Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic Review

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Effective Parenting Interventions
                                      to Reduce Youth Substance
                                      Use: A Systematic Review
                                      Michele L. Allen, MD, MS,a Diego Garcia-Huidobro, MD,b,c Carolyn Porta, PhD, MPH, RN,d Dorothy
                                      Curran, BS,b Roma Patel, MPH,a Jonathan Miller, MURP,e Iris Borowsky, MD, PhDb

CONTEXT: Parenting interventions may prevent adolescent substance use; however, questions                                                               abstract
remain regarding the effectiveness of interventions across substances and delivery qualities
contributing to successful intervention outcomes.
OBJECTIVE: To describe the effectiveness of parent-focused interventions in reducing or
preventing adolescent tobacco, alcohol, and illicit substance use and to identify optimal
intervention targeted participants, dosage, settings, and delivery methods.
DATA SOURCES: PubMed, PsycINFO, ERIC, and CINAHL.

STUDY SELECTION: Randomized controlled trials reporting adolescent substance use outcomes,
focusing on imparting parenting knowledge, skills, practices, or behaviors.
DATA EXTRACTION: Trained researchers extracted data from each article using a standardized,
prepiloted form. Because of study heterogeneity, a qualitative technique known as harvest
plots was used to summarize findings.
RESULTS: A total of 42 studies represented by 66 articles met inclusion criteria. Results
indicate that parenting interventions are effective at preventing and decreasing adolescent
tobacco, alcohol, and illicit substance use over the short and long term. The majority
of effective interventions required ≤12 contact hours and were implemented through
in-person sessions including parents and youth. Evidence for computer-based delivery was
strong only for alcohol use prevention. Few interventions were delivered outside of school or
home settings.
LIMITATIONS: Overall risk of bias is high.

CONCLUSIONS: This review suggests that relatively low-intensity group parenting interventions
are effective at reducing or preventing adolescent substance use and that protection may
persist for multiple years. There is a need for additional evidence in clinical and other
community settings using an expanded set of delivery methods.

                                                                                                                                                                             NIH

Departments of aFamily Medicine and Community Health, and bPediatrics, University of Minnesota Medical School, Minneapolis, Minnesota; cSchool of Medicine, Pontificia Universidad
Catolica de Chile, Santiago, Chile; and dDepartment of Population Health and Systems, School of Nursing, and eDivision of Epidemiology and Community Health, School of Public Health,
University of Minnesota, Minneapolis, Minnesota

Dr Allen conceptualized the study, led study design, contributed to data extraction, and wrote the initial draft of the manuscript; Dr Garcia-Huidobro contributed
to study design, led data extraction, and reviewed and revised the manuscript; Dr Porta contributed to study design and reviewed and revised early drafts of the
manuscript; Ms Curran and Ms Patel contributed to data extraction and study design and reviewed and revised early drafts of the manuscript; Mr Miller contributed

  To cite: Allen ML, Garcia-Huidobro D, Porta C, et al. Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic Review. Pediatrics.
  2016;138(2):e20154425

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PEDIATRICS Volume 138, number 2, August 2016:e20154425                                                                                                         REVIEW ARTICLE
Despite recent encouraging                  from the perspective of future                  METHODS
trends, youth tobacco, alcohol, and         implementers include the following:
other illicit drug use continue to          Who needs to be involved, for how               Search Strategy
represent a considerable source of          long, in what settings, and through
youth morbidity and mortality and           what means? However, to the best                As reported in the review protocol
establish behavioral patterns that          of our knowledge, no reviews have               (PROSPERO systematic review
have detrimental health outcomes            comprehensively examined the                    registry number CRD42014013069),
into adulthood.1,2 There is therefore a     state of the evidence regarding                 we searched PubMed, PsycINFO,
need to identify effective prevention       targeted participants (parents                  ERIC, and CINAHL for studies
strategies and to better understand         only vs both parents and youth),                investigating parent-focused
the delivery qualities contributing to      minimal dosages required to achieve             interventions designed to reduce
successful intervention outcomes.           outcomes, ideal delivery settings               substance use in adolescents. Search
                                            (schools, community organizations,              terms are presented in Table 1. The
One approach to adolescent
                                            clinics, homes), and optimal delivery           search included all dates available by
substance use prevention builds on
                                            modalities. The lack of evidence                respective online databases up to the
the recognition that parents play
                                            regarding success of implementation             date of March 1, 2015.
a key role in promoting healthy
                                            within clinics is problematic at a time
adolescent behaviors and therefore
                                            when prevention and integrated                  Eligibility Criteria
focuses on strengthening parenting
                                            services are emerging as pediatric
skills.2 The influence that parents
                                            primary care targets within the                 This review included studies
have on their adolescent children
                                            Affordable Care Act.8 In addition,              published in any language
has been substantiated by numerous
                                            although multiple modalities of                 meeting the following criteria:
studies linking a well-defined set of
                                            program delivery are known to                   (1) intervention studies focused
parenting practices (ie, monitoring,
                                            appeal to parents and increasing                on adolescents (mean age of
discipline, communication)
                                            evidence supports the use of online             participating youth between 10
and qualities of parent-youth
                                            prevention programming, few                     and 19 years), (2) reported youth
relationships (ie, warmth, support,
                                            reviews have examined the state                 smoking, alcohol, or illicit substance
acceptance, attachment) to
                                            of the literature across delivery               outcomes (intention, initiation, or
adolescent behavioral outcomes
                                            methods for parenting interventions             use), and (3) involved parent training
including substance use.3,4 Parenting
                                            focused on adolescent substance use             with focus on imparting parenting
interventions for parents of
                                            prevention.7,9                                  knowledge, skills, practices, or
adolescents broadly focus on building
parent self-efficacy in implementing                                                        behaviors.
                                            This systematic review therefore
skills and engaging with their
                                            aims to assess the effectiveness of             Exclusion criteria were (1) design
children in a manner encouraging
                                            parenting interventions over the                not a randomized controlled trial, (2)
health-protective and preventing risk
                                            short and long term on reducing                 adolescents were the participating
behaviors. Previous reviews suggest
                                            adolescent tobacco, alcohol, and illicit        parents, (3) intervention focused
that parent-focused interventions
                                            substance use and, secondarily, to              on specific populations (eg, parents
directed at adolescent substance use
                                            describe effectiveness in relation to           of children with cystic fibrosis or
are effective; however, to the best of
                                            intervention characteristics (targeted          other medical conditions), (4) study
our knowledge, no systematic review
                                            participants, intervention dosage,              compared 2 parenting interventions
of parenting interventions delivered
                                            delivery settings, and delivery                 without a usual care condition,
during adolescence has looked across
                                            method), using visual depictions of             and (5) individual family therapy
multiple substances,3,5,6 nor has any
                                            qualitative data summaries called               interventions distinguished from
considered intervention delivery
                                            harvest plots. These plots represent            parenting-skills interventions in their
modalities or contexts.
                                            a novel approach to synthesizing                focus on changing behaviors though
With increasing focus on evidence-          the findings of systematic                      therapeutic rather than curricular
based adolescent health promotion,          reviews focused on complex and                  approaches.
and given that poor reach is a known        heterogeneous interventions that
challenge for parenting interventions,      cannot be combined into a meta-                 Two independent reviewers (DGH
consideration of evidence                   analysis.10 Results of this review will         and RP) screened titles, abstracts,
regarding how to most effectively           inform the development, tailoring,              and full texts of potential articles.
and efficiently reach families of           and delivery of parent-focused                  A third reviewer (MLA) resolved
adolescents becomes important.7             interventions to improve adolescent             disagreements regarding inclusion of
Practical questions of interest             health.                                         a study.

