Richard Velleman

The role of the family in preventing and intervening with substance use and misuse: a comprehensive review of family interventions, with a focus on young people

The family plays a key part in both preventing and intervening with substance use and misuse, both through inducing risk, and/or encouraging and promoting protection and resilience. This review examines a number of family processes and structures that have been associated with young people commencing substance use and later misuse, and concludes that there is significant evidence for family involvement in young peoples taking up, and later misusing, substances. Given this family involvement, the review explores and appraises interventions aimed at using the family to prevent substance use and misuse amongst young people. The review concludes that there is a dearth of methodologically highly sound research in this area, but the research that has been conducted does suggest strongly that the family can have a central role in preventing substance use and later misuse amongst young people.

Prospective study of post-traumatic stress disorder in children involved in road traffic accidents

Abstract Objective: To determine the prevalence of severe psychological trauma—that is, post-traumatic stress disorder—in children involved in everyday road traffic accidents. Design: 12 month prospective study. Setting: Accident and emergency department, Royal United Hospital, Bath. Subjects: 119 children aged 5-18 years involved in road traffic accidents and 66 children who sustained sports injuries. Main outcome measure: Presence of appreciable psychological distress; fulfilment of diagnostic criteria for post-traumatic stress disorder. Results: Post-traumatic stress disorder was found in 41 (34.5%) children involved in road traffic accidents but only two (3.0%) who sustained sports injuries. The presence of post-traumatic stress disorder was not related to the type of accident, age of the child, or the nature of injuries but was significantly associated with sex, previous experience of trauma, and subjective appraisal of threat to life. None of the children had received any psychological help at the time of assessment. Conclusions: One in three children involved in road traffic accidents was found to suffer from post-traumatic stress disorder when they were assessed 6 weeks after their accident. The psychological needs of such children after such accidents remain largely unrecognised.

Family interventions in the treatment of alcohol and drug problems.

Alcohol and drug problems affect not only those using these substances but also family members of the substance user. In this review evidence of the negative impacts substance misuse may have upon families are examined, following which family-focused interventions are reviewed. Several family-focused interventions have been developed. They can be broadly grouped into three types: (1) working with family members to promote the entry and engagement of substance misusers into treatment; (2) joint involvement of family members and substance misusing relatives in the treatment of the latter; and (3) interventions responding to the needs of the family members in their own right. The evidence base for each of the three types is reviewed. Despite methodological weaknesses in this area, a number of conclusions can be advanced that support wider use of family focused interventions in routine practice. Future research needs to focus on (1) pragmatic trials that are more representative of routine clinical settings; (2) cost-effectiveness analyses, in terms of treatment costs and the impact of interventions on costs to society; (3) explore treatment process; and (4) make use of qualitative methods. In addition, there is a need to define more clearly the conceptual underpinnings of the family intervention under study.

Coping with Alcohol and Drug Problems: The Experiences of Family Members in Three Contrasting Cultures

This is an invaluable resource from leading commentators. The experiences of family members living with alcohol and drug misusers are examined via the literature and a three-centre study in Australia, England and Mexico.

The experiences of affected family members: a summary of two decades of qualitative research

This article is based upon the collective findings of a number of studies conducted in a number of countries during the past 20 years. Female partners and mothers are the family members who have been most represented in the study samples, but the latter also included sizeable numbers of male partners, fathers, sisters, brothers and adult sons and daughters. Citing examples taken from the studies, the article describes some of the most prominent elements of the stressful experience of living with a relative who is drinking or taking drugs excessively, notably: the relationship with a relative becoming disagreeable and sometimes aggressive; conflict over money and possessions; the experience of uncertainty; worry about the relative; and home and family life being threatened. The reasons why family members may put up with substance misuse are described, and the ways in which family members may either withdraw and gain independence or stand up to substance misuse, as alternative ways of coping, are outlined. Examples of the strain experienced by family members are given. The kinds of social support valued by family members are explained, as is the finding that good quality social support for family members is often lacking. The article concludes by offering an integrated view highlighting the disempowered position in which family members usually find themselves and the importance of good social support for family members in their coping efforts. Although the picture is coloured by factors such as sociocultural group and the ages and genders of family members and their relatives, we believe the core experience for affected family members is a universal one.

Addiction in the family is a major but neglected contributor to the global burden of adult ill-health

This paper offers a conceptual overview of a neglected field. Evidence is presented to suggest that, globally, addiction is sufficiently stressful to cause pain and suffering to a large but uncounted number of adult affected family members (AFMs), possibly in the region of 100 million worldwide. A non-pathological stress-strain-coping-support model of the experience of AFMs is presented. The model is based on research in a number of different sociocultural groups in Mexico, England, Australia and Italy and aims to be sensitive to the circumstances of AFMs in low and middle income countries and in minority ethnic and indigenous groups as well to those of majorities in wealthier nations. It highlights the social and economic stressors of many kinds which AFMs face, their lack of information and social support, dilemmas about how to cope, and resulting high risk for ill-health. The public sector and personal costs are likely to be high. Attention is drawn to the relative lack of forms of help designed for AFMs in their own right. A 5-Step form of help aiming to fill that gap is briefly described. Family members affected by addiction have for too long been a group without a collective voice; research and action using the model and method described can make a contribution to changing that state of affairs.

