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Family-Based Prevention: Critical Components

© 1999 Education Development Center, Inc.

I. OVERVIEW: FAMILY-BASED PREVENTION

A. Targeting Local Family Practitioners with Effective Strategies

Substance abuse problems do not merely erupt in late childhood or adolescence; they emerge as a symptom of an ongoing pattern of development in the child. For prevention to be effective, it is necessary to move upstream and change a family's less healthy dynamics and behaviors before they become entrenched.

Influencing children and their families early may be the most productive option, but it is not the only one. Family interventions can change behaviors, even in families with longer histories, more entrenched patterns, and older children.

Not all efforts directed at parents are equally effective. In general, parent education or parent support programs are considerably less effective than highly structured approaches, such as behavioral parent training, family skills training, family therapy, or comprehensive family support programs. ^[1] Research suggests specific ways that:

• Providers can act to strengthen families (e.g., they can teach them improved communication skills)

• Families can act to alter existing patterns of behavior in ways that enhance their children's abilities and skills (e.g., they can alter parental patterns of discipline)

• Children, as they develop, can increase the protective factors that are likely to buffer them from risk of substance abuse when they become adolescents (e.g., they can develop improved social skills)

B. Defining the Family

The family is defined as a constellation of adults and young people who share a social network, material and emotional resources, and sources of support. This may mean, for instance, one or two parents and a child or several children, a group that is biologically related (e.g., two sisters and an aunt), a gay or lesbian partnership that is raising a child, or a group that lives together through formal or informal assignment of guardianship.

C. Classifying Prevention

Today family-based prevention efforts put the population group targeted front and center: ^[2]

General population. In the context of family-centered prevention, universal measures are directed toward all families, including those who have not been identified on the basis of risk factors related to substance abuse but for whom exposure to prevention strategies may reduce the possibility of substance abuse.

Groups at risk. In the context of family-centered prevention, selective measures are directed toward subgroups of the population: primarily toward families whose children face above-average risks of developing substance abuse problems (though not necessarily identified as having specific problems).

Individuals at risk. In the context of family-centered prevention, indicated measures are directed toward families whose children have known, identified risks for developing substance abuse problems; usually families are referred because of identified problems (children's conduct problems, school failure, or delinquency or parental abuse or neglect).

II. FIVE FAMILY-BASED STRATEGIES

Research supports five major strategies for family-based interventions: ^[3]

• Parent and family skills training for general populations or for groups at risk (universal/selective)

• Parent and family skills training for families whose children are exposed to multiple risks or to one very serious risk, and show evidence of behavior disorders or conduct problems (indicated)

• Family in-home support (indicated)

• Family therapy (indicated)

• Interventions in early childhood (selective)

All five share certain characteristics:

• They focus on prevention; programs based on these strategies do not directly address existing substance abuse among children or adolescents.

• They focus on the dynamics of the family as a whole; not on one particular individual in the family.

• They are based in theory that identifies the ways in which risks and protective factors interact to shape children's lives.

• They emphasize the importance of reducing risk factors and also increasing protective factors.

• They do not include parent education characterized by didactic, knowledge-only approaches.

A. Strategy 1: Parent and Family Skills Training for General Populations (Universal) and Groups at risk (Selective)^[4]

1. Strategy 1 encompasses two kinds of skills training:

• Parent training is delivered to parents or other caretaking adults; it teaches parents how to enhance protective factors and reduce risk factors tied to substance abuse.

• Family training is delivered to parents, other family adults, and/or children, either in sessions held separately or in sessions that bring all family members together for structured activities; it is designed to change the way family members interact with one another.

2. Overall goals include:

• Promoting healthy children within the family setting

• Improving relationships between parents and children

• Increasing capacity of parents to address specific problem behaviors of their children

• Making general improvements in the structure, functioning, and interaction of families

Strategy 1 skill-building sessions can enable families to better nurture and protect their children, assist the children in developing prosocial behaviors, and train families to deal more effectively with situations and problems that arise in the household.

