Transcript PROSPER - Iowa State University

Prevention of Substance-Related Problems:
Effectiveness of Family-Focused Prevention
Richard Spoth
Partnerships in Prevention Science Institute
Iowa State University
United Nations Office on Drugs and Crime
Technical Seminar on Drug Addiction Prevention and
Treatment: From Research to Practice
December 17, 2008
1. Advances in Family-focused Prevention
Positive outcomes from rigorous studies
Caregiver-child bonding
 Child management
 Social, emotional and cognitive
competencies (e.g., problem solving, goal setting)
 Substance use, delinquency, conduct problems
 Mental health problems

See summaries in Spoth, R. (In press). Translation of family-focused prevention science into public health impact:
Toward a translational impact paradigm. Current Directions in Psychological Science; Spoth, R., Greenberg, M. &
Turrisi, R. (2008). Preventive interventions addressing underage drinking: State of the evidence and steps toward public
health impact. Pediatrics, 121, 311-336.
.
Selected Examples of
Prevention Programs
Meeting Rigorous Outcome Criteria
• Raising Healthy Children
[Catalano et al. (2003); Brown, Catalano, Fleming, Haggerty, & Abbott (2005); depts.washington.edu/sdrg]
• Nurse-Family Partnership Program (NFP)
[Olds et al. (1998); www.nursefamilypartnership.org]
• The Incredible Years
[Reid, Webster-Stratton, & Beauchaine (2002); Webster-Stratton & Taylor (2001); www.incredibleyears.com]
• Triple P-Positive Parenting
(Heinrichs et al. (2006); Sanders, Markie-Dadds, Tully, & Bor (2000); www.triplep.net ]
• Family Matters
[Bauman et al. (2000); Bauman et al. (2002); http://familymatters.sph.unc.edu/index.htm]
• Families That Care: Guiding Good Choices
[Park et al. (2000); Spoth et al. (2004); http://www.dsgonline.com/mpg]
See criteria in Spoth, R., Greenberg, M., & Turrisi, R. (2008). Preventive interventions addressing underage
drinking: State of the evidence and steps toward public health impact. Pediatrics, 121, 311-336.
2. Challenge of General Population
Intervention Impact—Substance Initiation
U.S. Monitoring the Future Study, 2005—
among 8th-12th graders, lifetime use prevalence rates
Cigarettes
Marijuana
Alcohol
Drunkenness
80%
70%
•Escalating rates
of use from
8th-12th grades
60%
50%
40%
30%
20%
10%
0%
8th Grade
10th Grade
12th Grade
•Early initiation
linked with
misuse/high
social, health,
economic costs
Two Windows of Opportunity for
Intervention with General Populations
No Use
Substance
Initiation
Advanced
Use
Intervene to
Reduce Probability
of Transition
See Spoth, Reyes, Redmond, & Shin (1999). Assessing a public health approach to delay onset and progression of
adolescent substance use: Latent transition and log-linear analyses of longitudinal family preventive intervention
outcomes. Journal of Consulting and Clinical Psychology, 67, 619-630.
Conditions for Public
Health Impact on Substance Use—Requires…
…a larger “piece” of evidence-based programs (EBPs) to delay
two types of transition with general community populations
…sustained, quality implementation on a large scale
Sustained, quality EBPs
EBPs
Evaluatednot effective
Not Evaluated
Rigorously demonstrated, long-term EBP impact is very rare (Foxcroft et al., 2003).
3. Illustrations of Evidence
That Universal Family Programs Work...
...with potential for public health impact.
Intervention Implementation Model for
Project Family Randomized Controlled
Trial II (First generation partnership model)
School/Community Implementers
assisted by University Outreach System
State University
Prevention Research Team and Extension Specialists
See partnership model description in Spoth, R. (2007). Opportunities to meet challenges in rural prevention
research: Findings from an evolving community-university partnership model. Journal of Rural Health, 23, 42-54.
One Example―
Strengthening Families
Program: For Parents and Youth 10-14* (SFP 10-14)
• Objectives
─ Enhance family protective factors (e.g., caregiver-child
bonding)
─ Reduce family-based risk factors for child problem
behaviors (e.g., ineffective discipline; low peer
resistance)
• Program Lengthweekly two-hour sessions
• Program Formatsessions include one hour for separate
parent and child training and one hour for family training
*Formerly known as Iowa Strengthening Families Program (ISFP)
SFP 10-14 Content
• Key program content for parents
─ Effective family management
─ Managing emotions/affective quality
• Key program content for adolescents
─ Peer resistance skills
─ Pro-social attitudes
─ Coping with stress and strong emotions
• Key program content for families
─ Problem-solving
─ Communication
• Observers confirm consistency with protocol
Project Family Trial II
Substance Initiation Results
Lifetime Drunkenness Through 6 Years Past Baseline:
Logistic Growth Curve
0.8
Trajectory for ISFP Condition
First Time Proportion
Trajectory for Control Condition
0.6
0.4
0.2
0
0 months
(Pretest)
6 months
(Posttest)
18 months
(Grade 7)
30 months
(Grade 8)
48 months
(Grade 10)
72 months
(Grade 12)
Source: Spoth, Redmond, Shin, & Azevedo (2004). Brief family intervention effects on adolescent
substance initiation: School-level curvilinear growth curve analyses six years following baseline. Journal
of Consulting and Clinical Psychology, 72, 535-542.
