence, less frequently enter the justice system, and when they do, improve to the degree that they can successfully function in schools, with peers, and in communities (Sexton et al. 2012; Sexton and Datachi 2014).
Evidence-based treatment and prevention programs have also been successfully implemented in local communities and some across entire statewide systems of care with impressive results. The evolution of evidence-based prevention and treatment programs for adolescent behavior problems fits within a broader movement of evidence-based model development in medicine, psychology, and other social services (Sexton et al. 2011). There are many different prevention and treatment programs in the professional literature (Elliott 1998 estimates over 1000); however, few have enough external evidence to suggest that they are effective. The most effective are family-based or family therapy intervention programs that are central to CFP.
Special Considerations for Couple and Family Psychology
There are two primary implications of the research on adolescents and adolescent problems and effective clinical intervention programs: youth problems are significant, and there are well-established intervention programs that work better than nonspecific approaches (Sexton et al. 2012); and to be effective, it is important to take a systemic/relational view of the family functioning and clinical problems.
Taking a Multisystemic Perspective
It is a challenging task to identify and describe youth behavior problems because to a certain extent, externalizing behaviors is part of the normal developmental trajectory of the youth. Oftentimes these children are simply labeled as having “dysfunctional” behavior. However, it should be recognized that they actually have very complex behavioral profiles and are undoubtedly experiencing a wide range of developmental, emotional, and behavioral problems. For example, part of normal adolescent development includes fighting, withdrawing, disagreeing, and standing up to authority figures. While helpful in understanding community prevalence rates, this approach is limited in its individual orientation and lack of help in identifying clinical intervention strategies. They are also limited in their individually focused scope that often misses factors in the large social context, within family factors, or normal family development (Sexton and Alexander 2006). For example, it is not easy to determine if an oppositional youth is going through normal adolescent developmental phases or if those behaviors represent the onset of more significant issues. Does fighting, withdrawing, disagreeing, and standing up to authority figures represent behaviors that are often part of normal adolescent development? Identification is made even more complex by the various systems in which with similar behavior problems are identified and the different labels given by these systems for similar behaviors (e.g., child welfare, juvenile justice, or mental health). What might be considered criminal behavior in the juvenile justice system is often seen as a mental health disorder in the community mental health center. While the acting-out behaviors exhibited by these children appear quite similar, each case is unique in that the behaviors occur at very different times in the biological development of the youth and within very different environmental and family contexts.
CFP has offered a unique and comprehensive multisystemic approach to understanding adolescent behaviors that both help identify how problems emerge and where the clinical intervention points may be to successfully help family relational system adjust and adapt. A CFP, multisystemic approach considers the biological, family, and social factors that help explain both the origins and the facilitating features of these chronic behavioral problems. In this view, it is the risk and protective factor that operates within and around a core family relational system that serves as the most comprehensive way to understand problematic adolescent behavior.
Risk and protective factors. Risk and protective factors approach, based on an established body of etiological research, integrates the epidemiological research into a developmental and multisystemic perspective that enhances successful intervention (Sexton and Turner 2010). Risk and protective patterns describe alterable behavior, rather than “labeling” the youth or family with characteristics that become stable and enduring. This model helps organize the complex information from the multiple systems (individual, family, and social). It is a useful way of thinking about problems because it describes them through a “probability lens” (determining the likelihood of problems), rather than in terms of causal relationships. The risk and protective factors model can be helpful in organizing critical information, such as how the multiple systems function in regard to difficulties as well as strengths. It allows the interventionist to identify which factors to develop, which to work around, and which to attempt to decrease. The risk and protective factor approach helps define the outcomes of prevention and therapy for children with these types of problems. Many risk factors are not changeable (e.g., unemployment, biological predisposition, and relational histories). Thus, successful intervention with adolescent behavior problems involves building protective factors to overcome some of the more static risk factors. In this way, intervention focuses on building the resiliency of the child, parents, and family.
A comprehensive risk-and-protective-factor view identifies risk and protective factors in each of the three areas: individual factors, family factors, and social factors. These include (1) child risk variables, including a difficult temperament or high rate of disruptive, impulsive, inattentive, and aggressive behaviors (Campbell and Ewing 1990); (2) parenting variables, including ineffective parenting strategies and negative attitudes (Patterson and Stouthamer-Loeber 1984); and (3) family variables, apart from the parent–child relationship, which include parental psychopathology, marital factors, socioeconomic factors, and other stressors (Webster-Stratton 1990).
