Parent education in the prevention of drug-related harm - DrugInfo
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Parent education in the prevention of drug-related harm - DrugInfo

Prevention ResearchEvaluation ReportNumber 6June 2003Parent education in theprevention of drug-related harmby Associate Professor John W. Toumbourou, Mr Bosco Rowland, Ms Bronwyn Lee,Dr Sheryl Hemphill, Dr Jann Marshall and Ms Mary DimovskiIntroductionIn the second Prevention Research EvaluationReport in this series (Toumbourou 2002b),parent education was defined as: “One ormore parents receiving information and/or acourse of instruction aimed at encouraginghealthy family development. Methods ofdelivery have included strategies targeted tohigh-risk families, universal delivery to allfamilies and strategies that combine universaland targeted interventions”.In this report we examine evaluationfindings from the research literature andcompare these with current practice. We talkedto 11 parent educators in Victoria about theirviews on current practice, and their definitionsof parent education are considered below.The available evidence suggests that wellconductedparent education potentially canmake an important contribution to theprevention of drug use by young people,although there have been few evaluations thathave examined longer-term outcomes orreduction of harm. Mitchell et al. (2001) andToumbourou and Gregg (2001) have recentlyreviewed research evaluating parent educationas a strategy for preventing drug abuse andother behavioural problems in young people.Defining parent educationResearch has demonstrated that a variety offamily factors influence young people’sinvolvement in potentially harmful drug use.Hawkins, Catalano and Miller (1992) reviewedrisk and protective factors for youth substanceabuse emerging from research conducted priorto the 1990s. Mitchell et al. (2001) summarisedsome more recent literature relevant to familylevel factors that predict drug problems inyoung people. Some of the earliest family levelrisk and protective factors include geneticinfluences, family history of drug use problems,drug use during pregnancy and parentalbehaviours encouraging healthy foetal growthand development. Additional factors becomerelevant from birth onwards, including thenurturing and care of children, family conflictand sexual abuse.From late childhood into early adolescence,parental attitudes, family attachment,communication, monitoring, and family rules,expectations and standards becomeincreasingly important. Factors such as familybreakdown, parent education and employmentmay influence parental effectiveness. Familyeffectiveness may, in turn, be important inmediating exposure to other risk factors suchas behavioural problems in childhood, school

Prevention Research Evaluation ReportNumber 6 June 2003readiness, school attendance, educationalattainment, participation in peer drug use anddelinquency, and access to drugs.Parent education interventions range inintensity from the delivery of one-offmessages, using social marketing strategies,through to sequenced curriculum packagesthat may involve professional contact overmultiple sessions. Interventions may havegeneral aims such as assisting parents todevelop behaviours, family rules and routinesto ensure healthy child development.Alternatively, aims may be targeted to addressmore specific risk contexts such as reducingchild exposure to substance use incircumstances in which parents experiencemental illness or drug use problems. The goalsof parent education may differ according tofactors such as the developmental stage of thechild and the family context. Bronfenbrenner’s(1979) ecological perspective suggested thatthe family context was influenced not just bythe internal family structure but also by morelocal community links and broad macro factorsthat influence family culture and socioeconomicresources. The ecologicalperspective predicted that the family would bemore critical for healthy youth developmentduring periods of social instability.Parent education can be considered to be aprocess that can be broken down into broadlysequential stages including recruitment,engagement, participation, programimplementation and family change. Strategiesaddressing each of these stages have beendeveloped on the bases of theoreticalframeworks that include social learning,operant behavioural, cognitive behavioural andsystems theory approaches.Parent education is sometimes criticised asa “bandaid” approach which does not addressthe underlying social and economic stressesthat can lead families to ineffective practices.There is evidence, however, that parentingmakes an important contribution to the healthydevelopment of children and young people,independent of socio-economic status (SES).A large follow-up study investigating thedevelopment of children in Canada noted thatpoor outcomes in children were less wellpredicted by SES than they were by parenting.In that study, poor parenting was related to theSES gradient, but also varied considerablyacross different levels of SES. At least 25 percent of children in the highest SES groupshowed developmental difficulties (McCain &Mustard 1999).In attempting to reduce young people’sinvolvement in harmful drug use, it is possiblethat program elements may have differentimportance for legal versus illegal drugs. In afollow-up of a Seattle cohort, Kosterman et al.(2000) found that parents inhibited alcoholinitiation by communicating clear rules againstalcohol use, while initiation of cannabis usewas reduced by family management practicessuch as good communication and monitoringof youth activities (Kosterman et al. 2000).Evidence from longitudinal follow-upresearch suggests that preventing youngpeople’s involvement in serious illicit drug usemay require early assistance for high-riskfamilies (Fergusson, Horwood & Lynskey1994). On the other hand, reducing alcoholmisuse and tobacco use by young people maybe assisted through more universal parenteducation programs that aim to reduce earlyand frequent youth involvement in thesebehaviours (Toumbourou 2002a).Practitioners’ views:What is parent education?To begin our comparison of current researchliterature with current practice, practitionerswere presented with a definition of parenteducation, similar to that given in theintroduction of this report, and were asked fortheir comments.All practitioners indicated that the definitionwas adequate as a broad and generaldescription of parent education. However,some had reservations about specific aspectsof the definition and suggested changes thatwould increase clarity or further the definition’sapplication. Because many young people liveaway from their parents, it was suggested thatthe term “parent” be replaced with “carer”.Consistent with this notion, another practitionerPage 2 of 17

