Intervention Summary

Strengthening Families Program

The Strengthening Families Program (SFP) is a family skills training program designed to increase resilience and reduce risk factors for behavioral, emotional, academic, and social problems in children 3-16 years old. SFP comprises three life-skills courses delivered in 14 weekly, 2-hour sessions. The Parenting Skills sessions are designed to help parents learn to increase desired behaviors in children by using attention and rewards, clear communication, effective discipline, substance use education, problem solving, and limit setting. The Children's Life Skills sessions are designed to help children learn effective communication, understand their feelings, improve social and problem-solving skills, resist peer pressure, understand the consequences of substance use, and comply with parental rules. In the Family Life Skills sessions, families engage in structured family activities, practice therapeutic child play, conduct family meetings, learn communication skills, practice effective discipline, reinforce positive behaviors in each other, and plan family activities together. Participation in ongoing family support groups and booster sessions is encouraged to increase generalization and the use of skills learned.

Descriptive Information

Areas of Interest	Mental health promotion Substance use disorder prevention
Outcomes	1: Children's internalizing and externalizing behaviors 2: Parenting practices/parenting efficacy 3: Family relationships
Outcome Categories	Family/relationships Mental health Social functioning
Ages	6-12 (Childhood) 13-17 (Adolescent) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Race/ethnicity unspecified Non-U.S. population
Settings	Home School
Geographic Locations	Urban Suburban Rural and/or frontier Tribal
Implementation History	The Strengthening Families Program was initially developed and evaluated in a National Institute on Drug Abuse (NIDA) randomized controlled trial (RCT) with children of addicted parents. Later independent replication studies with cultural adaptations for high-risk, culturally diverse families were conducted in Alabama, Colorado (Denver), Hawaii, Michigan (Detroit), New Mexico, and Utah with SAMHSA/Center for Substance Abuse Prevention (CSAP) and Center for Substance Abuse Treatment (CSAT) 5-year grants. NIDA and National Institute on Alcohol Abuse and Alcoholism (NIAAA) RCTs were conducted by independent investigators in Maryland, New York, Virginia, Washington, DC, and Canada with more than 1,300 families. SFP is currently offered by local agencies in every State nationwide and in 35 countries. Statewide evaluations have been conducted in Florida, New Jersey, North Carolina, and Virginia. LutraGroup, Inc., the prior authorized distributor, trainer, and evaluator of SFP with offices in Salt Lake City, Utah, and the new distributor, Ahearn Green Associates in Washington, DC, estimates that it has trained more than 12,500 individuals to deliver SFP to about 250,000 families in the last 10 years. SFP is currently being tested for the prevention of child abuse in Delaware, Iowa, Kansas, Nebraska, North Carolina, and Oklahoma with several tribes with funding from the Federal Administration for Children and Families. A new SFP 7-17 DVD video version is now being tested with high risk families in the regular family group curriculum version, but also a very low cost 12- to 14-week Home or Clinic Use version with excellent outcomes. An SFP family physical activity and nutrition education curriculum also is being tested with Utah and Colorado tribes for the prevention of obesity and diabetes.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	SFP has been adapted for African American, Asian/Pacific Islander, Hispanic, and American Indian families. Recently, independent researchers have developed language- and culture-specific versions for the Australian, Austrian, Canadian, Dutch, French, Italian, Norwegian, Portuguese, Russian, Spanish, Slovenian, Swedish, and Thai governments. Translations into Arabic and Farsi are underway.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Universal Selective Indicated

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Maguin, E., Nochajski, T., DeWit, D., Macdonald, S., Safyer, A., & Kumpfer, K. The Strengthening Families Program and children of alcoholic's families: Effects on parenting and child externalizing behavior. Manuscript submitted for publication.

Study 2

Kumpfer, K. L., Greene, J. A., Bates, R. F., Cofrin, K., & Whiteside, H. State of New Jersey DHS Division of Addiction Services Strengthening Families Program Substance Abuse Prevention Initiative: Year Three Evaluation Report. Salt Lake City, UT: LutraGroup.

Supplementary Materials

DeMarsh, J., & Kumpfer, K. L. Family-oriented interventions for the prevention of chemical dependency in children and adolescents. Journal of Children in Contemporary Society: Advances in Theory and Applied Research, 18(122), 117-151.

