Family Process - 2013 - Retzlaff - The Efficacy of Systemic Therapy For Internalizing and Other Disorders of Childhood and

The Efficacy of Systemic Therapy for Internalizing
and Other Disorders of Childhood and Adolescence:

A Systematic Review of 38 Randomized Trials
RUEDIGER RETZLAFF*#
KIRSTEN VON SYDOW†#
STEFAN BEHER‡
MARKUS W. HAUN§
JOCHEN SCHWEITZER¶
Systemic therapy (ST) is one of the most widely applied psychotherapeutic approaches in
the treatment of children and adolescents, yet few systematic reviews exist on the efficacy of
ST with this age group. Parallel to a similar study on adults, a systematic review was
performed to analyze the efficacy of ST in the treatment of children and adolescents. All
randomized or matched controlled trials (RCT) evaluating ST in any setting with child
and adolescent index patients were identified by database searches and cross-references, as
well as in existing meta-analyses and reviews. Inclusion criteria were: index patient diag-
nosed with a DSM-IV or ICD-10 listed psychological disorder, or suffering from other clini-
cally relevant conditions, and trial published by December 2011. Studies were analyzed
according to their sample, research methodology, interventions applied, and results at
end-of-treatment and at follow-up. This article presents findings for internalizing and
mixed disorders. Thirty-eight trials were identified, with 33 showing ST to be efficacious
for the treatment of internalizing disorders (including mood disorders, eating disorders,
and psychological factors in somatic illness). There is some evidence for ST being also effi-
cacious in mixed disorders, anxiety disorders, Asperger disorder, and in cases of child
neglect. Results were stable across follow-up periods of up to 5 years. Trials on the efficacy
of ST for externalizing disorders are presented in a second article. There is a sound
*Institute for Collaborative Psychosomatic Research and Family Therapy, Centre of Psychosocial Medicine,
Heidelberg University Hospital, Heidelberg, Germany.
†
Berlin School of Psychology/Psychologische Hochschule Berlin (PHB), Berlin, Germany.
‡
Department of Sociology, University of Bielefeld, Bielefeld, Germany.
§
Department of General Internal Medicine & Psychosomatics, Heidelberg University Hospital, Heidelberg,
Germany.
¶
Institute of Medical Psychology, Centre of Psychosocial Medicine, Heidelberg University Hospital, Heidelberg,
Germany.
Correspondence concerning this article should be addressed to Ruediger Retzlaff, Dr. sc. hum., Dipl.
Psych., Psychotherapist & Child and Adolescent Psychotherapist, Director of the Clinic of Marital and
Family Therapy, Institute for Collaborative Psychosomatic Research and Family Therapy, Centre of
Psychosocial Medicine, Heidelberg University Hospital, Bergheimer Str. 54, Heidelberg D-69115,
Germany. E-mail: [email protected].
#
Shared first authors.
We are grateful for the support of many colleagues: Claudia Borgers, Pia Weber (former graduate students of
KvS at Duisburg-Essen University), Jan Lauter, Joachim von Twardowski, Jia Xu (former doctoral students at
Heidelberg University), and Gu Min Min (Ph.D. student, Hongkong) for their help in identifying and collecting
relevant studies, Shi Jingyu (Shanghai/Heidelberg) for her translations of Chinese publications, and the follow-
ing researchers: China (Zhao Xu Dhong), Germany (Andreas Gantner, Wilhelm Rotthaus, Helmut Saile, Arist
von Schlippe, Michael Scholz, Helm Stierlin), Hong Kong (Joyce Ma), Singapore (Timothy Sim), the UK (Eia
Asen, Ivan Eisler), the USA (Charles Borduin, D. Russell Crane, Michael Dennis, Guy Diamond, Peter Fraenkel,
Scott Henggeler, Howard Liddle, William L. Pinsof, Jose Sczapocznik, the late Lyman Wynne), and many others.
619
Family Process, Vol. 52, No. 4, 2013 © FPI, Inc.
doi: 10.1111/famp.12041
620 / EFFICACY OF ST WITH INTERNALIZING DISORDERS
evidence base for the efficacy of ST as a treatment for internalizing disorders of child and
adolescent patients.
Keywords: Internalizing disorders; systemic therapy; family therapy; randomized

controlled trial (RCT); efficacy; psychotherapy research
Fam Proc 52:619–652, 2013
INTRODUCTION
F amily therapy evolved as part of a general paradigm shift in mental health towards
an ecological perspective. In contrast to earlier individually oriented conceptualiza-
tions of psychological problems, it focused on the social-ecological context in which they
arise (Bronfenbrenner, 1979; Engel, 1977; Minuchin, 1974). Many models of family ther-
apy had their roots in treatment projects for severe disorders of children and adolescents,
disorders which could not be adequately treated by other forms of therapy (Hoffmann,
1981) — psychosis, eating disorders, substance abuse, or delinquency. Today, systems ori-
ented therapies — having evolved out of earlier family therapy models — belong to the
most widely used approaches in the treatment of children and adolescents (Orlinsky &
Ronnestad, 2005). Systemic therapy (ST) has had a strong influence on other schools of
psychotherapy and, similarly, ideas and concepts from attachment theory, cognitive
behavior therapy, experiential/humanistic therapy, and Ericksonian therapy have been
integrated into systemic theory and practice (Retzlaff, 2012).
In some countries, psychotherapist licensing regulations rely on empirical evidence for
the efficacy of the specific psychotherapy “school” (e.g., behavioral, psychodynamic,
humanistic, and systemic). Similarly, health care providers generally require the treat-
ment to be recognized as evidence-based in order for psychotherapy to be reimbursed.
As a step towards gaining scientific recognition by the German Approval Board of
Psychotherapy/Wissenschaftlicher Beirat Psychotherapie (WBP) and the German Central
Regulatory Board of Health Care Providers, a systematic review of treatment studies on
ST was carried out. A systematic review is a critical assessment and evaluation of all
research studies, using an organized method of locating, assembling, and evaluating a
body of literature on a particular topic using a set of specific criteria.
The central hypothesis was that there is a sufficient evidence base for the efficacious-
ness of ST to meet the criteria of the WBP — namely, that there are at least three random-
ized controlled trials (RCTs) in at least three diagnostic groups showing that ST is equally
or more efficacious than established forms of treatment.
Results of our systematic reviews of ST with adults have been published elsewhere
(Sydow, Beher, Retzlaff, & Schweitzer-Rothers, 2007a; Sydow, Beher, Schweitzer, &
Retzlaff, 2010). An earlier review in German on ST with children and adolescents was
published in 2006 (Sydow, Beher, Schweitzer-Rothers, & Retzlaff, 2006).
For this review, we analyzed all randomized controlled (outcome) trials on the effi-
cacy of ST in children and adolescents with internalizing DSM-IV or ICD-10-diagnoses,
or other clinically relevant symptoms, published in English, German, Korean, Manda-
rin Chinese, or Spanish by December 2011. Findings for externalizing disorders will be
reported separately (Sydow, Retzlaff, Beher, Haun, & Schweitzer, in press). Clinically
relevant conditions included in this article were suicidality and child abuse and
neglect. While suicidality and child abuse are currently not classified as disorders, both
conditions frequently result in utilizing psychotherapeutic services, and were therefore
included.
www.FamilyProcess.org
RETZLAFF, VON SYDOW, BEHER, HAUN, & SCHWEITZER / 621
Family Interventions and Family Therapy Versus Systemic Therapy
In recent years, there has been a move towards psychotherapy integration (Fraenkel &
Pinsof, 2001; Grawe, Donati, & Bernauer, 1994; Lebow, 2005; Pinsof, 1995), resulting in a
growing trend to combine aspects of different psychotherapy models. Especially in the
treatment of children and adolescents, various forms of family interventions are now
applied by therapists of diverse theoretical orientations, such as cognitive behavior therapy
(CBT) or psychodynamic therapy.
While we generally applaud the trend to therapy integration and the proliferation of
family interventions into other psychotherapeutic schools, there is risk that specific
contributions of the systemic treatment model might be obscured. Most reviews on the effi-
cacy of psychotherapy focus on family interventions and trials in a family setting (Carr,
2000; Sprenkle, 2002) rather than on trials with a distinct systems orientation (Sydow
et al., 2010). This tendency might present a skewed picture of what contributes to treat-
ment effectiveness. “A systems orientation goes beyond working in a family setting or the
use of family interventions within an individual framework” (Sprenkle, 2002, pp. 13–14).
In our classification, we distinguish between different orientations of therapy (e.g.,
psychodynamic, behavioral, humanistic, systemic) and settings (e.g., individual, couples,
family, group or multiple family group setting). We use systemic therapy or systems ori-
ented therapy1 as a general term for a major therapy orientation that can be distinguished
from other major approaches like cognitive behavioral therapy (CBT) or psychodynamic
therapy (Grawe et al., 1994).
According to the current European mainstream, we define systemic therapy as (1) any
form of psychotherapy which perceives human behavior and especially psychological
symptoms and disorders within the context of the social systems patients live in; (2)
focuses on interpersonal interactions and expectations, the social construction of realities,
and recursive causality between symptoms and interactions; (3) includes family members
and other important persons (e.g., teachers, friends, professional helpers) directly or indi-
rectly through systemic questioning, hypothesizing, and specific interventions; and (4)
appreciates and utilizes clients’ perspectives on problems, resources, and preferred solu-
tions (see Sydow et al., 2010). The theory, diagnostics, and interventions of ST with chil-
dren and adolescents, as well as its basic therapeutic attitude, have been described in
depth in textbooks such as Combrinck-Graham (1986, 1989), Ford Sori (2006), and Retz-
laff (2012).
In contrast, family therapy can be defined as a setting in which psychotherapy is carried
out conjointly with relatives or significant others. There is a considerable overlap between
ST and family therapy, but they are not identical. Therapy may be implemented in a fam-
ily setting by therapists of other, not primarily systemic approaches. Family intervention
is an even broader term and can be defined as therapy techniques that aim at addressing
family members (Sprenkle, 2002).
Our operational criteria may differ from how studies are typically assessed in US
psychotherapy research; however, this type of classification is quite established in
European psychotherapy research (Grawe et al., 1994) and in European health care
regulations (e.g., in Austria, Germany, Poland, or Switzerland). European health care
regulations will often cover a certain number of sessions with a certain psychotherapy
orientation (such as behavior therapy or psychodynamic therapy) in any setting. It should
be noted that because we focus on trials with a predominantly systemic orientation, rather
than on therapy in a family setting, our systematic review includes fewer studies than other
reviews (Carr, 2009; Sprenkle, 2002). In a recent review on family-based interventions for
1
We prefer the shorter term systemic therapy, which is commonly used in countries such as the UK,
China, Germany, and partially in the USA.
Fam. Proc., Vol. 52, December, 2013