Prevention Research Evaluation ReportNumber 6 June 2003stated that in some of her programs it was notonly parents who attended, but rather anyonehaving “permanent contact with that youngperson and who is in a position to influencetheir behaviour”.Other comments on the definition includedremarks about the phrases “course ofinstruction”, “provision of information” and“healthy family development”. Two practitionersindicated that the first two phrasesgave the definition a patronising tone, andgarnered an image of a difference in powerbetween practitioners and parents, “expertsgiving and providing information to someonewho is down there and in obvious need…”Some practitioners suggested that the term“engagement” or the phrase “sharing of ideas”be used instead to reflect the view thateducation is also about exchange ofinformation and reflection on practice.Overall, the phrase “healthy familydevelopment” was accepted by mostpractitioners as a broad and general descriptorof the aim of parent education. Practitionersacknowledged that it emphasised parenteducation as not being solely limited to theprovision of information about drugs, but alsoas incorporating the provision of otherinformation, such as communicationtechniques, parenting styles and practices, andrelationship building. It was suggested bysome practitioners that the definition shouldstate explicitly these aspects of parenteducation. Others suggested that parenteducation programs sometimes just simplyfocused on the provision of information andwere not concerned with outcomes aroundfamily dynamics.Alongside the question pertaining to thedefinition of parent education, practitionerswere asked how effective they believed parenteducation to be in preventing drug-relatedharm. Practitioners were conscious that nodirect association could be made betweenparent education and the prevention of drugrelatedharm among adolescents, and thusclaimed that it was difficult to gauge theeffectiveness of parent education programs.However, a number of practitioners wereaware of the Catalano and Hawkins (1996)review that suggested that if there were strongconnections and communication within familiesthere was less likelihood that adolescentswould develop long-term and continuingproblems with drugs.Keeping this research in mind, manypractitioners designed their programs aroundhelping parents to promote protective factorsand reduce risk factors within their families.Some practitioners noted, however, that ifparents were experiencing “too manystressors” at home, or if basic family conditions,such as housing and finance, were poor,there was a greater chance that the skillstaught and encouraged during parenteducation sessions would not be implementedat home.In summary, despite differences in opinionaround some terms used in the definition ofparent education, comments above suggestthat practitioners agree with the initialdefinition. Practitioners also recognised that,even though no direct association could bemade between parent education and drugrelatedharm, research does suggest that theencouragement of certain protective factorsand the reduction of risk factors may reducedrug-related harm.Parent education programscurrently employed in VictoriaWe examine here evidence for theeffectiveness of parent education at differentlife stages of children and young people.Although we have been interested in exploringdevelopments within the internationalliterature, there is a surprisingly strongpresence within this literature of programsemerging from our own state, Victoria.Parent education in infancy andchildhoodConsiderable efforts have been made withinthe health care sector to encourage women toreduce their tobacco and alcohol use duringpregnancy. The effectiveness of thesePage 3 of 17

Prevention Research Evaluation ReportNumber 6 June 2003approaches in changing maternal behaviourand developmental outcomes for children areunclear.The period immediately following birth isconsidered to be a critical period in thedevelopment of healthy mother–infant bonding.In some cases, post-natal depression or otherfactors can make early mother–childinteraction difficult, and in this way canundermine the development of a positiverelationship. There is now a growing literaturedocumenting the value of early childhoodparent education programs. However, thereare few studies that provide longitudinaloutcomes greater than 1 to 2 years. From thedata that has been collected, it appears thatthere can be reasonable maintenance ofoutcomes, particularly where parent-relateddifficulties or social adversity does notcomplicate the child’s problems.The lack of long-term data means that thelink between early childhood parent educationand reductions in youth drug use is theoreticaland largely reliant on evidence that risk andprotective factors for youth drug use can beimpacted. In aiming to prevent harmful druguse by young people through parenteducation, it is relevant to consider familyprocesses that work in early development toincrease risk. The following presents examplesof relevant program evaluations.Maternal depression can undermine thedevelopment of a healthy bond between theparent and the child, and in this way canadversely impact child development. TheHUGS program was developed in Victoria as agroup intervention to assist mothers sufferingfrom post-natal depression in understanding,and responding appropriately, to their infants’needs. Trained facilitators lead groups ofparents through a sequenced curriculumconsisting of six content areas. Each contentarea is covered in one to three sessions of1–1.5 hours at a set time each week. Meagerand Milgrom (1996) reported a small trial of theprogram that demonstrated reduced levels ofmaternal depression and improved maternal–child interaction at program completion formothers exposed to the program, relative tocontrols.In the absence of assistance, parents withintellectual disabilities can find it difficult todevelop effective parenting skills. Step-by-stepchildcare is a prevention program designed toassist parents with intellectual disability toenhance the healthy development of theirchildren from birth to 3 years old. Parentsreceive individualised instruction in basic caretasks until they demonstrate performance ofthe task to a set criterion. Controlled evaluationshave demonstrated that exposure to theprogram enhances parenting skills and alsoleads to improvements in child developmentoutcomes. For example, Feldman, Sparks &Case (1993) demonstrated that in families inwhich parents received the parent–childinteraction components, significantimprovements in the children’s languagedevelopment were evident.Parents with child behaviourproblemsThere is now a range of parent educationprograms that have demonstratedeffectiveness in reducing specific behaviouralproblems evident in children. In overview,these programs have evidence that they canimprove family functioning and reduce childbehaviour problems. However, the availableevidence has consisted mainly of small studiescontrolled by researchers (efficacy trials), withfollow-up limited to 1–2 years. There has beensome longer-term follow-up work by Forehandand Long and their colleagues in which verysmall samples exposed to parent education totreat childhood behavioural problems werere-examined in adolescence and found not tohave higher rates of drug use, relative tomatched community controls (Long et al.1994).Findings of a meta-analysis study generallysupports the efficacy of parent educationprograms as a strategy for reducing childbehaviour problems. Compliance can be lowerin families which have a high number of riskfactors (Serketich & Dumas 1996). Mitchell etal. (2001) reported that these programs tendedPage 4 of 17

