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Clinical Child and Family Psychology Review, Vol. 5, No. 3, September 2002 (°
C 2002)

An Ecological Approach to Child and Family Clinical

and Counseling Psychology

Elizabeth A. Stormshak1,2 and Thomas J. Dishion1

The ecological model of child and family clinical and counseling psychology considers mental
health service delivery within a health maintenance framework, approaching the complexity
of children’s behavior in a systematic and organized fashion using science-based intervention
practices. The service delivery framework integrates assessment, intervention, and motivation
at all phases of an intervention. Assessments enhance the participants’ and professionals’ ap-
praisal, which in turn impact motivation to change. Interventions are sensitive to assessment-
based targets and participant motivation. A menu of interventions range from assessment,
feedback, and brief interventions to more extensive mental health services, potentially in-
tegrated with other community agencies and school settings. The ecological model suggests
revisions in the conceptualization of child and adolescent psychopathology, training for mental
health professionals, and strategies for the design and testing of interventions. In general, a re-
formulation of mental heath services for children and families within an ecological framework
enhances the potential for integrating science and practice.
KEY WORDS: family therapy; child therapy; ecological model; child and family interventions; conduct
problems.

DEVELOPMENT AND INTERVENTION different developmental problems and interventions.

SCIENCE
When considering the need for science-based
practices, developmental science is often neglected as
a relevant body of knowledge. Within developmental
science, there has been a quiet revolution in think-
ing about the importance of ecology in affecting the
direction and course of child development. The idea
is relatively simple: Children’s social adaptation can
be understood as embedded within multiple relation-
ships and contexts, including home, school, peers, fam-
ily, and communities (Bronfenbrenner, 1979, 1989).
This social ecology theory of development was
initially proposed by Bronfenbrenner (1979), but has
been adapted and revised as it has been applied to
1 Child and Family Center, University of Oregon, Eugene, Oregon.
2 Address
all correspondence to Elizabeth Stormshak, PhD, Child
and Family Center, University of Oregon, 195 West 12th Avenue,
Eugene, Oregon 97401-3408; e-mail: bstorm@darkwing.uoregon.
edu.
Originally, this theory was uniquely focused on both
context and the transactions between systems that im-
pact the child. Within this model, the child is the inner
circle and the environment is a series of nested struc-
tures surrounding the child, each imparting unique
influences on development. Ecological systems and
connections between various systems are viewed as
equally important. For example, the relationship that
a community has with schools may impact a child’s
development even though the individual child may
not be involved directly in the interactions. In gen-
eral, the ecological model of development proposes
that behavior can only be understood in context.
The ecological framework is not a “theory” of
development, other than proposing variation in chil-
dren’s adaptation as a function of context (Barker,
1960). More appropriately, it can be thought of as
a heuristic framework that helps organize a system-
atic attempt to disentangle the various levels of influ-
ence on development and the design of interventions.
For example, as shown in Fig. 1, when considering

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Fig. 1. An ecological framework for mental health in children and families.
a child’s antisocial behavior, it would be important
to consider characteristics of the child (perhaps at-
tention deficits), parent–child interaction processes,
peer relationships, teacher–child interactions, and the
neighborhood and school within which the child and
family reside (Dishion, French, & Patterson, 1995). As
argued in this paper, these multiple layers of influence
can also be critical in formulating a case conceptual-
ization and designing effective interventions.
Over the past 10 years, empirically validated
interventions have become increasingly ecological.
For example, in the treatment of serious ado-
lescent problem behavior, multisystemic therapy
is clearly ecological (Henggeler, 1993; Henggeler,
Schoenwald, Borduin, Rowland, & Cunningham,
1998). This family-centered intervention approach ad-
dresses peer dynamics, school, and diverse services of
mental health agencies within the context of an in-
tense proactive home-visiting program. Although os-
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Stormshak and Dishion
tensibly expensive in therapist time, the program has
been shown to reduce costs, when compared to con-
ventional procedures of managing adolecent problem
behavior, such as incarceration, inpatient treatment,
and other invasive procedures (Schoenwald, Ward,
Henggeler, & Pickrel, 1996). Similarly, Chamberlain
and colleagues (see Chamberlain & Moore, 1998)
have developed a treatment foster care program
that provides an ecologically sensitive, community-
based, empirically effective solution to incarcera-
tion. Sanders and colleagues developed the Triple P
program, which constitutes an exemplary multilevel
program that is intensely ecological (Sanders, 1999;
Sanders, Markie-Dadds, Tully, & Bor, 2000).
A central feature of the ecological model is the
idea that culture is more than a component of stressful
life contexts. Rather, culture potentially redefines the
meaning and validity of key psychological constructs.
The intervention research and model of Szapocznik
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Ecological Approach to Clinical and Counseling Psychology
and colleagues (for review see Szapocznik & Williams,
2000) illustrates the potential synergistic interchange
between ecological theory and the design of effec-
tive, sensitive intervention activities. Central to this
systemic model is the potential disruptive nature of
acculturation stress on parent leadership and guid-
ance of bicultural families with adolescents. Indeed,
bicultural parent training with recently immigrated
Hispanic families proved useful in improving fam-
ily process and reducing substance use (Szapocznik,
Kurtines, & Fernandez, 1980).
Clearly, the application of the ecological model
to prevention and intervention is not new. This model
is frequently applied to school-based interventions in
which a child’s behavior is evaluated in context and
interventions are developed that focus on the child,
teacher, and environment (Cohen & Fish, 1993). For
example, an intervention for a child who acts out in
school may involve working directly with the child,
changing teacher responses to behavior, and mov-
ing the child’s desk. In fact, the ecological model has
been the theory guiding most of the successful pro-
grams of prevention research in the past decade (e.g.,
FAST Track, Conduct Problems Prevention Research
Group, 1992; Seattle Social Development Project,
Hawkins et al., 1992). In these programs, individual
child, family, school, peers, and community level vari-
ables were targeted in order to achieve changes on
desired outcomes. In each case, the ecological model
was the theory that guided the research design, as-
sessment, and intervention plan. To be discussed in
more detail, Dishion and Kavanagh (2000) have ap-
plied ecological theory to the design of a school-based
program that targets parenting practices and the sys-
temic link between families and schools in the public
middle school environment.
