The effectiveness of Families First services: An experimental study

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Abstract

An intensive, short-term, family-based intervention was employed to help families overcome serious problems in child behavior and child management. This service was an adaptation of the Teaching-Family Model of therapeutic group home programming with some elements of child welfare intensive family preservation services. In a controlled, 3-year study, families receiving this service were found to report significant improvement in child behavior, physical care and resources, parental effectiveness, and parent–child relationships, when compared with similar difficulties in families who were referred for the service but not served. Not only were the improvements for treatment families apparent shortly after the conclusion of the service, but these changes were also maintained over a number of months' period, suggesting that the improved skills, behaviors, and relationship changes developed during the intervention may have become solidly implanted in parental and family functioning.

Introduction

Increasing concern is being expressed among the various helping professions that interventions and practices must meet rigorous tests of effectiveness, for example, the emergence in the medical field of what has been termed “evidence-based medicine.” This paradigm emphasizes using evidence from clinical research as the primary grounds for medical decision-making (Sackett, Richardson, Rosenberg, & Haynes, 2000). Proctor has recently applied the same challenge to social work, in connection with a proposed NASW policy statement to emphasize greater expenditure of resources for prevention and intervention services that are research-based when trying to deal with adolescent violence and with mental and physical health problems.

What and where are the effective treatments, programs, and services? The social work research community must redouble its efforts to develop and test the effectiveness of new programs and treatments. Given the public health priority and urgency of the problems and the mandate for evidence-based practice, the need for effectiveness studies is compelling. (Proctor, 2002).

Mullen (2002) (see also Corcoran, 2000, Howard et al., 2003) also has argued for an “evidence-based” social work, both for social work practice and for policy-making. The former he defined as “any practice that has been established as effective through scientific research according to some set of specific criteria.” He cites with approval several criteria elicited by a 1998 Robert Wood Johnson Foundation panel for defining evidence-based practice, including the existence of a standardized definition for the practice, that the practice had been evaluated with controlled research designs, that important outcomes had been identified, and that the research had been conducted by multiple research teams.

One area of services with a need for effectiveness studies is family-based interventions. A variety of family-based services has been developed recently for application in child welfare, delinquency prevention, and for mental health purposes, to benefit problem children including those at risk of institutionalization or out-of-home placement. While these interventions are often identified as having promise, there is considerable controversy over their value (see for example Gelles, 1993, Rossi, 1992), and even the most positive review laments the lack of well-designed and controlled research on the effects of such interventions (Fraser & Nelson, 1997). Much of the research that has been conducted has not used comparisons or controls so as to demonstrate the direct effects of the intervention on desired outcomes or has been seriously flawed by such things as poor subject selection or the compromising of the service model.

Fraser and Nelson have articulated a strategy for such research:

  • (1)

    Study single programs and settings, where the service model will be consistent, the children sampled are more homogeneous, and children or families are uniformly and “genuinely at risk” of the undesirable outcomes.

  • (2)

    Achieve experimental and control conditions of 65–75 families each.

  • (3)

    Do a number of such studies, which both replicate the core research and systematically vary the problems addressed, the conditions and settings, and specific features of the intervention.

  • (4)

    Work from effectiveness to efficacy studies. In other words, initial studies should address the overall success or effectiveness of the service, then later studies fine tune the components of the intervention as they relate to specific populations, settings, and types of interventionists (Fraser & Nelson, 1997).

One promising, but as yet untested, intensive, family-based approach for improving child and family functioning has arisen out of the Teaching-Family Model (TFM). The underlying model originated as an intervention program for therapeutic group homes for children and youth, focusing on the group home parents and the manner and content of their interaction with residents. The model is a very tightly specified and systematic approach based principally upon learning theory concepts, including modeling, reinforcement, and generalization of learning (Phillips, Fixsen, Phillips, & Wolf, 1979). The prototype for TFM was a small group home program, Achievement Place, established in 1967 in Lawrence, Kansas. With the aid of a group of psychologists from the University of Kansas and a grant from the National Institute of Mental Health, the model was defined and implemented in that facility (Willner, Braukmann, Kirigin, & Wolf, 1977). In the ensuing years, TFM was adapted to other group home settings throughout the country by a number of additional agencies and sponsors. A further development was the establishment of the Teaching-Family Association by these agencies in 1978, to ensure quality and standards in the application of the model. At the current time, as many as 279 group home programs using TFM have been established under auspices of at least 35 agencies across America (McElgunn, 2003, Teaching Family Association, 2002).

