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Alcohol & Sub. Dep.: Family Struggling with Sobriety
Alcohol & Sub. Dep.: Family Struggling with Sobriety

Section 15
Community Resources, the Process of Referring Affected Persons, Prevention,
& Parent Training Interventions

Question 15 | Answer Booklet | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Recognizing and Intervening with Family Members: Community resources offering assessment, treatment and follow-up for the abuser and family
Al-Anon-Alateen: 888-4AL-ANON
Alcoholics Anonymous World Services: 212-870-3400
American Council on Alcoholism treatment referral line: 800-527-5344
Kids Against Drugs: http://www.kidsagainstdrugs.com
Mothers Against Drunk Driving: 800-GET-MADD
Narconon: http://www.narconon.org/
Narcotics Anonymous: http://www.na.org
National Clearinghouse for Alcoholism and Drug Information: 800-729-6686
National Cocaine Hotline: 800-COCAINE (262-2463)
National Council on Alcoholism and Drug Dependence: 800-NCA-CALL
National Drug Information Treatment and Referral Hotline: 800-662-HELP (4357)
National Institute on Alcohol Abuse and Alcoholism: 301-443-3860
National Institute on Drug Abuse: http://www.nida.nih.gov
National Resource Center: 866-870-4979

Making Appropriate Interpretations, Interventions and Referrals: The Process of Referring Affected Persons
Alcohol abuse and dependence have a variable course characterized by periods of remission and relapse. There are three major hurdles to overcome in the treatment of alcoholism: (a) physiologic dependence (symptoms of withdrawal), (b) psychologic dependence (alcohol used as treatment for anxiety, depression, stress), and (c) habit (the central part that alcohol occupies in the framework of daily living).

Alcohol dependence is treated in two stages: withdrawal and detoxification, followed by further interventions to maintain abstinence.

IMMEDIATE TREATMENT: DETOXIFICATION
The severity of withdrawal symptoms increases with each withdrawal episode. Severe withdrawal (grand mal convulsions, delirium tremens) occurs in 2 to 5 percent of heavy drinking, chronic alcoholics fewer than three days after stopping alcohol consumption, and may last for three to seven days. With treatment, mortality is about 1 percent; death is usually caused by cardiovascular collapse or concurrent infection.

Withdrawal severity and indications for pharmacotherapy can be assessed by the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) instrument.22 Use of benzodiazepines greatly reduces the risk of seizure and symptoms of withdrawal. Alcoholics should be admitted to the hospital for detoxification if they are likely to have severe, life-threatening symptoms or have serious medical conditions, suicidal or homicidal tendencies, disruptive family or job situations, or are unable to attend outpatient facilities.23

SUSTAINED TREATMENT: LONG-TERM MAINTENANCE OF ABSTINENCE
Considerable evidence shows that long-lasting neurobiologic changes in the brains of alcoholics contribute to the persistence of craving. At any stage during recovery, relapse can be triggered by internal factors (depression, anxiety, craving for alcohol) or external factors (environmental triggers, social pressures, negative life events).23 Psychosocial treatments concentrate on helping patients to understand, anticipate, and prevent relapse.

BEHAVIORAL TREATMENT APPROACHES
Alcoholics Anonymous (AA) and 12-Step Facilitation Therapy
AA and similar self-help groups follow 12 steps that alcoholics should work through during recovery. This free program is particularly supportive for those who are poor, isolated, lonely, or who come from a heavy-drinking social background. Twelve-Step Facilitation (TSF) is a formal treatment approach incorporating AA and similar 12-step programs.24

Cognitive-Behavior Therapy (CBT)
The aim of CBT is to teach patients, by role-play and rehearsal, to recognize and cope with high-risk situations for relapse, and to recognize and cope with craving.25

Motivational Enhancement Therapy (MET)
This counseling method is used to motivate patients to use their own resources to change their behavior.26

Results of a large multisite study, Project MATCH,27 found that there was no difference in the efficacy of CBT, MET, and TSF during the year following treatment, however, MET was found to be most effective in those patients with high levels of anger, and TSF and AA involvement was particularly effective in patients from a heavy drinking social environment.27

When to Refer
After a screening questionnaire has identified problem drinking, the physician may question the patient further to determine the severity of alcohol misuse. The physician may try brief intervention and/or suggest AA, or refer the patient to an addiction specialist. The family physician should play a critical holistic role in treatment and prevention, working with the patient and family, even when other specialists may be involved.

Extend of the Alcohol and Drug Abuse Epidemic and its Effects on the Individual, Family, and Community: Education concerning and prevention of substance abuse
A number of different prevention approaches have been found to be effective in decreasing the risk of drug abuse and addiction. Simple lifestyle changes, like increased physical activity and using other stress reduction techniques, are thought to help prevent drug abuse and dependence in teens. More formal programs have also been found to be helpful. For example, the Raising Healthy Children program, which includes interventions for teachers, parents, and students, has been found to help prevent substance abuse and addiction in elementary school children when the program goes on for 18 months or more. The prevalence of easier access to technology has led to the development of computer-based prevention programs. Such programs have been found to be very promising in how they compare to more traditional prevention programs, as well as how many more people can be reached through technology.

