Parental substance and alcohol abuse: publications guide

Below are some citations and abstracts from publications from the library’s database:

Arria, A. M., Mericle, A. A., Meyers, K., & Winters, K. C. (2012). Parental substance use impairment, parenting and substance use disorder risk. Journal of Substance Abuse Treatment, 43(1), 114-122.

Using data from a nationally representative sample, this study investigated substance use disorder (SUD) among respondents with ages 15–54 years as a function of their parents’ substance-related impairment and parents’ treatment history. In addition, associations among maternal and paternal substance-related impairment, specific parenting behaviors, and risk for SUD in the proband were examined. As expected, parental substance-related impairment was associated with SUD. Paternal treatment history was associated with a decreased risk for SUD in the proband but did not appear to be associated with positive parenting practices. Results of post hoc analyses suggested that parenting behaviors might operate differently to influence SUD risk in children where parents are affected by substance use problems compared with unaffected families. Future research is warranted to better understand the complex relationships among parental substance use, treatment, parenting behaviors, and SUD risk in offspring. Opportunities might exist within treatment settings to improve parenting skills.

Berg, L., Bäck, K., Vinnerljung, B., & Hjern, A. (2016). Parental alcohol‐related disorders and school performance in 16‐year‐olds—a Swedish national cohort study. Addiction, 111(10), 1795-1803.:

To study the links between parental alcohol‐related disorders and offspring school performance and, specifically, whether associations vary by gender of parent or child and whether associations are mediated by other adverse psychosocial circumstances commonly appearing together with parental alcohol problems, such as parental mental health problems or criminal behaviour. Register study in a national cohort. Sweden. A total of 740 618 individuals born in Sweden in 1990–96. Parental hospital admissions for alcohol‐related disorders and school performance in their offspring, in the final year of compulsory school at age 15–16 years was analysed in relation to socio‐demographic confounders and psychosocial covariates, using linear and logistic regressions. Both mothers’ and fathers’ alcohol‐related hospital admissions were associated with lower Z‐scores of grades and national mathematics tests scores. After adjustment for parental education and socio‐demographic confounders, beta‐coefficients of Z‐scores of grades were –0.42 [95% confidence interval (CI) = –0.45, –0.39] and –0.42 (95% CI = –0.43, –0.40), and beta‐coefficients of mathematics tests scores were –0.36 (95% CI = –0.39, –0.33) and –0.31 (95% CI = –0.33, –0.29), for mothers’ and fathers’ alcohol‐related disorders, respectively. Adjusted odds ratios (ORs) for not being eligible for secondary school were 1.99 (95% CI = 1.84–2.15) and 2.04 (95% CI = 1.95–2.15) for mothers’ and fathers’ alcohol‐related disorders, respectively. Adjusting the analyses for psychosocial factors in the family almost eradicated the statistical effects of parental alcohol‐related disorders on offspring school performance to beta‐coefficients of 0.03 to –0.10 and ORs of 0.89–1.15. The effect of a mother’s alcohol‐related hospital admission on school performance was stronger in girls than in boys, whereas no gender differences were seen for a father’s alcohol‐related hospital admission. In Sweden, alcohol‐related disorders in both mothers and fathers are associated with lower school performance in their children at age 15–16 years, with most of the statistical effects being attributed to psychosocial circumstances of the family, such as parental psychiatric disorders, drug use and criminality and receipt of social or child welfare interventions.

Capaldi, D. M., Tiberio, S. S., Kerr, D. C., & Pears, K. C. (2016). The relationships of parental alcohol versus tobacco and marijuana use with early adolescent onset of alcohol use. Journal of Studies on Alcohol and Drugs, 77(1), 95-103.

Objective:This study examined whether the use of tobacco and marijuana by fathers or mothers predicted onset of alcohol use in their offspring over and above effects of parental alcohol use.Method:The present study included 146 children of 93 parents (90 fathers and 85 mothers). The fathers were originally recruited as boys to the Oregon Youth Study, a study of community, familial, and individual risk factors for delinquency.Results:Only mothers’ but not fathers’ alcohol use was associated with children’s age at onset. Children’s age at onset was predicted by mothers’ tobacco use and by the interaction of fathers’ marijuana use and alcohol use. These effects were observed when controlling for parental education, child’s gender, and also child’s antisocial behavior—a general developmental risk factor for substance use onset in adolescence.Conclusions:Mothers’ substance use played a major role in childhood onset of alcohol use, yet the role of maternal substance use as a risk factor for their children has previously received less attention than the role of paternal substance use. Also, findings imply that it may be important to identify children of polysubstance-using parents for targeted prevention programs.

Chuang, E., Wells, R., Bellettiere, J., & Cross, T. P. (2013). Identifying the substance abuse treatment needs of caregivers involved with child welfare. Journal of Substance Abuse Treatment, 45(1), 118-125.

Parental substance use significantly increases risk of child maltreatment, but is often under-identified by child protective services. This study examined how agency use of standardized substance use assessments and child welfare investigative caseworker education, experience, and caseload affected caseworkers’ identification of parental substance abuse treatment needs. Data are from a national probability sample of permanent, primary caregivers involved with child protective services whose children initially remained at home and whose confidential responses on two validated instruments indicated harmful substance use or dependence. Investigative caseworkers reported use of a formal assessment in over two thirds of cases in which substance use was accurately identified. However, weighted logistic regression indicated that agency provision of standardized assessment instruments was not associated with caseworker identification of caregiver needs. Caseworkers were also less likely to identify substance abuse when their caseloads were high and when caregivers were fathers. Implications for agency practice are discussed.

