Kevin P. Haggerty, Associate Director based at the Social Development Research Group, School of Social Work, University of Washington, Seattle, Washington, USA
Anne McGlynn-Wright, Graduate Research Assistant based at the Social Development Research Group, School of Social Work, University of Washington, Seattle, Washington, USA
Tali Klima, Research Scientist, based at the Social Development Research Group, School of Social Work, University of Washington, Seattle, Washington, USA.
This study was supported in part by the US National Institute on Drug Abuse (R01 DA021737, Haggerty, PI). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency.
Purpose – Adolescent problem behaviours (substance use, delinquency, school dropout, pregnancy, and violence) are costly not only for individuals, but for entire communities. Policy makers and practitioners that are interested in preventing these problem behaviours are faced with many programming options. The purpose of this review is to discuss two criteria for selecting relevant parenting programmes, and provide five examples of such programmes.
Design/methodology/approach – The first criterion for programme selection is theory based. Well-supported theories, such as the social development model, have laid out key family-based risk and protective factors for problem behaviour. Programmes that target these risk and protective factors are more likely to be effective. Second, programmes should have demonstrated efficacy; these interventions have been called “evidence-based programmes” (EBP). This review highlights the importance of evidence from rigorous research designs, such as randomised clinical trials, in order to establish programme efficacy.
Findings – Nurse-Family Partnership, The Incredible Years, the Positive Parenting Program (Triple P), Strengthening Families 10-14, and Staying Connected with Your Teen are examined. The unique features of each programme are briefly presented. Evidence showing impact on family risk and protective factors, as well as long-term problem behaviours, is reviewed. Finally, a measure of cost effectiveness of each programme is provided.
Originality/value – The paper proposes that not all programmes are of equal value, and suggests two simple criteria for selecting a parenting programme with a high likelihood for positive outcomes. Furthermore, although this review is not exhaustive, the five examples of EBPs offer a good start for policy makers and practitioners seeking to implement effective programmes in their communities. Thus, this paper offers practical suggestions for those grappling with investments in child and adolescent programmes on the ground.
Prevention; Adolescent; Evidence-based practice; Parenting; Family; Programmes.
Journal of Children's Services
Emerald Group Publishing Limited
In the past 30 years, physicians, educators, and scientists have made dramatic advances in what we know about effective parenting. It is now clearly possible to help parents raise more successful children – children who are mentally healthy, able to resist negative influences to take dangerous physical and health risks, confident, caring, and connected in positive ways to their schools and families. We now have evidence that certain scientifically tested parenting programmes create better outcomes for children whose parents participate in them. These programmes work with a wide variety of families in diverse settings. Often all it takes is parents’ willingness to make a small investment of time and effort – in some cases as little as ten hours of a workshop over a period of seven weeks – to learn skills that will change their children's development for the better for years.
Substance use, delinquency, school dropout, teen pregnancy, and violence all can be devastating for parents and also pose serious social, health, and economic consequences in developed societies (Catalano et al., 2012; Rehm et al., 2009). These five behaviours will be collectively referred to as “problem behaviours” in this paper. They are grouped together because they often coincide with one another (i.e. youth who display one behaviour also display others) and share common aetiological risk and protective factors (Catalano et al., 2011). Because problem behaviours have serious consequences in childhood and can lead to even more severe setbacks in adulthood (e.g. unemployment, crime), it is critical to prevent the initiation and progression of these behaviours. Various strategies have been proposed to date. Here, we focus on parent and family programmes for preventing problem behaviours.
An extensive body of literature has shown that parents are a key factor in the prevention of problem behaviours (Catalano et al., 2011; Hawkins et al., 1992; Stone et al., 2012). For instance, favourable parental attitudes towards antisocial behaviour, lack of clear guidelines for behaviour, poor monitoring, harsh or inconsistent discipline, and high levels of family conflict are predictive of more adolescent problem behaviour (Herrenkohl et al., 2012); therefore, these are known as risk factors. Alternately, strong parent-child bonding, opportunities for active involvement in the family, and recognition for positive behaviours are associated with less problem behaviour (Herrenkohl et al., 2012); thus, they are considered protective factors.
Effective parent and family-based programmes focus on changing known risk and protective factors. By intervening early in family dynamics, one can affect more proximal (later) factors that predispose adolescents to problem behaviours. For instance, parenting behaviour impacts children's internal norms (i.e., the acceptability of certain behaviours) as well as their expectations for harm due to risky behaviour, both of which are closely associated with adolescent problem behaviour. Similarly, family dynamics have been shown to affect the selection of antisocial peers in adolescence; deviant peers are, in turn, highly predictive of children's own substance use, violence, and delinquency (Haggerty and Kosterman, 2012; Skinner et al., 2009). In short, improving parenting skills and the parent-child relationship in early childhood, middle childhood, and into the teen years can affect problem behaviours through diverse developmental paths.
For policy makers and practitioners interested in implementing family-based programmes, the question remains of how to choose an appropriate programme among those that are available. One criterion is theory. Programmes that are theory driven have been shown to be better articulated, more focused, and therefore more effective (Fixsen et al., 2005). The programmes reviewed here reinforce components of a theory known as the “social development model” (SDM; Catalano and Hawkins, 1996), which has considerable empirical support. The SDM proposes that the relationship between a parent/caregiver and a child should provide five things in order to protect children from social, emotional, and behavioural problems and promote healthy development. The child must receive: opportunities, skills, rewards for prosocial behaviour, bonding, and clear expectations for behaviour. A child who has opportunities to engage in developmentally appropriate interactions and activities with adults in the home, the chance to develop new skills needed to succeed, and who is recognised and rewarded for positive behaviour is more likely to feel bonded to the family. When children feel bonded to their family, they are motivated to live according to the family's expectations and rules, which are generally prosocial. Thus, by improving the five dynamics laid out in the SDM, one might expect fewer problem behaviours (Figure 1).