However, despite the numbers of effective re-
search programs based on this model, a gap still ex-
ists between intervention science and actual services
to children and families (Dishion & Stormshak, in
press). For instance, service providers within schools
tend to be counselors who are trained in individual-
child interventions. It is rare for families to be in-
volved in services for children unless the child is go-
ing to be expelled or presents a serious danger to
the school environment. Even school psychologists
spend little time in schools connecting with families
(8%) or community services (2%; Fish & Massey,
1991). Similarly, child and family services delivered
at community mental health agencies usually take an
individual-child approach to treatment (Prilleltensky,
1991).
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199
A variety of reasons exist for this lack of im-
plementation, including limited funding to pay for
ecologically-based services, lack of funding for school
personnel and teachers, and limited training of mental
health professionals in the ecological model of service
delivery. In addition, the role of research scientists in
the past has been to assess outcomes rather than to
create collaborative models that may be retained in
communities (Weissberg & Greenberg, 1998). Eco-
logically driven models are often developed as “stand
alone” programs that can be purchased and dissem-
inated, but rarely are they designed from the inside
out, so that they can be embedded within existing ser-
vice delivery systems (Hoagwood & Koretz, 1996).
In this sense, we assume that future progress in
child and adolescent psychology will result from the
continued mindful application of ecological principles
to the design of service delivery systems (Dishion &
Patterson, 1999). For this reason, in this article, we
wish to step back and consider the frontiers of ap-
plying ecological theory to the design of empirically
justified and culturally sensitive interventions and ser-
vices for children and families.
There are several issues we address in discussing
areas of growth in this application of ecological the-
ory to intervention science. First is the design of as-
sessment batteries that guide clinical and client judg-
ment of optimal and realistic intervention targets.
The second is the integration of the Prochaska and
DiClemente’s transtheoretical model to ecologically
informed interventions (Prochaska & DiClemente,
1982), that is, systematically addressing motivation to
change as integral within a service delivery frame-
work (e.g., Miller & Rollnick, 1991). Third, we sug-
gest that the service delivery model underlying eco-
logical interventions needs reconsideration, moving
away from the disease model “treatment program”
approach to one in which a menu of empirically val-
idated interventions are embedded within contexts
that frequently serve and address the needs of chil-
dren and families. Finally, we discuss the future of
child and family intervention science with respect to
the above issues, promising new areas of focus (child
and adolescent affective disturbance) and questioning
the general framework within which we work.
ECOLOGICAL ASSESSMENT OF STRENGTHS
AND WEAKNESSES
An extensive literature exists on the fallibil-
ity of clinical judgment, when executed without the
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assistance of validated psychometric assessments (see
Dawes, 1994). Often, however, models that are eco-
logically based depend primarily on clinical judgment
for determining the optimal target, the timing of in-
terventions, and the ecological domains within which
to focus. An exception to this is the work by Sanders
(Sanders & Lawton, 1993), where the approach pro-
motes careful assessment and reviewing assessment
results with clients. Not only do we promote the use
of systematic, comprehensive assessments to buttress
decision making, but we suggest that the ecological
model provides a useful framework for considering
which domains to assess at various developmental lev-
els and in a variety of contexts. In the section that
follows, assessment is also a critical step in building
motivation to change.
In a traditional therapy model, assessment typ-
ically follows from the presenting problem. For ex-
ample, a child may present with a parental concern of
ADHD. Assessment includes behavior checklists, ob-
servations, and possibly individual testing to discern
whether or not ADHD is the appropriate diagnosis.
In this approach, the assessment package is driven by
the diagnosis, or presenting problem, and the goal of
assessment is to either confirm or disconfirm the di-
agnosis of ADHD. This model is deficit-driven rather
than strength-based because the data gathered tend
to be focused around the problem behavior.
Interventions conceptualized within an ecolog-
ical model take a different approach to assessment.
Based on a child’s ecology and development, assess-
ment is conducted across the major developmental
domains and contexts of interaction. Although the
assessment process is longer, the treatment process
may be shorter, given the comprehensive nature of
the data gathered and the feedback to families.
In this model, the goal is to gather information
on the child’s development across contexts with a de-
creased emphasis on the presenting problem. Instead,
strengths are actively pursued and targeted as areas of
growth. For instance, many families present to clinics
with complaints about children’s behavior at home.
In a traditional model, little or no contact with the
school is pursued given that the problem is occurring
at home. However, it is often the case that parents
do not know about school problems and, therefore,
have not addressed these problems. Alternatively, the
school context may be an area of strength for the
child and behavior plans that are working in that
context can be applied to home. In either scenario,
a comprehensive school evaluation, including direct
observation and teacher ratings, is conducted within
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Stormshak and Dishion
this framework. Treatment then builds on potential
strengths at school rather than focusing entirely on
weaknesses at home. The ecological framework de-
scribed previously (see Fig. 1) provides the map for
assessment and potential intervention. Each of these
levels are discussed in order to highlight relevant as-
sessment and intervention issues.
Individual Child Level
A variety of individual-level variables in chil-
dren and adolescents are amenable to change. These
may include maladaptive cognitions, impulse control
strategies, problem-solving skills, and understanding
emotions. However, there are also a number of child
traits that may be important to evaluate and inte-
grate into treatment, but which are not necessarily
amenable to change. These may include physical de-
velopment or appearance, early temperament, or gen-
der issues.
The biologically-based aspects of children may
not be changeable, but they exert important influ-
ences over the child’s ecology. For example, ample
research supports the potential risk factor of early
maturation for girls. Early maturation is associated
with increased risk of teen pregnancy, substance use,
and delinquent behavior (Ge, Conger, & Elder, 1996;
Tschann et al., 1994). Although not a changeable indi-
vidual child trait, early maturation may be a risk fac-
tor that influences other aspects of treatment, such as
parental monitoring and peer interventions. Aware-
ness of this vulnerability in an individual case, and pro-
viding parents the appropriate support and guidance,
may effectively prevent a life transition disruption.
There are a variety of empirically supported
approaches to working directly with children, in-
cluding cognitive–behavioral impulse control therapy
(Braswell & Kendall, 2001), prosocial coping (Prinz,
Blechman, & Dumas, 1994), and anger management
programs (Lochman, 1992). Although these treat-
ments have been linked to positive changes imme-
diately posttest, few studies find long-term benefits of
child-only programs without including other levels of
the child’s ecology, such as parents or schools, in the
treatment.
