Invited Paper
Effectiveness of a Culturally Tailored, Family-Focused Substance Abuse Program: The Strengthening Families Program

Karol L. Kumpfer, Ph.D.*
Health Education Department
University of Utah

Introduction

Providing the support that families need in order to raise well-adjusted children is becoming increasingly important because of escalating rates of juvenile crime, child abuse, and drug use. The Monitoring the Future study (Johnston et al. 1996) shows steady increases since 1992 in tobacco use and since 1993 in illicit drug use. One-third (34 percent) of high school seniors now say they smoked in the past 30 days, and 22 percent report smoking daily. In the past year, 40.2 percent of seniors have used an illicit drug. Marijuana 30-day use rates for seniors have almost doubled since 1992, rising from 11.9 percent to 21.9 percent.

Although these increases are correlated with the immediate precursors of decreased individual and peer perceptions of the harmfulness and disapproval of drugs, social ecology model (SEM) data suggest that parents have an early influence on the developmental pathways toward drug use (Kumpfer and Turner 1990/1991). Whereas many empirically tested etiological models (Oetting 1992; Oetting and Beauvais 1987; Oetting et al. 1989; Newcomb 1992, pp. 255-297) find that peer-cluster influence is the major reason to initiate drug use, parental disapproval of drugs is a major reason not to use drugs (Coombs et al. 1991). Moreover, parental support has been found to be one of the most powerful predictors of reduced substance use in minority youth (King et al. 1992; Dishion et al. 1995, pp. 421-471). Hansen and associates (1987) have found that increased parental supervision is a major mediator of peer influence. Models that more finely test the aspects of family dynamics related to youth problem behaviors (e.g., antisocial behavior, substance abuse, high-risk sex, academic failure) find family conflict associated with reduced family involvement at Time 1 (T1) that significantly predicts inadequate parental supervision and peer deviance at T2. Ary and colleagues (1996) found direct paths from parental supervision and peer deviance to problem behaviors, suggesting that not all family risk processes are mediated by deviant peer involvement.

These etiological research studies suggest that parenting and family interventions that improve family conflict, family involvement, and parental monitoring also should reduce problem behaviors, including substance abuse (Bry 1983, pp. 154-171; Mayer 1995). Parenting skills training programs are effective in reducing coercive family dynamics (Webster-Stratton 1981, 1982; Webster-Stratton et al. 1988) and improving parental monitoring (Dishion and Andrews 1995). Like other researchers (Bry 1996; Dishion 1996; Szapocznik et al. 1988), this investigator believes improving parenting practices is the most effective strategy for reducing adolescent substance abuse and associated problem behaviors. Strengthening families could significantly reduce this increased trend in adolescent drug use and other problem behaviors (Achenbach and Howell 1993).

One type of family support currently gaining in popularity is structured interventions for high-risk families, such as parent training and family skills training. According to the Institute of Medicine prevention classification scheme of "universal" (general population), "selective" (targeted), and "indicated" (subjects with identified risks) prevention interventions (Gordon 1987; Mrazek and Haggerty 1994), the family skills training intervention discussed in this paper is classified as a "selective" intervention targeting high-risk individuals or subgroups.

CSAP/PEPS Family Research Review

In a review of family intervention research for substance abuse prevention, only three family approaches appear to meet the National Institute of Medicine criteria for "strong level of evidence of effectiveness." According to the Center for Substance Abuse Prevention (CSAP) Family Prevention Enhancement Protocol System (PEPS) Expert Panel, this review of the research literature found that only behavioral parent training, family therapy, and family skills training approaches to prevention (Center for Substance Abuse Prevention 1998) show strong evidence of effectiveness in reducing risk factors for drug use, increasing protective factors, and decreasing drug use. Parent education, family support, and family education models did not have enough research studies with experimental or quasi-experimental designs with positive results to warrant qualifying as effective approaches at this time, although family support programs appear promising (Yoshikawa 1994).

The multicomponent family skills training approach appears to affect the largest number of measured family and youth risk and protective factors, according to a separate outcome analysis conducted for PEPS and presented at the NIDA family conference (Kumpfer, Wanberg, and Martinez 1996). Because multicomponent family skills training programs generally incorporate behavioral parent training, children's skills training, and behavioral family therapy, they address more risk and protective factors than other types of therapy.

Office of Juvenile Justice and Delinquency Prevention: Family Strengthening Research Interventions

In a 5-year evaluation of more than 500 family and parenting programs for the National Institute of Justice, Office of Juvenile Justice and Delinquency Prevention, the author articulated several principles for best practices in family programs (Kumpfer 1993; Kumpfer 1997). These included selecting programs that are comprehensive, family-focused, long-term, of sufficient dosage to affect risk or protective factors, developmentally appropriate, beginning as early in the family life cycle as possible, and delivered by well-trained, effective trainers.

The family programs were rated for their demonstrated impact in reducing risk factors and increasing protective factors. The top 25 promising programs were published in Strengthening America's Families (Kumpfer 1994b), which was rated as one of the top 25 family programs. The University of Utah staff won a rebid of this project, which included a new national search for model family programs, dissemination through two national conferences and training workshops in many exemplary and model family programs, and technical assistance in implementing these programs. These model programs and a literature review are available on the project Web site (http://www-medlib.med.utah.edu/healthed/ojjdp.htm).

Family-focused interventions appear to be more effective than either child-focused or parent-focused approaches. Child-only approaches, not combined with parenting or family approaches, can have a negative effect on family functioning (Szapocznik and Kurtines 1989; Szapocznik 1997). If high-risk youth are aggregated, deteriorated youth behaviors can occur (Dishion and Andrews 1995). Reviews of early childhood programs (Dadds et al. 1992; Mitchell et al. 1995; Yoshikawa 1994), elementary school-age children's programs (Kazdin 1993; Kumpfer and Alvarado 1995, pp. 253-292; Patterson et al. 1993, pp. 43-88), and adolescent programs (Center for Substance Abuse Prevention 1998; Szapocznik 1997) support the effectiveness of family-based interventions. In fact, a number of adolescent family programs have found significant reductions in substance use (Henggeler et al. 1995; Lewis et al. 1990; Szapocznik 1997). In recent years there has been a shift from focusing therapeutic activities primarily on the child to improving parents' parenting skills and to recognizing the importance of changing the total family system (Szapocznik 1997; Parsons and Alexander 1997).