Prevention Research Evaluation ReportNumber 6 June 2003to have large effect sizes (0.86), withimprovements observed for around two-thirdsof participants. Interventions are successful inenrolling around two-thirds of those eligible.Typically, these programs are timed to preventproblem behaviours between the age of 2 and8 years, and to reduce problem behaviourssuch as non-compliance and conduct disorderearly on, before they become resistant totreatment (Mitchell et al. 2001).The Positive Parenting Program—Triple PThe Triple P Positive Parenting Program is themost commonly implemented parentingprogram in Australia, and is implemented inVictoria through the Victorian ParentingCentre. Triple P is a multi-level programderived from more than 15 years of research,and has been implemented and researchedwith a variety of different family populations.The program has shown historical leadershipin developing a structure for addressing parenteducation needs across the spectrum ofproblem severity. There are five levels of theprogram provided to accommodate thediffering severity in disrupted family functioningor child behaviour problems. At Level 1,universal, media-based information campaignsare provided, and at Level 5 individuallytailored programs are provided to addressmore severe dysfunction.Based on cognitive-behavioural and sociallearning theories, the program is wellsupported through training events and a widerange of professionally developed materials.Recent research has included an outcomecomparison of the Level 5 Triple P (individuallytailored) and the Level 4 Standard and SelfdirectedTriple P and a waiting list controlgroup for families with children between 36and 48 months with a child with a behaviourproblem (parent-reported) and at least one riskfactor such as maternal depression,relationship conflict etc. The results arepresented post-intervention and at one-yearfollow-up (Sanders et al. 2000). All threeintervention programs provided betteroutcomes (child behaviour and parentingbehaviours) compared with the wait listcomparison group, and the Level 5 programwas better than both the Level 4 programs,with the Standard program better than the Selfdirectedprogram results. At one-year followup,however, there were no significantdifferences between the results of the threetypes of program.Although there is already an impressiveamount of Triple P research evidence andcontinuing research in progress, further longertermlongitudinal research would be helpful interms of understanding the maintenance ofoutcomes. Also, the publication of the resultsof the comparison design evaluation of theLevel 4 group Triple P program is awaited toinform policy and services, as this is currentlybeing implemented widely across Australia.The evaluations to date have generally beensmall efficacy trials under the control ofresearchers. Future research investigatingprogram effectiveness in the range of servicedelivery and family contexts would be valuablein guiding future investment in this program.Webster-Stratton’s Parenting CurriculumA series of parenting programs developed byDr Carol Webster-Stratton (a research nurseworking at the University of Washington inSeattle) have been developed for use inuniversal applications, and have beenevaluated for their impacts on targetedpopulations with high levels of behaviourproblems. There are different versions of theprogram for delivery in pre-school populationsand for the early school-age period. Centralcomponents involve facilitated groups ofparents and use of videotaped examples tostimulate discussion and to convey parentingprogram components. The program has beenevaluated in six randomised trials as anindicated or treatment intervention forbehavioural problems in children aged3–8 years (Webster-Stratton & Hammond1997). The results have been replicated byother researchers and in applied serviceeffectiveness evaluations. The program wasalso used and evaluated as a selectiveprevention program, with other populationgroups such as Head Start mothers, HispanicPage 5 of 17

Prevention Research Evaluation ReportNumber 6 June 2003mothers and African-American mothers indaycare centres (Webster-Stratton 1998). Ineach of the evaluations, increases in positiveparenting practices for participants have beenassociated with reductions in child behaviourproblems.Helping the Non-Compliant ChildHelping the Non-Compliant Child is anindicated and treatment intervention developedspecifically for parents with non-compliantchildren aged 3 to 8 years. The program isrelatively intensive. A therapist worksindividually with the parents and the child in aclinical setting. The program (anotheremerging from work at the University ofWashington in Seattle) incorporates coachingduring which the therapist communicates viaan earpiece, providing guidance to the motheras she plays with the child alone. The therapistobserves the parent–child interaction through aone-way mirror.Other components include modelling, roleplayingand homework for 8–10 sessions.Small, randomised trials have demonstratedpositive improvements in parenting practicesand child behaviour following exposure to theprogram (Forehand & Long 1988). In onesmall, longer-term study, 26 families in whichparents had completed the program werefollowed up. Children in these families hadbeen assessed prior to entry to the program tohave serious behavioural problems. Problemsof this type tend to be stable predictors oflonger-term developmental difficulties. Whenfollowed up in adolescence, 14 years aftercompletion of the program, and compared withcommunity subjects of similar age anddemographic characteristics, the childrenwhose families had completed the programappeared essentially to be normal. There wereno differences on measures of drug use,internalising and externalising behaviours,social competence, emotional adjustment,relationship with parents and academicprogress (Long et al. 1994). It should be notedthat participation in this study was not basedon random assignment and comparisonagainst a control group, hence it is possiblethat these positive findings may have resultedfrom other influences such as familymotivation, rather than parent education.Parent–Child Interaction TherapyThe Parent–Child Interaction Therapy programwas developed for children aged 2 to 6 yearswith conduct problems, and their families(Schuhmann et al. 1998). This is a groupprogram that combines play therapy (usingmodelling, role playing and coaching usingmicrophones) with behaviour managementtraining in a clinical playroom setting, to assistparents in building warm and responsiverelationships with their children and to managetheir children’s behaviour more effectively.Small experimental trials have evaluatedthe program, finding significant improvementsin child behavioural problems and in theinteractions between parents and children,maintained to 1–2 years following treatment(Eyberg et al. 2001). Other studies haveshown improved school behaviours(Funderburk et al. 1998; McNeil et al. 1991).One study showed that the parentingcomponent had a larger outcome effect whencompared with the play component (Eisenstadtet al. 1993).Targeted and social learningapproachesLate childhood or early adolescentbehaviour problemsIn some cases, parent education is selectivelytargeted to parents within specific settings,such as referral for school problems orbehavioural problems, juvenile justice or drugtreatment. Evidence demonstrates that positiveimprovements in adolescent functioning havebeen associated with a range of familyintervention strategies. In attempting tounderstand these changes, theorists havesuggested that critical program elementsinvolve changing parent behaviours toincrease supervision, encourage appropriaterule setting, increase positive feedback andensure consistent discipline (for example,Dishion & Andrews 1995).Much of the research examining parentintervention focuses on efforts to preventPage 6 of 17