Douglas-Siegel, J. A., & Ryan, J. P. (2013). The effect of recovery coaches for substance-involved mothers in child welfare: Impact on juvenile delinquency. Journal of Substance Abuse Treatment, 45(4), 381-387.

Despite the documented relationship between parental substance abuse and youth delinquency, the effects of parental interventions on delinquency outcomes are unknown. Such interventions are particularly vital for families in the child welfare system who are at heightened risk for both parental substance involvement and youth delinquency. The current study tested the impact of intensive case management in the form of a recovery coach for substance-involved mothers on youth delinquency outcomes among a randomized sample of 453 families involved in a Title IV-E experimental waiver demonstration in Cook County, Illinois. In comparison to control group participants, families enrolled in the Alcohol and Other Drug Abuse (AODA) waiver demonstration experienced a lower rate of juvenile arrest, net of factors such as demographic characteristics, primary drug of choice, and time spent in substitute care. Findings support efforts to curb delinquency among child-welfare involved youth by providing recovery coaches to their substance abusing or dependent parents.

Handley, E. D., & Chassin, L. (2013). Alcohol-specific parenting as a mechanism of parental drinking and alcohol use disorder risk on adolescent alcohol use onset. Journal of Studies on Alcohol and Drugs, 74(5), 684-693.

Objective:The primary aim of the current study was to examine three dimensions of alcohol-specific parenting (anti-alcohol parenting strategies, parental legitimacy in regulating adolescent drinking, and parental disclosure of negative alcohol experiences) as mechanisms in the prospective relations between parental drinking and alcohol use disorder (recovered, current, and never diagnosed) and adolescent alcohol use initiation.Method:Participants were from an ongoing longitudinal study of the intergenerational transmission of alcoholism. Structural equation modeling was used to test a maternal model (n= 268 adolescents and their mothers) and a paternal model (n= 204 adolescents and their fathers) of alcohol-specific parenting.Results:Results indicated that higher levels of drinking among mothers and current alcohol use disorder among fathers were related to more frequent parental disclosure of personal negative experiences with alcohol. Maternal disclosure of negative alcohol experiences mediated the effect of maternal drinking on adolescent onset of alcohol use such that more disclosure predicted a greater likelihood of adolescent drinking initiation at follow-up over and above general parenting. In addition, currently alcoholic mothers were perceived as having less legitimate authority to regulate adolescent drinking, and low levels of legitimacy among fathers was predictive of drinking onset among adolescents.Conclusions:Alcohol-specific parenting is a distinct and influential predictor of adolescent alcohol use initiation that is partially shaped by parents’ own drinking experiences. Moreover, parental conversations about their own personal experiences with alcohol may not represent a form of parent–child communication about drinking that deters adolescent drinking.

Hedges, K. E. (2012). A family affair: contextual accounts from addicted youth growing up in substance using families. Journal of Youth Studies, 15(3), 257-272.

There are currently over 8 million children in the USA living in households where at least one parent is dependent on or abusing substances. Research has shown a link between parental substance use and children initiating substance use. This article uses qualitative data to give a contextual understanding of the experience of growing up in substance using homes. Results found that the habitusof homes was so immersed in substances that children’s initiation into substance use was expected and became a ‘rite of passage’ into full acceptance as an adult member of the family. Furthermore, in many cases youth described a role reversal between child and parent roles or parentification in the family. The conclusion calls for early identification in treatment of youth who use substances with family members to target new norms and behaviors for the entire family posttreatment and to enhance successful recovery when returning to the family.

McCutcheon, V. V., Agrawal, A., Kuo, S. I. C., Su, J., Dick, D. M., Meyers, J. L., … & Schuckit, M. A. (2018). Associations of parental alcohol use disorders and parental separation with offspring initiation of alcohol, cigarette and cannabis use and sexual debut in high‐risk families. Addiction, 113(2), 336-345.

Parental alcohol use disorders (AUDs) and parental separation are associated with increased risk for early use of alcohol in offspring, but whether they increase risks for early use of other substances and for early sexual debut is under‐studied. We focused on associations of parental AUDs and parental separation with substance initiation and sexual debut to (1) test the strength of the associations of parental AUDs and parental separation with time to initiation (age in years) of alcohol, tobacco and cannabis use and sexual debut and (2) compare the strength of association of parental AUD and parental separation with initiation. Prospective adolescent and young adult cohort of a high‐risk family study, the Collaborative Study on the Genetics of Alcoholism (COGA). Six sites in the United States. A total of 3257 offspring (aged 14–33 years) first assessed in 2004 and sought for interview approximately every 2 years thereafter; 1945 (59.7%) offspring had a parent with an AUD. Diagnostic interview data on offspring substance use and sexual debut were based on first report of these experiences. Parental life‐time AUD was based on their own self‐report when parents were interviewed (1991–2005) for most parents, or on offspring and other family member reports for parents who were not interviewed. Parental separation was based on offspring reports of not living with both biological parents most of the time between ages 12 and 17 years. Parental AUDs were associated with increased hazards for all outcomes, with cumulative hazards ranging from 1.19 to 2.71. Parental separation was also an independent and consistent predictor of early substance use and sexual debut, with hazards ranging from 1.19 to 2.34. The strength of association of parental separation with substance initiation was equal to that of having two AUD‐affected parents, and its association with sexual debut was stronger than the association of parental AUD in one or both parents. Parental alcohol use disorders (AUDs) and parental separation are independent and consistent predictors of increased risk for early alcohol, tobacco and cannabis use and sexual debut in offspring from families with a high risk of parental AUDs.

