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ContentsABOUT THIS GUIDELINExixiThe PEPS Development ProcessPEPS Series GoalsxiiThe Scope of This GuidelineLevels of EvidenceRecommendations for Practicexi iA Request to ReadersINTRODUCTIONRationale for the Family as a Focal Point for Substance Abuse PreventionDefinitions Used in This GuidelineContent of the GuidelineInclusion and Exclusion of Research and PracticeReferencesCHAPTER 1:xiiixvixviixixxxxxixxviixxviiixxxSubstance Abuse Problems and the Status of the AmericanFamily1-1Substance Abuse in the United States: The Extent of the ProblemSubstance Abuse: Critical Issues for Families and ChildrenConclusionUsing This GuidelineContents of This GuidelineReferences1-41-181-271-271-281-29Risk and Protective Factors and Developmental Models in2-1the Etiology of Substance AbuseCHAPTER 2:The Influence of Risk and Protective FactorsEtiological Models for the Development of Adolescent Substance AbuseFamily-Centered Approaches to PreventionConclusionReferencesAnalysis of Evidence and Recommendationsfor Practice2-42-102-142-192-19CHAPTER 3:Classification of Preventive Measures and Description of ApproachesAnalysis of EvidencePrevention Approach 1: Parent and Family Skills TrainingPrevention Approach 2: Family In-Home Support as Indicated PreventiveMeasures3-13-43-73-73-21ix

Prevention Approach 3: Family Therapy as Indicated Preventive MeasuresGeneral Suggestions for Future Research for Family-Centered PreventionApproachesGeneral Recommendations for Practice for Family-Centered PreventionApproachesChapter 3 Appendix: Research and Practice Evidence AbstractsAbstracts for Prevention Approach 1: Parent and Family Skills TrainingAbstracts for Prevention Approach 2: Family In-Home Support as IndicatedPreventive MeasuresAbstracts for Prevention Approach 3: Family Therapy as Indicated PreventiveMeasuresResearch Evidence ReviewedPractice Evidence 3-933-93Program Development and Delivery of Family-CenteredPrevention Approaches4-1CHAPTER 4:Key Considerations for Program DevelopmentThe Assessment StageThe Planning StageDelivery of the InterventionThe Evaluation StageConclusionReferencesCHAPTER 5:4-34-74-204-264-324-384-38Emerging Areas of Research and PracticeEmergence of the Constructs of Resilience and Family 4A-1A.PEPS ParticipantsA-3B.Research and Practice Search ProtocolsMethodology for Arriving at RecommendationsCollateral Areas of InterestAbbreviations and GlossaryResource GuideB-1C.D.E.F.C-1D-1E-1F-110

About This GuidelineThe Prevention Enhancement Protocols System (PEPS) is a systematic andanalytical process that synthesizes a body of knowledge on specific prevention topics. It was created by the Division of State and Community SystemsDevelopment of the Center for Substance Abuse Prevention in the Substance Abuseand Mental Health Services Administration (CSAP/SAMHSA) primarily to sup-port and strengthen the efforts of State and territorial agencies responsible forsubstance abuse prevention activities. The PEPS program is CSAP's response tothe field's need to know "what works," and is an acceptance of the responsibilityfor leading the field with current information supported by the best scientific knowledge available.This second guideline in the PEPS series summarizes state-of-the-art approachesand interventions designed to strengthen the role of families in substance abuseprevention. This topic was chosen in response to the field's expressed need for direction and in recognition of the important role of the family as the first line of defenseagainst the dangerous, insidious, and addictive consequences of substance abuse.THE PEPS DEVELOPMENT PROCESSThe development of a PEPS guideline begins with the deliberations of a PlanningGroup comprising nationally known researchers and practitioners in the field ofsubstance abuse prevention. With input from their colleagues in the field, theseexperts identify a topic area that meets pre-established criteria for developing a guideline. A Federal Resource Panel (FRP) with representatives from appropriate Federalagencies then convenes to discuss the proposed content of the guideline. The FRP,taking into consideration recommendations from CSAP and the PEPS PlanningGroup, identifies those experts in the field best suited to serve on an Expert Panel forthe chosen topic.Once formulated, the Expert Panel meets to determine the scope of the problem tobe addressed in the guideline. The PEPS staff conducts exhaustive searches for relevant research and practice information, guided by the knowledge of the ExpertPanel and its chair. The studies and practice cases found are extensively analyzed andtheir findings compiled and presented in draft form according to the similarity ofthe prevention approaches used.xi

