Prevention of Substance-Related Problems: Effectiveness of Family-

Focused Prevention

Richard SpothPartnerships in Prevention Science Institute

Iowa State University

United Nations Office on Drugs and CrimeTechnical Seminar on Drug Addiction Prevention and

Treatment: From Research to Practice

December 17, 2008

1. Advances in Family-focused Prevention

Positive outcomes from rigorous studies Caregiver-child bonding Child management Social, emotional and cognitive

competencies (e.g., problem solving, goal setting) Substance use, delinquency, conduct problems Mental health problems

See summaries in Spoth, R. (In press). Translation of family-focused prevention science into public health impact: Toward a translational impact paradigm. Current Directions in Psychological Science; Spoth, R., Greenberg, M. & Turrisi, R. (2008). Preventive interventions addressing underage drinking: State of the evidence and steps toward public health impact. Pediatrics, 121, 311-336. .

Selected Examples ofPrevention ProgramsMeeting Rigorous Outcome Criteria• Raising Healthy Children

[Catalano et al. (2003); Brown, Catalano, Fleming, Haggerty, & Abbott (2005); depts.washington.edu/sdrg]

• Nurse-Family Partnership Program (NFP)[Olds et al. (1998); www.nursefamilypartnership.org]

• The Incredible Years[Reid, Webster-Stratton, & Beauchaine (2002); Webster-Stratton & Taylor (2001); www.incredibleyears.com]

• Triple P-Positive Parenting(Heinrichs et al. (2006); Sanders, Markie-Dadds, Tully, & Bor (2000); www.triplep.net ]

• Family Matters[Bauman et al. (2000); Bauman et al. (2002); http://familymatters.sph.unc.edu/index.htm]

• Families That Care: Guiding Good Choices [Park et al. (2000); Spoth et al. (2004); http://www.dsgonline.com/mpg]

See criteria in Spoth, R., Greenberg, M., & Turrisi, R. (2008). Preventive interventions addressing underage drinking: State of the evidence and steps toward public health impact. Pediatrics, 121, 311-336.

2. Challenge of General PopulationIntervention Impact—Substance Initiation

U.S. Monitoring the Future Study, 2005—

among 8th-12th graders, lifetime use prevalence rates

0%

10%

20%

30%

40%

50%

60%

70%

80%

8th Grade 10th Grade 12th Grade

Cigarettes Marijuana Alcohol Drunkenness•Escalating rates of use from 8th-12th grades

•Early initiation linked with misuse/high social, health, economic costs

Two Windows of Opportunity forIntervention with General Populations

See Spoth, Reyes, Redmond, & Shin (1999). Assessing a public health approach to delay onset and progression of adolescent substance use: Latent transition and log-linear analyses of longitudinal family preventive intervention outcomes. Journal of Consulting and Clinical Psychology, 67, 619-630.

Substance Initiation

No UseAdvanced

Use

Intervene to Reduce Probability

of Transition

Sustained, quality EBPs

Evaluated-not effective

EBPs

Conditions for PublicHealth Impact on Substance Use—Requires…

Not Evaluated

Rigorously demonstrated, long-term EBP impact is very rare (Foxcroft et al., 2003).

…a larger “piece” of evidence-based programs (EBPs) to delay two types of transition with general community populations

…sustained, quality implementation on a large scale

3. Illustrations of EvidenceThat Universal Family Programs Work...

...with potential for public health impact.

Intervention Implementation Model for Project Family Randomized Controlled Trial II (First generation partnership model)

State UniversityPrevention Research Team and Extension Specialists

School/Community Implementersassisted by University Outreach System

See partnership model description in Spoth, R. (2007). Opportunities to meet challenges in rural prevention research: Findings from an evolving community-university partnership model. Journal of Rural Health, 23, 42-54.

• Objectives

─ Enhance family protective factors (e.g., caregiver-child bonding)

─ Reduce family-based risk factors for child problem behaviors (e.g., ineffective discipline; low peer resistance)

• Program Lengthweekly two-hour sessions

• Program Formatsessions include one hour for separate parent and child training and one hour for family training*Formerly known as Iowa Strengthening Families Program (ISFP)

One Example―Strengthening FamiliesProgram: For Parents and Youth 10-14* (SFP 10-14)

SFP 10-14 Content

• Key program content for parents─ Effective family management─ Managing emotions/affective quality

• Key program content for adolescents─ Peer resistance skills─ Pro-social attitudes─ Coping with stress and strong emotions

• Key program content for families─ Problem-solving─ Communication

• Observers confirm consistency with protocol

Project Family Trial IISubstance Initiation Results

Source: Spoth, Redmond, Shin, & Azevedo (2004). Brief family intervention effects on adolescent substance initiation: School-level curvilinear growth curve analyses six years following baseline. Journal of Consulting and Clinical Psychology, 72, 535-542.