The second key criterion for choosing family-based programmes is evidence of a programme's efficacy. Programmes that demonstrate efficacy have been called “evidence-based programmes” (EBP). However, it is important to note that different types and levels of evidence for a programme's efficacy may exist. For instance, there may be anecdotes of success by past participants, programme implementers may experience progress first-hand, and surveys may even show that participants have improved in key skills or outcomes from start to the end of a program. All of these forms of evidence have some validity, yet they are not systematic in measuring and analysing outcomes of interest for a specific population.
The scientific community generally agrees that only when programmes have been rigorously tested through research designs such as randomised clinical trials or quasi-experimental methods can they be considered “evidence based.” When properly designed and well executed, randomised trials and experimental research designs compare a group of individuals who participate in a programme to a similar group of individuals who do not participate in order to isolate programme effects. In this way, research can identify for whom certain programmes work and under what circumstances (e.g. how exactly the programme should be implemented). This standard of efficacy has been adopted by not only scientists, but also by large US federal agencies that fund social programmes and by institutions that specialise in EBPs.
It is important to use programmes that have been tested and proven effective, since not all programmes have the positive outcomes that were intended. In fact, some programmes have been found to make child and adolescent problem behaviour worse. For example, research has consistently shown that peer group interventions with some at-risk youth increase risk for delinquency in adolescence and poor outcomes in adulthood (Dishion and Dodge, 2005; Dishion et al., 1999). As adults concerned with improving the well-being of children, we cannot afford to implement programmes in our communities that have not reliably demonstrated positive outcomes.
Despite advances in prevention science, skills training programmes are often unutilised. Each year in the USA, 56 percent of new expecting mothers attend birth classes to prepare for childbirth (Declercq et al., 2006), a process that will happen naturally. Yet, fewer parents begin their journey by learning about important parenting behaviours that can set their child on a positive and healthy trajectory. By the middle and high school years, even fewer parents participate in parenting or family programmes unless they have difficulties with their child. By participating in tested and effective parenting programmes, parents can make a positive difference in the lives of their children.
In this paper, we provide five examples of family-based EBPs that reduce family risk factors and increase family protective factors for child and adolescent problem behaviour. We examine programmes that can be implemented:
- in early childhood – Nurse-Family Partnership (NFP), The Incredible Years, and the Positive Parenting Program (Triple P);
- in middle childhood – Strengthening Families 10-14; and
- during the teen years – Staying Connected with Your Teen.
These programmes are not intended to serve as an exhaustive list of family-based prevention programmes, but offer examples of the types of skills that can be taught to families at various developmental stages and the outcomes that can be affected. For a robust list of evidence-based parenting and family programmes, see Blueprints for Healthy Youth Development.
This paper describes the basic format and skills taught by the five EBPs. It then summarises the research evidence for family risk and protective factors, as well as long-term outcomes such as substance use, delinquency, and educational outcomes. Finally, it provides a measure of cost savings that occur when a programme is implemented. Prevention programmes save money by avoiding negative outcomes that require costly services from community organisations and government agencies. For example, if a child is prevented from engaging in delinquent behaviours, the costs otherwise expended on law enforcement, juvenile justice institutions, and possibly treatment are averted. Likewise, if a child does not develop mental health problems or does not experience maltreatment, fewer resources will be expended on psychotherapeutic and social services, respectively. Prevention also promotes positive outcomes which lead to financial benefits. For instance, if, as a result of programme participation, a child's educational achievement improves and they graduate from high school, they are more likely to be employed in a higher paying job, which will result in greater public contributions (i.e. higher taxes) and less utilisation of public assistance. Economists have devised statistical models for monetising the average costs and benefits of social programmes, taking into account a diverse set of outcomes that may be affected by these programmes. Practitioners and policy makers who are interested in learning more about specific programme characteristics or how to implement a programme are referred to the Appendix, which includes a list of all programme web sites.
Nurse-Family Partnership (NFP)
NFP is an excellent example of a family programme that works. Developed by David Olds, now at the University of Colorado, the programme has been proven to prevent child abuse, neglect, and maternal arrest. It also reduced mothers’ problems due to drug and alcohol abuse (Olds et al., 1998).
The programme works with young, first-time, single mothers during their first pregnancy until their child is two years old. Mothers enrolled in NFP are visited by a registered nurse in their home at least once every other week, sometimes more often than that. The nurses work with the expecting mothers to reduce behaviours such as smoking, drinking, and drug use during pregnancy that may lead to poor birth outcomes. They also help the expecting mothers to identify potential signs of pregnancy complications.
After the child is born, nurses continue to work with mothers to recognise developmental or health problems and create safe environments for their children. In addition to helping mothers alleviate and cope with potential health issues of their child, the programme also teaches mothers how to interact positively with their children in a way that promotes social and emotional competence. Mothers learn how to play with their children in developmentally appropriate ways, how to use positive reinforcement, and how to develop strategies for dealing with difficult behaviours.
Note the elements of the social development strategy in the NFP programme. The programme increases opportunities for infants to interact with their mothers in positive ways, helps both the young mothers and the children to learn skills for positive interactions, and teaches young mothers to reinforce positive behaviours in their children. These elements build strong bonds between mothers and their infants. The nurses also help the mothers to develop goals for themselves, such as going back to school or finding a good job. Positive behaviour, positive goals, and successful outcomes are the hallmarks of this programme.
Studies have found that the programme was most effective for first-time mothers under the age of 22 years (Olds et al., 2004). These mothers showed 44 percent fewer problems due to alcohol and drug use (Olds et al., 1998). These effects have been found both when participating women's children were six years old and 12 years old. Mothers participating in the programme also had 31 percent fewer subsequent births than mothers who did not have the nurse visits and reported they had longer romantic relationships. Mothers in the programme had fewer months spent on welfare and using food stamps than women who were not enrolled in NFP (Olds et al., 2004).
The programme has demonstrated an impact on participating children's delinquency, criminal justice involvement, and substance use behaviour, even in adolescence. Children of mothers who participated in the programme have 60 percent fewer instances of running away from home and 56 percent fewer days of alcohol consumption by the time they reach age 15 years compared to a no-treatment control group (Olds et al., 1998). Recent findings suggest that NFP also has an impact on criminal justice involvement for girls (Eckenrode et al., 2010). Girls involved in the programme we less likely to experience an arrest or conviction by 19 years of age than girls who were not involved in the programme. Evidence-based parenting programmes like NFP also save money. According to a detailed cost-benefit analysis of the programme, for every dollar spent, the NFP programme saves $2.37 by reducing the amounts needed for the juvenile justice system, law enforcement, substance abuse treatment, and unemployment (Aos et al., 2012; Lee et al., 2012).