The central role of families. A systemic perspective would suggest that within family, risk and protective factors are critical to understand adolescent behavior (Sexton and Turner 2010). It is well-accepted that families characterized by conflict (anger and aggression), deficient parenting, and family interactions that are cold, unsupportive, or neglectful contribute to childhood psychopathology (Knutson et al. 2004). For example, as youth struggle, in what are many times very normal ways, the relational system around the youth and the family begins to strain the individual’s and family’s capacity to manage outside stressors. The decline of these abilities results in changes in the relational systems that develop around the specific behaviors of the youth. Finally, these stabilized relationships are connected to the chronic nature of the youth’s conduct problems. Furthermore, family dynamics that is unresponsive or rejecting of children likely exacerbates children’s genetic or temperamental diathesis to the development of conduct disorders and aggression (Repetti et al. 2002). Protective parenting factors include the quality of maternal instructions, frequent joint activities, monitoring, structuring the child’s time, and constructive discipline strategies (Hutchings and Lane 2005).
The sections below are intended to be an overview of the range of types of intervention types of family therapy-based interventions for helping with adolescent behavior problems, not a systematic review. As noted above, the goal is to illustrate the central role that CFP models play in the treatment of these difficult issues. For a comprehensive overview, please note the references below. It is also important to note that the lack of research evidence does not mean that a clinical intervention approach does not work. Couple and family therapy has an impressive research foundation demonstrating its effectiveness (Sexton et al. 2012). Common factors, or those core elements of any good therapy, are particularly important when working with adolescents. The CFP evidence-based approaches briefly described below illustrate a wide range of reliable, community-tested programs that, when implemented with fidelity, result in positive changes of youth and families.
Early prevention approaches. Certain evidence-based prevention programs have repeatedly demonstrated the critical importance of later adolescent behavior on the early family relationship system and parenting activities. These early prevention efforts are remarkable in that they show that changes in the family relational system during the infancy period as well as preschool years have demonstrated a considerable reduction in adolescent behavior problems, particularly for families at greater social risk (e.g., related to low SES and unmarried mothers, weak parental involvement, low educational attainment, marital discord) (Bor 2004; Olds et al. 1998). Two best practices for the prevention of adolescent conduct problems are early childhood home visitation and the Triple P (“Positive Parenting Program”). Nursing Home Visitation Program is designed both to promote maternal health-related behaviors early in the child’s life, as well as to promote maternal long-term self-development through family planning, educational achievement, and participation in the work force. At 15-year follow-up, child outcomes (in adolescence) of the nurse home visitation program were observable: fewer episodes of running away from home, fewer arrests and convictions (e.g., recurrent truancy, destroying parents property), fewer violations of probation, fewer sexual partners, and less frequent engagement in smoking and alcohol consumption (Olds et al. 1998). Given these clinical outcomes, it is clear that changing the family relational environment early in life can have an impact on later adolescent certain antisocial behaviors.
Parent skills training. A second set of categories of clinical interventions focus on helping parents with skills to change the ways in which they work with their adolescents. Hutchings et al. (2004) identified six essential components of parenting interventions for the treatment of conduct disorder: (1) the rehearsal of new parenting skills, (2) the teaching of management principles rather than techniques, (3) the practice of new parenting strategies at home, (4) the teaching of both (nonviolent) sanctions for negative behavior and strategies to build positive relationships, (5) the addressing of difficulties in the parental relationship, and (6) the early delivery of interventions, as later interventions are less effective.
Psychoeducational approaches. Psychoeducation treatment use information and education to change youth behaviors with the intent to prevent adolescent behavior problems. For example, the Life Skills Training Program (LST) targets middle- and junior high school youth in the prevention of tobacco, alcohol, and marijuana use and abuse through the development of skills that reduce the risk of engaging in high-risk activity (Botvin and Kantor 2000; Botvin 1998). The program consists of three components: drug-related knowledge and skills, personal self-management, and general social skills. The drug-related knowledge and skills component targets knowledge and attitudes related to drug use through drug education, discussion of norm expectations related to drug use, and the teaching of skills to resist media influences as well as peer and social pressures related to drug use. The personal self-management component targets the development of skills in decision-making, problem-solving, self-control, and self-improvement, and the general social skills component targets the development of skills in communication.