3. Objectives define what changes a program seeks to bring about.

Programs based on Strategy 1 focus on a number of changes in parents, children, and families.

Objectives for parents include acquiring or improving parenting skills, child management abilities, psychological helping skills, relationship development, and empathy. Some specific behavior changes that might be targeted to achieve these broad objectives include:

• improving communication, problem solving, anger management and coping skills

• improving parents' own communication and relationship

• learning more appropriate ways to deal with children's behavior problems

• learning to use leadership skills, instead of forced authority, that are less likely to induce rebellion in the children

• reducing punitive and authoritarian sanctions and providing more consistent discipline

Objectives for children include improving general behavior, psychological adjustments, attachment to family, and commitment to school. Specifically, programs based on Strategy 1 may seek to help youth to:

• improve their ability to listen and problem solve

• improve their ability to take responsibility for their own actions

• learn prosocial skills, such as coping with loneliness, making choices, controlling anger, recognizing feelings, and coping with peer pressure

Objectives for the family focus on improving family cohesion, organization, relationships, and conflict resolution. Some of the specific changes targeted might include:

• reducing family stress levels and family conflict

• moving from hierarchical to more democratic decision making in the family

• increasing the amount of time family members spend together with positive interactions

4. Activities

Programs in this category are usually delivered through structured activities, provided in community or clinic settings. Skill training sessions may be for (a) parents alone, (b) parents together with their children, and (c) parents and their children but trained separately. They include activities such as:

• Didactic group sessions

• Cognitive-behavioral workshops

• Video presentations

• Curriculum-based and video-based training and modeling sessions

• Lectures

• Demonstrations

• Role-playing and skill practice sessions

• Homework assignments, homework review

• Supervised practice exercises

• Games

Strategy 1 programs designed for a selective audience may be longer or more intensive than those designed for a universal audience, target a smaller number of participants (who are often specifically recruited into the program), and require more skilled staff, since they target multi-problem youth and families.

B. Strategy 2: Parent and Family Skills Training for Individuals at High Risk (Indicated) ^[5]

1. Strategy 2 is very similar to Strategy 1.

The difference is that strategy 2 is used with families whose children are exposed to multiple risk factors or who have a high level of exposure to a single risk factor. The children show evidence of behavior disorders or conduct problems.

2. Overall goals are the same as for Strategy 1.

3. Objectives

The objectives for programs based on Strategy 2 are very similar to those described in Strategy 1, with some additions.

Objectives for parents include acquiring or improving parenting skills, child management abilities, problem-solving skills, communication skills, and crisis management abilities, and improving parents' attitudes toward their children. Many of the specific behavior changes targeted in Strategy 2 are identical to those in Strategy 1. However, because the audience for Strategy 2 consists of families at high risk, and children who have demonstrated possible behavior disorders or conduct problems, there are additional changes that may be targeted by Strategy 2 programs, including:

• reducing parental depression

• reducing parental isolation (by strengthening social support, increasing interactions with people outside the home)

• supporting treatment participation for parents involved with substance abuse

• modifying mothers' over-involved or enmeshed behavior with children, often sons

Objectives for children include improving general behavior, acquiring or improving self-control and compliance, reducing antisocial and other problem behaviors, and reducing arrest rates. In addition to the specific behavior changes described in Strategy 1, programs based on Strategy 2 may aim to:

• modify oppositional-defiant or conduct-disordered behavior in children

Objectives for the family, too, draw largely from Strategy 1, including improving family cohesion, organization, relationships, and conflict resolution. The targeted behaviors are also the same as in Strategy 1. The primary difference, again, is the audience; achieving similar behavior changes with families at high risk may require more concentrated activities, such as therapeutic counseling.

4. Activities

Activities are more likely to be carried out in therapeutic or clinical settings than is the case with Strategy 1. Activities include the activities used in Strategy 1, with one additional activity (in italics):

• Didactic and group sessions

• Cognitive-behavioral workshops

• Video presentations

• Curriculum-based and video-based training and modeling sessions

• Lectures

• Demonstrations

• Role-playing and skill practice sessions

• Homework assignments, homework review

• Supervised practice exercises

• Games

• Therapy

C. Strategy 3: Family In-Home Support (Indicated) ^[6]

1. Strategy 3 provides crisis intervention.

Strategy 3 programs are used with families whose children are exposed to multiple risk factors or who have a high level of exposure to a single risk factor. The children show evidence of behavior disorders or conduct problems.

