Adolescent Health: Person-to-Person Interventions to Improve Caregivers’ Parenting Skills

The CPSTF finding is based on evidence from a systematic review of 12 studies (search period January 1980 – August 2007). The review was conducted on behalf of the CPSTF by scientists from Research Triangle Institute, Intl., through a contract mechanism and with input from a team of specialists in systematic review methods and experts in research, practice and policy related to adolescent health.

Twelve studies qualified for the review.

• Outcomes assessed include:
  • Sexual behaviors (7 studies)
  • Violence, delinquency, suicide, and self-harm (4 studies)
  • Alcohol, tobacco, and other drug use (7 studies)
  • Behaviors related to motor vehicle safety (1 study)
  • Teen pregnancy (2 studies)
• Estimated effects for individual studies and outcomes varied substantially; most estimates of effect favored the intervention, but were not statistically significant.
• A meta-analysis indicated that this intervention results in an approximately 20% reduction in the overall set of risk behaviors evaluated (p<.05).
  • For sexual behavior and violence, the effect estimates were RR=0.69 (95% CI 0.50, 0.94) and 0.68 (95% CI 0.49, 0.94), respectively, meaning that these risk behaviors decreased by approximately 30%.
  • The effect estimate for substance use was much smaller and was not statistically significant (RR=0.87, 95% CI 0.73, 1.04), suggesting the potential for a weaker effect or no effect on these outcomes.
  • Youth participating in these interventions also reported they had increased refusal skills and self efficacy for avoiding risky behaviors in the future.

An economic review of this intervention did not find any relevant studies.

Results of this review should be applicable to diverse populations and settings (including communities, homes, and schools) provided appropriate attention is paid to adapting the intervention to the target population.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. What are evidence gaps?

• What types of person-to-person formats lead to the greatest effectiveness in adolescent health outcomes?
• What types of caregiver behaviors, if changed, can lead to the greatest reduction or improvement in adolescent risk-taking behaviors?
• For what types of caregiver are these interventions most effective? As noted, the caregivers in these included studies were sufficiently motivated to participate. In addition, questions remain as to whether this intervention would work consistently well across all caregiver types. Specifically, are there types of caregivers for whom caregiver interventions will have no appreciable effect overall?
• Are certain types of caregiver-targeted interventions more effective in creating change for certain risk or protective behavior outcomes than others? Are there types of risk behaviors on which these interventions have only a minimal effect?
• How does the “problem behavior” construct hold up in terms of behavior changes within adolescents? For example, if one risk behavior changes for an adolescent, how likely are other risk behaviors to be affected?
• Once caregivers have received a targeted intervention, can they successfully extend the behaviors and skills to other children, so that potential benefits can be derived for those adolescents as well?
• Is there an optimal age of the child at which, or by which, a caregiver needs to have received the intervention to achieve the desired effects?
• What is the economic cost for these types of interventions?

• Three elements were common to all of the interventions in the qualifying studies:
  • An education component
  • A discussion component, and
  • An opportunity for the caregiver to practice new skills
• Specific topics covered in the educational components varied across interventions and included:
  • Information about communication strategies
  • Recommendations for parental monitoring
  • Information on more specific topics, such as teen sexual behaviors, along with guidance on how to approach the adolescent with these topics
• Evaluated interventions targeted caregivers only, or caregivers and adolescents together or separately. These interventions were delivered via group sessions or one-on-one training with the caregiver.
• Caregivers participating in the included studies were volunteers who were sufficiently motivated to attend.
• The majority of studies were conducted in the United States.

Burrus B, Leeks KD, Sipe TA, et al. Person-to-person interventions targeted to parents and other caregivers to improve adolescent health: a Community Guide systematic review. American Journal of Preventive Medicine. 2012;42(3):316-26. [PDF – 424 KB]

Community Preventive Services Task Force. Improving adolescent health through interventions targeted to parents and other caregivers: a recommendation. American Journal of Preventive Medicine. 2012;42(3):327-8. [PDF – 52 KB]

Effectiveness Review

Analytic Framework see Figure 1 on page 319

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Anderson NL, Koniak-Griffin D, et al. Evaluating the outcomes of parent-child family life education. Scholarly Inquiry for Nursing Practice 1999;13(3):211-34.

