Family Behavior Therapy (FBT) for Young People in Treatment for Non‐opioid Drug Use: A Systematic Review

This publication is a systematic Campbell review of the effect of the family therapy approach Family Behavior Therapy (FBT) for treatment for non‐opioid drug use (e.g., cannabis, amphetamine, ecstasy or cocaine) among young people aged 11‐21 years. After a rigorous search for all relevant studies conducted to date, we identified two randomized controlled trials with, respectively, 56 and 26 participants. We used meta‐analysis to synthesize the empirical evidence on the effects of FBT on reduction of drug use frequency, family functioning, and risk behavior. The evidence found was limited, as only two studies with very few participants were included in the data‐analysis. The quality of the evidence is also limited. We were therefore unable to draw any firm conclusion regarding the effectiveness of the treatment. Overall, Family Behavior Therapy for the purpose of treating young people's drug use has not been evaluated with sufficient rigor to unequivocally determine its effectiveness Key messages This publication is a systematic Campbell review of the effect of the family therapy approach Family Behavior Therapy (FBT) for treatment for non‐opioid drug use (e.g., cannabis, amphetamine, ecstasy or cocaine) among young people aged 11‐21 years. Youth drug use is a severe problem worldwide. Recent reports describe concerning trends in the use of drugs by young people and a lack of available treatment. FBT is a manual‐based family therapy approach that seeks to reduce drug use among youth by identifying stimuli and triggers for drug taking, and teaching self‐control and other skills to correct the problem behaviors related to drug use. This approach is based on the therapeutic premise that the family carries a profound influence on child and youth development and that interventions need to be flexible and tailored to the unique characteristics of the families. It is also argued that there is a need for interventions to be problem‐focused, targeting first those patterns of behavior that most directly influence the youth's drug use. After a rigorous search for all relevant studies conducted to date, we identified two randomized controlled trials with, respectively, 56 and 26 participants. We used meta‐analysis to synthesize the empirical evidence on the effects of FBT on reduction of drug use frequency, family functioning, and risk behavior. The findings are as follows: ‐ On drug usage: There is no evidence that FBT has an effect on reduction of drug use frequency compared to Individual Cognitive Problem‐Solving (ICPS) and supportive counseling (SC). ‐ On family functioning: FBT may improve family functioning as reported by parents compared to Individual Cognitive Problem‐Solving (ICPS) and supportive counseling (SC). There is no evidence that FBT has an effect on family functioning as reported by youth compared to Individual Cognitive Problem‐Solving (ICPS) and supportive counseling (SC). ‐ On risk behavior: There is no evidence that FBT has an effect on risk behavior compared to Individual Cognitive Problem‐Solving (ICPS) and supportive counseling (SC). The evidence found was limited, as only two studies with very few participants were included in the data‐analysis. The quality of the evidence is also limited. We were therefore unable to draw any firm conclusion regarding the effectiveness of the treatment. Overall, Family Behavior Therapy for the purpose of treating young people's drug use has not been evaluated with sufficient rigor to unequivocally determine its effectiveness. Executive summary/Abstract BACKGROUND Youth drug use is a severe problem worldwide, and the use of cannabis, amphetamine ecstasy and cocaine, referred to as non‐opioid drugs, are strongly associated with a range of health and social problems. This review focuses on Family Behavior Therapy (FBT) as a treatment for young people who misuse non‐opioid drugs. FBT is a manual‐based family therapy approach. The program is behavior and skill‐oriented. It is concerned with identifying psychological and situational stimuli and triggers presumed to be directly related to the youth's drug use, and skills training to improve self‐control. FBT is designed to accommodate diverse populations of youth with a variety of behavioral, cultural and individual preferences. FBT incorporates behavioral theory (reduction of undesired behavior by manipulating external reinforcement), structural family theory (in which the structure of the family influence the youth's behavior) and strategic family theory (where treatment methods are problem‐focused and pragmatic). OBJECTIVES The main objective of this review is to evaluate the current evidence on the effects of FBT on reduction of drug use frequency for young people in outpatient treatment for non‐opioid drug use and, if possible, to examine moderators of drug use reduction effects, specifically analyzing whether FBT works better for particular types of participants. SEARCH STRATEGY A relatively narrow search strategy to identify qualifying studies was performed. A wide range of electronic bibliographic databases were searched along with government and policy databanks, grey literature databases, citations in other reviews and in the included primary studies, hand searches of relevant journals, and Internet searches using Google. We also corresponded with researchers in the FBT field. Neither language nor date restrictions were applied to the searches. SELECTION CRITERIA Studies eligible for inclusion in the review are required to meet several eligibility criteria. Studies must: • have involved a manual‐based FBT treatment for young people aged 11‐21 years enrolled in outpatient treatment for non‐opioid drug use; • have used experimental, quasi‐experimental or non‐randomized controlled designs; • have reported at least one eligible outcome variable measuring abstinence, reduction of drug use, family functioning, education or vocational involvement, retention, risk behavior or any other adverse effects; • not have focused exclusively on treating mental disorders; and • have had FBT as the primary intervention. DATA COLLECTION AND ANALYSIS The literature search yielded a total of 10,779 records which were screened for eligibility based on title and abstract. 99 potentially relevant records were retrieved and screened in full text, of which 7 studies were potentially relevant. Of these, two studies were data‐extracted by the authors and included in the review. Meta‐analysis was performed to examine the effects of FBT on drug use reduction, family functioning and risk behavior. RESULTS For the primary outcome of reduction in drug use frequency, measured at end of treatment, the standardized mean difference was 0.49 (95% CI ‐0.51, 1.50). At 12 month post‐intake, Azrin et al. (2001) found no statistically significant difference between FBT and the comparison treatment, SMD=‐0.03 (95% CI ‐0.58, 0.52). For family functioning, measured at end of treatment, the standardized mean difference was 0.58 (95% CI 0.02, 1.13) reported by parents and 0.29 (95% CI ‐0.72, 1.30) reported by youth. At 12 month post‐intake, Azrin et al. (2001) found no statistically significant difference between FBT and the comparison treatment for parent satisfaction or youth satisfaction with family functioning, SMD= ‐0.30 (95% CI ‐0.86, 0.26) and SMD= 0.47 (95% CI ‐0.09, 1.04). For risk behavior, measured at end of treatment, the standardized mean difference was 0.29 (95% CI ‐0.16, 0.74). At 12 month post‐intake, Azrin et al. (2001) finds a statistically significant difference that favors the comparison treatment, SMD= ‐0.56 (95% CI ‐1.13, 0.00). Meta‐analysis was not possible for the education outcomes as the measures are incomparable. None of the studies reported statistically significant effect sizes for school outcomes. Due to lack of data for the number randomized in both studies it is not possible to report effects for retention. No other adverse effects are reported in the studies. AUTHORS' CONCLUSIONS The main conclusion of the review is that there is a lack of firm evidence on the effect of FBT. There is a need for more research, and particularly a need for more methodologically rigorous studies in the field of treatment for young drug users. The aim of this systematic review is to explore what is known about the effectiveness of FBT for the purpose of reducing youth drug use, in order to contribute to an evidence‐based approach in the treatment of young non‐opioid drug users. The evidence found does not provide a basis for drawing conclusions about actual outcomes and impacts. Consequently, no substantive conclusion about the effectiveness can be made, resulting in neither support nor rejection of the present FBT treatment approach.