This family strategy provides crisis intervention. It addresses immediate needs, such as food, clothing, and shelter. To help solve the problems that caused the crisis, it includes long-range planning, through advocacy, counseling, and referral. Intensive, multipurpose services are delivered in the home and usually involve all family members.

2. Overall goals include:

• Decreasing the likelihood of domestic violence, child abuse, or neglect

• Decreasing the likelihood that children will be placed in foster homes or institutions for juvenile delinquents

3. Objectives

Objectives for parents include acquiring or improving parenting skills related to discipline, family relations, communication, and anger management, and decreasing the likelihood of parents engaging in child abuse and neglect. To achieve these objectives, counselors work with parents and children to help them:

• increase mutual positive reinforcement

• decrease maladaptive interaction patterns

• improve family dynamics in families with juvenile offenders of adolescents with strong anti-social behaviors

• improve communication and self-management skills

• learn effective discipline methods (parents)

Objectives for children focus on improving communication skills and anger management, increasing compliance with curfew and school attendance, and lowering the rates of arrests and criminal activities among juvenile offenders. Programs following Strategy 3 may aim specifically to:

• reduce behavioral and emotional problems

• improve the functioning of juvenile offenders

• prevent the initiation of substance abuse

The primary objectives for the family in Strategy 3 are to prevent children from being removed from the family, and reuniting families that have previously been split.

4. Activities

Activities are likely to be carried out in the home; referrals are made to other services outside the home as well. Activities, which may be provided for several months or up to a year, include providing:

• Transportation

• Cash assistance

• Clothing

• Food

• Help with home repairs

• Individual and family counseling

• Crisis intervention

• Behavior management training

• Reunification services

• Case management services

• Referral to substance abuse treatment

D. Strategy 4: Family Therapy (Indicated) ^[7]

1. Strategy 4 programs provide direct family therapy.

These programs are used with families whose children are exposed to multiple risk factors or who have a high level of exposure to a single risk factor. The children show evidence of conduct problems or have diagnosed behavior or emotional problems that increase their risk of developing substance abuse problems.

Family therapy helps family members improve the ways they relate and talk to one another, manage family life, and solve problems. It helps the members develop interpersonal skills to improve communication and perceptions of one another; change behavior that no longer serves a useful purpose in the family group, decrease negative behavior, and create skills for health family interaction.

2. Overall goals include:

• Improving family dynamics

3. Objectives

The goals and activities of Strategy 4 are tailored to meet the needs of individual families; thus, the specifics can vary enormously, even within the same program. However, broadly speaking, some objectives can be identified for programs based on Strategy 4.

Objectives for children focus on reducing behavioral and emotional problems, lowering recidivism rates, improving the functioning of juvenile offenders, and preventing the initiation of substance abuse.

Objectives for families include increasing mutual positive reinforcement and decreasing maladaptive interaction patterns, improving family dynamics in families with juvenile offenders or adolescents with strong antisocial behaviors, acquiring skills, improving communication, learning effective discipline methods, and learning self-management skills.

4. Activities

Family therapy usually involves sessions with a trained therapist who meets with family members as a group.

E. Strategy 5: Interventions in Early Childhood (Selective) ^[8]

1. Strategy 5 programs provide prenatal and early childhood home visits.

These programs target low-income, first-time mothers and seek to change the behavior of new mothers in ways that can strengthen the child's chances for healthy development from an early age.

Behavior problems among young children are often an early marker for later antisocial, noncompliant, and aggressive behavior; this can lead to school dysfunction and conflicts with peers, events that put children at risk for substance abuse when they are older.