Prevention Research Evaluation ReportNumber 6 June 2003escalation or persistence in problembehaviours, and this work has emerged inlarge part from the Oregon Social LearningCentre. In juvenile justice settings, intensiveinterventions involving 44 hours of parentbehavioural training have been demonstratedto reduce offending and incarceration, whencompared with standard juvenile justicecontact (Bank et al. 1991).Using a similar strategy within an earlyintervention framework, Dishion & Andrews(1995) evaluated a 12-week parenting skillsprogram aimed at families in which youngpeople had exhibited behavioural problems aschildren. Externalising behavioural problemswere measured using both videotapedinteractions and mothers’ reports on the ChildBehaviour Check-List. Exposure to a parentgroup component reduced youth initiation totobacco use one year later. Reduced parent–adolescent conflict was associated with thesepositive changes. In alternative interventionconditions involving adolescent groups or bothadolescent and parent groups, youth tobaccouse and other problem behaviours increased.The authors argued that the positive benefitsof reduced parent–adolescent conflict werechallenged in these cases by contrary peerinfluence pressures. Findings suggested theimportance of strengthening the parental subsystemin family intervention through theadolescent phase.In a small trial of an interactive,computerised parent education program thatpresented options for potential parentresponses to common dilemmas faced inparenting adolescents, exposure to thepackage improved effective parentingresponses (Kacir & Gordon 1997). Gordon hasargued that the use of visual messagepresentation and reinforcement for correctresponding makes the computerised packagean effective means of conveying information tovulnerable parents (Gordon 1997).Assisting parents concerned by youthsubstance abuseAnother study emerging from within Victoriainvestigated the intervention opportunity thatcan arise when parents initially recognisesubstance abuse in their adolescents. Parentsin these situations often experienceconsiderable distress, which can undermineeffective responses. In an effort to provide acost-effective method of assistance, Blyth,Bamberg and Toumbourou (2000) developedan eight-week, professionally led groupintervention known as the BehaviouralExchange Systems Training (BEST) program.The program intervention theory aimed toreduce parental stress and depression,increase communication and encourageassertive parenting including the use ofappropriate consequences for adolescentmisbehaviour. High rates of depression amongparticipating parents at pre-test (87 per centwith high symptoms on the General HealthQuestionnaire) were observed to dropsubstantially over the course of theintervention (down to 24 per cent after eightweeks) (Toumbourou et al. 2001). A smallevaluation incorporating a wait-list controlgroup revealed differential improvements inmental health, parental satisfaction andassertive parenting behaviours for thoseexposed to the intervention (Toumbourou et al.2001). The impact of these changes on youthsubstance abuse is not yet known.The BEST program has recently beensupported for dissemination across all regionsin Victoria. In an analysis of parent changesachieved through participation in the BESTprogram, Bamberg et al. (2001) noted thatfurther reductions in youth substance abusemight have been achievable for approximatelyone-third of families had additional familyintervention been provided at the conclusion ofthe program. Future research is planned toinvestigate the potential to reduce youthsubstance abuse by adding behavioural parenttraining and family systems components as afollow-on intervention for parents who havecompleted the BEST program.Practitioners’ views:Programs and program deliveryIn our comparison of current practice inVictoria with current research literature,practitioners were asked whether they usedPage 7 of 17

Prevention Research Evaluation ReportNumber 6 June 2003targeted, universal or a combined mode ofdelivery, and what was the reasoning behindtheir choice. As can be seen from the definitiondescribed in the first section of this document,targeted interventions select parents fromwithin specific settings such as juvenile justice,school welfare or youth drug treatment.Universal interventions are offered to allparents within a defined population, andcombined interventions include both targetedand universal interventions.For all the practitioners interviewed,universal interventions were the predominantmode employed. Practitioners reportedchoosing this approach because it was themost practical; that is, it afforded a wide sweepand had a greater chance of attractingparticipants. However, a number ofpractitioners indicated that their programs werenot originally intended to be universalinterventions. For example, one practitionerstated that her “program was designed as atargeted program; however, it’s been verydifficult to attract parents … So it was sort of atargeted program but has broadened out toinclude everyone”.Similar to a targeted program evolving intoa universal program, practitioners alsodescribed universal programs that wereextended to become combined programs.Practitioners were referring specifically to theABCD program (described on page 9). TheABCD program is a four-week parentingcourse; however, if at the end of the programsome parents are still experiencing difficulties,the program can be extended by four weeks tobecome “ABCD Plus”. Thus the program canevolve into a combined intervention by offeringinitially a universal intervention and later atargeted intervention.Only two practitioners indicated that theyemployed the BEST program as a parentingprogram. Other practitioners mentioned theABCD program. The school-based programsCreating Conversations and Talking Tacticswere also described by practitioners who wereinterviewed.Overall, this suggests that practitionersconduct programs focusing on parents whohave children involved with substance abuse.The programs most commonly used have notbeen formally evaluated in the literature,although evaluation is under way in somecases. For pragmatic reasons the universalmode of delivery appears to be the mostpopular with practitioners; however, the ABCDprogram, with its four-week supplement, isconsidered by some practitioners to be acombined approach.Recruitment involving parentsin community change initiativesA growing range of programs aim to providetraining and information to all parents within agiven population. Existing evidence suggeststhat it is possible to involve parents as acomponent in programs aimed at addressingbroader community factors that can underminehealthy youth development. Such projectstypically incorporate community mobilisationactivities as an adjunct to school-based healtheducation (for example, Perry et al. 1996).Project Northland demonstrated a delayedentry to alcohol use by young peopleassociated with changes to local laws andordinances controlling alcohol sales to minors,improved family communication relating toalcohol use, and reductions in the perceptionthat young people drank alcohol.In another program, Pentz and colleagues(Johnson et al. 1990; MacKinnon et al. 1991)reported a program combining parent trainingin adolescent communication with school drugeducation and community mobilisation,including a parent organisation program forreviewing school prevention policy and skills.Rohrbach et al. (1994) reported that 73 percent of parents participated in one or more ofthe program components. The program waseffective in preventing escalation (recent use in30 days) in tobacco and marijuana use, but notfor alcohol.One of the issues to be addressed in parenteducation is the problem of engaging parents.Typically, between 10 per cent and 50 per centof families can be encouraged to enrol ininterventions when invitations are extended toall parents within a defined populationPage 8 of 17

