Advances in Family-Based Interventions To Prevent Adolescent Drug Abuse

Thomas J. Dishion, Ph.D.
Research Scientist
Oregon Social Learning Center, Inc.
University of Oregon

Introduction

There is reason for concern that the number of children enjoying success and good health may be decreasing in many communities. The overall rate of problem behavior in children (Achenbach and Howell 1993), rates of violence among children (Dishion et al. 1995, pp. 421-471), and the use of drugs in adolescence seem to be increasing, while the age of use is decreasing (Mathias 1996, pp. 8-9).

Targeting young adolescent drug use is a critical ingredient for the prevention of substance abuse, as onset by age 15 to 16 is among the best predictors of abuse in young adulthood (Robins and Przybeck 1985, pp. 178-193). To prevent early-onset drug use, it is necessary to organize interventions around the promotion of attentive and positive parenting with young adolescents. This statement is justified by findings from two areas of research. First, studies on the development of adolescent drug use show that such risk trajectories are directly or indirectly embedded within family disruption. Second, careful intervention research indicates that targeting families affects risk factors and adolescent problem behavior. The implementation of effective prevention practices depends on our collective understanding of the role of the family in the development of adolescent drug use and the effectiveness of family-based interventions. The following conclusions are based on extensive research conducted over the past 20 years:

• Parenting practices are central to children's development of risk for drug abuse.
• Family interventions are effective in reducing risk among children and adolescents.
• There are clear ingredients to those interventions that effectively target parenting practices.
• Family interventions can be integrated with other intervention strategies.
• Family interventions are economically feasible.

Central Role of Parenting

There is no single definition of success with children and adolescents. Similarly, positive parenting may take on a variety of forms depending on the culture, community context, and constellation of the family. Most parents are quite invested in their children's success and good health. As children mature, however, there is a natural tension that leads to increasing levels of independence and autonomy. Parenting in early and middle childhood sets the stage for the transition into adolescence. Continued parental support and positive family management can further reduce risk and promote success during this life juncture.

The scientific community has focused extensively on the role of parenting in establishing, maintaining, or exacerbating risk trajectories in children and adolescents. The goal of this research is to improve the understanding of developmental patterns leading to adolescent drug abuse as well as to identify which parenting practices to target in intervention and prevention trials. We now know a great deal about the risk and protective factors associated with adolescent problem behavior (Hawkins et al. 1992; Pandina, this volume). Early-onset drug use does not appear randomly, but is often a predictable and identifiable outcome of a developmental progression that begins early in childhood (see figure 1).

Longitudinal studies that examine children before they begin using drugs are relatively rare. However, from the available evidence, it is clear that aggressive or antisocial behavior in childhood precedes substance use in adolescence (e.g., Block et al. 1988; Kellam et al. 1983, pp. 17-51; Smith and Fogg 1979). The sequence of events from childhood to middle adolescence (conceptualized as a progression) appears to be the best predictor of early-onset drug use (Patterson et al. 1992). This progression is probabilistic - not all children go through these stages in exactly the same way. For example, a child with marginal adjustment in the sixth grade can escalate through this sequence of events over the course of 2 years, given a family disruption or change in community risk factors.

Schools are the primary setting in which children's social and economic future is negotiated. Children who do not follow rules quickly fall behind in academic achievement (Patterson et al. 1989). Antisocial children are often disliked by other children (Coie and Kupersmidt 1983; Dodge 1983). The combination of underachievement in school and antisocial behavior, in fact, may seriously undermine the child's acceptance by the peer group (Dishion 1990, pp. 128-153).

Children experiencing academic difficulties and peer rejection tend to cluster into "deviant peer groups" (Dishion et al. 1991), and this process begins quite early (Cairns et al. 1988). However, in early adolescence, such peer clustering has serious implications for early-onset drug use (Dishion et al. 1995, pp. 421-471; Oetting and Beauvais 1987) and delinquent and violent behavior in adolescence (Dishion, Eddy, et al. 1997; Elliott et al. 1985). Exposure to drug use among peers is the strongest correlate of early substance use. It is often at this point that families with troubled adolescents seek treatment, unfortunately, after the investment in drug-using peers has been made. Although change is certainly possible, it is often difficult for parents to compete with the peer socialization process during adolescence.

The structure of the risk progression does not unfold in a vacuum. There is considerable evidence to indicate that it is not so much who the parents are but, rather, their parenting skills that are critical for understanding risk and protection. Researchers are beginning to converge on a definition of parenting practices that fall under the heading of family management: relationship building, limit setting, positive reinforcement, monitoring, and problemsolving/negotiation (Hawkins et al. 1992; Patterson et al. 1992). These parenting practices are not independent skills, but highly correlated and mutually synergistic (Dishion, Li, et al., in press). Regardless of ethnicity or family constitution, adults who have assumed the parental role and use these family management practices can protect children from some of the adverse conditions that lead to drug abuse.