Meyers, J. L., Shmulewitz, D., Elliott, J. C., Thompson, R. G., Aharonovich, E., Spivak, B., … & Hasin, D. S. (2014). Parental alcohol history differentially predicts offspring disorders in distinct subgroups in Israel. Journal of Studies on Alcohol and Drugs, 75(5), 859-869.

Objective:The association between alcoholism in parents and related disorders in their offspring is well established in cultures with intermediate/high alcohol consumption, but not in those with low consumption, such as Israel. This study investigated differences in parental transmission of alcohol problems and related psychopathology between immigrants from the former Soviet Union (FSU) to Israel and other Israelis—two Israeli subgroups with differing alcohol consumption behaviors and social norms.Method:A total of 1,347 adults from a household sample were interviewed. Regression analyses were used to examine associations between parental alcohol problems and participant disorders: alcohol, nicotine, and cannabis use disorders (AUD, NUD, CUD); antisocial personality disorder (ASPD); major depressive disorder (MDD); and posttraumatic stress disorder (PTSD). We also examined the associations of parental alcohol problems with participant disorders characterized with two latent factors: externalizing (EXT: AUD, NUD, CUD, ASPD) and internalizing (INT: MDD, PTSD). Differential parental transmission of alcohol problems in FSU (n= 315) and non-FSU (n= 1,032) Israelis was examined with statistical interaction.Results:Among emigrants from the FSU, parental alcohol problems predicted AUD, NUD, CUD, ASPD, PTSD, EXT, and INT (mean ratios = 1.38–4.83). In non-FSU Israelis, parental alcohol problems predicted only ASPD and PTSD (mean ratios = 1.08–4.09). Significant interactions were observed for AUD, CUD, PTSD, and EXT; each relationship was stronger in FSU Israelis and null (AUD, CUD, EXT) or less robust (PTSD) in other Israelis.Conclusions:Parental alcohol problems were related to substance use and psychiatric disorders differently in FSU and other Israelis, two groups with different alcohol consumption levels and drinking norms. We propose that, in social contexts that vary in the degree to which they constrain alcohol behavior, underlying genetic predispositions may manifest as different disorders.

Moreland, A. D., & McRae-Clark, A. (2018). Parenting outcomes of parenting interventions in integrated substance-use treatment programs: A systematic review. Journal of Substance Abuse Treatment, 89, 52-59.:

The high prevalence of women in substance use treatment programs with children, and the co-occurring negative physical and mental health outcomes associated with substance use, led to the development of integrated substance use treatment programs that target a range of women-specific issues. Integrated programs typically offer some type of parenting component, although the level of parenting services varies widely. Existing reviews have found positive child and parent outcomes following integrated treatment programs in general, although studies were not selected on the basis of whether they included parenting interventions. Due to the large percentage of substance using parents and research that parenting interventions contribute to decreased maternal substance use, this critical review examines parental outcomes of published studies on integrated programs that specifically include a parenting intervention component, as well as moderators of parenting and parental substance use/relapse. Across the 15 studies identified, this systematic review primarily focused on 8 parenting outcomes, including program retention, substance use, parenting stress, psychosocial adjustment, depression, child abuse potential, parenting behaviors, and parent-child interaction; as well as 5 additional secondary outcomes. The review discusses results on each of these outcomes, as well as retention rates across the parenting interventions.

Rossow, I., Felix, L., Keating, P., & McCambridge, J. (2016). Parental drinking and adverse outcomes in children: A scoping review of cohort studies. Drug and Alcohol Review, 35(4), 397-405.

There is a growing interest in measuring alcohol’s harms to people other than the drinker themselves. ‘Children of alcoholics’ and foetal alcohol spectrum disorder have received widespread attention. Less is known about how children are affected by post‐natal exposure to parental drinking other than alcohol abuse/dependence. In this scoping review, we aim to assemble and map existing evidence from cohort studies on the consequences of parental alcohol use for children, and to identify limitations and gaps in this literature. Systematic review methods were used. Electronic databases were searched (1980 to October 2013) and a total of 3215 abstracts were screened, 326 full text papers examined and 99 eligible for inclusion according to selection criteria including separation of exposure and outcome measurement in time and report of a quantitative effect size. The main finding is the large literature available. Adolescent drinking behaviour was the most common outcome measure and outcomes other than substance use were rarely analysed. In almost two of every three published associations, parental drinking was found to be statistically significantly associated with a child harm outcome measure. Several limitations in the literature are noted regarding its potential to address a possible causal role of parental drinking in children’s adverse outcomes. This study identifies targets for further study and provides a platform for more targeted analytic investigations which ascertain risk of bias, and which are capable of considering the appropriateness of causal inferences for the observed associations.