Within an ecological model, child treatments are
goal focused and coordinated with other levels of
service. For example, impulse control strategies may
be taught to the child (at school, at home, or in a
clinic) and parent and coordinated with teacher re-
sponses. When included in a comprehensive model of
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Ecological Approach to Clinical and Counseling Psychology
treatment that is ecologically based, these skill-based
therapies can be more effective at reducing problem
behavior (Conduct Problems Prevention Research
Group, 1999).
Family Level
There is probably no greater body of literature
linked to maladaptive outcomes in children and ado-
lescents than the research suggesting strong relation-
ships between family functioning and later problems.
In general, family variables associated with later aca-
demic and behavioral problems include lack of care-
giver involvement, poor and inconsistent family man-
agement, and punitive or negative parenting (e.g.,
Patterson & Stouthamer–Loeber, 1984; Pettit, Bates,
& Dodge, 1993; Stormshak, Bierman, McMahon,
Lengua, & Conduct Problems Prevention Research
Group, 2000; Webster–Stratton, 1990). Patterns of in-
teraction learned in the context of parent–child ex-
changes are then generalized to school settings and
peer groups, leading to the development of later
problems, such as drug use, delinquency, and school
dropout (Loeber & Dishion, 1983; Loeber, Green,
Keenan, & Lahey, 1995; Robins, 1978).
As children develop into adolescents, lack of
monitoring and ineffective limit-setting exacerbate
existing behavior problems (Dishion & McMahon,
1998). Behavior problems associated with this early-
starter model and parenting skills contributing to
these problems can be identified as early as age
2 and are predictive and stable into middle child-
hood (Campbell & Ewing, 1990; Keenan & Shaw,
1994; Zahn–Waxler, Iannotti, Cummings, & Denham,
1990).
In addition to parenting-skill deficits, family dys-
function also contributes to child problems. Marital
discord and coparenting difficulties may impact par-
enting skill deficits, as well as child functioning. For
example, children of divorce tend to show poorer
achievement, conduct problems, psychological ad-
justment, and poor social relationships compared to
children who have not experienced divorce (Amato,
2001). Marital conflict and distress are directly linked
with behavior problems, internalizing problems, and
coparenting difficulties that may lead to long-
term maladjustment (Frosch & Mangelsdorf, 2001;
Ingoldsby, Shaw, Owens, & Winslow, 1999).
Marital difficulties also may be connected inex-
tricably to adult psychopathology such as depression
and substance use (McElwain & Volling, 2001; Mudar,
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201
Leonard, & Soltysinski, 2001; Simons, Lin, Gordon,
Conger, & Lorenz, 1999). Clearly, the family con-
text of children with psychological problems needs to
be carefully evaluated and targeted in intervention.
Some research suggests that when marital problems
go untreated in child and family therapy, parent–child
conflict will continue after treatment (Dadds, 1989).
From the existing research, it could easily be argued
that targeting family issues is the single most impor-
tant point of therapeutic intervention for children and
adolescents (Henggeler et al., 1998).
Schools and Peers
Schools serve as a critical socialization context
for children and adolescents (Kellam, 1990; Sugai,
Horner, & Sprague, 1999). Typically, children spend
the majority of their time at school, interacting with
peers and teachers. The complexity of school dynam-
ics and the interactions that children and families
have with teachers and school personnel can be over-
whelming to therapists.
Research linking changes in the school context
with subsequent changes across other developmental
systems has been scant. However, it is clear that posi-
tive parental involvement in schools is associated with
positive outcomes for children and families. Schools
also serve as an important link between families, chil-
dren, and peer groups (Reid, 1993). Ample research
evidence supports the positive outcomes for children
associated with social competence and quality friend-
ships, as well as the deleterious effects of aggressive,
deviant peer groups that promote antisocial behavior.
Parents play a critical role in promoting early aca-
demic success through parent–school involvement,
stimulation of cognitive growth at home, and promo-
tion of values consistent with academic achievement
(Greenwood & Hickman, 1991; McMahon, Slough,
& Conduct Problems Prevention Research Group,
1996).
Children who are able to form positive friend-
ships in early childhood show continuity in these pat-
terns of relationships over time, leading to positive
adjustment at school and decreased academic failure
(Ladd, 1990). Children who are aggressive and dis-
ruptive in early childhood tend to become rejected
by peers, leading to the formation of deviant peer
associations in middle childhood that are the con-
duit to antisocial behavior and substance use (Coie,
Belding, & Underwood, 1988; Dishion & Owen,
in press; Patterson & Bank, 1989). Schools exert
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202
influences over these peer dynamics in their approach
to classroom management and monitoring students
during free time (Kellam, Ling, Merisca, Brown, &
Ialongo, 1998; Stormshak et al., 1999). Lack of fund-
ing and school-level programs that are designed only
for academic instruction may neglect or even promote
adjustment difficulties (Eccles, Lord, & Roeser, 1995).
In early childhood, interventions include bring-
ing parents into the school, involving parents in
decision-making about school, and creating a posi-
tive home–school connection (Kaminski, Stormshak,
Good, & Goodman, in press). In middle school, en-
gaging parents in schools by providing family-based
services at the school effectively reduces substance
use and problem behavior (Dishion, Kavanagh,
Nelson, Schneiger, & Kaufman, in press). Working
directly with schools to provide services that are ap-
propriate for each child is also critical. Monitoring
children during recess, escorting children onto buses,
and monitoring lunch room behavior can significantly
reduce behavior problems for individual children.
Community Systems
Psychopathology and problem behavior emerge
when the socialization systems are disrupted by a
number of contextual and community influences,
including poverty (Elder, Caspi, & Van Nguyen,
1986; McLoyd, 1990), acculturation (Coatsworth,
Szapocznik, Kurtines, & Santisteban, 1997), or colo-
nial attacks on a community’s culture (Duran &
Duran, 1995). Much of the research on the impact of
context proposes a mediation model in which context
disrupts parenting practices, leading to a variety of
mental health problems, including antisocial behavior
(Conger, Patterson, & Ge, 1995; Forgatch, Patterson,
& Skinner, 1988; Patterson, Reid, & Dishion, 1992)
and adolescent depression (Sheeber, Hops, Andrews,
Alpert, & Davis, 1998).
