Drug and Alcohol Findings home page in a new window Background notes

Guide to implementing family skills training programmes for drug abuse prevention

Research backing for relatively well researched interventions: Strengthening Families Programme

On behalf of the United Nations, Karol Kumpfer of the University of Utah undertook the featured literature review, coordinated the technical consultation, and on the basis of this work, drafted the featured guide. Dr Kumpfer originated the Strengthening Families Programme, which in the featured review, and in another on the prevention of drinking, emerged as having the best research record among this type of programme.

This means research on the Strengthening Families Programme can be considered a measure of the maximal adequacy of research support for substance use prevention through family programmes in general. Promising as the research is, on this measure positive findings are lacking from studies which are convincing enough to be taken as an indication of how programmes would perform if applied to high-risk families or families across the board. In 2004 Findings reviewed this evidence and found it impressive in quantity but until recently deficient in methodological quality and the comprehensive reporting of results in scientific journals. Developed initially for high-risk families, later trials of a version for the general run of children and families overcame these methodological limitations, but suffered recruitment shortfalls which raised questions over the generalisability of the results. This limitation too was overcome in a later study which did recruit all the targeted children in 36 secondary schools in the rural US mid-west, and had high follow-up rates. It was a particularly stringent test because the revised programme supplemented evidence-based school drug education lessons, and was compared against the performance of other schools which implemented just the lessons. Still adding the family programme initially led to substantially reduced uptake of drinking, suggesting that earlier good results were not simply a methodological artefact or due to selective recruitment in to the studies.

However, benefits were short-lived. The latest follow-up found no real hint that adding the family programme had continued to improve on the school lessons in terms of drinking or the other substance use measures reported in the study, though there may have been other benefits. Remaining support for the universal application of the programme comes mainly from a study whose findings (impressive as they were) derived from just over a third Though every family who participated and supplied the relevant data was included in the analysis regardless of whether they had attended the sessions. Also on all but one (parent education) of the variables measured (parent education, household income, target child gender, parent marital status, number of children, child conduct problems, and social-emotional distress), the families who participated in the study did not differ from those who did not. of the mainly white and rural families asked to participate in the study. A similar limitation applied to a later study of a substantially revised version among poor black families. Because of the way they were designed, these trials could establish benefits only among the minority of families prepared or able to participate in the interventions and complete the studies.

The study among mainly white and rural families was the sole basis for a calculation of the cost-benefit ratio of the programme in terms of crime, substance abuse, educational outcomes, underage pregnancy, teenage suicide attempts, child abuse or neglect, and domestic violence. The same analysis made similar calculations for other prevention programmes aimed at young people. These in turn were a basis for a later analysis of the costs and benefits of substance use prevention programmes in particular. For the Strengthening Families Programme, the resultant estimate was $11 saved for every $ spent, a higher ratio than many school or parenting programmes but lower than some, and also lower than some entirely different kinds of initiatives like enforcing laws on serving drunk customers in licensed premises. It has been argued that this ratio should be more than tripled to $36 for every $ to take in to account benefits to the wider family including parents and other siblings. For this and for several of the other programmes in the analysis, the accounting of benefits was undoubtedly limited, but in the case of Strengthening Families, estimates rested on just a single study of what ended up being a highly selected set of families. As such they illustrate the potential for benefits rather than the degree to which these would materialise in real-world application as a universal prevention strategy.

Research on universal versions of the Strengthening Families Programme also exemplifies a major practical limitation in family-based approaches – persuading parents to participate. In the study mentioned above which did recruit all the targeted children, only a quarter But 38% of those actively recruited to the sessions. of the families allocated to the programme attended any of the family sessions. So far in the UK a small pilot study has established the programme's feasibility among a small set of families.

Research backing for relatively well researched interventions: Family Check-Up

Similar problems were experienced by another well constructed and relatively well researched programme. It sought to address recruitment of high-risk families by paving the way with elements applied universally to all families, and by offering its services in the form of a 'Family Check-Up', de-stigmatising the process and stressing its collaborative nature. All the families of the 11–12-year-old pupils who started the study (1 2) were offered the services of a Family Resource Centre at their schools staffed by a Parent Consultant, and all the children received health promotion lessons from the consultant. Building on these initial contacts, high-risk families were identified by teacher ratings of the children and offered the three-session Family Check-Up, involving assessment, feedback and planning of further services. Despite this proactive approach, most (about 60%) of these families did not receive the check-ups, and few of those who did elected to engage in further services. In a subsequent wave of the study, take-up was improved by a prior home visit by the consultant, making personal contact before the more high-risk families were offered the check-up.

Despite disappointing take-up of the full intervention, at first a composite measure of recent substance use Past-month use of alcohol, tobacco and for high-risk children, also cannabis. showed that across all the families in the study, and among high-risk families in particular, growth of substance use to age 14–15 had been significantly retarded compared to control group A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. children in school classes not offered the intervention package. But a later report on both waves of the study which followed the children up to age 16–17 found that across the entire samples, offering a family-based intervention had no impact on the growth of drinking, smoking or cannabis use, or on records of arrests.