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2                                                                                                                         ALLEN et al
TABLE 1 Search Terms Used to Search for Articles in PubMed, ERIC, CINAHL, and PsycInfo
                             (“Family”[Mesh] OR Famil* OR Parent*) AND “Adolescent”[Mesh] AND (“Clinical Trial” [Publication Type] OR “Clinical Trials as
PubMed                          Topic”[Mesh]) AND (“Alcohol Drinking”[Mesh] OR “Smoking”[Mesh] OR “Substance-Related Disorders”[Mesh] OR smok* OR
                                substance* OR alcohol* OR marijuana* OR cocaine* OR amphetamine* OR heroine*)
                             (parent* OR famil*) AND (“Clinical Trials+” OR Randomized OR “Parenting Education” OR “parent education”) AND (Adol* OR
ERIC                            teen* OR youth*) AND (tobacco or smok* or alcohol OR substance or marijuana or cocaine or heroin or methamphetamine or
                                amphetamine or prescription or drug*)
                             (parent* OR famil*) AND (“Clinical Trials+” OR Randomized OR “Parenting Education” OR “parent education”) AND (Adol* OR
CINAHL                          teen* OR youth*) AND (tobacco or smok* or alcohol OR substance or marijuana or cocaine or heroin or methamphetamine or
                                amphetamine or prescription or drug*)
                             (adolescent or teen or youth or adolescents or teens or youths or adolescence) AND (exp family/ or exp Parents/ or exp Parenting
                                Skills/ or exp Family Relations/ or exp Parenting/ or exp Parent Child Relations/) AND (exp Parent Training/ or exp clinical
PSYCINFO
                                trials/ or exp Family Intervention/ or exp Intervention/) AND (exp Alcohols/ OR exp Drugs/ or drug.mp OR exp Tobacco Smoking/
                                OR smoking.mp OR tobacco.mp)

Data Extraction and Risk of Bias                   recommendations,12 if insufficient                      ethnicity that comprised >75%
Assessments                                        information was presented to permit                     of the participants or as diverse
                                                   judgment, the risk was scored as                        populations if no one race/ethnicity
All manuscripts were grouped by                    “unclear.” To confirm unclear scores,                   comprised >75% of the participants.
study and assigned a study number.                 study protocols were searched,
Trained researchers (D.G.H., D.C., and             and authors were contacted asking                       Data Synthesis
J.M.) extracted data from each article             additional information on each                          We used harvest plots to graphically
using a standardized, prepiloted                   source of bias. Two independent                         synthesize the findings for the study
form. For studies with multiple arms,              coders (D.G.H. and J.M.) reviewed                       aims.10 In these plots, each study
data were only extracted for the arms              each article, study protocol, and                       or study arm for those evaluating
that had a parent focus. Extracted                 authors’ response to determine                          multiple interventions is represented
outcomes were adolescent smoking,                  the risk of bias of each study.                         by a bar, and the properties of the bar
alcohol, other illicit substance, and              Disagreement between coders was                         represent features of the study. The
polysubstance intention to use;                    resolved by consensus.                                  height presents the study risk of bias;
initiation of use; and use. Results
                                                   Intervention characteristics extracted                  taller bars represent studies with
were documented as either reduced,
                                                   included “targeted participants,”                       fewer sources of bias. Because some
no change, or increased when
                                                   classified as parents only, parents                     studies did not achieve low risk of
compared with control groups at the
                                                   and youth, and multilevel (targeted                     bias on any criteria and thus received
P < .05 level of significance. Time to
                                                   teachers, medical providers, or                         a count of zero, the heights on the
follow-up for all reported outcomes
                                                   others). “Intervention dosage”                          harvest plots represent the raw
were grouped by time from baseline
                                                   was calculated as the amount of                         counts plus 1. The location within a
as ≤12 months, 12.1 to 24 months,
                                                   time parents were intended to                           column represents the study results
24.1 to 48 months, and >48 months.
                                                   participate in the intervention                         classified as detrimental effect, no
If 2 time points fell within a grouping,
                                                   and was classified into low (≤12                        difference, or positive effect using
the longest time point presented was
                                                   parent-hours), moderate (12.1–24                        an α of .05. The bar’s color or fill and
presented.
                                                   parent-hours), and high (>24                            location within a row represent the
Risk of bias was evaluated using the               parent-hours). “Delivery setting”                       analyses of interest.
Cochrane Risk of Bias Assessment                   was defined as the primary location                     For the first aim, to assess the efficacy
Tool, a widely used and validated                  of intervention, classified as home,                    of the parenting interventions (see
tool.11 Sources of study bias assessed             school, community agency, or                            Fig 2), we included all adolescent
were a) random sequence generation,                combination. The primary “method                        smoking, alcohol, and illicit substance
b) allocation concealment, c) blinding             of intervention delivery” was                           use outcomes for all reported time
of study personnel and outcome                     categorized as in-person, typically                     points within each study. The bar
assessment, d) incomplete outcome                  group sessions with a professional;                     color indicates whether substance
data, and e) selective outcome                     workbook based; computer based; or                      use (black), substance use initiation
reporting. Risk of bias was judged                 a combination. Additional extracted                     (gray), or substance use intention
as low, high, or unclear. A summary                data included youth age described as                    (white) was reported in the study.
with the criteria for low risk of bias in          a range in years or grade level and                     When >1 outcome was reported for a
each of the domains is presented as                sex as percent female. Participant                      substance, we presented 1 outcome
a footnote in the Supplemental Table               race/ethnicity was classified as                        based on the following hierarchy:
3. As per Cochrane systematic review               reported by authors or by the race/                     use, initiation, and intention. The

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PEDIATRICS Volume 138, number 2, August 2016                                                                                                               3
bar’s location within rows represent
the follow-up times that the
study reported. The 4 studies
reporting only polysubstance use
outcomes are not included in the
harvest plots.
For the second aim, to determine
the interventions’ characteristics
associated with efficacy (see Figs
3–5), harvest plots synthesize dose
intensity, delivery setting, and
delivery method for each substance.
Only studies reporting these
characteristics were included in the
plots. In these harvest plots, the bar
pattern indicates the longest time
point of follow-up for each study;
white = ≤12 months, dotted = 12.1 to
24 months, horizontal stripes =
24.1 to 48 months, black = >48
months. The bar’s location within
rows represents the characteristic
of the intervention in each study.
Participant types (eg, parents vs
parents and youth) were
not presented in harvest plots
because of a lack of variability.

Because comparing counts between             FIGURE 1
the number of studies with positive          Study flow diagram. From Moher D, Liberati A, Tetzlaff J, Altman DG; The PRISMA Group. Preferred
                                             Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Intern Med.
and null results based on the study’s
                                             2009;151(4):264–269.
P value for the difference between
intervention and control groups
                                             effective outcomes is greater than                not a target of the intervention (n =
might be misleading,13 we conducted
                                             what would have been found by                     2), (2) the study targeted a population
a binomial test of proportions for
                                             chance.13 Using this same formula,                with a specific medical problem (n =
each outcome of interest, using the
                                             we calculated the number of studies               2), (3) youth substance use outcomes
following formula:
                                             that would need to be null to change              were not reported (n = 3), or (4) study
X score = [H - Kp / Kp(1-p) 1/2],            the conclusions of the review in any              did not meet methodological inclusion
                                             given category.                                   criteria (n = 4).
where H is the number of positive
studies, K is the number of total                                                              The final 66 manuscripts included
studies with the characteristic of           RESULTS                                           in the review represented 42
interest, and p is the criterion for                                                           unique studies (Table 2); 6 of
positivity by a 2-sided test (0.05 /         Of the 1883 studies identified, 1721              these studies included multiple
2 = 0.025).13 P values were calculated       unique articles were screened (Fig                parent-focused arms. Studies and
from a normal distribution. We               1). A total of 1644 articles were                 associated citations will hereafter
defined a “positive” study as one            excluded, largely because they did not            be referred to by the study number
reporting results with P values ≤.05         evaluate family skills interventions,             in Table 2 with letter subscripts
or lower; under the null hypothesis,         did not focus on substance use, or                indicating arms for multiarmed
1 in 20 studies would be expected            were not randomized controlled                    studies (eg, 9[a], 9[b]). Some
to meet this criterion. A significant        trials. The remaining 77 articles were            manuscripts reported combined
Xscore suggests that there is sufficient     screened in full, and 11 additional               data from multiple studies and
evidence to conclude that the                articles (representing 7 studies) were            are therefore presented in Table 2
proportion of studies showing                excluded because (1) parents were                 multiple times.