Positive Parenting Program (Triple P)
Matthew Sanders, a clinical psychologist, recognised that different communities and families need different levels of parenting intervention; therefore, along with his colleagues he developed a flexible system of parenting programmes called the Positive Parenting Program (Triple P). Growing out of Sanders’ early work with children as a graduate student in psychology at the University of Queensland, in Australia, Triple P has evolved to become a worldwide network accessed by millions of parents and involving large-scale trials and evaluations of its impacts. The programme now encompasses an integrated network in 21 countries and four universities: the University of Queensland, the University of South Carolina in the US, the University of Manchester in England, and the University of Glasgow in Scotland.
The programme has five different levels that vary in breadth and depth. The intent of the programme is to promote positive parenting and reduce the risk of child abuse and neglect, risk factors for later adolescent problem behaviours. Each level of the Triple P system focuses on five main goals: promoting safe and engaging environments, creating positive learning environments, using effective discipline, creating clear and reasonable expectations, and self-care for parents. Earlier levels target large audiences with general information, while later levels work with parents already experiencing problems by using more intensive interventions.
Elements of the social development strategy come alive for parents in the following ways: by providing opportunities for positive interaction between parents and children; by teaching skills through modelling; and by teaching parents how to reinforce positive behaviour, set clear rules and consequences in advance for violating them, and build strong bonds of affection in the family.
The ability of the programme to provide both breadth and depth, where needed, allows families to receive more tailored interventions and saves communities money by reducing unnecessary services. Most Triple P levels can also be modified for groups, one-on-one settings, or be self-taught, which may also reduce the cost of implementing the programme.
Level 1 is designed to reach a large audience. At this level, the programme uses marketing strategies to disseminate information about parenting issues and child development. For example, a variety of media forms may be used to deliver parenting messages, including radio campaigns or television series.
Level 2 builds on the first level and distributes additional information through primary care physicians and other service providers who have direct contact with caregivers and their children. Through brief sessions, primary care personnel offer psychoeducation and referrals for issues that caregivers may have with their children. The session can also be supplemented with tip sheets, resources, or other information. A more intensive version of Level 2 Triple P may also use the Triple P seminar series which consists of three 90-minute sessions: The Power of Positive Parenting; Raising Confident, Competent Children; and Raising Resilient Children. A portion of each seminar is devoted to responding to parents’ questions.
Levels 3 through 5 are more intensive approaches that generally focus on children with mild to severe behavioural problems. Level 3, for example, is administered to parents of children with mild or moderate behavioural issues. The counselling intervention occurs in four short sessions, consisting of issue-specific psychoeducation and parent skills training, with tip sheets for parents. Level 4 is intended for caregivers whose children display moderate to serious behavioural problems, so it provides more and longer sessions than the previous level. As is typical of interventions for serious behavioural issues, parents are taught key skills through modelling, rehearsal, and self-evaluation. The parents also engage in supervised practice of the skills with their child either at home or in a clinic setting. Sessions last from eight to ten weeks.
If participants in Level 4 continue to experience behavioural problems, such as adolescent delinquency or substance use, they are referred to Level 5, where they receive supplemental family intervention.
Triple P's flexible approach to helping families and a strong evidence base has made it a success in multiple countries and languages. A number of controlled trials have focused on the effects of specific Triple P components. Both the Level 4 group parenting programme and the Level 4 individual self-directed parenting programme for families of children with challenging behaviour problems in early childhood have shown positive effects on parent-reported child disruptive behaviour disorder symptoms across multiple studies (Morawska and Sanders, 2006; Plant and Sanders, 2007; Sanders, 1999; Sanders et al., 2002, 2004; Turner and Sanders, 2006). While Triple P has multiple studies indicating significant evidence, a recent meta-analysis (Wilson et al., 2012) determined that although there was evidence of significant effect sizes for maternal reports of problem behaviours, the effects were not long lasting and were not reported by neutral observers or fathers. Additionally, more recent studies replicating the Level 4 programme find no clear pattern of effect of the programme on child behavioural outcomes (Heinrichs et al., 2013; Little et al., 2012; Malti et al., 2011).
One question is whether implementation of the Triple P system can make a community-level impact. A randomised trial involving 18 counties in South Carolina assigned either to receive Triple P or no Triple P found that when the Triple P system (i.e. all five levels) was made available to parents county-wide in a variety of formats and organisational settings, substantiated cases of child maltreatment for children up to eight years old were 22 percent lower in the counties that received Triple P than in control counties. This is an important risk factor for later adolescent problem behaviours. Out-of-home placements decreased in the Triple P counties but increased in the control counties and were 16 percent higher in control counties than in experimental counties after Triple P. Another important finding was a reduction in child visits to emergency rooms and admissions to hospitals for injuries due to child maltreatment in the Triple P counties, while during the same time period child maltreatment injuries in the control counties increased (Prinz et al., 2009).
Another recent study examining the community-wide implementation of Triple P was conducted in Australia, where diverse community sectors, such as practitioners, schools, social workers, counsellors, and so on delivered all levels of Triple P (Sanders et al., 2008). This study found that caregivers in Triple P communities reported significant reductions in child emotional problems two years after the programme was implemented: participating communities showed a decrease from 15.3 to 12.6 percent of children in the clinical range of emotional problems. Caregivers also reported a reduction in emotional and behavioural problems from 13.9 percent of children being in the clinical range for emotional and behavioural problems to 10.9 percent of children in the clinical range after Triple P was implemented. Such wide-ranging effects on children and adults result in important cost savings. Recent estimates suggest that for every dollar spent on the Triple P system, $6.06 in savings may be realised (Lee et al., 2012).
