Telephone counseling to implement best parenting practices to prevent adolescent problem behaviors
Introduction
A major goal for parents and for society is that children reach adulthood without having developed what are considered problem behaviors. Problem behaviors include: a) substance use/abuse (most commonly cigarettes, alcohol, or marijuana); b) internalizing disorders such as depression, anxiety, hostility and anger; and c) externalizing disorders including status offenses (those not proscribed for adults, e.g. truancy; sexual activity, particularly unprotected; and antisocial behavior that starts with stealing and bullying and may escalate to violence or property crimes) [1]. There is considerable evidence that problem behaviors cluster within individuals [2].
Individuals without strong bonds to social institutions (such as the family) are likely to think and behave unconventionally and belong to unconventional and risk-taking peer groups [3]. The family and home environment have been identified as the most important factors associated with teen avoidance of problem behaviors [4]. There is now considerable consensus identifying the following set of parenting practices as critical to positive youth development: a) relationship-building skills, b) limit-setting, c) positive reinforcement, d) monitoring, and e) conflict resolution [5], [6], [7], [8], [9], [10].
Parental monitoring in the context of positive parent-teen relationships and communication is a key protective factor for limiting access to a deviant peer group and reducing peer influences on youth problem behavior [11], [12]. While developing autonomy is part of the adolescent process, how and when parents grant autonomy appears to be one of the critical factors in preventing problem behaviors. Unsupervised free time, particularly at night and on weekends, is a strong predictor of problem behaviors in multiple studies [13], [14], [15]. Several school-based studies have demonstrated that parent training leads to improved implementation of best parenting practice among parents with problem adolescents and that these improvements appear to reduce substance use and other problem behaviors [16], [17], [18]. However, few studies investigate whether such changes can be maintained through adolescence.
There are a number of reasons why even motivated parents with sound knowledge of recommended best parenting practices may have difficulty in maintaining implementation of recommended best practices throughout adolescence. The capability to implement known best practice is often disrupted by parental stressors such as separation or divorce, job loss [19], increased work hours [8], or even by a generalized growing disaffection (depression) and long-term disadvantage [20]. Culture and the media convey consistent negative images of parent-teen relationships that undermine parent morale and self-efficacy [10]. Low self-efficacy can lead to parental disengagement from their adolescent. One example is when the parent initially responds negatively to evidence of a problem behavior, triggering a defiant response from the adolescent. Should this spiral with further negativity from the parent, the parent-child conflict can escalate quickly. Usually, it is the parent who is the first to back down often with a significant lowering of their self-efficacy for parenting [10]. Careful attention to maintaining relationship building and negotiation skills can avoid such negative consequences.
In this study, we hypothesized that training parents in recommended best practices would lead to short-term improvements in their parenting. Further, we hypothesized that an extended implementation intervention would help if it used telephone-based motivational interviewing techniques [21] to encourage maintenance of these practices in the face of multiple stressors and situations. Maintenance of these best parenting practices should result in lower rates of problem behaviors in adolescents, as measured in multiple longitudinal surveys of teens.
Section snippets
Overview of study design
The Parenting to Prevent Problem Behaviors Project is a randomized trial of a national population sample of 1036 families whose oldest child was aged 10–13 years at baseline (Fig. 1). This study identified eligible families from respondents to a random survey of the United States population and invited them by mail to participate in the study. Baseline telephone surveys were completed with the parent who had most say in the care of the oldest child as well as with the target adolescent. Using
Enrollment of study participants
Between May and August 2003, Westat (our subcontracted survey firm) conducted random digit dialed surveys using a national sampling frame that oversampled areas known to have high densities of African-Americans. A total of 57,000 households were enumerated and 4781 (8.4%) met the criteria of having an oldest child at home who was 10–13 years of age. All were asked to express interest in participating in a future study by providing a name and address for further contact. Introductory letters
Representativeness of the enrolled sample
We compared our sample to national population estimates from households with an oldest child age 15 (the lowest age with data) from the 2001/2002 Current Population Survey of the US Census Bureau, the source for updating US census statistics. Nationally, these 15 year olds should be demographically similar to a national sample of our target population.