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4                                                                                                                                 ALLEN et al
TABLE 2 Summary of Studies Using Parent-Focused Interventions to Reduce Youth Substance Use
                                                                                                                                                                                                                                                                                                           Number Low Risk of Bias
                                                                                                               Study ID           Authors             Youth Demographics             Intervention Description          Control Description     Outcomes Measured               Resultsa (P < .05)                Criteriab
                                                                                                                     1       Bauman et al         N = 1326; Female NA; Race       4 booklets + 4 follow-up calls     No intervention           Smoking initiation;     12 mo: no difference smoking                  1
                                                                                                                               (2001)14             NA; 12–14 y                      (parent)                                                     alcohol use and        use or alcohol use
                                                                                                                                                                                                                                                  initiation
                                                                                                                     2       Brody et al          N = 332; 53.6% Female;          7 sessions (youth + parents)       3 leaflets                 Alcohol use and         3 mo: reduced alcohol initiation/             3
                                                                                                                               (2006)15             African American; 11–13.5                                                                     intention              use; 29 mo: reduced alcohol
                                                                                                                                                    y                                                                                                                    initiation/use
                                                                                                                     3       Brody et al          N = 667; Female (NA); African   5 sessions (youth + parents)       3 leaflets                 Alcohol use and         29 mo: reduced alcohol use; 65                2
                                                                                                                               (2010)16             American; 10.8 y                                                                              initiation             mo: reduced alcohol use
                                                                                                                     4       Brody et al          N = 502; 51% Female; African    5 sessions (youth + parents)       5 sessions on nutrition   Smoking, alcohol,       22 mo: reduced polysubstance                  1
                                                                                                                               (2012)17             American; Age 16 y (10th                                            (youth + parents)         substance and          use

PEDIATRICS Volume 138, number 2, August 2016
                                                                                                                                                    grade)                                                                                        polysubstance use
                                                                                                                     5       Connell et al        N = 998; 47.3% Female;          6 sessions (youth) + 3 family      No intervention           Smoking, alcohol,       72 mo: reduced smoking use,                   4
                                                                                                                               (2006,18 2007)19     Diverse population;              checkups + elective family                                   substance              alcohol use, and substance
                                                                                                                                                    11–17 y                          intervention (youth +                                                               use
                                                                                                                                                                                     parents)
                                                                                                                     6       Curry et al          N = 4026; 52% Female;           1 handbook + 2 counseling          Standard care             Smoking intention       6 mo: no difference smoking                   1
                                                                                                                               (2003)20             Primarily white; 10–12 y         calls + 1 newsletter (parent)                               and use                 intention, or use; 12 mo: no
                                                                                                                                                                                                                                                                         difference smoking intention,
                                                                                                                                                                                                                                                                         or use; 20 mo: no difference
                                                                                                                                                                                                                                                                         smoking intention, or use
                                                                                                                     7       DeGarmo et al        N = 361; 51% Female;            6 sessions (youth + parent)     No intervention              Smoking, alcohol, and   60 mo: reduced smoking                        4
                                                                                                                               (2009)21             European American;               + recess games (youth +                                     substance use and       and alcohol initiation, no
                                                                                                                                                    5th–12th grade                   teacher) + 7 phone calls                                    initiation              difference substance initiation
                                                                                                                                                                                     (parent) + newsletters
                                                                                                                                                                                     (teacher + parent)
                                                                                                                     8       Dembo et al          N = 315; 44% Female; Diverse    30 home visits (youth + parent) Phone contacts with          Alcohol use             36 mo: no difference alcohol use              1
                                                                                                                               (2002)22             population; 14.5 y                                              staff and referrals if
                                                                                                                                                                                                                    necessary
                                                                                                                    9(a)     Dishion &            N = 65; 47.5% Female; 90%       12 sessions + 6 newsletter      No intervention              Smoking and             4 mo: no change smoking use; 16               1
                                                                                                                                Andrews             Caucasian; 10–14 y               (parents)                                                   substance use           mo: no change smoking use
                                                                                                                                (1995)23
                                                                                                                    9(b)     Dishion &            N = 70; 47.5% Female; 90%       12 sessions + 6 newsletter         No intervention           Smoking and             4 mo: increased smoking use; 16               1
                                                                                                                                Andrews             Caucasian; 10–14 y              (youth + parents)                                            substance use           mo: increased smoking use

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                                                                                                                                (1995)23
                                                                                                                    10       Fang L, et al        N = 108; 100% Female; Asian     9 online sessions (youth +         No treatment              Smoking and alcohol     6.25 mo: no difference smoking                4
                                                                                                                                (2010)24            American; 10–14 y                parent)                                                     use; substance use       use, reduced alcohol
                                                                                                                                                                                                                                                 and intention            use, substance use, and
                                                                                                                                                                                                                                                                          polysubstance intention
                                                                                                                    11       Forman SG et al      N = 279; Female (NA); White;    10 youth sessions + 1 booster      10 sessions + 2 booster Smoking, alcohol and      12 mo: no difference smoking                  2
                                                                                                                               (1990)25             14.72 y                         + 5 parent sessions (youth         on peer support,        substance use              use or alcohol use, reduced
                                                                                                                                                                                    + parent)                          increase substance                                 substance use
                                                                                                                                                                                                                       knowledge (youth
                                                                                                                                                                                                                       only)

5
6
                                                                                       TABLE 2 Continued
                                                                                                                                                                                                                                                                                 Number Low Risk of Bias
                                                                                       Study ID           Authors             Youth Demographics             Intervention Description        Control Description      Outcomes Measured              Resultsa (P < .05)                Criteriab
                                                                                             12      Gonzales et al       N = 516; 50.8% Female;         9 sessions + 2 home visits        1 workshop on school      Smoking, alcohol,       12 mo: reduced polysubstance                  4
                                                                                                       (2012)26             Mexican American; 12.3 y        (youth + parent)                  resources/ school        substance and           use
                                                                                                                                                                                              success (youth +         polysubstance use
                                                                                                                                                                                              parent)
                                                                                            13       Guilamo-Ramos        N = 1386; 50.4% Female;        2 youth sessions + 2 parent       2 youth sessions +        Smoking use             15 mo: reduced smoking use                    4
                                                                                                       et al (2010)27       Diverse population; 12.1 y      sessions + 2 booster calls        parent class on high
                                                                                                                                                            (youth + parent)                  school selection
                                                                                           14(a)     Haggerty et al       N = 213; 48.7% Female; 50.8%   Intervention 1: self-             No treatment              Smoking initiation;     24 mo: no change in tobacco,                  1
                                                                                                       (2007)28             Caucasian, 49.2% African        administered video +                                        alcohol, substance     alcohol, substance or poly
                                                                                                                            American; 13.7 y (8th           workbook program (parent)                                   and polysubstance      substance initiation
                                                                                                                            grade)                                                                                      use and initiation
                                                                                           14(b)     Haggerty et al       N = 224; 48.7% Female;         Intervention 2: 7 Group video +   No treatment              Smoking initiation;     24 mo: no change in tobacco,                  1
                                                                                                       (2007)28             50.8%; Caucasian, 49.2%         workbook sessions (youth                                    alcohol, substance     alcohol, substance or
                                                                                                                            African American; 13.7 y        + parent)                                                   and polysubstance      polysubstance initiation
                                                                                                                            (8th grade)                                                                                 use and initiation
                                                                                            15       Komro et al          N = 5812; 50% Female;          Youth: 25 sessions + 9.5 peer     Standard care             Alcohol intention;      36 mo: no difference alcohol                  2
                                                                                                       (2006,29 2008)30     Diverse population; 11.8 y      leaderships training +                                      alcohol and            intention, alcohol or
                                                                                                                            (6th grade)                     community service project.                                  polysubstance use      polysubstance use
                                                                                                                                                            Youth + parent: 12 at
                                                                                                                                                            home booklets+ 2 family
                                                                                                                                                            fun events + 13 parent
                                                                                                                                                            postcards (youth + parent)
                                                                                           16(a)     Koning (2009,31      N = 1736; 49% Female; Dutch;   Intervention 1: 1 presentation    No intervention           Alcohol use             10 mo: no difference alcohol use;             3
                                                                                                       2011,32 2013)33      12.6 y                          + 1 parent consensus                                                               22 mo: no difference alcohol
                                                                                                                                                            meeting for rule making + 1                                                        use; 34 mo: no difference
                                                                                                                                                            information leaflet (parent)                                                        alcohol use; 50 mo: no
                                                                                                                                                                                                                                               difference alcohol use
                                                                                           16(b)     Koning (2009,31      N = 1747; 49% Female; Dutch;   Intervention 2: 1 presentation    No intervention           Alcohol use             10 mo: reduced alcohol use; 22                3
                                                                                                       2011,32 2013)33      12.6 y                          + 1 parent consensus                                                               mo: reduced alcohol use; 34
                                                                                                                                                            meeting for rule making + 1                                                        mo: reduced alcohol use; 50
                                                                                                                                                            information leaflet (parent)                                                        mo: reduced alcohol use
                                                                                                                                                            + 4 lessons + 1 booster
                                                                                                                                                            session (youth)

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                                                                                            17       Loveland-Cherry      N = 892; 54% Female;           3 home sessions + phone calls     No intervention           Alcohol use and         60 mo: reduced alcohol use                    1
                                                                                                       et al (1999)34       European American; 9 y          + newsletter                                                initiation
                                                                                                                            (4th grade)
                                                                                            18       Martinez et al       N = 73; 44% Female; Latino;    12 sessions + 12 notebook         No project-related        Smoking, alcohol        5.61 mo: reduced smoking                      1
                                                                                                       (2005)35             12.74 y (middle school)        exercises (parent)                intervention              and substance            intention, marginally reduced
                                                                                                                                                                                                                       intention                substance intention, no
                                                                                                                                                                                                                                                difference alcohol intention
                                                                                            19       Milburn et al        N = 151; 66.2% Female;         5 sessions (youth + parent)       Standard care             Alcohol, substance      12 mo: reduced alcohol use,                   3
                                                                                                       (2012)36             Diverse population; 14.8 y                                                                  and polysubstance       increased marijuana use,
                                                                                                                                                                                                                        use                     reduced hard substance use