To focus on the central role of parenting in the etiology of adolescent drug use does not justify blaming parents. A variety of stressful family, neighborhood, and community circumstances can disrupt positive parenting practices. Parental substance use is clearly a risk factor for early-onset drug use (Chassin et al. 1986) and may undermine parents' ability to set abstinence as the norm for their adolescents.

Similarly, economic stress associated with historical events like the Great Depression (Elder et al. 1985), recessions (Conger et al. 1992), or longstanding patterns of disadvantage (McLoyd 1990) disrupts parenting, which in turn feeds into the risk structure. Parents can buffer the effects of such stress, although under some circumstances, the performance of positive parenting requires Herculean efforts.

Cultural stress occurs in a variety of forms and affects a growing number of our Nation's families and children. It is difficult for parents to bridge the gap between two cultural worlds as is often the challenge for Hispanic families (Szapocznik et al. 1980). Acculturation can have a disruptive impact on parenting. Interventions that provide support for parents under these stressful circumstances (bicultural training) are known to improve family functioning and relate to more positive outcomes in children (Sza-pocznik et al. 1984).

A growing number of families are experiencing the disruption of divorce and remarriage. These events are far from trivial to the lives of children. Family management is clearly a protective factor in the context of divorce (Forgatch et al. 1988, pp. 135-154). How parents handle conflict and their ability to prioritize their children's best interests by cooperation and negotiation is the key factor in explaining why some children remain healthy and successful in the face of serious stress (Buchanan et al. 1991; Maccoby et al. 1990). The number of remarriage transitions is linearly related to the level of maladjustment, including the use of drugs in childhood and early adolescence. However, the use of family management practices can dramatically reduce that risk (Capaldi and Patterson 1991).

In light of the rising levels of substance use and violence, the role of communities requires examination. Unfortunately, much of this research does not directly assess such influences in juxtaposition to what parents are doing to mitigate adverse conditions. Pioneering research by Wilson (1980) is a notable exception. This research indicated that in high crime areas in inner-city London, parental supervision was a key protective factor for preventing delinquency.

It is becoming increasingly clear that parental monitoring is the foundation of positive family management, especially during adolescence when children become more independent and spend increasing amounts of time away from their parents (see figure 2; Dishion and McMahon 1998; Wilson 1980). To maintain a positive relationship, parents need to be aware of the positive efforts of their children.

In this sense, parental monitoring is both directly and indirectly related to early-onset drug use. The direct relationship is documented in various studies showing that poor parental monitoring predicts early substance use (Baumrind 1985, pp. 13-44; Dishion and Loeber 1985). Parental monitoring is also indirectly related to substance use via its impact on time spent with peers. Children who are not well monitored tend to wander about the community, freely selecting places to spend time that include drug use and other delinquent activities (Patterson and Dishion 1985; Stoolmiller 1994).

In summary, the evidence is clear that parenting practices can serve as a protective factor in the face of adverse, risky environments. Because of this protective role, parenting practices serve well as a target for the prevention of adolescent drug abuse.

Family Interventions Work

In general, a distinction should be made between interventions that support existing parenting competencies and those that target risk factors or family dysfunction. As discussed below, these two levels of intervention can be integrated. The bulk of the more rigorous research involving control groups and random assignment focuses on interventions that target risk and dysfunction.

Research has indicated that interventions aimed at improving parenting practices result in the reduction of risk factors as well as actual substance use in adolescence. Figure 3 summarizes the findings on the effectiveness of family-based interventions. These conclusions are based on the assiduous efforts of intervention scientists, most of whom are supported in their research by the National Institutes of Health.

Early Childhood

Oppositional problems in the preschool years are a precursor to antisocial behavior (Campbell 1994). Reduction of behavior problems at this age has the potential for long-term preventive effects. Webster-Stratton (1984, 1990) documented that parenting groups that focus on providing support for young families, in conjunction with skill development, produce marked improvements in observed parent-child interaction and teacher ratings of problems in preschool and that the positive effects persisted for at least 3 years after the intervention. Other researchers have found that parenting interventions are effective in reducing behavior problems in early childhood (Dadds et al. 1992). A critical piece of the Webster-Stratton program is the development of videotapes that provide examples of positive parenting practices. These videotapes are so useful to parents that change was observed in children's behavior as a function of the videotapes without the help of therapists (Webster-Stratton et al. 1988). However, in general mothers preferred to use the videotapes in leader-guided parent training groups.