child and adolescent disorders, Kaslow, Broth, Smith, and Collins (2012) concluded that
there is initial support for family interventions in adolescent depression, some pilot
indication that it is helpful in bipolar disorder and autism, compelling evidence for family-
based interventions in anxiety disorders, and substantial support for the effectiveness of
family interventions in anorexia but less evidence for bulimia nervosa. Differences to our
review are largely because cognitive and behavioral approaches in a family setting were
included in the review of Kaslow et al. (2012).
A problem with a categorial sorting of therapy approaches is that it does not allow
for shades and colors beyond black and white. Today, many approaches are much more
integrative than in previous decades, and systemic, behavioral, cognitive, narrative as
well as psychodynamic elements might contribute to a given treatment. Instead of a rather
simplistic sorting into major therapy approaches, a system that allows for a richer descrip-
tion of therapy approaches would seem to be desirable (e.g., Madanes, 1981).
However, our research arose within the context of European health care regulation,
and in many countries, psychotherapy approaches can only be practiced, or are only paid
for if they belong to one of the major therapy orientations which are accepted as an evi-
dence-based. We are aware that by paying tribute to this necessity, we had to leave out
important, clinically highly valuable approaches that for example rely on psychoeducation
or a social learning base. While various techniques and settings might be used across
many orientations of psychotherapy, systemic therapy can be distinguished by observers
from other approaches (such as behavioral family therapy) due to differences in the basic
premises, assumptions, and views of how therapy is conducted (Saile & Trosbach, 2001).
METHOD OF THE SYSTEMATIC REVIEW

Identification of Primary Studies
Trials were identified through database searches up to the publication date of December
2011 (methodology described in Sydow et al., 2010). We also searched China Academic
Journals Full-Text Database, cross-references in reviews, meta-analyses, Cochrane Reviews,
and existing primary studies. Members of the American Academy of Family Therapy
(AFTA) and the European Federation of Family Therapy (EFTA) provided additional help.
We analyzed general reviews of effectiveness trials on ST in all age groups (Empt &
Schiepek, 1997; Ludewig, 1996; Ochs, Schlippe, & Schweitzer, 1997; Stierlin, 1997; Strat-
ton, 2005); ST with children and adolescents (Cotrell & Boston, 2002; Malone, 2001),
specific forms of ST, including solution focused therapy (Kim, 2008; Kim & Franklin,
2009), and especially multisystemic therapy (MST) (Henggeler, 1999, 2004; Littell, 2005;
Littell, Campbell, Green, & Toews, 2005); family therapy/family interventions across all
age groups (Alexander, Holzworth-Munroe, & Jameson, 1994; Alexander, Sexton, &
Robbins, 2002; Asen, 2002; Diamond, Serrano, Dickey, & Sonis, 1996; Gurman & Liddle,
2002; Lebow & Gurman, 1995; Liddle & Rowe, 2004; Liddle, Santisteban, Levant, &
Bray, 2002; Pharoah, Mari, Rathbone, & Wong, 2010; Pinsof & Wynne, 1995; Scheib &
Balck, 2002; Scheib & Wirsching, 2004; Shadish, Ragsdale, Glaser, & Montgomery, 1995;
Sprenkle, 2002); ST with disorders of children and adolescents (Carr, 2000; Diamond &
Siqueland, 2001; Diamond et al., 1996; Heekerens, 1991); family therapy/interventions for
specific disorders in all age groups (different disorders: Fonagy & Roth, 2004a,b); ST for
somatic illness (Campbell & Patterson, 1995; Eccleston, Palermo, Williams, Lewandowski,
& Morley, 2009; Ersser, Latter, Sibley, Satherley, & Welbourne, 2007; Glasscoe & Quitt-
ner, 2008; Huertas-Ceballos, Logan, Bennett, & Macarthur, 2008a, 2008b; King, De Silva,
Stein, & Patel, 2009; Kröger, Hendrischke, Schweitzer, & Herzog, 1998; Oude Luttekuis
et al., 2009; Ranmal, Prictor, & Scott, 2008; Scott et al., 2003; Waters et al., 2011; Yorke,
Fleming, & Shuldham, 2005; Yorke & Shuldham, 2005), and for specific disorders in
children and adolescents, including affective disorders (Cotrell, 2003; Henken, Huibers,
Churchill, Restifo, & Roelofs, 2007; Justo, Soares, & Calil, 2007; Lane, Millane, & Lip,
2003; Merry et al., 2011), anxiety disorders and obsessive-compulsive disorders (James,
Soler, & Weatherall, 2005; O’Kearney, Anstey, von Sanden, & Hunt, 2006), eating dis-
orders (Fisher, Hetrick, & Rushford, 2010; Hay, Bacaltchuk, Stefano, & Kashyap, 2009;
Hay, Claudino, & Kaio, 2001; Le Grange, Lock, & Dymek, 2003; Lock, 2011; Pratt &
Woolfenden, 2002), enuresis (Glazener & Evans, 2004; Glazener, Evans, & Peto, 2004),
and fecal incontinence (Brazzelli, Griffiths, Cody, & Tappin, 2011); sexually abused
children (Macdonald, Higgins, & Ramchandani, 2006), child and adolescent psychother-
apy in general (Döpfner, 2003; Döpfner & Lehmkuhl, 2002; Heekerens, 2002; Kazdin &
Weisz, 1998; Weisz, Huey, & Weersing, 1998), interventions for enhancing medication
adherence (Haynes, Ackloo, Sahota, McDonald, & Yao, 2008), alternatives to inpatient
mental health care for children and young people (Shepperd et al., 2009), psychoeducation
(Lucksted, McFarlane, Downing, Dixon, & Adams, 2012), and resource orientation as a
therapeutic technique (Grawe & Grawe-Gerber, 1999).
Selection of the Trials

Selection criteria with regard to the research methodology applied
All randomized (or parallelized/matched)2 controlled trials published in English,
German, Korean, Mandarin, or Spanish by December 2011 on the efficacy of systemic
therapies with DSM-IV or ICD-10 diagnosed child and adolescent index patients (or
clinically relevant conditions such as suicide attempts, conduct disorders, bullying, self-
harming behavior, child abuse and neglect) were analyzed. We excluded unpublished
dissertations and trials which presented treatment results on relational outcomes only.
Selection criteria with regard to the systemic interventions
The idiosyncratic use of terms and labels has been an obstacle for the evolution of
systems oriented therapies (Eisler, 2007). In most reviews and meta-analyses “systemic
therapy” is used as a name for a major psychotherapy school which can reliably be differ-
entiated from other major orientations (Grawe et al., 1994; Justo et al., 2007; Kazdin &
Weisz, 1998; Shadish et al., 1993). Like most reviews, we use “systemic therapy” synony-
mously with “systems oriented therapy” as a general term for a major therapy orientation
(as defined above). According to the criteria applied in other meta-analyses and reviews,
ST was operationalized as any individual, family, group, or multi-family group focused
therapeutic intervention either referring to one of the systems oriented authors (including
T. Anderson, Boszormeny-Nagy, de Shazer, Haley, Minuchin, Satir, Selvini-Palazzoli,
Stierlin, Watzlawick, White, Zuk) or specifying the intervention through at least one of the
following terms: systemic, structural, strategic, triadic, Milan, functional, solution
focused, narrative, resource/strength oriented, McMaster model (Asen, 2002; Cotrell &
Boston, 2002; Grawe et al., 1994; Justo et al., 2007; Kazdin & Weisz, 1998; Shadish et al.,
1993). Integrative systemic approaches were included, as long as they were described as
predominantly systemic, which means that they defined themselves as systems based. Tri-
als which relied on predominantly behavioral, cognitive-behavioral, psychodynamic, or
psychoeducative interventions without a systems orientation were excluded, even if they
were conducted in a family setting.
For example, if the treatment condition was described as being based primarily on
behavior therapy, learning and social learning theory, and mentioned techniques such as
2
As in only one of 38 trials the sample was matched instead of randomized (Table 1), we generally speak
of “randomized” studies.