Thompson Jr, R. G., Alonzo, D., Hu, M. C., & Hasin, D. S. (2017). The influences of parental divorce and maternal‐versus‐paternal alcohol abuse on offspring lifetime suicide attempt. Drug and Alcohol Review, 36(3), 408-414

Research indicates that parental divorce and parental alcohol abuse independently increase likelihood of offspring lifetime suicide attempt. However, when experienced together, only parental alcohol abuse significantly increased odds of suicide attempt. It is unclear to what extent differences in the effect of maternal versus paternal alcohol use exist on adult offspring lifetime suicide attempt risk. This study examined the influences of parental divorce and maternal–paternal histories of alcohol problems on adult offspring lifetime suicide attempt. The sample consisted of participants from the 2001–2002 National Epidemiological Survey on Alcohol and Related Conditions. The simultaneous effect of childhood or adolescent parental divorce and maternal and paternal history of alcohol problems on offspring lifetime suicide attempt was estimated using a logistic regression model with an interaction term for demographics and parental history of other emotional and behavioural problems. Parental divorce and maternal–paternal alcohol problems interacted to differentially influence the likelihood of offspring lifetime suicide attempt. Experiencing parental divorce and either maternal or paternal alcohol problems nearly doubled the likelihood of suicide attempt. Divorce and history of alcohol problems for both parents tripled the likelihood. Individuals who experienced parental divorce as children or adolescents and who have a parent who abuses alcohol are at elevated risk for lifetime suicide attempt. These problem areas should become a routine part of assessment to better identify those at risk for lifetime suicide attempt and to implement early and targeted intervention to decrease such risk. 4.

Waldron, M., Bucholz, K. K., Lynskey, M. T., Madden, P. A., & Heath, A. C. (2013). Alcoholism and timing of separation in parents: Findings in a midwestern birth cohort. Journal of Studies on Alcohol and Drugs, 74(2), 337-348.

Objective:We examined history of alcoholism and occurrence and timing of separation in parents of a female twin cohort.Method:Parental separation (never-together; never-married cohabitants who separated; married who separated) was predicted from maternal and paternal alcoholism in 326 African ancestry (AA) and 1,849 European/other ancestry (EA) families. Broad (single-informant, reported in abstract) and narrow (self-report or two-informant) measures of alcoholism were compared.Results:Parental separation was more common in families with parental alcoholism: By the time twins were 18 years of age, parents had separated in only 24% of EA families in which neither parent was alcoholic, contrasted with 58% of families in which only the father was (father-only), 61% of families in which only the mother was (mother-only), and 75% in which both parents were alcoholic (two-parent); corresponding AA percentages were 59%, 71%, 82%, and 86%, respectively. Maternal alcoholism was more common in EA never-together couples (mother-only: odds ratio [OR] = 5.95; two parent: OR = 3.69). In ever-together couples, alcoholism in either parent predicted elevated risk of separation, with half of EA relationships ending in separation within 12 years of twins’ birth for father-only families, 9 years for mother-only families, and 4 years for both parents alcoholic; corresponding median survival times for AA couples were 9, 4, and 2 years, respectively. EA maternal alcoholism was especially strongly associated with separation in the early postnatal years (mother-only: birth—5 years, hazard ratio [HR] = 4.43; 6 years on, HR = 2.52; two-parent: HRs = 5.76, 3.68, respectively).Conclusions:Parental separation is a childhood environmental exposure that is more common in children of alcoholics, with timing of separation highly dependent on alcoholic parent gender.

Interventions and treatments for adolescent substance abuse: Publications guide

Annotated bibliography

Below are some citations and abstracts from publications about interventions and treatment for adolescent substance abuse.

Allen, M. L., Garcia-Huidobro, D., Porta, C., Curran, D., Patel, R., Miller, J., & Borowsky, I. (2016). Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic Review. Pediatrics, 138(2), e20154425.

Context: Parenting interventions may prevent adolescent substance use; however, questions remain regarding the effectiveness of interventions across substances and delivery qualities contributing to successful intervention outcomes.

Objective: To describe the effectiveness of parent-focused interventions in reducing or preventing adolescent tobacco, alcohol, and illicit substance use and to identify optimal intervention targeted participants, dosage, settings, and delivery methods.

Data sources: PubMed, PsycINFO, ERIC, and CINAHL.

Study selection: Randomized controlled trials reporting adolescent substance use outcomes, focusing on imparting parenting knowledge, skills, practices, or behaviors.

Data extraction Trained researchers extracted data from each article using a standardized, prepiloted form. Because of study heterogeneity, a qualitative technique known as harvest plots was used to summarize findings.

Results: A total of 42 studies represented by 66 articles met inclusion criteria. Results indicate that parenting interventions are effective at preventing and decreasing adolescent tobacco, alcohol, and illicit substance use over the short and long term. The majority of effective interventions required ≤12 contact hours and were implemented through in-person sessions including parents and youth. Evidence for computer-based delivery was strong only for alcohol use prevention. Few interventions were delivered outside of school or home settings.

