A Family-Centered Approach as Prevention for Substance Abuse

For centuries we have known the impact of alcoholism and drug addiction on children and families. Today parental substance abuse commonly involves alcohol and other drugs, as well as mental health problems, poverty, and violence. Addiction often runs in families, from generation to generation, the adult addict being the child or grandchild of an alcoholic or addict and likely to not have experienced nurturing or a healthy family. We are all well aware that addiction affects every member of the family. Children of alcoholics are more likely than other children to develop addiction due to environmental and genetic factors (NACOA, n.d.), and having parents active in their addiction during a child’s development can have long-term impact. Although children may be predisposed by their family environment and genetics, they are not predestined to become alcoholics or addicts. Prevention strategies can make a difference.

Prevention programs aim to reduce the likelihood of new cases of a disorder by altering the underlying mechanisms implicated in the development and maintenance of the disorder.  Prevention is distinct from—but complementary to—treatment in their common goal of reducing behavioral problems (Foster, Olchowski, & Webster-Stratton, 2007). The goal is to reduce the likelihood of developing a disorder in the future. Programs can be designed with the intended audience in mind: for everyone in the population; for those at greater risk; and for those already involved with drugs or other problem behaviors. Programs can also be geared for more than one of these audiences (NIDA, 2003).

Methods of prevention can be classified along four levels: universal, selective, indicated, and multilevel (Battistich, Solomon, Watson, & Schaps, 1997; NIDA, 2003). Universal prevention programs, often referred to as “primary preventions,” aim to prevent the onset of a disorder such as alcoholism or drug use. Delaying onset is important because it reduces the likelihood of addiction by reducing its duration. Selective prevention, or “secondary prevention,” attempts to reduce the prevalence of drug abuse by early identification and aggressive treatment. Indicated preventions intervene with individuals displaying symptoms but not meeting full criteria for drug abuse. Finally, prevention programs that contain more than one prevention level are called multilevel or “tiered” preventions (Battistich et al., 1997). 

Nearly all prevention programs include instructional and informational elements. Multilevel preventions also provide emotional support. Positive parent outcomes in universal prevention programs have included reductions in poor parenting behaviors such as rejection of the child, authoritarian parenting strategies, and physical punishment as well as increased use of positive parent management strategies, including greater use of praise and effective discipline as well as targeting alcohol and drug abuse (Niccols, 2009). 

In a well-researched article previously published in Counselor, Ford, Savas, Drymon, Ramsey, and Patterson (2014) make a case for the importance of prevention. Their solutions document programs that are held in school and community settings. They cite Cuijpers (2002) and Botvin (2000) that such programs have been found to be “somewhat ineffective over longer periods of time” (Ford, Savas, Drymon, Ramsey, & Patterson, 2014). Furthermore, they cite Fisher and Harrison (2013, p. 321) that prevention efforts that solely offered information “did increase knowledge of participants but had no effect on attitudes and drug use.” Clearly such efforts are too late in a child’s life and are not centered where a child’s attitudes are formed: the family.

It is generally agreed that prevention programs that target the whole family are most efficacious (UNODC, 2013). When family programs were compared with other prevention approaches, they were found to be the second most effective approach after in-home family support, and approximately fifteen times more effective than programs that provided youth only with information and self-esteem, and approximately three times more effective than life or social skills training (Hawkins, Kosterman, Catalano, Hill, & Abbott, 2008; Cheng et al., 2007; Hiscock et al., 2008). Moreover the effect of family skills training programs was sustained over time (Cheng et al., 2007; Miller-Heyl, MacPhee, & Fritz, 1998). The long-term results of family-skills training programs in children show delayed initiation of substance abuse, improved youth resistance to peer pressure to use alcohol, reduced affiliation with antisocial peers, improved problem-solving, and reduced levels of problem behaviors such as delinquency. In parents, positive results include sustained improvement in family and child management skills such as setting standards, monitoring of behavior, and consistent discipline (Ialongo, Poduska, Werthamer, & Kellam, 2001).

The purpose of this article is to examine the most efficacious elements of family-centered programs as preventive for drug and alcohol abuse and to present a successful, multilevel model program. Researchers can now compare program elements to gold standards; that is, those that lead in the field of prevention, that are most respected, and that give the best chance for prevention. Two publications meet that standard: The Guide to Implementing Family Skills Training Programs for Drug Abuse Prevention (UNODC, 2009) and Applying Preventive Principles to Drug Abuse Prevention Programs (NIDA, 2003). To that end we will address population risk and protective factors, the generally agreed upon essential elements of a successful, family-centered, evidence-based prevention program, and compare the multilevel program, Celebrating Families! to those standards.