Substance Abusers Parent Training Interventions
Research into risk factors for problem behavior among children has established clear links between family characteristics and the likelihood that children will become involved in drug abuse, delinquency and other forms of problem behavior (Jessor, 1976; Simcha-Fagan, Gersten & Langner, 1986; Hawkins, Catalano & Miller, 1992). Viewed through this paradigm, children whose parents are addicted to heroin or other opiates face numerous risk factors. In addition to possibly having a physiological predisposition toward drug abuse (Berstein et al, 1984; Zuckerman & Bresnahan, 1991; Griffith et al, 1994), these children are likely to receive inadequate parental supervision and support (Bauman & Levine, 1986; Kumpfer & DeMarsh, 1986; Kumpfer, 1987) and be exposed to the modeling of drug use and other illegal behavior by their parents (Kandel, Kessler & Margulies, 1978; Akers et al, 1979; Kolar et al., 1994; Peterson et al., 1994; Catalano & Hawkins, 1996).

Research suggests that behavioral parent training programs can reduce family-related risk factors, enhance family-related protective factors, and decrease children's antisocial behavior. (Patterson & Reid, 1973; Fraser, Hawkins & Howard, 1988; Dumas, 1989; Webster-Stratton, 1994; Dishion & Andrews, 1995; Ruma, Burke & Thompson, 1996; Serketich & Dumas, 1996). Three major challenges in working with high-risk parents have been noted in tests of parent training interventions. First, parent training programmers have had difficulty recruiting high-risk parents (Hawkins et al., 1987). Secondly, studies of high-risk families indicate that short-term programs (8-10sessions) are unlikely to succeed (Patterson & Reid, 1973). Clinical reports suggest that high-risk parents may require twice as many hours of training as parents from the general population to achieve the same level of change in their own and their children's behavior (Patterson, 1974; Patterson & Fleishman, 1979). Thirdly, parent training alone may not be potent enough to produce substantial, lasting changes in parents' and children's behaviors, especially among high-risk families (Nicol et al., 1985; Tremblay et al., 1992; Reid, 1993; Serketich & Dumas, 1996).

These challenges suggest that, in addition to focusing on parenting skills, parent training interventions with drug-abusing parents should be of long duration, pay particular attention to recruitment and retention mechanisms, teach parents skills to minimize their own drug use, and offer supportive services to address other areas of these families' lives which may need attention. Parents who are already in methadone treatment for drug abuse are good candidates for such programs because they have made a commitment to examine their drug use and have begun to work on making changes in their lives. If they attend treatment regularly, they are available for parent training recruitment efforts, and interventions can be of sufficient duration if the parent program is integrated into treatment. Treatment services, e.g., training in relapse prevention skills, can complement parent training, adding intensity that helps keep parents involved in the family training program.

There is little rigorous evidence about the effectiveness of parent training with substance-abusing parents, and there have been no published reports of randomized experimental evaluations of parent training interventions with this population. This article reports on the experimental test of an intensive family program, Focus on Families (FOF), for parents in methadone treatment and their children. Using a randomized experimental design, the program's impact on family risk and protective factors (including parents' drug use, skills and sense of self-efficacy in avoiding or coping with relapse, family communication and involvement, family management practices, family conflict, family bonding, school-related risk factors and deviant peer networks) and child problem behavior is examined at 6 and 12 months following the training.

This is one of the first published reports of prevention intervention with children of substance abusers. The program was delivered to parents in methadone treatment and their children. The goal of the intervention was to prevent parents' relapse and help them cope with its occurrence (if it did occur), and to reduce the likelihood of substance abuse among their children. The results suggest that the positive effects on parents appear to be stronger than effects demonstrated for their children.

By 12-month follow-up, parents in the experimental group improved their skill levels to avoid drug use in problem situations, had instituted more household rules, and had less domestic conflict. Further, at 12-month follow-up, their frequency of heroin use was almost two-thirds less than that of the comparison group, and they had lower prevalence of cocaine use. Among the children, few differences achieved significance. The child report data show less parental involvement in the experimental group at 6-month follow-up, which was no longer significantly different at 12-month follow-up. Differences in problem behavior and drug use did not reach significance but in most cases favored the experimental group at both follow-up periods.

The absence of child differences is reason for concern. The intervention was focused primarily on directly affecting parenting behaviors; consequently, it is reasonable to see the strongest effects on parent measures. It may be too early to see effects on children. Theoretically, we expect that changes in parent behavior will precede changes in child behavior, and will also precede changes in children's perception of parent behavior. The differences in parent skill levels, family management, domestic conflict and drug use favoring the experimental group were strongest at 12-month follow-up. It may be that effects on children will appear at a later time as changes in parent risk factors begin to affect children's perception of behaviors. Furthermore, the efficacy of the intervention in preventing problem behavior may only become measurable as children reach adolescence and the prevalence and severity of substance use and other problem behaviors increase. The analyses presented here are limited in power in this regard because many of the children were quite young. For instance, at the 12-month follow-up 44% of the children included in the analyses of child substance use were less than 13 years old.