Contexts can also disrupt families by undermin-
ing marital relationships, which in turn, compromises
parenting (Brody & Forehand, 1993). Communities
can have a disruptive effect on child development
by through how they are organized (Sampson &
Laub, 1994). For example, community organizations
may support a variety of opportunities for unstruc-
tured, unmonitored peer contact with at-risk youth,
yielding ample opportunity for peer associations that
encourage and amplify serious problem behavior
(Dishion et al., 1995; Simcha–Fagan & Schwartz, 1986;
Steinberg, 1986).
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Several research programs closely examined a
mediation model for child and adolescent socializa-
tion. Parenting practices identified in the majority cul-
ture covaried, as expected, with child and adolescent
outcomes in the African American community (e.g.,
Chilcoat, Anthony, & Dishion, 1995), as well as in
the Hispanic and Native American communities (Bar-
rera, Castro, & Biglan, 1999), and cultural commu-
nities outside the United States (Brook, Whiteman,
Win, & Gursen, 1998).
The ecological perspective proposes that in some
circumstances, context can totally redefine socializa-
tion and child and family outcomes. This would sug-
gest that relations between parenting practices and
child outcomes in one setting would not apply within
another setting, partly because of the unique orga-
nization of various cultural communities. However,
research that clearly identifies cultural variance is
sparse. Crane (1991) examined the impact of poverty
on African American children, finding an extremely
negative effect for boys in the poorest neighborhoods.
Mason, Cauce, Gonzales, and Hiraga (1996) identified
unique parenting practices associated with compe-
tence among minority youth. Stormshak et al., (2000)
and other researchers (Deater-Deckard & Dodge,
1997; Steinberg, Dornbusch, & Brown, 1992) found
spanking to be associated with problem behavior for
Caucasian children, but not for African American
children.
Additionally, the quality of family relationships
varies by culture (Dishion & Bullock, 2001), with
African American children displaying more positive
affect and warmth in sibling relationships than do
Caucasian children (Stormshak, Shepard, & Comeau,
2001). Extended kin support and sense of family obli-
gation may also differ between African American and
Caucasian families (Horwitz & Reinhard, 1995).
Although the research is limited, there certainly
is enough to give pause to the conclusion that one
parenting style fits for all communities. The idea that
cultural and community settings qualify the impact of
socialization practices is the defining distinction of the
ecological perspective. Having made this point, the
proximal linkages shown in Fig. 1 are relatively robust
across cultures. In work examining culturally-unique
patterns of direct observations of parenting, the indi-
vidual parenting behaviors such as limit-setting and
relationship quality did vary by ethnicity, but an ag-
gregate score of family management was equivalent
across cultures (Dishion & Bullock, 2001).
The findings suggest that overall patterns of in-
volved, active parenting are uniformly helpful for
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Ecological Approach to Clinical and Counseling Psychology
children. For example, studies that examine parent-
ing practices and deviant peer influences generally
find both to be significantly correlated with prob-
lem behavior in a variety of groups (Oetting &
Beauvais, 1990). Peers provide a context for problem
behavior from early childhood (Patterson, Littman,
& Bricker, 1967; Snyder, West, Stockemer, Givens, &
Almquist–Parks, 1996), middle childhood (Dishion,
Duncan, Eddy, Fagot, & Fetrow, 1994), and adoles-
cence (Dishion, Andrews, Kavanagh, & Soberman,
1996). Direct observations of parent–child interac-
tions reveal unresponsive, harsh, coercive parenting
to be associated with problem behavior from early
childhood (Shaw, Keenan, & Vondra, 1994; Snyder,
Edwards, McGraw, Kilgore, & Holton, 1994), middle
childhood (Patterson, 1982; Patterson et al., 1992),
and adolescence (Dishion & Andrews, 1995; Hops,
Tildesley, Lichtenstein, Ary, & Sherman, 1990).
SUPPORTING MOTIVATION TO CHANGE:
THE FAMILY CHECK-UP
Overview
The Family Check-Up (FCU) is a brief interven-
tion that focuses on supporting parenting strengths
and on providing motivation to change maladaptive
parenting. The FCU was designed around the clear
linkage between assessment, intervention, and mo-
tivation. Based on the Drinkers’s Check-Up (Miller
& Rollnick, 1991), this parent-focused intervention
is appropriate for all caregivers, regardless of demo-
graphic characteristics or severity of clinical problems.
In a prevention trial focused on reduction of substance
abuse in middle school youth, the FCU was success-
ful in reducing the growth of cigarette and alcohol use
between Grades 6 and 9 (Dishion et al., in press). In
this study, the FCU was administered to families by a
therapist in the middle schools and served as a school
based, family intervention. The FCU targeted both
families and the link between families and schools.
The FCU is the first step in the change process.
Based on a carefully conducted assessment, a collab-
orative set is established between the family and the
therapist with respect to the menu of possible inter-
ventions that are relevant and supportive of family
mental health. Caregivers with concerns considered
normative to children and adolescents can benefit, as
well as those who are in need of more intensive sup-
port or behavior change. In itself, the intervention in-
volves three sessions: an initial interview, an assess-
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203
ment session, and a feedback session. For families in
need of more support, the FCU comprises the first
phase of a treatment program that may target multi-
ple levels of the child’s ecology.
Initial Contact
There are a variety of settings and ways to make
the initial contact with families. The first step in the
process is the intake interview. Preferably, this should
be conducted in the home, but can be done in a pri-
vate room within the school or in a professional of-
fice. No better way exists to develop a shared perspec-
tive with a family than to sit with them in their own
home. Research reveals that engagement is enhanced
when meeting in the home (Stormshak, Kaminski,
& Goodman, in press; Szapocznik et al., 1988), and
several empirically-based interventions now are con-
ducted primarily in the home (e.g., Henggeler, Pickrel,
Brandino, & Crouch, 1996). In research within the
Adolescent Transitions Program intervention trials,
low participation occurred in the first session of par-
enting groups unless the families were visited in the
home before the initial session.
All the basic skills required to build rapport are
also important in developing relationships with par-
ents. As discussed by Miller and Rollnick (1991), re-
flective listening is critical for supporting parents’ ac-
tive efforts to self-assess readiness to change. Through
careful listening, the therapist can get an initial idea of
the strengths and weaknesses within a family. Through
reflective listening, the therapist and caregiver can ex-
plore possible discrepancies between the current state
of the family and the desired state.