According to NIDA (2007), the following key aspects of an effectual approach to intervention are:

• Addiction is a complex disease that is influenced by a tangle of factors involving genes, environment, and age of first use.
• Addiction is a developmental disease that usually begins in adolescence or even childhood when the brain continues to undergo changes.
• Prevention and early intervention work best to reduce the incidence of substance abuse.  The developmental years might also present opportunities for resiliency and for receptivity to intervention that can alter the course of addiction. We already know many of the risk factors that lead to drug abuse and addiction: mental illness, physical or sexual abuse, aggressive behavior, academic problems, poor social skills, and poor parent-child relations. This knowledge, combined with better understanding of the motivational processes at work in the young brain, can be applied to prevent drug abuse from starting or to intervene early to stop it when warning signs emerge.
• Family-centered programs work by strengthening powerful protective factors, thereby reducing the probability of risks.

Prevention science has made great progress in recent years. Since the early 1990s there has been a growing movement in health, education, and other behavioral service fields toward the delivery of services and practices whose impact on positive outcomes are grounded in science and research. The movement is defined by the term “evidence-based” that is assigned to practices, programs or interventions (UNODC, 2013). According to the Evidence-Based Practice Institute, 

Scientists have identified risk and protective factors that predict prevention of adolescent and adult drug and alcohol abuse and have identified prevention principles and prevention program delivery that has withstood testing in various populations and at various ages and stages. The basic principles of neuroscience indicate that early preventive intervention will be more efficient and produce more favorable outcomes than remediations later in life (Harvard, 2007). Over twenty years of research demonstrates that prevention interventions designed and tested to reduce risk and enhance protective factors can help children at every step along their developmental path, from early childhood into young adulthood (NIDA, 2007). 

Critical or sensitive periods in development may heighten the importance of risk or protective factors. For example, mutual attachment and bonding between parents and children usually occurs in infancy and early childhood. If it fails to occur during those developmental stages, it is unlikely that a strong positive attachment will develop later in the child’s life (NIDA, 2003). A recent trend is for prevention programs to intervene in families with younger children than in the past. NIDA has revised its drug abuse prevention literature to include prevention starting in infancy instead of its previous start point at preschool age (2003). A growing body of literature suggests that developmental stage is an important consideration for which protective factors are most salient or most responsive. Recent evidence of neurological and cognitive factors is concentrated on infancy and early childhood. Many social and behavioral theories state that family protective factors are particularly important during early and middle childhood. Community-level factors reflected by the stability of children’s living situations are important during those periods. The availability of economic resources and opportunities are most salient for adolescent and young adult populations (Children’s Bureau, 2014). For young children already exhibiting serious risk factors, delaying intervention until adolescence will likely make it more difficult to overcome risks. By adolescence, children’s attitudes and behaviors are well established and not easily changed.

The risk of becoming a drug abuser involves the relationship among the number and type of risk factors and protective factors. Many factors have been identified that help differentiate those more likely to abuse drugs from those less vulnerable to drug abuse. Factors associated with greatest potential for drug abuse are called “risk” factors, while those associated with reduced potential for abuse are called “protective” factors. A risk factor for one person may not be for another.

Risk and protective factors can affect children in a developmental risk trajectory or path. This path captures how risks become evident at different stages of a child’s life. For example, early risks, such as out-of-control aggressive behavior, may be seen in a very young child. If not addressed through positive parental actions, this behavior can lead to additional risks when the child enters school. Aggressive behavior in school can lead to rejection by peers, punishment by teachers and academic failure. If not addressed through preventive interventions, these risks can lead to the most immediate behaviors that put a child at risk for drug abuse, such as skipping school and associating with peers who abuse drugs. In focusing on the risk path, research-based prevention programs can intervene early in a child’s development to strengthen protective factors and reduce risks long before problems behaviors develop (NIDA, 2014a).

Risk factors can influence drug abuse in several ways. They may be additive—the more risks a child is exposed to, the more likely the child will abuse drugs. Some risk factors are particularly potent, yet may not influence drug abuse unless certain conditions prevail. Having a family history of substance abuse, puts a child at risk for drug abuse. However, in an environment with no drug abusing peers and strong antidrug norms, that child is less likely to become a drug abuser. The presence of many protective factors can lessen the impact of a few risk factors. For example, strong protection—such as parental support and involvement—can reduce the influence of strong risks, such as having substance-abusing peers. An important goal of prevention, then, is to change the balance between risk and protective factors so that protective factors outweigh risk factors (NIDA, 2014a).

Children’s earliest interactions occur within the family and can be positive or negative. For this reason, factors that affect early development in the family are probably the most crucial. Children are more likely to experience risk when there is:

• lack of mutual attachment and nurturing by parents or caregivers
• ineffective parenting
• a chaotic home environment
• lack of a significant relationship with a caring adult
• a caregiver who abuses substances, suffers from mental illness or engages in criminal behavior

These experiences, especially the abuse of drugs and other substances by parents and other caregivers, can impede bonding to the family and threaten feelings of security that children need for healthy development.  