Newly developed family-focused skills training programs are more comprehensive and include structured parent skills training, children's social skills, and parent/child activities, sometimes called behavioral family therapy, behavioral parent training, or family skills training. The new family skills training approaches often offer additional family support services, such as food, transportation, child care during sessions, advocacy, and crisis support.

A few examples of these structured family-focused interventions include the Strengthening Families program (SFP) (Kumpfer et al. 1989), which is effective with substance-abusing parents and parents from racial and ethnic minority groups (Kumpfer, Molgaard, and Spoth 1996); Focus on Families (Haggerty et al. 1991) for parents on methadone maintenance therapy (Catalano et al. 1997; Gainey et al. 1997) the Nurturing Program (Bavolek et al. 1983) for physically and sexually abusive parents; Families and Schools Together (FAST) (McDonald et al. 1991) for high-risk students in schools; and Family Effectiveness Training (FET) (Sza-pocznik et al. 1985).

Other researchers are employing these broad-based family skills programs as part of even more comprehensive school-based intervention strategies. The Fast Track program (Bierman et al. 1996; McMahon et al. 1996), one of the largest prevention intervention research projects funded by the National Institute of Mental Health (NIMH), is one exemplary program. This selective prevention program, implemented with high-risk kindergarten students with risk factors such as conduct disorders, is being implemented in several different sites in the Nation with a large team of nationally recognized prevention specialists. Fast Track includes behavioral parent training. Parents were found to be satisfied with this type of parent training, which involves therapist coaching and interactive practice between the parent and the child (McMahon et al. 1993).

One distinguishing feature of these new parent and child skills training programs is that they provide structured activities in which the curriculum addresses improvements in parent-child bonding or attachment (Bowlby 1969/1982) by coaching the parent to improve play time with the child during a "Child's Game." This "special therapeutic play" has been found effective in improving parent-child attachment (Egeland and Erickson 1987, pp. 110-120; Egeland and Erickson 1990). Using intervention strategies developed by Kogan and Tyler (1978) and Forehand and McMahon (1981), parents learn through observation, direct practice with immediate feedback by the trainers and videotape, and trainer and child reinforcement on how to improve positive play (Barkeley 1986), by following the child's lead and not correcting, bossing, criticizing, or directing. Teaching parents therapeutic play has been found to improve parent-child attachment and child behaviors in psychiatrically disturbed and behaviorally disordered children (Egeland and Erickson 1990; Kumpfer, Molgaard, and Spoth 1996). These family programs encourage family members to increase family unity and communication and reduce family conflict as found in prior SFP studies.

Strengthening Families Program

Theoretical Model Underlying SFP

The importance of a family approach to substance abuse prevention is based on an empirically tested model called the social ecology model of adolescent substance abuse (Kumpfer and Turner 1990-1991). This structural equation model of the precursors of drug use, derived from comprehensive data on 1,800 high school students, suggests that family climate or environment (see figure 1) is a root cause of later precursors of substance abuse. The family influences the youth's perceptions of the school climate, school bonding and self-esteem, choice of peers and deviant peer influence, and eventually substance use or abuse. Strong, positive relationships between child and parents create supportive, transactional processes between them that reduce the developmental vulnerability to drug use (Brook et al. 1990; Brook et al. 1992, pp. 359-388). Additional empirically derived models of the precursors of drug use also support the influence of the family (Newcomb et al. 1986; Newcomb 1992, 1995; Swaim et al. 1989).

The content of the SFP family intervention is based on empirical family research that elucidates a risk and protection or resilience framework presented by the author at the 1994 NIDA Resilience Conference (Kumpfer 1994a). The primary family risk factors include parent and sibling drug use, poor socialization, ineffective supervision and discipline, negative parent-child relationships, family conflict, family stress, poor parental mental health, differential family acculturation, and poverty (Kumpfer and Alvarado 1995).

Family protective factors (Kumpfer and Bluth, in press; Kumpfer, in press a) include one caring adult (Werner 1986; Werner and Smith 1992), emotional support, appropriate developmental expectations, opportunities for meaningful family involvement, supporting dreams and goals, setting rules and norms, maintaining strong extended family support networks, and other protective processes. The probability of a child's developing problems increases rapidly as the number of risk factors increases (Sameroff et al. 1987; Rutter 1987) relative to the number of protective factors (Dunst 1994, 1995; Dunst and Trivette 1994, pp. 277-313; Rutter 1993). Children and youth generally are able to withstand the stress of one or two family problems in their lives; however, when they are continually bombarded by family problems, their probability of becoming substance users increases (Bry et al. 1982; Newcomb et al. 1986; Newcomb and Bentler 1986). Future SFP content revisions will include more emphasis on resilience principles.

Overview of Prior SFP Research Studies

The Strengthening Families Program (Kumpfer et al. 1989) is a highly structured, 14-week, comprehensive family-focused curriculum. It includes three conjointly run components: parent training, children's skills training, and family skills training. Each 2.5- to 3-hour session is led by two cotrainers. The SFP for elementary school-age children of drug abusers was originally developed and evaluated between 1982 and 1985 (with 3 years of NIDA funding) employing a randomized phase III controlled intervention trial.