Bauman KE, Ennett ST, Foshee VA, Pemberton M, King TS, Koch GG. Influence of family-directed program on adolescent cigarette and alcohol cessation. Prevention Science 2000;1(4):227-37.

Dancy BL, Crittenden KS, et al. Mothers’ effectiveness as HIV risk reduction educators for adolescent daughters. Journal of Health Care for the Poor and Underserved 2006;17(1):218-39.

DiIorio C, Resnicow K, et al. Keepin’ it R.E.A.L.!: results of a mother-adolescent HIV prevention program. Nursing Research 2006;55(1):43-51.

Dishion TJ, Andrews DW. Preventing escalation in problem behaviors with high-risk young adolescents: immediate and 1-year outcomes. Journal of Consulting and Clinical Psychology 1995;63(4):538-48.

Li X, Stanton B, Galbraith J, et al. Parental monitoring intervention: practice makes perfect. Journal of the National Medical Association 2002;94(5):364 70.

Park J, Kosterman R, et al. Effects of the “Preparing for the Drug Free Years” curriculum on growth in alcohol use and risk for alcohol use in early adolescence. Prevention Science 2000;1(3):125-38.

Postrado LT, Nicholson HJ. Effectiveness in delaying the initiation of sexual intercourse of girls aged 12-14 two components of the Girls Incorporated Preventing Adolescent Pregnancy Program. Youth Society 1992;23(3):356-79.

Rotheram-Borus MJ, Lee MB, Gwadz M, Drimin B. An intervention for parents with AIDS and their adolescent children. American Journal of Public Health 2001;91(8):1294-302.

Simons-Morton BG, Hartos JL, et al. Increased parent limits on teen driving: positive effects from a brief intervention administered at the Motor Vehicle Administration. Prevention Science 2004;5(2):101-11.

Toumbourou JW, Gregg ME. Impact of an empowerment-based parent education program on the reduction of youth suicide risk factors. Journal of Adolescent Health 2002;31(3):277-85.

Wu Y, Stanton BF, et al. Sustaining and broadening intervention impact: a longitudinal randomized trial of 3 adolescent risk reduction approaches. Pediatrics 2003;111(1):e32-8.

Electronic searches of the literature were conducted by a public health librarian in PubMed, Cochrane, CINAHL, ERIC, SOCIOFILE, and PsycINFO. The team also reviewed the references listed in all retrieved articles, review articles, and systematic reviews, and consulted with experts on the systematic review development team and elsewhere to identify additional articles. Articles were excluded if they were not available in English. The initial literature search on the topic was conducted in September 2006 and an update search was conducted in August 2007.

Databases: Cochrane, CINAHL, PsycINFO, ERIC, SOCIOFILE

Timeframe: 1966 August 2007

• Adolescent (Limits: 13-18 years)
• Parents OR Legal Guardians OR Caregivers OR Mothers OR Fathers OR Grandparent OR Grandmother OR Grandfather OR Parent-Child Relations
• Health Education OR Patient Education OR Education
• Risk Taking OR Risk Factors OR Sexual Behavior
• Adolescent Behavior OR Adolescent Nutrition OR Adolescent Development AND Parent-Child Relations AND Risk-Taking
• Evaluation Studies OR Program Evaluation OR Outcome Assessment (Health Care) OR Risk Assessment OR Process Assessment (Health Care)
• Internet
• Therapy OR Intervention
• Person-to-Person

Search: 1 AND 2 AND 5
Search: 1 AND 2 AND 3 AND 6
Search: 2 AND 3 AND 4
Search: 1 AND 2 AND 3 AND 4
Search: 1 AND 7 AND 8 AND 9

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• It may be inadvisable to place high-risk youth together in groups, particularly without directly involving caregivers in the setting. Some of the included studies noted the potential for negative outcomes when adolescents gathered in intervention settings without caregivers present as youth who engage in risk behaviors may adversely influence youth who do not.
• Potential barriers to caregiver interventions include recruiting and retaining caregivers whose participation may be limited because of time, transportation, childcare, or other constraints.
• Additional benefits of this intervention include improvements in proximal outcomes, such as improved caregiver child communication, which may lead to long-term improvements in other outcomes, such as improved school performance.
• Benefits also were reported for adolescents who did not directly participate in the intervention.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of adolescents who have an adult they can talk to about serious problems — AH-03
• Increase the proportion of children and adolescents who communicate positively with their parents — EMC-01