The Incredible Years
The Incredible Years, developed by Carolyn Webster-Stratton, is a multi-component programme that has shown positive effects with a wide variety of families in diverse settings. They include low-income families, middle-income families, and African-American, Latino, Asian-American and white families. The Incredible Years encompasses eight programmes that target parents, children, and even teachers. The basic and advanced programme for early childhood works with parents of children ages three to six years. The programme uses videotapes and group interactions to teach children, parents, and teachers skills and strategies for handling difficult situations.
Central to the programme is an emphasis on creating opportunities for active involvement, teaching skills, reinforcing positive behaviour, and setting clear limits. These are all central to the social development strategy. The parent training programme focuses on four main programme areas: strengthening children's social skills, emotion regulation, and school readiness; teaching parents to use praise and incentives to encourage cooperative behaviour; establishing rules, routines, and effective limit setting; and handling misbehaviour (Reid et al., 2001; Webster-Stratton et al., 2001). The Incredible Years parent training sessions generally include 22 two-hour group-facilitated sessions over a minimum of 12 weeks. The sessions are reinforced by home practice activities. A companion child's programme, the Dinosaur school programme, includes 22 weekly therapist-led group sessions. Typically, the groups consist of six to seven children with serious behaviour problems. The focus of the group is to help children develop social and life skills such as problem solving, making friends, and cooperating with teachers, parents, and other children (Reid et al., 2001).
Over the past 25 years, Webster-Stratton's team has conducted six randomised controlled studies evaluating outcomes of the parenting programme on children's behaviours. In addition, there have been six independent evaluations in a dozen different countries. Together, these studies provide strong evidence that the programme improves parenting skills and children's behaviour for up to three years after programme participation on important risk factors for adolescent problem behaviours. Parents who had received this parenting programme reported fewer behavioural problems and increased positive behaviours (e.g., following expectations) of their children at three-year follow up, with 54 percent of the mothers and 75 percent of the fathers rating their child's behaviour as having improved (Webster-Stratton, 1990). Replications of this programme have also found strong effects on decreasing negative parenting behaviours, increasing positive child behaviours, and strengthening parent-child relationships (Little et al., 2012). The programmes appear to have the strongest effects when they are combined. For example, whereas 95 percent of children in a combined intervention of the parent basic programme and the Dinosaur school programme reported at least a 30 percent reduction in behaviour problems, only 59 percent of children in parent training alone and 74 percent of children in child training alone indicated a 30 percent or more decrease in behaviour problems (Webster-Stratton and Hammond, 1997). The programme has demonstrated long-term effects into adolescence for parents of children who were experiencing conduct disorders when they were three to eight years old (Webster-Stratton et al., 2011). For every dollar spent, the Incredible Years parenting programme is estimated to save $1.20; when the child programme is added, the savings do not decrease significantly ($1.14 for every dollar invested; Lee et al., 2012).
The Strengthening Families Program: For Parents and Youth 10-14 (Strengthening Families 10-14)
The Strengthening Families Program for ten- to 14-year-olds (formerly known as Iowa Strengthening Families Program) consists of seven two-hour sessions that target both the young person and caregiver. Parents and young people meet separately for the first hour. During that time, they learn to identify risk factors for substance use, enhance parent-child bonding, monitor compliance with parent guidelines, provide appropriate consequences, manage anger and family conflict, and foster positive child involvement in family tasks. Consistent with the SDM, the programme seeks to clarify expectations for behaviour while promoting bonding by involving children in family decisions and teaching skills in a reinforcing environment. Youth engage in activities that target communication, problem solving, and resisting peer pressure. Parents and young people then come together and use a variety of games and activities to practise skills. The activities are specially designed to promote family involvement and bonding. The programme has been used with various populations, including court-referred young people, families in low-income housing projects, churches, Native American groups, Asian families, and Spanish-speaking families. The programme has also been tested in an adaptation for rural African-American families living in the South, called the Strong African American Families Program (SAAF; Brody et al., 2004).
The Strengthening Families 10-14 Program (SFP) has been successful in reducing initiation rates of substance use, reducing delinquent behaviour, and increasing academic success in adolescence. In a four-year follow-up of the impact of SFP, Spoth et al. (2001) found that the programme delayed initiation of alcohol, drunkenness and cigarette and marijuana use in the tenth grade (15-16 years) compared to a control group that did not get SFP. In addition, for those that did initiate, the programme was found to reduce the frequency of alcohol and cigarette use compared to the control group (Spoth et al., 2001). The programme has also been found to effectively reduce initiation of marijuana and other illicit drug use by the 12th grade (17-18 years; Spoth et al., 2009). The authors suggest that decreased uptake of illicit drug use among the group receiving SFP is likely the result of a “protective shield.” Adolescents who took part in the programme were less likely to experience exposure to illicit drugs by the seventh grade (12-13 years), which led to less likelihood of using illicit drugs as high school seniors.
SFP has also been effective in reducing hyperactivity, aggressive behaviour, and destructive behaviours in high school when compared to control groups (Spoth et al., 2000). Further, the programme was found to increase school engagement in eight grade (13-14 years) and academic success, defined by school grades, in the 12th grade (Spoth et al., 2002, 2008). Spoth et al. (2008) suggest that such long-term effects are the result of the programme increasing parental competencies and reducing substance use-related risks.
The SAAF programme produced similar outcomes in delaying the onset of substance use by teens (Brody et al., 2006b). Seven months after the SAAF programme, young people involved in the programme displayed more factors that would protect them from drug and alcohol use and abuse, such as having negative attitudes about alcohol and drugs and being goal directed. Furthermore, the authors argued that these increases in child protective factors were a result of increases in communicative parenting practices (Brody et al., 2004). Later results suggest that these child protective factors predicted lower rates of alcohol initiation two years after the intervention (Brody et al., 2006a). Early cost-benefit analyses determined that the long-term effects ranged from $7.80 to $9.60 for every dollar invested (Aos et al., 2004; Spoth et al., 2002). However, a recent analysis with updated assumptions by the Washington State Institute for Public Policy estimates that for every dollar invested in SFP, the long-term financial benefit is about $0.65 (Aos et al., 2012).
