Supporting the supportive parents : community reinforcement and family training for families affected by alcohol or substance use

Abstract

Background: Concerned significant others (CSOs) of individuals with problematic alcohol- or substance use show increased levels of psychiatric and somatic ill-health, social and economic problems and exposure to violence. Children growing up with at least one parent with problematic alcohol-/substance use have increased risks of a variety of problems, such as own substance use problems, low school performance, internalized and externalized problem behaviors and mental health problems. Parents of substance using adult children is an especially burdened group of CSOs with elevated strains due to the parent-child bond, experiences of stigma and feelings of shame. The prevalence of alcoholand substance use is at a life-time high in young adulthood, which leads to increased risks for several physiological, psychological and social consequences. There is a treatment gap for young adults with problematic substance use, with large potential positive effects to gain from more young adults entering treatment at an earlier stage. There is a lack of evaluated support programs for CSOs who share a young child with a co-parent with problematic alcohol consumption, and also for parents of substance using young adults. For both of these contexts, variations of Community Reinforcement and Family Training (CRAFT) was deemed suitable to evaluate.

Aims: The overall aim of the thesis was to investigate the efficacy of different forms of CRAFT for parents in contexts where the program has not previously been evaluated. The specific aims were to investigate: i) the efficacy of a web-based self-delivered program combining CRAFT with a parenting training program; ii) reasons for seeking support as described by CSOs sharing a child with a drinking co-parent and to investigate how the CSOs described potential effects of the web-based program; iii) the efficacy of CRAFT for parents of treatment refusing young adults with problematic substance use; and iv) the experiences of CRAFT among parents of young adults with problematic substance use.

Methods: - Study I: A randomized controlled parallel-group superiority trial comparing the efficacy of the online intervention for CSOs sharing a child (3-11 y/o) with a drinking coparent (N=37), to an active control group (N=39) receiving written psychoeducational material. Primary outcome was the children’s mental health at 12 weeks, measured with the Strengths and Difficulties Questionnaire (SDQ). Linear mixed effect models were used to model time by group interaction effects. - Study II: A qualitative design conducting semi-structured interviews with 13 female CSOs who had completed at least two of four modules in the program. Transcribed interviews were analyzed using conventional qualitative content analysis. - Study III: A randomized controlled parallel-group superiority trial comparing CRAFT (n=58) to an active control group receiving counselling (n=55) for parents of treatment refusing young adults (18-24 y/o) with hazardous substance use, with young adult treatment seeking within 24 weeks as primary outcome. Setting was two outpatient clinics for adolescents and young adults in Stockholm, Sweden, subsequently via videoconference due to Covid-19. Outcome modelling was conducted using mixed effects models for all outcomes. - Study IV: A qualitative design conducting semi-structured interviews with 10 parents who had participated in CRAFT in study III. Transcribed interviews were analyzed using thematic analysis.

Results: - Study I: There were no significant time by group effects on either the primary or secondary outcomes. The CSOs reported significant reductions in co-parent alcohol consumption and severity of dependence and showed improvements in parental selfefficacy for handling effects of co-parent alcohol consumption, but no differences between conditions. - Study II: Main reasons for seeking support were wanting validation/emotional support and coping strategies for handling the co-parent, and negative perceptions of available support options for CSOs. Main perceived effects from the program were improved relationship to their children, increased own positive activities, and less adaptation to the co-parent. - Study III: At the 24 weeks follow-up, 33 % of CRAFT-participants and 31 % of counselling participants had reported young adult treatment entry, with no difference between conditions. Both conditions reported clinically relevant reductions in substance use, but no change in parents’ levels of depression, anxiety or stress, although from subclinical baseline levels. - Study IV: The parents appreciated the accessible support at a time when they needed it due to feelings of shock and powerlessness, and they described communication strategies together with positive reinforcement as the two most helpful CRAFT-sessions. The parents expressed wanting more easily accessed treatment alternatives when the young adults were ready to enter treatment, and described difficulties to practice CRAFT-components due to changing life-circumstances and fear of aggravated health for their young adults.

Conclusions: The findings from study I-II showed that the support led to important improvements in consequences from co-parent drinking in both conditions. It was difficult to attract the target population, which led to limited statistical power, and no differences were found between conditions. CSOs who completed the program described anonymity as important for them to seek help, the program was perceived as empowering, and the relationship to their children had improved. The findings from study III-IV showed that both CRAFT and the counselling program increased treatment seeking rates among young adults with problematic substance use. The lack of a non-active control condition reduces the possibility to draw definite conclusions regarding treatment efficacy. The parents found CRAFT to be valuable by providing strategies that resulted in an improved relationship to the young adults, a decrease in substance use, and in some cases young adult treatment entry. The results showed that CRAFT is suitable for the current population, but with some possible additions due to circumstances as part of the young adult developmental phase.