1. Evaluating the Effectiveness of Functional Family Therapy within Local Authority Social Work Services, (Glasgow and Renfrewshire, Scotland)
Using the Strengths and Difficulties Questionnaire Added Value Score
(Journal) Child and Adolescent Mental Health, 2016

2. Authors
Dr John J Marshall, Clinical Forensic Psychologist and Clinical Lead for Evidence Based Programme Development and Implementation, Greater Glasgow and Clyde NHS and Glasgow Council Social Work Services
Russell Hamilton, Programme Manager FFT, Renfrewshire Council and Action for Children
Nicole Cairns, Research Assistant, Greater Glasgow and Clyde NHS

3. Acknowledgements
FFT Teams in Glasgow and Renfrewshire
Susanne Miller, Chief Officer, Social Work Services Glasgow
Stephen McLeod, Head of Children’s Specialist (Mental Health) Services, NHS Greater Glasgow and Clyde
Steve Collins’ Former Operation Manager, Evidence Based Programmes and FFT Glasgow
Jessica Killilea, Research Assistant, Greater Glasgow and Clyde NHS
Peter Macleod, Director of Children’s Services, Renfrewshire Council
John Trainer, Acting Head of Early Years and Inclusion, Renfrewshire Council
Jim Cantley, Operational Director – Children’s Services, Action for Children
Michael S. Robbins Ph.D, Clinical Research Director, FFT. Senior Scientist - Oregon Research Institute
Joanna Pearce, Consultant Systemic Psychotherapist Family First Team Manager Brighton & Hove YOS. FFT National Consultant

4. What is FFT?
Functional Family Therapy (FFT) is an evidence based ‘Blueprints’ programme
Short term, Family focussed, Prevention intervention with high- risk young people aged between 11 and 18 and their families
Seeks to address problematic family relationships and resultant behaviours with a strengths based relational approach

5. Core Philosophy Family-Based Risk & Protection Respectfulness
Non-judgmental
Strength-based
Balanced Alliances
Relational vs. Individual
Matching to individuals, family relationships, environment
reducing risk and enhancing strengths
A Philosophy / Belief System about people which includes a core attitude of Respectfulness; of individual difference, culture, ethnicity, family form
A change model that is focused on risk and (especially) protective factors – “Strength Based”
Copyright FFT LLC 2012

6. The FFT Clinical Model Phase 1 – Engagement and Motivation
This phase concentrates on motivating the family to actively engage in the therapy by reducing blame and negativity, and building alliance within the family
Phase 2 – Behaviour Change
This stage builds on the alliance created within the family and teaches the family new skills for managing challenges together
Phase 3 – Generalisation
This phase supports the family in applying the skills learned to new situations inside and outside the home thus embedding permanent change

7. Positive outcomes in terms of:
Therapists are involved with families for between 3-5 months. Sessions are typically delivered at home but can be delivered in school or other community settings where there is a good reason to do so.
Positive outcomes in terms of:
Improved family relations
Improved communication skills
Improved adolescent behaviour
Improved parenting skills for handling subsequent problems
Improved parent supervision
Decreased family conflict

8. Why FFT?
The need for Social Work to demonstrate proof of concept for evidence based intervention
Children with complex needs (conduct disorder/ODD) not often receiving intensive treatment from mental health services despite poor life outcomes
FFT has a strong evidence base internationally however there is very little evaluation of its efficacy in a Scottish context.
The goal of the current study was to assess whether FFT was having a positive impact on families within the Local Authorities delivering it.
Family Based Therapy are recommended by NICE for CD along with systematic reviews of evidence

9. Participants
2 Local Authorities took part: Renfrewshire Council with Action for Children and Glasgow City Council Social Work Services.
Data was collected from 164 families with young people ranging in age from 11 to 16 years old.
These young people had a range of externalising and internalising behavioural issues and were at risk of becoming looked after or accommodated by the local authority.

10. Reasons for Dropping Out
164 families treated cases referred to FFT were not included in the study
No sig difference in psycho-social severity for referred child
Considering that 113 cases referred to FFT dropped out of the intervention the current sample of those who did finish the intervention may not be entirely representative of all those initially referred. A comparison of baseline parent-rated SDQ total difficulties scores and Outcome Questionnaire responses was therefore conducted to ensure that there were no significant differences between those who completed FFT and those who withdrew from the intervention. There was no significant difference found in SDQ total difficulties scores between those who did and those who did not complete the intervention (p > .05; 95% CI [-4.12, .88]). Similarly, the Outcome Questionnaire was completed by 35 of the families who dropped out and there was no significant difference between those who did drop out and those who completed the intervention on baseline scores (p > .05; 95% CI [-8.41, 14.3]). Thus it was deemed reasonable to continue with the analysis of change for those cases where pre- and post-data were provided.

11. Measures Outcome Questionnaire:
Measures any improvement made in adults receiving psychosocial intervention.
Client Outcome Measure (COM-A and COM-P):
Specific to FFT - focuses on family-reported changes following treatment.
Completed by both the parent and the young person

12. Measures Strengths and Difficulties Questionnaire:
Measures different psychological attributes in young people.
5 different subscales - emotional distress, behavioural difficulties, hyperactivity/ inattention difficulties, peer relationship problems, and prosocial behaviour.
Items on all scales, except the prosocial behaviour scale, can be combined to create the total difficulties score.