TABLE 1
624 /
Primary studies (RCT) on the efficacy of systemic therapy for child and adolescent index patients (38 Trials)
Sample (N-IP) Interventions Study design
Treatment and
control groups
Authors Age Number Duration Type of Results at the
(Year) – IP Sex of (weeks/ disorders ITT- PT- end of intervention Follow-up
Country Treated pt (years) IP sessions years) researched analysis Manual integrity (posttest) results Evaluation
1. Mixed disorders – 4 RCT

1.1 Garrigan 14 12 14.4 36% 10 16 week 1. Systems n/i — — Problem behavior — +
and Bambrick 14 14 (11–17.7) — 16 week oriented FT n/a n/a (observational
(1977) – USA (28) (26) (G. Zuk) data in school):
2. Untreated CG 1<2
“Attending classes Return to
for emotionally normal
disturbed classes: 1 > 2
adolescents” Marital
communication:
1>2
1.2 Ro-Trock 14 14 16.5 36% 10 10 week 1. Systems — — — 3-months: 3-year (N = 24): +/
et al. (1977) – 14 14 (13–22) 10 10 week oriented FT — — reintegration: Inpatient after-
USA (28) (28) 18.4 (inpatient) relapses: 1 < 2 care necessary:
Wellisch et al. 2. Eclectic IT Family 1 > 2 (!)
(1980) (inpatient) communication: BUT: more
Schizophrenic 1>2 schizophrenia
reactions, in 1
adjustment &
substance disorder
1.3 Rowland 26 25 14 42% n/i 24 week 1. MST — x x Externalizing — +
et al. (2005) – 29 26 n/i 2. TAU: youth — — and internalizing
USA (55) (51) services symptoms:
1<2
Minor criminal
activity: 1 < 2
Out-of-home-
placements:
1<2
1.4 Chen and 169 169 0–3 n/i 33 3 year 1. Systemic FT — n/i n/i Behavior — +
Tang (2004) – 169 169 n/a 2. No treatment n/a n/a problems
China (338) (338) (TAU) (CBCL):
1<2
(continued)
EFFICACY OF ST WITH INTERNALIZING DISORDERS
Table 1 (continued)
Treatment and
control groups
2. Mood disorders & suicidality (ICD-10: F 30 – 39; DSM-IV: 296, 300.4) – 6 RCT
2.1 Brent 37 30 13–18 76% 12.1 12–16 week 1. CBT (IT: Beck) x x x Dropout: 2-year: +?
et al. 35 24 10.7 12–16 week 2. Systemic- x x 1=2=3 Depression
(1997) – 35 24 11.2 12–16 week behavioral FT x x Functional improved by 80%,
USA (107) (78) (12–16) (12–16 week) (SBFT) = FFT + impairment:

1=2=3
Brent et al. BSFT 1 = 2 = 3 all Family
(1998) 3. Nondirective improved functioning:
Brent et al. supportive therapy MDD present: 2>1
(1997) (NST IT) 1=2=3 Anxiety
Renaud et al. + all 3 groups: Remission: 1 > 2,3 symptoms:
(1998) psychoeducation Symptom reduction: 1, 3 < 2
Birmaher et al. DSM-III-R: major 1 = 2, but 1 more 53% received
RETZLAFF, VON SYDOW, BEHER, HAUN, & SCHWEITZER
(2000) depression, rapidly additional PT:

Kolko, Brent, outpatients Suicidality 1=2=3
Baugher, reduction: - acute phase:
Bridge, and 1=2= 3 1 (11%) = 2 (11%)
Birmaher Dropout acute = 3 (14%)
(2000) suicidal: - follow-up phase:
Brent, Birmaher, 1 (8%) = 2 (6%) = 1 (49%)
Kolko, Baugher, 3 (9%) = 2 (37%)
and Bridge Maternal = 3 (40%)
(2001) depression Recurrence
Stein et al. moderates predicted by
(2001) treatment depressive
Gaynor et al. success: symptom severity
(2003) - mother not & family
Barbe et al. depressed: difficulties at end
(2004) 1 > 2, 3 of treatment.
- mother
depressed
(BDI):
2>3> 1
(continued)
/ 625
Table 1 (continued)
626 /
Treatment and
control groups
2.2 Diamond 16 16 14.9 78% 8(3–12) 12 week 1. ABFT + 1 — x x MDD remitted: 1 6-month (1 & +
et al. (2002) – 16 16 (13–17) n/a 6 week telephone/week n/a n/a (81%) >2 (56%) treated out of CG
USA (32) (32) 2. CG (waiting Depressive in the meantime):
Diamond, list): symptoms: 1 < 2 87% remitted
Siqueland, and 1 telephone/week Trait anxiety: 1 < 2 MDD
Diamond MDD (K-SADS) & Family conflict: 1 < 2
(2003) delinquency (47%) Bond IP-M: 1 > 2
parent-BSI: Suicidality IP: 1 < 2
depression (42%),
anxiety (47%),
hostility (37%)
2.3 Trowell 35 35 11.7 38% 24.7 + 12 36 week 1. Psychodynamic x x n/i Depressive 6-month: +
et al. (2007) – 37 37 (9–15) 11 36 week Therapy + parent x n/i symptoms: 1 > 2 Depressive
Finland, UK, (72) (72) support group (dosage of treatment symptoms:
Greece 2. Systemic in 1 was up to 29 1>2
Garoff, Therapy larger than in 2) (dosage of
Heinonen, Symptom reduction treatment in 1
Pesonen, and in patients who was up to 29
Almqvist completed larger than in 2)
(2011) treatment: 1 = 2
Reduction of
comorbid disorders:
1=2
Family functioning
(FAD, BICS)
1=2
Suicidality – 3 RCT
2.4 Harrington 85 n/i 14.5 90% 3.2 + 4 n/i 1. Routine care + — x — Posttest-, 2-, 6- 6-month: +/
et al. (1998) - 77 n/i (10–16) 3.6 n/i FT (theoretical — — month follow-up: Outcome: 1 = 2
UK (162) (149) background - suicidal thoughts, Cost-effectiveness:
Harrington unclear) hopelessness: 1 = 2 1=2
et al. (2000) 2. Routine - compliance: 1 > 2 Suicidal ideation
Byford et al. treatment after - parental in subgroup
(1999) suicide attempt satisfaction: 1 > 2 without MDD:
1<2
(continued)
Table 1 (continued)
Treatment and
control groups
2.5 Henggeler 57 57 12.9 35% 92 h 16 week 1. MST + — x x Reduction of 4-month: +

et al. (1999) – 56 56 (10–17) 1–2 week medication (64- — — external symptoms: Cost-effectiveness:
USA (113) (113) 77%) 1>2 1 (MST: 1617 $)
Schoenwald, 2. Inpatient Family functioning more favorable
Ward, hospitalization (structure): than 2

Henggeler, and (CBT based milieu 1>2 12-month:
Rowland (2000) program) + School attendance: Cost-effectiveness:
Henggeler medication (69- 1>2 1=2
et al. (2003) 76%) Improving IP’s Suicide attempts:
Huey et al. Candidates for self-esteem: 1 < 2 1<2
(2004) psychiatric Consumer Generally larger
Sheidow et al. emergency care satisfaction: 1 > 2 effects in 1 & 2; 1
(2004) (suicidality, Hospitalized days: had more rapid

homicidal, 1 (44%, mean length effects than 2, but
psychoses) 3.8 days) <2 1 year later effects
96% ≥ 1 DSM-III- PT-costs: 1 (5954 $) = of 1 = 2 (approx.)
R diagnosis 2 (6174 $)
PT- & out-of-home-
placement-costs:
1 (8017 $) =
2 (7878 $)
2.6 Diamond 35 35 15.1 83 (9.7) 24 week 1. ABFT x x n/i Reduction of 6-month: +
et al. (2010) – 31 31 (12–17) (2.8) 24 week 2. Enhanced n/i n/i suicidal ideation: Suicidal ideation:
USA (66) (66) usual care 1>2 1<2
Retention in
treatment:1 > 2
3. Anxiety disorders (ICD-10: F 40 – F42; DSM-IV: 300, 293.89) – 1 RCT
3.1 Siqueland 6 6 14.9 27% 14 ( 16) 16 week 1. CBT — x (x) Anxiety disorder 6-month:
et al. (2005) – 5 5 (12–17) 15(13–16) 16 week 2. CBT + ABFT x (x) remitted: Anxiety disorder
USA (11) (11) (CBT-ABFT) 1 (67%) > 2 (40%) remitted:
DSM-IV 1 (100%) > 2 (80%)
generalized AD,
separation AD
(continued)
/ 627
Table 1 (continued)
628 /
Treatment and
control groups
3.2 Bao and 31 31 15,9 69% 10 20 week 1. SFT & — — — Reduction of — +