Table 1 shows that our study population slightly under-enrolled the Hispanic/other category (this was expected as we did not screen or offer the
Comparability of randomized groups at baseline
Randomization was undertaken automatically by a computer program after first entry of an enrolled family into the study's relational database at UCSD. A random number generator and a permuted block design were used to allocate families within each of the following two-level strata: region of the country, parental smoking, child smoking risk, and hours out at night. At the completion of randomization, 514 families were in the intervention group and 522 in the comparison group.
Table 2 presents
Details on the study intervention
The purpose of the training phase was to ensure that all intervention group participants would have a similar knowledge base for best parenting practice as their oldest child was starting adolescence. For this phase of the intervention, all participants were sent a study-developed self-help manual that presents the consensus best parenting practices in 12 chapters organized into three modules: building positive behaviors, setting effective limits, and relationship building. Although not
Standardizing and controlling intervention quality
The study used a rigorous selection process for non-professional facilitators focused on people with knowledge of best parenting practices, and an aptitude for motivational interviewing and for following study protocols. Possession of significant basic computing skills was required. The study used computer-assisted telephone counseling scripts to ensure that a similar approach was taken with all intervention participants. All facilitators completed a 60-hour training program that included
Study assessments
Data are collected using computer-assisted telephone interview (CATI) surveys with trained assessors blinded to the participant's study group. There are a total of 8 adolescent questionnaires and 4 parent questionnaires throughout the study to provide snapshots of parenting practices, parent-child relationships and variables associated with problem behaviors. The content of each of these surveys is presented in Table 3.
Outcome questions
Tobacco use is sought with 15 questions from the standard set used in national and state telephone surveys and for which we have demonstrated validity in multiple studies [22], [23], [24]. Alcohol use questions are those used in the Oregon Healthy Teens Study [25] and marijuana use are from the national Youth Risk Behavior Survey [26]. The 7 Questions on High-risk Sexual Activity are also from the YRBS [26] and in this study will not be asked before age 16 years. We use a 6 item scale (α = 0.65)
Monitoring
A 9 item Likert-type Parental Monitoring Scale [28] asks teens about the information they give their parents about their activities and whereabouts. (α = 0.90) We also ask teens 8 questions from the Strictness/Supervision index [29]. The parent is asked 4 questions about the kinds of activities their teen does with friends, including hanging out at home, playing sports, etc. (α = 0.84).
Limit setting
We ask both the teen and parent the total number of hours the teen is typically allowed to stay out during the
Predictors of outcome variables
Following previous work [37], we measured Exposure to Substance Use in the Social Network by asking teens the frequency of use of tobacco and alcohol among their best friends. We asked whether the teen knew anyone who used any of 9 substances including marijuana and cocaine. We also asked about availability of cigarettes and alcohol in the home. Rebelliousness was measured using the validated [38] 6 item teen rebelliousness scale (α = 0.65) used in previous research [39], [40], [41], [42]
Cohort maintenance strategies
The Cochrane review notes that cohort maintenance has been a major problem with parenting studies [48]. We have implemented a variety of study activities designed to remind and update participants about the project and to reward them for completing various study tasks. The study puts out a semi-monthly newsletter for both study groups that includes a presentation on a relevant parenting topic with parenting tips, reviews of other resources, and a question-and-answer forum. All participants,
Study power and statistical issues
Primary hypothesis Adolescents from intervention group families will be 30% less likely to become adult established smokers by age 18–20 years than those from comparison group families.
The study is powered for the primary hypothesis. Participant loss to follow-up has been a major problem in parenting studies [48]. Accordingly, we calculate power for our expected loss to follow-up of 6%/year as well as for a very conservative estimate of 12%/year (Table 4). We used the latest estimates of adult current established
Discussion
There is considerable evidence to suggest that parenting practice is a major determinant of the development of adolescent problem behaviors. However, definitive studies have been limited by difficulty in retaining participants. A potential reason for this low continued participation is the participant burden involved in coming to group sessions at a time when parents need to be interacting with their teens.
A major strength of this project is the use of a telephone intervention that is scheduled
Summary
This is the first population-based study that we know of to investigate the role of parenting practice in preventing problem behaviors among adolescents. It has drawn a national sample of families and enrolled a high proportion of those eligible into the study. It uses a comprehensive set of assessments over the adolescent years from which the longitudinal trajectory of problem behaviors will be clearly drawn. The study has the power to identify the role of best parenting practices in
Acknowledgement
Preparation of this article was supported by funding from NCI grant CA093982.
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