This paper discusses the original NIDA positive results and subsequent SFP replications with minor modifications for African-American families in Alabama and Detroit and multiethnic families in three counties in Utah. All of the replications to date have reported similar positive results on the parents' and children's behaviors and drug use (Aktan 1995; Aktan et al. 1996; Sherwood and Harrison 1996; Harrison, Proskauer, and Kumpfer 1995; Kameoka and Lecar 1996; for a review of all studies, see Kumpfer, Molgaard, and Spoth 1996 or Kumpfer, in pressb). Positive results on intervention-targeted behaviors have been reported by Spoth and colleagues (in press) for a seven-session version of SFP (Molgaard et al. 1994). This SFP variant was based on resilience principles and developed for sixth-grade students in rural Iowa. It was tested in a 5-year, NIMH-funded randomized clinical trial in 20 counties in Iowa by Spoth at Iowa State University. The preliminary immediate session outcomes also look promising, with significant improvements in parenting attitudes and beliefs as well as significant increases in family meetings (Kumpfer, in press b). In addition, Spoth (1997) reported on positive outcome results for reductions in tobacco and alcohol use rates among youth participating in the program.

Original NIDA SFP Research Design and Subjects

The original NIDA-funded research was designed to reduce vulnerability to drug abuse in children of patients on methadone maintenance therapy and substance-abusing outpatients from community mental health centers. The experimental design tested the impact of a parent training program only, a children's training program added to the parent training program, and a family skills training and relationship enhancement program added to the other two components compared with no-treatment controls. In this experimental dismantling design, families were randomly assigned to either a 14-session SFP parent training program based on Patterson's (1975, 1976) parent training model; the combined SFP parent training program and SFP children's skills training program based primarily on Spivack and Shure's (1979) social skills training; or a three-part combination of the prior two programs plus the SFP family skills training program based on Forehand and McMahon's (1981) program described in their book, Helping the Noncompliant Child, and Bernard Guerney's Family Relationship Enhancement Program. The sample of 208 families consisted of 71 experimental intervention families, 47 no-treatment families matched on 8 demographic characteristics to the treatment families, and 90 general population comparison families.

Program Content

Both parents and children attend separate classes for the first hour and then work together in family sessions in the second hour. A third hour is spent in logistics, meals, and family fun activities. The underlying concept is to have the parents and children separately learn their skills or roles in a family activity and then come together to practice those family skills. To increase recruitment and retention, a number of incentives were developed by the various sites implementing the program, as recommended by Kumpfer (1991), including meals and snacks, transportation, rewards for attendance and participation (drawings, tickets, or vouchers for sporting, cultural, educational, and family social activities; movies, dinners, groceries, clothing, household items, and children's Christmas gifts), a nursery for child care of younger siblings, older adolescent recreation, and support/tutoring groups.

• The Parent Training Program sessions in the original SFP included group-building, teaching parents to increase wanted behaviors in children by increasing attention and reinforcements, behavioral goal statements, differential attention, chore charts and spinners (pie charts with sections representing rewards mutually decided on that children may get if they complete all chores), communication training, alcohol and other drug education, problemsolving, compliance requests, principles of limit-setting (timeouts, punishment, overcorrection), generalization and maintenance of limit-setting, and implementation of behavior programs for their children.
• The Children's Skills Training Program included a rationale for the program, communication of group rules; understanding feelings; social skills of attending, communicating, and ignoring; good behavior; problemsolving; communication rules and practice; resisting peer pressure; questions and discussion about alcohol and other drugs; compliance with parental rules; understanding and handling emotions; sharing feelings and dealing with criticism; handling anger; and resources for help and review.
• The Family Skills Training Program sessions provided a time for the families to practice their skills (with trainer support and feedback) in the Child's Game (Forehand and McMahon 1981), a structured play therapy session with parents trained to interact with their children in a nonpunitive, noncontrolling, and positive way.

Research and observation have shown that dysfunctional, antisocial, and drug-abusing parents are limited in their ability to attend to their children's emotional and social cues and to respond appropriately (Hans 1995); hence, the four sessions of Child's Game focused on training parents in therapeutic parent-child play. The next three sessions of Family Game meetings trained parents and children to improve family communication. Four sessions of Parents' Game focused on role-plays during which the parents practiced different types of requests and commands with their children. The beginning session focused on group-building, introduction to content of program, contracting, and brainstorming possible solutions to barriers to attendance. The 13th session focused on generalization of gains and connecting to other support services; the 14th session was a graduation celebration. A testing session before and after the program meant the families actually attended for 16 weeks, although the training program was 14 weeks long.

NIDA SFP Outcome Results

An extensive multi-informant, multisource instrument battery of parental, child, and therapist report measures (including both parents or caretakers, therapists, and all target children) was employed to assess improvements of hypothesized risk and protective factor outcomes, including the Child Behavior Checklist (CBCL) (Achenbach and Edelbrock 1988), Cowen Parent Attitude Scale (Cowen 1968), and the Family Environment Scale (FES) (Moos 1974). Analysis of the baseline, pretest data indicated that children of substance abusers in treatment have significantly more behavioral, academic, social, and emotional problems than a matched comparison group of children of parents who are not substance abusers or children in the general population (Kumpfer and DeMarsh 1986, pp. 49-89).

Outcome results using analyses of variance (ANOVAs) to compare the four different treatment groups suggest that the combined intervention that included all three components was the most powerful in improving the child's risk status in three theoretically indicated and intervention-targeted areas:

• Children's problem behaviors, emotional status, and prosocial skills
• Parents' parenting skills
• Family environment and family functioning (improved family communication, clarity of family rules, nonconflictive sibling relationships, decreased family conflict, and less social isolation).

In general, the pattern of results suggests that each program component was effective in reducing risk factors that were the most directly targeted by that particular component. For example, the parent training curriculum significantly improved parenting skills and parenting self-efficacy, the children's skills program improved children's prosocial skills, and the family program improved family relationships and environment. Use of tobacco and alcohol by older children was reduced, as well as expectations of alcohol and tobacco use by those nonusing children. Parents also reduced their drug use and improved in parenting efficacy (DeMarsh and Kumpfer 1986, pp. 117-151). Although the children's social skills increased with exposure to the Children's Skills Training Program in the parent-training-plus-child-training condition, the improvements in negative acting-out behaviors were not as good as that found for the Parent Training Program only. This result, plus the recent similar results of Dishion and Andrews (1995), calls into question the potential value of high-risk child-only groups because of possible negative contagion effects and smaller effects on improving risky youth behaviors.