Yang (2011) – 31 31 (12–18) 20 week medication anxiety (SAS) 1 > 2
China (62) (62) 2. Medication Generic Quality of
Life 1 > 2
Quality of child
rearing (EMBU)
1>2
4. Eating disorders (ICD-10: F 50; DSM-IV: 307) – 12 RCT
Anorexia nervosa – 10 RCT
4.1 Hall and 15 15 19.6 100% 12 12–24 week 1. Combined n/a — — — 1-year: +
Crisp (1987) – 15 15 (13–27) 12 12–24 week psychodynamic — — Both groups
UK (30) (30) IT & FT improved
(Palazzoli, Weight: 1 = 2
Minuchin) Sexual & social
2. Dietary advice adjustment:
(+ partially family 1>2
counseling) Cured: 1 (4
Anorexia nervosa women) > 2 (0
women) – all
others needed
further
treatment
4.2 Russell 41 36 21.8 91% 10.5 48 week 1. Maudsley — (x) — Weight:1 > 2 (only in 5-year: +?
et al. (1987) – 39 37 (14–55) 15.9 48 week Approach FT — — anorexia) Outcome: only young
UK (80) (73) 2. Supportive IT 1 more effective than 1 > 2 in only AN
Eisler et al. Anorexia nervosa 2 in <19 years & not young, not
(1997) (N = 57) & chronic chronified
Dare, Eisler, bulimia (N = 23) Otherwise 2 more patients
Russell, and (DSM III-R) effective than 1 All anorectic
Szmukler Outpatient Only 28% of patients
(1990) treatment after anorectic patients improved. Less
inpatient therapy recovered positive in
bulimia.
(continued)
Table 1 (continued)
Treatment and
control groups
4.3 Le Grange n/i n/i 15.3 89% 8.6 24 week 1. Maudsley — (x) (x) Weight: both n/i (+)
et al. (1992) – n/i n/i (12–17) 9.3 23 week Approach (x) (x) improved 1 = 2
UK (18) (18) conjoint FT IP psychological
2. Maudsley symptoms:
separated FT: both improved 1 = 2

IP & parental Family interaction:
couple treated mostly 1 = 2, but
separately parental criticism
DSM-III-R 1 > 2 (!)
anorexia nervosa
4.4 Robin, 19 11 14 100% n/i 64 week 1. Behavioral — x x Post-treatment: 12-month: +
Siegel, 18 11 (11–20) n/i 4 week Family Systems x x 1 > 2 (weight, BMI, BMI: 1 > 2 (both
Koepke, Moye, (37) (22) Therapy (BFST) menstruation) improved)

and Tice 2. Ego-oriented IT 1 = 2 (attitudes, Clinically
(1994) – USA (EOIT) & parent depression, improved
Robin et al. sessions ego-function, (menstruation &
(1995) DSM-III-R family relations) target weight
Robin et al. anorexia nervosa achieved): 1 (82%)
(1999) 1/3 additional = 2 (50%)
inpatient weight
program
4.5 Eisler 20 18 15.5 98% 16.4 48 week 1. Maudsley — — — Both improved: 1 = 2 5-year: (+)
et al. (2000) – 20 18 (11–17) 15.5 48 week Approach — — 2 > 1 with high degree of 1=2
UK (40) (36) conjoint FT maternal criticism of IP No deaths, 75%
Eisler et al. 2. Separated FT: Symptom reduction: 2 > 1 free from eating
(2007) IP & parent Mood, psychosexual disorder
treated separately adjustment: 1 > 2 symptoms
DSM-IV or ICD-10
anorexia nervosa
Outpatient
treatment PT
after 10 weeks
inpatient
treatment
(continued)
/ 629
Table 1 (continued)
630 /
Treatment and
control groups
4.6 Geist n/i n/i 14.3 (12–17) 100% 8 16 week 1. FT — — — Both successful: n/i +
et al. n/i n/i 14.9 (12–17) 8 16 week (theoretical n/i n/i Weight: 1 = 2
(2000) – (25) (25) orientation not No psychological
Canada clear) changes with regard
2. Family group to eating pathology
psychoeducation in both groups
Restrictive eating Family
disorders (DSM- psychopathology/
IV) requiring conflict increased
hospitalization posttreatment in
Treated first as both groups!
in-, than as More than half of
outpatients patients were
readmitted to
inpatient treatment
during or after
therapy
4.7 Lock et al. 44 42 (15.2) 90% 10 24 week 1. Short-term x x x Weight and eating 4-year: +
(2005) – USA 42 35 20 48 week SFT x x disorder symptoms: 1 = 2; 89% above
Lock et al. (86) (77) 2. Long-term 1=2 90% of ideal body
(2006) (71) SFT IP with obsessive weight
symptoms and 74% with eating
nonintact families disorder
may profit more examination in
from longer SFT. normal range
4.8 Rausch 6 6 17.5 98% n/i 24 week 1. SFT n/i x n/i 1=2 n/i +
Herscovici 6 6 (12–20) n/i 24 week 2. SFT with x n/i
(2006) – (12) (12) family lunch
Argentina intervention
4.9 Rhodes 10 10 13.7 100% 20 6 week 1. Systemic — x x Weight restoration: — +
et al. (2008) – 10 10 (12–16) 20 & 2 6.3 week Therapy x x 1<2
UK (20) (20) 2. Systemic
Therapy with
parents as
consultants
(continued)
Table 1 (continued)
Treatment and
control groups
4.10 Lock 60 52 14.1 91% 21 (21 h) 48 week 1. SFT x x x Full remission: 1 = 2 6-month & +
et al. (2010) – 61 51 (12–18) 32 (24 h) 48 week 2. Adolescent- x (super- Partial remission 12-month:
USA (121) (103) Focused vision) (BMI): 1 > 2 Full remission:
Therapy x Scores at end-of- 1>2
treatment: 1 < 2 Partial remission
(BMI): 1 = 2
Scores at end-of-

treatment:
1=2
Bulimia nervosa – 2 RCT
4.11 Schmidt 44 44 13–20 98% 13 24 week 1. CBT-guided x x x Binge attacks: 1 < 2 12-month: +/
et al. (2007) – 41 41 13 24 week self-care x (x) Cost of treatment: Binge attacks:
UK (85) (85) 2. Systemic 1<2 1=2
therapy
4.12 Le 41 41 (16.1) n/i 20 24 week 1. SFT x x X Binge and purge 6 months +

Grange et al. 39 39 12–19 (“most were female”) 20 24 week 2. Individual CBT x x remission/ fully remitted
(2007) – USA (80) (80) IP had bulimia frequency: 1 > 2 patients: 39
(50%) or met at Fully remitted higher in 1 > 2
least half of the patients: 29 higher
required DSM in 1 > 2
symptoms, 38% Reduction of
had additional additional
symptoms symptoms: 1 > 2
No differences
between patients
with BN and with
5. Psychological factors affecting medical condition (ICD-10: F 54; DSM-IV: 316) – 12 RCT Asthma – 4 RCT
5.1 Lask and 21 18 4–14 n/i 6 16 week 1. FT (focus: — (x) — — 1-year: +
Matthew 16 11 5 16 week family system) — — Respiratory
(1979) – UK (37) (29) 2. Standard function: 1 > 2
medical treatment (partially)
(control group) No information on
Asthma (grade C psychological or
or D: McNichol & family data
William (1973); the
21 children came
from 16 families)
(continued)
/ 631
Table 1 (continued)
632 /
Treatment and
control groups
5.2 Gustafsson 9 12 9 n/i 8.8 (2–21) 24–32 week 1. FT (Minuchin) — — — General pediatric 1-year: +
et al. (1986) – 8 6 (6–15) n/a 24 week & medical n/i — assessment: 1 > 2 Success in group 1
Sweden (17 + 1 pilot case) (18) routine Daily functioning: maintained then
treatment 1>2 overcross-design
2. Medical routine
treatment
Asthma: after
24 months
overcross-design
5.3 Onnis 10 10 9 (2–15) 50% 10–15 20–28 week 1. Systemic n/a — (x) Number of asthma Success in +
et al. (2001) – 10 10 n/a n/i Structural FT & — — attacks: 1 < 2 intervention
Italy (20)* (20) medical routine Medication: 1 < 2 group maintained
treatment Family conflicts: over 2 years
2. Medical routine 1<2 stable (no stat.
treatment test)
Severe, chronic
asthma (min. 5
inpatient
admissions/year)
5.4 Ng et al. 23 20 9.2 35% 11 11w 1. SFT & asthma — n/i n/i Somatic condition: 11 weeks +
(2008) – 23 17 (7–12) n/i n/i education n/i n/i 1>2 improvements
Hong Kong/ (46) (37) 2. Asthma Psychological were maintained
China education adjustment: 1 > 2
Insulin dependent diabetes mellitus – 5 RCT

5.5 Ryden 9 9 12.8 67% 7 24 week 1. Structural/ — — (x) Diabetes control: — +
et al. (1994) – 6 2 14.0 67% 7 24 week strategic FT — — 1>2
Sweden 10 n/i 12.6 70% n/i n/i (Minuchin) & — — Behavioral
(25) n/i conventional symptoms: 1 < 2
treatment Dropout-Rate: 1 < 2
2. Pediatric
support: education
3. CG: medical
routine care
Diabetes mellitus
(continued)
Table 1 (continued)
Treatment and
control groups
5.6 Wysocki 38 35 14.5 61% 10 12 week 1.BFST + Medical — x (x) Baseline: big group — +/
40 39 (12–17) 62% 10 12 week treatment n/i n/a differences!