Staying Connected with Your Teen
Staying Connected with Your Teen (formerly known as Parents Who Care) was developed by J. David Hawkins and Richard F. Catalano to promote the social development process in families and to reduce risk factors in families with children aged 12-17 with a view to preventing risky sexual activity, drug use, and violent behaviour. It was designed to include both parents and teenagers, and is delivered either through seven workshop sessions or as a self-directed programme used at home. The programme includes an interactive video or DVD and a workbook based on the social development strategy.
Consistent with the social development strategy, the programme features activities designed to provide teens with opportunities to contribute to their families and acquire the skills needed to take advantage of those opportunities, and increase parental monitoring, reduce harsh parenting, and use reward and recognition in order to promote bonding. The 108-page family workbook is written at an eighth-grade reading level, and a 117-minute video in 18 sections features Latino, African-American, and white families.
A pilot study evaluated a group-administered curriculum only. It was tested using random assignment to experimental and waitlist control conditions. Analyses revealed that the treatment group at posttest showed significantly lower poor family discipline, lower poor family supervision, and lower low parental commitment to school compared to controls. Family bonding also increased at posttest (Pollard, 1998). Overall, it appears that Staying Connected helped parents set strong norms with their teen against antisocial behaviour while simultaneously improving the level of closeness within the family.
A randomised controlled trial was conducted from 2000 to 2005 to evaluate whether there were differences between the effects of a self-administered programme compared to a parent-adolescent group-delivered programme and a no-treatment control group with a sample of white and black families (Haggerty et al., 2007). Generally, both interventions demonstrated moderate reductions in teenager attitudes about substance abuse and delinquency compared to controls two years after families were assigned to the intervention group, and greater positive parenting skills.
In addition, the trial indicated that both intervention methods significantly increased young people's use of condoms compared to the control condition. Sexually transmitted diseases were rare, but reported by four teenagers in the control group, compared to one in each of the intervention conditions. More notable, however, is the significant reduction in initiation of risky behaviour for black teenagers in both interventions when compared to black teenagers in the control group. The likelihood of initiation of alcohol, drugs, or sexual activity was reduced by almost 70 percent for black teenagers in the self-administered condition compared to controls, and by 75 percent for black teenagers in the parent-adolescent group-delivered programme compared to controls. Further, after two years, the frequency of violent behaviours among black adolescents was reduced by 60 percent in the self-administered condition compared to the control group. Thus, this programme seems to have particular promise for black young people and perhaps other minority populations. Although cost-benefit data for this programme are unavailable, the self-administered programme costs about 75 percent less to conduct than the parent and teenager group programme.
The prevention programmes in this review have several qualities in common. They are all widely recognised as EBPs. They also stand on firm theoretical ground, which likely leads to key outcomes. These outcomes are further enhanced by keen attention to programme fidelity among the developers and implementers of these programmes. Below, we discuss each of these important qualities.
Strong evidence for programmes
First and foremost, just as medications must be tested before they are approved for use, all of these psychosocial programmes have been thoroughly tested in high-quality randomised trials or rigorous comparison group studies. All have demonstrated reductions in family risk factors (e.g. family conflict, favourable attitudes towards problem behaviours) and have shown improvements in family protective factors (e.g. guidelines and monitoring, parent-child attachment). In addition, some programmes have revealed long-term outcomes among child participants, such as better high school success and lower rates of violent behaviour and adolescent substance use.
The outcome studies presented in this review were carefully selected based on theory, rigour, and quality. We urge policy makers and practitioners to be critical about the type of evidence accepted as proof of a programme's efficacy. Not all evidence is of equal value: only rigorous studies with a valid comparison group can definitively identify the effects of a particular intervention. For instance, children who undergo Programme X may exhibit less substance use at the end of a programme than the beginning. However, it is possible that as time passes and children mature, they naturally use fewer substances. Alternately, participants of Programme X may have also participated in Programme Y or experienced other changes, such as a large-scale school reform, at the same time. Without a tightly controlled comparison group, which only differs by its lack of participation in Programme X, it is difficult to rule out alternative explanations and conclude that Programme X led to better outcomes.
The family-based EBPs reviewed here are illustrative and not exhaustive. These programmes have been demonstrated to help a wide range of populations; however, there are also EBPs that target populations experiencing specific circumstances that place them at risk for problem behaviours. For instance, the New Beginnings Program helps children of divorced parents, and Families Facing the Future is intended for children of parents in substance abuse treatment. Of course, there are also evidence-based treatment programmes for children who are already experiencing substance use or related problems, for example, Multisystemic Therapy (MST) and Functional Family Therapy (FFT).
Theoretical basis for programmes
The programmes reviewed here are guided by sound theory, which is important for maintaining a focus on the “active ingredients” of an intervention during its implementation. Such focus facilitates more efficient allocation of limited resources and more powerful impact on target outcomes. The SDM is one theory that has gained considerable empirical support and can help practitioners organise their investment in family-based prevention programmes. It proposes that families that have five key components are more likely to promote their child's positive adjustment. These components include: opportunities, skills, rewards, bonding, and clear expectations for behaviour. As new programmes are being developed, these SDM components can serve to organise key intervention areas for parenting programmes and positive youth development.
The EBPs discussed here seek to strengthen opportunities for interaction and involvement between caregivers and children by promoting communication, listening, and quality time together. In addition, these programmes provide strategies and effective methods for learning and practising new skills in safe environments. Importantly, parents are taught to recognise and reward their children's positive behaviours. By emphasising improvements and accomplishments, parents shape child behaviour towards prosocial goals. The opportunities, skills, and rewards described above lead to stronger bonds between parents and children; therefore, all programmes encourage deeper familial connections through direct programming and continued application at home. Finally, these programmes promote clear expectations for children's behaviour by teaching parents how to articulate and consistently enforce their expectations. When such discipline is built on the foundation of strong family bonds, children are more likely to stay on the right track and correct themselves after mistakes.