Limitations: Overall risk of bias is high.

Conclusions: This review suggests that relatively low-intensity group parenting interventions are effective at reducing or preventing adolescent substance use and that protection may persist for multiple years. There is a need for additional evidence in clinical and other community settings using an expanded set of delivery methods.

Becker, S., Hernandez, L., Spirito, A., & Conrad, S. (2017). Technology-assisted intervention for parents of adolescents in residential substance use treatment: protocol of an open trial and pilot randomized trial. Addiction Science & Clinical Practice, 12(1), 1-13.

Adolescents in residential substance use disorder (SUD) treatment have poor outcomes post-discharge, with follow-up studies suggesting that most adolescents relapse within 90 days. Parenting practices directly influence adolescent SUD outcomes, but parents of adolescents with SUDs are difficult to engage in traditional behavioral treatments. The current study adapts and evaluates a technology-assisted intervention for parents of adolescents in residential SUD treatment. Based on pilot qualitative data with parents, adolescents, and residential staff, we augment an existing computerized intervention (Parenting Wisely; PW) with four in-person coaching sessions, personalized text messages, and an expert-moderated online parent message board. We hypothesize that parents will find enhanced PW (PW+) both feasible and acceptable, and that adolescents whose parents receive PW+ will have better post-discharge outcomes than adolescents who receive standard care (SC) only. A two phase approach is used to adapt and evaluate PW+. Phase 1 consists of an open trial with 10 parents of adolescents (age 12–17) in residential SUD treatment. Post-discharge qualitative and quantitative data from parents and adolescents will support PW+ refinement. Phase 2 is a randomized pilot trial with 60 parents testing the effectiveness of adding PW+ to SC. Adolescents and parents will complete assessments at baseline, 6-, 12-, and 24-weeks post-discharge. Primary outcomes will be measures of feasibility and acceptability. Secondary outcomes will include adolescent substance use, truancy, high-risk sexual behavior, and criminal involvement. Two parenting processes (monitoring and communication) are examined as potential mediators of change. This study will adapt and evaluate a technology-assisted parenting intervention as a means of improving adolescent outcomes following residential SUD treatment. Results have the potential to advance the field by: addressing a high-risk population, improving parental engagement; targeting parenting practices (putative mediators of change) that have been linked to adolescent outcomes; and developing a highly disseminable approach.

Black, J. J., & Chung, T. (2014). Mechanisms of change in adolescent substance use treatment: How does treatment work?. Substance Abuse, 35(4), 344-351.

Background: Adolescent substance use treatment outcome research generally shows small to moderate effects in reducing substance use, with no specific “brand” of treatment emerging as clearly superior to any other, and treatment gains that fade over time. The relatively weak and temporary effects of treatment call for improving the potency and durability of intervention effects. In response to this call, this critical narrative review summarizes research on mechanisms of change for both adults and adolescents in substance use treatment, with a particular focus on reviewing what is known regarding “how” adolescent substance use treatment works.

Methods: A comprehensive review of the adolescent (ages 11–18) substance use treatment literature was conducted to identify empirical studies that examined mediators of intervention effects. Relevant databases (e.g., PsychINFO, Medline) were searched using key words (e.g., “mediator”), and relevant articles from reference sections of identified studies and review papers were considered.

Results: Studies of mechanisms of psychotherapy change are rare in the adult, and particularly adolescent, substance use treatment outcome literature. The four adolescent studies that examined substance use treatment mechanisms found that positive social support, motivation to abstain, and positive parenting behaviors mediated treatment effects. To date, research has not supported therapy-specific mechanisms of change, finding instead that “common” processes of change largely account for improvements in outcome across distinct “brands” of treatment.

Conclusions: The lack of empirical support for treatment-specific mechanisms of change may be due to the need for greater precision in defining and measuring treatment-specific causal chains. Future directions include neuroscience approaches to examining changes in brain functioning that are associated with treatment response and recovery and examining mechanisms in adaptive treatment designs, which can accommodate individual differences in targets for intervention and response to treatment.

Das, J. K., Salam, R. A., Arshad, A., Finkelstein, Y., & Bhutta, Z. A. (2016). Interventions for adolescent substance abuse: An overview of systematic reviews. Journal of Adolescent Health, 59(4), S61-S75.

Many unhealthy behaviors often begin during adolescence and represent major public health challenges. Substance abuse has a major impact on individuals, families, and communities, as its effects are cumulative, contributing to costly social, physical, and mental health problems. We conducted an overview of systematic reviews to evaluate the effectiveness of interventions to prevent substance abuse among adolescents. We report findings from a total of 46 systematic reviews focusing on interventions for smoking/tobacco use, alcohol use, drug use, and combined substance abuse. Our overview findings suggest that among smoking/tobacco interventions, school-based prevention programs and family-based intensive interventions typically addressing family functioning are effective in reducing smoking. Mass media campaigns are also effective given that these were of reasonable intensity over extensive periods of time. Among interventions for alcohol use, school-based alcohol prevention interventions have been associated with reduced frequency of drinking, while family-based interventions have a small but persistent effect on alcohol misuse among adolescents. For drug abuse, school-based interventions based on a combination of social competence and social influence approaches have shown protective effects against drugs and cannabis use. Among the interventions targeting combined substance abuse, school-based primary prevention programs are effective. Evidence from Internet-based interventions, policy initiatives, and incentives appears to be mixed and needs further research. Future research should focus on evaluating the effectiveness of specific interventions components with standardized intervention and outcome measures. Various delivery platforms, including digital platforms and policy initiative, have the potential to improve substance abuse outcomes among adolescents; however, these require further research.

