Peter-Michael Sack

Selective prevention programs for children from substance-affected families: a comprehensive systematic review

Children from substance-affected families show an elevated risk for developing own substance-related or other mental disorders. Therefore, they are an important target group for preventive efforts. So far, such programs for children of substance-involved parents have not been reviewed together. We conducted a comprehensive systematic review to identify and summarize evaluations of selective preventive interventions in childhood and adolescence targeted at this specific group. From the overall search result of 375 articles, 339 were excluded, 36 full texts were reviewed. From these, nine eligible programs documented in 13 studies were identified comprising four school-based interventions (study 1–6), one community-based intervention (study 7–8), and four family-based interventions (study 9–13). Studies’ levels of evidence were rated in accordance with the Scottish Intercollegiate Guidelines Network (SIGN) methodology, and their quality was ranked according to a score adapted from the area of meta-analytic family therapy research and consisting of 15 study design quality criteria. Studies varied in program format, structure, content, and participants. They also varied in outcome measures, results, and study design quality. We found seven RCT’s, two well designed controlled or quasi-experimental studies, three well-designed descriptive studies, and one qualitative study. There was preliminary evidence for the effectiveness of the programs, especially when their duration was longer than ten weeks and when they involved children’s, parenting, and family skills training components. Outcomes proximal to the intervention, such as program-related knowledge, coping-skills, and family relations, showed better results than more distal outcomes such as self-worth and substance use initiation, the latter due to the comparably young age of participants and sparse longitudinal data. However, because of the small overall number of studies found, all conclusions must remain tentative. More evaluations are needed and their quality must be improved. New research should focus on the differential impact of program components and delivery mechanisms. It should also explore long-term effects on children substance use, delinquency, mental health, physical health and school performance. To broaden the field, new approaches to prevention should be tested in diverse cultural and contextual settings.

Heroin as an attachment substitute? Differences in attachment representations between opioid, ecstasy and cannabis abusers

Earlier studies indicated a relation between fearful-avoidant attachment and substance abuse. This study compares attachment representations (Family Attachment Interview; Bartholomew & Horowitz, 1991) of three groups of substance abusers and non-clinical controls. Heroin abusers (N = 22) were mainly fearful-avoidant, ecstasy abusers (N = 31) were preoccupied, fearful-avoidant and dismissing-avoidant, cannabis abusers (N = 19) were mainly dismissing and secure, and controls (N = 22) were mainly secure. Groups did differ in their level of psychosocial functioning (GAF) (cannabis > ecstasy > opioids). Differences in attachment prevailed when GAF was controlled. Based on the self-medication hypothesis we understand the preferences for specific substances to be influenced by specific attachment strategies. Heroin seems to be used as an emotional substitute for lacking coping strategies. Cannabis seems to be used to support existing deactivating and distancing strategies. Ecstasy abuse was related to insecure attachment but not to a specific attachment strategy.

Implementing and evaluating the German adaptation of the “Strengthening Families Program 10 - 14“– a randomized-controlled multicentre study

BackgroundSubstance use problems in childhood and adolescence can severely impact youth’s physical and mental well-being. When substance use is initiated early, the risk for moving from hazardous substance use to substance use disorders (SUD) is particularly high to developmentally induced biological and psychological vulnerability towards chronic trajectories in youth. Thus, risk factors for developing SUD should be addressed early in life by adequate preventive measures reaching out to children, adolescents, and their families. The study described in this protocol will test the effectiveness of the German adaptation of the Strengthening Families Program for Parents and Youth 10–14 (SFP 10–14) aimed at ten to 14 year old adolescents and their caregivers.Methods/DesignThe study is conducted in four large German cities by counselling centres in the areas of youth welfare, social work and addiction aid. The effectiveness of the manualised group programme “Familien Stärken” consisting of seven sessions and four booster-sessions is tested among N = 288 children and participating parents in a multicentre randomised controlled trial with standardised assessment instruments. The control condition receives a minimal 2-hour intervention on parenting delivered in a school setting. Data are collected shortly before and after as well as six and 18 months after the intervention. We expect to replicate the favourable effects of the SFP 10–14 programme in the United States in the area of substance use initiation, family functioning and individual psychosocial adjustment.DiscussionThe trial is expected to contribute to the growing literature on family-based preventive interventions, their effectiveness and feasibility. It is in line with several other current European efforts aimed at strengthening families against the detrimental effects of substance abuse in youth. The results of these trials will expand our knowledge on adapting evidence-based interventions and delivering them in diverse cultures and settings.Trial registrationCurrent Controlled Trials ISRCTN90251787

Brief motivational intervention for adolescents treated in emergency departments for acute alcohol intoxication – a randomized-controlled trial