ALLEN et al
TABLE 2 Continued
                                                                                                                                                                                                                                                                                                          Number Low Risk of Bias
                                                                                                               Study ID            Authors            Youth Demographics              Intervention Description        Control Description       Outcomes Measured             Resultsa (P < .05)                Criteriab
                                                                                                                   20(a)     O’Donnell et al      N = 268; 100% Female;           Intervention 1: 4 audio CDs       No materials               Alcohol use            12 mo: reduced alcohol use                    1
                                                                                                                                (2010)37            Diverse population;              (youth + parent)
                                                                                                                                                    11–13 y
                                                                                                                   20(b)     O’Donnell et al      N = 268; 100% Female;           Intervention 2: 4 booklets        No materials               Alcohol use            12 mo: no change in alcohol use               1
                                                                                                                                (2010)37            Diverse population;              (youth + parent)
                                                                                                                                                    11–13 y
                                                                                                                    21       Pantin et al         N = 213; 36% Female;            9 group sessions +10 family       3 individual and           Smoking, alcohol,      30 mo: reduced polysubstance                  3
                                                                                                                               (2009)38             Hispanic; 13.8 y (8th            visits + 4 booster sessions       family referrals to       substance and          use
                                                                                                                                                    grade)                           (youth + parent)                  agencies that serve       polysubstance use
                                                                                                                                                                                                                       delinquent youth

PEDIATRICS Volume 138, number 2, August 2016
                                                                                                                    22       Perry et al          N = 2351; 48.7% Female; 94%     Project Northland: classroom      Standard care              Smoking, alcohol,
8
                                                                                       TABLE 2 Continued
                                                                                                                                                                                                                                                                                Number Low Risk of Bias
                                                                                       Study ID           Authors             Youth Demographics             Intervention Description        Control Description      Outcomes Measured              Resultsa (P < .05)               Criteriab
                                                                                             26      Schinke et al        N = 325; 51.4% Female;         10 online sessions (youth) + 1    No intervention           Smoking, alcohol and
TABLE 2 Continued
                                                                                                                                                                                                                                                                                               Number Low Risk of Bias
                                                                                                               Study ID           Authors            Youth Demographics        Intervention Description         Control Description   Outcomes Measured            Resultsa (P < .05)                Criteriab
                                                                                                                     33      Spoth et al         N = 429; 52% Female; 99%   Preparing for Drug Free Years    4 leaflets on adolescent Smoking, alcohol,     12 mo: no change in smoking,        3
                                                                                                                               (1999,54            Caucasian; 6th grade       (PDFY): 4 sessions (parent)       development            substance and         alcohol, substance or
                                                                                                                               2001,55                                        + 1 session (youth + parent)      (parent)               polysubstance use     polysubstance initiation or
                                                                                                                               2004,56                                                                                                 and intention         use; 24 mo: reduced smoking,
                                                                                                                               2006,57                                                                                                                       alcohol, substance and
                                                                                                                               2006,58                                                                                                                       polysubstance initiation/use;
                                                                                                                               2008)59,                                                                                                                      48 mo: reduced, alcohol use,
                                                                                                                               Park et al                                                                                                                    marginally reduced smoking,
                                                                                                                               (2000)60,                                                                                                                     alcohol, substance initiation,
                                                                                                                               Mason et al                                                                                                                   no change in tobacco or

PEDIATRICS Volume 138, number 2, August 2016
                                                                                                                               (2003)61, Guyll                                                                                                               substance use; 6 y: reduced
                                                                                                                               et al (2004)62                                                                                                                smoking initiation & use,
                                                                                                                                                                                                                                                             no change in alcohol or
                                                                                                                                                                                                                                                             substance initiation or use; 10
                                                                                                                                                                                                                                                             y: marginally reduced misuse
                                                                                                                                                                                                                                                             of prescription drugs
                                                                                                                    34       Spoth et al         N = 446; 52% Female; 99%   Intervention: Iowa               4 leaflets on adolescent Smoking, alcohol,     12 mo: Reduced alcohol initiation   3
                                                                                                                               (1999,54            Caucasian; 6th grade        Strengthening Families           development            substance and         no change in smoking,
                                                                                                                               1999,63                                         Program (ISFP): 7 sessions       (parent)               polysubstance use     substance or polysubstance
                                                                                                                               2001,55                                         (youth + parent)                                        and intention         initiation or use or alcohol
                                                                                                                               2004,56                                                                                                                       use; 24 mo: reduced smoking,
                                                                                                                               2006,57                                                                                                                       alcohol, substance and
                                                                                                                               2006,58                                                                                                                       polysubstance initiation and
                                                                                                                               2008,59                                                                                                                       marginally reduced smoking,
                                                                                                                               2009,64                                                                                                                       alcohol, substance and
                                                                                                                               2012)65,                                                                                                                      polysubstance use; 48 mo:
                                                                                                                               Guyll et al                                                                                                                   reduced smoking, alcohol,
                                                                                                                               (2004)62                                                                                                                      substance and polysubstance
                                                                                                                                                                                                                                                             initiation, reduced tobacco
                                                                                                                                                                                                                                                             and alcohol use no change in
                                                                                                                                                                                                                                                             substance use; 6 y: reduced
                                                                                                                                                                                                                                                             smoking, alcohol, substance
                                                                                                                                                                                                                                                             and polysubstance initiation,

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                                                                                                                                                                                                                                                             reduced alcohol, substance
                                                                                                                                                                                                                                                             and polysubstance use,
                                                                                                                                                                                                                                                             no change in tobacco use;
                                                                                                                                                                                                                                                             10 y: reduced misuse of
                                                                                                                                                                                                                                                             prescription drugs

9
10
                                                                                       TABLE 2 Continued
                                                                                                                                                                                                                                                                                 Number Low Risk of Bias
                                                                                       Study ID           Authors           Youth Demographics            Intervention Description          Control Description   Outcomes Measured                 Resultsa (P < .05)                 Criteriab
                                                                                             35      Spoth et al        N = 1664; 47% female;         7 sessions (youth + parent)        4 leaflets on adolescent Smoking, alcohol,         12 mo: no difference smoking          3
                                                                                                       (2002,66           Caucasian; 7th grade                                              development            substance and             initiation; reduced alcohol
                                                                                                       2005,67                                                                              (parent)               polysubstance             initiation, substance initiation,
                                                                                                       2008)68,                                                                                                    use; alcohol              and poly substance initiation;
                                                                                                       Spoth et al                                                                                                 and substance             2.5 y: reduced poly substance
                                                                                                       (2006,57,58                                                                                                 initiation                initiation; no change
                                                                                                       2008)59                                                                                                                               substance use; 5.5 y: reduced
                                                                                                       describes                                                                                                                             smoking initiation/use,
                                                                                                       2 studies                                                                                                                             alcohol initiation, substance
                                                                                                       (including                                                                                                                            use, and poly substance
                                                                                                       this 1)                                                                                                                               initiation/use; no change
                                                                                                                                                                                                                                             alcohol use or substance
                                                                                                                                                                                                                                             initiation
                                                                                            36       Spoth et al        N = 11 931; 51% Female; 85%   Year 1: Strengthening Families No project support           Smoking, alcohol         12 mo: reduced substance              1
                                                                                                       (2007,69           Caucasian; 6th grade at       Program (10–14 y): 7                                        and substance            initiation and use, reduced
                                                                                                       2011,70            baseline                      sessions (youth + parent).                                  use, initiation          poly-substance initiation,
                                                                                                       2013)71,                                         Year 2: in-class lessons on                                 and intention;           marginally reduced tobacco
                                                                                                       Redmond                                          substance avoidance (youth)                                 polysubstance            use and initiation, no change
                                                                                                       et al (2009)72                                                                                               initiation and           in alcohol use or initiation; 2
                                                                                                                                                                                                                    intention                y: no difference polysubstance
                                                                                                                                                                                                                                             intention; 4 y: reduced
                                                                                                                                                                                                                                             smoking, alcohol, substance
                                                                                                                                                                                                                                             and polysubstance initiation;
                                                                                                                                                                                                                                             reduced substance use;
                                                                                                                                                                                                                                             marginally reduced tobacco
                                                                                                                                                                                                                                             use; no change in alcohol use;
                                                                                                                                                                                                                                             6 y: reduced smoking and
                                                                                                                                                                                                                                             substance use; no change in
                                                                                                                                                                                                                                             alcohol use
                                                                                           37(a)     Stanton et al      N = 579; 58% Female; 100%     Intervention 1: Intervention 1 +   8 youth sessions alone   Smoking, alcohol and     24 mo: reduced smoking use; no        2
                                                                                                       (2004)73           African American; 13–16 y      1 video (youth + parent)                                   substance use            change alcohol use; marginal
                                                                                                                                                                                                                                             change in substance use
                                                                                           37(b)     Stanton B, et al   N = 559; 58% Female; 100%     Intervention 2: Intervention 1     8 youth sessions alone   Smoking, alcohol and     24 mo: reduced smoking use; no        2