During the initial visit, a family should be in-
formed about the logistics of the assessment, as well
as the rationale. This is part of their process of change,
therefore, sufficient time should be allotted in order
to answer all their questions. Assessments are used
as support for the family’s decision-making and are
the foundation of the FCU process. Appealing to the
self-interest of the family promotes cooperation with
a process that can be tedious and uncomfortable.
The Family Assessment Session
The measures in the family assessment were se-
lected on the basis of the ecological model of prob-
lem behavior development, as described previously.
A multiagent, multimethod approach to assessment
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204
of each of the levels was used (see Fig. 1). Central to
feedback is the inclusion of a direct observation of the
parent–child interaction process. The assessment pro-
vides feedback on several domains of development:
family management and interaction processes, peer
influences, child characteristics, and contextual influ-
ences (home, school, neighborhood). Clearly, most
current measures of child and family adjustment were
not designed for the purpose of sharing information,
supporting positive parenting practices, or motivating
change in parenting. However, it is likely that over the
next 10 years, a clinical armamentarium of family as-
sessments will be designed with the family’s benefit in
mind.
Case Conceptualization
Four elements provide the organizing framework
for feedback: (a) the centrality of parenting to the
child’s success and well-being; (b) harm reduction;
(c) tailoring feedback; and (d) supporting motivation
to change.
Parenting Centrality
Direct observations of parenting provide infor-
mation on key family management practices appro-
priate to the developmental level of the child. There-
fore, it is important for the family therapist to carefully
view, as well as rate, the videotaped family inter-
actions. Ratings focus on strengths and weaknesses,
highlighting positive approaches to parenting.
Harm Reduction
When families are distressed and their assess-
ment data indicate several areas of difficulty, it is im-
portant to adopt a harm-reduction perspective. This
means that time is required to consider the optimal
next step and give advice to control damage that is sec-
ondary to pathological processes. Examples include
issues such as divorce-related conflict, parental drug
abuse, a death in the family, a runaway child, or phys-
ical or sexual abuse. When there are serious prob-
lems such as these, the feedback process then changes
to focus on the next step to reduce future harm to
the child, parent, or other family members. Improve-
ments in the child’s behavior, parenting practices, or
other goals are put aside in favor of creating a safe,
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Stormshak and Dishion
stable family environment. For instance, in the event
of severe conflict and the potential for an adolescent
to run away, harm reduction focuses on making the
changes necessary to keep the family together. When
there are severe school difficulties, the focus may be
on keeping a high-risk student from expulsion.
Tailoring Feedback
The importance of identifying larger contextual
family issues that counterindicate the parents’ abil-
ity to respond to specific detailed feedback is critical.
Likewise, a family could have many more risk factors
than protective factors, and given the goal of promot-
ing motivation and optimism about change, feedback
can be given in stages. For example, the peer domain
could be discussed and other domains saved until the
peer issues are worked through. Another possible sit-
uation involves a parent being limited in the ability to
process information. To maximize success and under-
standing, small portions of feedback should be given
over time. Even if all of the individual feedback can be
given in one meeting, the manner in which it is given
depends on the family situation.
Supporting Motivation
Parents should walk away from the feedback
interview feeling motivated to continue with their
strengths and empowered to address their needs. Dur-
ing the case conceptualization process, an important
goal is identifying current strengths in the parenting
system. Similar to the suggested praise-to-correction
ratio—a four-to-one proportion of strengths (protec-
tive factors) to concerns (risk factors)—should be the
goal. Even in the most difficult family circumstances,
parents’ follow-through with the FCU process can be
emphasized as a positive indication of concern for
their child and commitment to change.
The Feedback Session
The feedback session itself can be divided into
four phases as well. The first phase is an opportunity
for parents to discuss their own self-assessment, based
on their experiences in the assessment process. When
parents discuss their self-assessment, this is an oppor-
tunity to (a) appreciate their approach to behavior
change; (b) assess their level of insight; (c) learn more
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Ecological Approach to Clinical and Counseling Psychology
about the dynamics of the family; and (d) discover is-
sues not covered in the assessment. The second phase
is clarification and support, the third phase focuses
on summarizing feedback to families, based on the
information they provided, and in the fourth phase,
the therapist and the parents work collaboratively to
develop a menu of options for improving family life
and promoting the success of the child. The entire
feedback session is best thought of as the beginning
of a work-in-progress, with the final outcome reflect-
ing a parent-guided process of interaction with the
therapist.
Beginning the feedback session with a self-
assessment is an important strategy for understanding
the parents’ perspective and insight at the onset of the
change process. The majority of families raise at least
one key issue on which the therapist intended to pro-
vide feedback. Parents often perceive this question
as a request to self-disclose deficits in parenting. The
therapist’s response can help reframe this perception
from a deficit to a goal. How the parents respond also
allows the therapist to appreciate their approach to
behavior change.
The therapist begins the support and clarification
process by communicating his or her understanding
of the parents’ perspective, validation, and support.
The therapist also clarifies how the assessment results
might be helpful to the parents’ appraisal of their fam-
ily situation. The support and clarification phase can
be a brief transition into feedback and accomplishes
two goals: supporting the parents’ activity in the meet-
ing and supporting self-assessment efforts. With this
information, misconceptions about the feedback pro-
cess or the goals of the meeting can be clarified.
The entire feedback is a process of information
sharing, reflection, and validation, culminating in a
menu of change options. The collaborative stance and
the support for parents reevaluating self-appraisals of
their child and families provides the foundation for
the next step, which is developing a menu of interven-
tion activities.
Menu of Change Options
Consistent with the motivational interviewing,
parents are more likely to consider change when
there is a choice of intervention options. The menu,
derived in collaboration with the parent, always in-
cludes at least two items or choices for intervention.
One of these items is “No resources needed.” This
gives the parents a clear option not to change at this
August 8, 2002 15:46 Style file version Nov. 07, 2000
205
time. It is supportive to families who are not ready to
make changes, but who may benefit from the feedback
and assessment process in other ways. Any additional
comments are best worded in positive terms, such as
“Continue spending time with Nina checking in on
her homework” or “Wait one term to determine if
the program she’s in is working.”
A framework is provided for developing inter-
vention options, ranging from self-change, one or two
consultation sessions with the family on a specific is-
sue (e.g., problem solving and communication), a 12-
session parent focus group, individual family therapy,
or more comprehensive case management. In build-
ing a viable menu, knowledge of the school and com-
munity resources is needed. Again, the resources with
which the therapist should have expertise are those
that support family management and reduce barri-
ers to good parenting. For instance, if there is diffi-
culty monitoring a child’s daily behavior at school,
a home–school communication system (card or tele-
phone calls) would be an option on the menu.