Protective factors are conditions or attributes of individuals, families, communities, or the larger society that, when present, promote well-being and reduce the risk for negative outcomes.  A body of evidence suggests that protective factors “buffer” the effects of risk exposure and, importantly, may help individuals and families negotiate difficult circumstances and fare better in school, work, and life.

Focusing on protective factors offers a way to track child and adolescent development by increasing resilience in the short term and contributing to the development of skills, personal characteristics, knowledge, relationships, and opportunities that offset risk exposure and contribute to improved well-being and positive outcomes in the long term.  In this sense, protective factors can be used as interim results to monitor for progress over time towards the desired impacts that may not be realized for many years (Children’s Bureau, 2014).

Self-regulation skills, relational skills, and problem-solving skills are related to positive outcomes such as resiliency, having supportive friends, positive academic performance, improved cognitive functioning, and better social skills (Children’s Bureau, 2014).

Families can serve a protective function when there is:

• a strong bond between children and families
• parental involvement in a child’s life
• supportive parenting  that meets financial, emotional, cognitive, and social needs
• clear limits and consistent enforcement of discipline

Family skills training programs differ from parent education programs, which focus on providing parents with information about the use of substances in the absence of skills training for parents and children. Parent education programs are often shorter in duration (less than eight hours in total), whereas family skills training programs typically consist of a minimum of four to eight sessions of two to three hours each for universal programs. Moreover, parent education programs have not been found as effective as family skills training programs (Stormshak, Dishion, Light, & Yasui, 2005; Webster-Stratton, Reid, & Hammond, 2001; Willis, McNamara, Vaccaro, & Hirky, 1996; UNODC, 2009). A research review (Spoth, Redmond, Trudeau, & Shin, 2002) concluded that the most effective family skills training programs include active parental involvement, focus on the development of adolescents’ social skills and responsibility among children and adolescents, and address issues related to substance abuse. Effective interventions also involve youth in family activities and strengthen family bonds.

Children learn personal, social, and communication skills, and at the end of each session families come together to practice new skills as a family unit. These programs improve family functioning, organization, communication, and interpersonal relationships and have been found to have multiple positive outcomes for children and adolescents including decreased alcohol and drug use, increased child attachment to school and academic performance, decreased child depression and aggression, increased child social competence and prosocial behavior and decreased family conflict. In addition these programs have been found to be cost-effective. 

Family skills training programs generally combine training of parents to strengthen their parenting skills, training of children in personal and social skills, and family practice sessions. Thus, a typical session will see parents and children attending their own training groups and, at the end, coming together as a whole family for some practice time (Scheier, Botvin, Diaz, & Griffin, 1999; Spoth, Redmond, Shin, & Azevedo, 2004; Spoth, Guyull, & Day, 2002; Spoth et al., 2002).

Celebrating Families! (Tisch & Sibley, 2004) was originally developed for families in dependency drug courts, where one or both parents are in early recovery and children have been removed due to abuse or neglect. It was created to prevent children’s future addiction, facilitate healing from substance abuse, and help unify families legally separated as a result of substance and child abuse. The program has grown to fifty-three sites in twenty states in the United States and in Canada. It has been replicated in multiple settings, including schools, community-based sites, dependency drug courts, child welfare organizations, and treatment facilities. It is one of only a few programs listed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Registry of Evidence-Based Programs and Practices (NREPP) that engages all family members from infancy to adult in learning healthy living skills while addressing child maltreatment, family violence, and addiction and recovery issues. The Celebrating Families! program uses a multifamily, skill-building model to engage every member of the family, with the goal of breaking the cycle of chemical dependency. Celebrating Families! has a Spanish version, Celebrando Familias, and it is as effective in Hispanic communities as the English version is with English speakers (Sparks, Tisch, & Gardener, 2013). 

Table 1 compares essential elements of evidence-based prevention programs to essential elements of Celebrating Families!.

[PLACE TABLE 1 AROUND HERE]

Family-centered programs can strengthen protective factors among young children by teaching parents better family communication skills, developmentally appropriate discipline styles, firm and consistent rule enforcement, and other family management skills. Parents also can be taught how to increase their emotional, social, cognitive, and material support, which includes, for example, meeting their children’s financial, transportation, health care, and homework needs. Research confirms the benefit of parents taking a more active role in their children’s lives, by talking with them about drugs, monitoring their activities, getting to know their friends, and understanding their problems and concerns, providing consistent rules and discipline, and being involved in their  learning and education. The importance of the parent-child relationship continues through adolescence and beyond.

[PLACE TABLE 2 AROUND HERE]

Table 2 compares desired elements of family-centered programs to elements in Celebrating Families!.

Recent research on universal, selective, indicated, and multilevel prevention programs for drug and alcohol abuse has led to conclusions about program elements that yield the best methods of prevention for all levels of risk. In general, the best programs incorporate information and support in multilevel, family-centered, evidence-based programs tailored to individuals from infancy to adult ages. The Celebrating Families! model successfully meets the essential elements to be an effective prevention program.

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