Project Family Trial II
Substance Initiation Results
Lifetime Marijuana Use Through 6 Years Past Baseline
0.4
First Time Proportion
Trajectory for ISFP Condition
Trajectory for Control Condition
0.3
0.2
0.1
0
0 mo. (Pretest)
6 mo. (Posttest)
18 mo. Grade 7
30 mo. Grade 8
48 mo. Grade 10
72 mo. Grade 12
Source: Spoth, Redmond, Shin, & Azevedo (2004). Brief family intervention effects on adolescent
substance initiation: School-level curvilinear growth curve analyses six years following baseline.
Journal of Consulting and Clinical Psychology, 72, 535-542.
Project Family Trial II
Substance Initiation Results
Average age at given prevalence levels
Prevalence
Rate
Age
Intervention Control
Lifetime Alcohol Use
without parental permission
40%
15.5
17.0*
Lifetime Drunkenness
35%
15.3
17.5*
Lifetime Cigarette Use
30%
15.7
17.9*
Lifetime Marijuana Use
10%
15.5
17.8
*p < .05 for test of group difference in time from baseline to point at which initiation levels reach the
stated levels—approximately half of 12th grade levels—in control group.
Source: Spoth, Redmond, Shin, & Azevedo. (2004). Brief family intervention effects on adolescent substance initiation: School-level
curvilinear growth curve analyses six years following baseline. Journal of Consulting and Clinical Psychology, 72, 535-542.
Project Family Trial II―
Wide Ranging Positive Outcomes
Adolescents─Up to 6 Years Past Baseline
• Improved parenting skills
• Improved youth skills (e.g., peer resistance, social
competencies)
• Improved school engagement and grades
• Decreased aggressive/destructive behaviors, conduct
problems
• Decreased mental health problems (e.g., depression)
Other Long-term
Effects of Family Program
Young Adults─10 Years Past Baseline
• Significant effects on young adult drunkenness, cigarette use, illicit
drug use, offending behavior, health-risky sexual behavior
• Examples of practical significance
Drunkenness
Illicit Use
Offending
Family Program
20.2%
14.8%
7.1%
Control
29.5%
18.2%
14.3%
Yields relative reduction rate
22.0%
19.0%
50.0%
Sources: Spoth, R., Trudeau, L., Guyll, M., Shin, C., & Redmond, C. (2008). Universal intervention effects on substance use
among young adults via slowed growth in adolescent substance initiation. Under review (Journal of Consulting & Clinical
Psychology); Spoth, R., Trudeau, L., Shin, C., & Redmond, C. (August, 2008). Universal intervention effects on offending
behaviors among young adults via reduction in growth of adolescent problem behaviors. Invited presentation at the annual
conference of the American Psychological Association, Boston, MA.
Countries in Which
SFP:10-14 Has Been Implemented to Date
Costa Rica
Poland
El Salvador
Puerto Rico
England
Spain
Greece
Sweden
Italy
United States
Nicaragua
US Virgin Islands
Norway
Wales
Does the family
program work universally well?
Are observed initiation outcomes
truly “universal”—do they benefit all participants
comparably, regardless of initial risk status?
Conclusions from
Risk-Related Outcome
Studies─Benefits to
Higher-Risk
• Comparable benefit across risk-related subgroups
or higher-risk benefit (multiple studies)
• Leveraging effect (lower risk benefit more)
intuitively appealing but not empirically supported
• Findings are from studies wherein successfully
recruited and retained both higher-risk and
lower-risk participants
Does the family program
yield economic benefits?
(What are the economic
benefits of universal
intervention effects on
substance initiation?)
Project Family Trial II
Benefit-Cost Analysis
*Estimated $9.60 returned for each dollar invested
under actual study conditions.
Source: Spoth, Guyll, & Day (2002). Universal family-focused interventions in alcohol-use disorder prevention:
Cost-effectiveness and cost-benefit analyses of two interventions. Journal of Studies on Alcohol, 63, 219-228.
Family plus school more
effective than school alone?
• Both family and school are primary
socializing environments
• Etiological research confirms powerful
risk and protective factors originating
in both
• Prospect of intervention synergy—
teaching similar skills in two settings
• No prior randomized, controlled
studies of this universal combination
• Capable Families and Youth (CaFaY) Trial
CaFaY Meth Initiation Results at
4½ Years Past Baseline
8
7
6
Percentage
5
4
5.18
3
2.51
2
1
0
.53
SFP+LST (p<.05)
LST
11th Grade
Control
Source: Spoth, R., Clair, S., Shin, C., & Redmond , C. (2006). Long-term effects of universal
preventive interventions on methamphetamine use among adolescents. Archives of Pediatrics
and Adolescent Medicine, 160, 876-882.