Prevention Research Evaluation ReportNumber 6 June 2003(universal interventions). In their work in ruralUnited States, Spoth et al. (1997) reported thatparents who participated in parent educationtended to have higher levels of education.However, Toumbourou and Gregg (2002)reported that in the Australian Program forParents intervention, disadvantaged and soleparentfamilies were successfully recruited.A growing range of programs aim to providetraining and information to all parents in agiven population who have early adolescents.Community recruitment strategiesfor universal parent educationIn a recent United States project addressingtobacco use by young people, householdswere screened by phone to identify familieswith children in the age range 12 to 14. Of the2400 families identified, 55 per cent of parentsand adolescents agreed to participate in abaseline phone survey, and then half theparents were randomly assigned to participatein a program called Family Matters. Theprogram involved mailing a sequence of fourbooklets to parents, with discussion with aphone counsellor after each mailing. Earlybooklets focused on motivating parents tomake changes, and later booklets providedinstruction on implementing family changes toimprove communication and prevent youthsubstance use. Parents and adolescents werere-interviewed at the completion of the threemonthprogram and again 12 months later.Relative to the controls, smoking onset wasreduced by 16.4 per cent for the young peoplein the families exposed to the intervention. Theprogram had no impact on the initiation ofalcohol use (Bauman et al. 2001).Felner et al. (1994) reported an evaluationof a promising program that was designed toreduce youth substance abuse by providingparent education in the workplace. Facilitatedparent education groups were conducted twiceper week for 12 weeks, with content materialsmatched to be relevant for parents withchildren of different ages. The workplaceappeared to be a good setting for this type ofwork. Retention was generally high, with only16 per cent dropping out prior to programcompletion. Program participation was similarregardless of parental socio-demographicbackground characteristics or initial childbehaviour difficulties.This evaluation did not examine impacts onyouth substance use. However, follow-up after30 months suggested that parents whoattended at least 80 per cent of the parenteducation groups exhibited long-term gains inmeasures of parenting, reduced parentdepression, less favourable attitudes to youthsubstance use and improvements in perceivedchild behaviour relative to parents whoattended less of the program. As thisevaluation compared parents who selected toparticipate fully with those selecting lessparticipation, some of the observedimprovements may have been explained byself-selection factors and initial familydifferences.The ABCD programThe ABCD program is an important Victoriangovernment parent education initiative. Itinvolves facilitated parent education groupsconveying a range of information and skills.The groups run on a didactic educationframework in which parents are recruited froma variety of settings (schools, communities),provided with information through booklets andlectures, and then given brief tests to assessunderstanding.An interesting feature of the ABCD programis the use of existing community groups andnetworks to recruit parents. The program hastwo levels: the first level involves four sessionsand addresses general issues associated withparenting adolescents; the second level(ABCD Plus) involves a further four sessionsand targets parents with more specificproblems associated with adolescentsubstance use. The program is currentlyundergoing a roll out focusing ondisadvantaged and culturally and linguisticallydiverse communities, and will be finalisedthrough a formative evaluation.Page 9 of 17

Prevention Research Evaluation ReportNumber 6 June 2003Recruitment and universalsecondary school parenttraining groupsIn a number of parent education programs, theschool has been used as the site forrecruitment. Spoth et al. (1996) evaluated thedelivery of the parent training program knownas Preparing for the Drug Free Years (PDFY)in a United States middle school context(around age 11, equating with late primaryschool). PDFY is a five-session, professionallyled program aimed at reducing youthsubstance use by enhancing positive parent–child interactions, parent–child bonding andeffective family management. Parents areencouraged to provide their children withopportunities for positive family involvement, toteach their children skills for such involvementand reward them for this involvement whileproviding appropriate consequences for ruleviolatingbehaviour. Of the eligible parents withan early adolescent, 57 per cent were willing tobe involved in this parent training evaluationstudy, which was run in rural Iowa. For thoseassigned to intervention, the program wasdemonstrated to be effective in increasingyoung people’s intention to abstain fromalcohol and in enhancing family bonding.Follow-up revealed that benefits in the form ofreduced youth alcohol use were maintainedtwo years after the intervention. The programhas not yet been trialled in Australia.Toumbourou and Gregg (2002) reported anevaluation of yet another Victorian program,Parenting Adolescents: A Creative Experience(PACE), for parents of early adolescents.Designed as a universal intervention,facilitated groups based on an adult learningmodel utilised a curriculum that includedadolescent communication, conflict resolutionand adolescent development (Jenkin &Bretherton 1994). Seven-week PACE groupswere delivered across Australia to 3000parents who had adolescents in early highschool.Evaluation included longitudinal self-reportdata from 577 families (parents andadolescents) representing a 60 per centresponse for those sampled from 14 schoolstargeted for intervention and 14 matchedcontrol schools. Although only around 10 percent of parents in the intervention schoolswere successfully recruited into PACE groups,pre- and post-intervention findingsdemonstrated benefits extended more broadlyacross families in the schools in which PACEwas offered. At the 12-week follow-up, parentsand adolescents reported a reduction in familyconflict. Adolescents reported increasedmaternal care, less delinquency and lesssubstance use (the odds of transition toalcohol use were halved).Analysis suggested that intervention effectsmight have extended to young people at highrisk of substance use problems. Theevaluation demonstrated that the parentsrecruited into the intervention were morefrequently sole parents, and their childrenreported higher rates of family conflict andmultiple substance use. At the post-test, familyconflict and youth substance use had reducedmarkedly in these families. Evaluationsuggested that the substance use ofrespondents was influenced by their bestfriends’substance use. Improvements introubled family relationships appeared toimpact a wide group of families linked throughpeer-friendship networks (Toumbourou &Gregg 2002). The fact that the intervention andcontrol groups were not randomly assigned,and the lack of long-term follow-up, suggestthe need for caution in interpreting thesepromising early impacts.Evidence that peer attachments may be riskfactors for youth substance abuse has led tointerventions to assist parents to bettermanage their children’s peer relationships.Cohen and Rice (1995) evaluated anintervention that attempted to facilitate thisadjustment. The intervention failed to producechanges in adolescent initiation of tobacco oralcohol use. Parent participation was poor, andeven among those who participated,attempting to influence their child's choice ofpeer group was not considered a practicaltarget. Interventions for families withadolescents must be carefully designed, asPage 10 of 17