Lifetime Drunkenness Through 6 Years Past Baseline: Logistic Growth Curve

Project Family Trial IISubstance Initiation Results

Source: Spoth, Redmond, Shin, & Azevedo (2004). Brief family intervention effects on adolescent substance initiation: School-level curvilinear growth curve analyses six years following baseline. Journal of Consulting and Clinical Psychology, 72, 535-542.

0

0.1

0.2

0.3

0.4

0 mo. (Pretest) 6 mo. (Posttest) 18 mo. Grade 7 30 mo. Grade 8 48 mo. Grade 10 72 mo. Grade 12

Fir

st T

ime

Pro

po

rtio

n

Trajectory for ISFP Condition

Trajectory for Control Condition

Lifetime Marijuana Use Through 6 Years Past Baseline

   

 

Project Family Trial IISubstance Initiation Results

Prevalence Age

Rate Intervention Control

Lifetime Alcohol Use without parental permission 40% 15.5 17.0*

Lifetime Drunkenness 35% 15.3 17.5*

Lifetime Cigarette Use 30% 15.7 17.9*

Lifetime Marijuana Use 10% 15.5 17.8

*p < .05 for test of group difference in time from baseline to point at which initiation levels reach the stated levels—approximately half of 12th grade levels—in control group.

Source: Spoth,  Redmond, Shin, & Azevedo. (2004). Brief family intervention effects on adolescent substance initiation: School-level curvilinear growth curve analyses six years following baseline. Journal of Consulting and Clinical Psychology, 72, 535-542.

Average age at given prevalence levels

Project Family Trial II―Wide Ranging Positive Outcomes

Adolescents─Up to 6 Years Past Baseline

• Improved parenting skills• Improved youth skills (e.g., peer resistance, social

competencies)• Improved school engagement and grades• Decreased aggressive/destructive behaviors, conduct

problems• Decreased mental health problems (e.g., depression)

Other Long-termEffects of Family Program

• Significant effects on young adult drunkenness, cigarette use, illicit drug use, offending behavior, health-risky sexual behavior

• Examples of practical significance

Young Adults─10 Years Past Baseline

Sources: Spoth, R., Trudeau, L., Guyll, M., Shin, C., & Redmond, C. (2008). Universal intervention effects on substance use among young adults via slowed growth in adolescent substance initiation. Under review (Journal of Consulting & Clinical Psychology); Spoth, R., Trudeau, L., Shin, C., & Redmond, C. (August, 2008). Universal intervention effects on offending behaviors among young adults via reduction in growth of adolescent problem behaviors. Invited presentation at the annual conference of the American Psychological Association, Boston, MA.

Drunkenness Illicit Use Offending

Family Program 20.2% 14.8% 7.1%

Control 29.5% 18.2% 14.3%

Yields relative reduction rate 22.0% 19.0% 50.0%

Countries in WhichSFP:10-14 Has Been Implemented to Date

Costa Rica

El Salvador

England

Greece

Italy

Nicaragua

Norway

Poland

Puerto Rico

Spain

Sweden

United States

US Virgin Islands

Wales

Are observed initiation outcomestruly “universal”—do they benefit all participants

comparably, regardless of initial risk status?

Does the familyprogram work universally well?

Conclusions fromRisk-Related Outcome Studies─Benefits to Higher-Risk• Comparable benefit across risk-related subgroups

or higher-risk benefit (multiple studies)

• Leveraging effect (lower risk benefit more) intuitively appealing but not empirically supported

• Findings are from studies wherein successfully recruited and retained both higher-risk and lower-risk participants

Does the family programyield economic benefits?

(What are the economic benefits of universal intervention effects on substance initiation?)

Source: Spoth, Guyll, & Day (2002). Universal family-focused interventions in alcohol-use disorder prevention: Cost-effectiveness and cost-benefit analyses of two interventions. Journal of Studies on Alcohol, 63, 219-228.

Project Family Trial IIBenefit-Cost Analysis

*Estimated $9.60 returned for each dollar invested under actual study conditions.

Family plus school more effective than school alone?

• Both family and school are primary socializing environments

• Etiological research confirms powerful risk and protective factors originating in both

• Prospect of intervention synergy—teaching similar skills in two settings

• No prior randomized, controlled studies of this universal combination

• Capable Families and Youth (CaFaY) Trial

Source: Spoth, R., Clair, S., Shin, C., & Redmond , C. (2006). Long-term effects of universal preventive interventions on methamphetamine use among adolescents. Archives of Pediatrics and Adolescent Medicine, 160, 876-882.