Goorden, M., Schawo, S., Bouwmans-Frijters, C., van der Schee, E., Hendriks, V., & Hakkaart-van Roijen, L. (2016). The cost-effectiveness of family/family-based therapy for treatment of externalizing disorders, substance use disorders and delinquency: a systematic review. BMC Psychiatry, 16(1), 1-22.

Family therapy and family-based treatment has been commonly applied in children and adolescents in mental health care and has been proven to be effective. There is an increased interest in economic evaluations of these, often expensive, interventions. The aim of this systematic review is to summarize and evaluate the evidence on cost-effectiveness of family/family-based therapy for externalizing disorders, substance use disorders and delinquency. A systematic literature search was performed in PubMed, Education Resource information Centre (ERIC), Psycinfo and Cochrane reviews including studies conducted after 1990 and before the first of August of 2013. Full economic evaluations investigating family/family-based interventions for adolescents between 10 and 20 years treated for substance use disorders, delinquency or externalizing disorders were included. Seven hundred thirty-one articles met the search criteria and 51 studies were initially selected. The final selection resulted in the inclusion of 11 studies. The quality of these studies was assessed. Within the identified studies, there was great variation in the specific type of family/family-based interventions and disorders. According to the outcomes of the checklists, the overall quality of the economic evaluations was low. Results varied by study. Due to the variations in setting, design and outcome it was not feasible to pool results using a meta-analysis. The quality of the identified economic evaluations of family/family-based therapy for treatment of externalizing disorders, adolescent substance use disorders and delinquency was insufficient to determine the cost-effectiveness. Although commonly applied, family/family-based therapy is costly and more research of higher quality is needed.

Liddle, H. A., Dakof, G. A., Rowe, C. L., Henderson, C., Greenbaum, P., Wang, W., & Alberga, L. (2018). Multidimensional Family Therapy as a community-based alternative to residential treatment for adolescents with substance use and co-occurring mental health disorders. Journal of Substance Abuse Treatment, 90(1), 47-56.

This randomized clinical trial (RCT) compared Multidimensional Family Therapy (MDFT) with residential treatment (RT) for adolescents with co-occurring substance use and mental health disorders on substance use, delinquency, and mental health symptoms. Using an intent-to-treat design, 113 adolescents who had been referred for residential treatment were randomly assigned to either RT or MDFT in the home/community. The sample was primarily male (75%) and Hispanic (68%) with an average age of 15.4 years. Seventy-one percent of youth had at least one previous residential treatment placement. Participants were assessed at baseline and at 2, 4, 12 and 18 months post-baseline. During the early phase of treatment (baseline to 2 months), youth in both treatments showed significant reductions in substance use [substance use problems (d = 1.10), frequency of use (d = 1.36)], delinquent behaviors (d = 0.18) and externalizing symptoms (d = 0.77), and youth receiving MDFT reported significantly greater reductions in internalizing symptoms than youth receiving RT (d = 0.42). In phase 2, from 2 to 18 months after baseline, youth in MDFT maintained their early treatment decreases in substance use problems (d = 0.51), frequency of use (d = 0.24), and delinquent behaviors (d = 0.42) more effectively than youth in RT. During this period, there were no significant treatment differences in maintenance of gains for externalizing and internalizing symptoms. Results suggest that Multidimensional Family Therapy is a promising alternative to residential treatment for youth with substance use and co-occurring disorders. The results, if supported through replication, are important because they challenge the prevailing assumption that adolescents who meet criteria for residential treatment cannot be adequately managed in a non-residential setting.

Stanger, C., Lansing, A. H., & Budney, A. J. (2016). Advances in research on contingency management for adolescent substance use. Child and Adolescent Psychiatric Clinics, 25(4), 645-659.

Multiple interventions for treating adolescents with substance use disorders have demonstrated efficacy, but the majority of teens do not show an enduring positive response to these treatments. Contingency-management (CM) based strategies provide a promising alternative, and clinical research focused on the development and testing of innovative CM models continues to grow. This article provides an updated review on the progress made in this area since we last commented on the published literature in 2010¹. Areas covered include: controlled trials of treatment for adolescents referred to substance use treatment, innovative applications of CM to tobacco cessation among youth, analyses of moderators and mechanisms of CM treatment outcomes, the emerging literature on dissemination and implementation, and other literature suggesting a growing acceptance of CM as viable and effective intervention. The literature in this area continues to progress at a moderate pace, with many indicators of budding interest in the application of CM, and in finding cost effective models to enhance dissemination and implementation. As with other types of substance use disorder treatments, we need to continue to search for more effective models, focus on post-treatment maintenance (reduce relapse), and strive for high levels of integrity and fidelity during dissemination efforts to optimize outcomes.