13. SDQ Added Value Score
A proxy control group was created from a sample of high-risk adolescents who participated in the British Child and Adolescent Mental Health Survey in (Ford et al., 2009) to use in this study (609 children with similar problems).
Ford et al. (2009) developed the Added Value Score by using an algorithm to compare the follow-up outcome scores obtained from a sample that has received an intervention with the predicted outcome scores from the sample of high-risk adolescents that have not received any intervention.

14. Results
Parent-rated SDQ scores for emotional distress, hyperactivity/attention difficulties and prosocial behaviour were found to be within the range of the community population after FFT.
Adolescent self-reported SDQ total difficulty scores were significantly lower and scores for prosocial behaviour significantly increased following FFT.

15. Results
For adolescent self-reported SDQ scores, all subscales were reduced post-intervention. The only one that was not statistically significant was peer problems.
However mean scores in all areas on the main scale were below the clinical cut-off points post-intervention.
Parents also reported significant improvements in all areas of the SDQ as well as in all areas of their own psychosocial wellbeing on the OQ following FFT.

16. Results
The COM-P shows that the majority of parents rated family change (93.1%), communication skills (93.1%), adolescent problem behaviour (88.2%), parenting skills (94.4%), parent supervision (91.4%) and family conflict (92.6%) as ‘some better’ or higher, with most scores falling within the rating of ‘a lot better’.
Out of all the parents who completed the COM-P, there were only 8 accounts (5%) of change in one of the six areas being rated as ‘worse’.
These 8 adolescents were from different families to the 8 parents who reported a ‘worse’ rating on the COM-P, and although this indicates that there might be a mixed reception to FFT the data pool is very small making it difficult to further analyse and draw firm conclusions. It should also be noted that they rated the other areas of the COM-A/COM-P as better.
There were also only 8 accounts (5%) on the COM-A of change in any one of the 6 areas being rated as ‘worse’.

17. Results
The COM-A indicates that , most adolescents rated family change (92.9%), communication skills (86%), adolescent problem behaviour (83.5%), parenting skills (84.7%), parent supervision (87.3%) and family conflict (86.7%) as ‘some better’ or higher, again with the majority of these scores rated as ‘a lot better’.

18. FFT compared to Control
To determine if improved psychosocial functioning scores obtained on the SDQ were actually caused by the intervention, the SDQ Added Value Score was calculated.
The SDQ Added Value Score was found to be 2.64, with a moderate effect size of 0.53.
Compares to effect sizes – similar to other U.S Effect Sizes and higher than parenting programmes Effect Sizes.
Pharmacological Treatment and CBT Adult Depression EF
Data from only 146 main parent figures (89% of parents who completed the intervention) was used to calculate the SDQ Added Value Score as this was the number who completed the life impact supplement on the SDQ, which is necessary for the calculation.

19. Conclusions
Overall, the findings demonstrate that adolescents’ and parents’ perceived an improvement in the adolescents’ behaviour, parental well-being, and family functioning post- FFT.
Many of the scores of each measure fell within a range equivalent to the community population post-FFT.
These findings would suggest that FFT is having a positive impact upon the families who use the service in Scotland.

20. Limitations
While the results add to the evidence base of the effectiveness of FFT there were however several limitations with the current study. It is difficult to discern whether the positive effects of FFT are lasting as there is no long-term data available for either of the FFT sites evaluated. As both services are relatively new, there is a need for a longitudinal study to explore the lasting impact FFT has on the families who use the service in Scotland.

21. Limitations
The results of this study only include families who finished the intervention with completed pre- and post-outcome measures. Therefore families who dropped out are not included, meaning that the resultant sample is not entirely representative of all those who were initially referred to the service.
An attempt was made to counter this by comparing all available SDQ and OQ baseline scores of families who completed and dropped out of the intervention.
No significant difference was found indicating that the results are likely representative of all those referred. However it is not possible to draw a firm conclusion regarding this.

22. Limitations
While the SDQ Added Value Score has many advantages, using it does disadvantage the current study compared to an RCT.
As study was not an RCT the possibility of the effect found being caused by confounding factors cannot be ruled out.

23. Future Research
Future research should investigate why families drop-out and aim to consider how FFT can be delivered to minimise dropout rates.
The rationale behind families refusing to participate in FFT despite meeting the referral criteria should also be considered, with a view to making the intervention more accessible and increasing the participation rate.

24. Implications
The role of evidence base programmes for Social Work Services serving socially excluded families
The role of Clinical Support to Social Work in implementing and evaluating programmes.
Non diagnostic/formulation/ non clinical service with clinical gains.
Importance of model adherence and supervision/coaching around proven models delivered fully
Thinking relationally about problems
An Evidence Based Programme promotes attachments
Further large scale outcome trials required
Important for Policy makers focusing on scale for population impacts