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                                                                                                       (2004)73           African American; 13-16        + 4 booster sessions (youth                                substance use            change alcohol use; marginal
                                                                                                                                                         + parent)                                                                           change in substance use
                                                                                            38       Stormshak, et al   N = 593; 48.6% Female;        3 sessions (youth + parent)        School as usual          Smoking, alcohol and     24 mo: reduced smoking use,           4
                                                                                                       (2011)74 Van       Diverse population; 11.88                                                                 substance use            reduced alcohol use, reduced
                                                                                                       Ryzin, et al       (6th grade)                                                                                                        substance use; 36 mo:
                                                                                                       (2012)75                                                                                                                              reduced alcohol use
                                                                                            39       Werch, CE et al    N = 211; 49.8% Female; 85%    1 consultation (youth)+ 1 letter   Booklet on alcohol       Alcohol use initiation   1 mo: no change alcohol use; 12       2
                                                                                                       (1998)76           African American; 12.1         + 2-9 workbooks (youth +          (youth)                   and intention           mo: no change alcohol use
                                                                                                                          (6th grade)                    parent)

ALLEN et al
Number Low Risk of Bias
                                                                                                                                                                                                                                             Studies varied in operationalization,
                                                                                                                                                                                                                                             measurement of substance use
                          Criteriab

                                                                                                                                                                                                                                             outcomes, which included tobacco,
                                                                                                                                                                                                                                             alcohol, and illicit substance
                                                                                                                                                                                                                                             intention to use, initiation, and
                                                                                                                                                                                                                                             current use, as well as polysubstance
                    2

                                                             1

                                                                                                 3

                                                                                                                                   3
                                                                                                                                                                                                                                             use. Twenty studies (48%) reported
                                                                                                                                                                                                                                             3 substance use outcomes, 3 (7%)
                                                                                                 6 y: no change in polysubstance

                                                                                                                                   6 y: no change in polysubstance
                                                             2 y: reduced alcohol use; 3 y: no
                             intention, no change alcohol

                                                                                                                                                                                                                                             reported 2 substance use outcomes,
                                   Resultsa (P < .05)

                                                                                                                                                                                                                                             15 (36%) reported 1 substance use
                           12 mo: reduced alcohol

                                                                change alcohol use

                                                                                                                                                                                                                                             outcome, and 4 (9%) reported only
                             use or initiation

                                                                                                                                                                                                                                             poly-substance use. Outcomes are
                                                                                                                                                                                                                                             noted in Table 2 in the “Intervention
                                                                                                                                                                                                                                             Description” column. Control
                                                                                                    use

                                                                                                                                      use

                                                                                                                                                                                                                                             conditions were most often standard
                                                                                                                                                                                                                                             care, leaflets, or no intervention. All
                                                                                                    and polysubstance

                                                                                                    and polysubstance
                             Outcomes Measured

                                                                                                                                                                                                                                             but 2 studies were conducted in the
                            Alcohol use initiation

                                                                                                 Alcohol, substance

                                                                                                 Alcohol, substance

                                                                                                                                                                                                                                             United States. Eleven studies (29%)
                               and intention

                                                             Alcohol use and

                                                                                                                                                                                                                                             included a majority of participants of
                                                                intention

                                                                                                                                                                                                                                             white/Caucasian/European origin,
                                                                                                    use

                                                                                                    use

                                                                                                                                                                                                                                             11 studies (29%) focused on other
                                                                                                                                                                                                                                             specific race/ethnic groups (5 on
                                                                                                                                                                                                                                             African American, 1 on Asian, and 5
                                                                                                   adjustment (parent)

                                                                                                                                     adjustment (parent)
                                                               standard nationally
                              Control Description

                                                                                                 Books on postdivorce

                                                                                                                                   Books on postdivorce

                                                                                                                                                                                                                                             on Latino youth), 16 (38%) included
                            Booklet on alcohol

                                                               (curriculum is

                                                                                                                                                                                                                                             diverse youth populations, and 4 did
                                                             Control schools

                                                               in Croatia)

                                                                                                                                                                                                                                             not report race/ethnicity.
                              (youth)

                                                                                                                                                                                                                                             Risk of Bias
                               parent-child communication

                               individual sessions (parent)

                                                                                                                                      individual sessions (parent)
                               Northland) (youth + parent)

                                                                                                                                                                                                                                             Of the 42 included studies,
                               consultation (youth) + 10
                                Intervention Description
                            1 consultation + 1 follow-up

                               and peer communication

                            Intervention 1: 11 group + 2

                                                                                                                                   Intervention 2: 11 group + 2
                               postcards +4 workbooks

                                                                                                                                                                                                                                             approximately half described how
                            Intervention encourages

                                                                                                                                                                                                                                             the randomization sequences
                                                                                                                                      + 11 youth sessions
                               (based on Project
                               (youth + parent)

                                                                                                                                                                                                                                             were generated (n = 22, 52.4%),
                                                                                                                                                                                                                                             approximately a third described
                                                                                                                                                                                                                                             how these were concealed (n = 13,
                                                                                                                                                                                                                                             31.0%), and few reported blinding
                                                                                                                                                                                                                                             outcome evaluators (n = 9, 21.4%).
                                                                                                                                                                                                                                             Many had high attrition rates and
                            N = 650; 46% female; Diverse

                                                                                                   Primarily Caucasian; 10.8

                                                                                                   Primarily Caucasian; 10.8

                                                                                                                                                                                                                                             were selective in the outcomes
                                                               Croatian; 6th–8th grade
                                Youth Demographics

                                                                                                                                                                                                                                             that were reported in published
                              population; 11.4 (6th

                                                             N = 1981; Female (NA);

                                                                                                 N = 159; 51.8% female;

                                                                                                                                                                     b Number of Cochran Criteria indicating low risk of bias from 0 to 5.
                                                                                                 N = 157; 49% Female;

                                                                                                                                                                     a Reduction, no difference, or increase in substance use outcome.

                                                                                                                                                                                                                                             manuscripts (n = 16, 38.1% for both
                                                                                                                                                                                                                                             domains). Summary counts of the
                                                                                                   y at baseline
                                                                                                   at baseline

                                                                                                                                                                                                                                             risk of bias assessment is presented
                              grade)

                                                                                                                                                                                                                                             in Table 2 in the “Number of Low
                                                                                                                                                                                                                                             Risk of Bias Criteria” column and
                                                                                                                                                                                                                                             ranged from 0 (higher risk of bias,
                                                            West et al (2008)78

                                                                                                                                                                                                                                             1 study) to 4 (lower risk of bias, 7
                                 Authors

                                                                                                                                                                                                                                             studies) with an average number of
                                                                                                 Wolchik et al

                                                                                                                                   Wolchik et al
                            Werch et al
                              (2003)77

                                                                                                   (2002)79

                                                                                                                                     (2002)79

                                                                                                                                                                                                                                             low risk of bias criteria of 2.3 ± 1.1
                                                                                                                                                                                                                                             of a maximum score of 5. Because all
TABLE 2 Continued

                                                                                                                                                                                                                                             of the included studies had at least
                                                                                                                                                                     NA, not available.