Programme implementation fidelity
Programmes that have shown positive results with EBPs have taken great care to ensure programme fidelity. Fidelity is “the faithful implementation of programme components” (www.colorado.edu/cspv/blueprints/Fidelity.pdf). When programme components are developed based on theory, it is expected that these specific components will be responsible for the observed outcomes. Presumably, these are the “active ingredients” of the intervention. However, if the correct protocols are not in place, if dosage is lacking (i.e., not enough sessions), or if appropriate professionals are not involved, the programme's effectiveness can be compromised (Dane and Schneider, 1998). In fact, poor fidelity may even cause harm. For example, a study of FFT with juvenile offenders showed that young people who were treated by therapists rated as “not competent” had worse recidivism outcomes than young people who received no intervention at all (Barnoski, 2002). To avoid problems with programme fidelity, all of the EBPs reviewed here provide training, manuals, monitoring protocols and other materials to assist implementers.
Innovation in programming
It is clear that the authors of this paper – as well as the scientific community at large – place a high premium on programmes that have been shown to work. Given the social and personal value of preventing adolescent problem behaviours, we believe that we cannot afford to expend limited resources on programmes that have not demonstrated good outcomes. Thus, for widespread use in community settings, the most efficient investment is in programmes that are evidence based. For programmes that are theory based but as yet untested, efforts should be made to ensure implementation fidelity and strengthen evaluation evidence.
An emphasis on programmes with evidence, however, does not preclude the need for continued innovation, development and, of course, evaluation. For instance, self-administration holds great promise for recruiting and maintaining participation in family-based prevention programmes. Self-administration usually consists of providing materials (manuals, software, etc.) and brief staff contact (via phone or e-mail) to guide families through the programme. Such programmes offer greater flexibility and convenience for family members. Because time and logistic considerations (e.g. transportation, child care) have been consistently shown to be the most important barriers to family-based programme recruitment and retention (e.g. Spoth et al., 1996), self-administration offers a potential solution for many individuals. For example, an evaluation of Staying Connected with Your Teen found that 93 percent of families in the self-administered programme chose to pursue the programme compared to 78 percent in the site-based group programme (Haggerty et al., 2006). Thus, significantly fewer resources were spent on staffing, with far greater rates of exposure to the programme. The emergence of access to technology that includes access to video modelling of parenting skills holds promise for self-directed programmes. Yet it must be recognised that, given that these programmes offer flexibility because they are self-administered, they have the potential of diluting their impact.
As researchers, policy makers, and practitioners, we are all working towards a similar goal: to improve children's functioning, avoid problem behaviours, and increase well-being and productivity throughout the lifespan. Family-based prevention programmes are uniquely positioned to intervene early by targeting powerful risk and protective factors in the development of psychosocial problems. Today, due to the collaborative contributions of scientists and clinicians, we have a menu of options for effective family-based prevention programmes. By implementing them with fidelity in our respective communities, we have the unprecedented opportunity to improve the lives of many individuals.
We know what parenting and family programmes work; we know what parents can do to make sure their children have the best opportunities for success; and we know what works to get children back on track if and when they are derailed. It is important that we share this information with as many parents as possible and allow our communities to prosper with effective programmes that lead to strong families; successful, independent, caring children; and stronger communities.
Figure 1 The social development model.
Summary of policy and practice implications
See, for example, the US Substance Abuse and Mental Health Services Administration, US Department of Education, Office of Juvenile Justice and Delinquency Prevention, and Center for the Study and Prevention of Violence.
The authors are affiliated with the Social Development Research Group, which tested Staying Connected with Your Teen; however, none of the authors receive financial remuneration for endorsement of the programme or its utilisation by others. The authors have no affiliation with the other programmes reviewed here.
New Beginnings Program: http://asupreventionresearch.com/; Families Facing the Future: www.sdrg.org/fffsummary.asp
MST: http://mstservices.com/; FFT: www.fftinc.com/
Aos, S., Lieb, R., Mayfield, J., Miller, M., Pennucci, A. (2004), Benefits and Costs of Prevention and Early Intervention Programs for Youth, Washington State Institute for Public Policy, Olympia, WA, .
Aos, S., Lieb, R., Mayfield, J., Miller, M., Pennucci, A. (2012), Benefits and Costs of Prevention and Early Intervention Programs for Youth, Washington State Institute for Public Policy, Olympia, WA, .
Barnoski, R. (2002), Washington State's Implementation of Functional Family Therapy for Juvenile Offenders: Preliminary Findings, Washington State Institute for Public Policy, Olympia, WA, .
Brody, G.H., Murry, V.M., Chen, Y.-f., Kogan, S.M., Brown, A.C. (2006a), "Effects of family risk factors on dosage and efficacy of a family-centered preventive intervention for rural African Americans", Prevention Science, Vol. 7 No.3, pp.281-91.
Brody, G.H., Murry, V.M., Kogan, S.M., Gerrard, M., Gibbons, F.X., Molgaard, V., Brown, A.C., Anderson, T., Chen, Y.-f., Luo, Z., Wills, T.A. (2006b), "The Strong African American Families Program: a cluster-randomized prevention trial of long-term effects and a mediational model", Journal of Consulting and Clinical Psychology, Vol. 74 No.2, pp.356-66.
Brody, G.H., Murry, V.M., Gerrard, M., Gibbons, F.X., Molgaard, V., McNair, L., Brown, A.C., Wills, T.A., Spoth, R.L., Luo, Z., Chen, Y.-f., Neubaum-Carlan, E. (2004), "The Strong African American Families Program: translating research into prevention programming", Child Development, Vol. 75 No.3, pp.900-17.
Catalano, R.F., Hawkins, J.D. (1996), "The social development model: a theory of antisocial behavior", in Hawkins, J.D. (Eds),Delinquency and Crime: Current Theories, Cambridge University Press, New York, NY, pp.149-97.
Catalano, R.F., Haggerty, K.P., Hawkins, J.D., Elgin, J. (2011), "Prevention of substance use and substance use disorders: the role of risk and protective factors", in Kaminer, Y., Winters, K.C. (Eds),Clinical Manual of Adolescent Substance Abuse Treatment, American Psychiatric Publishing, Washington, DC, pp.25-63.