Figure 2 provides an overview of the central role
of the FCU to the service delivery model. Note that on
a normal distribution of families, a rather large group
of families who are at-risk might do well from a brief
motivational intervention. Those within the “clinical
range” also benefit from basing their treatment on a
comprehensive assessment, where many of the key
strengths and weaknesses relevant to service deliv-
ery are jointly considered by the therapist and clients
when appraising the need for change and how best to
accomplish that change.
CURRENT MODELS OF SERVICE DELIVERY
Unfortunately, many of the service delivery mod-
els still in place for children and families stem from
the adult therapy literature (e.g., interventions de-
signed and tested on adults have been adapted and
used with children and families). Probably no better
example of this problem exists than the tendency for
substance use treatment in adolescence to adhere to
a group therapy model similar to that used in adult
treatment. This common practice is not informed by
the developmental research, suggesting that relation-
ships with deviant peers are a significant risk factor for
youth engaged in problem behavior. Ample research
suggests that placing high-risk youth in groups with
aggregate peers is not helpful and can lead to even
greater problems (Dishion, McCord, & Poulin, 1999;
Poulin, Dishion, & Burraston, 2001).
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206
Fig. 2. Family check-up as a launching point for family intervention services.
Unlike adult therapy models, which are based
largely on language skills (e.g., talking), child and fam-
ily models cannot be effective if delivered exclusively
in this mode. The reason for this is multifaceted. First,
children have differing levels of language develop-
ment, as well as a wide range of emotional and so-
cial development. Although child development tends
to be predictable in course, it is also variable, with
each child developing at a unique pace across the dif-
ferent domains of development (e.g., social, behav-
ioral, physical, language). In a developmental model,
child psychopathology is framed in the context of
deviation from “typical” development across mul-
tiple domains (Cicchetti, 1990; Sroufe, 1997). Dis-
continuity is common and can lead to adaptation or
maladaptation, depending on the developmental tra-
jectory that has already been established (Granic,
Dishion, Hollenstein, & Patterson, in press; Lewis,
2000).
Secondly, children tend to develop in the con-
text of relationships, which serve to sustain, pro-
mote, or discourage maladaptive behavior (Hinde,
1989; Patterson & Dishion, 1988). Without attention
to these relationships, treatment will not be effective
(Patterson & Reid, 1984). Lastly, children learn ex-
perientially. Interventions that attempt to teach or
model appropriate behavior in the context of the ther-
apeutic relationship, but do not extend this learning to
the actual environment, will fall short in terms of gen-
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Stormshak and Dishion
eralizing behavior change to other contexts (Weinrott,
Jones, & Howard, 1982).
Recently, Weiss, Catron, and Harris (2000) con-
ducted a 2-year follow-up of the effectiveness of tradi-
tional child psychotherapy (e.g., working directly and
exclusively with children and adolescents). The results
did not support the efficacy of this model, which they
refer to as the standard approach to child treatment
in most outpatient settings. Similar work by the same
authors reached the same conclusion (Weiss, Catron,
Harris, & Phung, 1999).
Interestingly, parents often report greater satis-
fation with mental health services when their child is
the sole focus of treatment (Patterson, Dishion, &
Chamberlain, 1993). However, this satisfaction de-
clines significantly when the child stops receiving
treatment (Weiss et al., 1999). This is an interesting
finding from a systems perspective, which suggests
that “targeting” the child as the problem would lead
to parental satisfaction, colluding with the myopic
perspective that the problem is “within” the child.
For example, triangulation among family members,
detouring family problems onto the child, and dif-
ferential relationships between children and moth-
ers versus fathers all serve to maintain problem be-
havior (Kerig, 1995; Stormshak, Speltz, DeKlyen, &
Greenberg, 1997; Szapocznik & Kurtines, 1989).
After treatment is finished and the child’s func-
tioning remains essentially the same, parents may feel
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Ecological Approach to Clinical and Counseling Psychology
even more hopeless and become more frustrated with
their child. In this scenario, from an ecological per-
spective, child-only treatments actually may be dam-
aging to children and adolescents. The damage occurs
by targeting only one level of the system and inad-
vertently allowing the other levels of the system to
continue to sustain the problem behavior.
ECOLOGICAL SERVICE DELIVERY
A Health Maintenance Model of Mental Health
The medical model provides the framework for
psychological treatment, in general, and family ther-
apy, in particular. In the medical model, there is
a treatment with a specified dosage. The disease is
healed when the specified dosage is delivered. An
approximately linear relation is expected between
change and the dose of treatment, therefore, many
family therapists assume that the more sessions with
a family the better the outcome. Unfortunately, lit-
tle evidence supports this assumption. Dishion and
Kavanagh (in press) found that clinically significant
change in parenting groups occurred within the first 5
sessions of a 12-session curriculum. Clinically signifi-
cant change in parent groups seemed to occur rapidly
and was more a function of group dynamics than ther-
apist adherence to the curriculum.
In a careful analysis of 70 clinical cases treated
at Oregon Social Learning Center, Weber (1998) did
not find evidence for a dose–response relation be-
tween the number of sessions and the statistically re-
liable and clinically-significant change. In that study,
children aged 6–12 were recruited and retained if
they were in the clinically-significant distress range
on the parent version of the Child Behavior Check-
list (PCBC; Achenbach, 1991) and on direct observa-
tions within the home (using the Family Process Code;
Dishion, Gardner, Patterson, Reid, & Thibodeaux,
1983). Clinically significant and statistically reliable
change was defined using the criteria developed by
Jacobsen and Truax (1991). Using teacher and parent
ratings and direct observations, the data clearly in-
dicated no correlation between clinically-significant
change and the number of sessions families received.
It is possible that the dosage of behavior fam-
ily therapy is related to the magnitude of change and
not necessarily whether the change is clinically sig-
nificant. However, an analysis of statistically reliable
change (Jacobsen and Truax, 1991) revealed no cor-
relation between the number of sessions and the level
August 8, 2002 15:46 Style file version Nov. 07, 2000
207
of change in observed coercive interactions or parent
and teacher reports of problem behavior. Although
important change was documented in this study, it
appeared to be a function of the interchange between
the therapist and the client that was not captured in a
simplistic dose–response relationship (see Patterson
& Chamberlain, 1994; Stoolmiller, Duncan, Bank, &
Patterson, 1993).