et al. (2000) –
USA 41 41 14.1 51% n/i 2. Educational n/a n/a (100 $ per family for
(119) (115) 14.3 support + medical completion of
treatment evaluation)
3. CG (medical (1 + 2: together 100 $
standard per participant for
treatment) attending 10
Insulin-dependent sessions)
diabetes mellitus Post-therapy:

Familial
relationships:
1 better 2, 3
Diabetic control: 1
better 2, 3 only in
boys & young girls;
older girls in 1 did
worse
5.7 Ellis et al. 64 64 13.2 51% 48 24 week 1. Home-based n/i x x Hospitalization rate: 24-month: +
(2005) – USA 63 63 (10–17) n/a 24 week MST and n/a n/a 1<2 Hospitalization
Ellis et al. (127) (127) medical care Improvement HbA1C: rate: 1 < 2
(2007b) 2. Medical care 1>2 HbA1C: 1 = 2
Ellis et al. Improvement BGT: BGT improvement
(2008) 1>2 maintained only
Ellis et al. in 2-parent
(2007c) families
(continued)
/ 633
634 /
Table 1 (continued)
Treatment and
control groups
5.8 Wysocki 36 36 (11–16) 45% 12 24 week 1. BFST for x x x Family conflicts: 6- and 18-month: +
et al. (2006) – 36 36 12 24 week diabetes x n/i reduced in 1, Adherence and
USA 32 32 n/i 24 week 2. Educational n/i n/i increased in 2 & 3 family conflicts:
Wysocki et al. (104) (104) support Diabetes 1>2
(2007) 3. Standard care management:
Wysocki et al. 1 > 2, 3
(2008) Improvement of
HbA1C: 1, 2 > 3
5.9 Cakan 64 64 (10–17) 51% n/i 24 week 1. MST x x n/i Frequency of BGT: 24-month +
et al. (2007) – 63 63 n/a n/i 2. Standard Care n/a n/a 1>2
USA (127) (127) HbA1C: decreased in
1 > in 2, but only in
normal weight
youths
Obesity – 2 RCT
5.10 Flodmark 25 23 (10–11) 52% 6 + 5.5 56–72 week 1. Structural/ x — (x) BMI-Increase: 1-year: +
et al. (1993) – 19 19 5.5 n/i strategic FT + — n/a 1 (0.66%) < 2 (2.31%) Mean BMI:
Sweden (44) (42) conventional Subscapular skinfold 1 (25.8) < 2 (27.1)
treatment (2.) thickness: BMI-Increase:
2. Conventional 1 (-16.8%) > 2 (+6.8%) 1 (+5.1%) < 3
treatment (+12.0%) – other
(dietary differences not
counseling + significant
medical Severe obesity
check-ups) (BMI > 30):
BMI = 25.1+/ 2.0 1<3
SD
(continued)
Table 1 (continued)
Treatment and
control groups
5.11 Ellis 24 20 14.5 77% 48-72 24 week 1. MST — x x Reduction of weight — +

et al. (2010) – 25 22 (12–17) 10 + 3 24 week 2. Group weight x x and body fat: 1 > 2

USA (49) (42) loss program
6. Pervasive developmental disorders (ICD-10: F 84; DSM-IV: 299) – 1 RCT Asperger-syndrome
6.1 Lu (2009) – 5 5 5.4 20% 20 10 1. SFT & — — — Autistic symptoms: 2-month: +
China 5 5 n/i n/i behavior n/i n/i 1<2 Parent interview:
(10) (10) training reported
2. Behavior maintenance of
training improvements
7. Other clinically relevant symptoms – 2 RCT

Physical abuse or neglect of children by parents – 2 RCT
7.1 Brunk 21 16 n/i 76% 8 8 week 1. MST — (x) — Both showed — +
et al. (1987) – 22 17 8 8 week 2. Behavioral (x) — improvement
USA (43) (33) parent training Parental symptoms,
(group T) stress & family-
stress:
1=2
Improvement of
family problems &
parent-child-
interaction
(assessment by
therapists &
behavioral rating):
1>2
Social problems:
1>2
(continued)
/ 635
Table 1 (continued)

636 /
Treatment and
control groups
7.2 Swenson 44 43 13.9 56% n/a 16–24 week 1. MST for child x (x) (x) Youth mental health — +
et al. (2010) – 42 40 (6–18) n/a n/a abuse and (x) (x) symptoms: 1 < 2
USA (86) (83) neglect Parent psychiatric
(MST-CAN) distress: 1 < 2
2. Enhanced Parenting behavior
outpatient associated with
treatment maltreatment: 1 < 2
Youth out-of-home-
placements: 1 < 2
Social support for
parents: 1 > 2
Re-abuse: 1 = 2
Note. x = yes; — = no; n/a =not applicable; n/i = no information given.

Sample (N-IP) = sample size/number of index patients: treated = n that was treated; * = parallelized sample; PT = n of which posttest data are presented.
Age = average age or age range of index patients.
Sex = sex/gender of index patients, rate of female index patients in%.
Number of sessions = number of therapy sessions.
Duration (weeks/years) = duration of intervention in weeks or years.
Systemic interventions are printed in bold letters.
ITT-analysis = intent-to-treat-analysis (X = yes, realized; (X) = not necessary because sample was fully retained (no drop out); F = no/not mentioned).
Manual = manual mentioned (X = yes; (X) = publication about intervention mentioned, not clear if it is a “real” manual; F = no/not mentioned).
PT-integrity: Was the manual fidelity/adherence to the planned interventions systematically evaluated (X = yes, systematic evaluation; (X) = yes, only
through supervision; F = no evaluation mentioned).
Evaluation (of the trials and its results): 1 < 2 treatment 2 had significantly stronger effects than treatment 1; 1 > 2 treatment 1 had significantly stronger
effects than treatment 2; 1 = 2 there was no significant difference between the effects of treatment 1 and treatment 2.
=: no significant difference between the effect of the two interventions.
+: trial with positive results for the efficacy of systemic therapy (ST) (ST more efficacious than alternative interventions or control groups without interventions).
+?: trial with predominantly positive results for the efficacy of ST.
+/ : trial with mixed (positive and negative results) for the efficacy of ST.
: trial with negative results for the efficacy of ST (ST less efficacious than alternative interventions of control group).
ABFT = Attachment-based Family Therapy; AD = anxiety disorder; BDI = Beck Depression Inventory; BFST = Behavioral Family Systems Therapy; BSFT
= Brief Strategic Family Therapy; BSI = Brief Symptom Inventory; CBT = cognitive behavioral therapy; CG = control group; FFT = Functional Family Ther-
apy; FT = family therapy; IT = individual therapy; K-SADS = Kiddie-Schedule for Affective Disorders and Schizophrenia; MDD = major depressive disorder;
MST = Multisystemic Therapy; PT = psychotherapy; SFT = systemic family therapy; TAU = treatment as usual.
TABLE 2
Summary
Type of disorder Number RCT ST successful
Mixed disorders 4 3
Mood disorders and suicidality 6 5
Anxiety disorders 2 1
Eating disorders 12 11
Psychosocial factors in somatic illness 11 10
Pervasive developmental disorders 1 1
Others relevant: child neglect 2 2
SUM 38 33
Note. Number RCT: Number of controlled, randomized (or parallelized) primary studies. ST successful:
Number of RCT in which systemic therapy was more efficacious than other established interventions (e.g.
psychodynamic IT, CBT IT, nondirective IT, family psychoeducation, group therapy, antidepressant medi-
cation) or significantly more efficacious than control groups without treatment, or more efficacious than
routine treatment (including antipsychotic medication). Successful studies are marked in with “+” or “+?”.
Boldface type: disorders with good empiric evidence (3+ trials in which ST was successful).
operant techniques, training of social skills, communication and problem-solving skills,

cognitive training, exposure techniques, modeling, systematic desensitization, and self
instruction training control techniques without referring to a systems orientation, the
trial was not included. Psychoeducation is a very general intervention used across differ-
ent schools of psychotherapy and was therefore not included as specifically systemic.
While we believe that the combination of ST with psychoeducative or behavioral elements
often constitutes good clinical practice, in this review we were interested in evidence for
the efficacy of “pure” ST not combined with other approaches.
Trials identified in our searches were always classified by two members of our research
group. If there was a disagreement or an uncertainty, we checked additional descriptions
of the intervention, to find out what it relies on (e.g., family psychoeducation, a base in
learning theory, etc.). If we were still in doubt, we e-mailed the corresponding author of
the trial and asked for further information. Trials were only included if all raters agreed
that they qualified for inclusion. Evaluation of treatment effects was also performed by
two members of the research group.
The Final Sample of the Analyzed RCT Studies