Catalano, R.F., Fagan, A.A., Gavin, L.E., Greenberg, M.T., Irwin, C.E., Ross, D.A., Shek, D.T.L. (2012), "Worldwide application of the prevention science research base in adolescent health", Lancet, Vol. 379 No.9826, pp.1653-64.
Dane, A.V., Schneider, B.H. (1998), "Program integrity in primary and early secondary prevention: are implementation effects out of control?", Clinical Psychology Review, Vol. 18 No.1, pp.23-45.
Declercq, E.R., Saakala, C., Corry, M.P., Applebaum, S. (2006), Listening to Mothers II: Report of the Second National US Survey of Women's Childbearing Experiences, Childbirth Connection, New York, NY, .
Dishion, T.J., Dodge, K.A. (2005), "Peer contagion in interventions for children and adolescents: moving towards an understanding of the ecology and dynamics of change", Journal of Abnormal Child Psychology, Vol. 33 No.3, pp.395-400.
Dishion, T.J., McCord, J., Poulin, F. (1999), "When interventions harm: peer groups and problem behaviour", American Psychologist, Vol. 54 No.9, pp.755-64.
Eckenrode, J., Campa, M., Luckey, D.W., Henderson, C.R. Jr, Cole, R., Kitzman, H., Anson, E., Sidora-Arcoleo, K., Powers, J., Olds, D. (2010), "Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial", Archives of Pediatrics and Adolescent Medicine, Vol. 164 No.1, pp.9-15.
Fixsen, D.L., Naoom, S.F., Blase, K.A., Friedman, R.M. (2005), Implementation Research: A Synthesis of the Literature, University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network, Tampa, FL, .
Haggerty, K.P., Kosterman, R. (2012), "Helping parents prevent problem behavior", Better: Evidence-Based Education, Vol. 4 No.3, pp.22-3.
Haggerty, K.P., Skinner, M.L., MacKenzie, E.P., Catalano, R.F. (2007), "A randomized trial of Parents Who Care: effects on key outcomes at 24-month follow-up", Prevention Science, Vol. 8 No.4, pp.249-60.
Haggerty, K.P., MacKenzie, E.P., Skinner, M.L., Harachi, T.W., Catalano, R.F. (2006), "Participation in ‘Parents Who Care’: predicting program initiation and exposure in two different program formats", Journal of Primary Prevention, Vol. 27 No.1, pp.47-65.
Hawkins, J.D., Catalano, R.F., Miller, J.Y. (1992), "Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance-abuse prevention", Psychological Bulletin, Vol. 112 No.1, pp.64-105.
Heinrichs, N., Kliem, S., Hahlweg, K. (2013), "Four-year follow-up of a randomized controlled trial of Triple P group for parent and child outcomes", Prevention Science, doi: 10.1007/s11121-012-0358-2, .
Herrenkohl, T.I., Hemphill, S.A., Mason, W.A., Toumbourou, J.W., Catalano, R.F. (2012), "Predictors and responses to the growth in physical violence during adolescence: a comparison of students in Washington State and Victoria, Australia", American Journal of Orthopsychiatry, Vol. 82 No.1, pp.41-9.
Lee, S., Aos, S., Drake, E., Pennucci, A., Miller, M., Anderson, L. (2012), Return on Investment: Evidence-Based Options to Improve Statewide Outcomes, April 2012 (Document No. 12-04-1201), Washington State Institute for Public Policy, Olympia, WA, .
Little, M., Berry, V., Morpeth, L., Blower, S., Axford, N., Taylor, R., Bywater, T., Lehtonen, M., Tobin, K. (2012), "The impact of three evidence-based programmes delivered in public systems in Birmingham, UK", International Journal of Conflict and Violence, Vol. 6 No.2, pp.260-72.
Malti, T., Ribeaud, D., Eisner, M.P. (2011), "The effectiveness of two universal preventive interventions in reducing children's externalizing behaviour: a cluster randomized controlled trial", Journal of Clinical Child and Adolescent Psychology, Vol. 40 No.5, pp.677-92.
Morawska, A., Sanders, M.R. (2006), "Self-administered behavioural family intervention for parents of toddlers: effectiveness and dissemination", Behaviour Research and Therapy, Vol. 44 No.12, pp.1839-48.
Olds, D., Henderson, C.R. Jr, Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., Pettitt, L., Sidora, K., Morris, P., Powers, J. (1998), "Long-term effects of nurse home visitation on children's criminal and antisocial behaviour: 15-year follow-up of a randomized controlled trial", JAMA, Vol. 280 No.14, pp.1238-44.
Olds, D.L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D.W., Henderson, C.R. Jr, Hanks, C., Bondy, J., Holmberg, J. (2004), "Effects of nurse home-visiting on maternal life course and child development: age 6 follow-up results of a randomized trial", Pediatrics, Vol. 114 No.6, pp.1550-9.
Plant, K.M., Sanders, M.R. (2007), "Reducing problem behaviour during care-giving in families of preschool-aged children with developmental disabilities", Research in Developmental Disabilities, Vol. 28 No.4, pp.362-85.
Pollard, J.A. (1998), Final Report on NIDA SBIR Grant #DA07435, Risk Focused Family Training for Drug Use Intervention, Developmental Research and Programs, Seattle, WA, .
Prinz, R., Sanders, M., Shapiro, C., Whitaker, D., Lutzker, J. (2009), "Population-based prevention of child maltreatment: the US Triple P System Population Trial", Prevention Science, Vol. 10 No.1, pp.1-12.
Rehm, J., Mathers, C., Popova, S., Thavorncharoensap, M., Teerawattananon, Y., Patra, J. (2009), "Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders", Lancet, Vol. 373 No.9682, pp.2223-33.
Reid, M.J., Webster-Stratton, C., Beauchaine, T.P. (2001), "Parent training in Head Start: a comparison of program response among African American, Asian American, Caucasian, and Hispanic mothers", Prevention Science, Vol. 2 No.4, pp.209-27.
Sanders, M.R. (1999), "Triple P-Positive Parenting Program: towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children", Clinical Child & Family Psychology Review, Vol. 2 No.2, pp.71-90.
