Prevention of Substance-Related Problems: Effectiveness of Family-Focused Prevention

1. Prevention of Substance-Related Problems: Effectiveness of Family-Focused Prevention Richard Spoth Partnerships in Prevention Science Institute Iowa State University United Nations Office on Drugs and Crime Technical Seminar on Drug Addiction Prevention and Treatment: From Research to Practice December 17, 2008

2. 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. .

3. 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.

4. 2. Challenge of General PopulationIntervention Impact—Substance Initiation U.S. Monitoring the Future Study, 2005— among 8th-12th graders, lifetime use prevalence rates • Escalating rates of use from 8th-12th grades • Early initiation linked with misuse/high social, health, economic costs

5. No Use Substance Initiation Advanced Use Intervene to Reduce Probability of Transition 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.

6. Sustained, quality EBPs Conditions for PublicHealth Impact on Substance Use—Requires… …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 EBPs Evaluated- not effective Not Evaluated Rigorously demonstrated, long-term EBP impact is very rare (Foxcroft et al., 2003).

7. 3. Illustrations of EvidenceThat Universal Family Programs Work... ...with potential for public health impact.

8. School/Community Implementers assisted by University Outreach System State University Prevention Research Team and Extension Specialists Intervention Implementation Model for Project Family Randomized Controlled Trial II (First generation partnership model) 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.

9. One Example― Strengthening Families Program: For Parents and Youth 10-14* (SFP 10-14) • 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 Lengthweekly two-hour sessions • Program Formatsessions include one hour for separate parent and child training and one hour for family training *Formerly known as Iowa Strengthening Families Program (ISFP)

10. 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

11. Project Family Trial II Substance Initiation Results Lifetime Drunkenness Through 6 Years Past Baseline: Logistic Growth Curve 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.

12. Project Family Trial II Substance Initiation Results Lifetime Marijuana Use Through 6 Years Past Baseline 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.

13. Project Family Trial II Substance Initiation Results Average age at given prevalence levels 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.

14. 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)

15. Other Long-termEffects of Family Program • Young Adults─10 Years Past Baseline • Significant effects on young adult drunkenness, cigarette use, illicit drug use, offending behavior, health-risky sexual behavior • Examples of practical significance 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.

16. Countries in Which SFP: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

17. Does the family program work universally well? Are observed initiation outcomestruly “universal”—do they benefit all participants comparably, regardless of initial risk status?

18. 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

19. Does the family programyield economic benefits? (What are the economic benefits of universal intervention effects on substance initiation?)

20. *Estimated $9.60 returned for each dollar invested under actual study conditions. Project Family Trial II Benefit-Cost Analysis 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.

21. 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 SFP 10-14+LST • Capable Families and Youth (CaFaY) Trial

22. CaFaY Meth Initiation Results at 4½ Years Past Baseline 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.

23. When “combined” with school program, how well is it implemented—and working—under “real world” conditions? When the multicomponent intervention is implemented by a community team(“real world conditions”) is the quality of intervention implementationsufficiently high? Are the effects significantly better than “intervention as usual?”

24. Third Generation Sustainability Partnership Design For PROSPER Randomized Controlled Trial Local Community Teams Prevention Coordinator Team University/State-Level Team

25. 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

26. 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.

27. **p <0.01 PROSPER Sustainability TrialSubstance Initiation Results Outcomes at 1½ and 3½ Years Past Baseline 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.

28. General Conclusions about Family Programs • 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

29. Needed Work in Family-Focused Prevention―The 4 Es of Intervention Impact • EffectivenessMore 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) • EfficiencyMore programs with multiple outcomes, economically efficient programs • EngagementEffective 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.

30. 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.

31. …Linked with an International Research “Network”

32. 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/Scientists K. 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. Yoo Prevention Coordinators E. Berrena, M. Bode, B. Bumbarger, E. Hanlon K. James, J. Meek, A. Santiago, C. Tomaschik

33. Welcome to our website at... www.ppsi.iastate.edu