CSAP Replication Studies

Because of these positive NIDA SFP results, agencies in five States have been successful in attracting demonstration/evaluation research funding from CSAP. These five grants involved eight different community agencies with high-risk ethnic population families, including [two] studies with African-American families. Both of these studies - the Alabama State Department of Mental Health and Mental Rehabilitation study of low-income African-American drug-using mothers in rural Alabama and the Detroit City Health Department's study of inner-city African-American drug abusers - have published final positive results (Aktan 1995; Aktan et al. 1996; Kumpfer, Molgaard, and Spoth 1996; Kumpfer, in press b). Additional studies with low-income Hispanic families from housing complexes in Denver (Wanberg and Nyholm 1998), Asian/Pacific Islander and Latino families in three counties in Utah (Harrison and Proskauer 1995), and Asian and Pacific Islander families in Hawaii (Kameoka and Lecar 1996) demonstrate similar significant improvements in the children and families participating in SFP programs. A study of a language-modified and culturally modified SFP for high-risk French-Canadian families, which is funded by the Canadian government, is in its third year, and a new culturally modified SFP for Australian families was developed and implemented by the author.

These studies significantly demonstrate that SFP can be successfully implemented with ethnic families and that the dropout rates are low (15 percent) after the first few cohorts (Aktan 1995). The results for the African-American families only are summarized below. (See Kumpfer, Molgaard, and Spoth [1996] for a more detailed description of results.)

African-American SFP Results

Rural African-American SFP

The Alabama SFP program, implemented with 62 families in Selma, AL, by the Cahaba Mental Health Center, compared low-drug-using families (alcohol use only) to high-drug-using families (alcohol plus illicit drug use) in a quasi-experimental pretest, posttest, and 1-year followup design. Most (82 percent) of the families completed at least 12 of the 14 sessions.

Results showed that high-drug-using mothers not in drug treatment reduced their drug use (on a composite index of 30-day alcohol and other drug quantity and frequency of use), family conflict decreased, and family organization increased. Before the program began, the children of the high-drug-using mothers compared with children of low-drug-using mothers had significantly more (according to the CBCL) internalizing behavior problems (e.g., depression, obsessive-compulsive behavior, somatic complaints, social withdrawal, uncommunicative demeanor, and schizoid scales) and externalizing behavior problems (e.g., aggression, delinquency, and hyperactivity). By the end of the program, the children of high-drug-using mothers were rated as significantly improved on both the internalizing and externalizing scales and all subscales, except the "uncommunicative" subscale. Children of low-drug-using mothers improved only on the clinical scales for which they manifested relatively higher scores on the intake pretest, namely obsessive-compulsive behavior, aggression, and delinquency. SFP was equally effective for less educated and better educated mothers in improving the parenting style and behaviors of the children.

Urban African-American Families

The Safe Haven Program of the Harbor Light Salvation Army and the Detroit City Health Department is a 12-session SFP modified for inner-city African-American families. This program demonstrated similar positive results with 51 families by the end of the second year. Results showed significantly improved family relationships and family organization, reduced family conflict, and increased family cohesion. This increase in family cohesion, which was not found in Alabama, may have occurred because the Safe Haven program put more emphasis on reuniting the mothers and fathers as a total family. The families did report spending more time together. Also, the parents reported that parent-and-child activities increased as well as the amount of time that the parent and child spent together.

Parents reported a decrease in drug use, depression, and use of corporal punishment and an increase in their perceived efficacy as parents. According to parental reports, children's externalizing problem behaviors decreased significantly in aggression and hyperactivity and approached a significant decrease in delinquent behaviors. Significant improvements from pretest to posttest were found only for the children of the high-drug-using parents in terms of reduced school problems and less general internalization of problems. There was also a reduction in more specific measures of depression and social withdrawal and in uncommunicative, obsessive-compulsive, and schizoid behaviors. Parents in both groups reported increased school bonding, more children's time spent on homework, and no significant unintended negative effects. These parent reports matched the therapists' reports on behavioral improvements in the participating families.

Utah Community Youth Activity Project (CYAP) SFP Research

The Utah State Division of Substance Abuse tested SFP in three counties and eight agencies that serve ethnic populations in a quasi-experimental pretest, posttest, and 3-month followup design comparing SFP to Communities Empowering Parents Program, a local program with no family skills training. A total of 421 parents and 703 high-risk youths (ages 6 to 13 years) were recruited to attend one of the two programs. On the pretest, 57 percent of the youth had behavioral and academic problems. The total sample included 33 percent fathers, 59 percent mothers, and 8 percent guardians or foster parents from 49 percent single-parent families, 66 percent low-income families, 69 percent families from ethnic populations (26 percent Asian, 20 percent Pacific Islander, 18 percent Latino, and 5 percent Native American youth), and 50 percent families with little or no religious involvement. The program materials for both programs and the instrument battery were translated into Spanish, Vietnamese, Tongan, Korean, and Chinese for this project. Attendance and completion rates for the program were high, averaging 85 percent across the three county sites.

Data Analysis

The analysis of the pretest and posttest change scores suggested improvements in family environment, parenting behaviors, and children's behaviors and emotional status. Significant pretest-to-posttest reductions in the youths' problems were reported by the SFP parents on all CBCL subscales and composite externalizing and internalizing scales, but on only two of the FES scales for family conflict and cohesion. SFP was significantly more effective than the comparison program.

Five-Year Followup Study

A 5-year followup study of the participants in this three-county Utah CYAP/SFP study (Harrison 1994) included 87 families confidentially interviewed by a research psychiatrist from Harvard University. The results (Kumpfer, Molgaard, and Spoth 1996) suggested that, even after 5 years, a substantial percentage of families were still using the family management skills that had been taught. Family meetings once per month were reported by 68 percent of the families, and 37 percent conducted them weekly. The adults reported lasting improvements in family problems (78 percent), stress/conflict levels (75 percent), amount of family fun (62 percent), family talking together more (67 percent), and showing positive feelings (65 percent). Analyses revealed a gradual decline in the frequency of use of family skills taught in the program; however, the researchers (Harrison 1994) concluded, "The change figures show that a majority of families maintain lasting improvements, even over a 5-year period."