We identified a total of 38 RCTs on ST with child and adolescent patients, suffering
from internalizing and other (non-externalizing) disorders. In this article we present a
systematic review of these studies. The analysis of the remaining trials on externalizing
disorders will be presented in another article (Sydow et al., in press).
RESULTS
First, results of general meta-analyses across diagnostic groups are presented, then,
results of meta-analyses and primary studies for specific disorders follow. Table 1 provides
a methodological overview and results for each single trial we analyzed. Trials are pre-
sented by diagnostic groups as well as by date of publication. Table 2 provides a summary
of the efficacy data of ST for the various diagnostic groups.
General Meta-analyses
Many of the existing meta-analyses on the general effectiveness of child and adolescent
psychotherapy do not allow any inferences about the effectiveness of ST: Only the most

comprehensive and methodologically rigorous meta-analysis by Shadish et al. (1993;

n = 163 controlled trials) on the general efficacy of couple (n = 62) and family therapy
(n = 101) was considered relevant. A direct comparison of different therapy orientations
showed no significant differences in the efficacy of behavior therapy and ST. When all
potential confounding methodological aspects were taken into account all school differ-
ences disappeared in the regression analyses (Shadish et al., 1993, 1995).
Studies on Mixed Disorders

Two older RCTs examined the effectiveness of ST in the treatment of samples with
mixed diagnoses. Systemic treatment of schoolchildren from classes for “emotionally
disturbed adolescents” with their parents had a positive effect, compared with an
untreated control group. After the systemic treatment, the problem behavior of the index
patients decreased more strongly, more schoolchildren could return to normal classes, and
parents’ marital communication improved significantly (Garrigan & Bambrick, 1977).
In another, older study on a sample of adolescents with mixed disorders (including
adjustment disorders, substance abuse disorders, and schizophrenia spectrum disorders)
who received inpatient treatment, systemic family therapy had superior treatment effects
at end of treatment than eclectic individual therapy. But at 3-year follow-up, more
patients of the systemic family therapy condition needed additional outpatient treatment
(Ro-Trock, Wellisch, & Schoolar, 1977; Wellisch, Ro-Trock, & Kelton, 1980). This result is
somewhat skewed as the systemic family therapy condition included more patients with
schizophrenic disorders than the individual therapy condition.
Rowland et al. (2005) compared the effectiveness of MST with routine treatment in a
sample of adolescents with behavioral and/or emotional disorders (according to DSM-IV).
Six months after termination of treatment, patients in the experimental group showed a
significantly larger reduction of externalizing and internalizing symptoms and a signifi-
cant reduction of criminal behavior. Patients undergoing MST had significantly fewer
placements in residential settings, incarcerations, and in-patient treatments.
A Chinese study (Chen & Tang, 2004) investigating the effects of systemic family ther-
apy with infants, who received either systemic family therapy with their parents or
routine care in the first 3 years of life, showed positive effects of systemic family therapy.
Efficacy for Specific Disorders

Mood disorders and suicidality
Brent et al. (1997) demonstrated that CBT was more effective than Systemic Behav-
ioral Family Therapy (SBFT) or supportive individual therapy at end of treatment — but
contrary to the hypotheses of the researchers, at the 2-year follow-up there were no differ-
ences in the effectiveness of the different forms of treatment. The most important predic-
tor of persistent depression and necessity of continued treatment was a high initial level
of depressive symptoms and high self-reported parent-child conflict (Birmaher et al.,
2000; Brent, Kolko, Birmaher, Baugher, & Bridge, 1999).
Attachment Based Family Therapy (ABFT) resulted in a clinically significant improve-
ment rate of 82% in the intervention group, compared to a 56% rate in the waiting list con-
trol group. Effects were stable at 6-month follow-up (Diamond, Reis, Diamond, Siqueland,
& Isaacs, 2002).
A multi-center study compared the effectiveness of ST and individual psychodynamic
psychotherapy for children with major depression or dysthymia (Trowell et al., 2007).
Unfortunately, there was a marked difference in the therapy doses applied (max. 14
systemic sessions vs. 30 individual sessions plus a parent support group). Both interventions,
carried out over a period of 9 months, were effective. Treatment effects both at
termination of therapy and at the 6-month follow-up were significantly larger in the
psychodynamic condition than in the systemic treatment condition, which also had a
higher drop-out rate. When only therapy completers were compared, both conditions were
equally effective, even though patients in the psychodynamic condition had received
nearly twice as many therapy sessions. There was a comparable reduction of comorbid
disorders in both groups. Both groups continued to improve after termination of therapy,
and there were no relapses within 6 months after end of treatment. The systemic treat-
ment condition was more effective in younger children and in patients without a diagnosis
of both major depression and dysthymia (Garoff, Heinonen, Pesonen, & Almqvist, 2011).
Depression is a frequent correlate of suicide, attempted suicide, and suicidal ideation.
Adolescents with depression and acute or lifetime suicidality have a poorer treatment
prognosis and more frequently drop out of treatment than nonsuicidal patients with
depression. In a study by Barbe, Bridge, Birmaher, Kolko, and Brent (2004), suicidality
was not a moderating factor for treatment response to CBT or SBFT. But nondirective
supportive individual therapy did not result in a significant improvement in lifetime suici-
dality. A 3–4 session intervention did not differ significantly in the reduction of suicidality
in youths that had attempted suicide, compared with routine treatment (Harrington et al.,
1998, 2000). However, intensive MST (92 sessions) in suicidal youths was more rapidly
effective than inpatient treatment and was equally effective at 1-year follow-up. In youths
in psychiatric crises with externalizing behaviors, it reduced the number of subsequent
suicide attempts (Huey et al., 2004).
Diamond et al. (2010) conducted a randomized study with depressed adolescents having
suicidal thoughts. The treatment condition consisted of ABFT or an intense form of rou-
tine care (referral to a treatment center, weekly phone contacts, and a 24/7 crisis hotline).
Significantly, more patients in the ABFT condition met criteria for clinical recovery for
suicidal ideation at end of treatment and at follow-up. Patterns of depressive symptoms
were similar, as were results for the subsample of patients with diagnosed depression.
After ABFT, suicidal ideations were significantly reduced and depressive symptoms were
reduced more rapidly. Retention in ABFT was higher than in routine treatment.
Anxiety disorders
Anxiety disorders of children and adolescents are routinely treated by systemic thera-
pists, and numerous techniques have been developed (Madanes, 1981; Nardone, 1977;
White & Epston, 1990). Surprisingly, the efficacy of ST has been evaluated only twice,
once as a supplement to CBT: Both CBT and CBT combined with ABFT were successful.
However, “pure” CBT was somewhat more effective than the combined treatment
(primary anxiety disorder remitted at the 6-month follow-up: CBT: 100%, CBT-ABFT:
80%). However, index patients’ and parents’ satisfaction was the highest in the family
therapy condition, and the retention rate was somewhat higher in CBT-ABFT than in
CBT (Table 1; Siqueland, Rynn, & Diamond, 2005). In the treatment of adolescents with
anxiety disorders, the combination of systemic family therapy with medication resulted in
a larger reduction of symptoms and a larger improvement of quality of life and child rear-
ing than medication alone (Bao & Yang, 2011). However, no follow-up data were provided
in this study (Bao & Yang, 2011).
Eating disorders
Krautter and Lock (2004) identified nine RCTs on anorexia, with seven on ST and only
two on CBT. Systemic therapy with structural techniques had higher treatment effects
than CBT, psychodynamic therapy, or cognitive-analytical therapy. Especially for young
patients (under age 18) with duration of anorectic symptoms of less than 3 years, ST was