Prevention Research Evaluation ReportNumber 6 June 2003there are many tensions between issues suchas young people’s requirements for autonomyand increasing family cohesion.Integrating multi-level parenteducation within schoolsA number of research teams are currentlyactive in developing multi-level family supportprograms for delivery within late primary orearly secondary school. Dishion and Kavanagh(2000) report a program involving theintegration of three levels of support withinschool (early in United States’ middle school).At the universal level, all parents are invitedto an in-school meeting, and writteninformation and videos covering key parentingskills (co-operation in the home, supervision,problem solving and communication) aredistributed. At the next level, a four-hour“family check-up” offers a family assessmentand motivational interviewing to encourageaccurate appraisal of child risk behaviour andthe use of appropriate parenting resources.Finally, for families in which problems areevident, more extended parent training isoffered. The program is demonstrating someevidence for positive impacts, but longer-termoutcomes are unclear.Work is underway in Queensland schools toevaluate an adolescent version of the Triple PPositive Parenting Program. A group at theCentre for Adolescent Health in Melbourne (forexample, Toumbourou & Gregg 2001) arecurrently investigating the impact of anintegrated, multi-level secondary schoolintervention called Resilient Families. Thisprogram incorporates communication trainingfor students, an information night for parents,sequenced parent education groups, brieffamily therapy and community development toenhance the link between schools and thefamily. The project aims to explore further theassumption that community basedinterventions can generate benefits beyond theminority of participants directly exposed to theintervention.Practitioners’ views:Recruitment and barriers torecruitmentThe interviews with Victorian practitionersrevealed that recruitment was recognised byall as an essential component of a successfulparenting program. Each of the practitionersreported using a variety of approaches torecruitment, including advertising innewsletters and newspapers, and atcommunity health centres and police stations.Other strategies used included distributingflyers to support groups, advertising on localradio and in general practitioners’ newsletters,and placing posters in shopping centres.Practitioners who used local communityconnections for recruitment recognised it as animportant way of tapping into the parentalpopulation, and it was described by onepractitioner as being the “key” and “thegateway” to parents. He said that ifpartnerships with these providers aredeveloped and maintained, parent recruitmentwas far more successful. These strategiesdiffer somewhat from those described in theresearch literature.Similar to practitioners involved in theAmerican PDFY program and the AustralianPACE program, Victorian practitionersidentified schools as a valuable site forrecruitment. A number of practitioners statedthat they gave “one-off” presentations or wereinvited to make a presentation at a school;others reported advertising in the schoolnewsletter. Practitioners used theseopportunities to explain the program and inviteparents to attend.Despite the introduction within the literatureof multi-level approaches within schoolsettings, none of the Victorian practitionersindicated that they employed this method.However, one savvy practitioner indicated thatshe used a graduated approach to recruitingparents. Firstly, she invited parents to attendan evening event at which their child wasperforming or had a level of involvement.Secondly, during the course of the evening shewould acknowledge the importance of healthyPage 11 of 17

Prevention Research Evaluation ReportNumber 6 June 2003family relationships and subsequentlyencourage parents to attend her parenteducation sessions. Although this approach isnot strictly multi-level, the recruitmentmethodology suggests that the practitionerrecognises the need to approach parents bygrading the contact and promoting the programat a variety of levels.Information gathered from the interviewssuggests that no particular recruitment strategyappeared to be more successful than another.Most practitioners described their programs as“full” and thus successful at recruitment. Anaverage of 14 people was generallyrecognised as a sufficient number for aprogram; however, one practitioner stated thathe had 50 people attend an initial session ofhis parenting program. It was noted that morewomen than men attended most parentingprograms. Despite general satisfaction withrecruitment rates, it was suggested by onepractitioner that as there was no baselinerepresenting successful recruiting for aparenting program, it was difficult to knowwhether a program was successful or not inthis domain.Practitioners were also asked to makesuggestions about possible barriers torecruiting parents for education programs.Notwithstanding the usual funding issues,overall, practitioners’ comments could beplaced under the categories of timing andpreconceived notions. Comments aroundtiming focused on the need to run programs attimes when both working and home-basedparents could attend. If programs are limited toone time they allow for only a small proportionof parents to attend (mainly women). Anotherbarrier associated with timing was parents notbeing able to commit to the time required by aprogram. For example, the time commitment of2 hours for eight weeks for the BEST programwas difficult for parents to manage.Barriers that could be categorised aspreconceived notions included parents’assumptions about the content of parenteducation, and implied shame or guilt.Practitioners suggested that parents were notwilling to commit themselves to programsbecause they often associated attendance withbeing in a classroom with a teacher, and being“told how to run their lives” or being “given aset of instructions”. One practitioner suggestedthat this thinking was partly a legacy of the“medical model” of health, in which problemsare pathologised and subsequently associatedwith a particular treatment plan.Shame and guilt were said to be barriersbecause parents assumed that attendingparent programs implied that they hadproblems with their child and that they were apoor parent. Some parents did not want to beidentified by other members in the communitybecause of fear of being stigmatised. It wassuggested that shame and guilt experienceswere particularly salient in the Vietnamesecommunity.Although Toumbourou and Gregg (2002)report some success in recruiting parents fromdifferent socio-economic backgrounds, onepractitioner did indicate that she was moresuccessful with recruiting parents from middleclassbackgrounds than with parents fromlower socio-economic backgrounds. Shesuggested that parents from lower socioeconomicbackgrounds were less comfortablein a learning environment than parents fromother backgrounds. Another practitioner notedthat migrant parents who could be categorisedas low socio-economic status were oftenstymied by language and a lack of transport toattend parent education programs.Overall, these comments suggest thateducators recognise the need for a range ofrecruitment strategies, mostly for the capacityto reach a wider audience. Consistent with theresearch literature, practitioners appreciatethat the school is a setting rich with recruitmentopportunities. However, barriers to recruitmentinclude the time and timing of programs andparents’ preconceived notions about parenteducation. Some practitioners believed socioeconomicstatus hindered parents’participation in education programs.Page 12 of 17