Middle Childhood

Antisocial and aggressive behavior in childhood is a major predictor of adolescent drug use (Kellam et al. 1983, pp. 17-51). Interventions targeting parenting practices are the most promising in reducing antisocial behavior in middle childhood (Dumas 1989; Kazdin 1993; Patterson et al. 1993, pp. 43-88). The evidence is extensive, with several impressive studies of effectiveness. Patterson (1974) found that parent training interventions were effective in reducing antisocial behavior in the home and at school. Johnson and Christensen (1975) revealed that the impact of parent training was evidenced in parent perceptions, direct observations in the home, and brief telephone interviews. McMahon and colleagues (1993) found that parents were satisfied with parent training.

The advantage of family-based interventions is that the benefits accrue to all family members. For example, Arnold and colleagues (1975) documented that parent training produced statistically reliable changes in the behavior of the siblings of the referred child. This finding is particularly relevant when we consider that drug abuse and serious delinquency tend to run in families. West and Farrington (1973) found that 50 percent of the crimes in any given community are committed by no more than 10 percent of the families within them. Research by Kumpfer and colleagues (1996, pp. 241-267) is supportive of the preventive potential of the Strengthening Families program. This program of research is exemplary with respect to its applicability and amenability to a wide range of families in diverse ecological settings.

Adolescence

It is often asserted that it is necessary to intervene early if one wants to have a preventive effect. Current knowledge suggests that this is simply not true and that intervention during adolescence is critical within an overall prevention strategy. If one takes a life-cycle perspective, interventions with high-risk adolescents can prevent difficulties in the next generation of young children, especially those of teenage parents.

Harm reduction is an explicit goal of intervention in the adolescent phase of development. If interventions reduce the escalating cycle of drug abuse, delinquency, sexual precocity, or extensive incarceration, it is possible that very real negative outcomes could be prevented. From this perspective, it is for each developmental phase that interventions are designed that reduce risk and promote current adaptation and success in the next developmental transition (Dishion and Kavanagh, in press).

Results of outcome studies indicate that family-based interventions during adolescence are effective in reducing current problem behavior and future risk (Alexander and Parsons 1973; Bank et al. 1991; Henggeler et al. 1986, 1992). The data suggest that interventions that promote family management reduce adolescent substance use (Bry et al. 1982; Bry and Canby 1986; Friedman 1989; Henggeler et al. 1997; Lewis et al. 1990; Schmidt et al. 1996; Szapocznik et al. 1997, pp. 166-190). Thus, contrary to popular misconception, behavior does not crystallize in adolescence and become intractable to family intervention.

To surmise the potential of family-based interventions for the prevention of drug abuse, it is necessary to consider studies that target not only adolescent substance use but also known precursors, such as behavior problems in early childhood and antisocial behavior in middle childhood. Taken together, the data are quite strong in favor of family-based approaches.

Ingredients of Effective Family Interventions

The studies cited previously share a common focus on the use of family management skills and promoting parents as the leaders of families. In addition, the science of family-based intervention is converging on the ingredients. In short, effective family-based prevention efforts should have the characteristics described below.

Collaborative and Respectful

Webster-Stratton and Herbert (1993) summarized collaborative models as including support, empowerment, and expertise and challenging parents to change and foresee problems and setbacks. In the author and colleagues' work in parent groups, the parents' rate of "advice-giving" was associated with positive change in parenting practices. On the other hand, the more the therapist taught social learning skills, the less parents changed. This finding is consistent with those of Patterson and Forgatch (1985), who found that when therapists increased their level of teaching, client resistance to change followed suit immediately. Patterson (1986) initially discussed this as a paradox for behavior-oriented therapies, where the presumption is that therapists exercise influence on change via their expertise in behavior change technology (e.g., point charts, timeouts, etc.). Behavior change is a delicate process that requires a period of contemplation regarding the need for change (Prochaska and Diclemente 1982).

Ecologically and Culturally Sensitive

A major barrier in working with parents is engagement and collaboration. Professionals in schools who try to meet with parent groups at night report that the parents simply do not attend. Parents often drop out of parent training programs prematurely, seemingly hopeless about their potential for having an impact (Dishion and Patterson 1992).

Parents are sensitive to the dynamics of the engagement and change process. Szapocznik and colleagues (1988) found that home visits prior to family therapy were critical to promote engagement and reduce early dropout. Patterson and Chamberlain (1994) reviewed findings on optimal strategies for minimizing parent resistance to change by using "soft clinical skills" such as support and empathy, and minimizing teaching, directives, or confrontations with the family. Reframing verbal statements by family members regarding the "cause" of the problem is critical for change and the engagement of both the child and parents in the change process (Robins et al. 1996).