Family-Based Treatment Models
There are number of family-based and family therapy treatment models that are also central to the successful treatment to adolescent behavior problems. For example, trauma-focused cognitive behavioral therapy is designed for adolescents who experience traumatic events (e.g., child abuse, parental divorce, out-of-home placement, family violence) for they are prone to several mental health problems and to engaging in high-risk behaviors. Specific interventions that target the effects of trauma on the youth and their families are needed to foster resilience and decrease the risk of future mental health problems. TF-CBT that has strong empirical support to its effectiveness in treating children and adolescents (aged 3–18) and their families overcomes the experience of trauma. TF-CBT consists of 12–16 sessions delivered once a week.
Multidimensional family therapy (MDFT) is a rigorously studied outpatient treatment that integrates family therapy, individual therapy, drug counseling, and multiple systems-oriented intervention approaches to treat adolescent drug abuse and related emotional and behavioral problems (Liddle et al. 2002). MDFT builds on knowledge derived from research on risk and protective factors related to youth substance abuse in formulating its assessment and intervention techniques. It targets multiple aspects of youth presenting problems through four interdependent modules that together form the adolescent’s psychosocial world, each of which contribute to maintaining the problematic behavior.
Multisystemic therapy (MST) is systematic, manual-driven, family-based intervention for youths and families facing problems of juvenile delinquency, adolescent conduct disorder, and substance abuse (Henggeler et al. 1999). MST is an approach derived from social-ecological models of behavior, family systems, and social learning theories (Henggeler et al. 1993). Targets of change in MST include individual- and family-level behaviors, as well as outside system dynamics and resources like the adolescent’s social network. Treatment interventions are on an “as-needed” basis, focusing on whatever it takes to alter individual, family, and systems issues that contribute to the problem behavior. The typical treatment course for MST implementation ranges from 2 to 4 months. Multiple-level assessments of family and social systems functioning are embedded within the treatment protocol. Like FFT, MST has demonstrated outcomes with a wide range of adolescent externalizing disorders (conduct disorders, adolescent drug abuse, adolescent mental health issues), with families that represent diverse cultural and ethnic groups, in a number of contexts (Kazdin 1997; Sexton et al. 2012).
Functional family therapy (FFT) is a clinical model that has evolved over the last 35 years built on a foundation of integrated theory, clinical experience, and empirical evidence (Alexander et al. 2013; Sexton and Turner 2010; Sexton and Stanton 2016). FFT is a well-developed clinical model designed to treat at-risk youth aged 11–18 with a range of maladaptive behaviors including delinquency, violence, substance use, risky sexual behavior, truancy, conduct disorder, oppositional defiant disorder, disruptive behavior disorder, and other externalizing disorders. The primary focus of treatment is on the family relational system with an emphasis on the multiple domains of client experience (cognition, emotion, and behavior) and the multiple perspectives within and around a family system (individual, family, and contextual/multisystemic). As a treatment program, FFT has produced successful outcomes with at-risk youth and their families. FFT is a short-term family therapy intervention that ranges from 8 to 12 1-h sessions for mild to moderate cases and up to 30 h of direct intervention for more serious situations. The program also works as a preventive measure in diverting the path of at-risk adolescents away from the juvenile justice or mental health systems (Alexander et al. 2000; Sexton and Turner 2010; Sexton and Alexander 2002). FFT has demonstrated outcomes with a wide range of adolescent problems, with families that represent diverse cultural and ethnic groups, in a number of contexts.
CFP brings a unique multisystemic perspective to understanding adolescent behavior. This perspective is descriptive, relational, and family-based in which individual adolescent behavior is part of a larger relational system. The current treatment programs show remarkable success in successful intervention for substance use problems, behavior problems, and other mental health problems by working with and through families to enact long-term successful change. These approaches range from early prevention models to intense family therapy-based approaches. What each share is a grounding and a multisystemic way of understanding these complex clinical issues.
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