                                                                                                                                                                                                                                             1 feature that either was unclear or
                                                                                                                                                                                                                                             posed high risk of bias to the study
                                                                                                                                   42(b)
                                                                                                 42(a)
                                  40

                                                             41
                            Study ID

                                                                                                                                                                                                                                             findings (see Supplemental Table 3
                                                                                                                                                                                                                                             for scoring on each criteria for each

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PEDIATRICS Volume 138, number 2, August 2016                                                                                                                                                                                                                                      11
FIGURE 2
Tobacco, alcohol, and illicit substance use, initiation, and intention outcomes according to length of participant follow-up. Black, substance use; gray,
substance use initiation; white, substance use intention. Taller columns represent studies with lower risk of bias. Numbers indicate study ID. Xscore,
number of studies needed to be null (NNN).

study), the overall risk of bias of this            what would be expected by chance.                    earlier time periods. The Xscores were
systematic review is high, suggesting               However, the number of studies that                  significant at all time points. In this
results must be interpreted with                    would need to be null to change this                 case, the number of studies needed
caution.11                                          conclusion was much lower at the                     to be null to change this conclusion
                                                    48 months27 reported
so are presented in Table 2 but not                                                                      other illicit substance outcomes
                                                    no significant intervention effect at
in harvest plots. Of these, 3 were                                                                       (Fig 2, column 3), primarily use.
                                                    earlier time periods reinforces this
effective at outcome end points                                                                          The Xscores were again significant at
                                                    trend. There was variation in the
ranging from 12 to 30 months.4,12,80                                                                     all time points. Similar to alcohol,
                                                    risk of bias in studies but no pattern
                                                                                                         the number of studies needed to be
For smoking, 26 unique studies                      indicting that studies with greater
                                                                                                         null to change this conclusion was
assessed outcomes across the 4                      risk of bias were either more or less
                                                                                                         highest at the early time points.
time periods (Fig 2, column 1).                     effective than those with less risk of
                                                                                                         Again, there was variability in risk of
The majority of studies reported                    bias.
                                                                                                         bias across effective and ineffective
smoking as opposed to intent or
                                                                                                         interventions.
initiation; after 12 months, all but                Thirty-four studies reported alcohol
1 study81 reported smoking as the                   outcomes (Fig 2, column 2), primarily                Across all 3 substances (Fig 2, all
outcome. The Xscores were significant               use as opposed to intent or initiation.              columns), few studies reported
at all time points, indicating that                 Effective studies at >24 months                      efficacy across multiple substance
the proportion of studies showing                   either did not report early outcomes                 use outcomes. Three studies
effective outcomes was greater than                 or also indicated effectiveness at                   indicated significant effects for

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12                                                                                                                                            ALLEN et al
FIGURE 3
Tobacco use at the longest follow-up time according to dose of intervention, setting, primary delivery method, and program duration. White columns, ≤12
months of follow-up; dotted columns, 12.1–24 months of follow-up; horizontal stripe columns, 24.1–48 months of follow-up; black, >48 months of follow-up.
Taller columns represent studies with lower risk of bias. Numbers indicate study ID. Xscore, number of studies needed to be null (NNN).

preventing or reducing use of 2                     Only 1 of these reported significant                 or computer-based approaches
substances at 48                  For the 26 studies reporting                         alcohol outcomes, 65% reported
months.7,18 In terms of preventing all              smoking outcomes, 69% reported                       the intervention dosage, 85%
3 substances, 1 study showed efficacy               information that allowed calculating                 reported delivery setting, and 94%
at 48 months.
                                                    reported delivery method (Fig 3).                    1), the majority of effective studies
                                                    In terms of dosage, (Fig 3, column                   reported
FIGURE 4
Alcohol use at the longest follow-up time according to dose of intervention, setting, primary delivery method, and program duration. White columns, ≤12
months of follow-up; dotted columns, 12.1–24 months of follow-up; horizontal stripe columns, 24.1–48 months of follow-up; black columns, >48 months of
follow-up. Taller columns represent studies with lower risk of bias. Numbers indicate study ID. Xscore, number of studies needed to be null (NNN).

included ≤24 hours of training,                     interventions may generate a                        On the encouraging side, our
although Xscores were significant                   reduction on youth substance use                    findings indicate that relatively
for all dosages. There was a variety                over the short and long term.                       low-intensity interventions with
of effective delivery settings for                                                                      a dosage of a manageable ≥12
illicit substances (Fig 5, column 2);               Despite the existence of multiple                   parent contact hours achieve
most occurred in schools or in a                    effective programs, prevention                      outcomes. Although the dosage is
combination of settings. The majority               researchers have noted that uptake                  manageable, the delivery modality
of these studies used sessions with                 of evidence-based programming has                   may be problematic. The finding
a professional as their delivery                    been limited.81 Common challenges                   that group sessions were the most
method (Fig 5, column 3). Xscores were              for translation of evidence-based                   common means for delivering
significant for all delivery methods                interventions to nonresearch settings               these interventions to parents
except for computer based.                          include intervention intensity, a                   and youth may pose barriers for
                                                    discrepancy between skills needed                   some community settings. When
                                                    to implement the interventions                      implemented well, in-person group
DISCUSSION                                          and those available with current                    sessions may be powerful because
Results of this systematic review                   staff, and intervention relevance (to               of social support and shared
indicate that parenting interventions               population or setting).2 Maximal                    learning among the participants;
could be effective at preventing                    reach of interventions in this review               however, high-quality sessions
and decreasing adolescent tobacco,                  would be achieved if evidence existed               require dedicated staff with content
alcohol, and illicit substance use                  for a broad menu of minimally                       expertise, strong facilitation skills,
but that the substance of focus                     burdensome delivery modalities that                 and high-intensity training on
and delivery characteristics are                    could be easily accessed by families                intervention implementation. The
important. The finding that Xscores                 across a variety of settings and                    costs and staff requirements may
were highly significant for all                     impact multiple outcomes, yet our                   be beyond the means of community
outcomes at all time periods supports               results suggest a relatively limited set            organizations, particularly those
the conclusion that parent-focused                  of options.                                         in resource-limited settings where

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14                                                                                                                                           ALLEN et al
FIGURE 5
Illicit substance use at the longest follow-up time according to dose of intervention, setting, primary delivery method, and program duration. White
columns, ≤12 months of follow-up; dotted columns, 12.1–24 months of follow-up; horizontal stripes, 24.1–48 months of follow-up; black columns, >48
months of follow-up. Taller columns represent studies with lower risk of bias. Numbers indicate study ID. Xscore, number of studies needed to be null (NNN).

highest at-risk youth are often served               Overall, many studies were delivered                  patient-centered health care homes.8
and reside. In this review, alcohol use              in a combination of settings, largely                 This approach has shown positive
was unique among the substances                      schools and home. Few studies                         results with newborns86; more
in that multiple effective studies                   occurred in nonschool community                       research is needed to understand
used computer-based delivery                         agencies, such as health clinics.                     which delivery modalities are
modalities. The success of these                     There is evidence that parenting                      most appropriate for the clinic
                                                     interventions can be successfully                     environment and how policies and
interventions suggests that this may
                                                     implemented in health care                            clinical procedures can best sustain
be an effective and presumably less
                                                     settings, yet few studies have                        these effective programs with
costly approach to reaching a larger
                                                     made use of clinics as locations for                  adolescents.
group of parents of youth. An added
                                                     implementation of family-based
benefit of computer-based delivery                                                                         Finally, given limited resources
                                                     substance use prevention.84,85 As
is that content may be tailored to a                                                                       available for prevention
                                                     schools become overburdened with
particular family’s needs or cultural                                                                      programming and competing
                                                     initiatives focusing on academic                      demands within delivery agencies,
preferences, increasing the likelihood
                                                     achievement, it is important to                       parent-focused interventions would
of relevance and effectiveness.83
                                                     consider clinics and community                        ideally effectively target multiple
In sum, although group sessions                      agencies as alternative settings to                   substance use outcomes; however,
represent the most common and                        promote, sustain, and fund parent                     few studies were effective at reducing
evidence-based delivery modality                     training programming. This is                         adolescent use of multiple substances
for tobacco and illicit substance use                particularly true with the increased                  over the long term. Future research
prevention in particular, there is                   focus on “moving prevention to                        should investigate common core
need for additional studies using                    the mainstream of health,” clinical-                  principles, content, and delivery
alternative approaches, including                    community and public health                           modalities that contribute to study
social/online media, to develop a                    partnerships promoted through                         outcomes for a given substance use
broader set of options for translation               the Affordable Care Act,82 and                        to enhance programming in a manner
of effective programs.                               integrated care within family- and                    that will increase the likelihood of