A subpanel of selected Expert Panel members then meets to apply the PEPS Rules ofEvidence (described later in this section) to formulate summary judgments on thequality of the research and practice evidence, by approach, and to develop recommendations for the prevention field. This draft is reviewed by the full panel. A revised version of the guideline, including the revisions of the Expert Panel, is distributedfor extensive review by the field. The critique and analysis received are used to further refine and increase the accuracy, readability, and presentation of the guideline.PEPS SERIES GOALSThe primary goal of PEPS is to develop a systematic and consistent process for improvement of substance abuse prevention practice and research. Its objectives are tosynthesize research and practice evidence on selected topics,present recommendations for effective substance abuse prevention strategiesin versions suitable for several target audiences,ensure that PEPS products receive optimal dissemination among targetaudiences, andmonitor the usefulness and relevance of PEPS products.Although lessons from available science are distilled and specific recommendationsare made, this guideline is not a "how-to" handbook, nor is it a prescriptive prevention planning guide. Audiences for PEPS products include State prevention agen-cies, other Federal and State authorities, and community-based organizationsaddressing the problems of substance abuse or serving populations at high risk. Therefore, targeted users of PEPS guidelines include policy analysts and decisionmakers,who need sound data to justify funding for prevention planning; State agency andcommunity-based administrators and managers, who will find the series useful inallocating resources and planning programs; researchers, who will receive guidanceon the need for future studies; and practitioners, who will find recommendations forprogramming options that are most appropriate for the populations they serve.THE SCOPE OF THIS GUIDELINEPreventing Substance Abuse Among Children and Adolescents: Family-CenteredApproaches focuses on research and practice evidence for a select number of approachesto the prevention of family-related problems. The criteria used for inclusion of stud-ies in this guideline (described in appendix B) excluded some research and practiceevidence. Although other conceptual or practice approaches do exist, sufficient documentation of their use is not yet available. This guideline describes the followingthree prevention approaches:12xiiReference Guide

1.2.3.Parent and Family Skills Training.Family In-Home Support.Family Therapy.The information included in this guideline was used to develop two additional publications: a Practitioners' Guide and a Parents' and Community Guide. The Practitioners' Guide summarizes much of the information in this guideline and highlightspractical information that is most useful to those directly involved in planning andimplementing prevention programs. The Parents' and Community Guide providesa brief overview of substance abuse problems and courses of action for concernedcitizens, and provides tips for becoming involved in family-centered prevention.LEVELS OF EVIDENCEAt the heart of the guideline development process are several concepts concerningthe weight of evidence that makes research or practice information strong enough toserve as the basis for recommendations. Because these concepts are at the foundationof understanding the rigorous process used to develop this guideline, they are explained in detail in this introductory section.The term research evidence refers to the research-based body of knowledge that existsfor a specific prevention approach. This information is gained from scientific investigations that range in design rigor from experimental to quasi-experimental tononexperimental. The term practice evidence describes information gained from prevention practice cases, information generally presented in the form of well-designedand -executed case studies that include process evaluation information on programimplementation and procedures.In chapter 3, the description of each prevention approach includes at least one shadedbox that presents information on levels of evidence. These boxes highlight the con-sensus of the Expert Panel on conclusions that can reasonably be drawn from ananalysis of the research and/or practice evidence for each approach. These boxes alsoindicate the strength of the level of cumulative evidence supporting the conclusions.The criteria for assigning levels of evidence are shown in the following boxes. Thefirst three categories for level of evidence indicate the extent of research and practiceevidence for rating the varying degrees of confirmation of positive effect. The fourthcategory applies to research and practice evidence indicating that a prevention approach is ineffective.3Preventing Substance Abuse Among Children and Adolescentsxiii

Strong Level of Evidencea. Consistent positive results of strong or medium effect from a series of studies,including:At least three well-executed studies of experimental or quasi-experimental designORTwo well-executed studies of experimental or quasi-experimental designANDConsistent results from at least three case studiesb. The use of at least two different methodologiesc. Unambiguous time ordering of intervention and resultsd. A plausible conceptual model ruling out or controlling for alternative causal paths orexplanationsApplication. This level of evidence means that practitioners can use a prevention approachwith the most assurance that the approach can produce the particular effect specified inthe evidence statement.Medium Level of Evidencea. Consistent positive results from a series of studies, including:At least two well-executed studies with experimental or quasi-experimental designsORAt least one well-executed study and three prevention case studies showing statistically significant or qualitatively clear effectsb. The use of at least two different methodologiesc. Unambiguous time ordering of intervention and results when so measuredd. A plausible conceptual model, whether or not competing explanations have been ruledoutApplication. This level of evidence means that although the number or rigor of the studiesreviewed is limited at this time, there is still substantial support for a prevention approach'sability to produce the particular effect specified in the evidence statement. Practitionerscan proceed but should exercise discretion in application and in assessment of processand outcomes.14xivReference Guide