Hill, L. G., & Betz, D. L. Revisiting the retrospective pretest. American Journal of Evaluation, 26(4), 501-517.

Kumpfer, K. L., Alvarado, R., Smith, P., & Bellamy, N. Cultural sensitivity and adaptation in family-based prevention interventions. Prevention Science, 3(3), 241-246.

Kumpfer, K. L., Alvarado, R., Tait, C., & Turner, C. Effectiveness of school-based family and children's skills training for substance abuse prevention among 6-8-year-old rural children. Psychology of Addictive Behaviors, 16(Suppl. 4), S65-S71.

Pratt, C. C., McGuigan, W. M., & Katzev, A. R. Measuring program outcomes: Using retrospective pretest methodology. American Journal of Evaluation, 21(3), 341-349.

Sibthorp, J., Paisley, K., Gookin, J., & Ward, P. Addressing response-shift bias: Retrospective pretests in recreation research and evaluation. Manuscript submitted for publication.

Outcomes

Outcome 1: Children's internalizing and externalizing behaviors
Description of Measures	Children's internalizing and externalizing behaviors were assessed using items from the Ontario Child Health Study scale, the Gresham and Elliot Social Skills scale, parental reports of grades, and the Parent Observation of Child Adaptation Scale.
Key Findings	In a study conducted in the United States and Canada, families with a parent who had problems with alcohol in the past 5 years were exposed to SFP or a control condition (receiving free and widely available educational materials on parenting and family life skills to study at home). Children who received SFP had lower scores on conduct disorder symptoms (p < .01), oppositional defiance symptoms (p < .05), and behavior problems (p < .05) than children in the control group. The effects were modest (standardized coefficient = -.096, -.071, and -.078, respectively). Among parents who received SFP, U.S. parents reported significantly larger decreases in conduct disorder symptoms than Canadian parents (p < .025). In a statewide implementation of SFP, three annual cohorts of families completed retrospective pretests to assess change from baseline. Families who participated in SFP reported improvements in overt aggression, covert aggression, concentration problems, criminal behavior, social skills, alcohol and drug use, and depression (all p values < .01). The effect sizes were very small for covert aggression, criminal behavior, and alcohol and drug use (Cohen's d = 0.14, 0.01, and 0.03, respectively) and small for overt aggression, concentration problems, social skills, and depression (Cohen's d = 0.29, 0.48, 0.29, and 0.27, respectively).
Studies Measuring Outcome	Study 1, Study 2
Study Designs	Experimental, Preexperimental
Quality of Research Rating	3.1 (0.0-4.0 scale)

Outcome 2: Parenting practices/parenting efficacy
Description of Measures	Parenting practices and parenting efficacy were assessed using the Alabama Parenting Questionnaire, the Strengthening Families Parenting Scale, and a 30-day substance use measure used by the Center for Substance Abuse Prevention.
Key Findings	In a study conducted in the United States and Canada, families with a parent who had problems with alcohol in the past 5 years were exposed to SFP or a control condition (receiving free and widely available educational materials on parenting and family life skills to study at home). Parents who received SFP had lower scores on inconsistent discipline (p < .05) and verbal abuse (p < .01) than parents in the control group. The effects were modest (standardized coefficient = -.088 and -.095, respectively). In a statewide implementation of SFP, four annual cohorts of families completed retrospective pretests to assess change from baseline. Families who participated in SFP reported improvements in positive parenting (p < .01), parental involvement (p < .01), parenting skills (p < .001), parental supervision (p < .01), and parenting efficacy (p < .01). The effect sizes were small for parenting skills (Cohen's d = 0.46) and medium for positive parenting, parental involvement, parental supervision, and parenting efficacy (Cohen's d = 0.54, 0.52, 0.58, and 0.55, respectively).
Studies Measuring Outcome	Study 1, Study 2
Study Designs	Experimental, Preexperimental
Quality of Research Rating	3.1 (0.0-4.0 scale)