0

1

2

3

4

5

6

7

8

Per

cent

age

SFP+LST (p<.05) LST Control11th Grade

2.51

.53

5.18

CaFaY Meth Initiation Results at 4½ Years Past Baseline

When “combined” with school program, how well is it implemented—and working—under “real world” conditions?

Are the effects significantly better than “intervention as usual?”

When the multicomponent intervention is implemented by a community team(“real world conditions”) is the quality of intervention implementationsufficiently high?

Third Generation Sustainability Partnership Design For PROSPER Randomized Controlled Trial

University/State-Level Team

Prevention Coordinator Team

Local Community Teams

PROSPERCommunity Team Activities

• Meet regularly to plan activities/review progress• Recruit participants for family-focused program• Hire and supervise program

implementers• Handle all logistics involved with

program implementation• Market PROSPER programs in

their communities• Locate resources for sustaining

programs

PROSPER Implementation Study Findings• Poor implementation threatens validity• The range of percentage of adherence to protocol in

literature reviews is 42% to 86%.• Average over 90% adherence to the intervention

protocol with family EBIs • Average over 90% adherence with school EBIs• High ratings on other quality indicators• Quality maintained across cohorts

Source: Spoth, Guyll, Lillehoj, Redmond, Greenberg (In press). PROSPER study of evidence-based intervention implementation quality by community-university partnerships. Journal of Community Psychology.

PROSPER Sustainability TrialSubstance Initiation Results

.00

.05

.10

.15

.20

Marijuana Use** (I 1/2 years)

Marijuana Use** (3 1/2 years)

0.03

0.14

0.05

0.19

Past Year Use RatesInterventionControl

**p <0.01

Source: Spoth, Redmond, Shin, Greenberg, Clair, & Feinberg (2007). Substance use outcomes at 1½ years past baseline from the PROSPER community-university partnership trial. American Journal of Preventive Medicine, 32(5), 395-402.

Outcomes at 1½ and 3½ Years Past Baseline

• Ultimate goal is measurable public health impact on substance-related (and other health) problems—using universal preventive interventions delivered with quality on a large scale

• In this connection, our research suggests ISFP/SFP 10-14 (plus school interventions) can work well—effective long-term, across the risk spectrum, with economic benefits, even when “turned over” to community teams

General Conclusions about Family Programs

Needed Work in Family-Focused Prevention―The 4 Es of Intervention Impact• EffectivenessMore programs evaluated more vigorously (e.g.,

long-term follow-ups)

• Extensiveness of coverage Fill gaps re population needs (e.g., for sociodemographically diverse populations, rural to urban)

• EfficiencyMore programs with multiple outcomes, economically efficient programs

• EngagementEffective strategies at individual and organizational levels (e.g., increase organizational readiness to adopt and sustain quality implementation)

Spoth, R. (In press). Translation of family-focused prevention science into public health impact: Toward a translational impact paradigm. Current Directions in Psychological Science.

Plotting the Future Course―Key Tasks in Translating Science into Practice• Adopt comprehensive public health impact oriented models

─ Integrate service development models with evaluation research─ Factor organizational readiness and capacity building─ Factor quality implementation with sustainability

• Implement policies that ─ Prioritize implementation of programs with evidence of potential

economic/public health impact─ Fund broad-spectrum translational research to guide effective large-scale

delivery, guided by comprehensive public health models ─ Support infrastructure for effective large-scale delivery (e.g., practitioner-

scientist networks)

Spoth, R. (In press). Translation of family-focused prevention science into public health impact: Toward a translational impact paradigm. Current Directions in Psychological Science; Spoth, R. L., & Greenberg, M. T. (2005). Toward a comprehensive strategy for effective practitioner-scientist partnerships and larger-scale community benefits. American Journal of Community Psychology, 35, 107-126.

…Linked with an International Research

“Network”

Acknowledgement of Our Partners in Research

Investigators/Collaborators R. Spoth (Director), C. Redmond & C. Shin (Associate Directors),

T. Backer, K. Bierman, G. Botvin, G. Brody, S. Clair, T. Dishion, M. Greenberg, D. Hawkins,

K. Kavanagh, K. Kumpfer, C. Mincemoyer, V. Molgaard, V. Murry, D. Perkins, J. A. Stout

Associated Faculty/ScientistsK. Azevedo, J. Epstein, M. Feinberg, K. Griffin, M. Guyll, K. Haggerty, S. Huck, R. Kosterman,

C. Lillehoj, S. Madon, A. Mason, J. Melby, M. Michaels, T. Nichols, K. Randall, L. Schainker,

T. Tsushima, L. Trudeau, J. Welsh, S. YooPrevention Coordinators

E. Berrena, M. Bode, B. Bumbarger, E. Hanlon K. James, J. Meek, A. Santiago, C. Tomaschik

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