Suggestive but Insufficient EvidenceThis category is used to describe research and/or practice evidence that (1) is based on aplausible conceptual model or on previous research and (2) is being demonstrated inrigorous evaluation studies or appropriate intervention programs currently in process.One of two conditions typically causes evidence to be described as suggestive but insufficient:a.In the first condition, the evidence, although limited, appears to support a conclusion,but additional research is needed to fully support the conclusion. This condition oftenapplies to areas in which there has been little study, such as those that are impracticalto research or new areas of study.b. A second condition involves equivocal results. In this condition, a specific conclusionis supported in some studies but is not supported in others.Application. This level of evidence means that the prevention approach has shown promise for the effect specified but should be regarded as not well documented. Practitionersshould be cautious about undertaking approaches with this level of evidence. However,depending on local circumstances, should the approach fit the situation and merit adoption, special attention should be given to its systematic testing and documentation.Substantial Evidence of IneffectivenessThis category describes research and practice evidence demonstrating that a preventionapproach is not effective. The criterion for inclusion in this category is the absence of astatistically significant effect or a statistically significant negative effect in a majority ofwell-executed studies, including at least two quantitative studies with sample sizes sufficient to test for the significance of the effect.Application. This level of evidence means that the approach has not demonstrated theintended results or has shown negative findings for the particular effect specified. Practitioners should avoid these approaches because they offer no promise of success at thistime.Using Levels of Evidence in Program PlanningBecause prevention activities vary in their emphasis, scope, and content, no tworesearch studies or practice cases are the same. As they differ in the subjects of evalu-ation and in the methods used, it is difficult to reach a single conclusion about aparticular approach. Additionally, there may be varying levels of evidence for different desired results of a prevention approach, as shown by similar findings from morethan one study. Therefore, more than one evidence statement may be made to identify and rate conclusions that can be drawn from evidence available on a single approach. For instance, studies may show that a prevention approach has strong evidencefor attaining a desired effect in the short term, but suggestive but insu cient evidencefor sustaining that effect over time.ST COPY AMPreventing Substance Abuse Among Children and AdolescentsBLEXV

The prevention approaches presented in this guide should be considered in light oflocal circumstances; it may not be feasible to implement only those approaches witha strong level of evidence. Local needs, interests, resources, and abilitiesas well asthe level of evidencemust all be considered when planners and practitioners makeprogram development choices.RECOMMENDATIONS FOR PRACTICEFollowing analysis of evidence for each approach, a special section outlines recom-mendations for practice. This section presents the PEPS Expert Panel members'recommendations, suggestions, observations, and interpretations regarding the prevention approach evaluated in the preceding text. General recommendations andsuggestions that are applicable to more than one prevention approach appear later inthe chapter.Types of RecommendationsThe recommendations for practice vary considerably in nature and intent. Some arepractical suggestions for optimal implementation of a particular intervention whileothers suggest techniques and cautions to avoid problems. A few are practical observations about what to expect during certain prevention activities. Others interpretresearch findings or illustrate the practical context of prevention efforts. Some recommendations reflect expert opinions of the panel members, such as assumptionsand hypotheses that drive certain prevention activities. Many represent "best practices" among prevention experts. Some recommendations relate to implementationof specific prevention interventions. (A comprehensive discussion of implementation is presented in chapter 4.)Basis of RecommendationsThese recommendations are based on the research and practice evidence reviewed inthe Analysis of Evidence section, additional evidence not described in the section,and the professional experience and opinions of Expert Panel members. Many recommendations are derived from the experiences of Expert Panel members involvedwith research or practice activities that are not explicitly described in this chapter.These recommendations represent the transfer of practical information from prevention research and practice experts to prevention decisionmakers, such as Stateand local prevention authorities, other prevention practitioners and researchers, andmembers of community prevention organizations.1GxviReference Guide

A REQUEST TO READERSBased on comments received from users of the first guideline, Reducing Tobacco UseAmong Youth: Community-Based Approaches, several significant changes have beenmade in the structure and presentation of this publication. CSAP actively seeks acontinuing dialog with its constituents on the extent to which they find this seriesuseful and the ways in which future guidelines may be improved. Therefore, comments are actively solicited for inclusion in revisions of this guideline or in production of future guidelines. They should be referred to: PEPS Program Director, Divisionof State and Community Systems Development, Center for Substance Abuse Prevention, SAMHSA, 5600 Fishers Lane, Rockwall II, Rockville, MD 20857.Preventing Substance Abuse Among Children and Adolescentsxvii

IntroductionAmajor focus throughout our society is the importance of the family insustaining the foundations of American values; cultures; and religious, educational, economic, and community institutions. Increasingly, however, thereare significant indications that our Nation's children are having difficulty acquiringthe skills necessary to become competent, caring adults who can livetogether peacefully and productively in communities. In the face of tre- Sometime in early tomendous stresses in society and often in the family itself, many parentsmiddle adolescence,worry about their ability to help their children develop the values andmany young peopleskills that will enable them to succeed as adults.begin to use andIn particular, there is recognition that in early to middle adolescenceabuse alcohol,(and sometimes earlier), many young people begin to use and abuse alcohol, tobacco, and illicit drugs. For many of these young people, sub- tobacco,stance abuse is only the most recent manifestation of antisocial or other and illicit drugs.problem behaviors that developed during childhood years, a time whenthey were most closely supervised by their families. For a variety of reasons, theirfamilies were unable to prevent or arrest these early problems and the later onset ofsubstance abuse in their children. When these problems escalate during early adulthood, the result is often a lack of motivation or an antipathy

DOCUMENT RESUME. CG 028 814. Preventing Substance Abuse among Children and Adolescents: Family-Centered Approaches. Reference Guide. Prevention Enhancement Protocols System (PEPS) Series. Substance Abuse and Mental Health Services Administration (DHHS/PHS), Rockville, MD. Center for Substance Abuse Prevention.