Outcome 3: Family relationships
Description of Measures	Family relationships were assessed using the Conflicts Tactics Scale (parent version), the Family Effectiveness Scale, and the Family Strengths Scale.
Key Findings	In a statewide implementation of SFP, four annual cohorts of families completed retrospective pretests to assess change from baseline. Families who participated in SFP reported improvements in family organization (p < .01), family cohesion (p < .01), family communication (p < .001), family conflict (p < .001), and family strengths/resilience (p < .01). Effect sizes were small for family conflict (Cohen's d = 0.20) and medium for family organization, family cohesion, family communication, and family strengths/resilience (Cohen's d = 0.67, 0.50, 0.67, and 0.65, respectively).
Studies Measuring Outcome	Study 2
Study Designs	Preexperimental
Quality of Research Rating	3.1 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	6-12 (Childhood) 26-55 (Adult)	53.3% Male 46.7% Female	50% Non-U.S. population 29.7% Black or African American 15.9% White 2.4% American Indian or Alaska Native 1.9% Hispanic or Latino 0.1% Asian
Study 2	6-12 (Childhood) 13-17 (Adolescent) 26-55 (Adult)	51% Male 49% Female	43% White 36% Black or African American 17% Hispanic or Latino 3% Race/ethnicity unspecified 0.5% American Indian or Alaska Native 0.5% Asian

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Children's internalizing and externalizing behaviors	3.3	3.3	3.0	3.0	3.0	3.0	3.1
2: Parenting practices/parenting efficacy	3.3	3.3	3.0	3.0	3.0	3.0	3.1
3: Family relationships	3.3	3.3	3.0	3.0	3.0	3.0	3.1

Study Strengths

The first study used random assignment to help minimize potential confounds. The psychometric properties of the outcome measures used were generally well established. Use of a manualized curriculum, staff training and supervision, and a fidelity measure and process evaluations helped ensure fidelity. In the second study, which occurred over 4 years in real-world settings, improving fidelity each year produced stronger results over time.

Study Weaknesses

Studies relied on parental reports of child behavior with no collateral reports to verify that parents were not answering questions based on how they thought the program staff wanted them to answer. The second study used retrospective pretests to assess program effects (i.e., questionnaires administered following the intervention asked respondents to recall, for example, child behaviors at baseline as a pretest measure). Retrospective pretests are best used as measures of perceived change, rather than actual change, and they tend to inflate program effects.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Kumpfer, K. L., & Whiteside, H. Strengthening Families Program, 3 to 5 years [CD-ROM]. Salt Lake City: University of Utah, Strengthening Families Program Office.

Kumpfer, K. L., & Whiteside, H. Strengthening Families Program, 6 to 11 years [CD-ROM]. Salt Lake City: University of Utah, Strengthening Families Program Office.

Kumpfer, K. L., & Whiteside, H. Strengthening Families Program, 12 to 16 years [CD-ROM]. Salt Lake City: University of Utah, Strengthening Families Program Office.

Parent handouts

Program dissemination overview

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.8	4.0	3.8	3.8

Dissemination Strengths

Implementation materials are thoughtfully designed and contain considerable detail on establishing the program and addressing obstacles. Materials also include specific guidance for adapting the model to different cultures and ethnically appropriate artwork for use in the manuals. On-site training, an online supervision course, and implementation consultation and technical assistance are provided to support the delivery of this program. A comprehensive array of instruments is available to support quality assurance.

Dissemination Weaknesses

The program objectives outlined in the manuals are not clearly related to program content and evaluation. Additional guidance is needed for administering some of the quality assurance measures and interpreting the results.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
CD containing materials for one age group: 3-5, 6-11, 7-17 or 12-16 years	$450 each (or included in training fee)	Yes
2-day, on-site group leader training and one SFP CD master set	$4,350 plus travel expenses for 2 trainers for groups of 35 or fewer	No
2-day, on-site group leader training and one SFP CD master set	$3,700 plus travel expenses for 1 trainer for groups of 15 or fewer	No
Technical assistance (basic)	Free	No
Technical assistance (advanced)	$85 per hour	No
Evaluation services	$1,950-$12,000 annually depending on number of participants and number of evaluation reports	No
Fidelity site visits	$2,200 plus travel	No

Additional Information

Small agencies may find it economical to attend a training hosted by a nearby agency. Lutra Group, Inc., the entity that coordinates SFP training and technical assistance, can help in locating other trainings. Training in the United States is available in English and Spanish. Implementation requires a minimum of five trained staff: two group leaders for the parents, two group leaders for the children, and a site coordinator.