superior to individual therapy. About 65% of adolescent patients with anorexia can be
cured by ST (Lock, Le Grange, Agras, & Dare, 2001). In a Cochrane Review of family based
approaches for the treatment of anorexia nervosa, 12 of 13 trials evaluated systems
oriented approaches (Fisher et al., 2010). The authors found some evidence suggesting
that family therapy might be more effective than treatment as usual (TAU) for symptom
remission in the short term. But they called for caution in generalizing any conclusions of
the value of family therapy in the treatment of Anorexia nervosa because of the small
number of trials and small sample sizes. In their view, the evidence of treatment effective-
ness remains inconclusive.
The first uncontrolled study on ST for Anorexia nervosa was conducted by Minuchin
(1974), and most subsequent trials largely rely on concepts of structural family therapy.
Russell, Szmukler, Dare, & Eisler (1987) showed that systemic family therapy is particu-
larly effective for patients whose anorectic (and bulimic) symptoms started at age 19 or
younger. Robin, Siegel, & Moye (1995) and Robin et al. (1999) demonstrated the success of
a similar systemic intervention. Hall & Crisp (1987) compared the effect of individual
psychodynamic therapy with family therapy, which included some individual sessions.
The description of the systemic condition is very succinct; the treatment was described as
a form of systemic family therapy including work on family and individual commitment to
weight gain. Both conditions led to weight improvement, though psychosocial adjustment
was better in the systemic condition. Similarly, in a study by Geist, Heinmaa, Stephens,
Davis, & Katzmann (2000), both treatments led to weight gain (though the systemic treat-
ment was not well described), but readmission rate in both treatment groups was high. A
brief format of ST with ten sessions in 6 months can be as effective as a longer format with
20 sessions in 12 months (Lock, Agras, Bryson, & Kraemer, 2005; Lock, Coutrier, & Agras,
2006), but index patients with nonintact families and obsessive symptoms may profit more
from the longer form of therapy.
While it is important to involve the family of anorectic index patients, it is not manda-
tory to do so in a conjoint setting — parallel treatment of index patients and family
members can also be effective (Le Grange, Eisler, Dare, & Russell, 1992). In a study with a
5-year follow-up (Eisler, Simic, Russell, & Dare, 2007; Eisler et al., 2000), there were few
differences between conjoint and separated family therapy conditions. However, patients
from families with high maternal criticism profited less from conjoint family treatment.
In a small Argentinian study of ST with and without the family lunch intervention
(Rausch Herscovici, 2006), both conditions led to a significant improvement of somatic
indices, depressive symptoms, general psychological symptoms, and eating behavior. The
family lunch intervention did not result in a general additional weight gain. The results
indicate a specific beneficial effect of the family lunch intervention in therapy resistant
patients with distinct psychopathology. Systemic therapy supplemented by parents of
previous patients as consultants is significantly more efficacious than ST alone (Rhodes,
Bailee, Brown, & Madden, 2008).
In a study of systemic family-based therapy and adolescent-focused therapy (AFT), both
were equally successful in achieving full remission at end of treatment. However, at the
6- and 12-month follow-up, the systemic condition showed superior weight restoration
(Lock et al., 2010). Partial remission at end of treatment was more frequent in the
systemic condition, but these differences did not persist at follow-up.
Fewer trials exist on the efficacy of ST for Bulimia nervosa. A Spanish study demon-
strated that ST in a sample of both adult and adolescent patients was more effective than
the combination of group therapy for index patients and support groups for parents (Esp-
ina Eizaguirre, Ortego Saenz de Cabezon, & Ochoa de Alda Martinez de Appellaniz, 2000,
2002; see Sydow et al., 2010). Schmidt et al. (2007) compared the effectiveness and
cost-effectiveness of a brief, manualized systemic treatment condition with a manualized
form of CBT. At the end of treatment, CBT patients had significantly fewer binge attacks
compared with systemic patients. Frequency of vomiting, other symptoms, and general
well-being did not differ significantly. At 12-month follow-up, there was no significant
difference in binge attacks between the two conditions.
Le Grange, Crosby, Rathouz, & Leventhal (2007) compared the effectiveness of a form
of systemic family therapy with supportive manualized individual CBT for bulimic
patients. Criteria for affective disorders were met by 38% of patients. At end of treatment,
the number of binge-and-purge abstinent patients was more than twice as high in the sys-
temic condition as in the supportive CBT condition, and at follow-up the number of binge-
and-purge abstinent patients was three times higher in the systemic condition.
Psychosocial factors related to medical conditions and physical illness

A Cochrane Review on the efficacy of family based interventions in childhood asthma
(Panton & Barley, 2004) identified only two randomized studies. Both compared ST with
routine medical treatment to routine treatment alone. The results cannot be summarized
statistically because of methodological differences. One study shows that the addition of a
systemic intervention led to a significant improvement in patients’ gas volume, peak
exploratory flow rate, and daytime wheeze (Lask & Matthew, 1979). The other study
showed that the systemic condition was followed by advantages in general clinical assess-
ment (assessed by blind raters) and in reduced number of days with functional impair-
ment (Gustafsson, Kjellman, & Cederblad, 1986). In another study by Onnis et al. (2001),
the systemic treatment group showed advantages in clinical measures and in family func-
tioning when compared with routine treatment. Ng et al. (2008) investigated the effect of
adding systemic family therapy to psychoeducational asthma training. In the group with
an additional systemic treatment component, symptom related measures, individual man-
agement of the illness, and parent ratings were significantly better.
In adolescence, adjustment to insulin-dependent diabetes mellitus can become a prob-
lem both for youths afflicted with the illness and for their parents. Because family conflicts
are associated with insufficient treatment regime compliance and reduced diabetic con-
trol, family interventions are a key factor for the improvement of diabetic adolescents’
health situation (Wysocki et al., 2000). Behavioral Family Systems Therapy (BFST)
improved the relationship between adolescents and their parents and decreased diabetes-
related conflicts, both at treatment end and at 6- and 12-month follow-up (Wysocki, Greco,
Harris, Bubb, & White, 2001). In addition, there was delayed improvement on treatment
adherence with no effects on adjustment to diabetes or diabetic control.
A US trial evaluated the influence of home-based MST on treatment adherence, meta-
bolic control, and hospitalization rate of adolescents with instable diabetes type 1 and
diabetic ketoacidosis. Hospitalization rate for diabetic ketoacidosis (DKA) in the MST-
condition was significantly lowered, both at treatment termination and at follow-up.
Improvement in glycosylated hemoglobin HbA1c was lost at follow-up and increases in
blood glucose testing (BGT) were moderated by family composition: only two parent
families maintained improvements at follow-up (Ellis, Naar-King, Templin, Frey, &
Cunningham, 2007a; Ellis et al., 2005, 2007b, 2008).
Similarly, in a study with families of adolescents with instable diabetes type 1 (Wysocki
et al., 2006, 2007) a positive effect was found for an adapted form of Behavioral Family
Systems Therapy for Diabetics (BFST-D) when compared with standard care or multifam-
ily educational support. In the BFST-D group, HbA1c was significantly improved at treat-
ment end and at 6- and 18-month-follow-up. A significantly larger number of patients
undergoing BFST-D condition showed a moderate or high improvement of treatment
adherence and a reduction of family conflicts.

Cakan, Ellis, Templin, Frey, and Naar-King (2007) investigated the development of
weight status during the treatment of youths with type 1 diabetes and poor metabolic
control, with treatment conditions being MST versus standard medical care. Intention-to-
treat analysis showed a significant increase of blood glucose testing and a trend to signifi-
cant improvement of adolescents’ HbA1c in the MST condition, but only in normal weight
youths. This implies that young diabetic patients with severe overweight profit less and
need a focus on weight loss before a focus on diabetic related behaviors.
In adolescents with obesity, ST was more effective than routine pediatric and dietetic
treatment, compared to an untreated control group. It resulted in a reduced — but still
elevated — body mass index (Flodmark, Ohlsson, Ryden, & Sveger, 1993). In a trial com-
paring MST with a group weight loss intervention, MST increased family support for
behavior changes of index patients, which were directly related to weight status on body
fat (Ellis et al., 2010; Naar-King et al., 2009).
Pervasive developmental disorders

In China, children with Asperger disorder were randomly assigned to either a standard
treatment behavioral program (TEACH) or TEACH plus systemic family therapy. At the
end of treatment, scores on the Autism Behavior Check List had improved significantly
more in the family therapy group than in the control group (Lu, 2009).
Other clinically relevant symptoms

We identified two studies on abuse and neglect by parents, which are clinically relevant
problems though not a DSM- or ICD-diagnosis. Behavioral parent training and MST both
showed similar improvement of parental symptoms. Multisystemic therapy improved
parent–child interaction (rated by external observers) more than behavioral parent train-
ing, while behavior therapy resulted in a larger reduction of families’ social problems
(Brunk, Henggeler, & Whelan, 1987). In a second trial, MST for child abuse and neglect
(MST-CAN) was more efficacious at end-of-treatment than enhanced outpatient treatment
with regard to youth mental health symptoms, parent psychiatric distress, parental
behaviors associated with maltreatment and out-of-home placements of youths. The rate
of abuse was similar in both conditions, but instances were rare to begin with (Swenson,
Schaeffer, Henggeler, Faldowski, & Mayhew, 2010).
No studies were found on the systemic treatment of personality disorders, psychosis, or
intellectual disabilities in children and adolescents.
DISCUSSION
How Efficacious is Systemic Therapy with Internalizing Disorders?
In 33 of the studies found, ST was either significantly more efficacious than control
groups without a systems oriented intervention, or ST was more efficacious than other
evidence-based interventions (individual CBT, psychodynamic therapy, behavioral family
therapy/parent-training, family psychoeducation, group therapy, or inpatient treatment).
Systemic therapy with child and adolescent patients is particularly efficacious — defined
by more than three independent RCTs with positive outcomes — in the treatment of affec-
tive disorders and suicidality, eating disorders, and psychosocial factors related to medical
conditions.
Research on the efficacy of ST for children and adolescents has focused on certain
diagnostic groups, while other important disorders like anxiety and adjustment dis-
orders have been neglected (Retzlaff, Beher, Rotthaus, Schweitzer, & Sydow, 2009).
Methodological recommendations have been presented in an earlier publication (Sydow
et al., 2010).
According to the guidelines for classifying evidence-based treatments in couple and
family therapy proposed by Sexton et al. (2011), 19 of the trials are on Level I (evidence-
informed treatments clearly based on psychological research), as they do not provide
a clear description of the treatment; 17 trials can be classified as Level II treatments
(promising preliminary results), and only three studies (4.7; 4.10; 2.5) can be classified as
“evidence-based treatments” (Level III), as (a) all three specify the content of the
treatment model and use treatment manuals; (b) all apply measures of treatment fidelity;
(c) all clearly identify client problems; (d) describe service delivery contexts; and (e) use
valid measures of clinical outcome. With regard to the levels-of-evidence proposed by
Sexton et al. (2011) only a few trials on mixed disorders evaluated the absolute evidence
(Category 1: treatment compared to no treatment, s. Tab. 1: trial 1.1, 1.4). Most trials are
relative efficacy studies comparing systemic interventions either to treatment as usual
(TAU), or to various — specified or unspecified — individual, group, or other family thera-
pies, sometimes to evidence-based, manualized interventions (e.g., individual or group
CBT). Category 2, “Efficacious models with verified mechanisms,” is not fulfilled by any of
the trials reviewed here. With regard to category 3, “Effective models with contextual
efficacy,” only the trials on MST demonstrate clinical effectiveness with different specific
problems (emotional problems, diabetes, and obesity) in different service contexts, but
there are only a few trials on any of these conditions and at this time there have been no
replications of trials within the diagnostic groups. The Maudsley approach to eating dis-
orders has been applied in various sites and with two conditions (anorexia and bulimia),
and also with adult patients (Sydow et al., 2010).
In contrast to other reviewers (Carr, 2000, 2009; Kaslow et al., 2012; Sprenkle, 2002),
we focused on trials which investigated systems-oriented treatments rather than family
therapy as a setting, and therefore we include a smaller base of trials. The separation into
an article on trials on externalizing and one on internalizing disorders does not imply that
entirely different systemic approaches are needed. Making a conceptual distinction
between trials with a systemic orientation from trials working with behavioral, cognitive,
psychodynamic, and other approaches in a family setting complies with the way in which
regulations of health care provision are organized in some European countries and long
standing traditions in the psychotherapy field. With today’s tendency towards psychother-
apy integration, one might question the utility of this approach. Yet, currently, psycho-
therapy regulations in several European countries are still based on the concept of
psychotherapy schools. This makes it mandatory to compile evidence on the effectiveness
of ST. Otherwise, treatments that have been proven to be highly effective could not be leg-
ally provided to youths and their families in need. A possible advantage for this approach
could be that the specific merits of a systems perspective in contrast to other approaches
might show more clearly.
Within the German health system, only ST and CBT have been acknowledged as
scientifically validated treatments for children and adolescents (Wissenschaftlicher
Beirat Psychotherapie, 2009). Systemic therapy is particularly effective in the treat-
ment of eating disorders (Lock, 2011), psychological factors effecting somatic illness and
affective disorders, conduct disorders and substance use disorders (see Sydow et al.,
submitted).
Readers should be aware of some limitations of this review. Although considerable
effort was made to involve trials in a number of languages, RCT searches in other lan-
guages, such as Japanese, might yield additional studies. By including trials across a wide
time span (from the 1970s till today), trials with different qualities of methodology are
presented in our review, and one should be aware that generally some of the older studies