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PEDIATRICS Volume 138, number 2, August 2016                                                                                                             15
interventions being efficacious across                 of our review. In addition, because                    With the increased move to
substances.                                            of the heterogeneity of intervention                   translate effective interventions
                                                       components, contexts, samples,                         into broad use and the call for
This study has notable strengths,                      methods, outcomes, and measures,                       collaboration between clinic
including use of broad inclusion                       we did not perform a meta-analysis                     and public health initiatives to
criteria to identify all relevant                      and instead used harvest plots to                      promote disease-preventing
intervention studies, but given                        summarize the study findings and                       programming, there is need to
that the majority of studies had                       explore the effects of intervention                    identify effective interventions that
risk of bias based on available                        delivery methods on tobacco,                           prevent adolescent substance use
data, the overall conclusions must                     alcohol, and substance use outcomes.                   across multiple delivery modalities
be interpreted with caution.11                         Although this approach does not                        and settings, including clinics.
Conclusions were limited by the                        provide effect estimate summaries as                   Parent training interventions are
degree to which authors adhered                        in meta-analyses, it is an alternative                 an effective means to promote
to the CONSORT (Consolidated                           that visually represents different                     public health goals for adolescents,
Standards of Reporting Trials)                         aspects of intervention complexity.80                  and an opportunity remains to
guidelines for behavioral                              In addition, using the binomial test                   extrapolate what works to varied
interventions when reporting study                     of proportions to complement the                       community settings in a manner that
design and findings, particularly                      harvest plots allowed us to estimate                   prevents adolescent use of multiple
in the areas of randomization                          probabilities of observing the                         substances.
sequence generation and blinding of                    presented patterns of results, which
data collection processes.87 Better                    produced quantitative evidence                         ACKNOWLEDGMENTS
reporting of risk of bias outcomes                     supporting the qualitative summary.                    The authors acknowledge the
within articles would potentially                      The high number of studies needed to                   substantial contribution of Nicole
have increased the strength of our                     be null to change study conclusions                    Hassig in formatting the harvest
recommendations but not the results                    support the findings of our review.                    plots.

to data extraction and reviewed and revised drafts of the manuscript; Dr Borowsky contributed to conceptualization of the study and reviewed and revised drafts
of the manuscript; and all authors approved the final manuscript as submitted.
This trial has been registered at the PROSPERO systematic review registry (identifier CRD42014013069).
DOI: 10.1542/peds.2015-4425
Accepted for publication May 11, 2016
Address correspondence to Michele Allen, MD, MS, University of Minnesota Department of Family Medicine and Community Health, Program in Health Disparities
Research, 717 Delaware St SE, Minneapolis, MN 55414. E-mail: miallen@umn.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Garcia-Huidobro was supported by National Research Service Award in Primary Medical Care, grant. T32HP22239 (principal investigator: Dr
I Borowsky), Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS). This information or content and
conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or
the US government. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES
     1. Johnston LD, O’Malley PM, Miech                      Emotional, and Behavioral Disorders                    components associated
        RA, Bachman JG, Schulenberg JE.                      Among Young People: Progress and                       with parent training program
        Monitoring the Future national survey                Possibilities. Washington, DC: The                     effectiveness. J Abnorm
        results on drug use: 1975–2014:                      National Academies Press; 2009                         Child Psychol. 2008;36(4):
        Overview, key findings on adolescent                                                                         567–589
                                                          3. Kumpfer KL, Alvarado R. Family-
        drug use. Ann Arbor, MI: Institute
                                                             strengthening approaches for the
        for Social Research, University of                                                                       5. Petrie J, Bunn F, Byrne G. Parenting
                                                             prevention of youth problem behaviors.
        Michigan; 2015                                                                                              programmes for preventing tobacco,
                                                             Am Psychol. 2003;58(6–7):457–465
                                                                                                                    alcohol or drugs misuse in children
     2. National Research Council and Institute           4. Kaminski JW, Valle LA, Filene JH,
6. Thomas RE, Baker PRA, Thomas                      alcohol use. J Consult Clin Psychol.              substance use. Psychol Addict Behav.
     BC, Lorenzetti DL. Family-based                   2010;78(2):281–285                                1990;4(2):67–76
     programmes for preventing smoking                                                              26. Gonzales NA, Dumka LE, Millsap RE,
                                                   17. Brody GH, Chen YF, Kogan SM, et al.
     by children and adolescents. Cochrane                                                              et al. Randomized trial of a broad
                                                       Family-centered program deters
     Database Syst Rev. 2015;(2):CD004493                                                               preventive intervention for Mexican
                                                       substance use, conduct problems,
  7. Metzler CW, Sanders MR, Rusby                     and depressive symptoms in                       American adolescents. J Consult Clin
     JC, Crowley RN. Using consumer                    black adolescents. Pediatrics.                   Psychol. 2012;80(1):1–16
     preference information to increase                2012;129(1):108–115                          27. Guilamo-Ramos V, Jaccard J, Dittus
     the reach and impact of media-based                                                                P, Gonzalez B, Bouris A, Banspach
     parenting interventions in a public           18. Connell AM, Dishion TJ. Deater-Deckard
                                                       K. Variable- and person-centered                 S; GuilamoRamos V. The Linking
     health approach to parenting support.                                                              Lives health education program:
     Behav Ther. 2012;43(2):257–270                    approaches to the analysis of early
                                                       adolescent substance use: linking peer,          a randomized clinical trial of a
  8. Bultas MW, McMillin SE, Broom MA,                 family, and intervention effects with            parent-based tobacco use prevention
     Zand DH. Brief, rapid response,                   developmental trajectories. Merrill-             program for African American and
     parenting interventions within primary            Palmer Q. 2006;52(3):421–448                     Latino youths. Am J Public Health.
     care settings. J Behav Health Serv Res.                                                            2010;100(9):1641–1647
     2015;(Aug):20                                 19. Connell AM, Dishion TJ, Yasui M,
                                                                                                    28. Haggerty KP, Skinner ML, MacKenzie
                                                       Kavanagh K. An adaptive approach
  9. Portnoy DB, Scott-Sheldon LA, Johnson                                                              EP, Catalano RF. A randomized trial
                                                       to family intervention: linking
     BT, Carey MP. Computer-delivered                                                                   of Parents Who Care: effects on key
                                                       engagement in family-centered
     interventions for health promotion                                                                 outcomes at 24-month follow-up. Prev
                                                       intervention to reductions in
     and behavioral risk reduction: a                                                                   Sci. 2007;8(4):249–260
                                                       adolescent problem behavior. J Consult
     meta-analysis of 75 randomized                                                                 29. Komro KA, Perry CL, Veblen-Mortenson
                                                       Clin Psychol. 2007;75(4):568–579
     controlled trials, 1988-2007. Prev Med.                                                            S, et al. Cross-cultural adaptation
     2008;47(1):3–16                               20. Curry SJ, Hollis J, Bush T, et al. A             and evaluation of a home-based
 10. Ogilvie D, Fayter D, Petticrew M, et              randomized trial of a family-based               program for alcohol use prevention
     al. The harvest plot: a method for                smoking prevention intervention in               among urban youth: the “Slick Tracy
     synthesising evidence about the                   managed care. Prev Med. 2003;37(6 Pt             Home Team Program.” J Prim Prev.
     differential effects of interventions.            1):617–626                                       2006;27(2):135–154
     BMC Med Res Methodol. 2008;8:8                21. DeGarmo DS, Eddy JM, Reid JB, Fetrow         30. Komro KA, Perry CL, Veblen-
 11. Higgins JP, Altman DG, Gøtzsche PC,               RA. Evaluating mediators of the                  Mortenson S, et al. Outcomes from a
     et al; Cochrane Bias Methods Group;               impact of the Linking the Interests              randomized controlled trial of a multi-
     Cochrane Statistical Methods Group.               of Families and Teachers (LIFT)                  component alcohol use preventive
     The Cochrane Collaboration’s tool for             multimodal preventive intervention               intervention for urban youth: project
     assessing risk of bias in randomised              on substance use initiation and                  northland Chicago. Addiction.
     trials. BMJ. 2011;343:d5928                       growth across adolescence. Prev Sci.             2008;103(4):606–618
                                                       2009;10(3):208–220
 12. Higgins JP, Green S, eds. Cochrane                                                             31. Koning IM, Vollebergh WA, Smit
     Handbook for Systematic Reviews               22. Dembo R, Wothke W, Livingston S,                 F, et al. Preventing heavy alcohol
     of Interventions. Chichester, United              Schmeidler J. The impact of a family             use in adolescents (PAS): cluster
     Kingdom: Wiley-Blackwell; 2008                    empowerment intervention on juvenile             randomized trial of a parent and
                                                       offender heavy drinking: a latent                student intervention offered separately
 13. Rothman KJ, Greenland S, Lash TL.
                                                       growth model analysis. Subst Use                 and simultaneously. Addiction.
     Modern Epidemiology. Philadelphia, PA:
                                                       Misuse. 2002;37(11):1359–1390                    2009;104(10):1669–1678
     Lippincott Williams & Wilkins; 2008
                                                   23. Dishion TJAD, Andrews DW.                    32. Koning IM, van den Eijnden RJ,
 14. Bauman KE, Foshee VA, Ennett ST, et al.
                                                       Preventing escalation in problem                 Verdurmen JE, Engels RC, Vollebergh
     The influence of a family program on
                                                       behaviors with high-risk young                   WA. Long-term effects of a parent and
     adolescent tobacco and alcohol use.
                                                       adolescents: immediate and 1-year                student intervention on alcohol use
     Am J Public Health. 2001;91(4):604–610
                                                       outcomes. J Consult Clin Psychol.                in adolescents: a cluster randomized
 15. Brody GH, Murry VM, Kogan SM, et al.              1995;63(4):538–548                               controlled trial. Am J Prev Med.
     The Strong African American Families                                                               2011;40(5):541–547
     Program: a cluster-randomized                 24. Fang L, Schinke SP, Cole KC. Preventing
                                                                                                    33. Koning IM, van den Eijnden RJ,
     prevention trial of long-term effects             substance use among early Asian-
                                                                                                        Verdurmen JE, Engels RC, Vollebergh
     and a mediational model. J Consult                American adolescent girls: initial
                                                                                                        WA. A cluster randomized trial on
     Clin Psychol. 2006;74(2):356–366                  evaluation of a Web-based, mother-
                                                                                                        the effects of a parent and student
                                                       daughter program. J Adolesc Health.
 16. Brody GH, Chen YF, Kogan SM, Murry                                                                 intervention on alcohol use in
                                                       2010;47(5):529–532
     VM, Brown AC. Long-term effects                                                                    adolescents four years after baseline;
     of the strong African American                25. Forman SFJLMB. Effects of coping skills          no evidence of catching-up behavior.
     families program on youths’                       training on adolescents at risk for              Addict Behav. 2013;38(4):2032–2039