Strengthening Hawaiian Families Program

In Hawaii, the Coalition for a Drug-Free Hawaii, headed by Lecar, has revised the SFP to be more culturally appropriate for Hawaiian-Asian and Pacific Islander cultures. The Strengthening Hawaiian Families (SHF) Program has a 20-session curriculum that emphasizes awareness of family values, family relationships, and communication skills. To increase parental readiness for change, a 10-session family and parenting values curriculum precedes the 10-session SFP family management curriculum. The revised curriculum covers topics such as connecting with one another, caring words, generational continuity, culture, communication, honesty, choice, trust, anger, problemsolving, decisionmaking, and stress management. An audiotape and videotape accompany the curriculum manuals.

An independent evaluation was conducted by the University of Hawaii (Kameoka and Lecar 1996) using a quasi-experimental, pretest-posttest, nonequivalent control group design to evaluate the effectiveness of hypothesized outcome variables to program objectives. The original 14-session SFP implemented in four sites in fall 1992 was compared with the 20-session, culturally revised SHF program implemented in nine sites between spring 1994 and winter 1995.

The measurement battery was culturally modified by alteration of words and expressions not common in Hawaii and comprised several different tests, including the 53-item Brief Symptom Inventory (BSI) (Derogatis and Lazarus 1994, pp. 217-248) and the Center for Epidemiological Studies-Depression Scale (CESD) (Radloff 1977) rather than the Beck Depression Inventory (BDI) (Beck et al. 1961). Only the 113-item Teacher's Report Form (TRF) (Achenbach 1991) was used rather than the parent CBCL version. Teachers were paid $5 to complete and return the form to the evaluator in a stamped envelope. The same 49-item substance use measure (Kumpfer 1987, pp. 1-88) was used as the original SFP testing battery as well as the four 10-item subscales of the FES (cohesion, expressiveness, conflict, and organization) and two subscales of the Adult-Adolescent Parenting Inventory (AAPI) (Bavolek 1985) on physical punishment and inappropriate expectations. A third subscale on parents' use of positive reinforcers was developed by the evaluator (Kameoka and Lecar 1996).

Because of high attrition (48 percent), low attendance rates, and lack of risk-level equivalence of the experimental and comparison groups, the results of the outcome evaluation must be interpreted with caution. Small sample sizes (19 SFP subjects, 52 SHF subjects), reduced risk at pretest compared with drug treatment samples in other studies, and switching to a values-based curriculum versus a social learning theory-based family and social skills training curriculum all contributed to lower power and effectiveness. This program was interpreted by the evaluator as an "educational program designed for nonclinical populations"; hence, participants receiving professional services were eliminated from the data analysis, yet they may have benefited the most.

Because of the nonequivalence of the comparison and experimental groups, only the significant pretest and posttest changes are reported here. Both the SFP and SHF programs attained their goal of strengthening family relationships and resulted in significant improvements in family cohesion and family organization, and in reducing family conflict. However, significant improvement was reported for expressiveness or communication. Only the original SFP resulted in statistically significant improvements in attitudes and skills in rewarding positive behaviors. The largest mean improvement for physical punishment was for the original SFP, but because of low numbers and high variance, this positive result can be reported only as a nonsignificant trend.

Similarly, the original SFP appeared to be more effective in reducing parental depression than was the culturally modified SHF; SFP resulted in positive changes in somatization, interpersonal problems, anxiety, hostility, phobias, and paranoia, whereas the SHF program affected only hostility and paranoia in addition to depression.

Substance use decreased in SFP participants for parents, siblings, and children but use increased significantly for SHF among children and nonsignificantly for parents. No significant improvements were found in children's behaviors as rated by their teachers from pretest to posttest.

Strengthening Hispanic Families Program

The Denver Area Youth Services (DAYS) has been involved in modifying the SFP for increased local effectiveness primarily with Hispanic children and families in several inner-city housing projects. These are the families shown in the NIDA videotape "Coming Together on Prevention" (National Institute on Drug Abuse 1994). Preliminary results suggest that the DAYS staff has been successful in attracting and maintaining these high-risk families in SFP. Between September 1992 and January 31, 1996, SFP and a child-only Basic Prevention Program (BPP) comparison intervention had been implemented with 311 clients. Twenty-five percent of referrals came from schools and other community agencies, but the balance of 75 percent came from DAYS aggressive outreach efforts in housing complexes.

One of the major successes of this program was the high program completion rate of 92 percent, based on the criteria of a participant's attending at least 70 percent of all sessions and participating in the graduation ceremony to receive a certificate of completion (Kumpfer, Wanberg, and Martinez 1996). The mean age of the children was 8.4 years (range 5 to 12 years) with 53 percent boys and 47 percent girls. Single-parent homes accounted for 75 percent of the children, with 30 percent of the mothers reporting that they were never married to the biological father. Most participants were from low-income families, with a mean family income of $6,700. The manuals were substantially modified, and Spanish translation versions provided for Spanish-language families.

The Strengthening Hispanic Families Program is being evaluated by Wanberg and Nyholm (1998). Careful attention to retention in the followup design has resulted in 87 percent of the families completing the 6-month followup and 75 percent completing the 1-year followup. A relatively low level of risk factors is being reported for these children, possibly because this program is not selecting for children of substance abusers like the original NIDA research or the other Utah, Alabama, and Detroit studies.

Baseline data suggest that the major increase in exposure to tobacco, alcohol, and other drugs occurs in the lives of these Hispanic children between age 8 and 9 years. As in the Utah studies, many of the children (33 percent) report being sad or depressed, with 28 percent saying they have thoughts of hurting themselves or committing suicide. As many as 20 percent of these elementary school children are having difficulties with school adjustment, and 44 percent have been involved in fistfights.

