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 Downloaded from www.aappublications.org/news by guest on July 13, 2021 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. Downloaded from www.aappublications.org/news by guest on July 13, 2021 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 Downloaded from www.aappublications.org/news by guest on July 13, 2021 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. Downloaded from www.aappublications.org/news by guest on July 13, 2021 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 Downloaded from www.aappublications.org/news by guest on July 13, 2021 (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) Downloaded from www.aappublications.org/news by guest on July 13, 2021 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, Downloaded from www.aappublications.org/news by guest on July 13, 2021 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 Downloaded from www.aappublications.org/news by guest on July 13, 2021 (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 Downloaded from www.aappublications.org/news by guest on July 13, 2021 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 Downloaded from www.aappublications.org/news by guest on July 13, 2021 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 Downloaded from www.aappublications.org/news by guest on July 13, 2021 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 Downloaded from www.aappublications.org/news by guest on July 13, 2021 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,
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