Sanders, M.R., Turner, K.M.T., Markie-Dadds, C. (2002), "The development and dissemination of the Triple P – Positive Parenting Program: a multilevel, evidence-based system of parenting and family support", Prevention Science, Vol. 3 No.3, pp.173-89.
Sanders, M.R., Pidgeon, A.M., Gravestock, F., Connors, M.D., Brown, S., Young, R.W. (2004), "Does parental attributional retraining and anger management enhance the effects of the Triple P-Positive Parenting Program with parents at risk of child maltreatment?", Behaviour Therapy, Vol. 35 No.3, pp.513-35.
Sanders, M.R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S., Bidwell, K. (2008), "Every Family: a population approach to reducing behavioral and emotional problems in children making the transition to school", Journal of Primary Prevention, Vol. 29 No.3, pp.197-222.
Skinner, M.L., Haggerty, K.P., Catalano, R.F. (2009), "Parental and peer influences on teen smoking: are White and Black families different?", Nicotine & Tobacco Research, Vol. 11 No.5, pp.558-63.
Spoth, R., Randall, G.K., Shin, C. (2008), "Increasing school success through partnership-based family competency training: experimental study of long-term outcomes", School Psychology Quarterly, Vol. 23 No.1, pp.70-89.
Spoth, R., Redmond, C., Hockaday, C., Shin, C.Y. (1996), "Barriers to participation in family skills preventive interventions and their evaluations: a replication and extension", Family Relations: Journal of Applied Family and Child Studies, Vol. 45 No.3, pp.247-54.
Spoth, R., Trudeau, L., Guyll, M., Shin, C., Redmond, C. (2009), "Universal intervention effects on substance use among young adults mediated by delayed adolescent substance initiation", Journal of Consulting and Clinical Psychology, Vol. 77 No.4, pp.620-32.
Spoth, R.L., Guyll, M., Day, S.X. (2002), "Universal family-focused interventions in alcohol-use disorder prevention: cost-effectiveness and cost-benefit analyses of two interventions", Journal of Studies on Alcohol, Vol. 63 No.2, pp.219-28.
Spoth, R.L., Redmond, C., Shin, C. (2000), "Reducing adolescents’ aggressive and hostile behaviours: randomized trial effects of a brief family intervention four years past baseline", Archives of Pediatrics and Adolescent Medicine, Vol. 154 No.12, pp.1248-57.
Spoth, R.L., Redmond, C., Shin, C. (2001), "Randomized trial of brief family interventions for general populations: adolescent substance use outcomes 4 years following baseline", Journal of Consulting and Clinical Psychology, Vol. 69 No.4, pp.627-42.
Stone, A.L., Becker, L.G., Huber, A.M., Catalano, R.F. (2012), "Risk and protective factors of substance use and problem use in emerging adulthood", Addictive Behaviours, Vol. 37 No.8, pp.747-55.
Turner, K.M.T., Sanders, M.R. (2006), "Help when it's needed first: a controlled evaluation of brief, preventive behavioral family intervention in a primary care setting", Behavior Therapy, Vol. 37 No.2, pp.131-42.
Webster-Stratton, C. (1990), "Long-term follow-up of families with young conduct problem children: from preschool to grade school", Journal of Clinical Child Psychology, Vol. 19 No.2, pp.144-9.
Webster-Stratton, C., Hammond, M. (1997), "Treating children with early-onset conduct problems: a comparison of child and parent training interventions", Journal of Consulting and Clinical Psychology, Vol. 65 No.1, pp.93-109.
Webster-Stratton, C., Reid, M.J., Hammond, M. (2001), "Preventing conduct problems, promoting social competence: a parent and teacher training partnership in Head Start", Journal of Clinical Child Psychology, Vol. 30 No.3, pp.283-302.
Webster-Stratton, C., Rinaldi, J., Reid, J.M. (2011), "Long-term outcomes of Incredible Years parenting program: predictors of adolescent adjustment", Child and Adolescent Mental Health, Vol. 16 No.1, pp.38-46.
Wilson, P., Rush, R., Hussey, S., Puckering, C., Sim, F., Allely, C.S., Doku, P., McConnachie, A., Gillberg, C. (2012), "How evidence-based is an ‘evidence-based parenting program’? A PRISMA systematic review and meta-analysis of Triple P", BMC Medicine, available at: www.biomedcentral.com/content/pdf/1741-7015-10-130.pdf, Vol. 10 pp.130pp.
Herrenkohl, T.I., Lee, J.O., Hawkins, J.D. (2012), "Risk versus direct protective factors and youth violence: Seattle Social Development Project", American Journal of Preventive Medicine. Special issue: Protective Factors for Youth Violence Perpetration: Issues, Evidence, and Public Health Implications, Vol. 43 No.2 (Supplement 1), pp.41-56.
Nurse-Family Partnership: www.nursefamilypartnership.org
The Incredible Years: www.incredibleyears.com/
Triple P: www.triplep.net/
Strengthening Families 10-14: www.extension.iastate.edu/sfp/
Staying Connected with Your Teen:
About the authors
Dr Kevin P. Haggerty, MSW, PhD, is Associate Director of the Social Development Research Group and Director of Research in the School of Social Work, University of Washington. He specialises in conducting research on preventive interventions focused on families, schools and communities. A primary focus of his research is to examine how we can support environments to promote well-being. Dr Kevin P. Haggerty is the corresponding author and can be contacted at: email@example.com
Anne McGlynn-Wright, BA, is in the MA program in the Sociology Department, University of Washington and has worked on multiple projects with the Social Development Research Group since 2006. Her current work focuses primarily on the impact of race and gender on a variety of outcomes – including adolescent criminal justice involvement.
Dr Tali Klima, PhD, received her doctorate in clinical psychology at the University of California, Los Angeles. She was a Researcher at the Washington State Institute for Public Policy, advising the state legislature on investments in social programs, and recently joined the Social Development Research Group, School of Social Work, at the University of Washington. Her research interests include prevention of child and adolescent emotional and behavioural problems, and public policies intended to prevent and treat such problems.