Prevention that takes place later in the life of a child, or in families that have already incurred significant risk factors, requires interventions that may be increasingly intensive in degree and costly to implement. Research has begun to verify the hypothesis that money and effort spent early in the life of a family at risk may result in more effective prevention, yield more positive outcomes, and ultimately cost less.

2. Overall goals include:

• Improving the mother's health and habits so that she delivers a healthy baby

• Improving the mother's ability to give the infant proper care in a safe environment

• Keeping the mother's life on track by supporting her in avoiding substance abuse and criminal behavior, practicing birth control and planning future pregnancies, reaching her educational goals, and finding adequate employment

3. Objectives

Objectives are defined for mothers:

• Learn and apply healthy pregnancy practices that prevent low birth weight (improving diet, giving up cigarette smoking and the use of alcohol or other drugs)

• Learn to deal with depression, anger, impulsiveness, and substance abuse problems, in order to reduce chances of child abuse and neglect

• Learn about normal child development

• Increase ability to "read" babies' signals and anticipate their needs

• Learn effective use of social systems and community resources through referrals

• Increase confidence and the skills necessary to set and achieve goals, such as completing their education, finding work, and avoiding unplanned subsequent pregnancies

4. Activities

Home visitors (e.g., registered nurses, lay therapists, or parents' aides) receive considerable training, are well supervised, and make and maintain connections with individual parents over time. Meeting with mothers-to-be once a week or every two weeks, they encourage women to adopt healthy behaviors and prepare for delivery, plan early for subsequent pregnancies and contraception, and begin to think ahead to returning to school or finding employment. Following delivery, they may visit the mothers weekly in the beginning, then biweekly, focusing on promoting good physical care of the child and actions to foster healthy development. Home visitors also make connections, as needed, with formal health and social services.

III. IMPLEMENTATION

Local practitioners are in a strong position to adopt family-based strategies and use them to adapt existing programs or design programs that meet local needs. In taking these steps, there are key aspects of implementation to address:

• Providing leadership

• Carrying out strategic planning

• Collaborating across agencies to marshal community resources

• Attending to cultural traditions

• Selecting program sites

• Promoting the program

• Recruiting and retaining families

• Preparing trainers

• Building partnerships between prevention practitioners and researchers

IV. FAMILY CLIMATE

A. Changing the Family Climate

Local practitioners can encourage all families to consider taking steps to:

• Reduce the availability of substances in the home

• Refrain from serving alcohol to underage youth in their homes

• Collaborate with other families to reduce availability of substances in the homes of their children's friends

• Model non-substance use at home

• Talk to their children about substance use

B. Changing the Larger Environment

Local practitioners and individual family members can take action to bring about changes in the community beyond their homes. See Changing the Larger Environment: Critical Components.

FOOTNOTES

^[1]Kumpfer, K. L. & Alvarado, R. (Nov. 1998). Effective family strengthening interventions. OJJDP Juvenile Justice Bulletin, 4.

^[2] Gordon, R. (1983). An operational classification of disease prevention. Public Health Reports, 98, 107-109.

^[3] Center for Substance Abuse Prevention (CSAP) (1998). Preventing substance abuse among children and adolescents: Family-centered approaches, reference guide. P.L. Grover, (Ed). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; Kumpfer, K. L. & Alvarado, R., Effective family strengthening interventions.

^[4] CSAP. Preventing substance abuse among children and adolescents: Family-centered approaches, reference guide, 3-8; 3-11; Olds, D., Hill, P., and Rumsey, E. (Nov. 1998). Prenatal and early childhood nurse home visitation. OJJDP Juvenile Justice Bulletin.

^[5] CSAP. Preventing substance abuse among children and adolescents: Family-centered approaches, reference guide, 3-11; 3-20.

^[6] CSAP. Preventing substance abuse among children and adolescents: Family-centered approaches, reference guide, pp. 3-21; 3-27.

^[7] CSAP. Preventing substance abuse among children and adolescents: Family-centered approaches, reference guide, 3-27; 3-34.

^[8] Olds, D., Hill, P., and Rumsey, E. Prenatal and early childhood nurse home visitation.