The child and parent satisfaction and perceptions of usefulness of the two comparison programs were almost identical, although parents rated SFP slightly higher except in the areas of the child's "doing better at school" and "making friends," for which parents rated SFP about 20 percent higher (65 percent vs. 46 percent). The children participating in each program rated both programs about the same in usefulness.

Rural Families of Junior High School Students

Researchers at Iowa State University have developed a seven-session modification of SFP for junior high school students that is based on resiliency principles (Kumpfer, in press a), called the Iowa Strengthening Families Program (ISFP) (Molgaard, Kumpfer, and Spoth 1994). Research on this program was conducted with NIDA and NIMH funding for a phase III experimental intervention trial (Greenwald and Cullen 1985; Jansen et al. 1996) that compared 33 randomly assigned schools from 19 contiguous rural counties with either the ISFP and Preparing for the Drug-Free Years program (PDFY) (Hawkins et al. 1994) or no-treatment control schools.

Program Design

Like the original SFP, ISFP includes parenting and youth sessions in the first hour and a family session in the second hour. Parents are taught the importance of encouraging and supporting dreams, goals, and resilience in youth; providing appropriate expectations and discipline; engaging in effective communication with preteens; handling strong teen emotions; implementing family meetings to improve family togetherness, family organization, and planning; and determining family rules and consequences for breaking family rules. The children's sessions generally parallel the parent sessions and cover resilience with dreams and goals, stress and anger management, and social skills (such as communication, problemsolving, decisionmaking, and peer-refusal skills). The family sessions engage the participants in activities to increase the awareness of youth and family goals, increase family cohesion and communication, and reduce family conflict.

ISFP was implemented in winter 1994 with 161 families from 21 ISFP groups from 11 schools, but only 114 families completed the pretest and were included in the data analysis. The average group size was 8 families and ranged from 3 to 15 families, with about 20 parents and children attending each session. Approximately 94 percent of pretested participants completed at least five or more sessions, 88 percent attended at least six sessions, and 62 percent attended all seven sessions. Despite the use of the total parenting program videotape to help standardize the implementation as well as reduce the cost of the second trainer, fidelity observations of at least two sessions showed that 83 percent of the content of the parent training session was covered, 87 percent of the family session, and 89 percent of the youth skills training session. Spoth (in press) reports in more detail on the recruitment and retention rates for Project Family containing ISFP and PDFY.

Data were collected during a 2- to 2.5-hour in-home session using both questionnaires and including a number of standardized measures and three videotaped tasks, each lasting 15 minutes. The topics for the tasks included general questions about family life (such as approaches to parenting and household chores) that were discussed independently with either the mother and the child or the father and the child, selected randomly and then switched. In a second task, the family members discussed sources of disagreement determined previously by a checklist. The families were paid $10 per hour for the testing time.

ISFP Results

The preliminary session-by-session results were analyzed for comparison of the immediate behavioral intentions to change with actual changes (see Bry et al., in press, for additional discussion on these data). Overall, the data suggest a number of significant behavioral changes by the mothers and fathers from session to session that matched the actual objectives of the sessions. There are differential effects on mothers and fathers, related primarily to differences in baseline behaviors. Hence, fathers and mothers appear to change in those behaviors where they have more room for improvement.

The preliminary outcome data from the in-home video coding of family interaction patterns and the self-reported changes on the annual family assessments show significant improvements. Although the comparisons of each of the measurement scales have not yet been reported, Spoth and associates (in press) report significant pretest and posttest improvements in all hypothesized effects for both ISFP and PDFY, employing a "group code approach" for small sample structural equation models discussed by Aiken and colleagues (1994). This approach uses a common measurement model for both the experimental and control groups and includes a group code variable.

The major advantage of this type of SEM is that half as many parameters are required as for the multigroup approach, making this analysis attractive for smaller sample sizes relative to the number of parameters estimated. A finding of no statistically significant intraclass correlations associated with outcome measures indicated that family-level rather than school-level analyses would be appropriate despite the nested research design of families within randomly assigned schools. Spoth (in press) reports more on the preliminary results; however, at this point, the three hypothesized structural effects (parent-child affective quality, intervention-targeted behaviors, and general child management) appear to be statistically significant at both pretest and posttest at the .01 level when conducting an SEM analysis on data from 178 ISFP and 179 control group families (N=357).

Summary of SFP Outcome Results Across Diverse Ethnic Populations

The original NIDA SFP and the later Iowa SFP randomized control research provides strong evidence of the effectiveness of SFP with white families. Because of employing only quasi-experimental designs, the replication studies provide only weak, but consistently positive, support for SFP effectiveness for other ethnic groups. The effect sizes were quite large, as determined in a power analysis, in fact statistically significantly larger, for the higher risk families than for the lower risk families. However, the repeated replications with external evaluators suggest that SFP can be implemented by others with integrity and fidelity.

This is partially because the SFP manuals and training of trainers are very specific and detailed. The SFP trainings require the staff members who will be doing the training to prepare several sessions from the manuals and deliver them to the group whose members role-play typical parents or children. Time is spent in processing group dynamics and discussing how to most effectively deal with participant issues that could arise from the program session content. Therefore, the trainers learn the total content of the program, see many different delivery styles, and learn how to deal with group dynamics.

The positive program results are consistent across the sites implementing the program even when different evaluators have evaluated the program. Six different independent research evaluations have been conducted by university-based researchers in three departments at the University of Utah. In addition, researchers at the University of Hawaii, Case Western University, Harvard University, and the University of Colorado have evaluated the program on cultural modifications. One doctoral dissertation (Millard 1993) that addressed high-risk, general population families recruited through schools also supported the positive results. Because SFP appears to be rather robust in terms of consistently favorable results across multiple replications with culturally diverse populations, NIDA selected SFP as an example of a selective prevention program for its Drug Abuse Prevention Package (NIDA 1997). An implementation manual and videotape, "Coming Together on Prevention," are available from the National Clearinghouse for Alcohol and Drug Information (Kumpfer, Williams, and Baxley 1997).