BackgroundAlcohol misuse among youth is a major public health concern and numbers of adolescents admitted to the emergency department for acute alcoholic intoxication in Germany are recently growing. The emergency setting offers an opportunity to reach at-risk alcohol consuming adolescents and provide brief interventions in a potential “teachable moment”. However, studies on brief interventions targeting adolescents in emergency care are scarce and little is known about their effectiveness when delivered immediately following hospitalization for acute alcohol intoxication. In this protocol we present the HaLT-Hamburg trial evaluating a brief motivational intervention for adolescents treated in the emergency department after an episode of acute alcoholic intoxication.MethodsThe trial design is a parallel two-arm cluster randomized-controlled trial with follow-up assessment after 3 and 6 months. N = 312 participants aged 17 years and younger will be recruited Fridays to Sundays in 6 pediatric clinics over a period of 30 months. Intervention condition is a manual-based brief motivational intervention with a telephone booster after 6 weeks and a manual-guided intervention for caregivers which will be compared to treatment as usual. Primary outcomes are reduction in binge drinking episodes, quantity of alcohol use on a typical drinking day and alcohol-related problems. Secondary outcome is further treatment seeking. Linear mixed models adjusted for baseline differences will be conducted according to intention-to-treat (ITT) and completers (per-protocol) principles to examine intervention effects. We also examine quantitative and qualitative process data on feasibility, intervention delivery, implementation and receipt from intervention providers, receivers and regular emergency department staff.DiscussionThe study has a number of strengths. First, a rigorous evaluation of HaLT-Hamburg is timely because variations of the HaLT project are widely used in Germany. Second, prior research has not targeted adolescents in the presumed teachable moment following acute alcohol intoxication. Third, we included a comprehensive process evaluation to raise external validity. Fourth, the study involved important stakeholders from the start to set up organizational structures for implementation and maintaining project impact.Trial registrationCurrent Controlled Trials ISRCTN31234060 (April 30th 2012).

Evaluation of a German version of the Strengthening Families Programme 10-14: a randomised controlled trial.

BACKGROUND The purpose of this study is to evaluate the effects of a German adaptation of the Strengthening Families Programme 10-14 (SFP 10-14; Familien Stärken). METHODS A multi-centre randomised controlled trial comparing the German SFP version consisting of seven sessions and four booster-sessions with a minimal intervention on parenting as control condition. Outcomes comprise measures of adolescent substance use (initiation) and behaviour problems and are assessed at baseline, after programme delivery and at 6- and 18-month follow-ups. Primary outcomes were lifetime tobacco, alcohol and cannabis use at 18 months. Data of n = 292 families were analysed using baseline adjusted logistic regressions and mixed models. RESULTS We observed reduced rates of lifetime tobacco use in analyses with follow-up respondents, but not in data using the complete intention to treat sample with multiple imputation estimates for missing data. Parents reported fewer adolescent behaviour problems in analyses with the total sample and multiple imputed data, but not in data with follow-up respondents only. There were no other significant effects of SFP 10-14. CONCLUSION Overall the medium size effects found in previous US trials could not be replicated in a German context.

Short- to Midterm Effectiveness of a Brief Motivational Intervention to Reduce Alcohol Use and Related Problems for Alcohol Intoxicated Children and Adolescents in Pediatric Emergency Departments: A Randomized Controlled Trial.

OBJECTIVES The proportion of children and adolescents receiving emergency care for acute alcohol intoxication (AAI) in Germany has sharply increased over the past years. Despite this, no randomized controlled trials (RCTs) have studied guideline- and evidence-based interventions to prevent future alcohol misuse within this population. The objective of our investigation was to evaluate the effectiveness of a brief motivational intervention (b-MI) to reduce drinking and associated problems within pediatric emergency departments (PED) in Hamburg, Germany. METHODS This stratified cluster-RCT compared a widely established but modified targeted b-MI and treatment as usual (TAU) for patients recruited and treated on Fridays, Saturdays, or Sundays from July 2011 to January 2014 for AAI in EDs of six pediatric hospitals in Hamburg, Germany. Patients under the age of 18 years and their caregivers were included in the study. Intervention was delivered by trained hospital-external staff. The intervention group (n = 141) received a single-session b-MI with a telephone booster after 6 weeks and a brief consultation for caregivers. All intervention material was manual-based. The TAU control group (n = 175) received youth-specific written information on alcohol use and contact information for community resources. Primary outcomes were changes in binge drinking frequency, number of alcoholic drinks on a typical occasion, and alcohol-related problems using the brief Rutgers Alcohol Problem Index. Outcomes were measured by research assistants not involved in intervention delivery. Baseline data were collected in person at the PED, and follow-up data were collected via telephone 3 and 6 months after baseline. Secondary outcome was postenrollment health service utilization. Analyses were based on linear mixed models and intent to treat. RESULTS A total of 86.1% (87.5%) of patients in the b-MI group and 82.4% (86.9%) in the TAU group provided valid outcome data after 3 (6) months, respectively. The differences between groups for all outcomes were statistically nonsignificant at both follow-ups (p > 0.05). After 3 months the mean change in binge drinking frequency was -1.36 (95% confidence interval [CI] = -1.81 to -0.91), a reduction of 62.1% in the b-MI group, and -1.29 (95% CI = -1.77 to -0.95), a reduction of 49.0% in the TAU group. The mean change in number of alcoholic drinks on a typical occasion was -2.24 (95% CI = -3.18 to -1.29), a reduction of 37.5% in the b-MI group, and -1.34 (95% CI = -2.54 to -0.14), a reduction of 26.4% in the TAU group. The mean change of alcohol-related problems was -6.72 (95% CI = -7.68 to -5.76), a reduction of 60.5% in the b-MI group, and -6.43 (95% CI = -7.37 to -5.49), a reduction of 58.3% in the TAU group. The differences in mean changes between groups were similar after 6 months for all outcomes. CONCLUSION This study provides new information on the effectiveness of b-MIs delivered at discharge of young AAI patients in emergency care. Both trial groups reduced alcohol use and related problems but the b-MI was not associated with significant effects. Although the intervention approach appears feasible, further considerations of improving the outcomes for this relevant target group are required.