Post hoc analysis demonstrated that younger children in the experimental group were not reporting the negative effects for involvement reported by older children in the experimental group. In fact, younger experimental children reported more involvement with their parents than younger control children. It may be that changes introduced by parents who were not setting rules and limits prior to intervention may be experienced by older children as restricting their freedom and led to less positive involvement. This suggests that the program could be most effective with younger children. Older children may need more specialized and intensive intervention, perhaps attending more sessions with their parents (Szapocznik et al., 1988).

Regardless of the effects on children during this time period, the intervention had positive effects on parents' skills, rule setting, domestic conflict, and drug use. These are effects above those produced by involvement in a methadone treatment program. The curriculum devoted four of the 32 sessions to relapse prevention and coping skills. Considerable time was spent discussing and building the family management and family involvement skills of parents. Further, the program constantly reinforced reducing drug use as the most important change parents could make to improve family life. This suggests that attending to family and parenting issues may play a critical role for parents in drug treatment. Programs such as FOF may be an important adjunct to treatment programs to aid in reducing parent participants' drug use.

The analyses presented are a conservative test of the effects of the intervention. Several parents and their children in the intervention condition never received the program and only about half attended more than half of the sessions. Despite this underexposure there are still condition differences, suggesting a robust effect. However, since a fairly high proportion of the participants in the experimental group had little or no exposure to the intervention, we re-ran our analyses excluding 43 experimental parents who left methadone treatment prior to the end of the parent training portion of the intervention or attended fewer than half of the parent training sessions. To control for the potential bias of only including highly exposed parents, we also excluded 16 control parents who left methadone treatment prior to when they would have finished the parent training portion of the intervention if they had been in the experimental group. In general, the comparison between the more highly exposed experimental group and the matched control group revealed a pattern of results similar to those found in the larger sample. Differences at 6 months favoring the experimental group in the number of family meetings and relapse/refusal skills became significant at the p < 0.05 level while no loss of significance at the p < 0.05 level occurred for any variable. We also re-ran our analyses for children, limiting the sample to children of the more highly exposed experimental parents or matched control parents. This eliminated approximately 25% of the children in the control group and approximately 50% of the children in the experimental group. Again, the pattern of results remained similar to that found when looking at the larger sample.

Several caveats should be made. First, although methods were used to increase the validity of parents' reports of drug use and other problem behavior, children's self-reports of drug use were not verified. Secondly, it was not possible to engage all parents in the methadone clinics. Twenty-five per cent of parents approached by project staff refused to participate. It is unknown whether these participants differed from those who agreed to participate and, strictly speaking, results apply only to volunteers. Thirdly, participants were recruited from two branches of a single Seattle methadone treatment program, and the program or clientele may differ from methadone programs or clientele in other places. Fourthly, these results are achieved at 1-year follow-up. Long-term follow-up may be needed for two purposes. Program effects on parents may be maintained, increase or decay. The lack of effects on children may be maintained, or sleeper effects may appear that others have noted in prevention programs (Tremblay et al, 1992). The latter may be the case, since many of the children are young and effects for parents are strongest at 12-month follow-up. Finally, most participants (both children and parents) remained in the data collection portion of the study (87-94%). While fewer in the experimental group completed the full intervention, effects were demonstrated for the originally assigned group as well as those with more complete exposure. Attendance at multiple sessions over a long time period is difficult for these often dysfunctional families, yet repeated contact and longer length of treatment appears necessary to make changes in these families. Family programs with parents who are substance abusers may need to build in redundancy, and review and reinforce skills periodically to ensure mastery of content when parents and children miss sessions. FOF built in this periodic review and reinforcement and had case managers work with families to cover missed materials.
- Catalano, Richard, Gainey, Randy, Fleming, Charles, Haggerty, Kevin, & Norman Johnson, An Experimental Intervention with Families of Substance Abusers: one-year follow-up of the focus on families project, Addiction, Feb 1999, Vol. 94, Issue 2.
- Roxanne Dryden-Edwards, MD., Melissa Conrad Stöppler, MD, Drug Abuse and Addiction, http://www.medicinenet.com/drug_abuse/article.html
- Mary-Anne Enoch, M.D., M.R.C.G.P., and David Goldman, M.D., American Academy of Family Physicians
http://www.aafp.org/afp/2002/0201/p441.html

Personal Reflection Exercise #6
The preceding section contained information about substance abusers parent training interventions.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
What are the three major challenges in parent training interventions with high-risk parents?
To select and enter your answer go to Answer Booklet.

 

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