Clearly, examination of all the work of behavior
family therapy over the past 20 years shows that it is ef-
fective in reducing problem behavior in children and
is perhaps the most effective strategy known (Kazdin,
1996; Patterson et al., 1993). However, the process in
which change is initiated and maintained when inter-
acting with a therapist is not clear. When working with
families to support healthy change, there are many
untested assumptions about just how to achieve suc-
cess and the decisions that therapists need to make
about intervention strategies. The lack of a linear rela-
tionship between the number of intervention sessions
and positive outcomes may be a function of the lack
of a linkage between motivation, assessment, and the
intervention selected.
A unique feature of mental health service deliv-
ery is client engagement and motivation. Some time
ago, two major issues were discovered in providing
mental health service for children and families. One
was that the professional knowing the solution was not
sufficient to solving the problem (Patterson, 1985). To
engage caregivers in the change process, it is critical to
establish a collaborative set with respect to the change
agenda (Dishion & Kavanagh, in press; Patterson &
Chamberlain, 1994; Webster-Stratton, 1990). Careful
study of the client and therapist interactions leading
to change provided the empirical foundation for mo-
tivational interviewing (Miller & Rollnick, 1991). Di-
rectly addressing motivation to change is a crucial is-
sue in any mental health service, given that the change
process is embedded within the volition and affective
system of the family and therapist.
The second major problem involves attempting
to change families: Issues other than the problem be-
havior of the child were often noteworthy, at a min-
imum, and redefined the nature of the interventions,
at a maximum (Miller & Prinz, 1990; Prinz & Miller,
1994). Issues such as marital distress, maternal depres-
sion, history of trauma, stress, and substance use could
interfere with the change process if left unattended.
Based in part on the limited relationship be-
tween the number of sessions and positive outcomes, a
health maintenance model of service delivery may be
more appropriate for intervention services targeting
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208
problem behavior in children and adolescents. One
example of this model can be found in dentistry. So-
ciety as a whole is comfortable with the notion that
individuals vary in vulnerability to structural or tooth
decay problems and may often require more active in-
tervention to maintain dental health. A health main-
tenance model of service delivery proposes periodic
check-ups to maintain health and assessment-driven
interventions.
To summarize, the ecological model promotes
a health maintenance model of service delivery that
includes (a) frequent check-ups across key develop-
mental transitions, especially for families in transition
or individuals who are developmentally vulnerable;
(b) services that are assessment-driven rather than
theory-driven; (c) a menu of possible voluntary in-
tervention services that are empirically derived; and
(d) a focus on dimensions of mental health that are
systemically connected in a family. Finally, within an
ecological approach, the change process essentially
promotes mental health wellness.
IMPLICATIONS AND FUTURE DIRECTIONS
Intervention, therapy, treatment, and counseling
are all terms referring to the intervention phase of
working with children and families. In a traditional
model, after initial assessment is conducted, a plan
for working with the child, the family, or both is cre-
ated and implemented. This usually involves a focus
on goals, which are discussed in therapy and imple-
mented outside therapy (at home or at school). This
model of assessment–intervention is derived primar-
ily from the adult therapy literature and is based on
a variety of assumptions about client functioning that
are not necessarily present when working with chil-
dren and families.
First of all, in most ecological systems, not all
members are willing participants. Resistance to the
process of change comes from at least one family
member (mother, step-parent, father, or children) or
a member of the larger ecology (e.g., teachers). Using
a stages-of-change model (Prochaska & DiClemente,
1982), it would be nearly impossible for all members of
a system to be at the same stage of change. Addition-
ally, from a systems perspective, dysfunction within
the system creates problem behavior, so concordance
between members would be highly unlikely.
Figure 3 presents the process of assessment and
treatment from an ecological perspective. First, there
is a comprehensive assessment phase in which data
15:46 Style file version Nov. 07, 2000
Stormshak and Dishion
are gathered across systems. This phase of treatment
may be the only one some families complete. It may
also lead directly to changes in the family system (e.g.,
FCU). Next is a case management phase in which the
family is organized around change. This phase usually
is not present in adult models, but clearly is needed in
child and family models. For example, who are the ser-
vice providers involved in the treatment and what will
their role be in change (e.g., schools, teachers, other
case workers)? Who are the “targets” of treatment?
Where will the treatment occur (at home, school, or
in a clinic)? Who will deliver what aspects of the treat-
ment? And lastly, Who is responsible for coordinating
all these efforts? During this phase of case manage-
ment and organization, active resistance at one level
of the system is identified, targeted, and integrated
into the treatment model. The various adult caregivers
are evaluated for their willingness to participate, their
commitment to change, and likely follow-through on
treatment goals.
The last phase of treatment is the actual interven-
tion. Goals are targeted at each level of the ecological
system and change is tracked and monitored by the
family and therapist. Note that this phase of treat-
ment may be relatively brief, given that the treatment
is informed by a comprehensive assessment and well-
organized up front.
Appropriate intervention strategies from this
model include a variety of systemic interventions
that focus on change within and across systems,
such as family therapy and parenting interventions
that reduce home conflict and child behavior prob-
lems, school-based work with children and peers
that reduces problems at school and at home, and
home-to-school contracts and behavior plans that
reduce problems at school while linking parents
and teachers. Additionally, interventions that are
not typically administered by traditional therapists
are important components in the treatment model,
such as those helping families change the structure
of children’s lives (participation in after-school
programs, increased monitoring, coordinating with
other service-delivery agencies).
Affective Disturbance
It is ironic that the field of child and adoles-
cent mental health is bifurcated into treatments that
address anxiety and depression and those that ad-
dress “externalizing” problem behavior. It is easy to
question this split when considering two facts: (a) the
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Ecological Approach to Clinical and Counseling Psychology
Fig. 3. The process of child and family therapy.
lack of convergence across indicators of either anxiety
or depression measures in childhood and adolescence;
and (b) the high covariation between behavior prob-
lem and affective disturbance. The situation leads to
a paradox for the field. If investigators want a “pure”
sample of depressed children, they “screen out” those
with behavior problems. Unfortunately, this yields a
clinical sample that is atypical of children and fam-
August 8, 2002 15:46 Style file version Nov. 07, 2000
209
ilies that are seen by community child and adoles-
cent therapists. The other approach is to work with
those considered comorbid. Then, it would seem that
the vast intervention research on children and adoles-
cents with problem behavior would apply. Of course,
it is in handling problem behavior that the majority of
the ecological interventions have been designed and
validated.