Prevention Research Evaluation ReportNumber 6 June 2003What contribution can parenteducation make to preventingdrug-related harm?The available evidence suggests that parenteducation is generally a good socialinvestment in supporting the healthydevelopment of children, young people andtheir families. Depending on the context,moderate to strong effects can be achieved inaddressing change in children’s and youngpeople’s behaviours. Although there has beenlimited research examining impacts on youthdrug use specifically, the existing evidence ispromising. Victoria is at the cutting edge indeveloping and applying parent educationprograms to reduce drug-related-harm.Programs such as the Victorian government’sABCD initiative are exploring the importantquestion of whether parent education canreduce problems associated with youthsubstance use.Although findings from small research trials(efficacy studies) have suggested that thereare benefits through parent education, thereare many questions that have not yet beenaddressed. It is unclear whether specificelements of parent education or specificprograms offer differential benefits. Answeringquestions such as these will requirecompetitive trials comparing different programelements and programs. It is also unknownwhether parent education is effective inapplications outside research trials. It would bepossible to investigate the community impacton youth substance use of increasinginvestment in parent education, but to date thistype of evaluation has not been reported.In common with findings from otherprevention strategies, Webster-Stratton (1998)and others have noted deterioration of thepositive effects of parent education programsover time. Such observations suggest that theprograms may need to be broadened in orderto actively address other risk factors and toextend application through the pre-school andearly school years if their potential to reducedrug use, associated and conduct problems isto be realised in later years. The requirementfor parent education to be closely co-ordinatedwith other prevention strategies is an additionalquestion that should be followed up in futureevaluation.Practitioners’ views: Whatcontribution can parenteducation make?Consistent with research findings, practitionersgenerally agreed that parent education was agood social investment. However, the extent towhich parent education was seen to impact onthe development of children, young people andtheir families varied between practitioners. Onepractitioner said that she believed parenteducation programs worked only if they wereconsistent with the cultural context in whichthey were applied. Similarly, other practitionerssuggested that parent education programsworked only within a limited spectrum of socialneed, and thus needed to have flexibledelivery modes and to be directed toachievable goals.Practitioners who participated in researchor policy development recognised that therewas very little longitudinal research supportingthe efficacy of parent education in reducingdrug-related harm. However, thesepractitioners also pointed out that programs“based on social learning principles tend toshow themselves to be more effective thanprograms based on simply information givingand sharing”. One practitioner suggested thatprograms such as ABCD were demonstratingefficacy because parental observationssuggested an increase in parental confidence,and parent self-reports indicated a positivechange in the way parents related to theirchildren.Practitioners were quick to point out that avariety of factors influenced drug-relatedbehaviour, and thus it is difficult to gauge theefficacy of parent education. Nevertheless,practitioners usually attempted to gaugeeffectiveness by both qualitative andquantitative methods. Pre- and post-testing ofincreased knowledge, confidence and skills toPage 13 of 17

Prevention Research Evaluation ReportNumber 6 June 2003solve problems were the most commonquantitative methods employed. Practitionerswho used the BEST program sometimes usedthe survey included in the manual. Qualitativemethods usually included focus groups andfeedback examining communication skills andstrategies. The BEST program includes asession towards the end of the program duringwhich parents can talk about the skills andstrategies they have employed.Practitioners recognised that closelyconnected to the notion of effectiveness is theidea of program evaluation. Moreover, mostacknowledged the need to evaluate formallytheir parent education programs. Severalpractitioners indicated that they had theirprogram “externally evaluated”. In one case,internal evaluation information was sent toexternal evaluators who, in the light ofinformation gathered from focus groups and asix-month follow up, made interpretations ofthe findings.Other practitioners simply used pre- andpost-data to evaluate their programs,examining domains such as parents’confidence, decreased conflict, increasedproblem solving and increased concern aboutthe young person. However, one practitionerdid report that she avoided any large-scaleevaluation because it suggested to parentsthat they were participating in a “clinicalintervention” and that “something was wrongwith them”.No practitioner spoke about thedeterioration of positive effects of parentmanagement programs over time. However,consistent with the research literature,practitioners were aware of the need tobroaden the scope of parenting educationprograms.Practitioners saw the need to expandprograms to include the needs of parents fromculturally and linguistically diverse (CLD)backgrounds and, in particular, toaccommodate needs within Indigenouscommunities. Two practitioners indicated thatthey were aware that research around theadaptation of the ABCD program forIndigenous communities was currently beingundertaken. Other practitioners pointed outthat increasingly children are “leaving home ata later age”, and thus many parents havechildren at home between the ages of 21 and30. Yet, practitioners stated, there are not anyparent programs targeted at parents withchildren between these ages. One practitionersuggested that parent education should beflexible in being adjusted to the needs ofparents, with adaptations to cover differencesinthe age of the parent, the age of thechildren and the behaviour of the child”.Consistent with the researchrecommendations were practitioners’suggestions that parent education be closelyco-ordinated with other prevention strategies.It was noted that parent education lacked a“co-ordinated approach”, specifically a lack ofintegration between government departments,parenting programs and family services. Inorder to better integrate parent education,practitioners suggested that more funds be putinto resourcing and supporting professionals inthe field, and that researchers’ evidence bebetter circulated in the field.Despite having confidence about thecurrent status of parent education,practitioners had criticisms about what ishappening in Victoria. The most commoncriticism was the lack of funding. Onepractitioner suggested that the parentcomponent of “Turning the Tide” was a goodexample of poor funding. She stated that when“funding was available for parent drugeducation [as part of Turning the Tide], a twosessionprogram was run and was often run atone school with the idea that four or fiveschools in that area would have parents cometo it…” She went on to suggest that this type offunding merely “scratched the surface” ofparent education, and too often focused on theprovision of information.Another criticism was that parent educationwas often confused with general “drugeducation”. Practitioners saw general drugeducation as the provision of information about“what sort of drugs people normally take”, andparent education as adolescent-specificinformation, such as developmental issues,Page 14 of 17