Stockings, E., Hall, W. D., Lynskey, M., Morley, K. I., Reavley, N., Strang, J., … & Degenhardt, L. (2016). Prevention, early intervention, harm reduction, and treatment of substance use in young people. The Lancet Psychiatry, 3(3), 280-296.

We did a systematic review of reviews with evidence on the eﬀectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are eﬀective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is aﬀected by methodological issues; interventions that incorporate skills training are more likely to be eﬀective than information provision—which is ineﬀective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of eﬀectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large eﬀect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are eﬀective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations diﬀering in sex, age, and risk status. Concerted eﬀ orts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.

Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). The comparative effectiveness of outpatient treatment for adolescent substance abuse: A meta-analysis. Journal of Substance Abuse Treatment, 44(2), 145-158.

Meta-analysis was used to synthesize research on the effects of outpatient treatment on substance use outcomes for adolescents with substance use disorders. An extensive literature search located 45 eligible experimental or quasi-experimental studies reporting 73 treatment–comparison group pairs, with many of the comparison groups also receiving some treatment. The first analysis examined 250 effect sizes for the substance use outcomes of adolescents receiving different types of treatment relative to the respective comparison groups. As a category, family therapy programs were found to be more effective than their comparison conditions, whereas no treatment programs were less effective. However, not all treatment types were compared with each other in the available research, making it difficult to assess the comparative effectiveness of the different treatments. To provide a more differentiated picture of the relative improvement in substance use outcomes for different treatments, a second analysis examined 311 pre–post effect sizes measuring changes in substance use for adolescents in the separate treatment and comparison arms of the studies. The adolescents in almost all types of treatment showed reductions in substance use. The greatest improvements were found for family therapy and mixed and group counseling. Longer treatment duration was associated with smaller improvements, but other treatment characteristics and participant characteristics had little relationship to the pre–post changes in substance use. Based on these findings family therapy is the treatment with the strongest evidence of comparative effectiveness, although most types of treatment appear to be beneficial in helping adolescents reduce their substance use.

Van Ryzin, M. J., Roseth, C. J., Fosco, G. M., Lee, Y. K., & Chen, I. C. (2016). A component-centered meta-analysis of family-based prevention programs for adolescent substance use. Clinical Psychology Review, 45, 72-80.

Although research has documented the positive effects of family-based prevention programs, the field lacks specific information regarding why these programs are effective. The current study summarized the effects of family-based programs on adolescent substance use using a component-based approach to meta-analysis in which we decomposed programs into a set of key topics or components that were specifically addressed by program curricula (e.g., parental monitoring/behavior management, problem solving, positive family relations, etc.). Components were coded according to the amount of time spent on program services that targeted youth, parents, and the whole family; we also coded effect sizes across studies for each substance-related outcome. Given the nested nature of the data, we used hierarchical linear modeling to link program components (Level 2) with effect sizes (Level 1). The overall effect size across programs was .31, which did not differ by type of substance. Youth-focused components designed to encourage more positive family relationships and a positive orientation toward the future emerged as key factors predicting larger than average effect sizes. Our results suggest that, within the universe of family-based prevention, where components such as parental monitoring/behavior management are almost universal, adding or expanding certain youth-focused components may be able to enhance program efficacy.

Annotated bibliography: Teenagers and substance use

Annotated bibliography

Annotated bibliography: Unemployment and mental health

Annotated bibliography

Bidargaddi, N., Bastiampillai, T., Schrader, G., Adams, R., Piantadosi, C., Strobel, J., & … Allison, S. (2015). Changes in monthly unemployment rates may predict changes in the number of psychiatric presentations to emergency services in South Australia. BMC Emergency Medicine, 15(1), 1-6.

The aim of this paper was to establish if monthly presentation rates to Mental Health Emergency Departments (MHED) in South Australia Public Hospitals (SAPH) was associated with Australian Bureau of Statistics (ABS) unemployment rates. The data was collected using times series modelling of relationships between monthly MHED SAPH presentations obtained from the Integrated South Australian Activity Collection (ISAAC) and the ABS South Australia unemployment figures between January 2004 and June 2011. The study found that over 32% of MHED presentations in males could be predicted by male unemployment rates from the two months prior. Over 63% of MHED presentations in females could be predicted by male and female unemployment in the previous months. They concluded that small shifts in unemployment rates can increase MHED presentations particularly in women and that ABS unemployment statistics can be a useful tool for predicting future MHED. A limitation of this study is that it establishes an association between MHED presentations and unemployment but not causality, so increased unemployment might not be the cause of the increase in MHED presentations.

Buffel, V., van de Straat, V., & Bracke, P. (2015). Employment status and mental health care use in times of economic contraction: a repeated cross-sectional study in Europe, using a three-level model. International Journal for Equity in Health, 14(1), 1-19.

This study aimed to compare the mental health care use of the unemployed with that of the employed and whether the relationship between unemployment status and mental health care use varied across different economic climates. They wanted to establish whether the economic context affected mental health care use due to its impact on mental health or irrespective of mental health. Data from three waves of the Eurobarometer (2002, 2005/6 and 2010) was utilised, which consists of a repeated cross-sectional and cross-national design. The data was analysed using linear and logistic multi-level regression in which mental health and contacting a medical practitioner for mental health issues were considered variables. They found that mean unemployment rate was negatively associated with mental health, although in women this only applied to those employed. There was no association found in women between changes in the macro-economic climate and mental health. Men’s care use however is associated with changes in the unemployment rate and gross domestic product (GDP) irrespective of mental health. This is true of both employed and unemployed men. They conclude that it is important to consider macro-economic conditions when studying mental health care use, particularly in men. A limitation noted in the study is that the Eurobarometer records employment status at the time of the interview and mental health in the twelve months preceding the interview. Therefore it is not able to distinguish between causation and reverse causation for any association between mental health and employment.