Research Issues and Recommended Future Family Intervention Research

Because of the small amount of past funding, many family research projects conducted only "black box" research designs to determine overall effectiveness in comparison with control groups. In addition to an emphasis on examination of program effectiveness for different cultural and ethnic groups, more refined research questions should determine:

• The most effective program components
• Effectiveness of family programs compared with child-only programs
• Duration of effectiveness using longitudinal designs and booster sessions
• Best recruitment and retention methods
• Who benefits most by conducting analyses by client demographic or risk factor covariates
• Implementation variables in health services research
• Cost-benefit of programs
• Why some communities and agencies are more ready than others to implement family programs or can do so with fidelity and increased effectiveness.

Research on Relative Effect Sizes of Components of Family-Focused Interventions

Few family-focused prevention programs have examined the different components of their programs to determine the differential effectiveness of components on different risk and protective factors. The Strengthening Families Program in the original NIDA research study did use a dismantling design to examine the comparative effectiveness of a parent training program only (PT); PT plus children's social skills program (CT); PT, CT, and a family skills training program (FT); and a no-treatment control group. Using this four-group randomized design, the investigators (Kumpfer, Molgaard, and Spoth 1996) found that the combined program (FT) was most effective, but each component was most effective in changing the variables it was designed to affect. Hence, the children's program improved the children's social skills; the parent training program improved the parent's parenting skills and parenting self-efficacy, discipline methods, and children's acting-out behaviors; and the family program improved the family's communication, organization, and support-iveness. It would be helpful to have a more internal examination of component effectiveness in other family programs.

Research on Family-Focused Versus Child-Focused Interventions

Major questions still exist in the research literature (Kumpfer, in pressb) about whether to focus scarce prevention resources on the child-only, parent-only, or total-family approach. Many prevention providers prefer to work only with children in school or community programs. Family intervention researchers (Szapocznik 1997) strongly believe that to have a lasting positive effect on the developmental outcomes of a child, it is essential to improve the family ecology or context by creating more nurturing and supportive parent-child interactions. Parental support and guidance by prosocial, well-adjusted parents provide a sustaining positive influence on children's developmental trajectories and risk status for drug use. Although peer influence appears to be the final pathway to drug use as found in many etiological studies (Kumpfer and Turner 1990/1991; Newcomb 1992, 1995; Swaim et al. 1989), the primary reason not to use drugs appears to be positive family influence (Coombs et al. 1991).

There also is suggestive evidence that bringing a group of at-risk youth together in a child-only group creates a negative contagion effect (Gottfredson 1987). Dishion and Andrews (1995) randomly assigned 119 at-risk families with 11- to 14-year-olds to one of four intervention conditions: parent-focus-only, teen-focus-only, parent-and-teen focus, and self-directed change. Results showed positive longitudinal trends in substance use in the parent-focus-only group, but suggestive evidence of negative effects in the teen-focus-only condition. These results stressed the importance of involving parents and reevaluating strategies that aggregate high-risk youth, particularly in groups where insufficiently trained staff cannot control and improve group norms or influence. Social learning theory (Bandura 1986) suggests that youth need exposure to positive adult role models, such as parents and group leaders, who can provide opportunities for youth to learn behavior skills and social competencies and for exposure to higher levels of moral thinking (Levine et al. 1985).

In addition, in the original 1982-1985 NIDA SFP research (DeMarsh and Kumpfer 1986; Kumpfer and DeMarsh 1986; Kumpfer 1987, pp. 1-71), evidence suggested that increased exposure to high-risk peers with poor social competencies and moral reasoning reduced the positive gains in youth negative behaviors from the SFP parent training, although positive social skills increased more. This critical research and practice question has not been addressed with children younger than 11 years.

Longitudinal Studies of Family Intervention Effectiveness

The long-term effectiveness of family programs should be examined by means of improved longitudinal design and recently developed meas-urement and data analysis technologies. Unfortunately, there was no long-term followup funded in the original 3-year NIDA research study. The positive results were based on only the pretest and posttest changes in the youth and parents. A 5-year followup (Harrison et al. 1995) of SFP was implemented on a three-county Utah State grant funded by CSAP. Even though the abbreviated interview survey data collected suggest amazing longevity of positive family functioning and maintenance of principles and behaviors taught in the SFP, the data collection did not include the full parent and youth outcome assessment battery so critically needed to determine the true long-term impact on youth drug use.

Best Methods for Recruiting and Retaining High-Risk Families

Many prevention practitioners believe that it is "monumentally discouraging" to work with families and that they are almost impossible to recruit and maintain in family interventions. This is partially true, particularly in the first cycle of implementing the program, before the "bugs" are worked out and the staff becomes more competent, but many family skills training interventions, including the SFP, report retention rates of around 82 to 85 percent (Kumpfer, Molgaard, and Spoth 1996; Aktan 1995; Aktan et al. 1996; McDonald 1993).

Few family researchers have conducted systematic examinations using strategies of recruitment and attrition factors essential to successful program implementation. One notable exception is Spoth and associates (1996) from Iowa State University, who evaluated engagement and retention using marketing research strategies on data from the Iowa Strengthening Families Program. They have conducted many studies on the ISFP, including the following:

• A prospective participation factor survey (Spoth et al. 1995) found that perceived program benefits and barriers were strong predictors of inclination to enroll and that stated inclination to enroll and parent education level were the strongest predictors of actual participation.
• A refusal survey (Spoth et al. 1996) found that time and scheduling conflicts are major reasons to refuse to participate, as is gender (fathers see less benefit in family interventions than mothers).
• A risk by participation and retention analysis found no differential participation or attrition for higher risk families in contrast to common assumptions about the difficulties of attracting and retaining high-risk families (Center for Substance Abuse Prevention 1995).