Finally, interventions with parents must be culturally sensitive (Kumpfer et al. 1996, pp. 241-267). For example, families experiencing the stress of acculturation need expertise and support in this area (Coatsworth et al. 1996, pp. 395-404), as well as therapists who are sensitive to cultural perspectives.

Flexible Delivery

As the previous points suggest, in interacting with parents in the change process, family intervention leaders need to be flexible at an interpersonal level. Behavioral family therapy focuses on supporting change in the family interaction contingencies. However, how that is accomplished varies, is highly flexible, and depends on the history and motivation of the parent. In many respects, the behavioral therapist is required to go "beyond technology" to be successful in working within a behavioral modality (Patterson 1985, pp. 1344-1379).

Family-based interventions also must be flexible with respect to scheduling and locus of the intervention activity. Spoth and Redmond (1996, pp. 299-328) have advanced the field by using marketing research strategies to better understand optimal ways of engaging and working with families. Families are not inclined to participate in family interventions that are led by professionals, have more than a 5-week time commitment, or involve the school or other parents. Despite these preferences, not all parents will seek the same intervention services, and therefore it is necessary to offer a wide range of intervention times and modalities in a variety of locations.

Finally, a rigid focus on parenting issues is not as effective as encompassing multiple levels of issues that confront and disrupt parenting (Henggeler et al. 1986; Prinz and Miller 1994). The flexibility of the intervention agenda is consistent with the principles of effective interventions for reducing alcohol problems (Miller and Rollnick 1991). In general, a menu of intervention options is more motivating.

Effective family-based intervention strategies interact with parents respectively, supportively, and collaboratively. They actively empower parents to take a leadership role in the family and to engage in effective, noncoercive family management practices. It is critical that family-based interventions be sensitive to the cultural and ecological context of the family.

Family Interventions Are Integrative

To understand the etiology of drug abuse, many preventionists are moving toward an "ecological model" design of prevention/intervention programs (Henggeler 1993; Szapocznik et al. 1997). An ecological model proposes that the problem of drug abuse does not lie exclusively with the individual but is a net outcome of contextual (settings and cultural issues) and individual factors. Research by Pentz and colleagues (1989) indicates that comprehensive strategies that integrate parenting practices have meaningful long-term effects.

Parent interventions should be compatible with other intervention strategies and capable of integration into more comprehensive community intervention programs. Figure 4 summarizes this point, making the connections between school-based interventions, mentoring programs, recreation, and academic assistance.

The key point is that support for family management is at the center of the network. Communities need to consider the potential, unintended impact of an intervention program on family functioning. In general, interventions that inadvertently weaken the leadership role of parents or family management practices may have long-term negative effects. For example, Szapocznik and Kurtines (1989) found that a child-centered psychodynamic intervention may have caused family functioning to deteriorate. The assignment of a college student mentor can undermine a single parent who has little available time or resources. The mentor can take the child to recreational activities and always be upbeat, optimistic, and well rested; the child may make negative comparisons of the parent with the new mentor, or the parent's authority could be impaired by a mentor's scheduling events with the child without coordinating family management issues.

More optimistically, involving parents of high-risk youth in prevention activities such as recreation or clubs is likely to improve the preventive effect (St. Pierre et al. 1997). Certainly, integrating parents into prevention strategies shows promise (Telch et al. 1982).

If school-based programs ignore the role of parents in resisting drug use, over time this could have a negative impact on parents' collective sense of responsibility and empowerment in the effort to keep their children safe and healthy. Drug education and prevention would become the business of the school. It is in this sense that health promotion and the prevention of adolescent drug abuse would be better served by careful consideration of the critical role of caretaking adults in the long-term developmental trajectories of children.

Family Interventions Can Be Cost-Effective

One of the barriers to integrating family interventions into community prevention is the perceived cost. Yet, analyses of the benefits indicate that simple parent training is the most cost-effective strategy available for the prevention of crime (Greenwood et al. 1994). One can dramatically reduce such cost by matching the intervention with the levels of need and risk.

Several developments indicate that innovations in the cost-effectiveness of intervention models can be further improved by a focus on motivation to change. One development is a reformulation of the change process in the area of addictions. For example, it was found that most smokers who quit do so on their own. From this line of research, Prochaska and DiClemente (1986, pp. 3-27) developed a transtheoretical model of change that emphasizes the stages-of-change process. The major hurdle is reevaluating past behavior and making a decision to change and take action. Many individuals go through the contemplation-action cycle repeatedly until long-term change is maintained. This stages-of-change perspective has been empirically tested by Prochaska and colleagues (1991).