Prevention Research Evaluation ReportNumber 6 June 2003communication skills and relationship building.Consistent with the research literature, it wassuggested that both forms of education arenecessary. However, it was emphasised byone practitioner that they should be runindependently, and that the latter should be leftto trained family practitioners.ConclusionTaken as a whole, the comparison of currentpractice in Victoria with current researchliterature around parent education suggeststhat practitioners have good awareness of thegoals and strategies for effective parenteducation. Despite the limited evidence linkingparent education with the reduction of drugrelatedharm with adolescents, practitionersare aware of the benefits of promotingprotective factors and reducing the risk factors,described in the literature. Many practitionersare at the cutting edge in applying parenteducation programs. Overall, Victorianpractitioners should be applauded for theirefforts to deliver and evaluate programs thathave been designed to reduce drug-relatedharm. In order to ensure that the currentstandard of practice is maintained,practitioners ought to strive to use techniques,strategies and programs that are supported bycurrent research literature. Conversely,research enquiry should be informed bypractitioners’ experiences about what isfeasible and what is less practical in the field.ReferencesBamberg J, Toumbourou JW, Blyth A & Forer D2001 ‘Profiling changes for families in theBEST program, for parents coping withyouth substance abuse’, Australian & NewZealand Journal of Family Therapy, vol. 22,pp. 189–98Bank L, Marlowe JH , Reid JB, Patterson GR &Weinrott MR 1991 ‘A comparativeevaluation of parent-training interventionsfor families of chronic delinquents’, Journalof Abnormal Child Psychology, vol. 19, pp.15–33Bauman KE, Ennett ST, Foshee VA,Pemberton M, King T, Koch GC 2001 ‘Theinfluence of a family program on adolescenttobacco and alcohol use’ American Journalof Public Health, vol. 91 no. 4, pp. 604–10Blyth A, Bamberg J & Toumbourou J 2000Behaviour exchange systems training: Aprogram for parents stressed by adolescentsubstance abuse, Camberwell, Australia:Australian Council for Educational ResearchBronfenbrenner U 1979 The ecology of humandevelopment: Experiments by nature anddesign Cambridge Mass.: HarvardUniversity PressCatalano RF & Hawkins JD 1996 'The socialdevelopment model: A theory of antisocialbehavior', in JD Hawkins (ed. ) Delinquencyand crime: Current theories 1996, NewYork: Cambridge, pp. 149–97Cohen D & Rice J 1995 ‘A parent-targetedintervention for adolescent substance useprevention: Lessons learned’, EvaluationReview, vol. 19, pp. 159–80Dishion TJ & Andrews DW 1995 ‘Preventingescalation in problem behaviours with highriskyoung adolescents: Immediate and 1-year outcomes’, Journal of ConsultingClinical Psychology, vol. 63, pp. 538–48Dishion TJ & Kavanagh K 2000 ‘A multilevelapproach to family-centred prevention inschools: Process and outcome’, Addictivebehaviours, vol. 25, pp. 899–911Eisenstadt T, Eyberg S, McNeil C & NewcombK 1993 ‘Parent–child interaction therapywith behaviour problem children: Relativeeffectiveness of two stages and overalltreatment outcome’, Journal of ClinicalChild Psychology; vol. 22, pp. 42–51Page 15 of 17

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Prevention Research Evaluation ReportNumber 6 June 2003Mitchell P, Sanson A , Spooner C, Copeland J,Vimpani G, Toumbourou JW & Howard J2001 The role of families in thedevelopment, identification, prevention andtreatment of illicit drug problems, Canberra:National Health and Medical ResearchCouncil, Commonwealth of AustraliaPerry C, Williams CL, Veblen-Mortenson S,Toomey T, Komro K, Anstine P, McGovernP Finnegan J, Forster J, Wagenaar A &Wolfson M 1996 ‘Project Northland:Outcomes of a communitywide alcohol useprevention program during earlyadolescence’, American Journal of PublicHealth, vol. 86, pp. 956–65Rohrbach LA, Hodgson CS, Flay BR, Hansen,WB & Pentz MA 1994 ‘Parentalparticipation in drug abuse prevention:Results from the Midwestern PreventionProject’, Journal of Research onAdolescence, vol. 4, pp. 295–317Sanders M, Markie-Dadds C, Tully L et al.2000 ‘The Triple-P Positive ParentingProgram: A comparison of enhanced,standard, and self-directed behaviouralfamily intervention for parents of childrenwith early onset conduct problems’, Journalof Consulting and Clinical Psychology; vol.68, no. 4, pp. 624–40Schuhmann EM, Foote RC, Eyberg SM et al.1998 ‘Efficacy of parent–child interactiontherapy: Interim report of a randomized trialwith short-term maintenance’, Journal ofClinical Child Psychology; vol. 27, no. 1, pp.34–45Serketich WJ & Dumas JE 1996 ‘Theeffectiveness of behavioral parent trainingto modify antisocial behavior in children: ameta-analysis’, Behavior Therapy; vol. 27,pp. 171–86Spoth RL, Redmond C, Kahn JH & Shin C1997 ‘A prospective validation study ofinclination, belief and context predictors offamily-focused prevention involvement’,Family Process, vol. 36, pp. 403–29Toumbourou JW 2002a Preventing harmful druguse, Research evaluation report no. 1DrugInfo Clearinghouse, West Melbourne:Australian Drug Foundation, pp. 1–8Toumbourou JW 2002b Drug preventionstrategies: A developmental settingsapproach, Research evaluation report no. 2,Drug Info Clearinghouse, West Melbourne:Australian Drug Foundation, pp. 1–11Toumbourou JW, Blyth A, Bamberg J & Forer D2001 ‘Early impact of the BEST interventionfor parents stressed by adolescentsubstance abuse’, Journal of Community &Applied Social Psychology, vol. 11, pp.291–304Toumbourou JW & Gregg M E 2001 ‘Workingwith families to promote healthy adolescentdevelopment’, Family Matters, vol. 59, pp.54–60Toumbourou JW & Gregg ME 2002 ‘Impact ofan empowerment-based parent educationprogram on the reduction of youth suiciderisk factors’, Journal of Adolescent Healthvol. 31, no. 3, pp. 279–87Webster-Stratton C 1998 ‘Preventing conductproblems in Head Start children:Strengthening parenting competencies’,Journal of Consulting and ClinicalPsychology; vol. 66, no. 5, pp. 715–30Webster-Stratton C & Hammond M 1997‘Treating children with early-onsetproblems: A comparison of child and parenttraining interventions’, Journal of Consultingand Clinical Psychology vol, 65, pp. 93–109This report was prepared for the DrugInfo Clearinghouse by theCentre for Adolescent Health and the Centre for Youth Drug Studies, Melbourne. Toview our other reports in this series, see our website at 17 of 17

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