Family Members Affected by a Close Relative's Addiction: the Stress-Strain- Coping-Support Model

This article outlines the stress-strain-coping-support (SSCS) model which underpins the whole programme of work described in this supplement. The need for such a model is explained: previous models of substance misuse and the family have attributed dysfunction or deficiency to families or family members. In contrast, the SSCS model assumes that having a close relative with a substance misuse problem constitutes a form of stressful life circumstances, often longstanding, which puts affected family members at risk of experiencing strain in the form of physical and/or psychological ill-health. Coping and social support are the two other central building blocks of the model. Affected family members are viewed as ordinary people faced with the task of coping with such stressful life circumstances. It is an assumption of the model that, difficult though the coping task is, family members need not be powerless in maintaining their own health and helping their relatives. Good quality social support, in the form of emotional support, good information and material help, is an invaluable resource for affected family members, supporting their coping efforts and contributing positively to their health. The 5-Step Method, to be described later in the supplement, is based on the SSCS model. It can be seen as a way of increasing the positive social support available from professional sources.

The experiences of postnatal depression in women from black and minority ethnic communities in Wiltshire, UK

Objectives. To describe the experiences of women suffering from postnatal depression in black and minority ethnic communities in Wiltshire, UK. Design. Semi-structured interviews and focus groups with women across Wiltshire with current and past experience of postnatal depression. EPDS data are also reported. Qualitative data (via telephone and face-to-face interviews) were also collected from GPs and health visitors who worked with these women. Results. Qualitative analysis identified four main themes that were part of the experience of postnatal depression for the women and the primary health care professionals in contact with them—issues specific to pregnancy and birth (including postnatal depression), issues specific to primary health care, issues relating to culture, and ‘other’ issues. This latter theme describes the multitude of problems that many of the women endured, e.g. family/marital problems, violence, drinking alcohol, bereavement, financial difficulties, unemployment, accommodation and (racial) harassment. Conclusions. All the women had problematic lives, affected by a multitude of factors, and raised a number of serious concerns that related to health and social care. This has implications for practice and service provision, as demonstrated by the data from GPs and health visitors, in, for example, the provision of advice and information (and in different languages), training, improved communication and inter-agency working, in this area (where the research was conducted) and elsewhere in England. More research is needed to further explore the needs of women from minority ethnic groups, taking issues of, for example, cultural specificity and urbanity/rurality into account. Further research also needs to investigate ways of offering help and support to this patient group.

The development and evaluation of the pain indicator for communicatively impaired children (PICIC)

&NA; A previous study found that parents of communicatively impaired children with severe cognitive impairments identified six core cues as indicating definite or severe pain in their child (J. Pediatr. Psychol. 27 (2002) 209). The frequency of each cue was assessed by 67 caregivers of communicatively impaired children, twice per day over a 1 week period. On each occasion the caregivers also rated whether they considered their child to be in pain and the severity of any pain. There was a statistically significant relationship between five of the cues and the presence and severity of pain. The single cue of screwed up or distressed looking face was the strongest predictor and on its own correctly classified 87% of pain and non‐pain episodes. The study highlights the potential clinical utility of a short carer completed assessment to assess pain in this vulnerable group of children.

The relative efficacy of two levels of a primary care intervention for family members affected by the addiction problem of a close relative: a randomized trial

OBJECTIVES A randomized trial to compare two levels of an intervention (full versus brief) for use by primary health-care professionals with family members affected by the problematic drug or alcohol use of a close relative. DESIGN A prospective cluster randomized comparative trial of the two interventions. SETTING A total of 136 primary care practices in two study areas within the West Midlands and the South West regions of England. PARTICIPANTS A total of 143 family members affected by the alcohol or drug problem of a relative were recruited into the study by primary health-care professionals. All recruited family members were seen on at least one occasion by the professional delivering the intervention and 129 (90 %) were followed-up at 12 weeks. MAIN OUTCOME MEASURES Two validated and standardized self-completion questionnaires measuring physical and psychological symptoms of stress (Symptom Rating Test) and behavioural coping (Coping Questionnaire) experienced by the family members. It was predicted that the full intervention would show increased reduction in both symptoms and coping when compared to the brief intervention. RESULTS The primary analysis adjusted for clustering, baseline symptoms and stratifying variables (location and professional group) showed that there were no significant differences between the two trial arms. The symptom score at follow-up was 0.23 [95% confidence interval (CI): -3.65, +4.06] higher in the full intervention arm than in the brief intervention arm, and the coping score at follow-up was 0.12 (95% CI: -5.12, +5.36) higher in the full intervention arm than in the brief intervention arm. CONCLUSIONS A well-constructed self-help manual delivered by a primary care professional may be as effective for family members as several face-to-face sessions with the professional.