Currently the model serves as a guide to a brief, effective intervention with problem alcohol use, called motivational interviewing (Miller and Rollnick 1991). Motivational interviewing focuses on the stages of change by assisting individuals in the awareness of the discrepancy between their goals and their actual behavior. Motivation to change is induced through sharing of assessment approaches with clients and emphasis on support, empowerment, and responsibility for the behavior change process. The "Drinkers Check-Up" is an example of motivational interviewing that has been extensively tested (Brown and Miller 1993). The "Drinkers Check-Up" takes approximately two to three meetings with a client, but is superior to inpatient treatment (typically 28 days) in reducing alcohol problems.

This discussion is important to the design of family-based interventions in determining the viability of relatively brief interventions. In the next decade, a priority for many researchers will be to develop and evaluate a range of interventions, from brief motivational interventions to intensive family therapy.

The author is currently testing a family-based multiple gating model that integrates three levels of intervention: universal, which targets every person in the population; selected, which targets those families defined as at risk; and indicated, involving more intensive support for change for those who have been diagnosed with a given disorder. The multiple gating metaphor was derived from previous work in multistage assessments (Cronbach and Glesar 1965) and applied to screening and intervention with problem youth (Dishion and Patterson 1992; Dishion and Kavanagh, in press; Loeber et al. 1984). Figure 5 provides a brief overview of the multiple gating model of parent engagement and intervention.

The first task in engaging parents in the prevention of drug abuse is to make an effective link between the efforts of the school and the parents. A Family Resource Center is established for that purpose. In an average middle school, the prevention activities (available to the entire parent population) could be carried out by one full-time parent consultant. Research indicates that it is the ability to work collaboratively with parents, rather than the academic degree, that is crucial (Christensen and Jacobson 1994). Thus, nonprofessionals or paraprofessionals (with the proper training) could staff the Family Resource Center.

Several intervention activities are carried out through the Family Resource Center and are integrated with the prevention activities of the school. School-based curriculums (see Botvin, this volume) are often delivered in middle school health classes and have shown effects in delaying the onset of tobacco, marijuana, and alcohol use. The author has developed a similar school-based curriculum (Teen Focus) that integrates interventions for students with brief parent interventions. All parents of children in the health class receive information and engage in exercises in family management practices that promote positive child outcomes and reduction of the risk for early-onset drug use.

The second level of intervention is the Family Checkup. Teachers are highly effective at identifying which youths are at risk for future problem behavior (see Dishion and Patterson 1992; Loeber and Dishion 1983). To reach the second level, the Family Checkup service is offered to all families in the moderate risk range. For middle school boys, this is determined primarily by their social behavior in the classroom and at school. For girls, academic failure is an additional indicator of risk.

The Family Checkup is a two- to three-session evaluation and feedback service that builds on the work of Miller and colleagues. Families are intensively assessed in their homes (90-minute sessions), and the youths are assessed at school. Parents are then provided with feedback to build motivation to continue those positive family management practices that are already in place and to improve on those parenting practices or circumstances that have been shown to elevate the risk of drug use in early adolescence. It is essential that the feedback sessions utilize the principles described previously for effectively working with parents.

Finally, on the basis of the Family Checkup, a small percentage of families (approximately 5 to 10 percent) will require more intensive support for change, along the lines described in the work of Bry, Hennegler, and Szapocznik. Support for change in family management includes daily information regarding the child's attendance, behavior, and homework completion; meetings with the parent consultant to support and solve parenting issues; and mobilization of community resources to reduce the family disruption that interferes with effective parenting.

This comprehensive model is currently being tested in a NIDA-funded prevention trial. Participants include 1,200 youth and their families from different racial and ethnic groups. Although each of the components described above has been shown to be effective, research will extend the findings to determine which level of intervention is indicated for families with varying levels of risk.

Summary

The etiology of drug abuse is not a mysterious accumulation of risk factors, but rather an outcome of disrupted parenting. There are widely various trends that are stressful for American families and that expose children to early-onset drug use and potential drug abuse. The use of effective family management practices is seen as a major protective factor. In this sense, prevention strategies that promote family management and adult involvement are critical for the long-term effectiveness of prevention. The evidence is clear that mobilization of parents at various developmental stages is likely to be effective in reducing risk or harm to children and adolescents. Developments within the behavioral change sciences in general, and within family-based interventions in particular, are promising with regard to the cost-effectiveness of reaching out to parents to collaboratively promote the health, success, and well-being of children.

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