may not meet more modern research standards. We tried to minimize publication bias in
our review by asking experts, with the help of the American Academy of Family Therapy
(AFTA) and the European Federation of Family Therapy (EFTA), about any relevant
publications, but we cannot rule out the possibility that unpublished studies were not
identified.
While we regard the inclusion of RCTs from a large number of countries as a strength,
this might also be considered as a weakness. Delivery of health care interventions
and treatment as usual differs considerably from country to country, and it might make a
considerable clinical difference if therapy was conducted with only one ethnic group or a
variety of patients from various ethnic groups. Therapy approaches need to take into
account issues of gender, developmental age, culture, and ethnicity, as well as the larger
socio-cultural and health care system of the country in which an RCT is carried out. Treat-
ment programs must be adapted to the specific needs of different cultural groups (Robbins,
Horigian, & Szapocznik, 2008). Due to limits of space, we were not able to provide data on
the above mentioned categories, and information was not always provided in the descrip-
tion of the trials. In recent years, multi-centered studies in different countries have been
carried out. In our reviews, we found evidence that systemic approaches work across many
nations, that is, the Maudsley approach has been successfully applied in the UK and the
USA. In the trial of Trowell et al. (2007), the systemic intervention was successful in
diverse countries (Finland, Great Britain, and Greece). Systemic therapy, as a treatment
orientation, has been successfully employed in a wide range of countries with internaliz-
ing disorder in the USA, Canada, Argentina, China and Hong Kong, Finland, Greece,
Italy, Sweden, and the UK; with externalizing disorders in the USA, Germany, the Neth-
erlands, Norway, Sweden, the UK; and China (Sydow et al., in press); with adult patients
in the USA, Belgium, Finland, Germany, Italy, the Netherlands, Spain, UK, Turkey, and
China (Sydow et al., 2010). One might demand that a manualized treatment should be
tested for different ethnic groups and levels of society. This might work if there is a small
number of fairly large ethnic groups in a country, but this demand might be hard to fulfill
if a country has a large number of ethnic groups with a small number of members. Broad
categories such as Black, Asian, Caucasian might blur differences within these groups,
because of religion, different family histories, socio-economic, migration, or regional differ-
ences. Before the rise of manualized treatments, psychotherapy and ST were supposed to
be tailored to the individual needs of each family; therapists were requested to adapt their
approach to the specific culture of the family, including their social status and ethnicity
(Fraenkel, 1995) — to be meaningful, psychotherapies might need both sound evidence
from standardized treatments as well as an ideographic approach which takes into
account the individuality of families. Future research and analyses should allow for a
more fine-grained analysis of the role of ethnicity, race, socioeconomic group, and nation-
ality and its possible relation to outcome.
Excluding combinations of approaches (e.g., of ST with family psychoeducation) might
present a somewhat skewed picture, giving the impression that effective treatments for
conditions such as bipolar disorders, obsessive-compulsive disorders, or anxiety disorders
are wanting. However, we focused on trials with systemic treatments, and much more
research is needed for the combination of systems-oriented treatment with other forms of
interventions such as psychoeducation.
Results of this systematic review show that ST in its different settings (family,
group, multi-family group, individual therapy) is an efficacious approach for the
treatment of children and adolescents suffering from internalizing psychological disor-
ders, such as mood and eating disorders and psychological factors affecting physical
illness.
Based on prior reviews by our research team (Sydow, Beher, Retzlaff, & Schweitzer,
2007b; Sydow et al., 2006, 2007a), ST has been granted the status of an evidence-based
treatment approach for children and adolescents as well as for adults by the federal
German Scientific Approval Board for Psychotherapy (Wissenschaftlicher Beirat Psycho-
therapie, 2009). In the light of current evidence, ST is qualified as one of the major
evidence-based treatments. Considerable further research is needed on the treatment of
diagnostic groups such as anxiety disorders, somatoform disorders, and the processes that
lead to substantive change.
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Family Process - 2013 - Retzlaff - The Efficacy of Systemic Therapy For Internalizing and Other Disorders of Childhood and

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The Efficacy of Systemic Therapy for Internalizing

and Other Disorders of Childhood and Adolescence:

Keywords: Internalizing disorders; systemic therapy; family therapy; randomized

Fam Proc 52:619–652, 2013

Fam. Proc., Vol. 52, December, 2013

METHOD OF THE SYSTEMATIC REVIEW

Selection of the Trials

Fam. Proc., Vol. 52, December, 2013

Sample (N-IP) Interventions Study design

1. Mixed disorders – 4 RCT

Sample (N-IP) Interventions Study design

Fam. Proc., Vol. 52, December, 2013

(2000) depression, rapidly additional PT:

Sample (N-IP) Interventions Study design

Sample (N-IP) Interventions Study design

2.5 Henggeler 57 57 12.9 35% 92 h 16 week 1. MST + — x x Reduction of 4-month: +

Fam. Proc., Vol. 52, December, 2013

(2004) (suicidality, Hospitalized days: had more rapid

Sample (N-IP) Interventions Study design

3.2 Bao and 31 31 15,9 69% 10 20 week 1. SFT & — — — Reduction of — +

Sample (N-IP) Interventions Study design

Fam. Proc., Vol. 52, December, 2013

Koepke, Moye, (37) (22) Therapy (BFST) menstruation) improved)

Sample (N-IP) Interventions Study design

Sample (N-IP) Interventions Study design

Fam. Proc., Vol. 52, December, 2013

4.12 Le 41 41 (16.1) n/i 20 24 week 1. SFT x x X Binge and purge 6 months +

Sample (N-IP) Interventions Study design

Insulin dependent diabetes mellitus – 5 RCT

Sample (N-IP) Interventions Study design

Fam. Proc., Vol. 52, December, 2013

diabetes mellitus Post-therapy:

Sample (N-IP) Interventions Study design

Sample (N-IP) Interventions Study design

5.11 Ellis 24 20 14.5 77% 48-72 24 week 1. MST — x x Reduction of weight — +

Fam. Proc., Vol. 52, December, 2013

7. Other clinically relevant symptoms – 2 RCT

Sample (N-IP) Interventions Study design

Note. x = yes; — = no; n/a =not applicable; n/i = no information given.

Type of disorder Number RCT ST successful

operant techniques, training of social skills, communication and problem-solving skills,

The Final Sample of the Analyzed RCT Studies

Fam. Proc., Vol. 52, December, 2013

comprehensive and methodologically rigorous meta-analysis by Shadish et al. (1993;

Studies on Mixed Disorders

Efficacy for Specific Disorders

Fam. Proc., Vol. 52, December, 2013

Psychosocial factors related to medical conditions and physical illness

Fam. Proc., Vol. 52, December, 2013

Pervasive developmental disorders

Other clinically relevant symptoms

Fam. Proc., Vol. 52, December, 2013

Fam. Proc., Vol. 52, December, 2013

Fam. Proc., Vol. 52, December, 2013

Fam. Proc., Vol. 52, December, 2013

Fam. Proc., Vol. 52, December, 2013

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