Additional research is needed on special recruitment methods to attract and retain high-risk families, as discussed by Kumpfer (1991) in Parenting Training Is Prevention. Methods used to reduce barriers to recruitment and to retain high-risk families for many selective prevention programs like SFP include child care, transportation, meals, payments for testing time, graduation completion gifts, prizes for completion of homework, and small gifts (pencils, pens, stickers) for the children, earned with good behavior. Special family outings or retreats are also major attractions in family programs that increase family participation.

Who Benefits Most From Family Interventions?

In addition to addressing component effectiveness, family-focused intervention research should be directed toward a better understanding of intrafamily variables such as which types of clients benefit most by the different intervention components. Hence, it is possible that the different components of SFP will be differentially effective with different types of parents and youth. As did prior studies (Aktan et al. 1996), future studies should include outcome subanalyses by participant covariates to determine whether family interventions are more or less effective for different types of participants using post hoc, statistical quasi-experimental analyses, as recommended by Cook and Campbell (1979). These covariant analyses could examine program effectiveness by program site, multiethnic status, parental drug use, parental depression, educational status, parent and child gender, single- versus two-parent families, parental criminal status, and child's baseline level of risk and protective factor status.

Methods for Improving Program Implementation: Health Services Research

Most NIH research institutes, including NIDA, have a separate set-aside for health services research that examines questions related to improving the implementation and dissemination of model research-based programs. Researchers of model family programs should consider research designs that will allow them to examine and answer these important program implementation questions as subaims of their studies. These subaims can be examined through planned comparisons of process data linked to outcome data across the experimental groups to examine research questions concerning differential recruitment and attrition rates by demographic client variables (e.g., gender, education level, ethnic status) and program components; variables leading to increased program involvement; differential consumer satisfaction and participation rates compared to outcomes; factors related to fidelity of the program implementation across sites; impact of trainer variables (e.g., years of experience, delivery competence, perceived warmth and supportiveness by clients and evaluators) on program process and outcome variables; and other agency and staff variables recorded in forcefield analyses (Gottfredson 1986) affecting implementation quality. A strong process evaluation is needed to examine these important subaims.

Need for Cost-Effectiveness and Cost-Benefit Studies

Pentz (1993) and the staff at NIDA have strongly encouraged prevention programs to collect and report cost data. Conducting comparative cost-benefit analyses on major prevention interventions would help providers make better decisions about where to allocate scarce resources. There is little literature documenting the cost benefit or cost-effectiveness of drug abuse prevention because of difficulties measuring and devising monetary values for comparative prevention intervention outcomes (Kim et al. 1995). According to Apsler (1991, pp. 57-66), there have been no rigorous cost-effectiveness studies of drug prevention or treatment. The only published cost-effectiveness study (Hu et al. 1981) comparing different types of drug prevention (alternative, education, intervention, and information) contained no control group. An analysis of the benefits of different crime prevention strategies suggests that parent training is the most cost-effective strategy for the prevention of delinquency (Greenwood et al. 1994). Because of the overlap of etiological precursors of delinquency and drug use, it is highly likely that the most cost-effective strategy for drug abuse prevention is also family-focused approaches.

Benefit-cost analyses are easier to calculate because they require no control groups or comparison of interventions. Although Russell (1986) challenged the economic benefits of health promotion and prevention programs, Kim and associates (1995) calculated that the benefits of drug prevention exceed costs by a ratio of 15 to 1. Kristein (1997) reported a benefit-cost ratio of 1.8 to 1 for smoking cessation programs, and a larger ratio of 2.3 to 1 for employee assistance programs for alcohol misuse.

As discussed by Plotnick (1994), the program benefits in a cost-effectiveness analysis should be based on the magnitude of the statistically significant differences or effect sizes between the different programs by context and mediating and outcome cluster variables. The costs saved (benefits) attached to reductions in negative youth outcomes can be calculated for direct costs (e.g., medical, criminal, productivity, community service, and opportunity) with use of national economic cost data (Rice et al. 1991), local cost estimates for drug use and drug-related legal system costs, economic costs (loss of productivity), and medical costs; and indirect costs as recommended by French and associates (1991) and used by French and Zarkin (1992) for TOPS. Prospective service utilization rates (e.g., medical, mental health, legal, and community services in the prior year) can be collected from program participants on regular pretest and annual posttest questionnaires to determine alternative explanations for program effects and also for benefit analyses.

Readiness of Communities and Agencies To Implement Family Programs Effectively

The readiness of communities and agencies or schools to implement family programs can differ widely and affect their implementation success. Any researcher with access to many different sites interested in implementing family programs should consider a research design that allows for examination of variables in the community and agencies that would affect readiness to implement model research programs with fidelity and effectiveness. A review of factors affecting community readiness and ways to enhance community readiness for prevention programs is available in a new publication from NIDA, Assessing and Enhancing Community Readiness for Prevention (Kumpfer, Whiteside, and Wandersman 1997).

Lack of Research Funding for Family-Focused Prevention Approaches

Prevention programs have typically targeted young people in school-based, universal approaches. Over the years, a few family intervention approaches have been supported by NIDA and NIAAA, notably those of family programs developed by Drs. Alvey, Bauman, Hawkins and Catalano, Dielman, Dishion, Kumpfer, Szapocznik, and Zucker. Because of a major initiative at NIDA to support family-focused prevention efforts, and the increasing frustration of school-based researchers [trying] to get long- lasting and powerful effects, a number of new family research projects have been funded to Drs. Molberg and McDonald, Eggert, Whitbeck, and Spoth. The results from these research grants may help to strengthen support for this family approach.

Most of the funding for family-focused selective prevention programs has come through foundation or CSAP demonstration or evaluation initiatives, which generally do not require research designs with random assignment of subjects. The selective prevention approaches that have been rigorously evaluated have shown positive impact on many risk factors (see Goplerud 1990; Center for Substance Abuse Prevention 1993; Kumpfer 1997; and Lorion and Ross 1992, for reviews of effectiveness of many selective prevention programs for drug abuse prevention).

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