The analysis went on to assess the effects among the minority (23%) of families who were offered and accepted the family check-up. They were compared against families in the control group who it was thought would also have accepted the check-up had it been offered. Among these known or presumed intervention-accepters, growth of use of all three substances was significantly retarded (as also were diagnoses of dependence on the same substances and anti-social behaviour). This attempt to assess the effect of actually going through the check-up was however dependent on the validity of the assumptions behind the statistical methods used, and of the assessment of who among the control group families would have accepted the check-up, both of which were open to question. As yet it seems no published report taking in the results of both waves of the study has established consistent prevention impacts across the samples or in the high-risk families, though a future report is expected to do so.

Early positive results from the study were a major part The estimates were based on just two studies. of the basis for an estimate of the cost-benefit ratio of the programme in terms of crime, substance abuse, educational outcomes, underage pregnancy, teenage suicide attempts, child abuse or neglect, and domestic violence. The same analysis made similar calculations for other prevention programmes aimed at young people. These in turn were a basis for a later analysis of the costs and benefits of substance use prevention programmes in particular. For the Family Check-Up programme, the resultant estimate was $8 saved for every $ spent. As with the Strengthening Families Programme, this was higher than for many school or parenting programmes but lower than some, and also lower than some entirely different kinds of initiatives. However, with this programme too it can persuasively be argued that the ratio should be higher to take in to account benefits to the wider family. In this case though the estimates were unable to take in to account the later results from the study when pupils were aged 16–17, which found that across the entire samples, there had been no lasting impact on the growth of substance use or on records of arrests. As well as calling in to question the cost-benefit calculations on the Family Check-Up programme in particular, this lack of persistence in impact calls in to question a key assumption The assumption was made that substance abuse costs decline in proportion to delays in initiation as a result of prevention programming and that benefits accrue over a multi-year period. of the entire cost-benefit analysis in respect of school or parenting programmes – that short-term delays in the onset of substance use translate in to longer term savings in costs related to the misuse of those substances.

In sum, research on the Family Check-Up produced initial positive findings on composite measures of substance use, though across the entire sample by the time the children aged 16–17 disaggregated measures for each of the substances failed to show benefits, except perhaps among the minority of families of the kind who are prepared to participate in such an intervention. Apart from any impacts on substance use, promising features of this study are that it was the highest risk among the high-risk families who responded to the offer of a check-up by accepting it, perhaps prompted by the teacher's assessments that their children were not doing well, and that once all the steps were in place to make initial contact before this offer, take-up, though far from universal, seems to have been reasonably high.

Recruiting families of early adolescent children

The Family Check-Up study and experience with the Strengthening Families Programme when targeted at high-risk families suggest that recruitment obstacles can be effectively addressed, but British experience to date is that there is a serious risk of missing out on families in greatest need due to factors such as poor contact with the school, lack of commitment to parenting, or inability to attend (1 2).

Pilots of the Strengthening Families Programme targeted at high-risk families in the UK have found it difficult to recruit (though not then to retain) families to the intervention, and have (like the US Family Check-Up intervention) found prior home visits aided recruitment. Those families who did attend in these studies and in another similar but very small-scale UK study seemed to gain substantial benefits.

Recruitment can be an even bigger problem for programmes aimed at parents who are under no pressure and may see themselves as having no particular reason to participate. In the late '90s a UK trial of a combined family and parenting/community intervention aimed at teenage pupils found that parental drama workshops were poorly attended, especially by parents of high-risk pupils. Just 10% of year nine (age 13–14) pupils who intended to take drugs said their parents had gone compared to 16% who did not intend to take drugs. Additionally, in the vicinities of the three intervention schools, 12 groups were held with parents who were themselves interested in learning more about drugs. The only significant impact of the broad ranging intervention involving these components was the de-escalation of drug use among the few existing young users. There were no significant impacts across the entire population of pupils.

In the Blueprint school drug education study implemented in 2004 and 2005, involving parents was expected to be an important component. In the event, parental attendance at the launch events was poor (just 6% of families were represented) and across 23 schools, just one parent was persuaded to help recruit other parents to attend parent information and advice workshops. A knock-on effect was poor attendance at the workshops, which were implemented only at ten schools and involved just 69 parents.

Other examples include a project attempting to involve young black and ethnic minority fathers in London. This did recruit 20 to its action learning sets and groups dealing (among other issues) with parenting in respect of drug and alcohol use, but attendance was often sporadic, a shortfall which could not have helped in working through perceptions of drug use as either a sin or something simply to abstain from. Reaching "marginalised" parents of young adolescents in Sussex was also noted to have been challenging. At a school with 1612 pupils, 20 attended evening drug education workshops. In respect of drinking, attempts to involve parents in exercising greater control over their children's drinking also face the barrier of the relaxed attitude to underage drinking and even underage drunkenness among many British parents.

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