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210
Only a handful of studies even address family
issues when supporting young people who are de-
pressed and anxious. For instance, Lewinsohn and
Clark (1990) tested a parent-enhanced version of a
group intervention for depressed adolescents, finding
that it did not improve outcomes. However, these in-
vestigators did find low attendance to the parent con-
dition and the majority of the sessions were dedicated
to understanding adolescent depression. There was
less focus on the dynamics in families that may lead
to depression, some of which overlapped with prob-
lem behavior (Sheerber et al., 1998). Similarly, Brent
et al. (1998) did not find any clear incremental value in
adding parents and families to the intervention for de-
pressed adolescents. In preventing anxiety, however,
Dadds, Spence, Holland, Barrett, and Lacrens (1997)
did find that a parent component was important to
early intervention and prevention of anxiety prob-
lems in children. This intervention is quite promising
to the extent that it is ecological and integrates school,
person, and family factors in supporting children who
experience affective distress. This would seem to be
an obvious and promising future direction for work
that attempts to address these issues from a public
health perspective.
Preparing the Therapist
Child and family psychology is a broad area of
research and practice that ideally integrates multi-
ple disciplines into a comprehensive framework for
working with children and families. Child psycholo-
gist, family therapist, and child–family counselor are
all terms that may be used synonymously to refer to
professionals who work with children and families. In
each case, the child and family therapist must be fa-
miliar with a wide range of disciplines in order to be
effective (see Fig. 4).
Child and family psychology often involves the
application of knowledge and intervention skills
across several areas of expertise, including adult men-
tal health, social work, school psychology, career de-
velopment, and psychiatry. Training effective inter-
ventionists in this area requires competence across a
number of different content areas, including child de-
velopment, child–family interventions, developmen-
tal psychopathology, research methods, and ethical is-
sues with children and families (Roberts et al., 1998).
Therapists who administer child and family ser-
vices without adequate training are likely to refer
many of their families to other professionals for ad-
15:46 Style file version Nov. 07, 2000
Stormshak and Dishion
ditional services, which does not provide a compre-
hensive, ecological treatment plan for children and
families. In the first place, families do not typically fol-
low through on referrals to other therapists. Addition-
ally, children and families who complete treatment are
more likely to show therapeutic changes than those
who drop out of treatment prematurely (Kazdin &
Wassell, 1998). Given the high rates of attrition in ser-
vice delivery to this population (40–60%), retention
is clearly an important aspect of treatment efficacy
(Kazdin, 1993).
Additionally, the new therapist often spends time
and money reassessing the family, which leads to
costly insurance bills and sometimes decreases the
amount of service the family can actually attain. Fi-
nally, most people in the community do not under-
stand the difference between all the various disci-
plines shown in Fig. 4 and become confused by the
service delivery model, which prevents them from fo-
cusing on actual change and intervention.
Therapists working with children and families are
often asked the age-old question, “What is your the-
oretical orientation?” The traditional responses are
“psychodynamic,” “behavioral,” “family systems,” or
some other well-defined theory of change. However,
from an ecological model, the theory of change is truly
ecological: If changes are made in systems across the
child’s developmental context, changes in individual
behavior will emerge. Each of these theories (and oth-
ers) may be used as tools at each level to effect change.
For instance, family therapy may be based on family
systems theory, parenting skills training may be be-
havioral, and work with a child may be driven by a psy-
chodynamic model. All these theories, however, come
together under an ecological framework as the tools
for making changes within each level of the system.
The clinical application of this model, there-
fore, requires that therapists and service providers
work from a transtheoretical framework (Prochaska
& DiClemente, 1982). Awareness of the interven-
tion outcome studies prevents the use of play ther-
apy with a child who has severe forms of problem
behavior and instead focuses therapists on chang-
ing parenting practices. However, a child who is well
adapted at home and school (with respect to ba-
sic indices of achievement and behavior) may ben-
efit from individualized attention to address issues
of trust, security, or thought processes that under-
mine a sense of well-being. Future research in the
child and family area will accentuate the need to ad-
dress the question originally raised by many interven-
tion researchers: For whom, for what problems, and
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Ecological Approach to Clinical and Counseling Psychology
Fig. 4. The child and family therapy universe.
under what conditions are the various interventions
effective?
Public Health Perspective
It is no mystery that a great deal of clinical re-
search, and the burgeoning of the number of mental
health professionals since World War II, resulted in
no reductions in the epidemiology of mental health
problems for children. Dramatic increases in mental
health problems, as well as the trend to prescribe psy-
chotropic medications at younger ages, suggest the
need for mental health services that are prevention
focused (Zito et al., 2000). A move must be made
toward a science of addressing the service delivery
systems within which children and families have con-
tact. Interventions also need to be designed that fit
within these contexts (Biglan, 1995). Examples are
federal agencies that serve children and families, such
as Women, Infants, and Children (WIC), preschools
(e.g., Head Start), and public school systems.
In addition, administering interventions where
and when they are appropriate for families (at home,
at school, or at community agencies) and working di-
rectly with teachers and school personnel to improve
services for children is essential, as is working to-
gether with families on a schedule of their choosing.
Currently, funding for mental health services is based
August 8, 2002 15:46 Style file version Nov. 07, 2000
211
on child diagnoses. This model sets up childen and
families for mental health services that are problem
focused rather than strength based. Ultimately, this
model is more costly to both families and third-party
reimbursement. In an ecological approach, services
can be more cost-effective because a broad-based as-
sessment is conducted up front and the treatment is
designed to motivate parents to change. It is imper-
ative that therapists take an active role in educating
funding agencies on this model and redefining the dis-
tribution of mental health resources to children and
families.
ACKNOWLEDGMENTS
Thanks to the intervention staff of Project
Alliance (funded by National Institute on Drug
Abuse, Grant DA 07031), The Next Generation (Na-
tional Institute on Drug Abuse, Grant DA 13773),
and The Shadow Project (National Institute on Alco-
hol Abuse and Alcoholism, Grant AA12702) and to
Ann Simas for editing and graphics preparation on
this manuscript.
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