Crowe, L., Butterworth, P., & Leach, L. (2016). Financial hardship, mastery and social support: Explaining poor mental health amongst the inadequately employed using data from the HILDA survey. SSM – Population Health, 2(1), 407-415.

Data from the Household Income and Labour Dynamics in Australia (HILDA) Survey were analysed to try and establish if there was a relationship between employment status and mental health, along with the effects of financial hardship, mastery and support. They also wanted to explore how duration of unemployment impacted on mental health. Three waves of data were analysed from the HILDA Survey which encompassed 4965 adult respondents. The relationship between employment status and mental health was assessed using longitudinal population-averaged logistic regression models to explain associations between employment groups (unemployed vs. employed; employed vs. underemployed). The effect on duration of unemployment on mental health was evaluated using regression analysis. Unemployed or underemployed respondents exhibited poorer mental health than their employed counterparts. Mastery, financial hardship and social support ameliorated this association particularly in the underemployed. Transition to unemployment was associated with a decline in mental health among a broad age range of respondents. The relationship between mental health and unemployment duration was not linear but mental health showed a marked decline in the first nine weeks. The study concluded that mastery, financial hardship and social support are important factors to consider in the understanding of the relationship of poor mental health and un- or underemployment. It also suggests intervention should commence immediately after job loss with deterioration in mental health being most severe in the first weeks before plateauing. A limitation in this study is the possibility of reverse causation or low mastery and lack of social support causing unemployment.

Limm, H., Heinmüller, M., Gündel, H., Liel, K., Seeger, K., Salman, R., & Angerer, P. (2015). Effects of a Health Promotion Program Based on a Train-the-Trainer Approach on Quality of Life and Mental Health of Long-Term Unemployed Persons. Biomed Research International, 2015(1),

The authors of this study state that long-term unemployment is associated with poorer mental health. They therefore conducted this study to evaluate the effectiveness of a health promotion program to improve the mental health and health related quality of life (HRQL) utilising the train-the-trainer approach. A parallel-group study was performed using 287 unemployed participants (179 were in the intervention group and 108 in the control group), who were reassessed after 3 months. The intervention comprised individual sessions based on motivational interviewing and participatory group sessions, with the control group receiving no health promotion. Within 3 months HRQL improved and symptoms of depression and anxiety decreased in the intervention group, but not in the control group. The trainers were all professionals (mainly social workers) who had received three days training to deliver the interventions. A limitation of this study was that participants were not “blinded” and the positive results may be influenced by this.

Olesen, S., Butterworth, P., Leach, L., Kelaher, M., & Pirkis, J. (2013). Mental health affects future employment as job loss affects mental health: findings from a longitudinal population study. BMC Psychiatry, 13(1), 144.

Internationally, participation in the workforce is regarded as an important factor in mental health policies and social inclusion. This study aimed to examine simultaneously the effects on mental health on unemployment and how mental health effects employment prospects and participation. The data was derived from respondents who completed the nine waves of the HILDA Survey in Australia. They were all of working age (20-55 years) at commencement of the study (n=7176). Simultaneous relationships between employment and mental health were tested over time using cross-lagged path analysis, whilst adjusting for sociodemographic differences. They found that poor mental health was both a result of and a predisposing factor for unemployment. Poorer mental health in people who are unemployed can be both attributable to the unemployment and existing mental health issues. In women both these factors had equal rating, whereas in men the impact of unemployment on mental health was weaker than mental health on subsequent unemployment. The data available in the HILDA survey meant that the researchers were limited to using the respondents’ concept of their mental health rather than diagnosed mental illnesses.

Strandh, M., Winefield, A., Nilsson, K., & Hammarström, A. (2014). Unemployment and mental health scarring during the life course. The European Journal of Public Health, 24(3), 440.

The long-term relationship between unemployment and mental health over the life course has been little researched. This study examined the relationship between youth unemployment along with periods of adult unemployment and mental health at several life stages (16, 18, 21, 30 and 42 years) who all graduated from compulsory school in a town in Sweden. Originally there were 1083 participants and of those still living at the 27 year follow-up, 94.3% were still involved. The researchers measured mental health in three ways: nervous symptoms, depressive symptoms and trouble sleeping. These were analysed using a repeated measures linear mixed models approach at ages 16, 21, 30 and 42 years. Unemployment was measured using a period of unemployment of at least six months over three time periods: 18–21, 21–30 and 30–42 years. They found that youth unemployment was significantly associated with poor mental health at ages 21, 30 and 42 years. Later single unemployment periods did not appear to have the same long-term effects, although two or more periods of unemployment did have a significant relationship with poor mental health. A limitation of the study is its small geographical sample base, with consequent limits on sociodemographic variants.