Initially, TFM agencies and the Association placed major emphasis on developing effective Teaching-Family parents for service in group home settings. Formalized training methods were developed and progressive certification standards created. In recent years, there has been a trend to apply these approaches across a much broader spectrum of services for children, youth, and families. TFM agencies have experimented with applications of this model in day treatment, adult living, and programs for persons with autism and severe brain damage. The Teaching-Family Association now recognizes treatment foster care and intensive, short-term family or home-based treatment as normal TFM offerings by association agencies, in addition to group home treatment (Teaching Family Association, 2003). A recent survey of Association member agencies demonstrated that 54% provided foster care, 41% had independent living programs, 33% provides school-based services, and 50% offered home-based treatment to families (McElgunn, 2003).

While there has been a good deal of research on TFM model development and processes (Fixsen & Blasé, 2002), especially regarding group home applications, studies of the effectiveness of TFM family-based interventions have been very limited. Two studies are available, both of which limited their investigation to a treatment group. Friman, Soper, Peterson, Ferguson, and Bothern (1993) evaluated the influence of a TFM-based home-based intervention on child behavior problems. Behavior problems were measured by the Achenbach Child Behavior Check List (CBCL). Subjects were 36 children thought to be at imminent risk for out-of-home placement, who with their families were referred for in-home services by the State of Nebraska or Probationary Court. Services lasted 6–8 weeks and involved about 15 h of face-to-face contact a week. The caseload standard was two families. The consultants delivering the service had master's degrees (mostly MSWs) and Boys Town's competency-based training. No control group was used. The CBCL was administered at program entry, 3 months post-treatment and 12 months post-treatment. Findings were that CBCL scores were significantly decreased on all summative scales at 3 and 12 months post-treatment. The scores also decreased significantly on most subscales.

Lenerz, Cannon, Johnson-Meester, and Peterson (undated) also studied 79 families who participated in the same Boys Town program. Various measures were administered at admission, at program completion, at 90 day, and 1-year follow-up. No control group was used. Results indicated that family satisfaction, as measured on the Olsen Family Satisfaction Scale, improved significantly from admission to program completion (p<0.0001). Parent sense of competence, defined as parents' confidence in their ability to manage their children as measured by the Parent Sense of Competence Scale, also showed significant change from admission to program completion (p<0.0001). Child behavior was measured on the CBCL and these scores also showed significant improvement at program completion (internalizing: p<0.0001; externalizing: p<0.0001). All of the measures above tended to remain steady at 90 day and 1-year follow-ups. Families also reported improved problem-solving, lower family conflict, and increased ability to obtain needed resources.

No studies were identified in the literature utilizing experimental designs or that involved some kind of comparison group.

Given the movement of TFM agencies into home-based interventions and the shortage of programs generally with demonstrated effectiveness in helping families, it is important to answer the question—In families where a child has been identified as having serious behavioral or school-related problems, does a family-based, short-term, therapeutic intervention derived from TFM principles and skills significantly improve child and family functioning?

Section snippets

Method

In 1994, Utah Youth Village initiated a new family-focused intervention, Families First, designed to help families overcome serious problems in child rearing and child management. Families First was an adaptation of the Teaching-Family Model of therapeutic group home programming with some elements of child welfare intensive family preservation services similar to the Homebuilders© program. Utah Youth Village is a private, non-profit agency and an experienced TFM provider, having achieved full

Families First service: The experimental condition

In the Families First intervention, a Family Specialist worked intensively with families in their own home and community settings for a period of about 6 weeks. Family Specialists spent as much as 15 h/week with the family during this time period. The intervention used a strengths-based approach that focused upon the parents' agenda for change. It involved skill-based teaching, with an emphasis on modeling and the supervised practicing of effective parenting and parent–child relations, for such

The control condition

Families in the treatment and control groups were referred to Families First by either a school or the juvenile court, and assigned at random. School referrals were generally instigated by staff of multi-disciplinary programs, serving children with special needs and their families. Children referred by the court also were already involved in a system of services. Therefore, the comparison for Families First Services was not with a total absence of services but with other interventions normally

Results

To answer the study question, change scores were calculated comparing pre-test scores to both the initial post-test and the follow-up post-test scores, and the significance of these changes determined. Comparisons were made for the four composite scales described above. Table 1 shows the results, which demonstrate a strong positive effect of the intervention when compared to the control group. Combining all 63 problem-related variables, significant t scores were found for both the pre-test to

Discussion

Based upon parental reports in the context of an experimental study with random assignment of study families to treatment or control conditions, the Families First intervention demonstrated a significant positive impact on overall family functioning and factors of child behavior, physical care and resources, and parental effectiveness. Not only was this finding true shortly after completion of the intervention, but there was also evidence that families were able to maintain the gains and skills

Acknowledgements

This study was initiated through a grant by The Church of Jesus Christ of Latter-day Saints Foundation, and received additional support through gifts from Gary and Anne Crocker, the George S. and Delores Dore Eccles Foundation, and from other individuals and foundations.

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