When “combined” with school program, how
well is it implemented—and working—under
“real world” conditions?
When the multicomponent intervention
is implemented by a community team
(“real world conditions”) is the quality
of intervention implementation
sufficiently high?
Are the effects significantly better than
“intervention as usual?”
Third Generation Sustainability Partnership
Design For PROSPER Randomized Controlled Trial
Local Community Teams
Prevention Coordinator Team
University/State-Level Team
PROSPER
Community Team Activities
• Meet regularly to plan activities/review progress
• Recruit participants for family-focused program
• Hire and supervise program
implementers
• Handle all logistics involved with
program implementation
• Market PROSPER programs in
their communities
• Locate resources for sustaining
programs
PROSPER Implementation Study Findings
• Poor implementation threatens validity
• The range of percentage of adherence to protocol in
literature reviews is 42% to 86%.
• Average over 90% adherence to the intervention
protocol with family EBIs
• Average over 90% adherence with school EBIs
• High ratings on other quality indicators
• Quality maintained across cohorts
Source: Spoth, Guyll, Lillehoj, Redmond, Greenberg (In press). PROSPER study of evidencebased intervention implementation quality by community-university partnerships. Journal of
Community Psychology.
PROSPER Sustainability Trial
Substance Initiation Results
Outcomes at 1½ and 3½ Years Past Baseline
Past Year Use Rates
Intervention
Control
.20
0.19
.15
0.14
.10
.05
0.03
0.05
.00
Marijuana Use**
(I 1/2 years)
Marijuana Use**
(3 1/2 years)
**p <0.01
Source: Spoth, Redmond, Shin, Greenberg, Clair, & Feinberg (2007). Substance use outcomes at 1½ years past baseline
from the PROSPER community-university partnership trial. American Journal of Preventive Medicine, 32(5), 395-402.
General Conclusions about Family Programs
• Ultimate goal is measurable public health impact on
substance-related (and other health) problems—using
universal preventive interventions delivered with
quality on a large scale
• In this connection, our research suggests
ISFP/SFP 10-14 (plus school interventions)
 can work well—effective long-term,
 across the risk spectrum,
 with economic benefits,
 even when “turned over” to community teams
Needed Work in Family-Focused
Prevention―The 4 Es of Intervention Impact
• EffectivenessMore programs evaluated more vigorously (e.g.,
long-term follow-ups)
• Extensiveness of coverage Fill gaps re population needs (e.g.,
for sociodemographically diverse populations, rural to urban)
• EfficiencyMore programs with multiple outcomes,
economically efficient programs
• EngagementEffective strategies at individual and
organizational levels (e.g., increase organizational readiness to
adopt and sustain quality implementation)
Spoth, R. (In press). Translation of family-focused prevention science into public health impact: Toward a
translational impact paradigm. Current Directions in Psychological Science.
Plotting the Future Course―
Key Tasks in Translating Science into Practice
• Adopt comprehensive public health impact oriented models
─ Integrate service development models with evaluation research
─ Factor organizational readiness and capacity building
─ Factor quality implementation with sustainability
• Implement policies that
─ Prioritize implementation of programs with evidence of potential
economic/public health impact
─ Fund broad-spectrum translational research to guide effective large-scale
delivery, guided by comprehensive public health models
─ Support infrastructure for effective large-scale delivery (e.g., practitionerscientist networks)
Spoth, R. (In press). Translation of family-focused prevention science into public health impact: Toward a
translational impact paradigm. Current Directions in Psychological Science; Spoth, R. L., & Greenberg, M. T.
(2005). Toward a comprehensive strategy for effective practitioner-scientist partnerships and larger-scale community
benefits. American Journal of Community Psychology, 35, 107-126.
…Linked with an International
Research “Network”
Acknowledgement of
Our Partners in Research
Investigators/Collaborators
R. Spoth (Director), C. Redmond & C. Shin (Associate Directors),
T. Backer, K. Bierman, G. Botvin, G. Brody, S. Clair,
T. Dishion, M. Greenberg, D. Hawkins,
K. Kavanagh, K. Kumpfer, C. Mincemoyer,
V. Molgaard, V. Murry, D. Perkins, J. A. Stout
Associated Faculty/Scientists
K. Azevedo, J. Epstein, M. Feinberg, K. Griffin,
M. Guyll, K. Haggerty, S. Huck, R. Kosterman,
C. Lillehoj, S. Madon, A. Mason, J. Melby, M. Michaels,
T. Nichols, K. Randall, L. Schainker,
T. Tsushima, L. Trudeau, J. Welsh, S. Yoo
Prevention Coordinators
E. Berrena, M. Bode, B. Bumbarger, E. Hanlon
K. James, J. Meek, A. Santiago, C. Tomaschik
Welcome to our website at...
www.ppsi.iastate.edu