                                      Downloaded from www.aappublications.org/news by guest on July 13, 2021
PEDIATRICS Volume 138, number 2, August 2016                                                                                                    17
34. Loveland-Cherry CJ, Ross LT, Kaufman              interaction effects by parental stress           alcohol-positive adolescents treated in
     SR. Effects of a home-based family                and social support. Drug Alcohol                 an emergency department: results of a
     intervention on adolescent alcohol                Depend. 2012;125(suppl 1):S18–25                 randomized clinical trial. Arch Pediatr
     use and misuse. J Stud Alcohol Suppl.         44. Riesch SK, Brown RL, Anderson LS,                Adolesc Med. 2011;165(3):269–274
     1999;13:94–102                                    Wang K, Canty-Mitchell J, Johnson DL.        54. Spoth R, Lopez Reyes M, Redmond
 35. Martinez CR Jr, Eddy JM. Effects of               Strengthening families program (10-              C, Shin C. Assessing a public
     culturally adapted parent management              14): effects on the family environment.          health approach to delay onset
     training on Latino youth behavioral               West J Nurs Res. 2012;34(3):340–376              and progression of adolescent
     health outcomes. J Consult Clin               45. Schinke SP, Schwinn TM, Di Noia J, Cole          substance use: latent transition and
     Psychol. 2005;73(5):841–851                       KC. Reducing the risks of alcohol use            log-linear analyses of longitudinal
 36. Milburn NG, Iribarren FJ, Rice E, et              among urban youth: three-year effects            family preventive intervention
     al A family intervention to reduce                of a computer-based intervention with            outcomes. J Consult Clin Psychol.
     sexual risk behavior, substance                   and without parent involvement. J Stud           1999;67(5):619–630
     use, and delinquency among newly                  Alcohol . 2004;65(4):443–449
                                                                                                    55. Spoth RL, Redmond C, Shin C.
     homeless youth. J Adolesc Health.             46. Schinke SP, Schwinn TM, Fang L.                  Randomized trial of brief family
     2012;50(4):358–364                                Longitudinal outcomes of an alcohol              interventions for general populations:
 37. O’Donnell L, Myint-U A, Duran R, Stueve           abuse prevention program for                     adolescent substance use outcomes 4
     A. Especially for daughters: parent               urban adolescents. J Adolesc Health.             years following baseline. J Consult Clin
     education to address alcohol and sex-             2010;46(5):451–457                               Psychol. 2001;69(4):627–642
     related risk taking among urban young         47. Schwinn TM, Schinke SP. Preventing           56. Spoth R, Redmond C, Shin C, Azevedo
     adolescent girls. Health Promot Pract.            alcohol use among late adolescent                K. Brief family intervention effects
     2010;11(suppl 3):70S–78S                          urban youth: 6-year results from a               on adolescent substance initiation:
 38. Pantin H, Prado G, Lopez B, et al. A              computer-based intervention. J Stud              school-level growth curve analyses 6
     randomized controlled trial of Familias           Alcohol. 2010;71(4):535–538                      years following baseline. J Consult Clin
     Unidas for Hispanic adolescents with          48. Schinke SP, Cole KCA, Fang L. Gender-            Psychol. 2004;72(3):535–542
     behavior problems. Psychosom Med.                 specific intervention to reduce
     2009;71(9):987–995                                                                             57. Spoth R, Shin C, Guyll M, Redmond C,
                                                       underage drinking among early
                                                                                                        Azevedo K. Universality of effects: an
 39. Perry CLWC, Williams CL, Veblen-                  adolescent girls: A test of a computer-
                                                                                                        examination of the comparability of
     Mortenson S, et al. Project Northland:            mediated, mother-daughter program. J
                                                                                                        long-term family intervention effects
     outcomes of a communitywide alcohol               Stud Alcohol. 2009;70(1):70–77
                                                                                                        on substance use across risk-related
     use prevention program during early           49. Schinke SP, Fang L, Cole KC. Computer-           subgroups. Prev Sci. 2006;7(2):209–224
     adolescence. Am J Public Health.                  delivered, parent-involvement
     1996;86(7):956–965                                intervention to prevent substance use        58. Spoth RL, Clair S, Shin C, Redmond
                                                       among adolescent girls. Prev Med.                C. Long-term effects of universal
 40. Perry CLWC, Williams CL, Komro KA,
                                                       2009;49(5):429–435                               preventive interventions on
     et al. Project Northland: long-term
                                                                                                        methamphetamine use among
     outcomes of community action to               50. Schinke SP, Fang L, Cole KC. Preventing          adolescents. Arch Pediatr Adolesc
     reduce adolescent alcohol use. Health             substance use among adolescent girls:            Med. 2006;160(9):876–882
     Educ Res. 2002;17(1):117–132                      1-year outcomes of a computerized,
 41. Williams CL, Perry CL, Farbakhsh                  mother-daughter program. Addict              59. Spoth R, Trudeau L, Shin C, Redmond
     K, Veblen-Mortenson S. Project                    Behav. 2009;34(12):1060–1064                     C. Long-term effects of universal
     Northland: comprehensive alcohol                                                                   preventive interventions on
                                                   51. Schinke SP, Fang L, Cole KC, Cohen-
     use prevention for young adolescents,                                                              prescription drug misuse. Addiction.
                                                       Cutler S. Preventing substance
     their parents, schools, peers and                                                                  2008;103(7):1160–1168
                                                       use among Black and Hispanic
     communities. J Stud Alcohol Suppl.                adolescent girls: results from a             60. Park J, Kosterman R, Hawkins JD, et al.
     1999;13:112–124                                   computer-delivered, mother-daughter              Effects of the “Preparing for the Drug
 42. Prado G, Pantin H, Briones E, et                  intervention approach. Subst Use                 Free Years” curriculum on growth
     al. A randomized controlled trial                 Misuse. 2011;46(1):35–45                         in alcohol use and risk for alcohol
     of a parent-centered intervention             52. Simons-Morton B, Haynie D, Saylor                use in early adolescence. Prev Sci.
     in preventing substance use and                   K, Crump AD, Chen R. The effects                 2000;1(3):125–138
     HIV risk behaviors in Hispanic                    of the going places program on               61. Mason WA, Kosterman R, Hawkins
     adolescents. J Consult Clin Psychol.              early adolescent substance use                   JD, Haggerty KP, Spoth RL. Reducing
     2007;75(6):914–926                                and antisocial behavior. Prev Sci.               adolescents’ growth in substance
 43. Prado G, Cordova D, Huang S, et al The            2005;6(3):187–197                                use and delinquency: randomized
     efficacy of Familias Unidas on drug            53. Spirito A, Sindelar-Manning H, Colby             trial effects of a parent-training
     and alcohol outcomes for Hispanic                 SM, et al. Individual and family                 prevention intervention. Prev Sci.
     delinquent youth: main effects and                motivational interventions for                   2003;4(3):203–212

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18                                                                                                                                    ALLEN et al
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