Send email for updates
Bagley S.M., Ventura A.S., Lasser K.E. et al.
Pediatrics: 2021, 147, S215.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Bagley at firstname.lastname@example.org.
[Consultation draft subject to amendment and correction.] A group of paediatric addiction medicine experts in the US review the evidence base and agree on practice considerations for engaging the family in the care of young adults with substance use disorders, concluding that the more family members are able to engage in activities to improve their own health, the more likely the health of the entire family system will improve.
Summary Without the right support and information, family members can unintentionally have an adverse effect on a young adult’s engagement with treatment, and ultimately, their recovery. The aim of the featured paper was to communicate a series of evidence-informed principles of care pertaining to family members of young adults (defined as people aged 18–25) with substance use disorders, agreed by a national group of paediatric addiction medicine experts in the United States. Most of the evidence presented in the following article is based on information gleaned from adolescents and extrapolated to the young adult population.
Principles of care for engaging the family in the care of young adults with substance use disorders:
Principle 1: Where possible, care should involve family members.
Principle 2: Family members should be counselled on evidence-based approaches for enhancing their loved one’s engagement in care.
Principle 3: Family members should be counselled on resources that can improve their own health.
Evidence. There are few evidence-based family-based therapies for young adults with substance use disorders. These include multi-dimensional family therapy, functional family therapy, and brief strategic family therapy. Recent evidence suggests that all three models share four core elements:
• assessing family dynamics and communication, so that therapists can provide guidance to family members on how to improve interactions with a loved one who has a substance use disorder;
• helping the young person to see their substance use problem as related to problems with family relationships;
• exploring the perspective of the young person about what problems they need help with and how family therapy could make a difference;
• improving whole family health and functioning.
Practice considerations. Despite evidence that family members can play a positive role in their loved one’s care, many obstacles prevent family member involvement, including: few therapists being trained in family therapy for substance use disorders; most models of care failing to routinely involve family members as therapeutic allies; and young people choosing not to involve their family members. If the young adult initially refuses to consent to family involvement, this decision can be revisited because social support is an important factor in recovery and treatment adherence. For young adults unable to identify any family member they would like to be involved in treatment, clinicians should emphasise the importance of peer social networks that support risk reduction. It is also important to note that although family members cannot receive information about their loved one without consent, there is nothing that prohibits family members from providing the care team with information about the young adult.
Evidence. Providing support to families can have a positive impact on engagement in care, even if the loved one is initially not ready for treatment. The Community Reinforcement and Family Training (CRAFT) model teaches family members to engage loved ones who are not yet ready to change their behaviour, and importantly, does not rely on the involvement of the person with substance use problems. The intervention has three goals: help a loved one move toward treatment; help a loved one reduce substance use if treatment is not an option; and improve the well-being of the engaged family members. The CRAFT model teaches family members skills such as using positive contingencies (rewarding the desired behaviour), problem solving, self-care, and communication strategies (eg, avoiding conversations when the loved one is intoxicated). CRAFT has been found to increase treatment engagement from 40% to 71% for people with alcohol, opioid, and other substance use problems and improve anxiety and depression scores among parents (1 2 3). A newer approach, the invitation to change model, draws from CRAFT, motivational interviewing, and acceptance and commitment therapy (an intervention that uses acceptance, mindfulness, and behaviour change to address unpleasant feelings and increase psychological flexibility). In this parent-to-parent model, parents with a child who has a history of substance use (referred to as ‘parent coaches’) are trained over two days by mental health professionals to deliver a phone-based intervention to other parents seeking advice about how to address their child’s substance use. Coaches provide support to parents, education about dependence, and information on how to access treatment and promote the wellbeing of families. Although one study has demonstrated the feasibility and acceptability of this approach, its effectiveness has not yet been established.
Practice considerations. It is difficult for family members to receive evidence-based support on how to enhance their loved one’s engagement in care unless the loved one is ready to discuss treatment. Family members largely rely on support groups such as Al-Anon and Families Anonymous, which, although important resources for families to access, have not been rigorously studied and cannot replace professional support.
The more family members are able to engage in activities to improve their own health, the greater the probability that the health of the entire family system will improve.
Evidence. The more family members are able to engage in activities to improve their own health, the more likely the health of the entire family system will improve. The Five Step Method is an intervention developed specifically for primary care settings to reduce stress-related symptoms and improve coping skills of family members affected by substance use disorders. In this model, the five steps (or sessions) are: listening nonjudgmentally; providing relevant information; exploring ways of coping; discussing social support; and establishing the need for further help. This method can be delivered in person or with a self-help manual. The Five Step Method has been studied in the United Kingdom and has been shown to decrease stress and improve coping among family members (1 2). The CRAFT intervention ( description), has a similar goal of improving family member wellbeing, regardless of whether the loved one enters treatment or reduces substance use. CRAFT improves overall family functioning independent of whether an adolescent is engaged in treatment.
Practice considerations. Family members may not seek counselling or support due to stigma and shame. Some healthcare providers may hold stigmatising beliefs about the family, for example, viewing family members as a barrier to treatment rather than a facilitator. An additional challenge is simply identifying family members who could benefit from support services; screening to identify family members has not been studied.
Family members can provide valuable support to loved ones with substance use disorders and should be educated and empowered to do so. Care for young adults with substance use disorders can be structured so that family members are included, regardless of whether the care is outpatient, inpatient, or residential. Even if the young adult chooses not to allow family involvement in care, family members should still have access to accurate information about dependence, treatment, and how to reduce the risks to their own wellbeing from their loved one’s substance use.
The featured paper is the second in a set of papers covering the principles of care for young adults with substance use disorders, written by a working group of paediatric addiction professionals in the US. See the full set below:
In the UK, there is no more important document for UK clinicians involved in treating problem drug use than the ‘Orange guidelines’ (last published in 2017) – based on evidence and professional consensus on how to provide treatment for most patients, in most instances. These guidelines highlight considerations for children and adolescents as well as older people, but do not specifically address the population of young adults with substance use problems.
Rather than, or in addition to, being thought of as a treatment resource for the patient, an Effectiveness Bank hot topic focuses on families being a group needing support in their own right. This includes issues as varied and important as the (lack of) recognition that relatives might also be ‘carers’, why we should think of family members as individuals needing support as well as parts of a family unit needing support, and the dilemma for service providers about how to safely and effectively deal with conflict in families.
In 2009 the UK Drug Policy Commission designated five different levels of response to family members affected by drug problems: (1) responding to family members in non-specialist settings; (2) assessment; (3) services specifically focused on providing help and support to family members in their own rights; (4) responding to family members delivered as part of services for drug users; and (5) intensive family-based therapeutic interventions ( image).
These levels weren’t intended to depict a hierarchy of provision (ie, level 5 is not ‘better’ than level 4), but the range of interventions that should be available in order to meet the differing needs of family members. The key principle was that “there should be a range of flexible services of different intensities that can respond to the varied and complex needs of families affected by drug problems” (emphasis added).
This draft entry is currently subject to consultation and correction by the study authors and other experts.
Last revised 01 April 2021. First uploaded 01 April 2021
Give us your feedback on the site (two-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates