Parent Programs for Reducing Adolescent's Antisocial Behavior and Substance Use

16 Pages·2015·0.53 MB·English

by  Camilla Jalling

JChildFamStud(2016)25:811–826
DOI10.1007/s10826-015-0263-y
ORIGINAL PAPER
Parent Programs for Reducing Adolescent’s Antisocial Behavior
and Substance Use: A Randomized Controlled Trial
Camilla Jalling1 • Maria Bodin2 • Anders Romelsjo¨3 • Ha˚kan Ka¨llme´n1 •
Natalie Durbeej4 • Anders Tengstro¨m5
Publishedonline:9August2015
(cid:2)TheAuthor(s)2015.ThisarticleispublishedwithopenaccessatSpringerlink.com
Abstract Two theoretically based parent training pro- over time, but no time by group effect emerged. No pro-
grams, delivered in real-world settings by the social ser- gram effects were found in the adolescents’ self-reported
vices, were examined in this randomized controlled trial antisocial behavior, delinquency, or psychosocial func-
for effectiveness in reducing adolescents’ antisocial tioning. A threefold risk of illicit drug use was found in
behavior andsubstanceuse.Two hundredandthirty-seven both intervention groups. The results suggest that neither
(237) adolescents in ages between 12 and 18 and their Comet nor ParentSteps had beneficial effects on adoles-
parentswereassignedtooneoftwoprogramsortoawait- cent’s antisocialordelinquent behavior,or on alcohol use.
list control condition. The programs were the nine weekly Theonlysignificantgroupdifferencefoundwasathreefold
group sessions program Comet 12–18 (Swedish Parent risk of drug use in the intervention adolescents at follow-
Management Training Program) and the six weekly Par- up, but for several reasons this finding should be inter-
entSteps (Swedish shortened version by Strengthening preted with caution.
Families Program 10–14). Outcome measures were anti- Trial registration number: ISRCTN76141538.
social behavior, substance use, and delinquency, and psy-
chosocial dysfunction. Data based on adolescents’ and Keywords Antisocial behavior (cid:2) Substance use (cid:2)
parents’ ratings of the adolescents’ problem behavior at Adolescent (cid:2) Parent training (cid:2) RCT
baseline and 6 months later were analyzed with repeated
measures ANVOA, Logistic regression, and Kruskal–
Wallis H test. The results showed that parents’ ratings of Introduction
adolescents’ antisocial behaviors decreased significantly
Antisocial behavior has been broadly defined as behavior
that offends other individuals, property, social norms, or
& CamillaJalling
rules and laws (Bloomquist and Schnell 2002; Lahey and
[email protected]
Waldman 2005). In younger children, antisocial behavior
1 STAD,StockholmCenterforPsychiatryResearchand oftenappearsasdisruptivebehaviorandverbalorphysical
Education,KarolinskaInstitutet,NorraStationsgatan69,
aggression in daycare or school settings, while antisocial
11364Stockholm,Sweden
behavior in adolescents might also include delinquent
2 DepartmentofKnowledge-BasedPolicyandGuidance,
behavior and substance use. Younger children with anti-
NationalBoardofHealthandWelfare,Stockholm,Sweden
social behavior are known to be at elevated risk for con-
3 DepartmentofPublicHealthSciences,SocialMedicine,
tinued problems and youth violence (Lo¨sel and Farrington
KarolinskaInstitutet,Stockholm,Sweden
2012)aswellasforpoorerfunctioninginlifedomainssuch
4 DepartmentofClinicalNeuroscience,StockholmCentrefor
as education, employment, and personal relationships
PsychiatryResearchandEducation,KarolinskaInstitutet,
(Moffitt 1993). Against this background, early prevention
Stockholm,Sweden
has been suggested as an important policy with respect to
5 DepartmentofClinicalNeuroscience,StockholmCentrefor
childhood problem behavior (Welsh and Farrington 2007),
PsychiatryResearchandEducation,KarolinskaInstitutetand
KarolinskaUniversityHospital,Stockholm,Sweden and various interventions for parental support have been
123
812 JChildFamStud(2016)25:811–826
developed and evaluated over the last several decades. In program was initially intended for substance-abusing par-
Sweden, support for parents in their parenting roles has ents and their children, but it has been modified over the
beenagovernmentalpriorityforthelast10 years(National yearstomeettheneedsofnewpopulations(Kumpferetal.
InstituteofPublicHealth2006),andanumberofprograms 1996). The SFP 10–14 for school-based implementation is
have been developed and studied on initiative from the offeredtoallfamiliesandchildreninaclass,i.e.regardless
Ministry of Health and Social Affairs, the Public Health of the children’s level of risk for developing or consoli-
AgencyofSweden(SOU2008),andtheNationalBoardof dating antisocial behavior. It is a multimodal intervention
Health and Welfare (2014). Parent programs are offered that includes separate sessions for parents and children as
withinthesocialservices,butalsoinclinics,schools,youth well as joint family sessions. The program has its theo-
clinics, and by non-governmental organizations, and they retical basis in the Resilience Model (Richardson et al.
commonlyaimatalteringtheparents’behavior,improving 1990) and the Social Ecology Model of Adolescent Sub-
theircommunicationskills,andincreasingtheirknowledge stance Use (Kumpfer and Turner 1990), and it primarily
of how to promote their children’s prosocial behavior. aims at strengthening protective factors for adolescent and
Parent management training (Kazdin 2005) is an parents. Each session addresses a particular protective and
umbrella term for parenting programs based on operant corresponding risk factor. All parent sessions are video-
learning and social learning principles such as the Parent based and aim to improve, for example, communication
Management Training—Oregon Model [PMTOTM; (For- skills, family bonding, and expectations concerning sub-
gatch and Patterson 2010)] and the Incredible Years pro- stance use (Kumpfer et al. 1996; Ska¨rstrand et al. 2008).
gram (Webster-Stratton 1984). By teaching parents to use Results from a systematic review point out the SFP 10–14
more positive parenting skills (e.g. praising children when as one of the few programs with promising longer-term
engaginginprosocialbehavior)andlessnegativeandharsh outcomes when evaluated in US studies (Foxcroft et al.
parenting practices, these programs aim to support proso- 2003). In 2008, the SFP 10–14 was adapted to match a
cial behaviors in children. A systematic review from the Swedish context and was given the name Steg-fo¨r-steg
CochraneCollaborationshowsthatgroup-basedcognitive- (Step-by-Step) (Ska¨rstrand et al. 2008). The cultural
behavioral parenting programs are effective for decreasing adaptation left the contents largely intact but profoundly
behavioralproblemsinyoungerchildrenwithclinical-level affected the program format because the majority of joint
problems (Furlong et al. 2012). Typically, interventions in parent–childsessionswereomitted(Ska¨rstrandetal.2008).
the13trialsincludedintheCochranereviewencompassed When later evaluated in a cluster-randomized trial
10–15 group sessions where brief videotaped vignettes of encompassing19schoolsintheStockholmarea,noeffects
typical parent–childinteractions were used for observation of the Step-by-Step intervention were found on youth’s
and modeling. Other typical components were behavior drinking or substance use (Ska¨rstrand et al. 2014). Among
rehearsal through role-play, group discussions, and home- the possible reasons for the null findings was the omission
work assignments. One of the studies included in this of the joint parent–child sessions (Ska¨rstrand et al. 2008).
review evaluated the effects of the Swedish program Like in younger children, antisocial behavior among
Comet, which targets parents of children aged 3–11 years adolescents has been associated with low functioning in
(Kling et al. 2010). The results from that study were con- school andrelationshipdomains,andalso witha generally
sistent with the overall review findings and indicated poor adult outcome (Brosnan and Carr 2000). In order to
improved parenting skills and lower problem levels in decrease early signs and to prevent the consolidation of
children of the parents in the Comet group compared to a antisocial behavior in older adolescents, the Comet and
wait-list control immediately post-treatment (Kling et al. Step-by-Stepprogramsdescribedabovewerelateradapted
2010). However, the authors of the review emphasize that intoversionsforparentsofadolescents—Cometforparents
theresultsofthereviewarenotnecessarilygeneralizableto of youth 12–18 years old (Forster and Livheim 2009) and
group-based cognitive-behavioral parenting programs for ParentSteps for parents of youth 13–17 years old (Larsson
children of other age groups and problem levels (Furlong et al. 2009). Both of these programs are run at the sec-
et al. 2012). The Comet program for parents of children ondary prevention level, i.e. they target parents of adoles-
3–11 yearswasalsofoundtobeeffective inamorerecent centswithearlysignsofantisocialbehaviorandwhoareat
and larger Swedish randomized trial (Stattin et al. 2015). risk of maintaining such behavior. Each of the two pro-
Parenting and family programs that primarily aim to gramsisbasedonthesametheoriesastheversionsforthe
prevent underage alcohol drinking and substance use have younger ages described above. Both programs are uni-
also been shown to be effective (Hindelang et al. 2001; modal and involve parents only, meaning that the Par-
Smit et al. 2008). One well-known intervention from the entStepsdeviatesfromtheSFPandalsotheSwedishStep-
US is the Strengthening Families Program for Parents and by-Stepinthisrespect.Thoughthepreventionofsubstance
Youth10–14(SFP10–14)(Kumpferetal.1996).TheSFP useisamoresalienttargetdomainforParentStepsthanfor
123
JChildFamStud(2016)25:811–826 813
Comet 12–18, the programs share the general aim of pre- Method
venting antisocial behavior and improving psychosocial
functioning in at-risk adolescents. Participants
Whilethenotionofaddressingantisocialbehaviorearly
inchildren´sliveshasbeensupportedinseveralreviewsand Eligible participants were parents/caregivers and their
studies (Furlong et al. 2012; Piquero et al. 2009; Salari adolescentchildrenaged12–18 yearsoldwhowereatrisk
et al. 2014; Webster-Stratton and Hammond 1997), less is of consolidating antisocial behavior. When screening par-
known about the effects of parent interventions for at-risk entsforparticipation,antisocialriskbehaviorinadolescent
adolescents. It is quite common for adolescents to tem- wasdefinedasthepresenceofatleastoneofthefollowing,
porarily engage in different antisocial behaviors, but it is as indicated by single-item descriptions: delinquent
oftendifficulttodeterminewhetherantisocialbehaviorina behavior; bullying; repeated conflicts regarding family
specific individual is adolescence-limited or life-course rules; any use of alcohol, tobacco, and/or drugs; or
persistent (Moffitt1993).Addressingat-riskadolescentsin excessive computer use. The exclusion criteria were the
order to decrease early signs of antisocial behavior or adolescent’s ongoing psychotherapy, treatment for alcohol
substancemisuseandtopreventconsolidationis,therefore, or drug use, out-of-home placement, and parents’ partici-
an imperative for society. pation in another parent program. Participation also
The majority of programs involving parents of older necessitated living in one of the five participating munic-
adolescents, however, mainly concern adolescents who ipalities (see ‘‘Procedure’’), and the adolescent had to live
already have developed and consolidated antisocial atleastpart-timewiththeparticipatingparentorcaregiver.
behavior. A systematic review from the Cochrane Collab- Because this trial was carried out under real-world condi-
oration has investigated the effects of programs for youth tions, the inclusion criteria used was to reflect the social
10–17 years old who had either conduct disorder or services’ criteria for inclusion in their regular parent
involvementindelinquency.Theresultssuggestedthatthe groups. The use of excessive computer use as an inclusion
familyandparentinginterventionshadbeneficialeffectson criterion was requested by the social services since many
reducingthetimeyouthspentininstitutions,butnoeffects parents described it as being a source of family conflicts
were found for psychosocial outcomes such as child/ado- and, to some extent, of truancy. Excessive computer use
lescent behavior (Woolfenden et al. 2001). In later years, has been associated with health problems, academic fail-
enhanced versions of the SFP have also been successfully ure, and impaired impulse control (Holstein et al. 2014;
implemented with high-risk families with children of dif- Morenoetal.2011),andithasbeenfoundtocorrelatewith
ferentages.OneEuropeanexampleisaquasi-experimental other forms of addiction such as alcohol, drugs, and gam-
study that indicated positive effects of SFP 12–16 when bling (Sung et al. 2013). The study was approved by the
adapted for use in high-risk families in Ireland (Kumpfer Stockholm ethical review board at Karolinska Institutet
et al. 2012). In the scientific literature, there is, however, prior to onset (registration nr 2008-744-31), and the study
insufficient evidence concerning the effectiveness of pro- was registered in Current Controlled Trials (http://www.
grams for parents of pre-referred, pre-incarcerated, and controlled-trials.com) after participant enrollment (register
undiagnosed adolescents (Leijten et al. 2012). In Sweden nr ISRCTN76141538).
as well as internationally, randomized clinical trials of
parent programs that aim at reducing at-risk adolescents’ Design
antisocial behavior and substance use are rare.
Against this background, this study was set up to Thistrialhadasimplerandomizationdesignwitharatioof
investigate the effects of Comet 12–18 and ParentSteps on 1:1:1 for assignment to Comet 12–18, ParentSteps, or to a
measures of antisocial behavior when given under real- six-month wait-list control condition. The randomization
world conditions to parents of at-risk adolescents. Though sequence was generated by a research assistant drawing
the two programs have some similarities in content (see one of three folded opaque pieces of paper from a bowl.
‘‘Method’’), they differ in their theoretical backgrounds. Thepaperwasthenputbackinthebowlforthenextfamily
The secondary aim was to test the programs’ effectiveness to be randomized. The research assistant had not met the
on a subsample with poorer psychosocial functioning. In parents before randomization, and leaders of the interven-
both instances, the research question being addressed was tion groups were not involved in or aware of the random-
whether adolescents in either of the two intervention ization procedure. After randomization, the research
groupsengagedlessinantisocialbehaviorswhenfollowed assistant provided the group leaders with contact infor-
up than adolescents whose parents had not been given one mation for the parents who had been assigned to their
of the interventions. particular program to enable invitation to the group
123
814 JChildFamStud(2016)25:811–826
sessions. After the six-month follow-up, parents in the and through advertisements to visit a website with study
controlgroupwereofferedComet12–18orParentStepsin information. The site contained a screening form for eli-
accordance with their preferences. At the six-month fol- gibility that was based on the inclusion criteria. Eligible
low-up, 32 parents reported that they themselves or their families received postal consent forms for both the parent
adolescent child had participated in another intervention and the adolescent. Those parents and adolescents who
targeting the adolescent such as seeing a school counselor returned signed consent forms were randomized as a dyad
or a therapist at a child and adolescent psychiatry unit. to the Comet 12–18, ParentSteps, or control group. The
These were equally distributed across groups (Comet majority of parents were recruited to the trial by advertis-
12–18 14.1 %, ParentSteps 14.3 %, and control 12.2 %), ing. The proportions who were recruited by the social
and they were kept for analysis. serviceswere 18 % inComet12–18,27 %inParentSteps,
and 20 % in the control group. There were no significant
Sample Size Estimation group differences in this respect (Comet 12–18/control
z = - 0.579, p = .56; ParentSteps/control z = 1.77,
Because no previous study has reported on the effective- p = .08). Due to the relatively slow influx of participating
ness of parent training for this study group, little infor- families,weinvitedfourmoremunicipalitiesinStockholm
mationwasathandtoanchorthepowercalculation.Hence, County, Sweden, to participate after the first wave of
the calculation was based upon the results from a Swedish inclusion, and all four consented. We also added a fourth
study on the effectiveness of the Comet 3–11 program recruitingwavetothethreethatwereinitiallyplanned for.
(Kling et al. 2010). In that RCT, positive effect sizes for This enlargement—four additional municipalities and one
children’s problem behavior reached a Cohen’s d of 1.07 additional recruitment wave—eventually comprised four
compared to controls using the parents’ ratings on the recruitment waves in the municipalities of Huddinge,
Parent Practices Interview (PPI) (Webster Stratton 1998; Solna,Sundbyberg,Nacka,and12ofthe14districtsofthe
Webster Stratton et al. 2001). As PPI was shown in the city of Stockholm. The selection of municipalities was
mediation analysis by Kling et al. (2010) to causally basedonpopulationsize,theavailabilityofParentStepsor
change the behavior of the child, the PPI construct was Comet 12–18 by the social services, and geographic
chosen for the power calculation. In the present trial, proximityinordertominimizecommutingdistanceforthe
however, it was assumed that the effect size would be participating parents. At the social services, each head of
substantially lower because parents’ ability to influence division decided if their parent group leader team would
their adolescents´ problem behavior diminishes as the ado- participate, and the contracted group leaders where
lescent gets older. Considering this, the detectible effect recruited by an e-mail invitation sent to all certified group
sizedifferencewassetto.40,whichrequiredatotalsample leaders in Stockholm County.
sizeof300subjectswiththepowersetto.80andthealpha
set to .05. With the total actual sample size of 241 parents Measurements
and 237 adolescents, the detectible effect size difference
was .45. Thebaselineassessmentwasconductedpriortothestartof
the intervention. The research assistant administered the
Procedure baseline questionnaires to parents in the intervention
groups at the first parent group meeting. Postal question-
Recruitment naires were used for parents in the control group and for
subsequent follow-ups six months after baseline in all
Since this trial was carried out in a real-world setting, we groups. The majority of adolescents (79 %) answered
soughttoemulatetheordinaryenrollmentprocedureofthe e-mail–administrated web questionnaires. All participants
social services. The usual procedure for parents who seek were ensured confidentiality of self-reported information.
parenttrainingistocontactthesocialservicesthatprovide Thoughdifferentmodesofassessments,suchasself-report
these programs to their residents. Parents receive infor- and interviewer assessments, might bias the responses
mation about the regularly offered programs by ads, (Bowling 2005; Tourangeau and Smith 1996), self-ad-
pamphlets, or by recommendations. In order to reach the ministrated questionnaires are considered to increase
sample size required for this trial, we had to rely not only respondent openness concerning sensitive questions
on recruitment through the social services but also on (Tourangeau and Smith 1996) and to decrease desirability
advertisinginlocalnewspapersandonapplicablewebsites. distortion(Hoodetal.2012).Thegreatestdifferencesseem
During a one-month period at the beginning of each tobebetweenmode,notwithinmode(Bowling2005),and
semester between August 20, 2008, and February 2010, it has been found that the impact of the presence of others
parents were invited by staff at the social services offices is not significantly different from the absence of others
123
JChildFamStud(2016)25:811–826 815
whenrespondingtoquestionnaires(Hoodetal.2012).The programs because of the social services’ limited capacity
firstparentgroupinthefirstinclusionwavefilledouttheir for including trial parents in their regular Comet 12–18
baselinemeasurementonSeptember25,2008,andthelast group. This was due to the social services’ obligation to
follow-up for the fourth group who entered the study in provide parental support to their residents. In some groups
springof2010tookplaceonOctober19,2010.Thefollow- there were only two trial parents, while in two groups the
up for each group was planned to occur six months after wholegroupcomprisedparentsparticipatinginthetrial.In
baseline as reported to the trial registration. The span of the ParentSteps, almost all parents in each group were
responsetimesonthefollow-upquestionnairerangedfrom participating in the trial.
1to63 dayswithameanof9 days,andthusthefollow-up
deviated only slightly from the planned date. Program Comparisons
Interventions Both Comet 12–18 and ParentSteps are manualized and
executedasparent groupinterventionsledbytwocertified
General Preconditions leaders. As shown in Table 1, there are differences
between the two programs in the amount of training
Theparentprogramsinthistrialwererununderreal-world required to become a leader as well as differences in pro-
conditionsbythesocialservices.Eighty-fivepercentofthe gramdurationandstructure.Forexample,moretraining is
parent group sessions were held as part of the social ser- required for leaders in Comet 12–18 than in ParentSteps
vices’routinework.Therestwereheldbycontractedgroup (six days ? twoboostersforComet12–18vs.one dayfor
leaders at social services facilities or in rented meeting ParentSteps).Comet12–18alsohasalongerdurationwith
rooms. All partaking group leaders were social workers nine group sessions (?one optional booster) compared to
who were active within the social services either in family six sessions for ParentSteps, and it has a smaller recom-
oryouthunits.Theywerealltrainedandcertifiedprogram mended group size. Both programs use video vignettes in
leaders who had led at least one parent group prior to this each session to illustrate common parent-adolescent inter-
study. In order to minimize dropouts, the group sessions actions, and these serve as a basis for discussions. As
had to be carried out within one semester. In the Swedish further described below, the video films also provide the
school system, there are two semesters that start in the basic frame for the ParentSteps sessions while they play a
middle of August or January, respectively. This necessi- less prominent role in Comet 12–18.
tated that in less than a month the participants had to
respond to the study invitation, apply, consent, be ran- Comet 12–18
domized, be allocated to a suitable parent group, and
answer the baseline questionnaire prior to the start of the Like Comet 3–11 for younger children (Kling et al. 2010;
parent group intervention. As shown in Table 1, the num- Kling and Sundell 2006), Comet 12–18 rests theoretically
ber of conducted parent groups differed between the two on operant learning and social learning principles (Forster
Table1 Programcomparisons
Comet12–18 ParentSteps
Trainingofgroupleaders
Education/trainingdays 6?2boosters 1
Tutoringwhilecarryingoutthefirstgroupsession Yes No
Programstructure
Numberofweeklyparentsessions 9?1optionalbooster 6
Durationofeachsession,hours 2–2.5 1.5–2
Recommendedgroupsize,parents 6–8 8–12
Trialcharacteristics
Numberofgroupleadersinthetrial 31 13
Numberofconductedparentgroupsessions 30 12
Sessionsheldwithinsocialservicesroutinecare 28 8
Sessionsheldbycontractedgroupleaders 2 4
Becausethesocialserviceswereobligedtodelivertheinterventionsunderstudytotheirclientswithintheir
ordinary practice, only a limited number of study participants were allowed to enter each intervention
group.DuetothesmallerrecommendedgroupsizeofComet12–18,thislimitationwasmorepronounced
andledtomoresessionsbeingheldthanintheParentStepsprogram
123
816 JChildFamStud(2016)25:811–826
and Livheim 2009). The overall aim of the program is to adolescents and to improve their skills in dealing effec-
help parents to develop and enhance their skills and self- tively with their adolescents in everyday interactions. This
efficacy for parenting, thereby preventing consolidation of includes, for example, encouraging parents to set appro-
antisocialbehaviorsintheiradolescents.Principleprogram priate rules with reasonable consequences and to commu-
components are rehearsals of the use of reinforcement nicateclearexpectationsregardingsubstanceuseandother
principles (e.g. encouragement and praise and ignoring antisocial behavior. ParentSteps is conveyed and practiced
minor problems) through role-play and home-assignments by means of video vignettes, group discussions, and home
where parents practice and develop the principles in their assignments. The themes for the six sessions and home
daily lives. Parents are instructed to keep a diary to doc- assignments are Love and limits; Encouragement and
ument their interactions with their adolescent and home consequences; Risks and protection; Stress, fights and
assignmentsarefollowed-upinsubsequentsessions.Video different points of view; Youth, parents and alcohol; and
vignettesareusedineachsessiontoenhancelearning.The Youth, parents and drugs. ParentSteps has a highly struc-
first vignette shows a common, problematic parent-ado- tured format, and the video film for each session also
lescent situation that is used for discussion in terms of provides the time-points for the starting and ending of
reinforcement principles and possible solutions. The sec- group discussions and the assignments for that session
ondvignetteillustrateshowthesameproblematicsituation (Larsson et al.2009).Thus,thegroup leaders havelimited
canbedealtwithmoreconstructively.Examplesofthemes opportunities to depart from the schedule. For information
covered during the nine group sessions include taking on program intensity and duration, see Table 1.
initiatives for spending time together with the adolescent,
dealing with rejection, basic interactional (behavioral) Measures
analysis, positive communication and encouragement,
problem solving, and rules and consequences. For infor- Child Behavior Checklist and Youth Self-Report (CBCL
mation on program intensity and duration, see Table 1. and YSR). Achenbach’s CBCL and YSR were used to
assessparents’andadolescents’ratingsoftheadolescents’
ParentSteps antisocial and problem behaviors during the last six
months. Items are rated on a 3-point scale of 0 (never/
LiketheSFP10–14(Kumpferetal.1996)anditsSwedish seldom), 1 (sometimes), or 2 (often/always). The total
adaptation Step-by-Step (Ska¨rstrand et al. 2008), the Par- problem score (range 0–210 points) and the externalizing
entSteps intervention (Larsson et al. 2009) is theoretically behavior broadband syndrome scale, which measures rule
basedontheResilienceModel(Richardsonetal.1990)and breaking and aggressive behavior (range 0–64 points),
the Social Ecology Model of Adolescent Substance Use were used in this study. Higher scores indicate more
(Kumpfer and Turner 1990). The program focuses pri- problem behavior (Achenbach and Rescorla 2001). In the
marily on the prevention of substance use but it also manualfortheCBCLandYSR,Cronbach’saforthetotal
focuses on other types of antisocial behavior, and it seeks scores are .97 (CBCL) and .95 (YSR), and for the exter-
tostrengthenprotectivefactorsandtoreducingknownrisk nalizing behavior scores the a value are .94 (CBCL) and
factors in parents and adolescents. Family attachment/ .90 (YSR) (Achenbach and Rescorla 2001). In this study,
bonding, parental supervision, and communication of the Cronbach’s a was .92 for CBCL and .94 for YSR, and
positive family values and norms are viewed as the main for the externalizing scale a values were .87 (CBCL) and
protective factors (Kumpfer et al. 2003). For example, .89 (YSR).
‘‘spending-time-together’’ aims at strengthening the rela- Self-Reported Delinquency (SRD). The total scale score
tionbetweentheparentandtheadolescent,whichinturnis (excludingthesubscaleharddruguse,whichwasmeasured
assumedtopreventadolescentproblembehavior(Kumpfer with DUDIT) was used to measure overt and covert
et al. 1996). Unlike the SFP 10–14 that includes parent, behaviorthattapsviolence,generaldelinquency,andstatus
youth, and joint family sessions, the ParentSteps is unidi- offenses. Adolescents were asked how many times they
mensional and addresses parents only. Further modifica- committed any of the 40 behaviors on the list during the
tions in ParentSteps compared to the SFP 10–14 include last six months, and they could answer from ‘‘zero’’ to
the reduction fromseven parent sessions andfour boosters ‘‘nine times or more’’. The total score was 0–360 points
were reduced to six sessions, the omission of the element (ElliotandAgeton1980).Cronbach’saforthissamplewas
‘‘small penalties for small problems’’ (and vice versa), .92.
changing ‘‘I’’ statements to ‘‘talk-and-listen-communica- Alcohol Use Disorder Identification Test (AUDIT).
tion’’, and the addition of a section on tobacco use. One AUDIT was used to measure self-reported alcohol con-
program goal of ParentSteps is to increase parents’ sumption andrelated problems. The instrument consists of
understanding of developmental characteristics of ten items with a total score of 0–40 points. Cut-off points
123
JChildFamStud(2016)25:811–826 817
are set to C8 for men and C6 for women to define risky mothers’ ratings for the analysis of parents’ data (Moretti
alcoholuse.Theinstrumentisnotvalidatedforadolescents andObsuth2009).Achi-squaretestandone-wayAnalysis
aged 12–18 years (Kallmen et al. 2011). Cronbach’s a on of Variance (ANOVA) were used to test for group differ-
the total scale score was .86. ences inbaselinecharacteristics.Ttestswere conductedto
Drug Use Disorder Identification Test (DUDIT). testthedifferencesintheoutcomemeasuresbetweenthose
DUDIT measures self-reported illicitdrug use on 11 items who were lost to follow-up and those who were not lost.
with a total scale score of 0–44 points. No cut-off points Analyses of normally distributed outcome data were per-
are validated for adolescents. For analysis, the follow-up formed with the General Linear Model (GLM) repeated-
values were dichotomized with 0 = not used during the measuresANOVA,whiletheskeweddataontheSRDwas
last six months and 1 = those who had ever used illicit first log-transformed. Gender and age were added to the
drugs during the last six months (Berman et al. 2005). ANOVA models as secondary explanatory factors.
Cronbach’s a on the total scale score was .92. Severely skewed data were analyzed by the Kruskal–
Youth-Outcome Questionnaire Self-Report (Y-OQ(cid:3) and Wallis H test for independent samples (AUDIT) and by
Y-OQ(cid:3)SR). Parent and adolescent questionnaires, the binary logistic regression after dichotomization (DUDIT).
Y-OQ(cid:3) and Y-OQ(cid:3)SR, respectively, rate adolescents’ Cohen’s d for effect size was calculated for all outcome
psychosocial distress, functioning problems, and behavior variables except for AUDIT and DUDIT. Cohen’s opera-
change. Sixty-four items with six subscales are rated on a tional definitions of effect sizes are %0.20 (small, negli-
5-point scale (0 = never, 1 = rarely, 2 = sometimes, gible practical importance), %0.50 (medium, moderate
3 = frequently, 4 = almost always), including eight practical importance), and %0.80 (large, crucial practical
reversed items that measure healthy behaviors (with a importance)(Cohen1987).Inadditiontothemainanalyses
rangeofscoresfrom-2to2).Thetotalscalescoreranges of outcomes for the complete groups, two kinds of sub-
from-16to240points, andhigher scoresindicategreater group analyses were performed. One involved subsamples
psychosocial dysfunction. The cut-off score of C46 was with poorer functioning at baseline that were identified
used to define a subsample with clinical levels of psy- with the Y-OQ cut-off score for clinical levels of psy-
chosocial dysfunction (Burlingame et al. 2005). The chosocial dysfunction (C46 points) and with gender-
Y-OQ(cid:3)-SR total score has demonstrated high internal specific AUDIT cut-off scores for (young adult) risk
consistencywithaCronbach’saof.95(Ridgeetal.2009), drinking (C6 for girls and C8 for boys). The other sub-
and a of .95 also for the Y-OQ(cid:3)(Burlingame et al. 2005). group analyses omitted 18-year olds and included only
Cronbach’s a values in this study were .93 (Y-OQ(cid:3)-SR) adolescents 12–17 years old in order to improve the com-
and .94 (Y-OQ(cid:3)). parability with other studies. Lastly, in the Discussion we
compare mean values of YSR in a Swedish normal popu-
Program Implementation Measures lationofadolescentsandthisstudy’ssamplewithWelch’s
ttestforunequalsamplesizesinordertodemonstrate that
Dosage To assess to what extent parents participated in we pinpointed an at-risk sample of adolescents.
parentgroupsessions,thegroupleaderswereaskedtokeep
an attendance list. The group leaders in ParentSteps Intent-to-Treat and Missing Data
updated the list at every group session, while the Comet
12–18 leaders updated it at every second session. We used Intent-to-Treat (ITT) analysis, in which all par-
Program fidelity All group leaders self-rated to what ticipants who were measured at baseline were included in
degree the program manual and all single session sections the analyses even if they were dropouts from treatment.
werefulfilled,andweremeasuredwithquestionnairesafter ITT analysis was used to analyze the effect of the inter-
the sessions by both group leaders individually. Further- ventions because they were given in real-world practice.
more, to ensure fidelity only active social workers who Under such real-world conditions, participants might drop
were already certified group leaders participated in the out from treatment and the trial to a larger extent than
study. during more rigorous clinical trials, which can lead to
complications when interpreting the results. The ITT
Data Analysis approachreducestheriskthattheresultsarebiasedinfavor
oftreatment.Theriskofover-estimatingprogrameffectsis
In40oftheparticipatingfamilies,bothparentsenteredthe lowerwithITTcomparedtowhenonlytreatmentandstudy
trial, and in two families three parents entered the trial. completers are analyzed (Keene 2011). This approach
Since only independent respondents’ ratings should be entails an estimation of the non-completers’ missing data.
included in the analysis, and because the vast majority of The internal non-response rate in the data was low
all participating parents were mothers, we only used the (0.4–3.5 % on single items). Little’s MCAR (Missing
123
818 JChildFamStud(2016)25:811–826
Completely at Random) test revealed that the values were had fulfilled the manual sections ‘‘to a full extent’’, 13 %
missing at random (Donders et al. 2006; SPSSInc 2010), ‘‘to a greater extent’’, 2 % ‘‘to at least half’’, 1 % ‘‘to a
and the missing values were handled with the estimation lesser extent’’, and 1 % ‘‘not at all’’.
maximization algorithm single-imputation method. In the AsshowninTable 3,intheparents’ratingonCBCLtotal
rarecasewhereindividualswerelosttofollow-up(parents scoreandtheexternalizingbehaviorsubscalescore,allthree
1.2 %, adolescents 4.2 %), the Last Observation Carried groupsdecreasedsignificantlyovertime,butnosignificant
Forward procedure was performed. differences between the groups over time were found. The
samepatternscanbeseeninparents’ratingsonY-OQ(cid:3)and
when using the cut-off score C46 points to define a sub-
Results samplewithclinicallevelsofpsychosocialdysfunction.For
parents withadolescents inthe age group 12–17 years, the
Figure 1 shows the flow of participants through the trial. resultsweresimilartothetotalsamplewithnon-significant
Participants who did not answer the baseline measurement group differences for the CBCL (F (2, 221) = 0.80,
were omitted from the study even though they had been p = .45), externalizing behavior (F (2, 221) = 1.14,
randomized. The procedure to randomize the participants p = .32),andtheY-OQ(cid:3),(F(2,221) = 0.14,p = .87).For
prior to the baseline assessment had to be overlooked in adolescents’ratings,astatisticallysignificantimprovement
favortotheshorttimespanofrecruitment,randomization, in psychosocial functioning over time was observed in the
measurement, and group participation as described above. totalsampleaswellasintheclinicallydefinedsub-sample,
Among the 241 parents and 237 adolescents who partici- butagainnogroup-by-timeeffectswerefound.Therewasno
patedinthebaselineassessment,onlythreeparents(1.2 %) effectoftimeinadolescent’sreportsofanti-socialbehavior
and ten adolescents (4.2 %) were lost to follow-up. There forthetotalorfortheclinicalsub-sample.Fortheagegroup
was no significant difference between measurement com- 12–17 years,theresultsweresimilartothetotalsample,with
pleters and those lost to follow-up regarding externalizing non-significantdifferencesfortheYSR(F(2,227) = 0.21,
behavior (t = - 1.39, df = 237, p = .17), and there was p = .81), externalizing behavior (F (2, 227) = 0.50,
nosignificantdifferencebetweenconditionswithregardto p = .61),Y-OQSR(cid:3)(F(2,227) = 0.65,p = .52),and the
attrition rates (v2 (2) = 2.99, p = .22). SRD (F (2, 227) = 0.31, p = .73). Gender and age were
Table 2 shows the baseline characteristics of the partici- added to the ANOVA models but did not account signifi-
pants by group. There were significantly fewer girls in the cantly for any within-group variation, and the effect esti-
Comet12–18groupcomparedtothecontrolgroup.Noother matesremainedbasicallythesame.
differences were observed between groups. Regarding the AsTable 4shows,theanalysiswiththeKruskal–Wallis
outcome measures, we found no significant differences Htestonthefollow-updataindicatedthatthedistributions
between the groups, with exception of the DUDIT scores of the AUDIT scores were similar across groups for the
(Table 5).Atbaseline,70 %oftheadolescentsreportedever totalsample(p = .07)andforthesubsamplewithelevated
havingusedalcohol,and 53 %ofthegirlsand 23 % ofthe alcohol risk use (p = .57 and p = .91 for girls and boys,
boysscoredabovethecut-offdefiningriskyalcoholuseonthe respectively), and no group effect was found. In the
AUDITscale.Thevastmajority(95.4 %)oftheadolescents younger age group (B 17 years old) the Kruskal–Wallis
reported having engaged in any delinquent behavior during H test showed a statistically significant difference in the
thelastsix monthsthatprecededthebaselinemeasurement. between-group distribution at follow-up (v2 (2) = 6.033,
Of the six sessions in total, parents in the ParentSteps p = .049) with a mean rank of m = 131.1 for Comet
attended a mean of 4.7 sessions (SD = 1.44). Of the nine 12–18, m = 105.1 for ParentSteps, and m = 118.11 for
Comet 12–18 sessions in total, only every second session controls.However,intheposthoctestwiththesignificance
wasassessedandthemeanattendancefor4.5sessionswas leveladjustedformultipletesting,allpairwisecomparisons
3.6 (SD = 1.07). With dropout defined as absence during indicatednon-significantdifferencesbetweendistributions.
the two last sessions, the dropout rate in the ParentSteps Binary logistic regression analysis of DUDIT scores
was14.1 %.Itwasimpossibletoestimate thedropoutrate (Table 5) showed that adolescents whose parents partici-
in Comet 12–18 due to the lack of data from the two last pated in any intervention had more than threefold signifi-
sessions. Only social workers who were certified as pro- cantlyelevatedoddsofusingillicitdrugsatfollow-up.The
gram deliverers and were active as group leaders were 95 % confidence interval (CI) of the effect estimates was
involved in the trial. Comet 12–18 leaders reported that [1.24, 10.72], and in the younger sub-group the 95 % CI
78 % of the 73 sections in the manual were fulfilled ‘‘to a was[1.12,12.33].Table 5alsoshowsthattheproportionof
full extent’’, 17 % ‘‘to a greater extent’’, 3 % ‘‘to at least drugusershadincreasedinbothinterventiongroupsduring
half’’, 1 % ‘‘to a lesser extent’’, and 1 % ‘‘not at all’’. follow-up, while it decreased from 21 to 11 % in the
ParentSteps leaders’ self-assessments showed that 83 % control group.
123
JChildFamStud(2016)25:811–826 819
Assessed for eligibility (n= 879)
Excluded (n= 608)
Not meeting inclusion criteria
(n= 274)
Declined to participate/no consent
(n= 145)
Unable to contact (n= 189)
Families randomized
(n= 271)
Allocation
Families allocated to yComet (n=99) Families allocated to ParentSteps Allocated to control grp (n=86)
(n=86)
Family withdrew from participation before Family withdrew from participation before Family withdrew from participation before
completion of the baseline measurement completion of the baseline measurement completion of the baseline
(n= 12) (n= 11) measurement (n= 5)
Parents who completed baseline Parents who completed baseline Parents who completed baseline
measurement and received allocated measurement and received allocated measurement (n=82)
intervention (n=88) intervention (n=71) Youth who completed baseline
Youth who completed baseline Youth who completed baseline measurement measurement (n=81)
measurement (n=86) (n=70)
Follow-Up 1
Lost to follow-up Lost to follow-up Lost to follow-up
Parents (n=1) Parents (n=2) Parents (n=0)
Youth (n=4) Youth (n=5) Youth (n=1)
Analysis
Analyzed Analyzed Analyzed
parents n= 88 parents n= 71 parents n= 82
METHOD
youth n=86 youth n=70 youth n=81
Results
Fig.1 CONSORT 2010 flow diagram of participants. Flow chart of recruitment and dropout following the Consort Statement 2010 Flow
Diagram
Discussion programswereprovidedunderreal-worldconditionsbythe
social services in the greater Stockholm urban area. Our
This randomized trial aimed to evaluate the effects of two results suggest that neither the Comet 12–18 nor the Par-
Swedish prevention programs for parents of adolescents entSteps programs have beneficial effects on adolescents’
who are at risk for antisocial behavior. The prevention externalizing and delinquent behavior or substance use as
123
820 JChildFamStud(2016)25:811–826
Table2 Baselinecharacteristicsofthestudysample
Variable Comet12–18 ParentSteps Controls Teststatistic pvalue
Adolescents,n 86 70 81
Parents,n 88 71 82
Girls 38.4 45.7 58.0 v2(2,N=237)=6.56 .04
Meanage(SD) 14.6(1.67) 14.5(1.63) 14.7(1.89) F(2,N=237)=0.38 .69
Participatingmothers/stepmothers 92.0 95.8 93.9 v2(2,N=241)=7.39 .27
Participatingfathers/stepfathers 8.0 4.2 6.1 v2(2,N=241)=7.39 .27
Morethanoneparentinthetrial 18.2 15.5 17.1 v2(2,N=241)=0.20 .90
Foreign-bornmother 19.8 20.0 20.9 v2(2,N=237)=0.9 .92
Single-parentfamily 43.7 50.7 41.5 v2(2,N=240)=1.41 .49
Parenthasuniversitydegree 28.4 17.1 28.0 v2(2,N=240)=3.26 .20
Parentisemployed 86.4 84.5 84.1 v2(2,N=241)=0.19 .91
ValuesarepercentagesormeanvaluesandSD
reportedbyadolescentsandparentsincomparisontoasix- conductproblemsinyoungerchildren,buttheauthorsnote
month wait-list control group. Even though we also ana- that the results might not necessarily be generalizable to
lyzedsub-groups with elevated levelsofproblem behavior cognitive-behavioral programs for other age groups (Fur-
assessed with Y-OQ(cid:3) and risk levels of alcohol use with long et al. 2012). Also, results from other systematic
AUDIT, no significant group effects emerged. Nor were reviews have pointed to the value of supporting families
anysignificantdifferencesdetectedbetweenthegroupsina and parents early in the children’s lives (Piquero et al.
secondary analysis of the sub-group of adolescents 2009). Though age did not fall out as a significant mod-
12–17 years old. erator in their meta-analysis of behavioral parent-training
The only significant, and the most salient, finding was programs, Lundahl et al. (2006) found the highest effect
that the risk of illicit drug use at follow-up was threefold sizes instudieswith children upto5 yearsold(d = 0.44),
greater in both intervention groups compared to controls, somewhat lower effect sizes for children 6–10 years
suggesting that the studied parenting programs might (d = 0.31), and the lowest effect sizes for children
actually have caused harm in this particular outcome. 12 years and older (d = 0.27) (Lundahl et al. 2006). The
Although harmful effects of interventions are of outmost task ofdeveloping new interaction patterns when the child
importancetoconsiderwhentheyappear,webelievethere has reached the adolescent years might be more difficult,
are several reasons to treat this finding with caution. First, andmightbe,likeHindelang etal.(2001)state,‘‘…much
this was the result of an increase in drug use in the past like closing the barn door after the horse has left’’ (p. 82).
six monthsintheinterventiongroupsbetweenbaselineand Compared to younger children, adolescents spend more
follow-up and a concurrent decrease in the control group time outside the home and the influence from peers grows
from 21 % to 11 %. Given that drug use among Swedish relatively stronger. If developing new interaction patterns
adolescents in general is known to increase between the is more difficult than with younger children, a follow-up
ages of 15–18 years (Kallmen et al. 2011), the develop- period of six months might also be a too short a time to
ment in the untreated control group might better be allow effects to be seen in adolescents’ problem levels.
understood as a measurement error. Second, the low TheSFPassumesadevelopmentalperspective,withthe
occurrence of drug use in the sample makes the estimates family exerting relatively more influence on children and
uncertain, as displayed by the wide confidence intervals youngadolescentsthanonolderadolescents(Molgaardand
[95 % CI (1.24, 10.72)]. Finally, the theoretical mecha- Spoth 2001). With regard to the ParentSteps program for
nismsbywhichthetwoprogramsmightleadtoanincrease parents of at-risk adolescents (Larsson et al. 2009), the
in drug use (and at the same time leaving other outcomes program was theoretically modeled on the Swedish adap-
unaffected) are difficult to comprehend. tation (Ska¨rstrand et al. 2008) of the universal SFP 10–14
Onepossibleexplanationforthenullfindingsisthatthe (MolgaardandSpoth2001).However,ParentStepsdeparts
Comet12–18andParentStepsare,infact,noteffectivefor substantially from the SFP structure by only including
reducing antisocial behavior in this population of at-risk parentsessions(i.e.noyouthorfamilysessions).Asbriefly
adolescents. The systematic review from the Cochrane reviewed in Kumpfer et al. (2002), the original experi-
Collaboration by Furlong and colleagues (2012) showed mental SFP research found that the combined parenting,
that cognitive behavior therapy-based parent programs youth, and family intervention (which constitutes SFP
such as Comet 12–18 can be effective for improving today) led to significantly greater improvements in parent,
123