Exploring Attachment Patterns in Patients With Comorbid Borderline Personality and Substance Use Disorders.

Abstract Studies exploring attachment patterns in samples of patients with borderline personality disorder (BPD) report a combination of preoccupied and fearful-avoidant patterns. This has been interpreted as reflecting the approach-avoidance dilemma of BPD. Comorbid substance use disorders (SUD) have not been considered in these studies, despite the high proportions of SUD among BPD patients and despite the more avoidant attachment in SUD samples. This cross-sectional, naturalistic study explores attachment patterns in a sample of comorbid (BPD and SUD) patients, comparing them to two samples of patients with either SUD or BPD only. Within-group comparisons replicated findings of both preoccupied and fearful-avoidant attachment in BPD and comorbid groups. But between-group comparisons showed that comorbid patients were significantly less preoccupied (p = 0.018) and more dismissing-avoidant (p = 0.030). Although both groups were similar in several psychiatric measures, attachment patterns of the comorbid group were more similar to substance abusers than to borderline patients.

Familientherapie als Frühintervention bei drogenabhängigen Jugendlichen, jungen Erwachsenen und deren Müttern - Effektstärken und individuelle Verbesserungsquoten bei den Therapie-Beendern

Zusammenfassung: Fragestellung: Welche kurzfristigen Effekte einer familientherapeutischen Fruhintervention (der «Eppendorfer Familientherapie») bei Familien mit einem polytoxikoman drogenabhangigen Jugendlichen bzw. jungen Erwachsenen sind in einer multikriterialen Evaluation beobachtbar? Methodik: Die eingesetzte Familientherapie ist ambulant und abstinenz-orientiert. Das Design ist prospektiv, naturalistisch und misst pra-post-Effekte. Es beginnen 86 Familien die Therapie (86 drogenabhangige Indexpatienten, IP, im fruhen Suchtstadium, 76 Mutter, 57 Vater, 36 Geschwister). Zu 5 Zielkriterien werden intraindividuelle Verbesserungsquoten von IP und Muttern berichtet (Sucht-Status, Familienfunktion, Psychopathologie, Psychosoziale Integration, Therapiezufriedenheit), jeweils in Patientenangaben und Expertenbeurteilungen. Ergebnisse: Die Behandlung haben n = 62 (72%) der IP regular beendet. Bei 45 dieser 62 (73%) ergeben sich signifikante intraindividuelle Besserungen im Sucht-Status. IP und Mutter weisen i...

Nachhaltiger Transfer des Gesundheitsnetz Alkohol im Jugendalter: Eine Kooperation aus Forschung, Praxis und Politik

OBJECTIVES Testing the effectiveness of a brief motivational intervention in an emergency-setting for adolescents with acute alcohol intoxication in a randomized-controlled trial and sustained implementation within mental health care of Hamburg. METHODS Modification and evaluation of an established indicated prevention program in a transdisciplinary cooperation using a pragmatic RCT-research design. CONCLUSIONS This study contributes to the evidence base of an established prevention program which allows for broad dissemination building on existing capacities for broad dissemination.

Brief Intervention in Alcohol Intoxicated Adolescents-A Follow-up Study in an Access-to-Care Sample

In the present study, N=88 children, adolescents and young adults were examined in the emergency unit of three municipal hospitals, who were receiving inpatient treatment there in the year 2008 due to acute alcohol intoxication (AAI). The sample consisted of 49% female (MD=16 years old) and 51% male patients (MD=17 years old). With regard to twelve months prevalence, it was the first AAI for 71% of the patients up to 16 years old, whereas for 47% of patients older 19 years it was at least the tenth AAI. All patients received a brief motivational intervention (BMI) which was designed to encourage them to seek youth-specific counselling after receiving hospital standard care. Of 88 youth, 15 (17%) accepted this offer, and 78 of 88 adolescents (89%) took part in a telephone-based 6-month follow-up. In an intent-to-treat analysis, alcohol prevalence (g/l for the last 30 days) decreased from t1 (M=544, SE=102) to t2 (M=2, SE=0.12). Therefore, the BMI under study appears to be effective in principle, is currently being manualised, and will be tested in a randomised-controlled study.